[Senate Hearing 111-610]
[From the U.S. Government Publishing Office]
S. Hrg. 111-610
THE PREVENTABLE EPIDEMIC: YOUTH SUICIDES AND THE URGENT NEED FOR MENTAL
HEALTH CARE RESOURCES IN INDIAN COUNTRY
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
March 25, 2010
__________
Printed for the use of the Committee on Indian Affairs
U.S. GOVERNMENT PRINTING OFFICE
58-331 PDF WASHINGTON : 2010
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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
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Page
Hearing held on March 25, 2010................................... 1
Statement of Senator Dorgan...................................... 10
Statement of Senator Franken..................................... 1
Witnesses
Clayton, Paula J., M.D., Medical Director, American Foundation
for Suicide Prevention......................................... 15
Prepared statement with attachment........................... 17
Grinnell, Randy E., Deputy Director, Indian Health Service, U.S.
Department of Health and Human Services; accompanied by Rose
Weahkee, Director, Division of Behavioral Health............... 2
Prepared statement........................................... 4
Mangas, Coloradas, Sophomore, Ruidoso High School, Mescalero
Apache Reservation, NM......................................... 11
Prepared statement........................................... 13
Listening Session held on March 25, 2010......................... 21
Binney, Allison C., Majority Staff Director/Chief Counsel, Senate
Committee on Indian Affairs; accompanied by Rhonda Harjo,
Deputy Chief Counsel........................................... 21
Witnesses
Flynn, Laurie, Executive Director, TeenScreen National Center for
Mental Health Checkups, Columbia University.................... 21
Prepared statement........................................... 23
Genia, Hunter, Administrator, Behavior Health Services, Saginaw
Chippewa Tribe................................................. 29
Prepared statement with attachment........................... 32
Goklish, Novalene, Senior Program Coordinator, White Mountain
Apache Youth Suicide Prevention Program........................ 35
Prepared statement........................................... 37
Appendix
McCartney, Kevin, Senior Vice President of Government Relations,
Boys & Girls Clubs of America, prepared statement.............. 68
Response to written questions submitted by Hon. Byron L. Dorgan
to:
Paula J. Clayton, M.D........................................ 79
Novalene Goklish............................................. 84
Randy E. Grinnell............................................ 74
Hunter Genia................................................. 82
Response to written questions submitted by Hon. Al Franken to:
Paula J. Clayton, M.D........................................ 82
Novalene Goklish............................................. 89
Randy E. Grinnell............................................ 78
Response to written questions submitted by Hon. John Barrasso to:
Paula J. Clayton, M.D........................................ 81
Novalene Goklish............................................. 88
Watkins, Julia M., Executive Director, Council on Social Work
Education (CSWE), prepared statement........................... 68
Weiler, Mary J., Board Chair, American Foundation for Suicide
Prevention, North Dakota Chapter, prepared statement with
attachment..................................................... 70
Zapol, Dr. Warren, Commissioner, U.S. Arctic Research Commission,
prepared statement............................................. 65
THE PREVENTABLE EPIDEMIC: YOUTH
SUICIDES AND THE URGENT NEED FOR MENTAL HEALTH CARE RESOURCES IN
INDIAN COUNTRY
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THURSDAY, MARCH 25, 2010
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:37 a.m. in room
628, Dirksen Senate Office Building, Hon. Byron L. Dorgan,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. AL FRANKEN,
U.S. SENATOR FROM MINNESOTA
Senator Franken. [Presiding.] I call the hearing to order.
The Chairman, Senator Dorgan, will be here shortly. This is
a hearing on a topic of great importance to our American Indian
communities in Minnesota and across the Country. On behalf of
the Minnesota tribes, I want to thank the Chairman for his
leadership in getting the Indian Health Improvement Act
included in the health reform law.
American Indian teens commit suicide at rate nearly three
times the national average, and the rate is much higher in the
Upper Midwest and the Great Plains, five to seven times higher
than the national average.
Each suicide is an unspeakable tragedy from which families
and communities will never recover. We must learn from these
tragedies. We must find models and fund programs that work to
prevent suicide in Native communities.
As you may know, this month is the fifth anniversary of the
Red Lake massacre, and so I want to share with you an example
of how the learning continues in the Red Lake community even in
the face of ongoing challenges.
Last spring, Red Lake High School tragically lost another
student to suicide. Based on the changes at the school
following the 2005 tragedy, the school immediately brought in
what is called a CBTS team, Cognitive Behavioral Trauma in
School, following the suicide. The CBTS team of mental health
providers from Montana has a history with tribal communities
and worked with the school to assess the community's needs
following the suicide.
During the assessment, mental health workers discovered
that there was a suicide pact, that six other students had
plans to take their own lives. Fortunately, the team was able
to intervene and get students appropriate treatment. And now
these six students are back in school. Clearly, this model
worked by intervening early and minimizing more damage, and
clearly we have a problem as long as any suicide is occurring
among our youth.
I look forward to hearing from today's witnesses. I thank
you all for being here today and sharing your wisdom. I look
forward to hearing from you about other models that are working
in tribal communities and how we can get them the resources we
need to turn this tide.
The Chairman will be here any minute now. Unfortunately, we
are going to have to go for a vote fairly early. And so I read
all your written testimonies last night, and thank you for
those. I think what we are going to do today is, if you can
keep your testimony brief right now, we have your written
testimony. I think that the Chairman will be here any second,
but we will start the testimony now. And at a certain point,
all the Members of the Committee who either come, will have to
leave to go to the Floor to vote on the business before us.
Again, I just want to thank you all. I want to thank you
for your wisdom and your stories. And why don't we just begin
with Mr. Grinnell?
STATEMENT OF RANDY E. GRINNELL, DEPUTY DIRECTOR,
INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES; ACCOMPANIED BY ROSE WEAHKEE, DIRECTOR, DIVISION OF
BEHAVIORAL HEALTH
Mr. Grinnell. Thank you, Senator.
Good morning. I am Randy Grinnell. I am the Deputy Director
for Indian Health Service. I am accompanied today by Dr. Rose
Weahkee. She is the Director for the Division of Behavioral
Health.
Today, I appreciate the opportunity to testify on youth and
the need for mental health care resources in Indian Country.
Mental health care services are crucial for the well being of
American Indian and Alaska Native communities.
As you know, the IHS plays a unique role in the Department
of Health and Human Services because it is a healthcare system
established to meet the Federal trust responsibility to provide
healthcare for American Indians and Alaska Natives.
Good morning, Mr. Chairman.
The IHS, in partnership with Indian tribes, provides high
quality comprehensive care in public health services through a
system of IHS, tribal and urban-operated facilities and
programs based on treaties, judicial determinations and acts of
Congress to an estimated 1.9 million federally-recognized
American Indians and Alaska Natives.
Our duty is to uphold the Federal Government's obligation
to promote health among American Indian and Alaska Native
people, communities and cultures to honor and protect the
inherent sovereignty of tribes.
This week, the President signed the Patient Protection and
Affordable Care Act, the health insurance reform bill passed by
Congress. This new law permanently authorizes the Indian Health
Care Improvement Act. In addition to the many improvements made
in the Indian health system, this law authorizes a
comprehensive youth prevention effort as part of the behavioral
health services.
I would like to acknowledge Chairman Dorgan's leadership on
this issue and the Committee's effort to improve access to
healthcare for American Indians and Alaska Natives.
Suicide is a complicated public health challenge, with many
contributing risk factors. American Indians and Alaska Natives
face a greater number of these risk factors. Indian Country has
communities where suicide can take on a contagious form often
referred to as suicide clusters. The suicide act becomes a form
of expression of the despair and hopelessness experienced by
some Indian youth. Suicide and suicidal behavior and their
consequences send shock waves through many tribal and urban
communities.
The current system of services for treating mental health
problems is a complex and often fragmented system of tribal,
Federal, State, local and community-based services. American
Indian youth are more likely than non-Indian children to
receive treatment through the juvenile justice system and
inpatient facilities.
IHS and SAMHSA are working closely together to formulate
long-term strategic approaches to address the issue of suicide
and mental health care in Indian Country. IHS and SAMHSA are
actively involved on the Federal Partners for Suicide
Prevention Work Group. In partnership with tribes, IHS is
currently developing two five-year strategic plans, one to
address suicide and one to address behavioral health. These two
plans will foster collaboration among tribes, tribal
organizations, urban and other key community resources, and
provide the tools and framework for the next five years.
The IHS Mental Health Program provides primary community-
oriented outpatient mental health and related services, case
management, prevention programming and outreach services. Many
IHS tribal and urban mental health programs do not have staff
to operate 24/7. Some providers are so overwhelmed by the
demand for services, particularly during suicide outbreaks,
that even well-seasoned providers become at risk for burnout.
Strategies to remedy these problems include special pay
incentives, loan repayment and scholarships, active
recruitment, development of the Indians Into Psychology
Program, and emergency deployment of commissioned officers.
IHS first received $13.7 million in 2008 and now receives
recurring funding of $16.3 million to develop pilot projects
for model practices for meth and suicide reduction in Indian
Country. The Methamphetamine and Suicide Prevention Initiative,
or MSPI, marks a significant milestone in suicide prevention
efforts in Indian Country that embraces the President's
direction for tribal engagement and partnership.
IHS worked closely with tribes and tribal leaders over some
time to craft this model. MSPI now supports 127 community
programs targeted at prevention and intervention pilot
programs, the first of its kind in Indian Country, and
represents a shift from Federal to tribally based program
delivery. Local communities determine needs and establish
programs to meet those needs.
Tele-behavioral health services are being used or in
planning stages at over 50 tribal and IHS sites. In Alaska,
where often there is no other options, tele-health based
behavioral health services have worked. A Southwest tribe
currently provides youth and child tele-behavioral health
services and now shows an appointment rate of over 95 percent
being kept.
Services are also being delivered in schools and youth
treatment centers. In some locations, only within the past five
years, has the telecommunications infrastructure been reliable
enough for clinical care.
We are targeting $19 million of the health funding to
provide hardware for basic infrastructure development and also
to acquire state of the art videoconferencing equipment for the
tribal, urban and Federal sides to improve access for
videoconferencing.
The 2011 budget request for mental health is $77 million,
an increase of over $4.2 million above the 2010 enacted level.
The 2011 budget request for alcohol and substance abuse is $205
million, an increase of over $11 million from the 2010 level,
and includes an increase of $4 million to hire additional
qualified behavioral health counselors and addiction
specialists.
In summary, we look forward to the opportunity to address
this urgent need for mental health care services in Indian
Country.
Mr. Chairman, that concludes my statement. Thank you for
the opportunity to testify and we will be happy to answer any
questions.
[The prepared statement of Mr. Grinnell follows:]
Prepared Statement of Randy E. Grinnell, Deputy Director, Indian Health
Service, U.S. Department of Health and Human Services; accompanied by
Rose Weahkee, Director, Division of Behavioral Health
Mr. Chairman and Members of the Committee:
Good morning, I am Randy Grinnell, Deputy Director of the Indian
Health Service (IHS). I am accompanied by Rose Weahkee, Ph.D.,
Director, Division of Behavioral Health. Today, I appreciate the
opportunity to testify on youth and mental health care resources in
Indian Country. Access to mental health care services is an important
component of fostering well-being in American Indian and Alaska Native
communities.
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,
functions 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.
This week, the President signed the Patient Protection and
Affordable Care Act, the health insurance reform bill passed by
Congress. This new law permanently authorizes the IHCIA. In addition to
the many improvements made to the Indian health system, the law
authorizes a comprehensive youth suicide prevention effort as part of
the behavioral health services. I want to acknowledge Chairman Dorgan's
leadership on this issue, and the Committee's effort to improve access
to health care for American Indians and Alaska Natives.
Background
Suicide is a complicated public health challenge with many
contributing risk factors. In the case of American Indians and Alaska
Natives, they face, on average, a greater number of these risk factors
individually or the risk factors are more severe in nature for them.
Every year, several communities in Indian Country experience crisis
episodes during which suicides take 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. Access to adequate care is critical for those seeking help
for their loved ones in crisis, or those left behind as emotional
survivors of such acts.
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 also affected by very high levels of poverty,
unemployment, accidental death, domestic violence, alcoholism, and
child neglect. \1\ Significant health disparities among American
Indians and Alaska Natives exist across the spectrum of substance abuse
problems. The most current IHS health data statistics indicate:
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\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.
Alcohol-related age-adjusted mortality rate (43.7) for years
2002-2004 for AI/AN in the IHS service areas as compared to the
U.S. all races rate (7.0) for the year 2003. \2\
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\2\ U.S. Department of Health and Human Services. Indian Health
Service. Trends in Indian Health, 2002-2003 Edition. Washington:
Government Printing Office, Released October 2009. ISSN 1095-2896. p.
91.
Drug-related age-adjusted mortality rate (15.0) for years
2002-2004 for AI/AN in the IHS service areas as compared to the
U.S. all races rate (9.9) for the year 2003. \3\
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\3\ U.S. Department of Health and Human Services. Indian Health
Service. Trends in Indian Health, 2002-2003 Edition. Washington:
Government Printing Office, Released October 2009. ISSN 1095-2896. p.
196.
NOTE: Rates are per 100,000 population and are adjusted to
compensate for misreporting of American Indian and Alaska
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Native race on the state death certificates.
According to a 2001 mental health supplement report of the U.S.
Surgeon General, ``Mental Health: Culture, Race, and Ethnicity'', there
are limited mental health services in Tribal and urban Indian
communities. \4\ While the need for mental health care is great,
services are lacking, and access to these services can be difficult and
costly. \5\ 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. \6\ American Indian youth are more likely than non-Indian
children to receive treatment through the juvenile justice system and
in-patient facilities. \7\
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\4\ 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.
\5\ 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.
\6\ Ibid.
\7\ Ibid.
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Addressing Mental Health Care Resources in Indian Country
IHS and Substance Abuse and Mental Health Services Administration
(SAMHSA) work closely together to formulate long term strategic
approaches to address the issue of suicide and mental health care 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, Centers for
Disease Control and Prevention (CDC), National Institute for Mental
Health (NIMH), Health Resources and Services Administration (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.
Currently, in partnership with tribes, IHS is developing strategic
plans to address suicide and behavioral health for the Indian health
system. These strategic plans will foster collaborations among Tribes,
Tribal organizations, Urban Indian organizations, and other key
community resources. These collaborations will provide us with the
tools we need to adapt the shared wisdom of these perspectives,
consolidate our experience, target our efforts towards meeting the
changing needs of our population, and develop the framework that will
serve to pave the way over the coming years to address suicide and
behavioral health in Indian Country.
The 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 hours/7 days a week.
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.
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 become at-risk for 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 United States Public Health
Service Commissioned Corps.
Methamphetamine and Suicide Prevention Initiative
The IHS received an appropriation in the amount of $13.782 million
in FY 2008, an increase of $2.609 million in FY 2009, and $16.391
million in FY 2010 for a national initiative to support the development
of pilot projects for model practices for methamphetamine and suicide
reduction programs in Indian Country.
The Methamphetamine and Suicide Prevention Initiative (MSPI)
implemented by IHS and its tribal partners nationally, marks a
significant milestone in suicide prevention efforts in Indian Country
as well as tribal/federal partnerships for health that embraces the
Administration's commitment to tribal engagement and partnership.
MSPI now supports 129 community developed prevention and
intervention pilot programs across the country. Each program represents
partnerships between tribal communities and programs and the IHS, to
develop, implement, and disseminate promising prevention and treatment
service programs nationally.
To create the overall MSPI approach, IHS engaged in close
collaboration with Tribes and Tribal Leaders over the course of almost
a year. During this time, we crafted a model, and the IHS accepted all
of the Tribal Leaders' recommendations for approaches and funding
allocations with only minor adjustments for disbursement methodologies.
It was and remains a creation of close collaboration and partnership
with Tribes.
It is a new program focusing on suicide and substance abuse in
Indian Country. The program is completely community driven from
conception through execution for each program in each community. Indian
communities decide what they need and establish programs to meet those
needs.
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 health
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 many tribal communities.
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 2009 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 enough to be the recipient of ARRA funding to improve our
telecommunications infrastructure which will 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
telecommunications 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 our providers who is active in telemedicine told us recently,
``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 health 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. Such services would require behavioral health providers
including psychiatrists, psychologists, clinical social workers, and
therapists in addition to the tele-mental health technology.
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.
IHS FY 2011 Budget Request for Mental Health Services
The FY 2011 budget request for Mental Health is $77,076,000; an
increase of $4,290,000 over the FY 2010 enacted level. This increase
represents: increases of $748,000 for Federal and Tribal pay increases;
increases of $748,000 for non-medical inflation of 1.5 percent;
population growth increases of $1.092 million, and increases of
$1,702,000 for staffing/operation costs for new/expanded facilities. We
strive to support American Indian and Alaska Native communities
eliminating behavioral health diseases and conditions by: (1)
maximizing positive behavioral health and resiliency in individuals,
families, and communities; (2) improving the overall health care of
American Indians and Alaska Natives; (3) reducing the prevalence and
incidence of behavioral health diseases; (4) supporting the efforts of
American Indian and Alaska Native Communities toward achieving
excellence in holistic behavioral health treatment, rehabilitation, and
prevention for individuals and their families; (5) supporting Tribal
and Urban Indian behavioral health treatment and prevention efforts;
(6) promoting the capacity for self-determination and self-governance,
and; (7) supporting American Indian and Alaska Native communities and
service providers by actively participating in professional,
regulatory, educational, and community organizations at the National,
State, Urban, and Tribal levels.
IHS FY 2011 Budget Request for Alcohol and Substance Abuse Services
The Alcohol and Substance Abuse Program (ASAP) exists as part of an
integrated behavioral health team that works collaboratively to reduce
the incidence of alcoholism and other drug dependencies in American
Indian and Alaska Native communities. The FY 2011 budget request for
Alcohol and Substance Abuse is $205,770,000; an increase of $11,361,000
over the FY 2010 enacted level. This increase represents: increases of
$1,840,000 for Federal and Tribal pay increases; increases of
$2,605,000 to fund the costs of providing health care and related
services; population growth increases of $2,916,000, and; increases of
$4,000,000 for a grant program to expand access to and thereby improve
the quality of treatment for substance abuse treatment services by
hiring additional qualified and trained behavioral health counselors
and other addiction specialists to enhance substance abuse care in
Federal, Tribal, and Urban facilities. The purpose of the IHS Alcohol
and Substance Abuse Program is to raise the behavioral health status of
American Indians and Alaska Natives to the highest possible level
through the provision of preventive and treatment services at both the
community and clinic levels. These programs provide alcohol and
substance abuse treatment and prevention services within rural and
urban communities, with a focus on holistic and culturally-based
approaches. The Alcohol and Substance Abuse Program exists as part of
an integrated behavioral health team that works collaboratively to
reduce the incidence of alcoholism and other drug dependencies in
American Indian and Alaska Native communities.
SAMHSA's Role in Addressing Youth Suicides
American Indian and Alaskan Native tribes also look to SAMHSA for
help is addressing youth suicides. Through its Garrett Lee Smith State
and Tribal Grants, 20 American Indian and Alaskan Native tribes or
tribal organizations have received grants ranging from $400,000 to
$500,000 a year to prevent suicide. This represents 31 percent of all
grants given out in the last four years under this program. In addition
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.
Supports 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.
Funds the National Suicide Prevention Lifeline, 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 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.
In summary, we look forward to opportunities to address the mental
health care needs 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 the 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.
STATEMENT OF HON. BYRON L. DORGAN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. [Presiding] Mr. Grinnell, thank you very
much. We appreciate your work and your testimony. I apologize
for being delayed just a bit because of traffic. My colleague
opened the hearing. I appreciate that very much.
I wanted to mention as we begin now hearing from other
witnesses that we are going to have to do things a little
differently this morning. I will explain it. We were in
session, I think until close to three a.m. this morning with
votes, and are coming back at 9:45. You just heard the buzzer.
The first votes will likely start at 10 o'clock and last--10-
minute votes until 2 o'clock this afternoon. So we will be
voting for four hours. Because they are 10-minute votes, we
won't be able to leave the Floor.
We probably will not have to leave here until 10:10 because
the first vote will be the only vote that is a 20-minute vote.
So what I would like to do is, we will go ahead and hear as
many witnesses as we can before we have to leave. I want to
make certain that all of the testimony is a part of the
permanent record.
Then I am going to ask that we adjourn the hearing, and we
are going to have the remainder of what is now a hearing,
become a listening session. The Staff Director, Allison Binney,
and the Deputy Staff Director on the minority side, Rhonda
Harjo, will assume our places and receive the remaining
testimony, and it will still be a part of the permanent record.
This is a very important subject, very important. And we
have Coloradas Mangas, a sophomore in high school on the Apache
Reservation in New Mexico; Dr. Clayton, Medical Director,
American Foundation for Suicide Prevention in New York City.
Doctor, thank you for being with us and thanks for your work.
And Ms. Laurie Flynn, Executive Director, TeenScreen
National Center for Mental Health Checkups at Columbia. We
thank you very much for being here.
Mr. Hunter Genia, Behavioral Health Administrator, Saginaw
Chippewa Indian Tribe, Mt. Pleasant, Michigan; and Ms. Novalene
Goklish, Senior Research Coordinator, Celebrating Life Youth
Suicide Prevention Program, White Mountain Apache Tribe.
I know that Senator Franken and I have both had experience
with these issues on our reservations. I have a note in front
of me about a young man who took his life this week on the
Standing Rock Reservation, and I will call his parents sometime
later today.
I spoke this weekend with the Tribal Chairman at the Spirit
Lake Nation, where Avis Little Wind took her life and who I
have spoken about often. The late Avis Little Wind was 14 years
old, and her brother took his life just within recent weeks.
We have clusters of suicides, teen suicides especially,
that are very troubling. We are trying to everything we can to
recognize it, put a spotlight on it, and understand how to
address it in order to save the lives of some, particularly
young people who think things are helpless and hopeless, and
choose this way of responding.
It is not the right way to respond, and the work, Mr.
Grinnell, that your organization does is very important. We
just, as you know, had a crew be dispatched to Standing Rock a
while back.
So let me thank all of you. I just wanted to say that as a
way of explanation, I am pleased you are here. There was some
talk of having to cancel the hearing. I said, we have people
that have traveled here. We want to begin this hearing and do
the best we can, after which we will convert this to a
listening session, but we want to continue it and have a formal
hearing record because many of you have taken great pains to be
here.
With that, I want to hear the next witness, Coloradas
Mangas. I have read your statement and it is a poignant
statement. I so appreciate your being here and talking to us
about what this is like through the eyes of a high school
student. You have seen a lot and experienced a lot at this very
young age.
Coloradas Mangas, you may proceed.
STATEMENT OF COLORADAS MANGAS, SOPHOMORE, RUIDOSO HIGH SCHOOL,
MESCALERO APACHE RESERVATION, NM
Mr. Mangas. Good morning, Mr. Chairman and Mr. Franken and
other distinguished guests. It is a great honor and privilege
to testify on a public health and social justice issue that has
disproportionately affected Indian communities throughout my
country.
My testimony is dedicated in honor to those whose voices
will never be heard and who continue to suffer in a culture of
silence and shame.
[Greeting in native language.]
Mr. Mangas. How are you? My name is Coloradas Mangas. My
mother is CriCri Mangas and my father is Carl Mangas. I have
two sisters who are Danielle and Kiana Mangas. I am Chiricahua
Apache from the Mescalero Apache Indian Reservation in New
Mexico. I am 15 years of age and currently a sophomore at
Ruidoso High School in Ruidoso, New Mexico.
I am here due to my past and I am a survivor of teen
suicide. It is my sincere hope that my words will inspire
change and help address these serious situations. Allow me to
begin by telling you about my past.
The first time I had to deal with teen suicide was when my
sister Danielle's friend killed himself. I was in the seventh
grade and it was hard for me to see my sister in that stage.
The second time was when my sister Kiana's friend killed
himself about two years ago. Next was in September of 2009 at
the beginning of the school year. That is when it really had
taken a hard toll. My friend killed himself. He was a good
helper and a person to all. He was a fire and rescue worker and
had seen it all, things I could never imagine. No one saw it
coming.
My friend is Larry Anjotti who is the 19 year old posted on
the left hand side to you and on this side to these people.
Two weeks later, my sister Kiana's other friend killed
herself. That was a hard one, not only for her, but for a lot
of youth on the reservation as she was a friend to all. Her
name is Brandy Little. She is the 17 year old on the bottom of
the poster board on this side and on this side.
My grandmother passed into the next life right after she
killed herself. After that, another two weeks went by and my
other friend killed herself. Another two weeks later, my other
friend killed herself. That night, I didn't know what to do and
I had no one to run to or to talk to.
These two people, one of them is Kayla Sheff, who is the 17
year old on the top of the board. My mother I couldn't get a
picture of her, so I am sorry that I couldn't be able to put
her on there.
The only thing I could do was go to church. It was the one
thing, and I attend youth group regularly at our Reformed
Church. As I was at church, I got a message I never thought I
would get, a text message from my friend saying she loved me
and that I will always have a place in her heart. I didn't know
what to do. The only thing I could do was call the police, who
didn't respond. I went and I walked in the woods from 9 o'clock
p.m. to midnight. I looked everywhere, every tree, and I found
her. It was a good thing I found her when I did. Otherwise, she
would have been gone forever.
I knew that this issue was bigger than I could handle by
myself. I made an appointment with the psychologist at the
mental health clinic. It was nice having someone who listened
and understood what I was going through. I am more of an
exception than the rule because most youth would not go to the
mental health clinic. The stigma and shame keeps people away.
When I look at the resources that our neighbors have in the
town of Ruidoso, I can't help but notice how limited our IHS
hospital is when it comes to basic care and, more importantly,
mental health services. We have a mental health clinic with
only one full-time psychologist, one psychologist to serve a
community of 4,500 children, youth and adults. It is my
understanding that she is currently on administrative leave
indefinitely. With her gone, we have a huge gap in the
continuity of care.
What troubles me is that law enforcement and the court have
a larger role to play during an attempt or completed suicide
compared to our mental health clinic. Most attempters don't
seek help and some are court-ordered to attend therapy. This
role of the courts and law enforcement criminalizes their
behavior and makes their recovery seem less important.
I applaud our community, though. The tribal administration
finally understands that our community-based services are not
connecting in a vital way to meet the challenges of children
and youth with serious mental health needs and their families.
With this said, our tribe has recently applied for the SAMHSA
Systems of Care Grant. It is my hope that we can fundamentally
change the way our services are delivered.
Due to the most recent rash of suicides, a new program
started in the community called Honor Your Life Program. It is
a SAMHSA Garrett Lee Smith-funded program that is designed to
implement and evaluate a comprehensive early intervention and
suicide prevention model.
A new program that is supposed to change attitudes and
beliefs about suicide can be culturally taboo, because in our
culture, we do not talk about death. When it comes to suicide,
talking about death and dying is the only way to break the
culture of silence that is taking the lives of so many of my
friends and other youth.
I believe in change. I believe that we can meet the needs
on our reservation. First, we need to increase program
awareness and cooperation, targeting both youth and adults to
get involved in these programs. Second is by helping the mental
health clinic become fully staffed, getting faster hiring
approval for these clinicians, and ensuring faster Medicaid
approval for persons referred to residential treatment centers.
Having more providers is vitally important. We have four
providers at our school I attend and it seems unjust that we
only have one provider for our community on the reservation. We
need more than one psychologist so more people can be seen more
regularly. Having one provider means that most people are
operating in a crisis mode between long visits. We could also
help by getting providers to work with the law enforcement
during suicide attempts or completions to immediately provide
family-based aftercare.
Other things that I believe would prevent suicide is by
giving the youth more things to do so it would get them away
from drugs, alcohol and idle trouble. We need more leadership
activities to inspire our youth to change their life courses.
Sometimes I think our community forgets that a tribe's legacy
rests in its children and not in how well the tribe's
enterprises operate.
We desperately need a shelter for our youth if they need a
place to stay at certain times when the home life becomes very
toxic. We have heard from other youth that if they just had a
place to go for the night, they would not have made an attempt
on their life.
I am very thankful to have the opportunity to share these
ideas that other youth in Mescalero also have. I am also from a
new generation of young men and women who believe in breaking
the silence and seeking help. I come from people whose pride
runs deep, but I also understand that sometimes pride can keep
us from asking for help.
So lastly, I would like to thank not only my friends, but
also the people that believe in me and mostly mainly all of you
for your time in listening to me. And I would also like to
thank everybody for helping me take another step towards my
plans of becoming a future leader of not only my people on the
reservation, but people across the Country.
And in my native language, Ixehe'. Thank you.
[The prepared statement of Mr. Mangas follows:]
Prepared Statement of Coloradas Mangas, Sophomore, Ruidoso High School,
Mescalero Apache Reservation, NM
Good Morning Honorable Members of the Committee on Indian Affairs
and other distinguished guests. It is a great honor and privilege to
testify on a public health and social justice issue that has
disproportionately affected Indian communities throughout the country.
My testimony is dedicated in honor of those whose voices will never be
heard and who continue to suffer in a culture of silence and shame.
[Introduction in Apache Language] English Translation: My name is
Coloradas Mangas. My mother is Cri-Cri Mangas and my Father is Carl
Mangas. I have two sisters: Danielle and Kiana Mangas. I am Chiricahua
Apache from the Mescalero Apache Indian Reservation in New Mexico. I am
15 years of age and currently a sophomore at Ruidoso High School in
Ruidoso, New Mexico.
I'm here due to my past and I'm a survivor of teen suicide. It is
my sincere hope that my words will inspire change and help address this
serious situation. Allow me to begin by telling you about my past.
The first time I had to deal with teen suicide was when my sister
Danielle's friend killed himself, when I was in the seventh grade. It
was hard for me to see my sister in that stage. The second time was
when my sister Kiana's friend killed himself two years ago. Next was in
September of 2009 at the beginning of the school year. That's when it
really started to take a hard toll. My friend killed himself. He was a
good person and a helper to all. He was a Fire Rescue worker and he had
seen it all. Things I could never imagine. No one saw it coming.
Two weeks later, my sister Kiana's other friend killed herself.
That was a hard one. Not only for her, but for a lot of youth on the
reservation as she was a friend to all. Right after she killed herself.
my grandmother passed into the next life. After that, another two weeks
went by and my other friend killed herself. Two weeks later, my other
friend killed herself. That night I didn't know what to do. I had no
one to turn to or talk to.
The only thing I could do was go to church. It was a Wednesday
night and I attend youth group regularly at our Reformed church. As I
was at church, I got a message I thought I never would get. A text
message from my friend saying she loved me and that I'll always have a
place in her heart. I didn't know what to do. The only other thing I
could do was call the police--who didn't respond. I went and walked in
the woods from 9 p.m. to midnight. I looked everywhere, every tree, and
I found her. It was a good thing I found her when I did, otherwise she
would be gone forever.
I knew that this issue was bigger than I could handle by myself. I
made an appointment with the psychologist at the mental health clinic.
It was nice having someone who listened and understood what I was going
through. I am more of an exception than the rule because most youth
won't go to the mental health clinic. The stigma and shame keeps people
away.
When I look at the resources that our neighbors have in the town of
Ruidoso, I can't help but notice how limited our I.H.S. hospital is
when it comes to basic care and more importantly, mental health
services. We have a mental health clinic, with only one full time
psychologist. One psychologist to serve a community of 4,500 children,
youth and adults. It is my understanding that she is currently on
administrative leave--indefinitely. With her gone, we have a huge gap
in the continuity of care.
What troubles me is that law enforcement and the court have a
larger role to play during an attempt or completed suicide compared to
our mental health clinic. Most attempters don't seek help and some are
court ordered to attend therapy. This role of the courts and law
enforcement criminalizes their behavior and makes their recovery seem
less important.
I applaud our community though. The tribal administration finally
understands that our community-based services are not connecting in a
vital way to meet the challenges of children and youth with serious
mental health needs and their families. With this said, our tribe has
applied for the SAMHSA Systems of Care grant. It is my hope that we can
fundamentally change the way our services are delivered.
Due to the most recent rash of suicides, a new program started in
the community called the Honor Your Life Program. It is a SAMHSA funded
program that is designed to implement and evaluate a comprehensive
early intervention and suicide prevention model.
A new program that is supposed to change attitudes and beliefs
about suicide can be culturally taboo, because in our culture, we don't
talk about death. When it comes to suicide, talking about death and
dying is the only way to break the culture of silence that is taking
the lives of so many of my friends and other youth.
I believe in change. I believe that we can meet the needs on our
reservation. First, we need to increase program awareness and
cooperation--targeting both youth and adults to get involved in these
programs. Second, by helping the mental health clinic become fully
staffed, getting faster hiring approval for these clinicians, and
ensuring faster Medicaid approval for persons referred to residential
treatment centers.
Having more providers is vitally important. We have four providers
at the school I attend and it seems unjust that we only have one
provider for our community on the reservation. We need more than one
psychologist so more people could be seen more regularly. Having one
provider means that most people are operating in a crisis mode between
long visits. We could also help by getting providers to work together
with law enforcement during suicide attempts or completion to
immediately provide family based aftercare.
Other things that I believe would help prevent suicide, is by
giving the youth more things to do so it would get them away from
drugs, alcohol, and idle trouble. We need more leadership activities to
inspire our youth to change their life course. Sometimes I think our
community forgets that a tribe's legacy rests in its children and not
in how well tribal enterprises operate.
We desperately need a shelter for the youth if they need a place to
stay at certain times when the home life becomes very toxic. We have
heard from other youth that if they just had a place to go for the
night, that they would not have made an attempt on their life.
I am very thankful to have the opportunity to share these ideas
that other youth in Mescalero also have. I am also from a new
generation of young men and women who believe in breaking the silence
and seeking help. I come from a people whose pride runs deep, but I
also understand that sometimes, pride can keep us from asking for help.
Lastly, I would like to thank my friends and the people that believe in
me and mostly for your time. In my Native language, Ixehe' [Thank you].
The Chairman. Coloradas Mangas, you are wise beyond your
years. Thank you for your testimony and for being here. We
appreciate that very much.
And Dr. Paula Clayton is with the American Foundation for
Suicide Prevention. We appreciate that work.
Dr. Clayton, I should tell you that many of us have had
experience with this issue of suicide. I walked in and found a
friend of mine who had taken his life one morning, and it is a
moment you never, ever, ever forget. I mean, it is as if it
happened 10 seconds ago.
So I thank you for the work and for the work of the
Foundation and appreciate your being here. We will take your
testimony and then see if we can get Ms. Flynn's testimony. A
vote has started, so we will have about 10 minutes before
Senator Franken and I will have to leave and then we will have
the Staff Directors continue the rest of the listening session.
Dr. Clayton?
STATEMENT OF PAULA J. CLAYTON, M.D., MEDICAL
DIRECTOR, AMERICAN FOUNDATION FOR SUICIDE
PREVENTION
Dr. Clayton. Good morning, Senator Dorgan and Senator
Franken.
My name is Paula Clayton. I am a physician and I do serve
currently as the Medical Director of the American Foundation
for Suicide Prevention.
Suicide is the 11th leading cause of death in the United
States, and the third leading cause of death in teens and young
adults from the ages of 15 to 24. In one study of a well-
monitored tribe, which are here today, the suicide rate in
young adults, rather than being nine per 100,000 was 128.5 per
100,000. It was 13 times the rate of the rest of the youth of
the United States.
In this single tribe, there were 25 deaths of teens and
young adults in a year. And the thing is that they did very
excellent monitoring. And so that is one thing we need. We need
suicide attempt and suicide completion monitoring on all these
tribes and pueblos.
Suicide is the result of unrecognized and untreated mental
disorders. In more than 120 studies of a series of completed
suicides across the world, at least 90 percent of the people
who died by suicide were suffering from a mental illness at the
time of their death. The most common is major depression,
followed by alcohol abuse and drug abuse, but all psychiatric
disorders have an outcome of suicide.
So the major risk factors for suicide are the presence of
an untreated mental disorder, a history of a past suicide
attempt, and a family history of suicide or suicide attempts.
That has to be taken into account.
The most important interventions, then, are recognizing
these disorders and treating them. Every culture has a bias
against doing that. These must be identified in each of these
cultures and overcome.
One such effort to present youth suicide to the general
population is two films AFSP has developed. It is in this
little package called, More Than Sad. The first is about
depression and is for the teens in the high school. And the
second is a companion film to help teachers recognize the
mental illnesses that teens suffer from that may lead to
suicide. Both deal with recognition and treatment.
The first one for the teens depicts four teenagers with
different types of depression who are referred to treatment by
four different people. One is a parent. Another is peers and
the guidance counselor. The third is the kid himself. And the
fourth is the primary care physician.
The package is currently being used in more than 1,000
schools across the United States, and I am sure it is in North
Dakota, and has recently been adopted by the State of Alabama
to show in every high school in that State.
A similar film could and should be made for and about
Native American teens. Although the film would need clinicians
and a filmmaker who are culturally sensitive, the messages are
the same: depression is a medical illness; it is not your
fault; it is okay to seek help; and treatments can make you
well.
A second approach being used in the general population is
screening for early detection and referral, and this is best
exemplified by TeenScreen, which you will hear about. For young
adults, AFSP has an anonymous online screening program that is
evidence-based and approved by the Suicide Prevention Resource
Center. It involves having a counselor available to respond
quickly to an email questionnaire that the troubled young
person submits to engage them sort of in a dialogue in order to
finally convince the person to come in for an evaluation. It is
proven to engage people who are not known to the health system
because it is anonymous and online.
The third, but extremely important aspect of suicide
prevention is to train nurses, other health personnel and
primary care physicians to recognize disturbed kids and begin
treatment early. I would think that this should entail getting
the entire tribe or pueblo involved. There are many public
health models of para-professionals being the first source of
recognition.
Those people who do not respond to the initial treatment
then need to be referred to mental health services or substance
abuse specialists. The referral process, which is apparently
not always the same, needs to be clear and simple. Substance
abuse treatment should start with self-help groups. There are
proven short-term psychotherapy interventions for suicide
attempters and for people with depression in the general
population. Money needs to be invested in these treatment
programs that are developed for Native American youth.
Finally, AFSP believes that suicide postvention behavior is
an important part of prevention. So we have multiple ways to
interact with survivors. AFSP has already done two suicide
support group training programs in South Dakota, which included
Native American participants. AFSP is writing a postvention
instruction for middle and high school personnel to guide them
in their plans in the aftermath of a suicide. Our Web site
contains many other resources that for someone who has lost
someone to suicide that could be used or modified.
Suicide in Native American youth is rising and is in
crisis. Depression can be fatal. Excessive drinking and drug
use can be fatal. The fatality is mainly suicide. Culturally
sensitive, but sustained efforts, with multiple approaches
offer the best hope.
Obviously, if there is a shortage of treatment resources,
which there seems to be, then dollars need to be allocated to
develop innovative treatments for Native Americans. We must
reduce this fatal outcome.
Thank you.
[The prepared statement of Dr. Clayton follows:]
Prepared Statement of Paula J. Clayton, M.D., Medical Director,
American Foundation for Suicide Prevention
Good morning Chairman Dorgan, and Ranking member Barrasso, and
members of the Committee. Thank you for inviting the American
Foundation for Suicide Prevention (AFSP) to provide testimony on Youth
Suicides and the Urgent Need for Mental Health Resources in Indian
Country. My name is Paula Clayton. I am a physician. I currently serve
as AFSP's medical director. My responsibilities include overseeing and
working closely with the AFSP's scientific council to develop and
implement directions, policies and programs in suicide prevention,
education and research. I also supervise staff assigned to the research
and education departments within AFSP.
Prior to joining AFSP I served as professor of psychiatry at the
University of New Mexico School of Medicine in Albuquerque. I also
currently serve as professor of psychiatry, Emeritus, for the
University of Minnesota, where I was a professor and head of the
psychiatry department for nearly twenty years. My research on bipolar
disorder, major depression and bereavement allow me to understand some
of the antecedents of suicide and to appreciate medical research and
public/professional education programs aimed at preventing it.
AFSP is the leading national not-for-profit organization
exclusively dedicated to understanding and preventing suicide through
research, education and advocacy, and to reaching out to people with
mental disorders and those impacted by suicide. You can see us at
www.asfp.org.
To fully achieve our mission, AFSP engages in the following Five
Core Strategies, (1) Funds scientific research, (2) Offers educational
programs for professionals, (3) Educates the public about mood
disorders and suicide prevention, (4) Promotes policies and legislation
that impact suicide and prevention, (5) Provides programs and resources
for survivors of suicide loss and people at risk, and involves them in
the work of the Foundation.
I have provided the committee staff with a Power Point presentation
I recently delivered here in Washington, DC on March 8, 2010, entitled,
``Suicide Prevention--Saving Lives One Community at a Time.'' * I also
included a copy of AFSP's 2010 Facts and Figures on Suicide. Both
documents will provide Committee members and their staff an overview on
the issues associated with suicide in America today, along with some
examples of programs and services to prevent this major public health
problem.
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* The information referred to has been retained in Committee files
and can be found at www.afsp.org/index.cfm?page_id=598DA610-DC4C-A681-
45A4701729BA0C93.
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Suicide is the 11th leading cause of death in the United States and
the third leading cause of death in teens and young adults from ages
15-24. The suicide rate in this younger group is about 9/100,000. In
one study of a well monitored tribe the rate was 128.5/100,000 or more
than 13 times that of all other US young people. In this single tribe
there were 25 deaths in one year. Monitoring of suicide attempts and
suicide is an essential first step.
Suicide is the result of unrecognized and untreated mental
disorders. In more than 120 studies of a series of completed suicides,
at least 90 percent of the individuals involved were suffering from a
mental illness at the time of their deaths. The most common is major
depression, followed by alcohol abuse and drug abuse, but almost all of
the psychiatric disorders have high suicide rates.
So, the major risk factors for suicide are the presence of an
untreated psychiatric disorder, the history of a past suicide attempt
and a family history of suicide or suicide attempts. The most important
interventions are recognizing and treating these disorders. Every
culture has strong biases against doing that. These must be identified
and overcome.
One such effort to present youth suicide to the general population
is two films AFSP developed. The first is about depression and is for
teens and the second is a companion film to help teachers recognize the
mental illnesses in teens that may lead to suicide. Both deal with
recognition and referral. The first depicts four teens with different
types of depression who are referred for treatment by four different
people (parent, peers and a guidance counselor, the kid himself and a
primary care physician). The package is currently being used in more
than 1,000 schools across the country and has recently been adopted by
the State of Alabama to show in every high school in the state. A
similar film could and should be made for and about Native American
teens. Although such films need clinicians and a filmmaker who are
culturally sensitive, the messages should be the same: depression is a
medical illness, it is not your fault, it is OK to seek help and
treatments can make you well.
A second approach being used in the general population is screening
for early detection and referral. An approach best exemplified by Teen
Screen. For young adults AFSP has an anonymous online screening program
that is evidenced based and approved for use by the Suicide Prevention
Resource Center. It involves having a counselor available to respond
quickly to an e-mail questionnaire that the troubled young person
submits to engage them in a dialogue in order to finally convince the
person to come for an evaluation. It is proven to engage young people
who are not known to the health system.
A third, but extremely important aspect to suicide prevention is to
train nurses, other health personnel and primary care physicians to
recognize disturbed kids and begin treatment. I would think this should
entail getting the entire tribe or pueblo involved in the endeavor.
There are many public health models of paraprofessionals being the
first source of recognition. Those young people who do not respond to
initial treatments need to be referred to mental health and substance
abuse specialists. The referral process needs to be clear and simple.
The substance abuse treatment should also start with self help groups
on the reservations. There are proven short term psychotherapy
interventions for suicide attempters and for people with depression in
the general population. Money needs to be invested to develop such
therapies for Native Americans.
Finally, AFSP believes that suicide postvention behavior is
important in suicide prevention, so we have multiple ways to improve
this aspect of care. AFSP has already done two suicide support group
training programs in South Dakota that included Native American
participants. AFSP is writing postvention instructions for middle and
high school personel to guide them in their plans in the aftermath of a
suicide. AFSP's website contains many other resources that those who
have lost someone to suicide can review and use or modify.
Chairman Dorgan, Ranking member Barrasso, suicide in Native
American youth is rising and is an absolute crisis. Depression can be
fatal. Excessive drinking or drug use can be fatal. The fatality is
mainly by suicide. Culturally sensitive but sustained efforts with
multiple approaches offer our best hope to get students into
treatments. Obviously, if there is a shortage of treatment resources,
than dollars need to be allocated to develop innovative new treatments
for Native American youths. We must reduce this fatal outcome. The
American Foundation for Suicide Prevention is ready and willing to
offer our expertise and advice to this Committee and to all members of
Congress as you make the important decisions on how to reduce suicide
in the Indian nations.
I will be happy to answer any questions you and your colleagues
might have. Thank you.
Attachment
The Chairman. Dr. Clayton, thank you very much.
There are four minutes remaining in the vote, so Senator
Franken and I will have to depart shortly.
Laurie Flynn, I would like to have our staff connect with
you after this hearing with respect to the TeenScreen Program.
It appears to me TeenScreen is something that perhaps could be
very helpful for us to collaborate with you and try to move it
in a much more significant way nationally. I had a chance to
review a bit of what you have written, and it seems to me very,
very inspiring.
So two things: number one, we apologize for the
inconvenience of this short hearing; number two, all of the
statements will be part of the permanent hearing record; number
three, the hearing record will remain open for two weeks, and
we will submit written questions and would like to complete the
hearing record with questions from the Senators.
In the meantime, I want to adjourn the hearing and then
begin a listening session with our Staff Director and the
Deputy Staff Director on the minority side for the remaining
testimony.
We thank you very much for being here.
The hearing is adjourned and the listening session will
begin. And I would hope Ms. Binney and Ms. Harjo will come up
and take their chairs.
[Whereupon, at 10:12 a.m., the Committee proceeded to other
business.]
LISTENING SESSION ON THE PREVENTABLE EPIDEMIC: YOUTH SUICIDES AND THE
URGENT NEED FOR MENTAL HEALTH CARE RESOURCES IN INDIAN COUNTRY
----------
THURSDAY, MARCH 25, 2010
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The listening session began at 10:12 a.m. in room 628,
Dirksen Senate Building, Allison Binney, Majority Staff
Director/Chief Counsel and Rhonda Harjo, Deputy Chief Counsel
of the Committee, presiding.
STATEMENT OF ALLISON C. BINNEY, MAJORITY STAFF
DIRECTOR/CHIEF COUNSEL, SENATE COMMITTEE ON
INDIAN AFFAIRS; ACCOMPANIED BY RHONDA HARJO,
DEPUTY CHIEF COUNSEL
Ms. Binney. Good morning. I am Allison Binney. I am the
Staff Director for Chairman Dorgan on the Senate Committee on
Indian Affairs. And with me is Rhonda Harjo, the Deputy Chief
Counsel for the Vice Chairman.
So as Chairman Dorgan said, we are going to go ahead and
continue on with the listening session, so this listening
session will continue to be broadcast via the website, and it
is still available for people to watch it. We are still going
to continue with the transcript that will then be available to
all the Committee Members.
With that, let's go ahead and begin with Ms. Laurie Flynn
from the TeenScreen Project.
Thank you, Ms. Flynn.
STATEMENT OF LAURIE FLYNN, EXECUTIVE DIRECTOR, TEENSCREEN
NATIONAL CENTER FOR MENTAL HEALTH CHECKUPS, COLUMBIA UNIVERSITY
Ms. Flynn. Thank you and good morning. Again, I want to
join my colleagues in thanking the Senator, the Chairman for
organizing this hearing and session, and I want to thank you
very much for gathering the wonderful group that you have to
share information about how we address this very, very
significant public health problem.
I am very honored to be here this morning. My name is
Laurie Flynn. I am the Executive Director of the TeenScreen
National Center for Mental Health Checkups at Columbia
University. I have been at Columbia University working with
this program since 2001.
The TeenScreen National Center's mission is to prevent
adolescent suicide and reduce the disability associated with
mental illness by mainstreaming mental health checkups as a
routine procedure for adolescents in healthcare, in schools and
other youth-serving settings.
We are able to provide our tools, our training, our
technical assistance and support to communities throughout the
Country at no cost because we have been very generously funded
by a family philanthropy.
As a parent whose oldest daughter made a very serious
suicide attempt at age 17, I want to thank the young man to my
right, Carlos Mangas, for his lovely testimony, very moving.
And I really think that having the photographs of these young
people here with us really helps to keep our minds directed to
the ultimate goal, and it is to step up to this problem for our
youth in Native American and Alaska Native communities.
We have heard from Dr. Clayton and we have heard from our
colleagues at the Indian Health Service the significant
statistics that surround the tragedy of adolescent depression
and youth suicide. And what I want to share with you very
briefly is one part of an effort at solution.
We know that suicide in adolescents nearly always is an
outgrowth of depression and other serious mental illnesses. And
we know that 20 percent of adolescents suffer from a mental
disorder at some point during their youth. We know that about
10 percent or 11 percent of those youngsters have a disorder
significant enough to seriously impair their functioning. These
are the youth at great risk.
And yet only about one-fifth of youngsters with mental
illnesses are identified and receive services, and we have
reason to believe that in Indian Country that number may even
be smaller.
Yet we know there is a window of opportunity of perhaps two
to four years between the onset of the first symptoms of mental
disorder and the development of the full-blown disorder which
can then create severe outcomes, including death.
Screening for mental illnesses can be accomplished. We have
been doing this now for a number of years using a variety of
evidence-based screens that can be safely and effectively
administered in a wide range of settings.
Screening for mental illness with an evidence-based tool in
primary care settings, physicians' offices and clinics, has
been proven much more effective than informal interviews, which
tend to miss over 50 percent of youth at risk. We know that by
identifying youngsters with signs of mental illness early, we
can begin to provide the range of supports to the family, to
the community, and to the youngster that can make a lifesaving
difference.
These are not just my opinions. Screening is based in over
20 years of solid science led at Columbia University. Mental
health screenings or mental health checkups, as we call them,
have been safe and effective. The Institute of Medicine in its
national report last week recommended regular screening for
adolescents for mental disorders.
The U.S. Preventive Services Task Force has recommended
annual depression screening and primary care for all of our
teens. Our program is recognized by SAMHSA in its national
registry of evidence-based practices. We know that mental
health checkups can be administered safely in a variety of
ways. In schools, and we have had a lot of experience in Indian
Country with the Gila River Schools, with Turtle Mountain
Schools, and with the Riverside Indian School.
For many years, we have seen in a variety of Indian Country
settings, as well as working with Alaska Native sites, that
these mental health checkups can be administered in ways that
are culturally sensitive and surround the youngster with the
immediate help and support if they need it.
In schools, we provide a service that trains the guidance
counselor, the school nurse or a visiting health professional
to work with the youngster, to provide the checkup which is
self-administered. It is a brief screen.
Let me just give you an example of what it looks like. This
is the one we use most frequently in doctors' offices. It is
this simple. It is an evidence-based checkup. It can be given
on a clipboard while the youngster is in the waiting room
waiting for his appointment with his primary care physician or
with the health practitioner.
It can be scored within a minute and it can indicate
whether or not the youngster has problems that require further
counseling, further probing or referral if necessary if there
is a real crisis at hand. We always work to engage the family
and the community because we know that health and healing will
require the engagement of all the youngsters' close
connections.
We do know, too, that for youngsters who have the most
severe depression and are at greatest risk for suicide, it is
essential that programs like tele-medicine and the program that
has been active in the situation in New Mexico can make the
difference.
We believe that early detection, identifying the youngsters
who need the help, and being able to sort out quickly which
ones are at the greatest risk will help us use our limited
resources most effectively. And in combination with community
supports, efforts to increase the availability of appropriate
mental health resources, and tele-medicine, we can make a real
difference for youngsters in Indian Country.
We are delighted to offer our program to officials at the
Indian Health Service, to various tribal councils, and to
Members of this Committee so that we can work with you as
partners to reduce this ongoing tragedy, to implement mental
health checkups, to identify those youth who are in trouble who
need support, and to help them get lifesaving assistance.
Thank you.
[The prepared statement of Ms. Flynn follows:]
Prepared Statement of Laurie Flynn, Executive Director, TeenScreen
National Center for Mental Health Checkups, Columbia University
Good morning Chairman Dorgan, Ranking Member Barrasso, and members
of the Committee. I am honored to appear before you today to present
testimony about the tragic and ongoing problem of youth suicide in
Indian Country. My name is Laurie Flynn and I am executive director of
the TeenScreen National Center for Mental Health Checkups at Columbia
University. I have served in this capacity since January 2001, and I am
pleased to share information about our program and our role in
addressing adolescent suicide.
The mission of the TeenScreen National Center is to prevent
adolescent suicide and reduce disability associated with mental illness
by mainstreaming mental health checkups as a routine procedure for
adolescents in health care, schools, and other youth-serving settings.
From our beginning, we have provided tools, training and technical
assistance at no cost, and we now support mental health screening in
more than 900 sites in 43 states, including tribal settings.
We are fortunate to be funded by a generous family foundation. Our
benefactors share our dedication to reducing the devastating impact of
undetected depression and other serious mental health problems on
adolescents and their families. As a parent whose oldest daughter made
a very serious suicide attempt at age 17, I can understand the ongoing
pain of families in Indian Country as they struggle to find help and
hope for their children.
Depression and Suicide among Native American and Alaska Native Youth
Today's hearing is important because youth suicide remains a
significant public health challenge in the United States. Suicide is
the third leading cause of death for all youth 11 to 21 years of age,
and it accounts for approximately 12 percent of all deaths in this age
group. As alarming as these statistics are, we know that the problem is
much worse among American Indian and Alaska Native youth. The suicide
rate for American Indian and Alaska Native youth is almost twice that
of young people generally, and suicide is the second leading cause of
death among 15- to 34-year-olds in these populations.
Unfortunately, suicide rates do not capture the full extent of the
problem. According to data cited by the Centers for Disease Control and
Prevention (CDC), there are approximately 100 to 200 suicide attempts
for each completed suicide among young people 15 to 24 years of age.
Among American Indian and Alaska Native youth attending Bureau of
Indian Affairs schools, a 2001 Youth Risk Behavior Survey found that 16
percent had attempted suicide in the preceding 12 months.
Despite these alarming numbers and widespread recognition of the
epidemic of youth suicide among American Indian and Alaska Native
youth, we are still not doing enough to identify and assist young
people suffering from depression and mental illness. National Institute
of Health (NIH) research shows that more than 90 percent of all
individuals who commit suicide are suffering from diagnosable mental
illness in the year preceding their death. Yet, according to the
Substance Abuse and Mental Health Services Administration (SAMHSA) more
than half of all persons who die by suicide have never received
treatment from a mental health provider. Once again, the picture is
even worse in tribal communities, with even fewer individuals receiving
treatment.
This epidemic of preventable suicide among young people has been
exacerbated by shortfalls in funding for the Indian Health Service
(IHS), provider shortages, and the difficulty of providing services in
rural, isolated locations. Each year, funding shortfalls within IHS
limit referrals for medically necessary contracted health services. The
vacancy rate for physicians in the IHS is approximately 20 percent, and
27 percent of the IHS workforce--nearly one-third--will be eligible for
retirement in 2011. And the rural nature of Indian Country provides
additional hurdles for both patient access and provider recruitment.
Despite these challenges, there are effective and efficient ways to
improve the early identification and treatment of mental illness and
reduce needless deaths by suicide. Mental health screening can identify
youth most at risk and provide intervention early, when it is most
effective.
Defining Mental Health Screening
Mental health screening, also referred to as a mental health
checkup, refers to the administration of a standardized, evidence-based
mental health questionnaire, such as the Pediatric Symptom Checklist
(PSC) or the Patient Health Questionnaire 9 Adolescent (PHQ-9A). These
mental health screens include between 9 and 35 questions and take 5 to
10 minutes to complete. The questionnaire is then scored to determine
whether additional follow-up is necessary. It is important to note that
a positive mental health screen is not a diagnosis of mental illness.
Rather, a positive score on a mental health screen is an indication
that further evaluation by a health or mental health provider is
necessary. Whether provided in a school, community, or medical setting,
the TeenScreen mental health checkup involves providing assistance with
referral for mental health evaluation or treatment to interested youth
and their families, who may accept or decline to receive services. In
school and community settings, where a formal referral network like
those in many medical settings may not exist, active steps to engage
parents and assist them in linking to services are encouraged.
While some have raised concerns about whether mental health
screening might increase thoughts of suicide, research published by
Gould et al. in the Journal of the American Medical Association
demonstrated that there is no increased risk posed by mental health
screening. Inquiring about mental health status, suicidal ideation and
previous suicide attempts does not increase distress or suicidal
thoughts in youth. The research also found beneficial effects for
depressed youth and previous suicide attempters post-screening.
Anecdotal evidence suggests that many young people are relieved to have
the opportunity to discuss their mental and emotional concerns in a
confidential setting.
Why Screen for Depression--Science and Research Support
The importance of early detection, through screening of mental
illness, has been well documented through medical research and by
governmental entities. In 1999, the Surgeon General released both The
Surgeon General's Call to Action to Prevent Suicide and Mental Health:
A Report of the Surgeon General. These publications highlighted mental
health screening as an effective tool for suicide prevention and
suggested that primary care providers and schools could provide
effective settings for the detection of mental illness. In 2003, the
President's New Freedom Commission on Mental Health recommended an
increase in early identification efforts by primary care providers.
More recently, the Institute of Medicine (IOM) and National Research
Council (NRC), in their report Preventing Mental, Emotional, and
Behavioral Disorders Among Young People: Progress and Possibilities,
recommended that the federal government make preventing mental,
emotional and behavioral disorders, and promoting mental health in
young people a national priority. Medical panels and professional
groups have also recommended mental health screening for adolescents,
including the United States Preventive Services Task Force (USPSTF),
the American Academy of Pediatrics (AAP), the American Academy of
Family Physicians (AAFP), and the American Medical Association (AMA).
A mental health checkup using an evidence-based, standardized tool
should be incorporated into the annual well-child visit for all
adolescent youth as part of routine preventive care. We now know that
in youth up to age 21 there is a window of opportunity of two to four
years, between the first symptoms and the onset of the full-blown
diagnosable disorder, when treatment is most effective at reducing the
severity of specific disorders.
However, we also know that primary care providers often rely on
informal, unproven mental health screening methods and that mental
health issues are sometimes not addressed at all. Further compounding
the problem, many young people do not receive regular preventive care
visits. This is especially true for American Indian and Alaska Native
youth in rural settings, where the closest pediatrician may be several
hours away. In fact, according to the AAP, the average number of well-
child visits within the American Indian and Alaska Native populations
has dropped more than 35 percent over the last decade. As a
consequence, it is important to incorporate mental health screening
into a wider array of youth serving programs, such as those offered in
school and community-based settings.
TeenScreen Schools and Communities--Our Work with Tribal Communities
The TeenScreen Schools and Communities program has been affirmed as
an evidence-based method of addressing youth suicide. The TeenScreen
Schools and Communities program is included in the Best Practices
Registry for Suicide Prevention put out by the Suicide Prevention
Resource Center (SPRC). The program is also included in the SAMHSA
National Registry of Evidence Based Programs and Practices (NREPP).
TeenScreen has assisted a number of school and community based sites in
providing mental health screening and referral to youth in Indian
Country. Together, these programs have offered mental health screening
to thousands of young people. I would like to highlight a few of these
programs.
A number of Garrett Lee Smith grantees have chosen to incorporate
TeenScreen into their suicide prevention efforts. Signed into law on
October 21, 2004, the Garrett Lee Smith Memorial Act (GLSMA) was the
first federal suicide prevention program targeted toward youth and it
created grants for states and tribal organizations to create and
implement statewide/tribal suicide prevention plans. In all, at least
13 grantees in 12 states have incorporated TeenScreen into their
suicide prevention programs, including both campus and state/tribal
grantees.
Gila River Behavioral Health Authority
One such grantee is the Gila River Behavioral Health Authority
Youth Suicide Prevention Project in Sacaton, Arizona. This program
serves the Gila River Indian community, which includes a population of
14,000 located on 372,000 acres south of Phoenix. The Gila River grant-
funded services include TeenScreen.
The Gila River Regional Behavioral Health Authority began providing
mental health screening to youth in schools within the region during
the 2007-2008 school year. In the first year of screening, they were
able to provide just 80 screenings, due to a low rate of parent
consent. They also noted that a lack of good communication channels has
made implementing large scale programs, such as TeenScreen, more
challenging.
With continued effort and by building trust in the community, the
Gila River Regional Behavioral Health Authority was able to increase
their screening rate considerably during the 2008-2009 school year,
with a total of 455 youth screened. This was an increase of more than
400 percent, and the program has trained 11 teachers, counselors and
staff at four sites to implement the TeenScreen program and promote its
sustainability.
Among students screened in the program, 87 youth (approximately 19
percent) screened positive due to risk of suicide or need for early
intervention services. All youth identified were referred for some type
of support services: 74 youth were referred for mental health services
and 13 were referred for non-mental health services, such as social
support services.
The Gila River program is continuing its screening program in the
2009-2010 school year, and the grant funding is currently authorized
through September 2011.
Turtle Mountain Schools of Belcourt, North Dakota
In 2002, Paul Dauphinais, Ph.D., a practicing school psychologist
employed by the Turtle Mountain Community School District, learned of
the TeenScreen Program and decided to work to bring mental health
screening to Turtle Mountain Schools. The schools are located in
Belcourt, North Dakota and on the Turtle Mountain Chippewa Indian
Reservation.
At the onset, Dr. Dauphinais knew that community support would be
critical to the success of the screening program. By educating
community members and giving presentations on the subject to key
stakeholders, he was able to garner support from the Tribal Chairman,
parents, school administration, and area treatment providers who would
provide clinical interviews and referral resources for youth identified
through the screening process.
By 2004, Dr. Dauphinais developed a screening plan that would
enable him to offer screening in Turtle Mountain's middle and high
schools. He developed and strengthened relationships with local
entities and staff that would participate in administering and
supporting the screening program. Eventually, his screening team was
comprised of school personnel, Indian Health Service (IHS) clinicians,
community treatment providers and one case manager, whose position was
funded by a Safe and Healthy Students Grant. (This position was first
funded during the program development phase of the project, and has
continued to be funded in each subsequent year.) Coordination with IHS
staff and clinicians provided a unique opportunity for collaboration,
which benefited the families that both the schools and IHS exist to
serve. The well-orchestrated screening program also ensured that no
single system was overwhelmed with referrals at any given time, and
that each youth and family, starting with the most critical cases,
received appropriate referral services and case management.
During the 2004-2005 school year, fewer than one hundred students
participated in the program. Despite seeing lower numbers than the
screening team anticipated, this first year allowed the team and
supporting organizations to familiarize themselves with the screening
process and work to best utilize the community's limited resources for
the youth who required follow-up interviews and referral services. Over
two hundred youth (225 total) were invited to participate in the
program during the 2005-2006 school year. One hundred twenty-five youth
received parent consent and were screened. Of those youth, 33 scored
positive on the screening instrument, requiring a clinical interview
with program staff.
Unfortunately, personnel difficulties and a lack of funding
resulted in a stalled program, i.e. they were no longer able to provide
screening, in 2008.
Riverside Indian School of Anadarko, Oklahoma
Riverside Indian School (RIS) is a federally operated off-
reservation boarding school located in Anadarko, Oklahoma. RIS is the
largest Bureau of Indian Affairs boarding school in the United States,
with an enrollment of 600 students in grades four through 12 and
students from more than 100 different tribes across the United States.
The student population is 100 percent American Indian.
Gordon Whitewolf is a school therapist and counselor at RIS. Mr.
Whitewolf provides counseling and therapeutic services for students
experiencing variety of behavioral and mental health problems. He is an
Oklahoma Licensed Behavioral Practitioner, and an Internationally
Certified Alcohol/Drug Counselor.
By 2002, Mr. Whitewolf was well into his tenure at RIS and
witnessed first-hand the alarming rates of mental illness, substance
abuse and suicide risk among his students. He felt that through his
work at RIS, he and his colleagues could proactively identify youth who
might be at the highest risk for suicide or other mental health
concerns. Mr. Whitewolf found that many students came to RIS with a
variety of mental health problems that were not previously identified.
Some youth were struggling with depression and suicidality; others were
dealing with anxiety-related disorders, associated with separation from
their family and friends, and learning to adjust to a new environment.
Mr. Whitewolf set out to identify a program or intervention that
would enable the RIS counseling and medical staff to identify students
in need of immediate intervention, as well as those students who would
benefit from additional support throughout the school year. A colleague
presented him with preliminary information about a new mental health
checkup program being offered by Columbia University. After collecting
information on the program and presenting it to the Director of Student
Services, he was granted permission to bring the TeenScreen Program to
RIS during the 2002 school year.
``Native American's have survived centuries of historical trauma
and infirmity,'' Whitewolf says. ``Today, Native American youth face
similar discord constructed by society such as violence, racism,
substance abuse, and mental health problems. These problems impact
youth in different ways, and may bring about a feeling of hopelessness
or worthlessness. That is why Riverside Indian School implemented the
Columbia University TeenScreen Program. The Program helps staff
identify those students showing evidence of suicidal ideation, previous
suicide attempts, possible mood disorder, as well as substance use.''
In the program's first year, Mr. Whitewolf and the counseling team
offered screening to the entire student body. The screening team
consisted of two school therapists who administered the screening
questionnaire and provided clinical interviews, and a nurse
practitioner who provided case management services. In addition, close
consultation and cooperation with Parent Liaison staff and Medical
Center staff ensured that every element of the student's care and well-
being was considered.
The results of the screening in the first year were telling: staff
found that 17 percent of youth screened reported suicidal ideation or a
previous suicide attempt; 20 percent reported problems with substance
abuse; and 19 percent reported symptoms of depression. Mr. Whitewolf
and RIS counseling staff assisted youth at highest risk immediately,
and provided follow-up assessments (and treatment when necessary) for
all students who screened positive. With such a large segment of the
student population suffering from mental health and substance abuse
problems, screening allowed the counseling team to provide triage
evaluations to all students, and identify youth at highest risk,
ensuring that cohort of students receives the critical care they need.
Since his initial success in 2002, Mr. Whitewolf and colleagues
routinely offer mental health screening to all new students at the
beginning of each school year. ``The TeenScreen Program provides an
opportunity for therapeutic intervention for students in need of
services, and the ability to assist each student both at school and
when they return to their respective tribal community upon completion
of the school year,'' Mr. Whitewolf has explained. In addition, he has
stated that screening has allowed counseling staff to communicate more
effectively with the medical unit on campus, creating a unique system
that fosters better over-all care for RIS students.
Lessons Learned
These case studies highlight both the successes and the challenges
of reaching at-risk youth in Indian Country through mental health
screening. Thousands of young people have received a screening, and
hundreds have been connected to needed support services. More
importantly, for many youth, the screenings serve as an opportunity to
start a conversation about mental and emotional health.
However, much as in medical settings, we cannot reach all young
people through these screening programs. Funding shortfalls often lead
to the end of a screening program; when a grant runs out, the program
stops. We also know that some of the most at-risk young people cannot
be reached in a school setting. Mental illness is the leading cause of
disability-related school dropout, and youth suffering from mental
illness are much more likely to leave school before graduation. In
fact, a 2010 report from the University of California, Los Angeles
(UCLA) Graduate School of Education and Information Studies found that
fewer than 50 percent of American Indian and Alaska Native youth in the
Pacific and Northwest of the United States graduate from high school.
Recommendation--Integrate Screening into Multiple Youth Serving
Settings
In order to provide comprehensive services and reach as many at-
risk youth as possible, it is imperative that we provide opportunities
for prevention and early intervention in all youth-serving settings
where appropriate supports can be arranged. This may include, but is
not necessarily limited to, medical, school and community settings.
In American Indian and Native American communities, cultural
programs can play an important role in promoting and providing access
to mental health screening. TeenScreen site coordinators in Indian
Country have repeatedly stressed the importance of engaging tribal
leaders to communicate about the importance of mental health screening
and to build trust within the community. Many suicide prevention
programs incorporate initiatives to celebrate and preserve Native
culture into their efforts, and these settings should play a role in
helping to identify at-risk youth through screening.
The health care reform bill signed into law by President Obama on
Tuesday will go some way to helping to expand mental health screening
in the medical setting. The language includes provisions to provide
United States Preventive Services Task Force recommended services
without cost-sharing in benefit plans, which includes annual depression
screening for adolescent youth ages 12 to 18. However, we know that
mandating coverage of a service does not always translate into the
service being provided in clinical practice. Therefore, we must
continue to work to raise the visibility of the need for mental health
screening as we expand access in multiple youth-serving settings.
Recommendation--Expand Telemedicine With Focus on Mental Health of
Youth
Identifying youth in need of mental health services through
screening is of little utility if we are unable to connect them to
necessary services. As we referenced earlier, the IHS suffers from a
provider shortage for all types of providers, and child and adolescent
psychiatrists are in short supply, not just in the IHS, but the system
more generally. Furthermore, the rural and often isolated locations in
which many American Indian and Alaska Native youth reside contribute to
the difficulty of connecting them to appropriate mental health
providers.
An important solution to addressing these challenges has been the
expansion of the use of telemedicine services, including
telepsychiatry. For example, the University of New Mexico's Center on
Rural Mental Health has been providing telepsychiatry services, also
referred to as tele-behavioral health services, to the Mescalero tribe
and others in New Mexico. Through a contract with the IHS and the State
of New Mexico, the Center is able to offer patient diagnosis,
treatment, and supervision services. The Center is also able to help
address the workforce shortage by providing additional training and
supervision to mental health providers, such as social workers.
The success of such programs has spurred an increased investment in
tele-behavioral health services. The Methamphetamine and Suicide
Prevention Initiative (MSPI) included funding to establish a National
Tele-Behavioral Health Center of Excellence, and at least 50 IHS and
federal sites are using or in the process of creating tele-behavioral
health services. The American Recovery and Reinvestment Act of 2009
(ARRA) also provided funding to expand the infrastructure necessary to
support telemedicine.
The health care reform legislation signed into law earlier this
week also includes provisions that will help expand access to services
for American Indian and Alaska Native youth. New grant moneys for
telepsychiatry projects are included in the legislation, as well as
provisions targeted toward addressing IHS workforce recruitment;
improving rural health services; reducing health disparities; and
expanding access to preventive services.
These are all steps in the right direction, but we remain far from
being able to serve all youth who are in need of mental health services
adequately. We must continue to address the shortage of services
through common-sense, proven approaches such as telemedicine.
TeenScreen National Center as a Resource
Thank you for the opportunity to testify. The TeenScreen National
Center stands ready to serve as a resource, and I look forward to
working with the members of this Committee as you develop policies to
improve the lives of American Indian and Alaska Native youth.
Ms. Binney. Thank you, Ms. Flynn.
Next, we will hear from Hunter Genia, who is the Behavioral
Health Administrator at the Saginaw Chippewa Tribe in Michigan.
STATEMENT OF HUNTER GENIA, ADMINISTRATOR, BEHAVIOR HEALTH
SERVICES, SAGINAW CHIPPEWA TRIBE
Mr. Genia. Good morning. [Greeting in native language.]
My name is Hunter Genia. I am the Behavioral Health
Administrator for the Saginaw Chippewa Indian Tribe. I would
like to thank the other panelists that have spoken. Probably
unlike many of them, except for the young man that spoke, I
don't work on a Federal level. I actually work in our tribal
community on the ground level and kind of see what is going on
for our nation.
I also work with a collaboration of tribes in Michigan that
are recipients of a SAMHSA grant called Access to Recovery. I
believe that was originally started under the Bush
Administration and has continued hopefully under the Obama
Administration. I want to talk about that briefly as well.
I also recognize that where I come from, the Odawa and
Ojibway Nation in Michigan that I descend from Pontiac, who
back in the 1700s was a leader among the Great Lakes tribes
that tried to thwart the expansion of Western Civilization
because his fear was that we would adopt too many of the non-
native ways and we would lose ourselves and become lost.
And I think what we are seeing here in Indian Country is a
deep psychological wound that has not healed for many, many
generations and hundreds of years. We have seen this through
the Indian boarding schools that often goes untalked about here
in America in our history books. And we have not recovered as
an Indian people in this Country as a result.
A lot of people believe that the Indian boarding schools
was only from the 1870s to the 1930s. But in Michigan, we had
one Indian boarding school that remained open until the early
1980s. And my own brother and my own sister attended these
schools. And if you want to talk about trauma, it has only been
disclosed in recent years that sexual abuse, physical abuse,
emotional abuse has occurred in these Indian boarding schools,
often led by a lot of the church institutions and missionaries.
But as the Administrator, I have been asked to try to
address some of the lack of resources that we have in our
community regarding mental health services. So for the last
four years, I have been the Saginaw Chippewa Behavioral Health
Administrator, and prior to that for six years, our Clinical
Mental Health Director. Prior to that, for 10 years I worked in
the American Indian urban population where there is virtually
zero dollars for Indian healthcare for the majority of the
American Indian population that live in non-reservation
communities.
The Saginaw Chippewa Behavioral Health Program and the
Saginaw Chippewa Indian Tribe is providing nearly 70 percent of
our funding just to operate our own programs. So the amount of
dollars coming from Indian Health Service or other grant
funders is much less than that. So I just want to point that
out.
So right now, our tribe is putting over $1.5 million into
just our behavioral health services. We offer an outpatient
mental health, substance abuse, residential program, but we are
very unique as a tribe. And I also want to point out that the
majority of gaming tribes are not profitable. The majority of
gaming tribes are in the red and can't do what we are doing and
providing. So in Michigan, our tribe is very unique.
One of the things I want to point out about the Access to
Recovery grant is that it also recognizes our cultural and
spiritual beliefs and our teachings and our ceremonies, and
that they are actually utilized in our efforts in recovery. So
whether we are working with adolescent children or adults or
elders, the majority of our people are asking that traditional
and cultural practices be a part of their treatment process.
And that is one of the beautiful things about the Access to
Recovery grant, which is under SAMHSA, is that it actually
acknowledges and respects who we are as an indigenous people
here in this Country.
And I just want to point out and remind people that it
wasn't until 1978 that the American Indian Freedom of Religion
Act was even passed in this Country, which took a special act
by Congress. So until then, many of our people have had to live
in generations of hiding and privatize, really, who we are as
an indigenous people. And I just want to point that out because
I think a lot of these programs are great, but it is not really
talking about where a lot of these wounds are originating from.
And so oftentimes what we have are band-aid approaches to
addressing American Indian health needs, especially the mental
health needs.
During the 2008 and 2009 fiscal years, at any given time we
have had an average number of up to 60 tribal members,
community members waiting to access our behavioral health
services. During this time, they could wait up to an average of
three months before they could even see a counselor of a
clinician. And I just point that out because if we had more
funding, we could add more staff to our programs and our
resources and be able to address some of those needs.
The Saginaw Chippewa Indian Tribe also made a decision to
build our own residential treatment facility. Before we even
laid the first brick down to build this facility, we had phone
calls from all of the other Michigan tribes asking if our
residential facility will be open to their tribes. And
unfortunately, they are not. And some of that has to do with
some of the Indian Health Service policies regarding funding
and some of the access to care.
But one of the reasons why we built the residential
treatment center on our own reservation is because other than
our tribal residential program, our community members had to
travel at least six to eight hours or out of State to even
access culturally sensitive treatment facilities and programs.
Otherwise, it would go to non-native programs that oftentimes
were not sensitized to our values, our traditions and our
culture. And therefore, a lot of the non-native approaches to
treating our people were often utilized and a lot of our people
were discriminated against or biased in those treatment
settings that they were non-native.
So I think since we opened up our own residential program,
over 250 of our own tribal members have gone through our
residential program. And if that residential program was not
there, probably the majority of them would have never even gone
into treatment at all.
So one of the things I want to point out is, our tribe is
footing the bill for most of our Indian health care, not the
United States or the Federal Government or Indian Health
Service, for that matter. We are very fortunate that all the
tribes of Michigan are part of the Access to Recovery grant
under SAMHSA, but it still is not adequate funding to provide
the level of services and care that we need in our tribal
communities.
I am 40 years old. I got my master's in social work from
Grand Valley State University. I don't drink. I don't do drugs.
I don't smoke. But I am very much in a non-conceited way unique
in that regard.
I was talking to a young man here earlier before the
meeting started that is from Pine Ridge. I think the difference
is that somebody along the way said that I could be somebody
and had an opportunity. And I think we can call it mental
health illnesses and things of that nature, but the fact is
that the majority of American Indian youth in this Country
don't see the opportunity. They are not given a chance to see
what dreams that they can aspire to.
If you look across the Nation here, how many of our people
do you see that are in politics? How many do you see that are
in sports? How many do you see that are in entertainment?
Virtually none. Until we are able to place our own people in
places of leadership that our young people can turn on the
radio or look on TV and see, all they see is what is there on
our reservation communities. And they don't understand coming
to Washington, D.C. is a possibility for them, you know, to be
a Governor, to be a Senator, to be a Congressman. It is very
far and few in between.
And I think what we are trying to do and address in our
community, I will give you two examples. Last October, we had
GONA, Gathering of Native Americans. It is a four-day training
actually facilitated by our own people, which initially started
under SAMHSA. And it brought all of our community together in a
good way, in a good place to talk about things that we needed
to do to heal as a community.
Because that is one thing that we all have as universal
truths in Indian Country is that there is a lot of walking
wounded people in our community that have not healed from post-
traumatic historical trauma. And until we address some of those
things and give it a name and acknowledge those, I am not sure
that all the programs in the world are going to help. We need
to focus on healing and wellness in our tribal communities and
look at those kinds of things that are generated from multi-
generational traumas.
The other thing that happened in our community is that with
the assistance of White Bison, is that we have the Journey for
Forgiveness hosted in our community. And that, for the first
time in the Mt. Pleasant community, addressed the impact that
Indian boarding schools had on our people. And as you know,
Indian boarding schools was very good at taking away our
language, our culture and our traditions, and basically their
goal was to Americanize us.
So I think a lot of what is happening in Indian Country is
that we have big who am I cultural identity issues that are
going on among a lot of our young people. Where do we belong?
How do we fit in? Are we invited to the table? Are we
important? I think a lot of our young people don't feel that.
And so a lot of the things that we are trying to do in our
community is to let them know that they are important and to
help programs set up like that.
But I will say that the majority, 60 percent to 70 percent
of our behavior health funding is because our tribe made it a
priority, the Saginaw Chippewa Indian Tribe. If we were to rely
on Indian Health Service's funding or the Federal Government, I
mean, we would not have a majority of our programs available to
our own community.
And so we need more funding. We need more resources. We
need more American Indian Native American leaders to step up
and be a part of our tribal communities and lead these efforts
and be seen and be visible in this Country in our communities.
So that is basically my main message that I wanted to bring
here. And I thank you for the opportunity, and I hope that in
the future years that more funding and resources will be
available to our tribal communities. But I also know that we as
native people have to take the leadership role in making that
happen.
[Phrase in native language.]
[The prepared statement of Mr. Genia follows:]
Prepared Statement of Hunter Genia, Administrator, Behavior Health
Services, Saginaw Chippewa Tribe
Ahnii, Giwesinini Ndihzinkaaz, Wabezhenshi dodem, Mt. Pleasant, MI
ndojibaa. My name is Hunter Genia and I am the administrator for the
Saginaw Chippewa Indian Tribe Behavioral Health Services in Mt.
Pleasant, MI., approximately one hour north of Lansing, our state
capitol. The Saginaw Chippewa Indian Tribe behavioral health services
provides mental health services to all eligible Native Americans of any
federally recognized tribe residing in a five county district in the
central lower peninsula of Michigan. The Saginaw Chippewa Tribe has
over 3,400 tribal members with roughly 50 percent of our population
being under the age of eighteen.
I have been the administrator here for 4 years and prior to that,
the mental health director of our program for six years. Upon my
employment here we were an outpatient mental health, substance abuse,
and prevention program providing clinical mental health services to
over four hundred fifty open clients, with no residential services. In
2005, we opened up our own residential treatment center, funded solely
by the Saginaw Chippewa Indian tribe.
During my tenure as the Administrator and Clinical Director, the
Saginaw Chippewa Indian Tribe has carried the burden financially for
providing the Behavioral Health care for our tribe. The Saginaw
Chippewa Indian Tribe is providing 66 percent of our operational budget
in this current fiscal year which equates to roughly 1.9 million
dollars. The Saginaw Chippewa Indian Tribe Behavioral Health Program
during the last four years has provided over 8 million dollars to
support Behavioral Health Services; this figure does not include any
Indian Health Service funding.
During the 2008 and 2009 fiscal years at any given time we had an
average number of sixty tribal members waiting to receive services. The
average waiting time to receive services once on the waiting list could
be up to three months before they could receive any type of counseling
services. The Saginaw Chippewa Indian Tribe made a decision to build a
residential treatment center here on our reservation. The primary
reason for this was so that our tribal community members could access
this care without having to travel several hours, or out of state to
receive Native American residential services. Distance to residential
treatment provided a barrier for a lot of our tribal members to access
services when needed. The closest Native American residential program
was located over eight hours away, which made it virtually impossible
for family members to participate in the treatment process. Since we
have opened up our residential services we have provided care to over
250 Saginaw Chippewa Tribal Members. The residential treatment center
operational costs are solely funded by the tribe. The majority of
Native Americans receiving residential cares with us have had a
combination of mental health and substance abuse disorders, known as
co-occurring. Many of our tribal members have preferred to remain on
our waiting list with our tribal services instead of seeking behavioral
health services with other agencies and programs.
During my employment with the Saginaw Chippewa Indian Tribe,
barriers to providing appropriate behavioral health care in our tribal
community have been; inadequate staffing levels, lack of available
psychiatrist for adults and children, adult and child psychologist to
see clients in need of specialized treatment and assessments, cultural
competency, Native American staff, and funding. Other issues include
inadequate prevention, education, and screening for early
identification of youth or adults at risk for suicide. In order for
these barriers to be addressed effectively adequate funding is needed.
Many of our tribal community children are faced with enormous
challenges that can be barriers to success in their lives. Higher
prevalence of physical, emotional, sexual abuse and neglect are
experienced by children and adolescents in our tribal communities. Our
community's children are more likely to experience a higher prevalence
of substance abuse, domestic violence, mental illness, neglect and or
have witnessed such before they reach the age of eighteen than any
other racial ethnic group. Due to these higher rates of behavioral
health issues roughly 40 percent of our clients we see are children and
adolescence.
The substance abuse and mental health issues we face and see in our
community can be traced back to multigenerational trauma experienced by
their parents, elders, and grandparents before them. A lot of the
trauma can be traced directly to federal policies and practices like
the Indian Boarding Schools. I am not surprised by this comparison
which has gone severely unaddressed in tribal communities due to a lack
of resources, funding, and staffing. Our tribal community has begun to
address the mental health devastation that past federal government
practices and policies have contributed to our people. Mental health
issues we are addressing such as historical trauma, relocation, grief
and loss, foster placement, physical, sexual, emotional, spiritual
abuse, reactive attachment disorder, and trauma in tribal communities
is enormous. This is what we see everyday coming into our clinic. This
also means that specialized treatment and care is called for along with
the acknowledgment and respect for cultural, traditional, and spiritual
practices that were outlawed thirty years ago prior to 1978's American
Indian Freedom of Religion Act. Also prior to this, the 1975 Indian
Child Welfare Act was passed which protected our tribal children from
being erroneously removed from their homes and community. These acts
took special legislation and acts of Congress to protect our tribal
community and our most precious resource, our youth.
As an American Indian raised in an large urban American Indian
population in Grand Rapids, MI and also on my reservation in Mt.
Pleasant, Michigan, I can tell you that in both respects, it comes down
to financial and people resources. Unmet needs are still very rampant
today for the American Indian population who need access to substance
abuse and mental health care that are appropriate for their level of
needs. Often times in my experiences, the city, county, and state
levels do not want to work cooperatively with the tribal governments
and communities to ensure that we are able to access this care
equitably.
I thank you for allowing me to be here this morning.
Attachment
Ms. Binney. Thank you, Mr. Genia.
Next, we will hear from Novalene Goklish, who is the Senior
Research Coordinator for Celebrating Life Youth Suicide
Prevention Program, White Mountain Apache Tribe/Johns Hopkins
Center for American Indian Health, Celebrating Life/Johns
Hopkins Project.
Thank you.
STATEMENT OF NOVALENE GOKLISH, SENIOR PROGRAM
COORDINATOR, WHITE MOUNTAIN APACHE YOUTH SUICIDE PREVENTION
PROGRAM
Ms. Goklish. Thank you. Good morning. My name is Novalene
Goklish. I direct the suicide prevention efforts of my tribe,
the White Mountain Apache.
Youth suicide, as you have heard, is the single biggest
human loss a family or community can experience. It is
destroying American Indian and Alaska Native communities. When
you think of other behavioral health problems that affect
youth, drug abuse, obesity, diabetes, some believe our Indian
communities tend to see what is to come for other U.S.
populations unless interventions are developed to stop these
tragedies.
In the United States, suicide is the third leading cause of
death for youth ages 15 to 24. Within the White Mountain Apache
Tribe, our rates of death for this age group are 13 times the
U.S. average and six times the all-Indian rate. In the United
States, up to 500,000 persons a year require emergency
department care as a result of a suicide attempt.
On our reservation alone, with a population of 15,500
members, our Indian Health Service hospital treats more than
200 youth a year for suicide attempts. The White Mountain
Apache Tribe is devastated, but not broken by our problems of
suicide. We see it as an obstacle we must overcome in order to
share lessons learned with the world.
We choose research as our tool, with the help of our long-
time partners, Johns Hopkins Center for American Indian Health.
We have tackled past health disparities by producing public
health interventions that now save more than 3 million lives a
year worldwide. Today, we are turning our research focus on a
range of interventions to prevent youth suicide. We are
designing this research so that it can be reproduced across
Indian Country and in rural and indigenous communities across
our Nation and our world.
I want to share with you the important elements of our
work. The White Mountain Apache Tribe, with technical support
from Johns Hopkins, has developed the first tribally mandated
suicide surveillance and follow-up system in the United States.
In 2001, our tribe mandated that all health and human service
providers and tribal members report suicidal behaviors to the
Centralized Suicide Prevention Task Force.
These behaviors include suicidal ideations, attempts,
deaths, binge drinking, drug use and cutting, which are also
forms of self-injury in our community. Johns Hopkins assists in
managing date, tracking quarterly patterns in suicidal
behaviors and reports the information back to all tribal
departments.
Along with Johns Hopkins, we have trained and employed a
team of case managers who follow-up on every incident reported
through the suicide surveillance system. The case managers
assist youths at risk for suicidal death and triage youth and
their families to available care. Prior to this, very few
youths who attempted suicide, less than 25 percent, ever
received treatment due to numerous treatment barriers. This the
first community-based follow-up and triage system of its kind
in this Country.
We are grateful for grants from SAMHSA, Garrett Lee Smith
Youth Suicide Prevention Program and the Native American
Research Centers for Health, managed by NIH and IHS. With this
support, we are now developing evidence-based prevention
interventions, including the following.
First, we have adapted an emergency department intervention
of youth who have attempted suicide and their family members.
Apache case managers meet with the youth and their families to
help them develop a safety plan to keep the youth alive. We are
now developing a research trial to prove the effectiveness of
this intervention.
Second, we have adapted a life skills curriculum to be used
in home outreach by Apache case managers with at-risk youth and
their families. The curriculum teaches conflict resolution,
coping and problem solving skills. We are planning a randomized
control trial of this intervention in the near future to prove
its effectiveness.
Third, we have trained and certified two Apache case
managers to conduct gatekeeper trainings in our community, and
that is myself along with my colleague Francene Larzalere-
Hinton, who is sitting behind me.
Fourth, we have developed an Elders Advisory Council. Our
elders are focusing on promoting traditional protective
factors. They are speaking in elementary and middle schools and
taking groups of at-risk and healthy kids on field trips to
sacred sites on our reservation. They are teaching the youth
the core strengths of our Apache heritage and are creating
media campaigns to promote protective factors on our
reservation.
Native communities have tremendous resiliency. We have
survived untold adversity by blending our traditional wisdom
with new technologies. Culturally appropriate research is a
great example. We must harness the power of traditional
understanding and rigorous scientific research to stop youth
suicide.
Tribal and university partnerships that are built on trust
and long-term commitment, such as the White Mountain Apache
Tribe and Johns Hopkins, are the most powerful means for
achieving renewed health.
Federal funds are well spent in the arena of suicide
prevention to reduce the high toll of medical costs and human
suffering to ensure our most precious asset, which is our
youth, so that they can live to their full potential. In our
belief system, every human life serves a purpose to maintain
the health and well being of Mother Earth.
We must find the means to re-learn as a human race that
life is sacred, that life is precious, that life is meant to be
lived out serving our greater common purpose.
Thank you.
[The prepared statement of Ms. Goklish follows:]
Prepared Statement of Novalene Goklish, Senior Program Coordinator,
White Mountain Apache Youth Suicide Prevention Program *
---------------------------------------------------------------------------
* DISCLAIMER: None of the opinions expressed within are those of
Johns Hopkins University.
---------------------------------------------------------------------------
Mr. Chairman and Members of the Committee, good morning. I am
Novalene Goklish. I direct the suicide prevention efforts of my Tribe,
the White Mountain Apache.
Youth suicide is the single biggest human loss a family or
community can experience, and it is destroying American Indian and
Alaska Native communities. When you think of other behavioral health
problems that affect youth--drug abuse, obesity, diabetes--some believe
our Indian communities tend to see what is to come for other U.S.
populations, unless interventions are developed to stop these
tragedies.
In the United States, suicide is the third leading cause of death
for youth ages 15-24. Within the White Mountain Apache Tribe, our rates
of death for this age group are 13 times the U.S. average, and 6 times
the All Indian rate. In the U.S., up to 500,000 persons a year require
Emergency Department care as a result of suicide attempt. In our
reservation alone, with a population of 15,500 tribal members, our
local Indian Health Service hospital treats more than 200 youth a year
for suicide attempts.
The White Mountain Apaches are devastated but not broken by our
problems of suicide. Rather, we see it as an obstacle we must overcome
in order to share lessons with the world. We choose research as our
tool. With the help of our long-time partners, Johns Hopkins Center for
American Indian Health, we have tackled past health disparities by
producing public health interventions that now save 3 to 5 million
lives a year worldwide. Today, we are turning our research focus to a
range of interventions to prevent youth suicide. We are designing this
research so that it can be reproduced across Indian country and in
rural and indigenous communities across our nation and our world.
I want to share with you the important elements of our work:
The White Mountain Apache Tribe, with technical support from Johns
Hopkins, has developed the first tribally mandated suicide surveillance
and follow-up system in the United States. In 2001, our Tribe mandated
that all health and human service providers and tribal members report
suicidal behavior to a centralized suicide prevention task force. These
behaviors include: suicidal ideation, attempts, deaths, as well as
binge drinking, drug use and cutting, which are also forms of self-
injury in our community. Johns Hopkins assists in managing data and
tracking quarterly patterns in suicidal behaviors and reports the
information back to all tribal departments.
In addition, with Johns Hopkins' help, we have trained and employed
a team of Apache case managers who follow-up on every incident reported
through the suicide surveillance system. The case managers assess
youth's risk for suicidal death and triage youth and their families to
available care. Prior to this, very few youth who attempted suicide
(<25%) ever received treatment due to numerous treatment barriers. This
effort is the first community-based follow-up and triage system of its
kind in the country.
Our tribe has been fortunate to receive federal funding for our
suicide prevention research. We are grateful for grants from SAMHSA's
Garrett Lee Smith youth suicide prevention program and the Native
American Research Centers for Health, managed by NIH and IHS. With this
support, we are now developing evidence-based prevention interventions.
What has been accomplished to date is state-of-the-art, and includes
the following:
First, we have adapted an Emergency Department intervention
for youth who attempt suicide and their immediate family
members. Apache case managers meet directly with the youth and
their families to help them develop a safety plan to keep youth
alive; we also help them connect to available services and
follow-up to ensure they go. More than anything, we teach them
that their suicide attempt was very serious and taking one's
life is not the Apache way. We are now doing a research trial
with 30 White Mountain Apache youth who've attempted suicide to
prove the effectiveness of this intervention.
Second, we have adapted a life skills curriculum to be used
in home outreach by Apache case managers with at-risk children
and their families. This curriculum, originally called the
American Indian Life Skills Curriculum, was previously designed
for schools. We have found that many of our youth who are at
risk do not regularly attend school. Nor are their families
involved with their schools. The curriculum, which we have
named, ``Re-Embracing Life,'' teaches conflict resolution,
coping and problem-solving skills. It serves as extra support
as the Apache case managers work to get youth and families to
available mental health treatment on the reservation. We are
planning a randomized controlled trial of this intervention in
the near future, so we can prove its effectiveness.
Third, we have trained and certified two Apache case
managers to conduct ASIST gatekeeper training in our community.
We as Apaches have renamed this intervention ASIST
``caretaker'' training. The training educates adults who work
with at-risk youth to recognize signs of suicide and connect
youth to care. The Apaches are planning to culturally adapt the
ASIST training to be more relevant to Native peoples.
Fourth, we have developed an Elders advisory council. Our
elders are focusing on promoting traditional protective
factors. They are speaking in elementary and middle schools,
and taking groups of at-risk and healthy kids on field trips to
sacred sites. They are teaching youth about the core strengths
of their Apache heritage. Elders and youth are also creating
media campaigns to promote protective factors on our
reservation.
Some unique highlights of our work include:
The Apache community-based suicide surveillance system is
the first of its kind in the country. We hope it becomes a
resource to other tribal nations across North America, and will
strengthen culturally specific responses to suicide prevention
and treatment.
The training and employment of Apache case managers to
increase the safety net and community connections for suicidal
youth is completely unique. It has great potential for solving
current barriers to mental health care on reservations and in
other indigenous communities worldwide.
Johns Hopkins and the Apaches have had a 30-year
relationship developing evidence-based public health
interventions that have been disseminated across the globe. The
suicide prevention work is being designed accordingly, to have
relevance in populations worldwide.
The interventions we are designing are low cost and tap and
strengthen our local human resources. Much of the prevention
and post-intervention is focused on connecting youth to caring
adult family members and to community treatment resources. The
latest data from the CDC demonstrates that bridging connections
to families is the most powerful prevention strategy.
Native American communities have tremendous resiliency. We have
survived untold adversity by blending our traditional wisdom with new
technologies. Culturally appropriate research is a great example. We
must harness the power of traditional understanding and rigorous
scientific research to stop youth suicide. Tribal-university
partnerships that are built on trust and long-term commitment--such as
the White Mountain Apache Tribe and Johns Hopkins--are the most
powerful means for achieving renewed health. Federal funds are well
spent in the arena of suicide prevention to reduce the high toll of
medical costs and human suffering and to ensure our most precious
asset--our youth--live to full maturity and potential. In our belief
system, every human life serves a purpose to maintain the health and
well-being of Mother Earth. We must find the means to re-learn as a
human race that life is sacred; that life is precious; that life is
meant to be lived out serving our greater common purpose.
Ms. Binney. Thank you.
So we are in a listening session right now, and as I said
earlier, it is continuing to be webcast, so a lot of people in
Indian Country watch our hearings via webcast, so we wanted to
continue to do that. And there is a transcript that is still
being taken that will be given to each of the Members of this
Committee afterwards.
We thought that it would be helpful to go ahead and engage
in a dialogue about this issue since you are all here, and
maybe ask some questions. I know some of you have to leave,
though, I think particularly Mr. Grinnell, you might have
another function to go to. So feel free to leave when you need
to, but we thought it would be nice to ask some questions and
engage in a dialogue.
As part of the Indian Health Care Improvement Act that just
was signed into law, there was a smaller bill that was
basically aimed at youth suicide prevention in Indian Country
that Chairman Dorgan sponsored and several Members of this
Committee on both sides of the aisle sponsored as well.
And our hope is that that will make some progress in the
prevention of youth suicides in Indian Country, but we know it
won't solve the problem. And that is why we are holding the
hearing today is to basically learn what are some other ideas
that are working out there already that we can try to inject
into the system nationally.
And with that, I would like to go ahead and ask some
questions, Rhonda and I, and start with Coloradas Mangas.
Mr. Mangas, you mentioned in your testimony that there is a
stigma with suicide among some Indian youth your age. And I
grew up in a Native American community and am part Native
American, and I agree with that, but I don't fully know where
it comes from.
And since you are in the midst of it now, I was wondering
if you had some thoughts about why there is a stigma with it?
Mr. Mangas. This is kind of hard for me.
Ms. Binney. We can start with someone else, too.
Mr. Mangas. Most youth won't go to our mental health clinic
because there is stigma of shame that keeps people away. It is
because they are afraid of getting talked about.
Myself, I know that by going to the mental health clinic,
that I would be talked about by other Native American youth and
by many other Native American people that I live with on the
reservation. But I took that chance of going to the mental
health clinic to get myself help.
I believe that most people really won't go because the
problems that they have are big and then by adding on more
problems of other people talking about them, it makes it even
harder for them. So it is like most people want to seek help,
but they won't do it because of the shame that is there of
getting talked about or by having other people put you down
because you did go these mental health clinics, or because you
did show your face at one of these faces that most people won't
even dare be seen walking out of a building like that.
And most of our youth that did do this, I believe that if
they did go and get help, that yes, they would have got talked
about, but the help that they would have received would have
really helped them in a way that they wouldn't have made these
attempts on their life or completed these attempts.
And it is hard for a lot of youth to get talked about. I
mean, it is like just every little thing you do, you get
criticized for what you did or you get placed a name on you
that you don't really appreciate or something. And like for me,
many of these children that I go to school with, they all like
to talk about each other, and I knew that from the minute being
seen walking out of this building, I was going to get talked
about. But I was willing to take that risk just to get myself
help.
And it was hard for me to get talked about because many of
these people are like, oh, we have seen you walking out of this
building, and I am, like, well, it is because I needed help. I
really think that I needed help at the time. That is why I
seeked it.
I wasn't afraid of getting talked about by these people or
by other children, and I just put all that aside from the
minute I walked into the building, thinking, well, this is
going to help me and this is going to help my future because
it's not something that I should be doing is making an attempt
with my life. That is why I seeked help.
And the shame that is there for many of these children,
they can't overcome it because it is too big on some people. I
mean, if our people weren't afraid of going or being seen
walking out of this building, I am pretty sure that many of the
kids that did complete suicide would still be here with us
today.
And I think it is just a shame that comes from being seen
walking out of this building is what is kind of helping these
kids stay away from this building because of not wanting to be
seen or not wanting to be talked about.
And that is what I think is kind of leading to some of
these suicides is that these children are seeking help, but
they do not want to be criticized for seeking that help or
being seen walking out of this building and get talked about.
Ms. Binney. Yes. Thank you.
So in light of those comments, Ms. Flynn, do you run into
any problems using the TeenScreen questionnaire? Because if
there is a stigma in Indian Country amongst the youth to kind
of have a little bit, have shame if you go into a building and
seek help. It seems to me that there might be a similar stigma
or thoughts of shame if you are filling out a form and a
questionnaire specifically about suicide and whether you are
high risk. So have you run into that?
Ms. Flynn. One of the keys, I think, is to try to bring
mental health checkups into as many settings as is possible. So
we have found that making mental health checkups available in
schools, maybe as part of a health class or a science class, as
part of a larger discussion about health and what we are
learning about our emotions and the mind/body interaction. It
can be built into that sort of a discussion in schools.
We also find that by inserting it into the routine sports
physical as part of the basic checkup with your primary care
physician in the clinic, just continuing to have it as a
component of total health. It enables us to bring it forward
and talk about it in the way that we, there are a lot of things
we didn't use to talk about, a lot of disorders and diseases
where the stigma has slowly eroded because we bring them
forward. We explain and we talk about them openly.
It is also, I think, very important to pick up on what we
have heard about these significant cultural components, and
even the spiritual and historical components that are
particular to Alaska Native and American Indian communities.
And here again, where we see mental health checkups endorsed
and supported by youth development organizations, by tribal
elders, by leaders in the health community, it becomes
something that is seen as part of healing the nation and
supporting the youth.
We have also, frankly, heard in individual interactions
from youngsters that although it may be difficult and awkward
at the beginning for these kinds of issues and conversations to
begin, but once they start, just as we heard from Coloradas,
youngsters are relieved to have a safe and confidential place
to go to deal with the concerns they have, to ask for the help
that they need. Sometimes all they need is an opportunity for
that open conversation to begin.
Ms. Binney. Thank you.
You mentioned the need to, as Mr. Genia was talking about,
incorporate cultural and traditional aspects of Native American
life. Does the questionnaire do that?
Ms. Flynn. The questionnaires themselves, and we didn't
invent these questionnaires. They are science-based screening
tools and there are a variety of them. They are standard. What
makes them appropriate is how they are explained; how they are
administered; the education and support that surrounds the
setting and the individual who is part of that. But they
themselves are, just as with any physical health check-up, they
are just basic questions that enable us to determine whether
someone is at great risk for suicide; is beginning to show
symptoms of depression or not.
The really important thing is to make them comfortable and
culturally sensitive to the community in which they are being
implemented.
Ms. Binney. Dr. Clayton, were you going to add something?
Dr. Clayton. I just wanted to add that, that the good thing
about our film that I am recommending that you make with Native
American youths in it. This was a film that the State of New
York paid us to make. They asked us to make a suicide
prevention film and we gathered a group of experts, and they
were child psychiatrists and psychologists. And they said, we
don't want to talk about suicide. You have to teach kids to
talk about depression, and they didn't want kids to talk about
themselves. They wanted them to show what it looks like to be
depressed.
So we wrote 17 scripts. It took us two years. And then we
hired a company and these are acted. So there are two girls and
two boys, and one of them is a very good student. One of them
is kind of, she is slowed by her depression. One of the kids, a
boy, drinks too much and is irritable and pushing away his
friends. And the fourth one is bullied on the computer. And so
they all have different depressions and they get into treatment
differently. It is 26 minutes, and we did test it, focus group
test it on kids. And then we show it now in high schools, and I
said it may be in 2,000 high schools around the Country.
And it does help the stigma. That is the whole idea of the
film. It helps the stigma so that in school, there is a teacher
guide, and the teacher is taught how to show the film in
school. And it starts the conversation, we got feedback. I got
feedback this week from a teacher who showed it in her school
and she said afterwards two kids came up to her and talked
about their own problems and she could then refer them. We talk
about what to do next, which in this film is to refer to the
guidance counselor, but each school has its own sense of where
to go next.
But it really is a de-stigmatization film. We actually are
going in May to win the American Psychiatric Association award
for the best de-stigmatization film for this year.
So I really think there are scripts that have to be written
so you have to know the culture and know what these kids
present as. But once that is done, it is an amazing way to de-
stigmatize depression in the school and drinking. We actually,
because there was so much drinking, there is a party and there
is all this other stuff, and beer bottles. And we had to get
permission from the State school psychologist. They also looked
at it, the head of the New York State School, to make sure that
it wasn't excessive, the drinking and that. But they said, oh,
no, that is the way it is. It is okay to do that.
So I mean I think a film is a really powerful way to begin
to go. Then because we made this one film for kids, the State
of New Jersey had passed a law that all teachers needed a two-
hour training program in suicide prevention before they can be
recertified. So we then went on and made a second film for
teachers, and it shows clips of the kids, but it also has
teachers talking about what they have seen in kids in school.
So again, you could do it with Native American teachers in
Native American schools. So I really think it is a powerful
tool that you should investigate.
Ms. Harjo. Thank you.
I have a couple of questions that I wanted to direct to Mr.
Grinnell before you have to leave. And then, of course, there
are a few that could apply to the entire panel. So if anybody
wants to respond after Mr. Grinnell, please feel free to do so.
First of all, as you know, healthcare services are
important to treatment and screening for mental health issues
and other risk factors that face Indian youth. But as we have
heard from testimony today and in prior hearings, health
providers are not the only element that is important in
reducing suicide attempts and ideation.
Could you elaborate a little bit more on the partnerships
that you referenced in your written testimony, not only with
other Federal health agencies, but also with other components
of the tribal community like law enforcement, the courts and
schools?
Mr. Grinnell. Yes. The first partnership I would like to
talk about is actually under Dr. Roubideaux, our Director, her
first priority has been consultation with tribal leaders. Under
her tenure, she has actually established the National Tribal
Advisory Committee for Behavioral Health. It is composed of
tribal leaders across every area of IHS and there has been
ongoing consultation with them about the strategic plans, as
well as the funding that we receive for MSPI, for the
Methamphetamine and Suicide Prevention Initiative, as well as
other funding within behavioral health.
And so first and foremost, the Indian Health Service is
reaching out and having consultation with tribal leaders, and
that is the direction that the Director wants to go.
Secondly, the ongoing partnerships and collaboration that
is taking place now, especially with SAMHSA and with other
agency heads. Dr. Roubideaux has met with Pamela Hyde, the new
Administrator for SAMHSA, as well as staff. Dr. Weahkee and her
staff have been meeting with her colleagues at SAMHSA as well.
And she currently sits on a number of Federal committees,
and I will let her elaborate on some of the other partnerships
and activities that are underway.
But Dr. Roubideaux is fully committed to engaging with
tribal leadership. She fully believes also that the success
that we will have with these programs in behavioral health will
be at the local level. They will be tribally managed. They will
be tribally administered. They will establish the priorities.
They will be culturally sensitive as well.
So I would like Dr. Weahkee to also talk about some of the
other collaborations and partnerships that are underway as
well.
Ms. Weahkee. Thank you. So a couple of the other
partnerships I represent IHS on are the Federal Partners for
Suicide Prevention Workgroup. And there are a number of Federal
agencies that sit on that workgroup, including SAMHSA, CDC, the
V.A., Department of Defense, a whole range of Federal agencies.
And we meet on a monthly basis to, one, share what we are
doing in terms of addressing suicide prevention in the
populations that we serve, but also to figure out ways where we
can collaborate.
One of the things that we did collaborate on was that CDC,
IHS and SAMHSA sponsored a meeting on suicide among American
Indian and Alaska Natives and Hispanic Latino adolescents last
September, where we invited national suicide prevention
organizations such as the Suicide Prevention Resource Center
and other Federal agencies and tribal leaders to provide input
and recommendations on how we should address suicide.
In addition to that, as Mr. Grinnell mentioned, we are
working very closely with SAMHSA in terms of coordinating our
suicide prevention efforts. Also recent discussions occurred
with the Veterans Administration in terms of outreach to Native
veterans and their families of suicide prevention. So we are
working very closely with their Suicide Prevention Office.
And also in addition to that, working with BIA and BIE, the
Bureau of Indian Education and Bureau of Indian Affairs, on how
we coordinate our suicide prevention efforts in Indian Country.
So these are all in the planning stages in terms of
implementing specific strategies. And again, working with our
National Tribal Advisory on Behavioral Health to ensure that we
are including the tribal voice in what we are implementing.
A few of the other national organizations that we work with
are the National Suicide Prevention Lifeline, of the hotline,
in terms of outreach and making sure that Indian Country is
aware of that resource. We also have a relationship with Health
Canada, the First Nations and Innuit Health Branch. And again,
we share information on best practices and the strategies that
both of our countries are engaging in to address suicide in
Indian Country.
Ms. Harjo. Thank you.
Mr. Grinnell, we received testimony today from Ms. Flynn
regarding some of the multiple activities they are conducting
at Riverside Indian School, for example. Have you all been able
to examine those types of activities and whether this is
something that you could import into your strategies that you
are working with with the BIA and BIE?
Mr. Grinnell. I would like Dr. Weahkee to address that, if
I could.
Ms. Weahkee. In terms of a national perspective, we haven't
looked specifically at the TeenScreen, but definitely in terms
of screening. She mentioned the Institute of Medicine report
and the National Preventive Task Force and that they do promote
screening among adolescents.
As an agency, one of our performance measures is screening
for depression and we are expanding that into addressing
screening for adolescents. So in terms of implementing that
within our system, promoting integration of behavioral health
in the primary care system, including screening for such issues
as depression, is an important element that we are promoting
nationally and that we are training on nationally all of our
providers in our system.
Ms. Binney. Just to follow-up on that, one of the things
is, Senator Dorgan has been personally impacted by suicide. And
so one of the things that happens in Indian Country is many
times when there is a suicide in Indian Country, we hear about
it. He gets a note about it and he tries to call the family
because it is a personal issue to him.
But one of the things that seems to be lacking is sort of a
database on the amount of suicides that are going on in Indian
Country. It seems that if we had better data, we could sort of
better figure out where the crises are and where more funding
or emergency funding needs to be sent out to.
And Ms. Goklish over at White Mountain Apache Tribe, they
have implemented a mandatory surveillance and follow-up system.
And I wonder if that is something, what your thoughts are if
that could be implemented nationally in Indian Country. As
Congress considered that, we would probably be going through
the Indian Health Service to implement that.
Ms. Weahkee. We do have a suicide surveillance tool. It is
called a suicide reporting form that we use in our system. It
is part of our resource and patient management system. So it
does collect information in terms of the gender, whether the
person has attempted, whether there has been a death by
suicide, if there is ideation, a plan, a means.
And so that is the tool that we do utilize, so we do
collect that information currently. However, this is for the
programs who actually are using the resource and patient
management system. As you may know, many of our tribal programs
choose to use another clinical information system and so their
data may not necessarily be captured on our system. We do have
some of that data.
One of the projects that we are currently working on is
developing what we call a behavioral health data mart so that
we can capture that information in one place. And someone, for
example, myself could look at the data not only nationally, but
all the way down to the service unit level and perhaps see the
top 10 communities where there are suicide completions.
And hopefully, in terms of implementing that system, that
we can, like you are saying, intervene much earlier by
identifying when there are a high number of suicide attempts or
suicide completions in a community.
Ms. Binney. Is the reporting mandatory or voluntary?
Ms. Weahkee. It is part of our performance measures, one of
our GPRA performance measures, so that is something that is
promoted. We do train all of our providers in terms of
utilizing that system. The different programs can also generate
their own reports, so it is useful in that way. But we still do
have a long way to go in terms of improving our system to make
sure that all of our providers are properly trained, know the
tool is there, and actually enter that data into the RPMS
system.
And the other piece of that is just working in terms of the
partnership with CDC on suicide surveillance. They will be
coming out with a published report on suicide surveillance
definitions, so we will be looking at that in terms of
improving our system.
Ms. Harjo. I think that data is really important, but that
only applies to people who actually present or stop in to IHS
or the tribal health facilities. What about the children that,
I guess for lack of a better term, fall through the cracks, who
don't show up to IHS? Or as Mr. Mangas referenced, will not go
into the behavioral health center or have dropped out of
school?
We don't have those youth-serving settings applying to
those children. How do we reach out to those kids so that we
can provide them with appropriate interventions and prevention
services? And this is for the entire panel.
Dr. Clayton. I think the study that has mandatory
surveillance, that Novalene talked about, is the answer. I
mean, it is an amazing outreach where they train para-
professionals, people in the community to collect the data once
the police or the health center or the E.R. has notified them.
And they have a form they fill out. And they get pretty
complete data on both attempters and completions, but it
depends on the community and these para-professionals who fill
in all this information.
She can tell you more about it, but it is very impressive.
Ms. Binney. Does it also depend on where there are mental
health providers on the reservation? I mean, do you need them?
Because I know in many Indian reservations, there is a
significant vacancy in the mental health providers out there.
So do you need to have those there in order to do the mandatory
surveillance?
Ms. Goklish. No, our surveillance system, because spikes
that we had on the reservations was implemented by the Tribal
Council. And we do know that we have a shortage of mental
health providers. And so the Tribal Council decided that we as
a community needed to take our own action by doing something,
and therefore they implemented the mandatory reporting and they
also established the Prevention Task Force. And they started
working with Johns Hopkins to establish some type of protocol
so that we had the reporting system plus also a follow-up
system so that, like what Rhonda said earlier, where they fall
through the cracks.
We have a lot of that, where they don't go to the Indian
Health Service. Of if they do, like for some of the examples
that we have, a young lady went to the hospital because she
wanted them to check her neck. She said her neck was hurting.
She wasn't feeling well. And she explained to them that she was
having thoughts of suicide. So in their system, it is put in
there as her having ideations.
Once we receive the form and then our case managers, para-
professionals follow-up with the young lady, she told us that
it was an actual attempt. She hung herself. Her mom took her in
to have her checked, but they never explained to the medical
provider, the doctor, that her mom found her hanging and cut
her down.
And so our data that we get, it is from a large range of
different departments on the reservation. We work very closely
with all the schools on the reservation. We also get self-
referrals because we do a lot of in-services, so therefore a
lot of community members are aware of the surveillance system
that we do work on.
And it is not restricted to age. Our age group that is at
high risk is 15 to 24, but the people that we receive a yellow
form on is whomever. And so the youngest child that we have
followed up with was only three years old and they were in the
preschool program. And once we received this form the staff was
shocked because of the age. And our oldest that we have ever
followed up with is in their 70s.
And so, it is not restricted to age. Suicide is not
restricted to anybody. It goes after whoever regardless of what
your wallet looks like. And so we feel as a community that if
we don't take action ourselves that it is not going to stop.
And by us being able to follow-up with the youth, myself and
Francene, we are also the ones that follow-up. We are out there
doing these follow-up visits along with the other staff that we
work with.
And it is hard to do this on a regular basis. Monday
through Friday, we are constantly following up with individuals
who have suicidal behaviors. But more than 80 percent of them
will never receive treatment. So we know that, if we at least
talk to them, at least somebody is talking to them. If they are
not going to get help from our Behavioral Health Program or the
hospital, at least someone is talking to them.
We have also started an outreach program with the churches.
We have quite a bit of churches on our reservation. One day I
decided to go ahead and call all of the churches to see if they
would be willing to meet with some of the community members who
attend their churches because that is a request we were
getting.
And so once I started talking to them and explaining why I
was asking these questions and if they would be willing to talk
to some of their members from their congregation, and they
agreed that they would be willing to do that. But if the person
needed further help, that we could also provide them with some
referral forms so that they could get more assistance.
Our whole purpose of the reporting system is so that we can
connect them to services to try to get them some type of help.
And if they are really at high risk, then we try to keep
following them until we get them something. But we hold on to a
lot of our forms and we follow them. We have a long tracking
system, so we follow them and try to find them and we have a
90-day window. Once we receive the form, we have the form for
90 days until we find them.
We receive over 500 referrals, the yellow forms that we
call them because it is on yellow paper, the referral form. We
have over 500 a year that come through our office and we
follow-up with more than 80 percent of that. And we are able to
enter that and track that. And so we know exactly what is going
on, why it happened, if they were using drugs or alcohol, if
they got into an argument or a fight.
So we ask a variety of questions to better understand what
is going on, to better understand why our youth are doing what
they are doing, why are they taking their lives. So that is why
we said coping skills. They need some type of skills to help
them get through this. And so it allows us to look into that
further and to try and develop the program that we are also
working on.
Thank you.
Ms. Harjo. I want to follow-up with you on your program out
there, but I want to grab Randy Grinnell before he leaves. I
guess this will be sort of my last two questions.
We often hear and have heard today about the
intergenerational trauma that faces Indian people and youth in
particular. What kind of research is out there or has been
conducted on that issue?
Mr. Grinnell. I will let Dr. Weahkee address the research
questions.
Ms. Weahkee. Yes, there has been quite a bit of research.
Marie Yellow Horse Braveheart, Bonnie Duran, all of those
individuals, Joseph Gone, have focused on historical trauma and
its impact in terms of the mental health issues that we are
seeing today in Indian Country and how important it is to not
only address the current traumas that many native communities
are experiencing such as domestic violence and sexual assault
and all of these issues that we hear about, but also to address
the issues around historical trauma.
And as Hunter mentioned, until we acknowledge that this is
also playing a role and a factor in Indian communities, we
really won't begin that healing process. So I think by
acknowledging historical trauma, the boarding school experience
and what impact that has had on Indian Country, then we can
move forward and begin to heal.
And you see that as part of components of the programs in
Indian Country such as GONA, the Gathering of Native Americans,
where they acknowledge historical trauma. But thankfully, now
we have a lot more native researchers who are focusing on that
issue.
Ms. Harjo. Do you think fetal alcohol disorders play a role
in some of the mental issues of the youth today?
Ms. Weahkee. Yes. Fetal alcohol spectrum disorders
definitely play a role. As you know, alcohol abuse and
substance abuse are huge issues in Indian Country, and so that
is something that as an agency we also focus on to ensure that
we are educating communities about that issue, training our
physicians and healthcare personnel in terms of screening and
identifying early when that is an issue, and also having that
as one of our performance measures, making sure that we are
screening woman of childbearing age so that we can intervene
earlier. So, yes.
Ms. Binney. It seems that, and Mr. Mangas has probably seen
this in his community, several times in 2009, including on the
Mescalera Apache Reservation, one or two suicides sets of a
string, and you end up with a cluster. And I know that both
Indian Health Service and SAMHSA try to be helpful in
responding to those situations.
But it seemed like there was a lack of resources. And every
department is being pulled in hundreds of directions, and we
are in our economy and our Country is in a deficit right now.
But when it comes to lives, particularly of youth, Indian
youth, do you feel that there are enough resources available to
address the problem, not just funding-wise, but mental health
providers, resources, materials, research?
Mr. Grinnell. As far as resources, and I am definitely not
the expert on suicide, but it takes an effort of more than just
the community. When you talk about a local community, then you
talk about the larger community that it takes in order to
really have an impact and prevent this major health issue.
The health aspect is just one component of it. Rhonda
mentioned about justice and the importance of it. One of the
things that has been pointed out, especially in some of the
communities, is public safety is a major issue. That is
something that has a tremendous impact on it.
I know that in some of the work that we have been involved
in, such as at Rosebud and so forth, the youth said it is an
issue about hope. And that comes into, as I mentioned in my
written testimony about poverty in some of the places. In the
reservations, there is high, high poverty, unemployment, these
other factors that really come into play. We have heard about
the issues about kids in schools concerned about their safety
and bullying and all those things.
And so it is going to take more resources than just within
the health arena. It is going to take all the partners working
with the tribes. And the key to this, and I really believe the
success of this is really going to be at the local level. It is
going to be the tribal leadership and their ability to
establish their infrastructure and to maximize the resources
that are available. And I think it is up to us and it is
incumbent on us to help them to identify those resources and
try to find ways to get those resources to those communities.
I know that one of the things that Secretary Sebelius has
been since she has been in her position is really reaching out
to tribal leaders to have consultation with them, to have true
consultation about what is going on within HHS, about the
programs that they have, and trying to improve the access of
those resources for tribes.
And I think it is going to take a collaborative effort
among everybody to really make sure that the resources are out
there, they are effective, and they are there when they are
needed.
Ms. Harjo. Well, one of the resources that was mentioned
today in written testimony was having more youth shelters,
particularly when the home life becomes toxic. According to the
testimony, for some youth if they had a place to go for the
night, they would not have made an attempt on their life. And
that is very disturbing to hear, I think.
But for the entire panel, what kind of recommendations do
you have for engaging the parents and the families so that
these youth can feel secure at home?
Mr. Genia. I just want to share a little bit. Some of the
things that Novalene and Coloradas have pointed out is tribes
being able to take ownership in their own direction for
wellness and well-briety on our reservations. And again, I want
to point out that over 80 percent of the American Indian
population live off-reservation and oftentimes a lot of our
efforts are directed towards on-reservation.
And so when we are talking about funding and resources, we
need to remember our people that are in the cities and urban
areas that don't have any Native American health centers and
oftentimes struggle with going to local community mental health
agencies. There is a big trust and fear factor there.
I think one of the things that I see that has happened
here, the success of White Mountain Apache is that they took
ownership in developing their own program. In our residential
treatment program, nobody directed us to do that except for our
own Tribal Council. Now that we have opened it and increased
access to it, over 250 of our own tribal members have gone
through our own residential treatment program in just a little
over four years.
If they were to go to Wisconsin, Minnesota or out west to
where the Native American treatment centers are, I would guess
probably over 200 of them wouldn't have gone at all. And so we
need to put the dollars directly into the tribal communities
and let us take our own direction and ownership with that.
And like what Mr. Grinnell had said is support us. Don't be
a roadblock for us and make it harder with a lot of the red
tape that prevents those dollars from coming directly to the
tribal behavioral health centers.
Now that we have had a lot more of our own people go
through residential treatment, we have more of our own people
saying, you know what? It is okay to get help. They are in
recovery. They are sober. When I go to tribal membership
meetings, I can sit down and talk to our people that said, a
year ago I mean they didn't want to even show their faces.
Their heads were covered, their hats low in shame. And now,
they are bright. I mean, they are going to tribal college. They
have jobs. They are working for our tribe.
And I am hoping that for our residential treatment program
that a lot of them that have gone through recovery and are
staying sober will actually come back and work for our own
treatment center so that they can help those that are coming up
behind them.
So when we are talking about reducing stigma and making it
okay is that we need to feel good about it is okay to get
treatment; that it is actually a cultural warrior value of
courage and bravery, not one of weakness and shame.
And that is kind of what is happening in our community. We
have had a lot of initiative towards wellness, well-briety, of
all the things, of putting a name to it. Nobody liked to talk
about how much sexual abuse has gone on in Indian Country
because it was shameful to talk about it. It was the secrets
and nobody wanted to talk about it and where it happened.
Now, we have a lot more people that are coming out and
talking about it. And now that that they begin to talk about
it, it makes it okay that it is, you know what? I don't have to
feel ashamed of that anymore. So I think the same thing applies
to alcohol and drug treatment, any kind of mental health, you
know, issues or disorders.
And we have a lot of our spiritual leaders, our traditional
people that are involved in our treatment care. Behind our
Behavioral Health Center, we have a 55-foot longhouse and we
have a sweat lodge and we have a teaching lodge. And we have 80
percent of our people or more that are asking for those
approaches to be a part of their treatment. They are asking for
it.
So we are just able to provide it, but they are the ones
that when they come into treatment and are part of that intake
and assessment process, they are saying, I want to learn more
about language. I want to learn about my clan. I want to learn,
I want to meet with a traditional healer.
And the funding source is, whether it be SAMHSA, IHS or
other organizations, they need to recognize and acknowledge
that that is who we are as tribal people, instead of saying,
you know what? We are not going to pay for that type of service
because we don't value and recognize that those are valid
methodologies to helping our people, when we are that it is,
and our people are getting better slowly.
We have a lot more work to do, but they are getting better
and more people are saying, you know what? I feel good about
being native and being sober and well. So I think those are
some of the things that we need to take a look at is reducing
the roadblocks to recognizing that there are more than just
Western methodologies to treatment and care.
Ms. Binney. And it sounds like it goes--your statements
just now go to Coloradas' statement of a stigma, and your tribe
was basically able to break the stigma. But it sounds like that
was only possible for, and I am wondering which one is the most
important. It sounds like the Saginaw Chippewa Tribe made this
a priority, mental health. And it sounds like as part of making
it a priority, the Tribal Council decided to invest a
significant amount of its own money into the effort.
The Saginaw Chippewa Tribe is fortunate in that it is one
of those few tribes that do have a successful Indian operation.
If you didn't have that, I wonder if you would be able to be as
successful with it.
So given the resources and given the Tribal Council making
it a priority, and maybe Novalene can discuss it too. I mean,
to really go after breaking the stigma in the community, I
mean, it sounds like it needs to be raised to the level of a
top priority with the entire tribal community, particularly the
leadership.
Mr. Genia. I would say absolutely. I mean, in the saying
of, you can't give away what you don't have. I mean, so if we
as a native people are not well, how are we going to give away
wellness? How are we going to give away positive mental health
if we are not well ourselves?
And we can have all the experts come in and tell us how to
do it, but really it is up to us as a tribal community to take
ownership in saying, you know what? Can we share with you what
we think will work for our people? And can you help us that way
and not the other way around?
And I think we are seeing a change and we are seeing a
shift, but it is just in recent years where they are actually
listening to the local tribal communities in helping us to not
make getting funding such a red tape and bureaucratic process.
So definitely if--and I want to restate the Saginaw
Chippewa Tribe is the exception when it comes to gaming and
making money, the resources a priority to our tribal community.
Most of the tribal communities in Michigan are not in that
position. And when we go to tribal behavioral health quarterly
meetings in Michigan, you are right. There are a lot of
vacancies. There are a lot of position. I mean, we get
recruited to go work for their tribes because they cannot fill
those positions and we don't have enough of our own tribal
people going into the counseling, social work, mental health,
behavioral health fields.
So we have to come up with examples like what Nova in her
community is doing, is by empowering our own people, our
elders, our parents, peer to peer type of programs to invest in
that way.
Ms. Binney. And it sounds like partnerships with research
institutions, educational institutions are helpful. It seems
like that is a hard partnership, maybe, to establish, coming
from a Native American community myself, because there are a
lot of distrust issues that are multi-generational because of
multi-generational trauma.
And so I was wondering, Ms. Goklish, how did the White
Mountain Apache Tribe develop the partnership with Johns
Hopkins?
And I know, Ms. Flynn, that TeenScreen works with several
tribes and I wonder how those partnerships came about.
Ms. Goklish. Our relationship with Johns Hopkins started in
the early 1980s when we were having problems with diarrhea on
the reservation and a lot of fatalities due to that, with
infant fatality death. The tribe reached out and asked for
assistance, and Johns Hopkins was the university that
responded.
And Dr. Mathuram Santosham was the physician that came out,
who is sitting behind me, and he came out then. And he was to
work on the reservation with the tribal community for one year
on the oral rehydration solution that was being developed at
that time, which we now know as Pedialyte. And so that was the
first time that they ever did that in any community and it was
being done on our reservation.
It started in October of 1979, and Dr. Santosham came out
and he was scheduled to be there for one year. He lived on the
reservation for six years, working as a physician, and Johns
Hopkins was able to establish a relationship with the tribe and
also the Indian Health Service to start this research study
program so that they could develop the oral rehydration
solution.
And from there, they remained on the reservation and we
have had a 30-year relationship with them since. They have
never left. We have always had an office there. I have been
working with Johns Hopkins for 13 years, and worked on several
different programs. And a lot of our community members, some of
them feel that certain programs we shouldn't be doing, but a
lot of the programs that are developed under Johns Hopkins are
not programs that are decided by Johns Hopkins. It is the
tribal community that decides on what we are going to work on
as a community, and then that is then taken before our local
health board members and our Tribal Council.
And we usually have meetings with them on a regular basis
to decide on what different areas we also need to look at. Like
recently, binge drinking is now an issue on our reservation. We
are having a lot of problems with binge drinking. This past
year in 2009, we have had 10 suicides on our reservation. I
already named the population size that we have, so that is
really high.
And then in October, the school suspended over 50 kids from
the local high school for binge drinking at school. So the kids
are actually going to school and they are drunk. They are
already intoxicated by 10 o'clock in the morning. And so the
schools are reaching out. And so now, they are reaching out for
help to the tribe and the tribe is gearing them towards us and
saying, we want you guys to focus on this.
And so that is why the relationship is really strong. They
reach out and they tell the staff that they have at the Center
for American Indian Health with Johns Hopkins exactly what they
want Johns Hopkins to focus on and that is how we have been
able to work with them.
And when Dr. Santosham was there, he was able to build a
strong relationship with the tribal leaders and it was a
relationship that has continued to this day. He has worked with
a lot of the delegates that were in office then who are in
office now. And so, we are able to move forward and establish
different programs and protocols that we have to follow that
the tribe wants us to abide by.
And so, yes, we are the ones, we work directly under Johns
Hopkins, but we are tribal members and we work directly in our
community. And we also are the ones who maintain the data and
tracking system of all the projects that are there, and all the
data belongs to the tribe. And whenever Johns Hopkins wants to
utilize the data for whatever reason, they still have to go
back to the tribe and ask their permission to use whatever they
need, even though they are the ones that found the funding to
work on certain programs and design different data templates
for us to collect different data that we are working on.
And so it has been a long relationship. But it is because
they took the commitment to stay and remain in our community.
That is why the relationship is still strong.
Ms. Binney. Thank you.
Ms. Flynn, how did the tribal partnerships develop with
Columbia University?
Ms. Flynn. In our case, in each of the areas where we have
worked, one of the members of the tribal leadership reached out
to us. And I think why we were able to continue and move
forward was because we made very clear that we wanted to learn
from them and with them as we moved forward with
implementation; that we didn't have a particular point of view
about how the screening needed to be implemented; that we
wanted to learn what was appropriate within that cultural
context in that specific community; and that we were there to
provide support and help. But again, it was, as you have heard,
it was their leadership. It was their program. It is their
youth. And I think that that fit very well with the general
context in Indian Country, and so our program has been well
received.
The other thing, I think, was that we felt and continue to
feel very strongly that respect for the family and for the
parents and engaging them as part of recovery is a very
important component. So we really emphasize in all of our
settings the significant importance of reaching and educating
and engaging and helping families. Because parents want to do
what is the very best thing for their children. Even parents
who are impaired care deeply about their children. And whatever
strength they can bring needs to be tapped because the health
professionals and the programs have a tendency to fade away,
but family remains, just as the tribal culture and community
remains.
So we have always emphasized the importance of the family.
And I think that, too, fit within the values framework of the
tribal communities that we have been working with.
Ms. Binney. Dr. Clayton, does the American Foundation for
Suicide Prevention have any partnerships with tribal
communities?
Dr. Clayton. The only partnerships we have had are in our
postvention works. And we have this training program to teach
people to run support groups after there has been a suicide.
And so we do it all over the Country. It is a day and a half
program. And in South Dakota, we have done it twice in two
different communities, and Native American people have come.
Now, I did not ask our survivor leader what the follow-up
on that was because we do collect follow-up data. Have you
actually held support groups in your home or in your church?
You can do it wherever you please. So I don't know if, we have
those data, but I don't know it.
And we have also reached out to V.A. hospitals, too. And
had meetings in V.A. for survivor training. Again, it is all
this postvention training that we have been involved in.
Ms. Binney. And it does seem that a movie, like you said,
with Native American actors would probably resonate with Indian
communities.
I don't know what you think about that, Mr. Mangas, being
able to go into a classroom and kind of see your own peers,
other Native Americans in the movie about suicide, and sort of
how to respond to that.
Mr. Mangas. I think it would really help a lot of the youth
that are on the reservation because, like, many of us don't
really have nobody to look up into these movies or stuff. All
we mainly see is white actors or Mexicans or any other people
except Native Americans.
And what if Native American actors being in like a suicidal
movie or something like that, like showing what Native
Americans really actually do go through, it would help a lot of
the Native American youth, knowing that they are not the only
ones out there that are going through this, and there are other
reservations across the United States that do go through these
suicidal attempts or suicidal completions like this.
And having other Native American youth from my reservation,
like, seeing these movies or stuff, it would kind of help them
not only knowing that they were not the only ones out there
suffering with this kind of stuff, but knowing that there is
help out there besides what we do have on the reservation. And
they could go to our Council and kind of ask them to refer
these people to come to our reservation and to help us not only
with the suicide and drinking and stuff like that, but like
with depression and with problems at home that would lead to
these suicides, and that would lead these children to like
using drugs or alcohol or getting into trouble.
It kind of, to me, it would kind of help the youth
understand that there is help and that they don't always have
to make an attempt on their life to get this help. They could
as easily just go out there and ask a teacher or another person
if they could see if they could try and help this youth to get
this help to the reservation so that everybody could have it
and not just people from different reservations like here in
the East or out on the West Coast.
Because there are many reservations that are right in the
middle of the United States that really don't seek this help
because of, like, the shame and stuff that comes with it.
Seeking this help is too great on some of the people. There is
such a great honor of not even needing this help or anything,
that they are too afraid or too shameful to seek it at the last
minute.
And by having Native American actors in movies or stuff
like this, then it would kind of help the youth to understand,
well, we can seek this help because other Native Americans out
there are seeking this help, and they are not ashamed of it, so
we shouldn't be ashamed of it.
Ms. Harjo. You had referred to the film as helping the
students, the Indian youth. But what would you say to the
service providers, to the teachers, to the doctors and other
people out there in the community? What do they need to be
doing to help these young people who will not seek out help?
Mr. Mangas. They need, like, some of the people need to
kind of put these cultural values into some of the youths'
heads because many of the youth where I come from don't really
respect their culture. They don't want nothing to do with it.
And by having these, like our elders or like our Tribal Council
leaders or just mainly their parents, having them put these
cultural values into their head, and having them understand,
well, this isn't what our Native American people used to do
when they were having problems way back when, or they wouldn't
use to use these ways of having people see that they need help.
They would have, it would kind of help the youth to
understand, well this isn't what we should be doing because it
is not what our people would want for us. And it is not what
our people went through way back when to get us to where we are
today.
And by having the elders put these cultural values in some
of these people's heads or the youths' heads, it would kind of
really help some of the youth to understand, well, my people
did this for me, and I should be trying to help my people
instead of trying to bring all this depression and all this to
my people. I should be out there making an effort to help other
youth better going through this and helping them to get through
this so that they won't make these attempts on their life or
make these completions with their life.
It would kind of really help a lot of youth because on our
reservation, the thing about death is that whenever you do
something to your body and you die, that is the way you are
going to go into the next world. If you hang yourself, there is
going to be a rope around your neck when you go into the next
world. If you shoot yourself and you shoot your head off or
something like that, that is how you are going into the next
world.
And some of these youth don't understand, well, that is
what our people used to believe way back when and that is why
they wouldn't make these attempts or completion of suicide.
That is why they would be out there fighting for their lives or
fighting against other people.
And it would kind of really help a lot of youth to
understand, well, maybe this is true. Maybe we will go into the
next world looking like that. And some of these youth are so
high on their horse that they want to look so perfect and
everything, and then they do make this attempt on their life
they are not understanding, well, what if this is really what
is going to happen to me in the next life? What if I do come
out looking like that?
And I believe that some of these kids don't really
understand what their cultural values are and what is being
taught to them. And so I think that if the elders and the
Tribal Council would get out there and teach these children,
well, this is what is going to happen in the next world. This
is what you are going to look like if you do this to yourself
in the next world.
I think it would help a lot of youth to understand, well,
maybe I shouldn't do that because I want to look the same way
for the rest of my life, even in the next world. And I think
that would kind of help a lot of the youth to understand, well,
we shouldn't make these attempts on our life or we shouldn't
make these completions on our life about suicide.
Ms. Binney. That is such an interesting point, in light of
Mr. Genia talking about a lot of the people who have now gone
through the residential program are asking about their culture
and wanting to get more in touch with their culture.
Mr. Genia. I want to kind of comment on that, too, because
we built our own behavioral health facility, which has our
prevention program, outpatient, residential. We have a domestic
violence emergency shelter. Prior to that, where our program
was, we had people that requested to come into the side of the
building or behind the building to their appointments because
receiving services for mental health and substance abuse was
like, they didn't want anybody to know.
And slowly that has started to change, where we have had
people in leadership within our tribe actually go through our
residential program. And I am just, I am really so proud of
them for doing that and taking the courage and that step to get
help for themselves. Now other people can see that and say, you
know what? It is all right. It is a good thing to do that to
try to help myself.
But one of the things I wanted to mention, and I will
mention this again, is that over half or half of our Native
American population are under the age of 18. So probably your
experiences and like mine going through secondary education is
that oftentimes we were the only Native American student in our
college or graduate courses.
And one of the things that I had done when I went through
Grand Valley State University is that they were sending all
these students these opportunities to go and study about other
cultures from other countries. And I was thinking why are they
putting so much money into sending people to Europe, to
wherever, anywhere but tribes.
And so about six years ago, I had approached the master's
in social work program about having their students come up to
stay with us on the reservation for two weeks, and it is going
on its sixth year. And I can tell you, in that short two weeks,
they have learned more than they will ever learn in public
school education through college education about who we are as
a people, as a culture, our values, our history, why we deliver
treatment services, mental health services the way that we do.
Now it is a very popular program, but we can't do that for
all the universities and their social worker counseling
programs. Unfortunately, we have no minimum standards here in
America about what outcomes they need to learn about Native
Americans in this Country.
So there is this population of populations graduating not
knowing who we are, and there is a lot of ignorance. So I
really think we need to somehow address some of the education
standards so that people really still refer to us as those
people, that we are still part of the invisible population here
in America.
And until we do really look at some of those core things, I
mean, I think we are always going to be kind of the minority
and feel that way. Anyway.
Ms. Harjo. Earlier, in previous hearings as well as this
one today, we have received testimony that many of the cultural
practices need to be incorporated into treatment for behavioral
health. But we also received testimony today that there perhaps
should be some of the behavioral health methodology
incorporated into some of the cultural settings, like
screening, for example.
Ms. Goklish and Mr. Genia, what do you think about that as
tribal health providers, the recommendation that screening
ought to be incorporated in some of the cultural settings?
Mr. Genia. I would definitely agree. Actually, in our
behavioral health program, we have a cultural healer that is a
part of our behavioral health staff. And so when we have
ceremonies, actually, we have substance abuse treatment groups
that actually meet in our longhouses and some of the groups
actually go into sweats and our other cultural practices. So
that is already happening in our setting.
And I would also say that because we don't have enough
Native Americans in the field of counseling and social work,
that a lot of the non-native staff actually stay on to work
with us because there is something different than they have
ever experienced in a non-native organization with their
spiritual practices and cultural practices. So it is really
kind of a unique thing that is happening.
But to get to your question is I definitely believe that we
need our traditional healers, our spiritual leaders, our faith.
She mentioned working with the churches and stuff. I mean,
everybody has to come on board and this has to be a multi-
disciplined, multi-faceted approach to addressing health issues
in our tribal communities, including suicide prevention. It has
to be okay to talk about. It has to be okay to receive help.
And the more of our people that are in different disciplines
within a tribal community, even if they are just non-working
tribal members and staff, I think that is great. And we need to
do that. And we are doing that somewhat already in our tribal
community.
Ms. Goklish. For us, we really don't have a lot of our
culture and tradition tied into, like, the behavioral health
services that are provided. They do offer assistance if
somebody would like a medicine man to do a prayer for them or
if they would like to speak with a medicine man. If they can't
provide the financial means that, the behavioral health
services would be able to assist with that.
We feel that on our reservation, that a lot of our, not
just our youth, but a lot of our tribal members feel a sense of
loss. They don't have a sense of belonging because they really
don't know the traditional setting. They don't know our
culture, the language. We are losing our language, like a lot
of other tribes are.
And so for us, being able to incorporate a lot of the
cultural aspects into a lot of the questionnaires that are
being asked, or like I don't know what type of surveys they
have or what type of intake assessments they do, but in there,
maybe ask information on how or what type of questions they can
ask that would be culturally appropriate.
And then also to work directly with them to see what other
things they would do, maybe they can incorporate sweats or
other things that would make them feel more like they can be
comfortable being native and then going and getting help for
the mental problems that they might be having. We don't have a
lot of that on our reservation. That is where we started
working with our Elders Council. And the unique thing about our
Elders Council is the majority of our Elders Council are very
traditional, and the other half have a strong Christian faith.
But that doesn't cause conflict with anything that we are doing
with the youth because it is not about our elders. It is about
our youth.
And so when our elders come together, when we first started
this, we thought that we would have a problem with that because
of their belief system and because they are older and you have
to, we are very respectful of our elders. But working with
this, our Elders Council that we have established, we have been
able to do a lot with them. We have been able to work with the
youth and the elders have been able to talk to them about what
it means to be White Mountain Apache and that in order for them
to be complete, what they need to understand.
And so we haven't reached out to a lot of kids, but the
ones that we have been able to touch, we know that we have been
able to make a difference just with our elders working with
them, taking some of the kids to the sacred sites. When we took
some of them to a couple of the sacred sites, some of the kids,
they didn't even know that we were still on the reservation.
They thought we had actually left.
So that is sad because they don't even know how big the
land is. They don't know where it ends. They thought that we
were going somewhere, on this big field trip off the
reservation. We never left the reservation. The whole time, we
were taking them on these field trips so they could better
understand who they are and where they come from.
And so I think that the more we include things like that
into the behavioral health, the mental health, that it is going
to help them better understand who they are, accept who they
are, and then it will make them even stronger so that they can
become healthy again.
Ms. Harjo. Part of the testimony today indicated that the
Federal dollars spent on Indian youth suicide prevention or
Indian suicide prevention in general reduces a lot of the
medical cost that is associated with the treatment and
aftermath.
Mr. Grinnell or any of the panel, Ms. Goklish, is there any
estimates about how much we are actually saving?
Mr. Grinnell. No, I don't think we could come up with that
information right now. I am not sure that we are able to
capture that because that is a prevention aspect. I can ask
some of our staff to look into it and we can get back with you.
Ms. Harjo. That would be really helpful.
Ms. Goklish, you elaborated on several aspects of the
mandatory surveillance system. Of course, that being mandatory,
could you describe, what are some of the teeth to that system
out there? How do you require people to actually report?
Ms. Goklish. Well, the teeth in it is the resolution
itself. And so the tribe did pass the resolution mandating all
tribal departments, health providers and tribal members to
report suicidal behavior. So the teeth in itself is the
resolution that was passed.
And I think the backbone behind it is the staff that are
working directly on it, which is us. And you know, us providing
in-services on a regular basis to all departments on the
reservation, reminding them that this is mandated by the tribe,
and that when the tribe, considering that they are a sovereign
nation, that they make their laws and that that is one of the
laws that they have passed.
And so we work closely with the Police Department and other
departments on the reservation, along with the Indian Health
Service. We have a really strong relationship with the Indian
Health Service and our Tribal Council on implementing this with
all departments.
If we feel resistance from any department, we don't go back
to the Tribal Council and let them know. We don't do that. We
work directly with that department to make sure that they
understand that this is something that the tribe wants and the
community has accepted this, as part of our responsibility as
natives, what we need to do to take better care of ourselves
and also to step up and say that, yes, either I am suicidal or
I do have a family member who is suicidal and that they do need
help. I would rather have that person mad at me than that
person gone.
And so we do have family members that will fill out a form
on another family member, a friend will fill it out on another
friend, or another individual will fill it out on themselves,
saying that, yes, I do need help. I do recognize that I am
suicidal.
And when we first started doing this, we had a hard time
because speaking about suicide, it is a taboo. We were told,
you don't speak about it because it is going to happen. You
don't need to advertise it.
And so when we first started doing this, it took us a long
time to get where we are at. So we have been working and doing
this for nine years. It started in 2001, but actually the
tribe's been really struggling with suicide for 19 years. And
so it has been a long time that we have been trying to get
help. And when we first had the spike on our reservation, I was
in high school then. And so a lot of my cousins, my friends
died from suicide. There are a lot of names out there.
And so, with the 19 years, there comes a lot of numbers of
the people that have passed by suicide. And so with us, it is
the tribes that put in those policies and we are enforcing it,
but with permission from the tribe. We are tribal members, but
we do work for an outside agency or department, which is Johns
Hopkins.
But we are tribal members and I think that is what gives us
strength and that we speak in our language and that we can
explain to the community the importance of us doing this. And
that, yes, it is taboo for a lot of our elders, but since we
have established our Elders Council, they have told us that
even though it is taboo, it needs to be spoken of because if we
don't speak about it, it is going to continue and it is going
to continue to take lives on our reservation.
And so with that, we were able to produce a DVD that we
use, which we call New Hope. Our production crew is native and
our actors are native. And so the DVD that we produced is
geared towards youth who have made an actual attempt to make
them realize that the impact that it has on their family and
the community. One attempt that we have has a big impact
because the first responders who are going out there are also
community members and so it affects them. And so they deal with
that, and we explain that to the youth.
And the core purpose of that particular DVD is for them to
understand that they do need help and that their attempt was
serious and that it wasn't a joke. And that they could have
ended their life and they wouldn't be here today. And so that
was a DVD that we also produced.
Ms. Binney. That sounds similar to your guys' movies as
well, Dr. Clayton.
Ms. Flynn. Could I just add one comment. I searched through
my papers in response to your question. I do have some
information about how screening of youth can save healthcare
dollars. And I have just a quick from the field story to share.
It did not occur with American Indian population, but it did
occur recently. And it is why we are working as well in
emergency departments because so often that is a primary care
spot for many youth.
With the advent of electronic medical records at Cincinnati
Children's Hospital, a young girl came in, age 16, and her name
was typed in for the first time as the electronic record came
online. They saw over 35 previous entries. She had been seen in
the emergency room for ear ache, headache, stomach ache, back
ache, a whole panoply of symptoms. She had had all kinds of
tests, MRIs. She had had all kinds of blood tests. She had been
admitted overnight twice for all kinds of procedures.
Finally, on this 37th or 40th admission, she was screened
for depression, which indeed she was found to have very
significant and severe symptoms of depression, showing up as
physical health symptoms. Perhaps because of stigma, she didn't
want to discuss these other issues.
When she was asked about it, she readily acknowledged this
was a problem. And indeed, now they have been able to address
what was really driving all of these repeated visits for
symptoms that were in fact symptoms of untreated depression.
I think it is not a rare example. We hear from emergency
departments across the Country that this is a component that
brings youngsters into the emergency room.
Ms. Harjo. So from that experience, one, is it perhaps a
recommendation or something that needs to be evaluated as to
the training for other providers, the rest of the community as
the White Mountain has done in identifying these types of
issues and symptoms?
Ms. Flynn. I think absolutely. As we see integration of
mental health, physical health, we look at the whole health of
the youngster. And we realize that it is in adolescence that a
lot of these significant mental health issues first arise. This
is when we can first find the symptoms, but we do need
colleagues across healthcare to learn about this, to be part of
identifying and then connecting youngsters who need help to the
treatment and supports they need. I think that is where we have
to work together.
Mr. Genia. Can I just add? A lot of the research and stuff,
too, shows that when at the impact or onset that someone has
been traumatized, a lot of their developmental emotions,
maturity levels kind of are thwarted at that age.
And if you take a look at what has happened a lot in Indian
Country is that a lot of, whether women, parents that are at
that age now have been victimized or traumatized in some way in
their own tribal communities or wherever they grew up at, in
their adolescence or teen years or younger.
And I guess the point I am trying to make really is that a
lot of our efforts as far as putting money more into the
prevention, the youth, adolescent ages is kind of where we need
to be directing a lot of our monies. I mean, we do have
treatment programs and stuff, and that is good to see. But we
know that the majority of our youth, again, are under the age
of 18. And if we can develop them, help them, nurture them and
help them grow that hopefully this cycle will continue to stop.
So, and you had asked about the behavior, the money put
into prevention versus medical care. And one of the statistics,
Jessica, who is on the National Indian Health Board kind of
pointed this out, too, was that for about every dollar that is
spent in prevention, we save about three dollars in medical
care costs or more.
So it makes a lot of sense if direct a lot of those efforts
in Federal funding towards those efforts. We could be saving a
lot more in healthcare costs down the road.
Dr. Clayton. I would just like to comment one more thing
about the film, and then something else. I think the film is
also useful, they have used in schools for the parents, too, at
PTAs, to show them that kids can get depressed. And this isn't
just a growing pain or bad behavior or a bad patch they are
going through. It really could be depression.
So I think if you make a good film, that it can be used in
multiple places. And the way we make sure it is used well is to
have a very, very complete facilitator guide for the teacher,
hopefully with a mental health worker, but when it is
presented. So I think it has a lot of depth to it.
But I would like to say a couple of other things. Senator
Franken opened by talking about a tribe in Minnesota who had
another set of copycat suicides. And so they called in a team
from Montana, he said, to help them evaluate the situation. And
they did discover that there was some kind of pact in that
particular community.
So I think another thing that should be done is that you
ought to have some crisis intervention teams because contagion
is a problem for adolescent suicide. There is a contagion thing
that we have been involved with now on the campus at Cornell.
And there is a contagion in Palo Alto, California in the high
school.
So it is really a problem for youth because they are
depressed, drinking and impulsive, and then this happens. So
you need some well-trained intervention teams, I think, to go
to other reservations when something like that starts to occur.
You have to do it immediately.
And then I still think there are now very good short-term
therapies for depression. There are psychotherapies. I mean,
there are many drugs that are good. There are drugs for the
treatment of alcoholism that have been used, I am told, in New
Mexico successfully in Native American populations.
But there are good short-term psychotherapies. And there is
one for suicide attempters that was developed by Tim Beck in
Philadelphia, in the heart of the city. And 40 percent of the
people in the study were men, which is very unusual, and 40
percent of them were black. So it was really in the
neighborhood of downtown Philadelphia.
And they have used that same therapy now for the elderly.
They have to adjust it. And I think you need to invest money in
developing a kind of psychotherapy, a CBT therapy for Native
American youths who are depressed or who make suicide attempts.
I think a suicide attempt specific psychotherapy, while you are
there, while the person is there, with focus groups. It is a
complicated process to develop a psychotherapy, but it is
proven to be effective. So I think it would be a mistake not to
invest in those kinds of things.
And then finally, the V.A. in order to solve its problem
with suicide attempts, it took a long time to work out, but
they got the Crisis Hotline, which is all over the United
States, to press 1 if you are a veteran, and then it goes to
your community of veterans hospitals and that.
And I think you have talked about the Crisis Hotline some,
but I think you should have a way to partner with this national
Crisis Hotline so that Native American communities could also
use it specifically.
I don't know. Those are just my thoughts on it.
Ms. Binney. So basically it would be like a, press 2 if you
are a Native American?
Dr. Clayton. I think you have to press 1 if you are a
veteran and then I think 2 if you are just--it was developed as
a crisis hotline for the whole Country, not by age or anything.
And so then when the veterans presented with this enormous
increase in suicides, the first thing they did, it took about a
year to partner with them. And so it would be press 3 if you
are something, or 2, I don't know how they do it, but I think
you need kind of a national crisis hotline.
Ms. Binney. I think you are right in that suicide,
particularly among youth, can be contagious. And the studies
and the stories and the anecdotes have shown that. And I think
our hope and our Senators' hope is that having strong leaders
in the community like Coloradas and Hunter and Novalene to sort
of break away the stigma, that that becomes contagious to where
people feel like they can talk about these issues openly and
comfortably.
Also there are good young leaders who obviously are very
proud of their culture and where they come from and of being
Native American, and that becomes contagious as well.
We thank everybody for being here. We are going to wrap up,
but I wanted to remind you all that with the hearing, the
record will stay open for two weeks, as Chairman Dorgan
mentioned. And that him and other Members of the Committee,
because they couldn't be here and couldn't be here for the full
time, will submit written questions to you for the record, and
we will give you some time to respond to those questions as
well.
I just want to thank everybody for being here on behalf of
Chairman Dorgan, Vice Chairman Barrasso and all the Members of
our Committee. We appreciate your coming for the hearing. We
are sorry it got cut short, and we really appreciate your
staying around for the listening session and engaging in
dialogue with us.
I don't think this Committee is going to stop holding
hearings on this issue. They have been holding a number of
hearings on this issue over the last seven years, and I think
it is going to continue until we can really decrease the number
of youth suicides that are occurring in Indian Country.
So again, thank you for being here.
[Whereupon, at 12:05 p.m., the listening session was
adjourned.]
A P P E N D I X
Prepared Statement of Dr. Warren Zapol, Commissioner, U.S. Arctic
Research Commission
Good morning, Chairman Dorgan, Vice Chairman Barrasso and
Members of the Committee on Indian Affairs. I am pleased to
submit testimony on Youth Suicide in Indian Country as part of
the Committee's March 25, 2010, hearing. My testimony focuses
specifically on youth suicide in the Arctic and on the goals of
the U.S. Arctic Research Commission, which I represent as a
commissioner.
I am the Director of The Anesthesia Acute Care Laboratories
at Massachusetts General Hospital (MGH) and the Reginald Jenney
Professor of Anesthesia at Harvard Medical School in Boston. I
received my undergraduate education at Massachusetts Institute
of Technology, attended the University of Rochester School of
Medicine, and after graduation, served in the Public Health
Service (1967-1970) at National Institutes of Health as a staff
associate of the National Heart Institute. I currently serve as
a commissioner for the U.S. Arctic Research Commission,
representing academics and research while focusing on human
health. It is in my capacity as the ``human health''
commissioner that I submit my comments.
The Federal Government, Congress and the Supreme Court have
all determined that the Federal Government has a fiduciary
responsibility to provide for the health, safety and wellbeing
of Alaska Natives and American Indians. With youth suicide
rates, especially in Alaska Native males, drastically exceeding
the national average--the Arctic Human Development Report
states that Alaska Native males are 80 percent more likely to
commit suicide than the general American population--the
Federal Government is not fulfilling this trust responsibility.
Millions of dollars have been provided to stem these deaths,
but youth suicide rates among Alaska Natives are increasing and
continue to drastically outpace the American population,
generally. We owe it to our Alaska Native populations to ensure
that the federal funding provided for their health and
wellbeing is used to promote maximized benefits--reductions in
youth suicides.
Currently, the Federal Government does not know which
programs work or which programs work most effectively to reduce
youth suicides in Indian Country. It is critical that the
Federal Government study these programs to determine how best
to fulfill its fiduciary responsibility--without this, the
Federal Government will continue to fund prevention and
intervention programs, without regard to the programs'
effectiveness in reducing youth suicides. This is not fair to
our Alaska Native populations.
In recent years, there has been significant improvement in
the general health of the Arctic resident populations, but
significant behavioral and mental health disparities persist,
especially between indigenous and non-indigenous populations of
the Arctic. These disparities include unintentional injuries,
suicide, homicide, infant mortality, and in part, account for a
shorter life expectancy and increased mortality related to
suicide and accidents in Arctic residents, as compared to
residents in more temperate climates.
Although Alaskans face the same behavioral and mental
health issues faced by communities in other states, the
severity of many of the problems is often greater and there are
special challenges posed by the remoteness of many Alaskan
communities. Some of the health problems of greatest concern
include, but are not limited to, elevated suicide prevalence,
child abuse/neglect, sexual assault, alcohol use, high
prevalence of Fetal Alcohol Spectrum Disorders, and
unintentional injuries. Additionally, the rates of smoking and
obesity are higher in the Alaskan Natives, compared to non-
Natives, and there has been a rapidly rising incidence of
diabetes.
As described in the Arctic Human Health Assessment
Program's 2002 report, the younger age structure, and
predominantly remote locations of the majority of the Alaskan
Native populations makes the State's communities particularly
vulnerable to these disparities; however, it also provides an
opportunity for establishing culturally specific, community-
based intervention programs that emphasize resiliency and
preventive measures for behavioral and mental health promotion.
Many agencies and organizations have recognized the need to
invest in further research and improve current services. There
is also increased attention to the issue of culturally
appropriate training of community-based health care providers.
It is believed that coordination of these efforts will provide
a maximal benefit to the affected communities.
The indigenous populations and other residents of the high
northern latitudes disproportionately face a variety of mental
and behavioral health and health-related social issues.
Although many of these issues parallel those faced by residents
of other rural areas, and are similar to those faced by other
Native American populations in the lower 48 states, the
problems in Alaska are compounded by the challenging physical
environment (including extreme cold and photoperiod changes)
and limited availability of and access to health services, and
aggravated by the rapid social changes of the past few decades.
The Arctic Research and Policy Act, passed in 1984 (P.L.
98-373) and amended in 1990 (P.L. 101-609) was enacted to
establish national policy, goals, and priorities for Arctic
research. The Act established the Arctic Research Commission
and an Interagency Arctic Research Policy Committee (IARPC).
The Commission publishes a report on goals and objectives every
two years to help guide the activity of the IARPC and its
member federal agencies. In its 2009 report, the Commission
outlined several research program recommendations. In addition
to studies of the Arctic Region, Bering Sea Region, and
research on resource evaluation and civil infrastructure, the
Commission has called for a review of Arctic health research.
The Commission's recommendation for a research program on
Arctic health calls for a focus on mental health in the Arctic
since behavioral problems such as alcoholism, drug use, suicide
and accidents are among the most frequent causes of ill health
and death in Arctic populations (USARC, 2009). The Commission
recommended that IARPC begin planning an interagency program to
coordinate and emphasize research on mental health concerns in
the Arctic, with the National Institutes of Health as the focal
point for the effort. In response, a meeting on Arctic Mental
Health was held under joint sponsorship of the NIH Fogarty
Center and USARC in Anchorage on June 2 and 3, 2009. After a
thorough review of the problems with extensive representation
from Alaskan Native groups, federal organizations (NIMH, NIAAA,
NIDA, Fogarty Center, CDC, etc.), State of Alaska agencies
(Dept. of Health, CMO of AK, etc.), state legislators, and
voluntary agencies (Mental Health Trust), it became clear that
the problem was both difficult and chronic and little progress
is being made toward reducing the suicide rate.
It was also believed that it would take extensive research
to identify successful interventions, rigorously test them,
scale them up, sustain them, and evaluate their effectiveness.
The complete discussions of that meeting were published in
December 2010 as a supplement to the International Journal of
Circumpolar Health and are available on our website
(www.arctic.gov).
It should be noted that, although a great number of
northern residents are at risk and experience disportionate
mental and behavioral health complications, there are also
Arctic inhabitants who are resilient to these risk factors.
These differences can be seen not only between individuals, but
between communities or villages, suggesting an important socio-
cultural component to resilience. It is unclear what makes some
individuals or villages more resilient to the same factors that
put so many others at risk. With few exceptions, there is no
current, compelling framework to guide development of a primary
prevention approach for mental illness or addictive disorders
in the Arctic. That is, it is not known which societal
strategies are the most effective at fundamentally lowering
incidence and prevalence of these disorders. Strategies might
include modifications in housing, socioeconomic status,
education, environmental hazards, behavior and violence.
In Alaska, multiple federal, state and local agencies are
involved in promoting, preventing and treating mental and
behavioral health disorders. In some cases, these agencies
collaborate with international partners in the pan-Arctic such
as the Canadian Ministry of Health. Each of these agencies
comprises a critical piece of the infrastructure that supports
and maintains the health of Alaskans. For example, within the
Federal Government there are at least five agencies active in
providing assistance, including the Indian Health Service,
Centers for Disease Control, National Institutes of Health,
National Science Foundation, and the Health Resources and
Services Administration. In addition there are well over 20
non-federal agencies providing behavioral health services in
Alaska. A coordinated effort among the various agencies and
organizations is needed to provide the most effective
prevention and intervention services.
Researchers in the behavioral and social sciences are
exploring resilience factors that allow better coping,
recovery, and resiliency to social and physical trauma.
Research in neuroscience is identifying mediators and
mechanisms of altered brain functioning and behavior.
Community-based researchers are employing educational programs
to teach cultural values and traditions, within the context of
the modern society that may be successful in reducing youth
suicides. Additionally, medical research is finding new
approaches to diagnose and pharmacologically treat depression.
Focused research is desperately needed to identify more
effective and comprehensive strategies for promoting resilience
and recovery in individuals who live in the northern
communities as well as to facilitate effective coordination
among federal, state and local agencies. Despite many trials of
intervention or ``pilot programs'' there is little
effectiveness testing of interventions and no interventions
have been scaled up to a statewide level. The mental health
research agenda for northern residents is much broader than can
be accommodated by a single agency. Despite the enormity of the
problem, a minuscule amount of funds are devoted to mental
health research in Alaska.
The U.S. Arctic Research Commission recommends that $1.2
million be made available for the Institute of Medicine (IOM)
of the National Academies of Science to review what research is
needed to improve the health of Alaskan Natives. This study
will examine the science base, gaps in knowledge, and
strategies for the prevention and treatment of mental and
behavioral health problems faced by populations in Arctic
regions, with a focus on Alaska. Specifically, the IOM research
would:
1. Summarize the scope and nature of mental and
behavioral health among residents of Arctic regions,
with special emphasis on Alaska.
2. Assess the infrastructure for research into the
mental and behavioral health issues in Alaska to
determine if current mechanisms and resources are
appropriate to facilitate progress in the field. This
should include an analysis of which federal agencies
are funding research programs and the mechanisms used
to review research proposals.
3. Describe factors that contribute to promoting
resilience and recovery among Arctic residents. Learn
if any of these have been robustly tested for
effectiveness. Learn if any of these have been scaled-
up for large scale implementation. Have any scaled-up
programs been tested?
4. Provide recommendations for strategies of
implementation and testing of programs designed to
increase resilience in the affected populations and
reduce health disparities.
5. Describe and assess the infrastructure for
prevention and treatment of mental and behavioral
health in Alaska; including federal- , state- and
community-based programs. This should include
examination of collaborative efforts and discussion of
ways to improve coordination between the multiple
public and private agencies involved in promoting
improved mental and behavioral health. The testing of
pilot programs for effectiveness will be emphasized,
and the scaling potential of pilot therapeutic efforts
will be examined.
6. Identify steps that could be taken in the short- ,
medium-, and long-term to improve the mental and
behavioral health of Arctic residents, including
research needed to understand the impact of abrupt,
Arctic climate change and rapid social changes on
mental and behavioral health, improvements in community
infrastructure directly related to improved health,
changes in prevention and treatment programs, and
mechanisms to improve selection and training of
personnel for mental and behavioral health care
services. Special emphasis will be made on the use of
telepsychiatry to augment these efforts.
The U.S. Arctic Research Commission understands the
widespread needs for funding of behavioral mental health
services in Alaska for Alaskan Natives. In this vein, it is
vital that the Federal Government carry out an IOM-based report
of our knowledge and knowledge gaps to learn which strategies
for sustainable interventions and prevention might most
effectively and efficaciously be developed to optimize the use
of these federal dollars and achieve the most beneficial
effects. Only through rigorous examination and testing can
evidence-based, sustainable interventions reduce the complex
set of factors that influence mental and behavioral health in
the Arctic, especially in Alaska Native youth. Thank you so
very much for the opportunity to present this testimony before
the Senate panel.
------
Prepared Statement of Julia M. Watkins, Executive Director, Council on
Social Work Education (CSWE)
Dear Chairman Dorgan and Ranking Member Barrasso: On behalf
of the 3,000 individual members and 650 graduate and
undergraduate programs of professional social work education
comprising the Council on Social Work Education (CSWE), I
respectfully submit the enclosed report, Status of Native
Americans in Social Work Higher Education, * to the official
Committee record for the hearing that took place on March 25,
2010 on Youth Suicides and the Urgent Need for Mental Health
Care Resources in Indian Country.
---------------------------------------------------------------------------
* The information referred to has been retained in Committee files
and be found at www.cswe.org/File.aspx?id=25694
---------------------------------------------------------------------------
CSWE is a nonprofit national association representing
graduate and undergraduate programs of professional social work
education. Founded in 1952, this partnership of educational and
professional institutions, social welfare agencies, and private
citizens is recognized by the Council for Higher Education
Accreditation (CHEA) as the sole accrediting agency for social
work education in the United States. Social work education
focuses students on leadership and direct practice roles
helping individuals, families, groups, and communities by
creating new opportunities that empower people to be
productive, contributing members of their communities.
In 2007, CSWE formed a Native American Task Force to
examine the current state of Native Americans in social work
education. The report, finalized in late 2009, takes a close
look at the disparities that exist with respect to Native
Americans in higher education, focusing primarily on social
work education. It examines the extent to which social work
programs have been successful in recruiting and retaining
social work students and faculty, as well as the extent to
which all social work students are taught core competencies
needed to serve the mental health needs of Indian Country. A
primary finding of the report is that social work graduates
(regardless of whether they are American Indian/Alaska Native
or not) need to have baseline knowledge of Native American
culture in order to effectively practice. The report also
discusses social work programs across the country that have
been successful in recruiting American Indian/Alaska Native
students and faculty and suggests that these programs could
serve as models for other social work programs.
As you will see by reading the report, and as was discussed
during the March 25 hearing, capacity building can be a
challenge for professions responsible for providing mental
health services, especially to Indian Country. CSWE is
committed to addressing the severe shortfalls plaguing the
social work profession by implementing the recommendations made
in the report to recruit and retain Native American students
and faculty into social work programs, and to integrate Native
American content into social work curriculum.
I hope you will take a moment to read the attached report.
If CSWE or the Native American Task Force can ever be of
assistance to the Committee, please do not hesitate to contact
CSWE's government relations staff, Ms. Wendy Naus.
------
Prepared Statement of Kevin McCartney, Senior Vice President of
Government Relations, Boys & Girls Clubs of AmericaWhat do we know
about adolescent suicide in America?
One adolescent attempts suicide every minute.
Boys are 4 times more likely to successfully commit
suicide than girls; however, girls will attempt suicide
4 times more frequently than boys.
For every completed suicide, there are 100 kids who
attempt it.
There are 500,000 to 1,000,000 attempted suicides
each year.
There will be 100 suicides a week, 14 a day this
year.
Suicide is common to all people, not just a particular
ethnicity or socioeconomic group. There are many different
reasons for suicide such as loss of a boyfriend/girlfriend,
feelings of hopelessness or powerlessness, poor self-esteem,
pressure to succeed, stress, family or school problems, abusive
situations, depression, loneliness, and sometimes no visible
cause at all. As front-line youth development professionals,
Clubs are often first-responders to kids in crisis and in
regions where suicide attempt and completion rates have
skyrocketed, Clubs have established programs and protocol to
address the issue. Two examples follow.
Alaska
When the Boys & Girls Clubs of Southcentral Alaska launched
an outreach program for Native youth, they began in remote
village of Tyonek. This tiny community of approximately 150
Athabascan Indians had been plagued by alcoholism and a
terrible teenage suicide problem, averaging more than one such
death every year. The problem was so bad that tribal elders
constructed a Suicide Wall to list the names of the young
victims.
Since the Boys & Girls Club opened in 1993, not one child
has taken his or her own life, and the Suicide Wall has been
removed. Today, every youth in the village is a member of the
Club, and names are now being added to the Youth of the Month
Wall, which recognizes positive contributions by the young
people in the village.
Alaska has the highest suicide rate in the nation and
Alaskan youth are nearly four times more likely than youth
nationwide to commit suicide. In response to this phenomenon,
Boys & Girls Clubs launched a statewide suicide prevention
initiative, Project LEAD, in 2002. Project LEAD (Leadership,
Education, Acceptance, and Determination) is targeted toward
at-risk youth in Clubhouse communities throughout urban and
rural Alaska. Project LEAD builds protective factors in youth
through academic and leadership programming, along with alcohol
and substance abuse prevention programming. In the project's
first year, sixteen youth suicide interventions took place. To
date, 60 suicide interventions have occurred; three
interventions were suicide pacts involving a total of nine
young people.
The five-year $930,000 project, championed by key
legislators, funded an Instructor in each community to network
with mental health and medical providers, school counselors,
cultural leaders, churches and parents to identify and serve
at-risk and in-crisis youth. As a result of the initiative,
over 150 front-line Club professionals in 30 communities are
trained in suicide intervention skills, and provide watchful
support to over 15,000 children and teens statewide. These
trained eyes and ears have identified 312 youth who exhibited
one or more warning signs and are now building ``profiles'' on
these youth. Profiles are a paper trail of each youth's
progress in academic and job performance, peer and family
relations, and counseling referrals.
North Dakota
Boys & Girls Club of the Three Affiliated Tribes forged a
critical partnership with the State of North Dakota and the
Garrett Lee Smith Memorial Fund in January 2008 to address the
devastating trends of suicide among Native American youth.
Clubs approached the initiative as a way to change the culture
of hopelessness among teens. Clubs worked with health
professionals to insert the Sources of Strength curriculum in
Clubhouses and school-based afterschool programs to reach
children as young as age five. Sources of Strength is a suicide
prevention and health promotion program designed to prepare
diverse students to be capable ``Peer Leaders'' for focused
suicide prevention activities with ongoing adult mentoring. The
program raises awareness and uses protective factors (sources
of strength) that help all students be resilient. The program
focuses on positive strengths and resources that help students
to overcome problems in their lives.
The Clubs' suicide prevention efforts are supported with a
$40,000 grant, as well as in-kind services with Three
Affiliated Tribes, Tribal Mental Health, Indian Health Service,
five school districts on the Fort Berthold Indian Reservation,
the Gerald Fox Justice Center and the University of North
Dakota. To date, 1,364 students are enrolled in at least one of
our suicide prevention programs or activities. The program is
evaluated by the State of North Dakota on a quarterly basis.
Other Efforts
Boys & Girls Clubs in New Mexico, Arizona, Oklahoma and
Colorado are also meaningfully engaged in teen suicide
prevention.
New Mexico
Navajo, NM and AZ--Club professionals participate in
community-based suicide prevention task forces; the
Native HOPE curriculum is utilized in four schools that
partner with Boys & Girls Club.
Mescalero Apache, NM--The community has a grant
through the school that uses the Native HOPE curriculum
in a community center. There are Club members that
attend this program.
The Native HOPE curriculum by Dr. Clayton Small focuses on
strengthening adult-youth relationships and community action
planning. Key elements include: (1) Culturally competent
activities incorporating spirituality, humor, and important
values such as belonging, mastery, interdependence and
generosity; (2) Teaching team building, adult/youth trust,
communication and team effectiveness; and (3) Providing
advocates with information, skills and abilities needed to
develop and maintain an active community team committed to
creating an action plan to implement prevention and wellness
activities to increase youth resiliency.
Oklahoma
Tahlequah, OK--The school district has a three-
year grant for drug and alcohol prevention, and suicide
prevention. The grant supports three therapeutic counselors at
the high school, and Clubs have access to this resource.
Chelsea, OK--County-wide counseling services are
available in one Club facility.
Southern Ute, CO--The Club partnered with the county in
its training of 60 gatekeepers in the ASSIST program;
Clubs intend to seek support to train kids in the
ASSIST program, too.
------
Prepared Statement of Mary J. Weiler, Board Chair, American Foundation
for Suicide Prevention, North Dakota Chapter
Thank you for the opportunity to provide written testimony
for this committee hearing. My name is Mary Weiler--I am a
survivor of suicide loss. On October 6, 2005, I lost my young
daughter, Jennifer, to suicide.
This shining star graduated with honors, was an
accomplished musician, an avid environmentalist, a loving and
attentive daughter/sister, an advocate for the poor and
disadvantaged--yet struggled with chronic depression and
anxiety for over a decade.
Over time, I've come to learn that more than 90 percent of
people who die by suicide have an illness such as depression,
bipolar disorder, schizophrenia, or substance abuse at the time
of their death--sometimes diagnosed, sometimes not. And after
reading the letter that my daughter left for us, I have also
come to understand that death by suicide is not intentional--it
is a result of many complicated factors. I found out that due
to the stigma that surrounds mental illness, she lived in fear
and isolation and felt she was a burden. At the core, suicide
is an escape from psychic pain or distress by a person who
cannot--at the specific moment in time--find another way to
cope. What I learned is that her experience with depression was
totally remote from a normal experience, the horror induced by
depression took on the quality of real physical pain that
ultimately became unbearable for her.
I have also learned that suicide is influenced by biology,
personal and social psychology, roles and relationships, and
issues about the very meaning of each of our lives. Many
factors come together in a multitude of different combinations
to make a death by suicide. The more factors or types of mental
distress or illnesses that one experiences, the stronger the
state of vulnerability. I have learned that just as people can
die of heart disease or cancer, they can die as a consequence
of mental illness. It has been established with reasonable
certainty that such severe depression is chemically induced
amid the neurotransmitters of the brain, probably as a result
of systemic stress, which for unknown reasons causes a
depletion of certain chemicals in the brain.
I've also learned that I'm hardly alone: research shows
that more than 60 percent of us will lose someone we know to
suicide during the course of our lifetime; more than 20 percent
of us will lose a family member. Nevertheless, the historical
stigma surrounding suicide persists, leaving many survivors of
suicide loss feeling misunderstood and abandoned, yearning for
comfort and understanding.
Survivors of suicide are also often victims of stigma--
people feel awkward and don't know what to do or say to
surviving family members. It is stigma that continues to keep
suicide from the public's eye. People are afraid of the word,
and worse, too often unwilling to be open to talk about the
topic. If we can't get through the stigma, we struggle to be
able to educate. It is only when we get beyond the stigma that
education will be possible and suicide prevention a reality.
The stigma issue is so important and critical to suicide
prevention that over the last several years the American
Foundation for Suicide Prevention (AFSP) has dedicated over 12
Million dollars to research alone and continues to be committed
to funding research projects in the future.
North Dakota loses someone to suicide every four (4) days.
Suicides rates of American Indian youth are the highest in the
nation and escalating in recent years. There is still a great
deal of work to be done to bring mental services to the local
community to end the stigma and reduce the number of suicides
on our reservations.
What Mental Health Care Resources Are Needed
1. Better Data and Definitions--See Attached Public Policy Brief
Fund demonstration projects in tele-mental health to find
how these systems can be of greatest benefit in Indian County
and fund infrastructure to connect service provides, families,
and patients for communication and treatment planning with
support networks while in treatment.
Promote and fund the interface of data and a national
registry through IHS for suicidal behaviors and treatment, to
provide data informing continuity of care across systems for
inpatient, outpatient, dual diagnosis and other supportive
services.
Collecting statewide data and establishing a mandatory
reporting system to gather data; plan programming, and get
youth needed services before they complete suicide.
Establishing Uniform definitions--collecting all the types
and causes in injuries in emergency rooms is needed to develop
uniform definitions (undetermined). Some drowning and single
motor vehicle deaths are ``misclassified'' as natural or
accidental when suicide would be more correct. Misclassifying
of such deaths contributes to under reporting of official
numbers.
2. National and State Research
Encouraging research to develop new treatment initiatives
aimed at reducing suicide by:
Examining the relationship of domestic violence and
child violence on suicide rates.
Implementing Suicide Screenings Tools for our
adolescents and college students such as the
Interactive Screening Program through AFSP.
Improving fire arms storage practices.
Funding for research to determine evidence-based
treatments for American Indian (AI) and Alaskan Native
(AN) populations. Seek grant from AFSP.
3. Mental Health Services
Increase funding to Indian Health Service (IHS) to
increased the number of credentialed mental health
professionals providing services in Indian country.
Increase funding of Indians into Psychology and Indians
into Medicine to increase the number of American Indian (AI)
and Alaskan Native (AN) providers in Indian Country.
Increase funding of loan repayment programs to recruit and
retain qualified mental health service providers in Indian
County.
Fund aftercare treatment programs and circle-of-care
services for transition and follow-up treatment for Indian
youth. Explore Post-vention program offered by AFSP.
4. Education and Training
Providing Training Opportunities
Require cultural competence training for service providers
in Indian Country. Providers must relate to the cultural values
of the people they serve.
Fund clinical placement, internship, and post-doctoral
residency programs for AI/AN students for experiences working
with clients in Indian Country.
Provide training for selected community members to begin
Survivor of Suicide Loss Support Groups on the reservations.
5. Focusing on Protective and Prevention Factors
Provide Skill Building tools for our young people--problem
solving, conflict resolution, non-violent ways of handling
disputes and new coping mechanisms.
Foster and celebrate connectedness and strengths with
family and friends. Enlist the family members and friends in
the plan for a young person who is struggling with coping.
Explore Sources of Strength--Peer Resiliency Model.
Restricting access to lethal means of self-harm (i.e.
firearms is still the leading method of suicide death).
Develop ``hope kit'' for our young people to increase their
social supports--who to call; knowing the triggers of their
depression then having a support person or action to deal with
the trigger.
Provide appropriate funding for mental health care programs
such as ``Mental Health First Aid'' that help to build
community capacity and reduce stigma related to mental health
issues and crises.
6. Advocacy and Collaboration
Although suicide is clearly a clinical issue, it is also a
public health issue. This necessitates a shift in focus from
prevention and treatment at the individual level to prevention
and treatment at the community level. Therefore, suicide
prevention should no longer be solely the concern of mental
health professionals but also that of the entire community.
The AFSP-ND Chapter has been fortunate to be able to
collaborate with:
The ND Coalition for Suicide Prevention
The Gay Lesbian Bisexual Transgender community
The ND Department of Health and ND Department of Human
Services
The Veterans Administration for Suicide Prevention
Survivors of Suicide Loss Support Groups
Mental Health America-ND
Law Enforcement and First Link
Prairie St. John's--Psychiatric Hospital
R.S.V.P Older Adults Volunteer Program
Public and Private School Districts
Universities and Colleges
Community Churches
In closing, what I have found is that individuals who are
suffering from depression are not helped by lectures or by
hearing all the reasons they have to live. What they need is to
be reassured that they have someone to whom they can turn--be
it family, friends, school counselor, physician, or teacher--to
discuss their feelings or problems. It must be a person who is
very willing to listen and who is able to reassure the
individual that depression and suicidal tendencies are very
treatable. Seventy-five percent of all suicides give some
warning of their intentions to a friend or family member. All
suicide threats and attempts must be taken seriously. Treatment
is of utmost importance, and may involve medications, talk
therapy or a combination of the two.
The American Foundation for Suicide Prevention is the only
national not-for-profit organization exclusively dedicated to
understanding and preventing suicide. AFSP promotes research,
awareness and education and reaches out to people with mood
disorders and those affected by suicide. In May 2007, the AFSP
North Dakota Chapter was formed to engage in the following five
core strategies:
Funds scientific research
Offers educational programs for professionals
Educates the public about mood disorders and suicide
prevention
Promotes policies and legislation that impact
suicide and prevention
Provides programs and resources for survivors of
suicide loss and people at risk, and involves them in
the work of the Foundation
The work of suicide prevention must continue to occur at
the community level where human relationships breathe life into
public policy. The mindset should always be to improve mental
health and get the best value (saving lives) for our spending--
NOT just saving money!
If we provide mental health resources to the right people
at the right time we can actually save money but most
importantly we are SAVING LIVES.
Attachment
------
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Randy E. Grinnell
Question 1. Can you describe how IHS becomes aware of and
responds to these tragedies?
Answer. Most of the time, IHS becomes aware of these
suicides from IHS Service Unit staff, Tribal health providers,
or Tribal leadership. Our experience in responding to these
types of events has taught us that our effectiveness hinges on
a coordinated community response involving Tribal government;
the local Health Departments; Emergency Medical Services; law
enforcement; schools; faith-based institutions and spiritual
leaders; and pertinent State and Federal offices. Proactive
coordination of services and a designated point of contact are
particularly important to reduce confusion in the community and
increase the effectiveness of each partner's activities, as
well as the effectiveness of the overall response. The more we
can get people and agencies to work together collaboratively,
the more likely the crisis can be managed quickly. A clearly
defined intervention plan, consisting of adherence to a unified
message and crisis response is important for those needing
immediate assistance and support.
Primary support comes through the IHS Area Office. The IHS
Headquarters supports the Area Office in their efforts to
assist the Tribal community. The Area Office works closely with
the Tribal community to help coordinate IHS resources in the
response. ``In the case of self-government Tribes additional
funding and resources maybe provided to assist in responding to
a crisis in their communities.''
While most responses are handled by the communities
themselves, there are times when a crisis can be of such great
magnitude that local response capacity may be inadequate or
temporarily overwhelmed. In some of these situations, we may
also be able to help coordinate emergency community
stabilization assistance utilizing the U.S. Public Health
Service Commissioned Corps Emergency Response Mental Health
Teams. The IHS Emergency Response Model design responds both to
the individual(s) in crisis and the community affected. This
model is designed to assist all American Indian or Alaska
Native communities in mitigating the immediate crisis, and
stabilizing the community so that long-term solutions
(planning, prevention, and implementation plans) can be
developed by the community.
Question 1a. Do each of these communities have a mental
health provider?
Answer. These communities often have a mental health
provider. However, when there are vacancies or limited
behavioral health providers, this can have a negative impact on
access to behavioral health care. For example, a Tribal
community may have difficulty recruiting certain disciplines
such as psychiatrists and psychologists while, in other
communities, there may be only one or two behavioral health
providers. So, when there is a vacancy or a staff person takes
time off, the community may not have access to behavioral
health services. The availability and adequacy of mental health
programs for American Indians and Alaska Natives varies
considerably across communities.
Question 1b. How do you think Tribes, the Indian Health
Service, and Congress could best work together to improve youth
suicide prevention efforts and increase the availability of
mental health resources?
Answer. The key strategy that IHS employs to address Indian
youth suicide is to work in partnership with Tribes to bring
services and resources together to focus on mental health needs
and reduce the rate of suicide within American Indian and
Alaska Native (AI/AN) communities. Tribes must be involved at
every step of developing and implementing suicide prevention
strategies within their communities. The IHS is currently
working with Tribal leadership to coordinate programs,
services, and resources to address this problem. This focus on
Tribal collaboration marks only the beginning of a much larger,
long-term process.
There also needs to be continued collaboration between
Federal partners (such as IHS with SAMHSA, NIMH, DOJ, BIA
etc.). This is not only beneficial but it is necessary.
Continued coordination of resources across numerous agencies
will allow the development and implementation of a
comprehensive, integrated, public health approach to reducing
deaths by suicide and suicide attempts. IHS plays a key role
along with Tribal leaders in this collaboration.
The IHS National Suicide Prevention Initiative has five
targeted approaches for suicide prevention and intervention
that we continue to implement including assisting IHS, Tribal,
and urban Indian programs and communities in addressing suicide
utilizing community level cultural approaches, identifying and
sharing information on best and promising practices, improving
access to behavioral health services, strengthening and
enhancing IHS' epidemiological capabilities, and promoting
collaboration between Tribal and urban Indian communities with
Federal, State, national, and local community agencies.
Question 2. Does the IHS track the number of mental health
care providers in Indian Country?
Answer. IHS can generate reports that look for certain job
categories, but there are limitations to the amount and type of
data that can be generated. This information will only provide
a ``snapshot in time'' because there is a great deal of
turnover among mental health providers in tribal communities.
In addition, behavioral health disciplines may not be clearly
defined in data collection tools (e.g., ``psychiatrists'' fall
under the general ``medical officer'' series); so, it may be
difficult to ascertain which of those medical officers are
psychiatrists. With over 50 percent of the Mental Health
program and over 85 percent of the Alcohol and Substance Abuse
program under tribal management, the IHS does not have access
to tribal and urban Indian health mental health care provider
data.
Question 2a. If so, how many mental health care providers
work in Indian Country?
Answer. The numbers of mental health providers in the IHS
civil service system are as follows:
Social Sciences (0101) = 93
Social Sciences Aid/Technician (0102) = 54
Clinical Psychologist (0180) = 60
Social Worker (0185) = 92
Social Services Assistant/Aid (0186) = 41
Social Services (0187) = 14
Medical Officer-Psych (0602) = 24
Psych Nurse (0610) = 5
Practical Nurse-Psych (0620) = 4
These numbers only represents IHS' federal service and does
not take into account Tribal and Urban Indian mental health
care provider data.
Question 2b. What is the vacancy and turn-over rate?
Answer. Although this information may be collected for IHS
the vacancy and turn-over rate for mental health providers is
currently unavailable. In order for IHS to be generated both a
vacancy and turn-over rate, it (the number of vacancies and
number of turn-over) would have to be monitored over a period
time. The data for Tribal and Urban Indian programs are
unavailable.
Question 2c. How many tribes have mental health providers?
Answer. This is a difficult question to answer given the
increasing contracting/compacting of mental health programs by
tribes and tribal programs, and their having no obligation
under P.L. 93-638 to report such information to the federal
government for programs they themselves operate. Subsequently,
it is difficult to give an answer that accurately reflects all
tribes and programs, so while we can report federal staff as in
the question below, we are unable to do so for tribal programs.
It is our experience and understanding, however, that the vast
majority of tribally contracted/compacted programs do have
their own providers. For some, most often smaller or more
isolated programs, there are tribal consortia that pool
resources and providers for their programs and communities. For
higher level services as in intensive outpatient, residential,
and hospital care, many tribes and tribal programs share
resources or utilize contract health services to access
providers.
Question 2d. And what is the breakdown of between
psychiatrists, psychologists, social workers, and other mental
health care providers?
Answer. We do not have a breakdown of behavioral health
providers for Tribal and Urban Indian health programs. However,
for the IHS federal civil service providers, the breakdown is
as follows:
Social Sciences (0101) = 93
Social Sciences Aid/Technician (0102) = 54
Clinical Psychologist (0180) = 60
Social Worker (0185) = 92
Social Services Assistant/Aid (0186) = 41
Social Services (0187) = 14
Medical Officer-Psych (0602) = 24
Psych Nurse (0610) = 5
Practical Nurse-Psych (0620) = 4
Question 3. Do you think the current funding for mental
health and suicide prevention is adequate?
Answer. The President's FY 2011 budget request for an
increase of $4 million will help support AI/AN communities in
eliminating behavioral health diseases and conditions which
include early identification of factors contributing to
suicide. The President's total FY 2011 budget request for
Mental Health of $77,076,000 is approximately 13.8% over the
Omnibus FY 2009 budget of $67,748,000, and approximately 5.9%
over the FY 2010 enacted budget of $72,786,000. This is in
addition to the $11.3 million increase for the Alcohol and
Substance Abuse program which includes funding for the
Methamphetamine and Suicide Prevention Initiative (MSPI)
program. These increases reflect the President's commitment to
addressing the ongoing need for mental health and alcohol and
substance abuse programs servicing Indian Country.
Question 3a. What kinds of resources and funding do you
think is necessary?
Answer. Funding provided for the Methamphetamine and
Suicide Prevention Initiative, is now, for the first time,
offering community developed and delivered direct services and
support in 127 programs across Indian Country. These programs
were developed and are now being delivered by the communities
themselves, and are acting as pilot projects and community
laboratories for innovations that will hopefully be able to be
utilized across systems and communities.
Current program funding has been used to develop a suicide
surveillance reporting tool which documents incidents of
suicide in a standardized and systematic fashion. This tool
captures data related to specific incidents of suicide which
are essential to accurate data analysis. Through programs like
the surveillance reporting tool, IHS can better target
resources both now and in the future. In addition, funding for
the Methamphetamine and Suicide Prevention Initiative, is now,
for the first time, offering community developed and delivered
direct services and support in 127 programs across Indian
Country. This program is being implemented by communities
acting as pilot projects and community laboratories for
innovations that will hopefully be utilized across systems and
communities. These types of programs and initiative maximize
current resources and target current funding to where it is
most needed.
Question 3b. Of the funding going to tribes for mental
health services, how much is devoted to suicide prevention or
related activities?
Answer. IHS does not have data on how much of the total
funding going to tribes for mental health services is
specifically dedicated to suicide prevention. What we do know
is that in FY 2010, $16.3 million of the IHS alcohol and
substance abuse budget is dedicated to the Methamphetamine and
Suicide Prevention Initiative.
Question 4. What do you think is the biggest barrier to
data collection in the Indian health system?
Answer. We have made substantial efforts over the last
several years to improve our behavioral health data collection
in the Resource and Patient Management System (RPMS) and will
continue these efforts. The biggest barrier to data collection
is that not all tribes utilize this electronic method of data
collection although it is increasingly being used across our
Indian health system. The data from tribes that do not utilize
RPMS may or may not be integrated into the larger RPMS data
set, dependent upon the tribal program. In addition, tribes can
elect to not transmit their data to the IHS national data
warehouse. Inconsistent data collection does not provide a
complete picture of the health issues in Indian Country.
Question 4a. Do you think improvements in tracking and
collecting youth suicide statistics would be helpful in
preventing youth suicide?
Answer. Yes. In order to address the suicide epidemic in
Indian Country, data collection and analysis are pertinent
components to developing a comprehensive public health response
to the problem. The greater the levels and quality of
information available from the point of care through to
national programs, the better Indian health programs and health
systems can track and trend needs, then target limited
resources and services to where they are needed most. The
better the data, meaning the better the nature and quality of
health information, the better the systems of care can then
respond to health needs.
Question 4b. In the past, has IHS looked at implementing a
mandated reporting system like the one being used on the White
Mountain Apache Reservation?
Answer. IHS has already developed and implemented a suicide
surveillance reporting tool to document incidents of suicide in
a standardized and systematic fashion which is available to all
providers in the RPMS health information system. The suicide
surveillance tool allows clinicians to document incidents of
suicide, including ideations with intent and plan, attempts,
and completions. It captures data related to a specific
incident of suicide, such as date and location of act, method,
contributing factors and other useful epidemiological
information. With the expansion of suicide data collection to
the primary and emergency care settings, IHS will have more
comprehensive and reliable information about these occurrences.
The data will be used to better understand the prevalence of
suicide in the populations served by IHS, Tribal, and Urban
Indian healthcare facilities and to inform intervention and
prevention activities.
Most patients with serious suicidal ideation or attempts
present first to providers in primary or emergency care. The
availability of the RPMS suicide surveillance tool for all
providers in IHS, Tribal, and Urban Indian healthcare settings
will promote standardized and systematic documentation of
suicide events. Suicide data can be analyzed locally through
RPMS reports and is exported nationally, so that we can develop
a better understanding of this important public health problem.
------
Response to Written Questions Submitted by Hon. Al Franken to
Randy E. Grinnell
Question 1. Mr. Grinnell, we have a serious shortage of
mental health providers in Minnesota, especially on the
reservations. In your testimony, you describe the challenges
that these providers face in Indian country and some of the
remedies that IHS has tried. Your description of telehealth
services seems like a point of light and I'd like to see them
expanded. Have other remedies have been effective?
Answer. There have been other promising approaches to
address access to and quality of mental health care. IHS is
promoting the integration of behavioral health services into
the general healthcare delivery system through the spread of
primary care-based behavioral health services following models
already successfully implemented by the Veterans Healthcare
Administration and branches of the Department of Defense. A
good example of such activities coordinated across the
healthcare system is the nation-wide promotion of the Alcohol
Screening Brief Intervention model, which has been demonstrated
to reduce trauma recidivism by up to 50% in some settings. Such
models recognize the complex interrelationship of medical and
behavioral health concerns and offer opportunities for early
intervention rather than waiting for the development of fully
manifested mental health disorders. The IHS is also working to
improve the psychosocial care delivered to patients with
chronic illnesses such as diabetes and improve their long-term
outcomes through recognition of and attention to intertwined
behavioral health concerns.
Question 1a. What can we do to attract mental health
providers to Indian Country and keep them there?
Answer. Over the years, we have attempted to apply a number
of remedies to attract mental health providers such as 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 United
States Public Health Service Commissioned Corps mental health
teams. Increasing access and availability to these programs is
necessary to attract additional mental health providers. For
example, this year the IHS scholarship program received
approximately 1,200 applicants while only a little over 100
will be selected. Increasing staff self-care, clinical
supervision, and support will also serve to reduce staff
burnout and isolation.
Intern programs allow Indian Country to utilize mental
health providers still in training that can see patients under
the supervision of a licensed health professional. The
initiation of pre-doctoral intern programs will help increase
the number of patients accessing care and serve as a
recruitment tool for psychologists and psychiatrists. Standing
Rock has implemented a pre-doctoral psychology intern program
and has been able to triple their patient load as a result. In
addition, multiple interns have agreed to stay on and continue
to practice mental health on the reservation when they are
licensed. The IHS Albuquerque Area Office has funded an
American Indian psychology intern program since 1993. The
Albuquerque Area Office is part of the Southwest Consortium
Pre-doctoral Psychology Internship program, which includes IHS,
the Albuquerque Veterans Healthcare Administration Medical
Center, the University of New Mexico Hospital, and Forensic
Health Services. The interns work in numerous sites across the
Albuquerque Area. They have trained numerous American Indian
psychologists, many of whom now work in Indian Country.
The potential for expanding these types of programs is a
way to improve health care and recruit mental health providers.
Without psychology internships in rural and underserved areas,
there is a failure to complete the ``pipeline'' of training
needed to recruit and retain mental health providers in Indian
Country. IHS will continue to make every effort to support and
expand psychology internship programs. The President's FY 2011
budget request for over $41 million for Indian Health
Professions contributes to this effort.
Question 2. What are the challenges that arise when people
have to attend non-tribal facilities?
Answer. Although providers in these facilities may be well-
trained in medicine and healthcare and are eager to practice
and serve American Indian and Alaska Native patients, they lack
knowledge and understanding about this population. This can
hinder their communication with their patients. We know from
the Institute of Medicine that effective provider-patient
communication can build respect and trust, resulting in better
patient outcomes. We also know that patient-centered care is
essential for quality care and, ultimately, more equitable care
for all. It is important that providers understand the cross-
cultural aspects of mental illness in American Indian and
Alaska Native patients so that they can effectively evaluate
and manage these disorders. Providers who understand the
differences between Western and traditional Indian perspectives
in the role of culture in mental health and how these
perspectives may influence the types of mental disorders seen
in American Indian and Alaska Native patients can be more
effective in treating their patients.
Question 3. Can you please discuss what IHS mental health
programs do to help families, not just individuals with regard
to mental health and substance abuse?
Answer. We strive to support American Indian and Alaska
Native individuals, families, and communities by: (1)
maximizing positive behavioral health and resiliency in
individuals, families, and communities; (2) improving the
overall health care of American Indians and Alaska Natives; (3)
reducing the prevalence and incidence of behavioral health
diseases; (4) supporting the efforts of American Indian and
Alaska Native communities toward achieving excellence in
holistic behavioral health treatment, rehabilitation, and
prevention for individuals and their families; (5) supporting
Tribal and Urban Indian behavioral health treatment and
prevention efforts; (6) promoting the capacity for self-
determination and self-governance, and; (7) supporting American
Indian and Alaska Native communities and service providers by
actively participating in professional, regulatory,
educational, and community organizations at the National,
State, Urban, and Tribal levels.
Specifically for families, IHS supports the development of
locally-driven initiatives that aim to lessen the impact of
risk factors while enhancing those factors that are known to
protect against suicide, mental health conditions, and alcohol
and substance abuse issues. Families provide the essential
support and nurturing for individuals, thus supporting families
is critical to supporting individuals, and vice versa. The vast
majority of mental health programs offer services for both
individuals and families. In fact, in most tribal communities
and programs it is difficult to separate families and
individuals in overall provision of direct services. Indeed,
particularly for youth, standard treatment includes regular
family involvement. Additionally, traditional knowledge, along
with the role of elders, spiritual leaders, and extended
family/clans needs to be respected and validated for the
important role they play in healing and wellness. In this
regard, family, again, is central and integral. Increasing
protective factors, as in utilizing traditions and family, are
equally or more effective than decreasing risk factors in terms
of reducing suicidal risk, mental illness, and alcohol and
substance abuse. Family, culture, and tradition are
cornerstones to providing effective behavioral health services.
IHS works to use practice based interventions that can
integrate these to increase their effectiveness in Indian
Country. We have found that programs that integrate them are
more effective within the communities and with our youth,
families, and communities.
Nurturing of children and promoting their safety are the
most basic aspects of American Indian and Alaska Native
cultures. Protection of children against harm is embedded in
cultural and spiritual beliefs, child-rearing methods, extended
family roles, and systems of clans, bands, or societies.
Traditional family values bring strength to community-driven
efforts to prevent suicide, mental health conditions, and
alcohol and substance abuse among youth, families, and
communities. Every community member including families,
businesses, community leaders, and others have a role to play
in keeping children and youth safe. Community members can
promote protective factors by ensuring their programs include
spiritual beliefs, traditional values and healing methods,
spiritual and cultural continuity, and ensuring that their
young people have a valued role in preserving their heritage.
------
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Paula J. Clayton, M.D.
Question 1. The American Foundation for Suicide Prevention
(AFSP) organization has 32 community-based chapters focused on
grassroots suicide prevention, including an active chapter in
the state of North Dakota. How many of the AFSP state chapters
of work with tribal communities? Do you think there are ways
for AFSP to get more involved and assist in youth suicide
prevention activities in Indian Country?
Answer. AFSP currently has 40 chapters, many of which are
on the East Coast, fewer on the West Coast and fewest in-
between. As you indicated, our firmest connection with tribal
communities is in North Dakota, but an additional two or three
chapters have some connections with Native American groups. I
believe, however, that if more suicide prevention materials
specifically addressing these populations were available, other
AFSP chapters would reach out to tribal communities.
We currently have three programs that might be applicable
to these communities. One is the award-winning More Than Sad
film series that I brought with me to the hearings, which
include a film on teen depression designed to be shown to high
school-aged youth, and another on youth suicide prevention for
teachers and other school personnel. More information about
these products is available on the website, http://
morethansad.org. With the necessary financial resources, these
films and the accompanying educational materials could be
adapted to specifically address youth depression, drug use, and
suicide in Native American communities. We would recommend
using Native American teens as the actors and actresses in the
teen film, establishing an advisory committee to guide the
effort that includes both adults and youth from tribal
communities and focus group testing all products while in draft
form to assure that they will be readily accepted by the
intended audiences and effectively convey the intended
messages. The More Than Sad films have been well-received by
schools in general but I should note that they are expensive to
make. Our funding came from a grant from the New York State
Office of Mental Health, which was supplemented by gifts from
several additional donors and by proceeds from our Out of the
Darkness community walks. If a parallel package of educational
materials were available for teens and educators in tribal
communities, I can envision our chapters reaching out, as they
do so well, to bring them to the appropriate communities across
the country.
The second project is a DVD on Depression and Bipolar
Disorder that educates patients with mental illness and their
families about these illnesses. Like the previously discussed
films, this DVD was made for a general population, but may be
informative for Native Americans communities. Again, its
relevance and resonance should be focus group tested with
appropriate community members. In this case as well, developing
a parallel product that specifically addresses these illnesses
and perhaps others having high prevalence in tribal communities
would be ideal, although would require special funding. I would
like to emphasize that well-developed, appealing materials is
in the long run a cost-effective way of educating and engaging
youth, their parents, teachers, community leaders and other
adults around the topic of suicide prevention. Investing in the
development of culturally appropriate materials would represent
a major step toward encouraging treatment for depression and
other mental disorders and reducing suicidal behavior in these
communities.
Third, AFSP has developed an anonymous, online interactive
screening program for persons aged 18 and older, which would be
extremely helpful for those Native Americans who have access to
the Internet. It is possible it could also be accessed through
use of online chat rooms. This program screens for stress,
depression, alcohol and substance use, anxiety, eating
disorders and suicide, and is currently being expanded to
include PTSD and other conditions prevalent among veterans. Its
purpose is to engage an individual through an anonymous online
discourse that will lead to in-person evaluation and treatment.
As part of this program, AFSP staff work closely with the
schools, workplaces, veterans facilities and other sites that
are using it, and would welcome the opportunity to discuss with
tribal leaders how the program might be adapted to Native
American communities.
Question 2. In your testimony you described the research
and suicide prevention work of the AFSP and also your extensive
work on youth suicide prevention and mental health issues.
Most of the AFSP efforts you discussed seem to be focused
on screening and early detection. Once you have identified a
child that should be referred to a mental health professional,
how difficult is it to get that child into treatment?
Do you think a dramatic increase in access to mental health
providers and other resources could help to turn around the
tragic rates of suicide in Indian Country?
Answer. You note, rightly, that most of AFSP's efforts are
on screening and early detection but you wonder about entry
into treatment. As I read the testimony from various tribes
that were sent to me before the committee hearing, I was struck
by the complexity of getting a referral. In some tribes the
route of the referral has to be approved by the governing
council. It seems to me that the simplest thing for the tribes
to consider is to refer all suspected problems to the
individual's primary care doctors, who would be trained how to
detect depression, substance abuse and other problems, how and
when to treat and when to refer. Multiple studies indicate that
when primary care doctors are taught to recognize and treat
depression, the suicide rate goes down, significantly, in the
community being studied. Other primary care providers such as
nurse practitioners and physician assistants could also benefit
from such training. I am sure each tribe has different
resources, so it will vary. Certainly, as was told in the
hearing, it would prevent the provider from not appreciating
the seriousness of a distressed young woman with rope burns on
her neck from attempted hanging and from only giving her a
cursory evaluation and no treatment before sending her home.
I am also not clear why there are not AA and DA groups on
the reservations. Clearly, that treatment is as successful as
almost any we have for alcohol and substance abuse. I believe I
was told by Jeremiah Simmons from The Mescalero NM tribe that
they had an association with UNM medical school to give a
medication for alcohol abuse to those members who have an
addiction problem in their tribe and that it may be working.
I would think before one considers a dramatic increase in
mental health resources to the tribes, one should do pilot
testing of such a plan in two or three very different tribes.
It may be that just having one full time mental health nurse
practitioner in each site is the best answer. And unless the
tribes are willing and able to tackle the alcohol and drug
abuse problems that run in families, it may be that the problem
cannot be solved.
Question 3. Today we heard testimony about the lack of data
collection of both the incidence of youth suicide and
prevention activities in Indian Country. In your testimony, Dr.
Clayton, you emphasized the importance of collecting youth
suicide data. Do you think the Indian Health Service and tribes
should have more data collection activities as a part of youth
suicide prevention efforts? How do you think they could improve
this data collection?
How does the availability of data on suicide and
availability of mental health services in Indian Country
compare to non-tribal communities?
Answer. I absolutely believe that improvements are needed
in collecting data on attempted and completed suicide in tribal
communities, starting with mandated suicide surveillance in
every tribe. The data from cancer registries and registries for
other serious medical illnesses show that registries are
important first steps in identifying the problem. These help to
calculate trends and identify high risk groups as well as
evaluate interventions. They provide a vital resource to
estimate the incidence of known risk factors (such as mental
illness, access to firearms, access and use of alcohol or other
drugs, previous attempts) and protective factors (like whether
a family member was available, they were brought in by police,
what are their social supports). Unless we know the extent of
the problem, we cannot begin to tackle it and we cannot measure
a change if an intervention is initiated.
Although U.S. law requires that all sudden deaths are
reviewed by a medical examiner or comparable official, I
understand the law does not apply to Native American tribes. In
all other deaths that are not sudden, a doctor must certify the
cause of death. I do not know how Native Americans handle this.
Anyway, that makes it possible to track suicides across the
nation, region by region. Although there are undetermined
deaths also, only a portion of them are probably suicide. And
the CDC has designated 17 states (we are lobbying for funds for
all 50 states) be trained to assess and record all violent
deaths and acts of unexplained injury, including suicide
attempts that occur in these states. The system is called the
National Violent Death Reporting System (NVDRS). In most states
this includes toxicology tests on the deceased. Such a system
would greatly benefit Native American tribes. It would help to
de-mystify the event, reduce stigma and call attention to the
problem, both for individuals, families and caretakers
responsible for them. The collaboration between Johns Hopkins
and the White Mountain Apache Tribe is an example of how it can
be done.
When I was young, some people thought cancer was contagious
and avoided anyone with the diagnosis. As it became clear this
life threatening medical illness was not contagious and
registries were developed to help identify the problem and test
newly developed treatments, the myths about the illness ended.
We must do the same for the brain disorders that lead to
suicide.
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Response to Written Questions Submitted by Hon. John Barrasso to
Paula J. Clayton, M.D.
Question 1. Your written testimony suggests that young
people who do not respond to initial treatment for mental
health issues need to be referred to mental health and
substance abuse specialists.
How would reach those young people who are referred to
these specialists but refuse to go?
Answer. In all communities, non-compliance with
recommendations regarding mental health treatment is an issue.
Our experience is that young people are more likely to be
willing to get treatment for depression, substance abuse and
other mental disorders when they understand them to be medical
problems rather than character disorders, and are supported to
seek help by their peers and by respected adults in their
community. Thus, broad educational efforts, aimed at changing
attitudes as well as providing scientifically-grounded
information, are necessary in the effort to increase the
willingness to get specialized treatment for mental health
problems. Linking distressed youth to caring adults in the
community can also be an effective way of cultivating support
for help-seeking for mental health problems.
Compliance with recommendations from a primary care
provider to seek specialized treatment is also furthered when
treatments for physical and mental disorders are provided under
the same roof, thus facilitating patients' access to services
and communications among care providers, and reducing the shame
associated with seeking psychiatric treatment.
Anonymous online screening tools, such as AFSP's
Interactive Screening Program, are also useful in engaging
reluctant young patients to seek mental health treatment. Our
evaluation data show that for many such youth, anonymous online
conversations with a local counselor were effective in
addressing and resolving negative attitudes about treatment,
fears of being stigmatized and other factors that pose barriers
to help-seeking.
Question 2. The Committee has received testimony
recommending more youth shelters, in particular, as places for
young people to go when their lives at home become toxic.
According to the testimony, for some youth, if they had had a
place to go for the night, they would not have made a suicide
attempt.
Do you have any other recommendations, such as ways in
which to engage parents or other family members, so that Indian
children feel secure in their homes?
Answer. Although I know little about youth shelters, the
idea of creating them sounds solid. Here again, however, it
would take a tribal commitment to make the use of them
acceptable to the teens in the community. Since shame is always
a problem, they would have to be presented as a wise choice for
the teens that need help. Again, if there were suicide
surveillance, it would be possible to learn whether more
suicide attempts occur on weekends and then perhaps begin by
making it available and acceptable first on weekends. Maybe the
tribe could even encourage non-distressed youth to be present
during the early months after it opened. Of course, there would
also have to be appropriate physical and mental health
assistance for those who come in, or at least the same familiar
and wise counselor.
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Response to Written Questions Submitted by Hon. Al Franken to
Paula J. Clayton, M.D.
Question 1. I learned a sobering statistic recently--a
study of American Indian teens in Minnesota found that more
than one-quarter believed they had only a 50 percent chance of
living to age 35, compared to 10 percent of white teens. This
statistic seems to show how difficult life is overall for these
teens.
Dr. Clayton, can you please discuss the role of poverty in
the youth suicide problem?
Answer. As you know, poverty contributes to access to
health care, quality of health care, quality of education, and
unemployment. All of those may shorten life span so if young
people live in poverty, their assessment of the future may not
be unfounded. The most important factors that can change that
future for youth who are born into poverty are a first-rate
education and access to first-rate health care. This must
include mental health care. But as AA informs, in addition, the
individual must also take responsibility for themselves and
admit he or she needs help. In the case of teens, it is the
family, the community, or an appropriate substitute for the
family that needs to make that decision. Certainly,
surveillance that includes the school teachers, police force
and designated adults would also provide a valuable network to
engage these teens in treatment.
The American Foundation for Suicide Prevention (AFSP) would
like to thank each of you, as well as all members the Senate
Committee on Indian Affairs for your interest and leadership on
suicide prevention in Indian Country. Our entire AFSP team at
our national headquarters in New York City, in our Washington
DC public policy office and all of our Chapters throughout this
great nation pledge our support to do whatever we can to assist
you and our tribal communities to prevent suicide through
education, research and treatment.
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Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Hunter Genia
Question 1. In your written testimony you discussed the
Tribe's mental health program in great detail and the extensive
behavioral health programming available through the Tribe. When
did the Tribe begin supplementing the mental health program
with tribal funds? Do you still find that more mental health
resources are needed in your community?
Please describe the activities specific to youth suicide
prevention that are ongoing on the Reservation.
Answer. The Saginaw Chippewa Indian Tribe was supplementing
the mental health program since at least the year 2000 if not
longer. I began working for the Saginaw Chippewa Indian Tribe
in the year 2000.
More mental health resources are certainly needed in the
way of prevention and residential services for our young
people. Our Behavioral Health program provides an expansive
amount of resources and outreach to our community that could be
deemed youth suicide prevention. This occurs on the prevention,
intervention, and treatment levels in our program. There is
also a saying in Indian Country, ``Culture is Prevention'' we
believe that to be true as well here on our reservation. Having
pride and self esteem is also in direct correlation with a
strong healthy cultural identity. An emphasis on prevention and
mental health occurs year around with a tremendous amount of
community activities. The Saginaw Chippewa Indian Tribe has
made a commitment to doing what we can for our community
members. However, there are still too many health issues to
address without proper funding.
Question 2. What is the biggest contributing factor to the
high need for mental health services and how can it be
prevented in the future?
Answer. I believe we haven't recovered as an Indian
community or tribe from some of the policies and practices that
have contributed to the traditional values and roles that
governed our families and tribes. We are talking one to two
generations removed from our families who attended the boarding
schools that assisted in stripping away our traditional
practices, languages and families. As a race of people who have
had to adapt to another cultures values, this created a
hardship for many families and communities where it tore apart
intact tribal communities and systems. What replaced these
cultural and traditional rich values were unhealthy behaviors
that turned into alcoholism, depression, trauma, violence,
helplessness, and hopelessness. These are the same health
issues we are still dealing with today.
Our biggest challenge in recruiting mental health care
providers is the low number of Native Americans in the field of
social work and counseling. With 50% of the total US Native
American population being adults only a small percentage move
onto seek a higher degree education. A small percentage of that
are going into the social work and counseling fields. We are
very fortunate that we have a small turnover of mental health
providers for our tribal program. This can be attributed to the
tribe's generosity and care towards the workers health and
wellness.
Question 3. What resources would a tribe need to develop a
Youth Treatment Center in their community?
Answer. We do not operate a youth treatment center. We do
have an adult residential substance abuse treatment program. A
youth treatment center is an idea the tribe is looking at
providing as well. If we were to operate a youth treatment
center I believe we can model after the traditional Native
American (Ojibway, Ottawa, and Potawatomi) values of the Seven
Grandfather Teachings. These seven teachings promote love,
respect, honesty, bravery, courage, humility, and truth. We
would surround the youth with these teachings and provide
activities that promote the Medicine Wheel which reinforces the
development of positive physical, emotional, mental, and
spirituality of an individuals being.
Funding for staffing and an appropriate facility would be
instrumental to making a youth treatment center a reality.
Health leadership internally within the tribe is also very
important. A shared and supported vision within the tribal
leadership is very important. The latitude, respect, and
recognition of modalities and cultural processes that promote a
healthy cultural self esteem and identity are desired is needed
from funding administrators and grantors. The access to
recovery (ATR) grant, which is a SAMSHA grant, is a great
example of recognition of cultural processes that are valued
within a grant process.
Question 4. What can we do for American Indian you to
prevent mental health and substance abuse issues before they
begin?
Answer. I believe in short that healing and wellness is
needed in every tribal community. Universal truths within
tribal communities means that trauma, substance abuse, mental
health, domestic violence, sexual assault, and many more health
disparities are so elevated in most tribal communities.
Community member participation is needed in order to be able to
identify risk and protective factors. Native Community wellness
initiatives such as Gathering of Native Americans (GONA) should
occur on every reservation in order to scratch the surface of
issues in a fun, friendly, safe, and culturally sensitive
manner. This would be followed by a strategic planning on a
grass roots community level that community members would need
to buy into and follow through with action steps. Resources on
a federal level need to cut back on the red tape for acquiring
such resources and make them accessible for tribes. The healing
of tribes needs to come from within each tribe. Assistance from
outside the tribes can occur on a complimentary level but the
control, pace, and solutions need to be identified with the
tribal community members at the table. Native American tribes
need to be at the helm of solutions and allow us to control our
own destiny.
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Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Novalene Goklish
Response to Written Questions Submitted by Hon. John Barrasso to
Novalene Goklish
Response to Written Questions Submitted by Hon. Al Franken to
Novalene Goklish