[Senate Hearing 114-446]
[From the U.S. Government Publishing Office]
S. Hrg. 114-446
ADDRESSING TRAUMA AND MENTAL HEALTH CHALLENGES IN INDIAN COUNTRY
=======================================================================
FIELD HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
AUGUST 17, 2016
__________
Printed for the use of the Committee on Indian Affairs
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COMMITTEE ON INDIAN AFFAIRS
JOHN BARRASSO, Wyoming, Chairman
JON TESTER, Montana, Vice Chairman
JOHN McCAIN, Arizona MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska TOM UDALL, New Mexico
JOHN HOEVEN, North Dakota AL FRANKEN, Minnesota
JAMES LANKFORD, Oklahoma BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana HEIDI HEITKAMP, North Dakota
MIKE CRAPO, Idaho
JERRY MORAN, Kansas
T. Michael Andrews, Majority Staff Director and Chief Counsel
Anthony Walters, Minority Staff Director and Chief Counsel
C O N T E N T S
----------
Page
Field hearing held on August 17, 2016............................ 1
Statement of Senator Heitkamp.................................... 1
Statement of Senator Hoeven...................................... 2
Witnesses
Cruzan, Darren, Director, Office of Justice Services, Bureau of
Indian Affairs, U.S. Department of the Interior................ 13
Prepared statement........................................... 17
DeCoteau, Tami, Ph.D., Clinical Psychologist, DeCoteau Trauma--
Informed Care and Practice, PLLC............................... 35
Prepared statement........................................... 39
Eagle-Williams, Kathryn R., M.D., CEO/Quality Care Director,
Elbowoods Memorial Health Center, Mandan, Hidatsa and Arikara
Nation......................................................... 28
Prepared statement........................................... 30
Robinson, Hon. Lillian Sparks, Commissioner, Administration of
Native Americans--Administration for Children and Families,
U.S. Department of Health and Human Services................... 3
Prepared statement........................................... 9
Warrington, Hon. Myrna, Chairwoman, Health and Family Committee,
Menominee Indian Tribe of Wisconsin............................ 19
Prepared statement........................................... 24
Appendix
Octeti Sakowin youth, prepared statement......................... 55
Yellow Hammer, Stephanie, Standing Rock Sioux Tribe Member,
prepared statement............................................. 58
ADDRESSING TRAUMA AND MENTAL HEALTH CHALLENGES IN INDIAN COUNTRY
----------
WEDNESDAY, AUGUST 17, 2016
U.S. Senate,
Committee on Indian Affairs,
Bismarck, ND.
The Committee met, pursuant to notice, at 9:30 a.m. at the
Lewis Goodhouse Wellness Center, United Tribes Technical
College, Hon. Heidi Heitkamp, U.S. Senator from North Dakota,
presiding.
OPENING STATEMENT OF HON. HEIDI HEITKAMP,
U.S. SENATOR FROM NORTH DAKOTA
Senator Heitkamp. Good morning. We're calling this hearing
to order. I want to first thank all the tribal leaders,
activists, providers, and community members for joining us
today to discuss this critical issue. I want to thank the UTTC
for hosting. I also want to recognize the staff of the Senate
committee on Indian Affairs who have worked so closely with my
office to make this field hearing happen. Today the Committee
will examine, ``Addressing Trauma and Mental Health Challenges
in Indian Country''. I am so honored to be hosting the field
hearing in North Dakota to discuss how we can work together to
address trauma in American Indian and Alaska Native
communities. The U.S. and National Library of Medicine found
implications of trauma on health, academics, and economic
outcomes are significant. The average lifetime cost for a child
exposed to non-fatal child maltreatment is over $200,000. This
creates a significant cost and a need for services when 22
percent of Native American children suffer from post-traumatic
stress. The costs are not only financial but impact Native
American communities as a whole. Adults experience trauma in
racism, poverty, poor nutrition, alcoholism, and suicide. In
2005 to 2008 data, the suicide rate for American Indians and
Alaska Natives was 14.68, higher than the overall U.S. rate of
11.15. To mitigate the effects of trauma, the Department of
Health and Human Services designated 4,000 mental health
professionals to professional shortage areas across the
country, many of which include Native American and Alaska
Native communities. This shows that primary care providers
generally have limited training in recognizing and diagnosing
mental health disorders. Of the 53 counties in North Dakota,
only six are identified as not having a mental health
professional shortage. Of the 53 counties in North Dakota, only
six have enough mental health providers. I hope that today we
find some attainable proposals that will achieve Native
American and Alaska Native Communities that will benefit them
across the nation, as well as focus on intervention models from
the traumatic experience. I'm pleased and actually thrilled
that I'm on this Committee, which I think speaks volumes to the
history that we have in the Senate of Senators from North
Dakota believing that this is an important issue. Senator John
Hoeven has joined me here today to listen to this important
testimony, provide questions, and take the message along with
me back to Washington D.C. I turn now to Senator Hoeven for
remarks.
STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
Senator Hoeven. Thank you, Senator Heitkamp. I'm pleased to
be here with you. Thanks to all of you for attending. Thanks to
our witnesses and UTTC for hosting this event on a very, very
important subject. The purpose of the hearing is to discuss how
Federal agencies can coordinate to provide services to Native
American children who suffer from trauma and mental health
issues. Trauma is defined as a series of events that cause
physical and psychological stress reactions. Native American
children experience abuse and neglect at higher rates than non-
native children. As a result, they are more likely to
experience trauma due to depression, substance abuse,
homelessness, and poverty. Native Americans suffer from PTSD,
post-traumatic stress disorder, at twice the rate of the
general population in North Dakota. Between the years of 2006
and 2010 the suicide rate among Native American people was
twice that of non-natives. As we all know, the devastating
effects of trauma are all too common to Native American
communities, specifically among the children. I'm committed to
doing all I can to work with my colleagues and Senator Heitkamp
to address this very serious concern. I believe the most
effective way to address trauma in Native American communities
is to prevent it from happening in the first place, especially
for children. So we're working on trying to prevent trauma, and
one example is the Native American Children Safety Act that
ensures that foster children on the reservation are placed in
safe homes. We need to take this step and other steps in a
comprehensive way. Let's hear from our witnesses as to how we
can address the very important issue and comprehensive approach
working together. Thank you to Senator Heitkamp for organizing
this very important discussion. Thank you.
Senator Heitkamp. Thank you so much, Senator Hoeven. I want
to now turn to our witnesses, some of whom we've seen many
times in front of our committee in Washington D.C, I dare say
this, maybe a little more friendly than what you've seen in the
past. But I also want to thank those of you who have traveled
from so far to provide this testimony at this field hearing and
to open up this discussion that we did a couple years ago on
trauma and realize that this is not a one off. This isn't
something that we talk about today and not realize we need to
continue that dialogue well into the future. Our first witness
is Lillian Sparks Robinson. She is Commissioner of the
Administration of Native Americans--Administration for Children
and Families within the U.S. Department of Health and Human
Services. I am pleased that she is here with us today. I remind
you your testimony is five minutes. I will introduce each of
you before you speak.
STATEMENT OF HON. LILLIAN SPARKS ROBINSON, COMMISSIONER,
ADMINISTRATION OF NATIVE AMERICANS--
ADMINISTRATION FOR CHILDREN AND FAMILIES, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Ms. Robinson. Senator Heitkamp and members of the Senate
Committee on Indian Affairs, it is my honor to testify before
this Committee on behalf of the Department of Health and Human
Services (HHS) on the important topic of Addressing Trauma and
Mental Health Challenges in Indian Country.
I am a member of the Rosebud Sioux Tribe, which is located
in South Dakota. I serve as the Commissioner for the
Administration for Native Americans, which is part of the
Administration for Children and Families (ACF), as well as the
Chair of the Intradepartmental Council on Native American
Affairs (ICNAA).
Development of HHS-Wide Policy to Address Trauma. In my
role as chair of the ICNAA, I have led meetings involving
leadership from ACF, the Indian Health Service (IHS), and the
Substance Abuse and Mental Health Services Administration
(SAMHSA) to discuss how we may better lead collaborative
efforts on an intra-departmental level to support improved
outcomes in the health and emotional well-being of American
Indians and Alaska Natives (AI/AN) and others in tribal
communities. ACF, SAMHSA, and IHS were highlighted in the
Committee's December 17 letter requesting HHS develop and
implement an integrated and coordinated Federal approach to
addressing complex trauma, including historical trauma in
Indian communities and are the primary agencies bringing a
trauma-informed lens to this work. We have examined the causes
and effects of trauma, including historical and childhood
trauma, with an intentional view toward better understanding
and highlighting steps tribes themselves are taking to prevent
and address the effects of trauma. We believe developing a
comprehensive, integrated, and trauma-informed HHS-wide policy
that is sustainable over the long-term requires collaboration
not only across the health and the human services components of
HHS, but also, with other Federal agencies and our AI/AN
partners.
We are actively engaged in the development of an HHS-wide
policy and are planning on releasing and implementing it within
this calendar year. We are currently soliciting input from our
tribal partners as well as incorporating substantive material
from HHS Operating Divisions contributing to the Department's
comprehensive trauma-informed policy. The policy will focus on
moving tribal health promotion forward as well as learning from
and incorporating AI/AN models of prevention, care, and healing
in partnership with tribal leaders, experts, and communities.
Recently, I invited tribal leaders to a listening session
held on August 9 to solicit input and recommendations to inform
this important work. This listening session was held in
Portland, Oregon in conjunction with the 2016 IHS American
Indian/Alaska Native Behavioral Health Conference. We are
tentatively planning additional listening sessions.
In addition, guidance and recommendations of tribal leaders
in the development of the National Tribal Behavioral Health
Agenda (TBHA), led by SAMHSA, has greatly informed the on-going
development of our HHS-wide policy addressing trauma. The
process for development of the TBHA was the result of SAMHSA's
months of information gathering, discussion, analysis,
validation, sharing, and revalidation of input received from
Indian tribes and tribal leaders in coordination with the
Indian Health Service's Office of Clinical and Preventive
Services (OCPS) and the National Indian Health Board (NIHB).
Development of the TBHA has been a strong collaborative effort
among Indian tribes, national and regional tribal leaders,
SAMHSA regional administrators and staff, and numerous Federal
partners.
As you know, tribal leaders have consistently asked for
support in addressing behavioral health issues affecting their
communities as part of broader discussions of health and
wellness. To bring a targeted focus to such issues at the
outset of our work to develop Department-wide policy, in March
2016, we solicited and tribal leadership provided, through the
HHS's Secretary's Tribal Advisory Committee (STAC), their
recommendations on how we could approach the development of a
comprehensive, integrated departmental policy to address
complex trauma in AI/AN communities. Among the input we
received were recommendations that we not only identify and
understand the root causes of trauma, but that we make specific
efforts to ensure that Federal partners are educated about
models and approaches developed from tribal perspectives to
more effectively prevent and address trauma in tribal
communities including trauma affecting AI/AN children, youth,
and families. Based on this and other feedback from tribes, we
are encouraged to move beyond a deficits-based perspective and
to reflect in our policy emphasis on protective factors and
positive youth development strategies aimed at promoting
resilience, which, we believe may have a larger impact on
prevention than risk reduction strategies alone. Further, since
the most effective trauma-informed activity is to prevent
trauma from occurring, we are working to identify and promote
interventions, such as home visiting, which address the
intergenerational transmission of trauma and build on the
strengths of young parents.
With our tribal partners, we are moving forward to develop
approaches that focus on cultivating, strengthening, and
lifting up the Native assets and cultural resources found in
AI/AN Communities. One of the recommendations we heard through
the STAC members was that our policy should acknowledge tribal
elders as assets and resources. At a STAC meeting in June, we
discussed the critical role of tribal elders in the development
and implementation of policies addressing trauma, including
strategies to foster resilience. Our colleagues in the
Administration for Community Living (ACL), whose mission
includes working with seniors and tribal elders, will be
indispensable in our work to fully reflect tribal elders' roles
in addressing trauma.
At the Departmental Fiscal Year (FY) 2018 Tribal Budget
Consultation, Ms. Mirtha Beadle, the Director of the Office of
Tribal Affairs and Policy at SAMHSA shared with tribal leaders
that in HHS we take trauma and its effects very seriously and
that it is something that informs our work every day as part of
an all-HHS commitment to Native Americans.
Beyond our work to develop a written HHS policy to
effectively address trauma in AI/AN communities, others in the
Department and I are working with Federal agency partners
through the White House Council on Native Americans Affairs, an
interagency body established to improve coordination of Federal
programs, to develop a Federal Government-wide approach to
improve our capacity, coordination, and collaboration in
addressing the wellness of AI/AN communities.
Ongoing Work to Address Trauma--Since receipt of the
Committee's letter, my colleagues and I have worked hard to
reach across agencies to identify trauma-informed work already
being done in the Department and ways we as champions for AI/AN
children, youth, families, and communities, can coordinate this
work better. We are focused on ways we can more effectively
take advantage of the Department's health and human services
assets.
I would like to share with the Committee and participants
in this field hearing the three-pronged framework HHS is
pursuing.
Increase Awareness and Understanding. The initial step is
to improve information available to key staff across HHS about
the extent and impact of trauma in tribal communities and
opportunities to more effectively improve well-being. This
prong will be supported by increasing Federal staff access to
webinars and informational materials and encouraging greater
engagement with tribal leaders and representatives. Resources
and discussions are intended to build staff knowledge about
cultural, practice, and evidence-based opportunities for
creating and/or supporting systems that are trauma-informed.
Among some examples of specific HHS activities to increase
Federal staff awareness and understanding of trauma and its
effects are:
The development of the ACF Principles for Working with
Federally Recognized Indian Tribes; a set of principles
designed and intended to foster AI/AN well-being by providing a
framework for Federal leadership, partnership, and
compassionate and effective human services delivery. These
principles are intended to guide the internal management of ACF
in its partnership with people in Federally-recognized tribes.
The launching of the ACF Trauma Network, which is a
community of practice for ACF staff designed to share lessons
learned and promising practices and to strengthen the agency's
ability to support trauma-informed programmatic work. The ACF
Trauma Network will host an internal training on issues of
trauma and resilience in AI/AN communities, currently scheduled
for October 2016. This program will address research on
protective factors and positive youth development strategies
that may have a larger impact on prevention of negative health
outcomes than risk reduction strategies. Representatives from
the Center for American Indian Health of the Johns Hopkins
School of Public Health will share with ACF leadership and
staff strength-based interventions developed and evaluated with
the White Mountain Apache and Navajo communities; interventions
that have now been scaled to 75 tribal communities across 15
states, and two non-Native communities.
Each year, SAMHSA, through its Tribal Training and
Technical Assistance Center, hosts a training program focused
on improving the Agency's work with AI/AN people. The training
includes experiential exercises to assist SAMHSA staff gain
greater awareness and understanding of intergenerational and
historical trauma and their effects on tribal communities. The
training is delivered in a format that allows SAMHSA staff at
all levels to participate during the three-day program.
Webinars are also offered throughout the year to improve
knowledge about trauma-related issues in tribal communities and
opportunities for addressing them.
Home visiting helps expectant families and those with young
children provide stimulating learning environments and
nurturing relationships. Beginning in 2013, the IHS Community
Health Representatives Program also partnered with the Center
for American Indian Health of the Johns Hopkins School of
Public Health to implement Family Spirit, an evidence-based,
culturally tailored home-visiting program as a core strategy to
support young families. Six pilot sites received intensive on-
site training and technical assistance. Using lessons learned
from the pilot project, IHS and Johns Hopkins will expand
Family Spirit for implementation in other tribal communities
beginning in 2016. Since 2010, ACF has been operating the
Tribal Home Visiting Program, part of the Maternal, Infant, and
Early Childhood Home Visiting Program. The Tribal Home Visiting
Program is an unprecedented expansion of culturally responsive
services for vulnerable AI/AN families and children. The
program serves some of the most vulnerable families who
experience multiple challenges often attributed to historical
trauma. The program has served a total of 1,523 families and
provided nearly 20,000 home visits through 25 funded grantees
in 14 states. There are currently 15 rural grantees, three
urban grantees, and seven grantees in a mix of rural and urban
settings.
IHS provides comprehensive training options to build a
workforce that is trauma-informed and responsive. Topics cover
historical trauma, adverse childhood experiences, early
screening and assessment of trauma, treating complex trauma,
trauma informed care services and programming, and many others.
Training is available online through the IHS TeleBehavioral
Health Center of Excellence.
This year's IHS AI/AN National Behavioral Health Conference
was planned around the theme, Creating Trauma Informed Systems
in AI/AN Communities. The conference was held in Portland,
Oregon, from August 9-11, 2016, with 550 registrants over 35
breakout sessions, 90 presenters, and more than 45 continuing
education hours offered at no cost to participants.
Improve Coordination and Collaboration. HHS is developing a
comprehensive, integrated policy on actions that support
healing from trauma and advance trauma-informed practices
through programs that contribute to improving the health and
well-being of tribal communities. As part of our work with the
other agencies on these issues, we are developing a template
for creating complementary policies across Federal agencies
that support trauma-informed practices. The intent is to: (1)
strengthen support systems across health, behavioral health,
education, child welfare, justice services, environmental, and
other Federal programming; (2) improve actions to recognize and
address the impacts of adverse childhood experiences among AI/
AN populations; and (3) to the extent possible, better align
programs to address trauma, prevent additional trauma, and
support trauma-informed services that are continuous across
systems.
Examples of specific HHS activities to improve coordination
and collaboration include: ACF, in collaboration with the
Centers for Disease Control and Prevention, Health Resources
and Services Administration, IHS, and SAMHSA, is leading work
to support improved social-emotional and behavioral health for
children and families in tribal communities. The agencies
hosted a one-day Tribal Experts Workgroup Meeting on February
25. The meeting included tribal leaders, community members,
researchers, and advocates, as well as representatives from
Federal agencies including HHS, the Department of Justice, and
the Office of Management and Budget. The goal of the meeting
was to learn from experts and discuss how we can better work
together to: (1) raise awareness of challenges that pre-school
children face in tribal populations with high rates of adult
mental health and substance abuse issues; (2) provide tools and
effective strategies for caregivers to support improved social-
emotional and behavioral health outcomes for children and their
families in tribal communities; and (3) develop policy
recommendations to address funding and service delivery
challenges. Development of a comprehensive ACF Native American
Child and Youth Policy Agenda to highlight the ongoing work of
ACF program and staff offices to support thriving, resilient,
safe, healthy, and economically secure children, families, and
communities. The focus areas for this Policy Agenda are: (1)
quality early childhood development and learning; (2) the role
of self-determination and nation-building in strengthening
families; (3) fostering child and youth well-being and
resiliency in the face of trauma and adversity; (4) financial
and economic security; and (5) building a new narrative with
data. The ACF Policy Agenda is intended to both function as a
structure for innovative policymaking to guide stronger and
more effective programming and to lift up successful tribal
models across the identified five focus areas. The Policy
Agenda is very much an action-oriented roadmap we hope will
provide AI/AN parents, caregivers, leadership, and children and
youth, and federal staff with the tools they need to ensure
improved child and youth outcomes.
IHS, in collaboration with SAMHSA, developed the FY 2016
funding opportunity for the Methamphetamine and Suicide
Prevention Initiative Generation Indigenous. The funding
opportunity is framed around addressing trauma by focusing on
the following objectives: increasing positive youth
development, building resiliency, and promoting family
engagement. Newly awarded projects will have the opportunity to
hire behavioral health providers to implement trauma informed
services and programs, including the option to increase the
number of paraprofessionals serving children, adolescents, and
families.
SAMHSA established the Federal Partners Committee on Women
and Trauma that is co-chaired by the Department of Labor. The
Committee's work has been guided by the recognition that the
impact of violence and trauma on women is a public health
problem with profound consequences for many different Federal
departments and agencies. Initial efforts focused on
identifying the impact of trauma on the mission and activities
of each agency, raising awareness about trauma across
government, and promoting evidence-based public health
practices. The Committee includes more than 100 members from 40
divisions of 13 Federal departments and agencies. An objective
is to build a trauma-informed Nation through effective
practices and cross-agency, systemic efforts at governmental
levels. The Committee hosted a trauma event that reached an
estimated 2,000 individuals each day, over the course of two
days. Given the impact of the Committee's work and significance
of trauma-informed approaches for AI/AN women.
Discussions are underway on opportunities for leveraging
these efforts as Federal partners work to support trauma-
informed efforts for tribal youth, families, and communities
build Federal and Tribal Capacity through On-Going and
Coordinated Technical Assistance. HHS will continue to provide
dynamic and collaborative technical assistance solutions that
are evidence- and practice-informed, culturally relevant, and
designed to help agencies and organizations build their
capacity to improve and expand quality services to tribal
communities. Examples of HHS work in this area include: ACF, in
partnership with other HHS agencies and offices, is currently
developing toolkits to assist human services programs bring a
trauma-informed lens to programs serving children, youth, and
families, including focused resources tailored to the needs of
programs serving AI/AN individuals and communities. To assist
managers and administrators of HHS-supported human services
programs, the HHS Behavioral Health Coordinating Committee's
Subcommittee on Trauma and Early Intervention, which is co-led
by ACF and the Office of the Assistant Secretary for Planning
and Evaluation, will produce a Primer on Trauma-Informed Human
Services. The Primer is designed to introduce human services
program leaders and their staff at the state, tribal,
territorial, and local level to recent advances in trauma,
toxic stress, and executive functioning, and inform program
leaders and their staff about the implications of this research
for program design, policy, evaluation, and service delivery.
The Primer stresses historical trauma, a form of complex trauma
that manifests throughout the life span and is passed down
through generations. This psychological suffering endured by a
group is particularly relevant to AI/AN communities, and the
Primer provides a road-map to resources from ACF, SAMHSA, IHS,
and others on addressing trauma through human services programs
in AI/AN communities.
Discussions with tribal leaders on SAMHSA's Tribal
Technical Advisory Committee (TTAC) led to the
conceptualization of the National Tribal Behavioral Health
Agenda. The voices of TTAC were joined by tribal leaders on the
HHS STAC and other engaged leaders who sought a comprehensive
behavioral health effort grounded in tribal and federal
collaboration. Their intent was to address the root causes of
behavioral health problems in tribal communities and not just
the contributing factors. Some of these problems result from
adverse childhood experiences and traumatic events that have
been experienced historically and intergenerationally. The root
causes and resulting behavioral health issues impact other
areas that contribute to well-being such as overall health,
education, employment, child welfare, and engagement with the
justice system in response to these concerns, SAMHSA and IHS
worked with other Federal agencies and the National Indian
Health Board to identify foundational elements, priorities, and
strategies for the TBHA. The TBHA was drafted based on the
voices and recommendations of tribal leaders and
representatives acknowledges the importance of tribal wisdom
and cultural practices in meeting the needs of tribal
communities; provides a clear, national statement about
prioritizing behavioral health as an essential component to
improving overall health and wellness; facilitates tribal/
Federal collaboration on common behavioral health priorities;
and supports opportunities for improving behavioral health-
related policies and programs geared to the specific needs of
tribal communities.
I would be happy to share with your staff a more complete
listing of the programs and activities HHS is engaged in which
focus on addressing trauma and behavioral health and wellness.
Thank you for your work on this important issue and the
opportunity to speak with you today. I am happy to answer any
questions you may have.
[The prepared statement of Ms. Robinson follows:]
Prepared Statement of Hon. Lillian Sparks Robinson, Commissioner,
Administration of Native Americans--Administration for Children and
Families, U.S. Department of Health and Human Services
Senator Heitkamp and members of the Senate Committee on Indian
Affairs, it is my honor to testify before this Committee on behalf of
the Department of Health and Human Services (HHS) on the important
topic of ``Addressing Trauma and Mental Health Challenges in Indian
Country''. I am a member of the Rosebud Sioux Tribe, which is located
in South Dakota. I serve as the Commissioner for the Administration for
Native Americans, which is part of the Administration for Children and
Families (ACF), as well as the Chair of the Intradepartmental Council
on Native American Affairs (ICNAA).
Development of HHS-Wide Policy to Address Trauma
In my role as chair of the ICNAA, I have led meetings involving
leadership from ACF, the Indian Health Service (IHS), and the Substance
Abuse and Mental Health Services Administration (SAMHSA) to discuss how
we may better lead collaborative efforts on an intra-departmental level
to support improved outcomes in the health and emotional well-being of
American Indians and Alaska Natives (AI/AN) and others in tribal
communities. ACF, SAMHSA, and IHS were highlighted in the Committee's
December 17 letter requesting HHS develop and implement an integrated
and coordinated Federal approach to addressing complex trauma,
including historical trauma in Indian communities and are the primary
agencies bringing a trauma-informed lens to this work. We have examined
the causes and effects of trauma, including historical and childhood
trauma, with an intentional view toward better understanding and
highlighting steps tribes themselves are taking to prevent and address
the effects of trauma. We believe developing a comprehensive,
integrated, and trauma-informed HHS-wide policy that is sustainable
over the long-term requires collaboration not only across the health
and the human services components of HHS, but also, with other Federal
agencies and our AI/AN partners.
We are actively engaged in the development of an HHS-wide policy
and are planning on releasing and implementing it within this calendar
year. We are currently soliciting input from our tribal partners as
well as incorporating substantive material from HHS Operating Divisions
contributing to the Department's comprehensive trauma-informed policy.
The policy will focus on moving tribal health promotion forward as well
as learning from and incorporating AI/AN models of prevention, care,
and healing in partnership with tribal leaders, experts, and
communities.
Recently, I invited tribal leaders to a listening session held on
August 9 to solicit input and recommendations to inform this important
work. This listening session was held in Portland, Oregon in
conjunction with the 2016 IHS American Indian/Alaska Native Behavioral
Health Conference. We are tentatively planning additional listening
sessions.
In addition, guidance and recommendations of tribal leaders in the
development of the National Tribal Behavioral Health Agenda (TBHA), led
by SAMHSA, has greatly informed the on-going development of our HHS-
wide policy addressing trauma. The process for development of the TBHA
was the result of SAMHSA's months of information gathering, discussion,
analysis, validation, sharing, and revalidation of input received from
Indian tribes and tribal leaders in coordination with the Indian Health
Service's Office of Clinical and Preventive Services (OCPS) and the
National Indian Health Board (NIHB). Development of the TBHA has been a
strong, collaborative effort among Indian tribes, national and regional
tribal leaders, SAMHSA regional administrators and staff, and numerous
Federal partners.
As you know, tribal leaders have consistently asked for support in
addressing behavioral health issues affecting their communities as part
of broader discussions of health and wellness. To bring a targeted
focus to such issues at the outset of our work to develop Department-
wide policy, in March 2016, we solicited and tribal leadership
provided, through the HHS' Secretary's Tribal Advisory Committee
(STAC), their recommendations on how we could approach the development
of a comprehensive, integrated departmental policy to address complex
trauma in AI/AN communities. Among the input we received were
recommendations that we not only identify and understand the root
causes of trauma, but that we make specific efforts to ensure that
Federal partners are educated about models and approaches developed
from tribal perspectives to more effectively prevent and address trauma
in tribal communities including trauma affecting AI/AN children, youth,
and families. Based on this and other feedback from tribes, we are
encouraged to move beyond a deficits-based perspective and to reflect
in our policy emphasis on protective factors and positive youth
development strategies aimed at promoting resilience, which, we believe
may have a larger impact on prevention than risk reduction strategies
alone. Further, since the most effective trauma-informed activity is to
prevent trauma from occurring, we are working to identify and promote
interventions, such as home visiting, which address the
intergenerational transmission of trauma and build on the strengths of
young parents.
With our tribal partners, we are moving forward to develop
approaches that focus on cultivating, strengthening, and lifting up the
Native assets and cultural resources found in AI/AN communities. One of
the recommendations we heard through the STAC members was that our
policy should acknowledge tribal elders as assets and resources. At a
STAC meeting in June, we discussed the critical role of tribal elders
in the development and implementation of policies addressing trauma,
including strategies to foster resilience. Our colleagues in the
Administration for Community Living (ACL), whose mission includes
working with seniors and tribal elders, will be indispensable in our
work to fully reflect tribal elders' roles in addressing trauma.
At the Departmental Fiscal Year (FY) 2018 Tribal Budget
Consultation, Ms. Mirtha Beadle, the Director of the Office of Tribal
Affairs and Policy at SAMHSA shared with tribal leaders that in HHS we
take trauma and its effects very seriously and that it is something
that informs our work every day as part of an all-HHS commitment to
Native Americans.
Beyond our work to develop a written HHS policy to effectively
address trauma in AI/AN communities, others in the Department and I are
working with Federal agency partners through the White House Council on
Native Americans Affairs, an interagency body established to improve
coordination of Federal programs, to develop a Federal Government-wide
approach to improve our capacity, coordination, and collaboration in
addressing the wellness of AI/AN communities.
Ongoing Work to Address Trauma
Since receipt of the Committee's letter, my colleagues and I have
worked hard to reach across agencies to identify trauma-informed work
already being done in the Department and ways we, as champions for AI/
AN children, youth, families, and communities, can coordinate this work
better. We are focused on ways we can more effectively take advantage
of the Department's health and human services assets.
I would like to share with the Committee and participants in this
field hearing the three-pronged framework HHS is pursuing.
Prong 1--Increase Awareness and Understanding. The initial step is
to improve information available to key staff across HHS about the
extent and impact of trauma in tribal communities and opportunities to
more effectively improve well-being. This prong will be supported by
increasing Federal staff access to webinars and informational materials
and encouraging greater engagement with tribal leaders and
representatives. Resources and discussions are intended to build staff
knowledge about cultural, practice, and evidence-based opportunities
for creating and/or supporting systems that are trauma-informed.
Among some examples of specific HHS activities to increase Federal
staff awareness and understanding of trauma and its effects are:
The development of the ACF Principles for Working with
Federally Recognized Indian Tribes; a set of principles
designed and intended to foster AI/AN well-being by providing a
framework for Federal leadership, partnership, and
compassionate and effective human services delivery. These
principles are intended to guide the internal management of ACF
in its partnership with people in Federally-recognized tribes.
The launching of the ACF Trauma Network, which is a
community of practice for ACF staff designed to share lessons
learned and promising practices and to strengthen the agency's
ability to support trauma-informed programmatic work. The ACF
Trauma Network will host an internal training on issues of
trauma and resilience in AI/AN communities, currently scheduled
for October 2016. This program will address research on
protective factors and positive youth development strategies
that may have a larger impact on prevention of negative health
outcomes than risk reduction strategies. Representatives from
the Center for American Indian Health of the Johns Hopkins
School of Public Health will share with ACF leadership and
staff strength-based interventions developed and evaluated with
the White Mountain Apache and Navajo communities; interventions
that have now been scaled to 75 tribal communities across 15
states, and two non-Native communities.
Each year, SAMHSA, through its Tribal Training and Technical
Assistance Center, hosts a training program focused on
improving the Agency's work with AI/AN people. The training
includes experiential exercises to assist SAMHSA staff gain
greater awareness and understanding of intergenerational and
historical trauma and their effects on tribal communities. The
training is delivered in a format that allows SAMHSA staff at
all levels to participate during the three-day program.
Webinars are also offered throughout the year to improve
knowledge about trauma-related issues in tribal communities and
opportunities for addressing them.
Home visiting helps expectant families and those with young
children provide stimulating learning environments and
nurturing relationships. Beginning in 2013, the IHS Community
Health Representatives Program also partnered with the Center
for American Indian Health of the Johns Hopkins School of
Public Health to implement Family Spirit, an evidence-based,
culturally tailored home-visiting program as a core strategy to
support young families. Six pilot sites received intensive on-
site training and technical assistance. Using lessons learned
from the pilot project, IHS and Johns Hopkins will expand
Family Spirit for implementation in other tribal communities
beginning in 2016. Since 2010, ACF has been operating the
Tribal Home Visiting Program, part of the Maternal, Infant, and
Early Childhood Home Visiting Program. The Tribal Home Visiting
Program is an unprecedented expansion of culturally responsive
services for vulnerable AI/AN families and children. The
program serves some of the most vulnerable families who
experience multiple challenges often attributed to historical
trauma. The program has served a total of 1,523 families and
provided nearly 20,000 home visits through 25 funded grantees
in 14 states. There are currently 15 rural grantees, three
urban grantees, and seven grantees in a mix of rural and urban
settings.
IHS provides comprehensive training options to build a
workforce that is trauma-informed and responsive. Topics cover
historical trauma, adverse childhood experiences, early
screening and assessment of trauma, treating complex trauma,
trauma informed care services and programming, and many others.
Training is available online through the IHS TeleBehavioral
Health Center of Excellence.
This year's IHS AI/AN National Behavioral Health Conference
was planned around the theme, ``Creating Trauma Informed
Systems in AI/AN Communities.'' The conference was held in
Portland, Oregon, from August 9-11, 2016, with 550 registrants
over 35 breakout sessions, 90 presenters, and more than 45
continuing education hours offered at no cost to participants.
Prong 2--Improve Coordination and Collaboration. HHS is developing
a comprehensive, integrated policy on actions that support healing from
trauma and advance trauma-informed practices through programs that
contribute to improving the health and well-being of tribal
communities. As part of our work with the other agencies on these
issues, we are developing a template for creating complementary
policies across Federal agencies that support trauma-informed
practices. The intent is to: (1) strengthen support systems across
health, behavioral health, education, child welfare, justice services,
environmental, and other Federal programming; (2) improve actions to
recognize and address the impacts of adverse childhood experiences
among AI/AN populations; and (3) to the extent possible, better align
programs to address trauma, prevent additional trauma, and support
trauma-informed services that are continuous across systems.
Examples of specific HHS activities to improve coordination and
collaboration include:
ACF, in collaboration with the Centers for Disease Control
and Prevention, Health Resources and Services Administration,
IHS, and SAMHSA, is leading work to support improved social-
emotional and behavioral health for children and families in
tribal communities. The agencies hosted a one-day Tribal
Experts Workgroup Meeting on February 25. The meeting included
tribal leaders, community members, researchers, and advocates,
as well as representatives from Federal agencies including HHS,
the Department of Justice, and the Office of Management and
Budget. The goal of the meeting was to learn from experts and
discuss how we can better work together to: (1) raise awareness
of challenges that pre-school children face in tribal
populations with high rates of adult mental health and
substance abuse issues; (2) provide tools and effective
strategies for caregivers to support improved social-emotional
and behavioral health outcomes for children and their families
in tribal communities; and (3) develop policy recommendations
to address funding and service delivery challenges.
Development of a comprehensive ACF Native American Child and
Youth Policy Agenda to highlight the ongoing work of ACF
program and staff offices to support thriving, resilient, safe,
healthy, and economically secure children, families, and
communities. The focus areas for this Policy Agenda are: (1)
quality early childhood development and learning; (2) the role
of self-determination and nation-building in strengthening
families; (3) fostering child and youth well-being and
resiliency in the face of trauma and adversity; (4) financial
and economic security; and (5) building a new narrative with
data. The ACF Policy Agenda is intended to both function as a
structure for innovative policymaking to guide stronger and
more effective programming and to lift up successful tribal
models across the identified five focus areas. The Policy
Agenda is very much an action-oriented roadmap we hope will
provide AI/AN parents, caregivers, leadership, and children and
youth, and federal staff with the tools they need to ensure
improved child and youth outcomes.
IHS, in collaboration with SAMHSA, developed the FY 2016
funding opportunity for the Methamphetamine and Suicide
Prevention Initiative Generation Indigenous. The funding
opportunity is framed around addressing trauma by focusing on
the following objectives: increasing positive youth
development, building resiliency, and promoting family
engagement. Newly awarded projects will have the opportunity to
hire behavioral health providers to implement trauma informed
services and programs, including the option to increase the
number of paraprofessionals serving children, adolescents, and
families.
SAMHSA established the Federal Partners Committee on Women
and Trauma that is co-chaired by the Department of Labor. The
Committee's work has been guided by the recognition that the
impact of violence and trauma on women is a public health
problem with profound consequences for many different Federal
departments and agencies. Initial efforts focused on
identifying the impact of trauma on the mission and activities
of each agency, raising awareness about trauma across
government, and promoting evidence-based public health
practices. The Committee includes more than 100 members from 40
divisions of 13 Federal departments and agencies. An objective
is to build a trauma-informed Nation through effective
practices and cross-agency, systemic efforts at governmental
levels. The Committee hosted a trauma event that reached an
estimated 2,000 individuals each day, over the course of two
days. Given the impact of the Committee's work and significance
of trauma-informed approaches for AI/AN women, discussions are
underway on opportunities for leveraging these efforts as
Federal partners work to support trauma-informed efforts for
tribal youth, families, and communities.
Prong 3--Build Federal and Tribal Capacity through On-Going and
Coordinated Technical Assistance. HHS will continue to provide dynamic
and collaborative technical assistance solutions that are evidence- and
practice-informed, culturally relevant, and designed to help agencies
and organizations build their capacity to improve and expand quality
services to tribal communities. Examples of HHS work in this area
include:
ACF, in partnership with other HHS agencies and offices, is
currently developing toolkits to assist human services programs
bring a trauma-informed lens to programs serving children,
youth, and families, including focused resources tailored to
the needs of programs serving AI/AN individuals and
communities. To assist managers and administrators of HHS-
supported human services programs, the HHS Behavioral Health
Coordinating Committee's Subcommittee on Trauma and Early
Intervention, which is co-led by ACF and the Office of the
Assistant Secretary for Planning and Evaluation, will produce a
Primer on Trauma-Informed Human Services. The Primer is
designed to introduce human services program leaders and their
staff at the state, tribal, territorial, and local level to
recent advances in trauma, toxic stress, and executive
functioning, and inform program leaders and their staff about
the implications of this research for program design, policy,
evaluation, and service delivery. The Primer stresses
historical trauma, a form of complex trauma that manifests
throughout the life span and is passed down through
generations. This psychological suffering endured by a group is
particularly relevant to AI/AN communities, and the Primer
provides a road-map to resources from ACF, SAMHSA, IHS, and
others on addressing trauma through human services programs in
AI/AN communities.
Discussions with tribal leaders on SAMHSA's Tribal Technical
Advisory Committee (TTAC) led to the conceptualization of the
National Tribal Behavioral Health Agenda. The voices of TTAC
were joined by tribal leaders on the HHS STAC and other engaged
leaders who sought a comprehensive behavioral health effort
grounded in tribal and federal collaboration. Their intent was
to address the root causes of behavioral health problems in
tribal communities and not just the contributing factors. Some
of these problems result from adverse childhood experiences and
traumatic events that have been experienced historically and
intergenerationally. The root causes and resulting behavioral
health issues impact other areas that contribute to well-being
such as overall health, education, employment, child welfare,
and engagement with the justice system.
In response to these concerns, SAMHSA and IHS worked with
other Federal agencies and the National Indian Health Board to
identify foundational elements, priorities, and strategies for
the TBHA. The TBHA was drafted based on the voices and
recommendations of tribal leaders and representatives--it
acknowledges the importance of tribal wisdom and cultural
practices in meeting the needs of tribal communities; provides
a clear, national statement about prioritizing behavioral
health as an essential component to improving overall health
and wellness; facilitates tribal/Federal collaboration on
common behavioral health priorities; and supports opportunities
for improving behavioral health-related policies and programs
geared to the specific needs of tribal communities.
I would be happy to share with your staff a more complete listing
of the programs and activities HHS is engaged in which focus on
addressing trauma and behavioral health and wellness.
Thank you for your work on this important issue and the opportunity
to speak with you today. I am happy to answer any questions you may
have.
Senator Heitkamp. Thank you. Next we will hear from Officer
Darren Cruzan. He is the Director of the Office of Justice
Services at the Bureau of Indian Affairs in the Department of
the Interior.
STATEMENT OF DARREN CRUZAN, DIRECTOR, OFFICE OF
JUSTICE SERVICES, BUREAU OF INDIAN AFFAIRS, U.S.
DEPARTMENT OF THE INTERIOR
Mr. Cruzan. My name is Darren Cruzan and I am the Director
for the Office of Justice Services at the Bureau of Indian
Affairs in the Department of the Interior. I am pleased to
submit this statement for the Department on the topic of
``Addressing Trauma and Mental Health Challenges in Indian
Country.''
As a result of repudiated past federal policies intended to
disrupt American Indian and Alaska Native (AI/AN) families,
today many tribal citizens suffer from the effects of
generational trauma. Trauma may be from emotional abuse,
physical abuse, sexual abuse, emotional neglect, physical
neglect, witnessing substance abuse or domestic violence in the
home, or experiencing a parent's divorce or incarceration.
Symptoms can range from anxiety, impulsivity, to depression,
and can manifest themselves as criminal behavior, poor school
performance, chronic illness, and mental health issues. In
November 2014, the Attorney General's Taskforce on American
Indian/Alaska Native Children Exposed to Violence documented a
high rate of trauma in Indian Country and made policy
recommendations to reduce it.
As the Department responsible for providing law
enforcement, child protection services and social workers,
support for tribal courts, and education services, we know we
are a key partner in addressing trauma in Indian Country. While
we do not diagnose or treat individuals, we or tribes that
administer our programs and services are the often the first
responders to crisis in the home or at school and serve as a
bridge for connecting families and individuals to the services
they need. Officers, teachers, social worker and other
professionals also witness firsthand the lack of resources
available to treat the underlying conditions responsible for
many of the troubling statistics. We appreciate the Committee's
efforts to raise awareness of this important issue and the
opportunity to provide testimony today.
BIA Trauma Informed Care Training Progress in addressing
trauma in Indian Country cannot be made until more education on
trauma and its effects occurs. To better equip our staff,
earlier this year, the BIA provided training to all BIA
regional social workers on trauma informed care. This training
was presented by subject matter experts from the National
Institute of Health and Johns Hopkins University. The regional
social workers received information on historical trauma and
additional training opportunities regarding this issue.
In addition to this nationwide training, many of the
regions are providing training directly to, or in partnership
with, tribes in their service areas. Some examples are: Alaska
Region--In partnership with the Southcentral Foundation Family
Wellness Program, the Alaska Region provided trauma informed
care training at the BIA Providers Conference this past year.
The presentation was attended by approximately 400 tribal
representatives, including ICWA workers, tribal administrators
and tribal council members. Southern Plains Region, The
Anadarko Agency, located in the Southern Plains Region,
operates the Positive Indian Parenting Program, an effort to
address the parenting challenges the Agency has identified in
their clients. This program was developed by the Agency after
years of seeing how historical trauma impacting parenting
skills as a result of the parents, experience during the
boarding school era. These problems have been passed down
generation to generation, and impacts many child protective
services referrals the Agency receives. The Positive Indian
Parenting Program instructor is certified through the Active
Parenting Program and has attended and uses the curriculum from
the National Indian Child Welfare Association's (NICWA)
Positive Indian Parenting training. Through the combination of
these parenting programs, the Agency has provided positive
Indian parenting courses to Native parents. ,h Rocky Mountain
Region--The Rocky Mountain Regional Office has forged a
partnership with the Native Children's Trauma Center--
University of Montana for the last five years to develop Trauma
Informed Child Protection Services. The Native Children's
Trauma Center has done training for social service staff and
tribal court staff over that period, and has provided onsite
technical assistance at case staffing and child protection
meetings. The region provided several region-wide trainings, a
webinar series and more recently in 2016, developed a two-week
trauma informed training curriculum for Social Service staff.
,h Midwest Region--The BIA, Midwest Regional Office in
partnership with the Native Wellness Institute (NWI) offered a
series of trauma-informed training to the Tribes at the Midwest
Region's 2016 Partners in Action Conference. The NWI recognizes
the great impacts of historical trauma on Native people, and
its impact on current day trauma in our families and
communities. The NWI's mission is to promote the well-being of
individuals, families and communities; to create an awareness
of where our negative behavior comes from and provide
opportunities for community/family growth and healing.
We are also empowering tribal communities to address trauma
in their communities. As recommended by the Attorney General in
3.1 of its report, Ending Violence so Children Can Thrive, we
created a new initiative to allow tribes to braid federal funds
together to address the distinct needs of their communities.
Tiwahe, which means family in Lakota, is an initiative
designed to demonstrate the effectiveness of wraparound
services in tribal communities. It looks at funding streams
from social services, child welfare, employment and training,
recidivism and/or tribal courts and asks tribes to develop a
plan to combine these funding streams to improve outcomes. The
goal is to reduce the rate AI/NA children enter foster care,
increase family reunification rates, reduce recidivism rates,
and build capacity within tribal courts.
In FY 2016, six tribes are participating in the
demonstration project. These are: the Association of Village
Council Presidents (AVCP); the Spirit Lake Tribe; Red Lake Band
of Chippewa Indians; Ute Mountain Ute Tribe; Fort Belknap
Indian Community; and the Pascua Yaqui Tribe. In addition, all
tribes received an across-the-board increase to their base
funding, referred to as Tribal Priority Allocation, for Indian
Child Welfare Act and Social Services. We recently hired a
National Tiwahe Coordinator who will start later this month to
work with participating tribes.
As we continue to build this program, our hope is to also
improve how we collect data in partnership with tribes to fully
understand how trauma and its effects impact Indian County.
Current, relevant, and robust data is necessary to make
informed policy decisions to craft effective trauma
interventions.
There is no more important issue than addressing the high
suicide rate in Indian Country, particularly among youth, which
is often the result of an individual's exposure to trauma.
Indian Affairs is directly involved in youth suicide prevention
through the BIE, which provides technical assistance and
monitoring to ensure schools are compliant with intervention
strategies and reporting protocols to further ensure student
safety. In addition, under the BIE reorganization the School
Health Policy Advisor position was created. This individual
will support the BIE Associate Deputy Directors, staff in the
Education Resource Centers and BIE schools with the development
of additional mental health programs, initiatives and policies
as well as suicide and substance abuse prevention. They will
also coordinate with the BIA and support interagency work of
the White House Council on Native American Affairs.
BIE's partnering with other federal agencies, including the
Departments of Health and Human Services (Substance Abuse and
Mental Health Services Administration and the Indian Health
Service (IHS)) and Education, has enabled BIE to address the
unique needs of students within these schools in the areas of
mental and substance use disorders, including suicide.
The BIE has developed a Suicide Prevention, Early
Intervention and Postvention Policy to promote suicide
prevention in BIE schools. The policy mandates specific actions
in all schools, dormitories and the two post-secondary
institutions; and encourages tribally-operated schools to
develop similar policies. These actions create a safety net for
students who are at risk of suicide and promotes proactive
involvement of school personnel and communities in
intervention, prevention and postvention activities.
The BIA Office of Justice Services (OJS) partners with
numerous health and social service programs to assist in
educating and presenting at schools, seminars, workshops and
community events to the youth and the community on suicide
prevention. OJS gathers statistical data and identifies youth
suicide trends within Indian Country, and will look for ways to
expand suicide prevention training with other stakeholders in
the future.
The BIA's Law Enforcement and Tribal Services programs,
along with the BIE, continually seek ways to collaborate and to
support activities directed at suicide prevention and services
coordination. The BIE utilizes the Youth Risk Behavior Survey,
Native American Student Information System (NASIS), local BIA
Law Enforcement, and IHS data to develop interventions and
track trends for program implementation and is committed to
seeking out and enacting prevention strategies while ensuring a
safe and secure environment for our students.
Additionally, BIE schools and dormitories use NASIS to
track and identify specific behavior trends to develop
interventions to address school specific behavior issues.
Training is provided on site by the School Safety Specialist at
a number of locations throughout the school year during staff
training sessions and all residential staff are required to
receive suicide prevention training.
It is important to note that Indian Country continues to
suffer from a lack of comprehensive mental health treatment
options. For example, OJS officers responding to a call for
service involving a suicide threat are often left with no
option but to arrest the individual. Without mental health
facilities, jail is oftentimes the only place where the safety
of the individual can be guaranteed.
Indian Affairs has the advantage of working alongside
tribes and understands firsthand the severity of the lack of
resources in Indian Country and the impact it has on tribal
communities. We look forward to our continued partnership with
Tribal governments, on a government-to-government basis, and
with our federal partners to continue to address trauma related
issues.
Thank you. I will give the rest of my time to the others.
[The prepared statement of Mr. Cruzan follows:]
Prepared Statement of Darren Cruzan, Director, Office of Justice
Services, Bureau of Indian Affairs, U.S. Department of the Interior
My name is Darren Cruzan and I am the Director for the Office of
Justice Services at the Bureau of Indian Affairs in the Department of
the Interior. I am pleased to submit this statement for the Department
on the topic of ``Addressing Trauma and Mental Health Challenges in
Indian Country.''
As a result of repudiated past federal policies intended to disrupt
American Indian and Alaska Native (AI/AN) families, today many tribal
citizens suffer from the effects of generational trauma. Trauma may be
from emotional abuse, physical abuse, sexual abuse, emotional neglect,
physical neglect, witnessing substance abuse or domestic violence in
the home, or experiencing a parent's divorce or incarceration. Symptoms
can range from anxiety, impulsivity, to depression, and can manifest
themselves as criminal behavior, poor school performance, chronic
illness, and mental health issues. In November 2014, the Attorney
General's Taskforce on American Indian/Alaska Native Children Exposed
to Violence documented a high rate of trauma in Indian Country and made
policy recommendations to reduce it.
As the Department responsible for providing law enforcement, child
protection services and social workers, support for tribal courts, and
education services, we know we are a key partner in addressing trauma
in Indian Country. While we do not diagnose or treat individuals, we or
tribes that administer our programs and services are the often the
first responders to crisis in the home or at school and serve as a
bridge for connecting families and individuals to the services they
need. Officers, teachers, social worker and other professionals also
witness firsthand the lack of resources available to treat the
underlying conditions responsible for many of the troubling statistics.
We appreciate the Committee's efforts to raise awareness of this
important issue and the opportunity to provide testimony today.
BIA Trauma Informed Care Training
Progress in addressing trauma in Indian Country cannot be made
until more education on trauma and its effects occurs. To better equip
our staff, earlier this year, the BIA provided training to all BIA
regional social workers on trauma informed care. This training was
presented by subject matter experts from the National Institute of
Health and Johns Hopkins University. The regional social workers
received information on historical trauma and additional training
opportunities regarding this issue.
In addition to this nationwide training, many of the regions are
providing training directly to, or in partnership with, tribes in their
service areas. Some examples are:
Alaska Region--In partnership with the Southcentral
Foundation Family Wellness Program, the Alaska Region provided
trauma informed care training at the BIA Providers Conference
this past year. The presentation was attended by approximately
400 tribal representatives, including ICWA workers, tribal
administrators and tribal council members.
Southern Plains Region--The Anadarko Agency, located in the
Southern Plains Region, operates the Positive Indian Parenting
Program, an effort to address the parenting challenges the
Agency has identified in their clients. This program was
developed by the Agency after years of seeing how historical
trauma impacting parenting skills as a result of the parents'
experience during the boarding school era. These problems have
been passed down generation to generation, and impacts many
child protective services referrals the Agency receives. The
Positive Indian Parenting Program instructor is certified
through the Active Parenting Program and has attended and uses
the curriculum from the National Indian Child Welfare
Association's (NICWA) Positive Indian Parenting training.
Through the combination of these parenting programs, the Agency
has provided positive Indian parenting courses to Native
parents.
Rocky Mountain Region--The Rocky Mountain Regional Office
has forged a partnership with the Native Children's Trauma
Center--University of Montana for the last five years to
develop Trauma Informed Child Protection Services. The Native
Children's Trauma Center has done training for social service
staff and tribal court staff over that period, and has provided
onsite technical assistance at case staffing and child
protection meetings. The region provided several region-wide
trainings, a webinar series and more recently in 2016,
developed a two-week trauma informed training curriculum for
Social Service staff.
Midwest Region--The BIA, Midwest Regional Office in
partnership with the Native Wellness Institute (NWI) offered a
series of trauma-informed training to the Tribes at the Midwest
Region's 2016 Partners in Action Conference. The NWI recognizes
the great impacts of historical trauma on Native people, and
its impact on current day trauma in our families and
communities. The NWI's mission is to promote the well-being of
individuals, families and communities; to create an awareness
of where our negative behavior comes from and provide
opportunities for community/family growth and healing.
Tiwahe Initiative
We are also empowering tribal communities to address trauma in
their communities. As recommended by the Attorney General in 3.1 of its
report, ``Ending Violence so Children Can Thrive,'' we created a new
initiative to allow tribes to braid federal funds together to address
the distinct needs of their communities.
Tiwahe, which means family in Lakota, is an initiative designed to
demonstrate the effectiveness of wraparound services in tribal
communities. It looks at funding streams from social services, child
welfare, employment and training, recidivism and/or tribal courts and
asks tribes to develop a plan to combine these funding streams to
improve outcomes. The goal is to reduce the rate AI/NA children enter
foster care, increase family reunification rates, reduce recidivism
rates, and build capacity within tribal courts.
In FY 2016, six tribes are participating in the demonstration
project. These are: the Association of Village Council Presidents
(AVCP); the Spirit Lake Tribe; Red Lake Band of Chippewa Indians; Ute
Mountain Ute Tribe; Fort Belknap Indian Community; and the Pascua Yaqui
Tribe. In addition, all tribes received an across-the-board increase to
their base funding, referred to as Tribal Priority Allocation, for
Indian Child Welfare Act and Social Services. We recently hired a
National Tiwahe Coordinator who will start later this month to work
with participating tribes.
As we continue to build this program, our hope is to also improve
how we collect data in partnership with tribes to fully understand how
trauma and its effects impact Indian County. Current, relevant, and
robust data is necessary to make informed policy decisions to craft
effective trauma interventions.
Suicide Prevention
There is no more important issue than addressing the high suicide
rate in Indian Country, particularly among youth, which is often the
result of an individual's exposure to trauma. Indian Affairs is
directly involved in youth suicide prevention through the BIE, which
provides technical assistance and monitoring to ensure schools are
compliant with intervention strategies and reporting protocols to
further ensure student safety. In addition, under the BIE
reorganization the School Health Policy Advisor position was created.
This individual will support the BIE Associate Deputy Directors, staff
in the Education Resource Centers and BIE schools with the development
of additional mental health programs, initiatives and policies as well
as suicide and substance abuse prevention. They will also coordinate
with the BIA and support interagency work of the White House Council on
Native American Affairs.
BIE's partnering with other federal agencies, including the
Departments of Health and Human Services (Substance Abuse and Mental
Health Services Administration and the Indian Health Service (IHS)) and
Education, has enabled BIE to address the unique needs of students
within these schools in the areas of mental and substance use
disorders, including suicide.
The BIE has developed a Suicide Prevention, Early Intervention and
Postvention Policy to promote suicide prevention in BIE schools. The
policy mandates specific actions in all schools, dormitories and the
two post-secondary institutions; and encourages tribally-operated
schools to develop similar policies. These actions create a safety net
for students who are at risk of suicide and promotes proactive
involvement of school personnel and communities in intervention,
prevention and postvention activities.
The BIA Office of Justice Services (OJS) partners with numerous
health and social service programs to assist in educating and
presenting at schools, seminars, workshops and community events to the
youth and the community on suicide prevention. OJS gathers statistical
data and identifies youth suicide trends within Indian Country, and
will look for ways to expand suicide prevention training with other
stakeholders in the future.
The BIA's Law Enforcement and Tribal Services programs, along with
the BIE, continually seek ways to collaborate and to support activities
directed at suicide prevention and services coordination. The BIE
utilizes the Youth Risk Behavior Survey, Native American Student
Information System (NASIS), local BIA Law Enforcement, and IHS data to
develop interventions and track trends for program implementation and
is committed to seeking out and enacting prevention strategies while
ensuring a safe and secure environment for our students.
Additionally, BIE schools and dormitories use NASIS to track and
identify specific behavior trends to develop interventions to address
school specific behavior issues. Training is provided on site by the
School Safety Specialist at a number of locations throughout the school
year during staff training sessions and all residential staff are
required to receive suicide prevention training.
It is important to note that Indian Country continues to suffer
from a lack of comprehensive mental health treatment options. For
example, OJS officers responding to a call for service involving a
suicide threat are often left with no option but to arrest the
individual. Without mental health facilities, jail is oftentimes the
only place where the safety of the individual can be guaranteed.
Conclusion
Indian Affairs has the advantage of working alongside tribes and
understands firsthand the severity of the lack of resources in Indian
Country and the impact it has on tribal communities. We look forward to
our continued partnership with Tribal governments, on a government-to-
government basis, and with our federal partners to continue to address
trauma related issues.
Senator Heitkamp. I have been preaching to the rest of the
world about the great success that you had addressing trauma.
So I want to congratulate you and the tribal leadership on
taking this on. Your work has been recognized. You have a long
history of working on behalf of your tribe and importantly on
behalf of the children of your tribe. So I'm interested in
hearing, and I know my colleagues and Senator Hoeven are
interested in hearing about your success and what ideas we can
share with the rest of the world. Thank you.
STATEMENT OF HON. MYRNA WARRINGTON, CHAIRWOMAN, HEALTH AND
FAMILY COMMITTEE, MENOMINEE INDIAN TRIBE OF WISCONSIN
Ms. Warrington. Thank you for inviting us here. It's good
to know that tribes have been recognized nationally for their
effort to address the problems of our children and families.
Senator Heitkamp, Senator Hoeven, and members of the Committee,
my name is Myrna Warrington. This is my 8th year serving as on
the Menominee Tribal Legislature and at this time I serve on
the Menominee Indian Tribe's Executive Team as the Secretary.
Thank you for the opportunity to provide the Committee with the
Menominee statement that addresses the trauma and mental health
challenges experienced in Indian Country.
The Menominee Indian Tribe is located in northeast
Wisconsin, within our ancestral territory. Our Reservation is
comprised of 234,000 acres of land; bountiful in rivers, lakes,
streams, wildlife, and forest land. Roughly 90 percent of the
land held in trust for the Tribe is held in sustained yield for
the Tribe's long-standing practice in Sustainable Forest
Management. The Tribal membership includes over 9,000 enrolled
members.
The Tribes history is mired in trauma due to the loss of
Tribal status, identity, language and culture that was forced
on our people by the Federal Government through overarching
assimilation objectives, enactments of federal Indian policy,
treaties, and judicial rulings. The negative remnants of trauma
experienced from the treaty era, Boarding School Era, Menominee
Termination Act of 1954, Federal Relocation Act of 1956, and
finally the Restoration of the Menominee Indian Tribe to
Federal Recognition in 1973, remain visible in the lives of our
Tribal members. Throughout the last two centuries, the
Menominee endured the large loss of ancestral territory, near
extinction of Menominee language, and the loss of many critical
cultural and religious beliefs, practices and communal values
that guided the traditional Menominee society. Our oral history
and the historical record remain to help guide the Tribe in the
right direction to address the impacts from these experiences.
In 2006, the Menominee Tribal Government, Menominee Indian
School District, and Menominee Tribal Clinic, who, because of
limited resources with narrow guidelines, broke down the silos
to form the community collaboration. The Menominee Community
Collaboration committed to creating data-driven solutions. The
purpose was aimed at addressing the cumulative impacts that
historical and intergenerational trauma were presenting upon
the families of the Menominee Community. The initial
identification process began with defining the negative
behavioral, health, and educational problems that were
manifesting in the lives of the Menominee youth. The community
collaboration research led to the premise that the symptoms of
poverty, low academic achievement, and poor health outcomes and
factors were interconnected. Through this process, the Tribe
was forced to confront the reality that the negative changes
occurring within the youth population were a direct result of
the changing family dynamic and community structure that were
symptoms of a larger problem. These issues had not manifested
overnight and were not isolated to just one event, but rather
were symptoms resulting from trauma experienced throughout the
course of the Tribes history.
What is trauma informed care? Trauma Informed Care is
defined as an organizational structure and treatment framework
that involves understanding, recognizing, and responding to the
effects of all types of trauma. Trauma informed care also
emphasizes physical, psychological and emotional safety for
both consumers and providers, and helps survivors rebuild a
sense of control and empowerment for the Menominee, the
definitional scope of trauma was lacking any recognition of
self-worth and cultural competency and had to be expanded to
include the loss of Menominee language, values, and beliefs in
order to accurately examine the collective impacts that
historical and intergenerational trauma had on the community as
a whole. By doing so, the Tribe was able to identify the
symptoms of trauma which included suicide, poverty, substance
abuse/addiction, identity loss, loss of societal/cultural
norms, and many others and identify the impacts that these had
on the individual, family unit, and community.
To accurately assess the magnitude of traumatic experiences
and the impact these had on Menominee youth and within the
family dynamic, the Community Collaboration examined the
statistics identifying child victimization rates in Menominee
County which included neglect, abuse, suicide attempts, and
alcohol and drug use/abuse. In 2013, 1,423 children resided on
the Menominee Indian Reservation. According to the 2013
Wisconsin Department of Children & Families Annual Report to
the Governor and Legislature, approximately 10 children in
1,000 were victimized by either neglect, physical, sexual or
emotional abuse. Equally alarming was the high incidence of
youth hospitalizations for AODA and self-harm. For example, in
2015, there were 10 youth hospitalizations for emergency
detention alone. From January through June 2016, there have
already been a total of 14 emergency detention
hospitalizations, 11 youth hospitalized, and 8 out of 11 youth
hospitalized reported substance abuse and/or tested positive
for alcohol or drugs at the time of admission. Statistics such
as these are what initiated what is now known as the Menominee
Fostering Futures Pilot Project that began in 2013.
Based on the statistics identifying the high incidence of
traumatic experiences for tribal children, the Community
Collaboration identified that existing policies, procedures,
and mandates were not working. Menominee children and families
were continuing to suffer. The County/Tribe was continually
ranked 72 out of 72 for health outcomes and factors by the
University of Wisconsin Population Health Institute.
Educational Attainment was at an all-time low among high school
students. The Menominee Indian School District was in fact,
coined a drop-out factor due to the extremely low percentage of
students graduating. Finally, crime, victimization, and death
rates remained high.
The Community Collaborative Workgroup started by building a
Menominee Model using the Bridges Out of Poverty framework
which was a model for economic and social change,
sustainability and stability. The simple premise of the
Community Collaboration Workgroup identified that the causes of
poverty, low academic achievement and poor health are inter-
connected and formulated that the resources and responses the
Community Collaboration would develop to combat them must also
be inter-connected. This Community Collaborative workgroup
vision of the Menominee Model evolved over time, which included
the introduction and development of the Menominee Fostering
Futures Initiative.
The goal of Fostering Futures was designed to improve the
lives of children and families by translating the knowledge
gained from the Adverse Childhood Experience Study,
neuroscientific information, and mental health literature on
the long-term effects of chronic adversity and trauma in
childhood. As a part of our Fostering Futures work, we had to
pick 2 areas of concentration for our community. We chose the
following: (1) Providing Adverse Childhood Experience Study and
Trauma Informed Care education; and (2) Evaluating and
modifying policies and procedures to be congruent with the
Adverse Childhood Experience study and Trauma Informed Care.
From the first goal, our Introduction to Trauma Informed
Care training was developed. Initiatives of the Community
Collaboration have included: Education Summits focused on
Historical Trauma due to boarding schools and termination; the
implementation of the Fostering Futures Program reservation
wide promoting community awareness of Adverse Childhood
Experiences (ACEs) and Trauma Informed Care (TIC).
Trauma Informed Service Delivery is a key component and
focus of the Community Engagement Workgroup. The Community
Engagement meetings focus on the development, execution and
completion of 90-day plans developed and reported quarterly on
issues established by the workgroup that now involve all
community service providers. The Tribe's programs are
implementing Trauma Informed Services by: reviewing internal
policies and practices with an awareness of Trauma Informed
Care; Continuing the Fostering Future Initiatives aimed at
awareness of Trauma Informed Care, Adverse Childhood
Experiences and sustainability; development of an AODA specific
strategic plan to focus community efforts in areas of most
critical need; using the Community Engagement Initiative to re-
design the service delivery systems of government to ensure
they are client focused and Trauma Informed; working to develop
functions that: document processes being employed so that they
can be cataloged and replicated; establishing a sustainable
community-wide data collection and analysis function to measure
results and guide decisionmaking; and requiring continuous
collaboration among service providers when new grants or other
initiatives are begun to eliminate duplication and stretch
limited resources.
Through diligence, outreach, community education and
involvement of elected leaders from the various governmental
entities, the workgroup now includes all 41 departments of the
Menominee Tribal Government, Menominee County Human Services;
the Menominee Indian School District and the College of
Menominee Nation.
The expansion of Trauma Informed Service Delivery across
Menominee Community had led to extensive organizational and
institutional changes that are showing growing success for our
people. Some of these changes are evidenced by the following:
1. Menominee Indian School District--The Menominee Indian
School District has made many organizational changes aimed at
increasing the student's ability to self-identify and obtain
assistance to regulate emotions in order to increase function
and learning ability. Staff at all learning facilitates have
been trained in Adverse Childhood Experiences, Trauma and
Regulation. Beginning with the youngest learners, the District
has removed the stigma of disciplinary action and created the
morning mood check, the ``Sakom Room'' and Calm down boxes that
allow the student who is disregulated the opportunity to
restore balance in a safe setting before returning to the
learning environment. The District also provides for student
physical and mental health at each facility and instituted the
Screening, Brief Intervention, Referral Treatment (SBIRT)
program for students with substance concerns. Finally, the
District provides graduation coaches for all High School
seniors. These interventions have led to a dramatic increase in
high school graduation rates from 60 percent person in 2007 to
nearly 99 percent percent in 2014.
2. Menominee Tribal Head Start Program--At the Menominee
Tribal Head Start all staff has completed the Head Start Trauma
Smart Training and each facility has trained trauma coaches and
family coaches. This aids in early recognition and intervention
strategies benefiting our youngest learners and their families.
In the coming academic year, families will have the opportunity
to participate in the 10 module training.
3. Menominee Tribal Clinic--The integration of Trauma
Informed Care and Adverse Childhood Experiences (ACES) survey
has redesigned and changed operations in order to better assist
patients, family and service providers by completely
integrating services available. Noticing a problem of the high
absenteeism, the Tribal Clinic redesigned the system by
deviating from traditional appointment scheduling and offered
same-day appointments, which was shown a dramatic decrease in
absenteeism rates. By changing policies and procedures, the
clinic has increased access to medical, dental, and mental
health care to many individuals. The clinic has trained all
staff on Trauma Informed Care; each patient is regularly
screened for trauma in both the behavioral health and medical
departments. The Tribal Clinic also has 4 full-time counselors
trained in trauma interventions. These counselors rotate
through the student health center at the Menominee Indian High
School. The Tribal Clinic has also been accepted to start a
Learning Collaborative in September 2016, to begin the
accreditation process for pre and post PhD Psychology Interns.
4. Menominee County Health and Human Services--The
Menominee County Health & Human Services has trained all staff
on Trauma Informed Care approaches. They have also started the
Alternative Response, which focuses on providing less
intimidating approaches to working with families.
5. Community Education Initiative--The Community Education
Initiative serves to provide the foundation for the Fostering
Futures Initiative by providing awareness, information, and
outreach to the Community and Service Providers on the
principles of Trauma Informed Care and the relationship to
historical trauma, brain development, Adverse Childhood
Experiences, Secondary Trauma, and Resiliency. We have 2 Master
Trainers working in the Community who have completed the
Wisconsin Adverse Childhood Experience Training. Educational
opportunities are offered to the community on a quarterly basis
and to agencies upon request. This education is also offered to
our families participating in the Temporary Assistance for
Needy Families Program.
What is Resilience? Resilience is the ability to adapt well
over time to life-changing situations and stressful conditions.
While many things contribute to resilience, studies show that
caring and supportive relationships can help enhance
resilience. Factors associated with resilience include, but are
not limited to: (1) the ability to make and implement realistic
plans; (2) A positive and confident outlook; (3) the ability to
communicate and solve problems.
We have recognized that while it is important to understand
how and why traumatic experiences influence the person over
their lifetime, we also know that it is equally important to
understand and provide a foundation to overcome those traumatic
experiences through education, awareness and support. The
Community Collaboration has provided all agencies that work
with children and families with consistent resiliency materials
from the Children's Resiliency Initiative or also known as
Resilience Trumps ACES.
In October 2015, the Menominee Indian Tribe, Menominee
County, and Menominee Indian School District were recognized as
1 of 8 communities to receive the Robert Wood Johnson Culture
of Health Award for our innovative efforts to help our
community lead healthier lives. The Tribe has been featured in
the SAMSHA Spotlight and we continue to receive requests from
other Communities for our presentation delivery of Trauma
Informed Care.
Trauma Informed Care requires removal of silos created by
limited resources with narrow guidelines and dated beliefs in
service delivery to achieve outcomes based on mutual
collaboration of resources for all community partners,
providers, and individuals. To achieve that end, I am here
today on behalf of the Menominee Community Collaboration to not
only demonstrate the growing success of this concept, but to
also ask the United States Senate Committee on Indian Affairs
to assist and support Indian Country in this endeavor. We are
asking that you recommend to Congress to appropriate funding
for Native American need-specific interventions that include
the ability for Tribes and organizations to pool goal-specific
funding across federal agencies to progress our intervention
goals. We are also asking that Tribes and partnering
organizations have the ability to pool federal funds from any
agency that were for the purpose of addressing some aspect of
the problems facing that community.
Fortunately, such provisions have already been created
within the 2014 Consolidated Appropriations Act, titled the
Performance Partnership for Disconnected Youth. This piece of
legislation addresses siloing of Federal Programs by
authorizing ten pilot projects under which states, cities, and
tribes would be permitted to pool grant funds from any agency
that were for the purpose of addressing some aspect of the
problems facing disconnected youth. It directs OMB to designate
a lead agency to manage the pooled grants. It also empowers
each Secretary to waive any statute or regulations that will
increase the efficiency of the program or increase access by
the target population, so long as the waiver is consistent with
the overall purposes of the program.
[The prepared statement of Ms. Warrington follows:]
Prepared Statement of Hon. Myrna Warrington, Chairwoman, Health and
Family Committee, Menominee Indian Tribe of Wisconsin
I. Introduction
Posoh (Hello in my Menominee Language) Senator Heitkamp, Senator
Hoeven, and members of the Committee, my name is Myrna Warrington. This
is my 8th year serving as on the Menominee Tribal Legislature and at
this time I serve on the Menominee Indian Tribe's Executive Team as the
Secretary. Thank you for the opportunity to provide the Committee with
the Menominee statement that addresses the trauma and mental health
challenges experienced in Indian Country.
The Menominee Indian Tribe is located in northeast Wisconsin,
within our ancestral territory. Our Reservation is comprised of 234,000
acres of land; bountiful in rivers, lakes, streams, wildlife, and
forest land. Roughly 90 percent of the land held in trust for the Tribe
is held in sustained yield for the Tribe's longstanding practice in
Sustainable Forest Management. The Tribal membership includes over
9,000 enrolled members.
The Tribes history is mired in trauma due to the loss of Tribal
status, identity, language and culture that was forced on our people by
the Federal Government through overarching assimilation objectives,
enactments of federal Indian policy, treaties, and judicial rulings.
The negative remnants of trauma experienced from the treaty era,
Boarding School Era, Menominee Termination Act of 1954, Federal
Relocation Act of 1956, and finally the Restoration of the Menominee
Indian Tribe to Federal Recognition in 1973, remain visible in the
lives of our Tribal members. Throughout the last two centuries, the
Menominee endured the large loss of ancestral territory, near
extinction of Menominee language, and the loss of many critical
cultural and religious beliefs, practices and communal values that
guided the traditional Menominee society. Our oral history and the
historical record remain to help guide the Tribe in the right direction
to address the impacts from these experiences.
In 2006, the Menominee Tribal Government, Menominee Indian School
District, and Menominee Tribal Clinic, who, because of limited
resources with narrow guidelines, broke down the silos to form the
community collaboration. The Menominee Community Collaboration
committed to creating data-driven solutions. The purpose was aimed at
addressing the cumulative impacts that historical and intergenerational
trauma were presenting upon the families of the Menominee Community.
The initial identification process began with defining the negative
behavioral, health, and educational problems that were manifesting in
the lives of the Menominee youth. The community collaboration research
led to the premise that the symptoms of poverty, low academic
achievement, and poor health outcomes and factors were interconnected.
Through this process, the Tribe was forced to confront the reality that
the negative changes occurring within the youth population were a
direct result of the changing family dynamic and community structure
that were symptoms of a larger problem. These issues had not manifested
overnight and were not isolated to just one event, but rather were
symptoms resulting from trauma experienced throughout the course of the
Tribes history.
What is trauma informed care? Trauma Informed Care is defined as
``an organizational structure and treatment framework that involves
understanding, recognizing, and responding to the effects of all types
of trauma. Trauma informed care also emphasizes physical, psychological
and emotional safety for both consumers and providers, and helps
survivors rebuild a sense of control and empowerment'' (Trauma Informed
Care Project, 2016). For the Menominee, the definitional scope of
trauma was lacking any recognition of self-worth and cultural
competency and had to be expanded to include the loss of Menominee
language, values, and beliefs in order to accurately examine the
collective impacts that historical and intergenerational trauma had on
the community as a whole. By doing so, the Tribe was able to identify
the symptoms of trauma which included suicide, poverty, substance
abuse/addiction, identity loss, loss of societal/cultural norms, and
many others and identify the impacts that these had on the individual,
family unit, and community.
II. Statistics
To accurately assess the magnitude of traumatic experiences and the
impact these had on Menominee youth and within the family dynamic, the
Community Collaboration examined the statistics identifying child
victimization rates in Menominee County which included neglect, abuse,
suicide attempts, and alcohol and drug use/abuse. In 2013, 1,423
children resided on the Menominee Indian Reservation. According to the
2013 Wisconsin Department of Children & Families Annual Report to the
Governor and Legislature, approximately 10 children in 1,000 were
victimized by either neglect, physical, sexual or emotional abuse (p.
71). Equally alarming was the high incidence of youth hospitalizations
for AODA and self-harm. For example, in 2015, there were 10 youth
hospitalizations for emergency detention alone. From January through
June 2016, there have already been a total of 14 emergency detention
hospitalizations, 11 youth hospitalized, and 8 out of 11 youth
hospitalized reported substance abuse and/or tested positive for
alcohol or drugs at the time of admission. Statistics such as these are
what initiated what is now known as the Menominee Fostering Futures
Pilot Project that began in 2013.
III. Menominee Problem Identification & Solutions
Based on the statistics identifying the high incidence of traumatic
experiences for tribal children, the Community Collaboration identified
that existing policies, procedures, and mandates were not working.
Menominee children and families were continuing to suffer. The County/
Tribe was continually ranked 72 out of 72 for health outcomes and
factors by the University of Wisconsin Population Health Institute.
Educational Attainment was at an all-time low among high school
students. The Menominee Indian School District was in fact, coined a
``drop-out factory'' due to the extremely low percentage of students
graduating. Finally, crime, victimization, and death rates remained
high.
IV. Menominee Model Making the Difference
The Community Collaborative Workgroup started by building a
Menominee Model using the ``Bridges Out of Poverty'' framework--which
was a model for economic and social change, sustainability and
stability. The simple premise of the Community Collaboration Workgroup
identified that the causes of poverty, low academic achievement and
poor health are inter-connected and formulated that the resources and
responses the Community Collaboration would develop to combat them must
also be inter-connected. This Community Collaborative workgroup vision
of the Menominee Model evolved over time, which included the
introduction and development of the Menominee Fostering Futures
Initiative.
The goal of Fostering Futures was designed to improve the lives of
children and families by translating the knowledge gained from the
Adverse Childhood Experience Study, neuroscientific information, and
mental health literature on the long-term effects of chronic adversity
and trauma in childhood. As a part of our Fostering Futures work, we
had to pick 2 areas of concentration for our community. We chose the
following:
1. Providing Adverse Childhood Experience Study and Trauma
Informed Care education; and
2. Evaluating and modifying policies and procedures to be
congruent with the Adverse Childhood Experience study and
Trauma Informed Care.
From the first goal, our Introduction to Trauma Informed Care
training was developed. Initiatives of the Community Collaboration have
included:
Education Summits focused on Historical Trauma due to
boarding schools and termination;
The implementation of the Fostering Futures Program
reservation wide promoting community awareness of Adverse
Childhood Experiences (ACEs) and Trauma Informed Care (TIC).
Trauma Informed Service Delivery is a key component and focus of
the Community Engagement Workgroup. The Community Engagement meetings
focus on the development, execution and completion of 90-day plans
developed and reported quarterly on issues established by the workgroup
that now involve all community service providers. The Tribe's programs
are implementing Trauma Informed Services by:
Reviewing internal policies and practices with an awareness
of Trauma Informed Care; Continuing the Fostering Future
Initiatives aimed at awareness of Trauma Informed Care, Adverse
Childhood Experiences and sustainability;
Development of an AODA specific strategic plan to focus
community efforts in areas of most critical need;
Using the Community Engagement Initiative to re-design the
service delivery systems of government to ensure they are
client focused and Trauma Informed;
Working to develop functions that: document processes being
employed so that they can be cataloged and replicated;
establishing a sustainable community-wide data collection and
analysis function to measure results and guide decision-making;
and
Requiring continuous collaboration among service providers
when new grants or other initiatives are begun to eliminate
duplication and stretch limited resources.
Through diligence, outreach, community education and involvement of
elected leaders from the various governmental entities, the workgroup
now includes all 41 departments of the Menominee Tribal Government,
Menominee County Human Services; the Menominee Indian School District
and the College of Menominee Nation.
The expansion of Trauma Informed Service Delivery across Menominee
Community had led to extensive organizational and institutional changes
that are showing growing success for our people. Some of these changes
are evidenced by the following:
Menominee Indian School District
The Menominee Indian School District has made many organizational
changes aimed at increasing the student's ability to self-identify and
obtain assistance to regulate emotions in order to increase function
and learning ability. Staff at all learning facilitates have been
trained in Adverse Childhood Experiences, Trauma and Regulation.
Beginning with the youngest learners, the District has removed the
stigma of disciplinary action and created the morning mood check, the
``Sakom Room'' and Calm down boxes that allow the student who is
dysregulated the opportunity to restore balance in a safe setting
before returning to the learning environment. The District also
provides for student physical and mental health at each facility and
instituted the Screening, Brief Intervention, Referral Treatment
(SBIRT) program for students with substance concerns. Finally, the
District provides graduation coaches for all High School seniors. These
interventions have led to a dramatic increase in high school graduation
rates from 60 percent person in 2007 to nearly 99 percent percent in
2014.
2. Menominee Tribal Head Start Program
At the Menominee Tribal Head Start all staff has completed the Head
Start Trauma Smart Training and each facility has trained trauma
coaches and family coaches. This aids in early recognition and
intervention strategies benefitting our youngest learners and their
families. In the coming academic year, families will have the
opportunity to participate in the 10 module training.
3. Menominee Tribal Clinic
The integration of Trauma Informed Care and Adverse Childhood
Experiences (ACES) survey has redesigned and changed operations in
order to better assist patients, family and service providers by
completely integrating services available. Noticing a problem of the
high absenteeism, the Tribal Clinic redesigned the system by deviating
from traditional appointment scheduling and offered same-day
appointments, which was shown a dramatic decrease in absenteeism rates.
By changing policies and procedures, the clinic has increased access to
medical, dental, and mental health care to many individuals. The clinic
has trained all staff on Trauma Informed Care; each patient is
regularly screened for trauma in both the behavioral health and medical
departments. The Tribal Clinic also has 4 full-time counselors trained
in trauma interventions. These counselors rotate through the student
health center at the Menominee Indian High School. The Tribal Clinic
has also been accepted to start a Learning Collaborative in September
2016, to begin the accreditation process for pre and post PhD
Psychology Interns.
4. Menominee County Health & Human Services
The Menominee County Health & Human Services has trained all staff
on Trauma Informed Care approaches. They have also started the
Alternative Response, which focuses on providing less intimidating
approaches to working with families.
5. Community Education Initiative
The Community Education Initiative serves to provide the foundation
for the Fostering Futures Initiative by providing awareness,
information, and outreach to the Community and Service Providers on the
principles of Trauma Informed Care and the relationship to historical
trauma, brain development, Adverse Childhood Experiences, Secondary
Trauma, and Resiliency. We have 2 Master Trainers working in the
Community who have completed the Wisconsin Adverse Childhood Experience
Training. Educational opportunities are offered to the community on a
quarterly basis and to agencies upon request. This education is also
offered to our families participating in the Temporary Assistance for
Needy Families Program.
V. Resilience
What is Resilience? Resilience is the ability to adapt well over
time to life-changing situations and stressful conditions. While many
things contribute to resilience, studies show that caring and
supportive relationships can help enhance resilience. Factors
associated with resilience include, but are not limited to: (1) the
ability to make and implement realistic plans; (2) A positive and
confident outlook; (3) the ability to communicate and solve problems.
(DS Bigfoot, 2015).
We have recognized that while it is important to understand how and
why traumatic experiences influence the person over their lifetime, we
also know that it is equally important to understand and provide a
foundation to overcome those traumatic experiences through education,
awareness and support. The Community Collaboration has provided all
agencies that work with children and families with consistent
resiliency materials from the Children's Resiliency Initiative or also
known as Resilience Trumps ACES.
In October 2015, the Menominee Indian Tribe, Menominee County, and
Menominee Indian School District were recognized as 1 of 8 communities
to receive the Robert Wood Johnson ``Culture of Health'' Award for our
innovative efforts to help our community lead healthier lives. The
Tribe has been featured in the SAMSHA Spotlight and we continue to
receive requests from other Communities for our presentation delivery
of Trauma Informed Care.
VI. Tribal Ask
Trauma Informed Care requires removal of silos created by limited
resources with narrow guidelines and dated beliefs in service delivery
to achieve outcomes based on mutual collaboration of resources for all
community partners, providers, and individuals. To achieve that end, I
am here today on behalf of the Menominee Community Collaboration to not
only demonstrate the growing success of this concept, but to also ask
the United States Senate Committee on Indian Affairs to assist and
support Indian Country in this endeavor. We are asking that you
recommend to Congress to appropriate funding for Native American need-
specific interventions that include the ability for Tribes and
organizations to pool goal-specific funding across federal agencies to
progress our intervention goals. We are also asking that Tribes and
partnering organizations have the ability to pool federal funds from
any agency that were for the purpose of addressing some aspect of the
problems facing that community.
Fortunately, such provisions have already been created within the
2014 Consolidated Appropriations Act, titled the ``Performance
Partnership for Disconnected Youth.'' This piece of legislation
addresses siloing of Federal Programs by authorizing ten pilot projects
under which states, cities, and tribes would be permitted to pool grant
funds from any agency that were for the purpose of addressing some
aspect of the problems facing disconnected youth. It directs OMB to
designate a lead agency to manage the pooled grants. It also empowers
each Secretary to waive any statute or regulations that will increase
the efficiency of the program or increase access by the target
population, so long as the waiver is consistent with the overall
purposes of the program.
Senator Heitkamp. Thank you. And I know we'll have an
opportunity to expand on our testimony during our questions.
Next we're going to hear from Dr. Kathryn Eagle-Williams. Dr.
Eagle-Williams, it's good to see you again. Thank you for your
committed effort holistically on what you do as a health care
provider.
STATEMENT OF KATHRYN R. EAGLE-WILLIAMS, M.D., CEO/QUALITY CARE
DIRECTOR, ELBOWOODS MEMORIAL HEALTH CENTER, MANDAN, HIDATSA AND
ARIKARA NATION
Dr. Eagle-Williams. My name is Dr. Kathryn Eagle-Williams
(Red Cedar Women) I am the Chief Executive Officer of Elbowoods
Memorial Center of the Three Affiliated Tribes and an enrolled
member of the Arikara. First of all, I would like to thank for
your interest in addressing trauma and mental health challenges
in Indian Country and in particular in North Dakota. I am going
to start by informing the committee that I am a survivor of
suicide. On September 7, 2011 I lost my daughter to depression.
She died by way of hanging. As a result of her death we have an
entire immediate family of approximately 50 plus individuals
affected by her death, and an even large number of extended
family and community members. She died in Tucson, Arizona where
we made our home. Within 7 months of her death I moved home to
North Dakota and this is where my healing process began.
Although, we were in Arizona at the time the picture is still
the same. In general, access to basic health services is
limited as is funding and expertise in working with Native
American populations in regard to mental health and trauma.
Access to mental health services is more limited due to lack of
mental health providers, programs, and funding.
As health care providers in behavioral health we are aware
of the fact that adverse child experiences contribute
significantly to the health outcomes of any individual within a
population, but must be mindful of the disparities within our
Native American populations.
Based on the latest statistics from 2009-2013 the suicide
rate among AIAN was the highest in the United States, 34.3
deaths per 100,000 for men and 9.9 deaths per 100,000 for
women. AIAN males are twice as likely to complete suicide
compared to other gender, racial and ethnic subgroups. Suicide
is the 2nd leading cause of death for AIAN persons age 15-24
and 4x the national average.
Losing a child to depression is my story, but we all know
there are many more stories of our men, women, and children who
are suffering and have died from mental illness. We as Native
people have heard the stories of our historical trauma and are
still suffering from not only those traumas that affected our
ancestors, but also the traumas that are a daily occurrence on
our reservations and among our family and community members. We
are still trying to overcome the Garrison Dam experience, we
have a few elders still living who actually recall life before
the dam and who remember a life that was much happier with few
social and health issues and who recall the devastation of
having to move from the bottom lands to higher ground.
Through my personal journey with the help of friends,
colleagues, and my tribe have been able to work on healing and
for that I am grateful. Much my healing experience did not come
from sitting in a counselors office, but from the support of my
community and spiritual leaders. Our work in the area of health
and wellness is has only begun, we need mental health first
responders or behavioral health technicians to help with sudden
unexpected deaths and trauma such as domestic violence and
sexual assaults; we need grief counselors, and must
destigmatize mental illness.
In order to begin to heal a community we must first
identify and recognized the trauma before we deal with it. Our
people are living in crisis situations as I once was and are
simply just trying to survive. At Elbowoods Memorial Health
Center we are fully aware of the need for and protective
factors associated with traditional medicine, but it seems as
though the federal and state governments have not recognized
the importance of spirituality and identity, which limits our
ability to create programs that are meaningful and successful.
We would like to see more of an investment into these
modalities of therapy and health practices. We would like to
offer these practices here with the possible consideration of
medical reimbursement.
Today I would like to share with some of what we experience
on the Fort Berthold Reservation otherwise known as the Three
Affiliated Tribes.
The core of our challenges are as follows: (1) Limited
access to services as a result of underfunding, criteria
requirements, and licensure required for clinicians (locally),
and lack of availability regionally. (2) Lack of access to
hospital beds required for acute care and life threatening
mental health conditions. (3) Lack of a plan to transport
emergency life threatening mental health conditions requiring
ambulance verse civil transports to the accepting hospitals.
(4) Limited human resources and expertise: inability to staff
our already under funded behavioral health programs. (5) Lack
of funding, funding is often competitive and requires data that
is often not available or scattered. (6) Lack of culturally
sensitive trauma informed care models and training. (7) Limited
resources in regard to prevention and intervention programs
associated with suicide and mental and brain health. (8) Stigma
associated with mental illness. (9) Social determinates of
mental health. (10) Need of mental health first responders
program to be established reservation wide.
So, the question is how do we address these core
challenges? First of all, it is through support of our
leadership, tribal, state, and federal that we can begin to
impact the disparities. Secondly, we must educate and inform
our policy maker and funding agencies the importance of working
with Tribes and understanding the true demand may not always be
established through data as we may not have access to
meaningful data. Finally, the continuation of tribal
consultation is a necessity initially and throughout the
process of planning and development of programs.
With that being said we are appreciative of the state's
respect and consideration to ask for tribal consultation and
would like to be an integral part of a state wide plan to the
development of realistic services and training that are not
only on paper, but are being implemented throughout the great
plains. Dr. Monica Taylor-Desir, Chief Medical Officer for
Elbwoods Memorial Health Center, who we are very fortune to
have, has reviewed the ND suicide prevention plan. Dr. Taylor
Desir has identified the plan includes working with Native
Americans but there is no evidence in the last 6 months of the
enactment of that plan in particular with our tribes. We need
action not just words. We need support to educate and train our
own people to help address the lack of human resources and
access.
We need help in addressing the social determinants of
mental health which include the following: discrimination and
social exclusion; adverse childhood experiences; poor
education, unemployment, underemployment, job insecurity;
income inequality, poverty and neighborhood deprivation; food
insecurity; poor housing quality and housing instability; poor
access to mental health care.
It is our recommendation that when working with Native
American people we must work from a strength based approach. It
must be recognized that our cultural traditional ways of life
and living are important protective factors in regard with
mental, spiritual wellbeing of our people. We must destigmatize
mental illness and focus on brain health and wellness. We must
incorporating cultural practices into approved grants and other
funding opportunities. We must promote commitment to cultural
spirituality as well as promote strengthening of family ties
and relationships. Incorporating, traditional spirituality and
wellness must be recognized as a best practice. And in order to
get at the heart of mental health we must incorporate trauma
informed care while addressing addictions. We must not
criminalize the addict or the broken spirit.
As I conclude I would once again like to say thank you for
your interest and consideration as we attempt to meet the
health needs of our people. In writing this testimony I am
honored and humbled to share my story which is an experience I
unfortunately share with far too many of my people.
[The prepared statement of Dr. Eagle-Williams follows:]
Prepared Statement of Kathryn R. Eagle-Williams, M.D., CEO/Quality Care
Director, Elbowoods Memorial Health Center, Mandan, Hidatsa and Arikara
Nation
My name is Dr. Kathryn Eagle-Williams (Red Cedar Women) I am the
Chief Executive Officer of Elbowoods Memorial Center of the Three
Affiliated Tribes and an enrolled member of the Arikara. First of all,
I would like to thank for your interest in addressing trauma and mental
health challenges in Indian Country and in particular in North Dakota.
I am going to start by informing the committee that I am a survivor of
suicide. On September 7, 2011 I lost my daughter to depression. She
died by way of hanging. As a result of her death we have an entire
immediate family of approximately 50 plus individuals affect by her
death, and an even large number of extended family and community
members. She died in Tucson, Arizona where we made our home. Within 7
months of her death I moved home to North Dakota and this is where my
healing process began. Although, we were in Arizona at the time the
picture is still the same. In general, access to basic health services
is limited as is funding and expertise in working with Native American
populations in regard to mental health and trauma. Access to mental
health services is more limited due to lack of mental health providers,
programs, and funding.
As health care providers in behavioral health we are aware of the
fact that adverse child experiences contribute significantly to the
health outcomes of any individual within a population, but must be
mindful of the disparities within our Native American populations.
Based on the latest statistics from 2009-2013 the suicide rate
among AIAN was the highest in the United States.
34.3 deaths per 100,000 for men
9.9 deaths per 100,000 for women
AIAN males are twice as likely to complete suicide compared
to other gender, racial and ethnic subgroups
Suicide is the 2nd leading cause of death for AIAN persons
age 15-24 and 4x the national average
Losing a child to depression is my story, but we all know there are
many more stories of our men, women, and children who are suffering and
have died from mental illness. We as Native have heard the stories of
our historical trauma and are still suffering from not only those
traumas that affected our ancestors, but also the traumas that are a
daily occurrence on our reservations and among our family and community
members. We are still trying to overcome the Garrison Dam experience,
we have a few elders still living who actually recall life before the
dam and who remember a life that was much happier with few social and
health issues and who recall the devastation of having to move from the
bottom lands to higher ground.
Through my personal journey with the help of friends, collages, and
my tribe have been able to work on healing and for that I am grateful.
Much my healing experience did not come from sitting in a counselors
office, but from the support of my community and spiritual leaders. Our
work in the area of health and wellness work is has only begun, we need
mental health first responders or behavioral health technicians to help
with sudden unexpected deaths and trauma such as domestic violence and
sexual assaults; we need grief counselors, and must destigmatize mental
illness.
In order to begin to heal a community we must first identify and
recognized the trauma before we deal with it. Our people are living in
crisis situations as I once was and are simply just trying to survive.
At Elbowoods Memorial Health Center we are fully aware of the need for
and protective factors associated with traditional medicine, but it
seems as though the federal and state governments have not recognized
the importance of spirituality and identity, which limits are ability
to create programs that are meaningful and successful. We would like to
see more of an investment into these modalities of therapy and health
practices. We would like to offer these practices here with the
possible consideration of medical reimbursement.
Today I would like to share with some of what we experience on the
Fort Berthold Reservation otherwise known as the Three Affiliated
Tribes.
The core of our challenges are as follows:
1. Limited access to services as a result of underfunding,
criteria requirements, and licensure required for clinicians
(locally), and lack of availability regionally.
2. Lack of access to hospital beds required for acute care and
life threatening mental health conditions.
3. Lack of a plan to transport emergency life threating mental
health conditions requiring ambulance verse civil transports to
the accepting hospitals.
4. Limited human resources and expertise: inability to staff
our already under funded behavioral health programs.
5. Lack of funding, funding is often competitive and requires
data that is often not available or scattered.
6. Lack of culturally sensitive trauma informed care models
and training.
7. Limited resources in regard to prevention and intervention
programs associated with suicide and mental ``brain'' health.
8. Stigma associated with mental illness
9. Social determinates of mental health
10. Need of mental health first responders program to be
established reservation wide
So, the question is how do we address these core challenges? First
of all, it is through support of our leadership, tribal, state, and
federal that we can begin to impact the disparities. Secondly, we must
educate and inform our policy maker and funding agencies the importance
of working with tribes and understanding the true demand may not always
be established through data as we may not have access to meaningful
data. Finally, the continuation of tribal consultation is a necessity
initially and throughout the process of planning and development of
programs.
With that being said we are appreciative of the state's respect and
consideration to ask for tribal consultation and would like to be an
integral part of a state wide plan to the development of realistic
services and training that are not only on paper, but are being
implemented throughout the great plains. Dr. Monica Taylor-Desir, Chief
Medical Officer for Elbwoods Memorial Health Center, who we are very
fortune to have, has reviewed the ND suicide prevention plan. Dr.
Taylor-Desir has identified the plan includes working with Native
Americans but there is no evidence in the last 6 months of the
enactment of that plan in particular with our tribes. We need action
not just words. We need support to educate and train our own people to
help address the lack of human resources and access.
We need help in addressing the social determinants of mental health
which include the following:
Discrimination and social exclusion
Adverse childhood experiences
Poor education
Unemployment, underemployment, job insecurity
Income inequality, poverty and neighborhood deprivation
Food insecurity
Poor housing quality and housing instability
Poor access to mental health care
It is our recommendation that when working with Native American
people we must work from a strength based approach. It must be
recognized that our cultural traditional ways of life and living are
important protective factors in regard with mental, spiritual wellbeing
of our people. We must destigmatize mental illness and focus on brain
health and wellness. We must incorporating cultural practices into
approved grants and other funding opportunities. We must promote
commitment to cultural spirituality as well as promote strengthening of
family ties and relationships. Incorporating, traditional spirituality
and wellness must be recognized as a best practice. And in order to get
at the heart of mental health we must incorporate trauma informed care
while addressing addictions. We must not criminalize the addict or the
broken spirit.
As I conclude I would once again like to say thank you for your
interest and consideration as we attempt to meet the health needs of
our people. In writing this testimony I am honored and humbled to share
my story which is an experience I unfortunately share with far too many
of my people.
Below you will find more information that has been gathered by our
Behavioral Health Director, Dr. Lisa Keller-Schafer, a trained
psychologist.
Behavioral Health (BH) Obstacles for NA residing on and off Fort
Berthold reservation
1. Access to mental health services is severely limited for those
living on and off the reservation due to:
a. Lack of insurance
i. 33 percent reported not having insurance compared to 11
percent of Whites; with 46 percent reported they could not
afford the cost of healthcare
ii. 57 percent rely on IHS for care
b. Lack of tribal funding
i. Due to changes in budgeting and outside payee sources
many programs' funding has been cut--some--including behavioral
health, up to 50%
c. Lack of transportation
i. Of those who own a car, most cannot afford to fix minor
repairs, pay for gas, or general upkeep.
ii. Others rely on relatives/friends to transport them,
which often is money paid out of their pocket. An elderly lady
reported having to pay $100 to her relative for each trip she
took to a store
d. Lack of providers
i. currently Fort Berthold has one provider to cover the
entire reservation
ii. of those who apply for counseling positions, most are
underqualified or not licensed
iii. the only recruiting incentive is student loan repayment
programs for those who are licensed
iv. In regards to reasons tribal members do not seek BH
services: 39 percent of tribal members reported a lack of
providers and 48 percent reported limited clinic hours kept
them from seeking mental health services; another 40 percent
did not trust their information would not be kept confidential
e. High poverty rates
i. The percentage of the reservation population with income
below the poverty level is at 23.1 percent. In comparison, this
is more than double the average North Dakota poverty rate of
11.2 percent and is higher than the U.S. rate of 15.9 percent.
In respect to children, the situation is worse, with 31.6
percent of the reservation population under the age of 18
living below the poverty line compared to 13.2 percent in North
Dakota and 22.6 percent in the U.S. overall
f. Emergency Service Barriers
i. 78 percent of tribal members report there are no
emergency services available in their area
ii. ambulance drivers can refuse to transport individuals
presenting with psychosis or a danger to others claiming they
are at greater risk of harm because those individuals are
violent--WHICH is a myth
iii. there are no police transports for individuals
presenting with severe mental illness--even those with
homicidal and suicidal ideations due to boundary issues--
basically TAT police are required to place criminal charges on
individuals who they transport. This means for clients
presenting with mental illness, they would have to be
criminally charged before police can transport. AND even if
police could transport they could only bring a client to the
reservation line and then another police officer from the next
county would need to take the client from there. AND the client
would not be escorted to a hospital ED, but instead because
criminal charges were placed on that client--the client would
go to jail until his/her hearing.
iv. There is no clean-cut civil commitment on the
reservation. Family and friends who are attempting to get their
loved ones help and the loved one is over 18 years must
complete affidavits indicating why the loved one is a danger to
the self or others. This goes to the judge who decides if the
individual should be detained--but that is if the loved one can
be easily found--given the PD are also understaffed.
g. Lack of awareness about mental health issues and services
AND Stigma
i. Many elderly believe talking about mental health issues
such as suicide will make things worse
ii. Approximately 78 percent of all individuals presenting
for mental health services have reported a dislike of
psychotropic medications, but have used licit and illicit
substances to relieve their symptoms
iii. Many do not believe their information will remain
confidential
iv. misguided views that people with mental health problems
may be more violent or unpredictable than people without such
problems, or somehow just ``different'', but none of these
beliefs has any basis in fact; Psych ward--insane asylums--
bloodthirsty killers in straightjackets -
v. early beliefs about the causes of mental health problems,
such as demonic or spirit possession, were `explanations' that
would almost certainly give rise to reactions of caution, fear
and discrimination.
vi. Even the medical model of mental health problems is
itself an unwitting source of stigmatizing beliefs. First, the
medical model implies that mental health problems are on a par
with physical illnesses and may result from medical or physical
dysfunction in some way (when many may not be simply reducible
to biological or medical causes). This itself implies that
people with mental health problems are in some way `different'
from `normally' functioning individuals. Secondly, the medical
model implies diagnosis, and diagnosis implies a label that is
applied to a `patient'. That label may well be associated with
undesirable attributes (e.g. `mad' people cannot function
properly in society, or can sometimes be violent), and this
again will perpetuate the view that people with mental health
problems are different and should be treated with caution.
vii. stigma directed at adolescents with mental health
problems came from family members, peers, and teachers.
viii. stigma perpetrated by teachers and school staff, who
expressed fear, dislike, avoidance, and under-estimation of
abilities
ix. Mental health stigma is even widespread in the medical
profession, at least in part because it is given a low priority
during the training of physicians and GPs
h. Limited services available on the reservation
i. There is no speech or occupational services--46 percent
have requested these services
ii. There are no pain clinics--41 percent have requested
these services--these services are essential for those using
opiates to mask mental illness
iii. No alternative care such as massage, acupuncture--35
percent have requested these services
iv. There is no CT, MRI, Pet Scans
v. There is no sleep study program, respiratory care, EEG
Consequences
1. Suicide: There are currently no statistics for the Fort Berthold
Reservation in regards to the number of suicides. However, the Aberdeen
IHS office has presented the following example from other reservations
in its' area. ``It could be argued that the senseless stabbing death of
a young teenage girl in January 2007 by two other young teenage girls
being egged on by a circle of peers really set the tone for the 2014
year: one of dread and despair that led to a continuous cycle of death.
. . of 16 other adolescents who took their own lives. In spite of
efforts over the past 12 months to reach-out to youth and families, to
train all community members on prevention and intervention strategies,
to partner with state and federal agencies for an increase in services,
these lives lost are the best indicator that there are gaps,
inadequacies, and barriers to current service structures. As shown
above, in the number of agencies and organizations devoting resources
to youth, there is dedication of purpose. These purposes and efforts,
however, have not yet led to a transformed community where the choice
for life far outreaches the choice for death.''
2. Serious Emotional Behavioral Disorder (SEBD) reflects an
individual (ages 8 to 89 years) who:
a. Is angry, bitter, hostile, and aggressive, prone to
fighting and bulling, uses excessive profanity, who is
constantly getting into trouble, prone to steal, arson and gang
activity and who may act out sexually;
b. Appears withdrawn, upset, frustrated, pouting and sulking,
lazy and lethargic, confused, lacking attention, and who has
poor hygiene, inadequate nutritional intake, sleep disturbance,
and prone to lying, running away from home, self-mutilation;
c. Shows a lack of respect, failure to thrive, has health
problems and depression, is defiant, has low self-esteem, has
attachment issues and prone to gang participation, has poor
academic performance; and,
d. Is prone to suicidal thoughts and ideations, social phobias
and fear of certain people, has a false pride and demonstrates
grandiosity or `big head'.
3. Methamphetamine use is increasing. The Aberdeen Area Indian
Health Service (IHS) reported that on average Behavioral Health Units
(Alcohol Programs as well as IHS Mental Health Programs) are seeing an
average of 48.5 cases of confirmed methamphetamine use per month per
site.
4. Liver diseases are ``broken spirit'' diseases for Indian people.
HIV and Hepatitis (HBV and HCV) affects AI/AN in ways that are not
always apparent because of small population sizes. Of all races/
ethnicities, AI/AN had the highest percentages of diagnosed HIV and
Hepatitis infections due to injection drug use. AI/AN face HIV and
Hepatitis prevention challenges, including poverty, high rates of STIs,
stigma, and lack of psychiatric care to treat predisposing mental
illnesses.
5. A national study on Violence Against Women reported that
American Indian women and experience the highest rate of Domestic
Violence in the United States, and that three-fourths of Native
American women and children have or will experience some type of sexual
assault in their life time; with approximately 76 percent of women
being raped by their significant other at least one time. Although
recent reports of violence vary and specific numbers are not known, it
is estimated that over the past 3 years Fort Berthold shows an increase
in the number of violence-induced injuries including 664 assaults, 60
stabbings, and 31 possible rapes. This report is a rough estimation of
persons seeking medical or legal intervention on and off the
reservation.
6. The poverty of the area has a major impact on the health and
wellness of the people. The Aberdeen Area Indian Health Service IHS
which provides health care to Fort Berthold, and the tribes in South
Dakota and Iowa, has some of the most startling health statistics of
the twelve national IHS service areas (Indian Health Service, 2007):
The age-adjusted death rate (all causes) is more than double
the U.S. All Races rate, and is the second highest Area rate in
the Indian Health Service.
Other Data on Mortality rates: the 2nd highest Suicide Death
Rate; the highest Alcoholism Death Rate; the second highest
Diseases of the Heart Death Rate
The Diabetes Mellitus Death Rate is five times the U.S. All
Races Rate. Diabetes is the fifth leading cause of death for
Tribes in the Aberdeen Area (following heart disease, cancer,
accidents, liver disease and cirrhosis).
The lowest Life Expectancy at Birth: 64.8 years compared to
75.8 years for the U.S. All Races and 71.1 years for the All
IHS service populations.
The highest Years of Potential Life Lost Rate: 119.5 years/
per 1,000 persons under the age of 65, which is 2.5 times the
U.S. all races total.
Senator Heitkamp. Thank you very much, Dr. Eagle. Next we
have Dr. DeCoteau shares some responsibility of talking about
what more we could do to carry forward the idea and the
knowledge about trauma. She is a leading expert throughout the
country.
STATEMENT OF TAMI DeCOTEAU, Ph.D., CLINICAL
PSYCHOLOGIST, DeCOTEAU TRAUMA--INFORMED CARE AND PRACTICE, PLLC
Dr. DeCoteau. Thank you, Senator Heitkamp. I am honored to
be here. My name is Dr. Tami DeCoteau. I am an enrolled tribal
member of the Mandan Hidatsa Arikara Nation and a proud
descendant of the Turtle Mountain Chippewa. I have worked as a
licensed clinical psychologist with an emphasis on the
treatment of trauma disorders for more than a decade. In
addition to maintaining a busy patient caseload, I own a
Bismarck-based private practice that employs 6 mental health
workers who are uniquely trained in the application of trauma-
specific interventions for adults, children and families. Thank
you for holding this hearing on trauma and mental health
challenges in Indian country and inviting me to testify.
Senator Heitkamp, I would like to thank you for your key
role in advancing Native American priorities, your efforts to
improve the lives of Native American people and for
illuminating the important but tragically overlooked issue of
historical trauma. I would also like to thank you for drafting
and advocating for S. 246, ``The Alyce Spotted Bear and Walter
Soboleff Commission on Native Children.'' S. 246 is essential
to enhancing the lives of Native children.
I have been asked by members of the Committee to focus my
testimony on my professional experience and my clinical
perspective on trauma.
I obtained a doctorate degree in Clinical Psychology in
2003 from the University of Nebraska-Lincoln with
specialization in the cognitive-behavioral treatment of anxiety
disorders, which at the time encompassed trauma disorders. My
professional practice work has focused on providing services to
trauma-survivors. I am certified in trauma-focused cognitive
behavioral therapy. I have received training in the
Neurosequential Model of Therapuetics (NMT), a developmentally
sensitive, neurobiology-informed approach to working with at-
risk children; Trust-Based Relational Intervention (TBRI), a
therapeutic model that trains caregivers to provide effective
support for at-risk children; and Eye Movement Desensitization
and Reprocessing (EMDR), an intervention approach that helps
reduce the long-lasting effects of traumatic memories.
During my undergraduate and graduate training I received
the honor of becoming a McNair Scholar and then an American
Psychological Association (APA) Fellow. I also received the
Indian Health Service 2009 Health Professional of the Year
Award for outstanding service and the American Psychological
Foundation 2010 Early Career Award for providing culturally
competent practice techniques for Native Americans and for
developing training programs in rural, underserved areas.
My career began with the Veteran's Administration where I
provided psychological services to traumatized Veterans. During
my interim at the VA, Dr. Arthur McDonald (Ogala Lakota) and I
joined forces to create psychology internship training and
services for Native Americans. Our initial effort was funded by
HRSA/BHP. During the 3-year grant phase we designed and
implemented a model for training psychologists to provide
culturally competent and relevant services in rural Native
American communities. From this experience, evolved the
stimulus for a much greater vision to develop reservation-based
internship programs with unique missions to restore the
individual and the collective sense of worth of Native American
people by supporting the belief that the healing of Native
Nations lies within the Nations themselves.
The Standing Rock Psychology Internship and Post-doctoral
Program became the flagship model of our vision. The Program
evidenced success in recruiting and retaining psychology
providers for rural Native American populations and
substantially increased accessible mental health services.
Doctorate-level trainees worked collaboratively with tribal
health, schools, and judicial departments. In addition to the
well over 3,000 hours of direct patient care, trainees provided
community education, suicide prevention, and even equine
assisted psychotherapy. One of the highlights of the Program
was the mobile crisis response team that worked to prevent and
reduce suicides on the reservation. The Program was a tribally-
driven initiative that provided an excellent example of Indian
self-determination.
Unfortunately, it is difficult to sustain mental health
services on the reservation. Mental health providers in Indian
Country are at a particularly high risk for burnout. We work in
an intense and crisis-oriented environment on a day-to-day
basis. We face an unusual array of highly-stressful conditions
including inadequate compensation, safety issues, lack of basic
resources such as supplies and testing materials, professional
isolation, lack of appropriate referral and consultation
resources, excessive time demands, and inadequate funding. In
addition, we serve a patient population that has an
unimaginable amount of emotional trauma and social problems.
These conditions cause us to experience a constant state of
physical and mental exhaustion and lead to feelings of
depersonalization and dissatisfaction. It is no surprise that
decreased worker effectiveness and burnout are common among
mental health professional in rural Indian Country.
While my heart still resides in working on Indian
reservations, I have been drawn towards education and advocacy
for trauma-survivors including training local teachers,
educating congressional leaders, and serving as the president
of Council for Native American Trauma-Informed Initiatives
which is hosting this afternoon's Roundtable on the Causes and
Effects of Trauma In Native American Communities.
Thus, in 2011, I step away from my clinical work on the
reservation and began work as a private practice and consulting
psychologist in Bismarck, ND. In a very short amount of time my
clinic schedule was full of patients, primarily children in
foster care with complex developmental trauma. Whether it be
on, or off the reservation the need for trauma-based
psychological services in North Dakota is immense. Over the
course of my career I have become acutely aware of the
``culture of trauma'' that is overwhelming Indian communities
and inhibiting the traditional ``healing culture'' practices. I
will discuss the culture of trauma first.
Historical trauma is the cumulative impact of historical
losses caused by European settlers' efforts to exterminate
Native Americans and our culture and transmitted across
generations. The assimilation policies of the federal
government, particularly the one that involved sending young
Indian children to boarding schools, continue to have a
tremendous detrimental effect on Indian people. This history
has led to a generational pattern of trauma that perpetuates
itself in the form of abuse, neglect, substance addiction,
violence, mental unwellness, physical illness, and unresolved
grief.
Trauma by definition is an unbearable and out of control
sensation in the body. It leaves an imprint on the mind, body
and brain and results in reorganization of the way the mind and
brain manage perceptions. Trauma changes what we think, how we
think, and our very capacity to think. Traumatized people have
trouble deciphering what is going on around them. They
superimpose their trauma on everything. Individuals who become
conditioned to adversity come to believe they have no control
over their lives so they give up trying--a response referred to
as learned helplessness. Trauma affects those who are directly
exposed to it as well as those around them. The current
challenges in Indian country, including difficulties with
social-environmental, physiological and psychological
functioning, are evidence that the trauma that occurred long
ago continues to impact Native Americans today.
The therapists in my practice serve hundreds of traumatized
individuals, many of whom are Native American children. The
gut-wrenching impact of trauma on these precious souls is
evident in their persistent hyperarousal and hyperactivity.
These children struggle to regulate their own emotions, attend
to stimuli, and their capacity for learning is often greatly
impaired. While they are desperate for love and affection,
their persisting fear-response causes them to perceive
everything as threatening, and they are likely to lash out at
even the most loving caregivers. Children who have such complex
trauma cannot become functioning members of society without
skillful trauma-focused intervention.
Research shows that helping trauma survivors to describe
their trauma is helpful, but is often not enough. Since trauma
is encoded in the mind and body, for healing to occur, mind-
body communication is needed. Scientists have discovered that
individuals can restore their arousal system through practices
such as mindfulness, movement, and rhythm--principles that have
been used by Native American cultures for centuries. Although
Native principles in healing have long been regarded as
nonsense by modern day medicine, we now have scientific proof
that the ability to heal ourselves and our communities lies
within our traditional cultural practices.
Recent scientific studies have developed some practical and
effective interventions for trauma, and we now have a pretty
good idea of what tribes can do to address the causes and
effects of historical and childhood trauma. A comprehensive
trauma-informed initiative that involves every institution on
the reservation must be implemented. My recommendations are
provided below.
1. Implement Comprehensive Trauma Informed Initiatives.
There is no one single intervention that every tribe must
adopt. Rather, there are a number of different ones that have
been shown to be effective for a specific area--the schools,
the mental health program, the law enforcement system, and so
on. Each tribe needs to select the approaches that are most
appropriate for its values and culture. The keys are that the
initiative must be comprehensive and the community must be
fully educated about trauma and involved in the initiative. The
problem is that right now there is no place a tribe can turn to
in order to obtain technical assistance in setting up a
comprehensive trauma-informed program. I urge Congress to
appropriate funds to create an institute that would provide on-
going assistance to tribes that are seeking to implement a
comprehensive trauma-informed initiative.
2. Provide funding for the use of interns. There is a
desperate and immediate need for increased human service
resources in order to address childhood and historical trauma.
Although the Standing Rock Program is no longer in operation
its model is universally applicable and has the ability to be
reproduced in other underserved areas. By providing funding to
enable tribes to implement psychology intern programs that
bring pre- and post-doctoral psychologists to reservations we
can expand the mental health workforce in our region.
Senator Heitkamp and honorable members of the Committee,
childhood and historical trauma are long-standing issues that
have detrimental effects on our Federal and State budgets,
health, and overall well-being. Indian Country needs maximum
mental health power to deal with the trauma. Money must be
allocated for tribal comprehensive trauma initiatives. I thank
you for the time and opportunity to share my perspective on
trauma and mental health challenges in Indian Country.
[The prepared statement of Dr. DeCoteau follows:]
Prepared Statement of Tami DeCoteau, Ph.D., Clinical Psychologist,
DeCoteau Trauma--Informed Care and Practice, PLLC
Mr. Chairman and members of the Committee, my name is Dr. Tami De
Coteau. I am an enrolled tribal member of the Mandan Hidatsa Arikara
Nation and a proud descendant of the Turtle Mountain Chippewa. I have
worked as a licensed clinical psychologist with an emphasis on the
treatment of trauma disorders for more than a decade. In addition to
maintaining a busy patient caseload, I own a Bismarck-based private
practice that employs 6 mental health workers who are uniquely trained
in the application of trauma-specific interventions for adults,
children and families. Thank you for holding this hearing on trauma and
mental health challenges in Indian country and inviting me to testify.
Senator Heitkamp, I would like to thank you for your key role in
advancing Native American priorities, your efforts to improve the lives
of Native American people and for illuminating the important but
tragically overlooked issue of historical trauma. I would also like to
thank you for drafting and advocating for S. 246, ``The Alyce Spotted
Bear and Walter Soboleff Commission on Native Children.'' S. 246 is
essential to enhancing the lives of Native children.
I have been asked by members of the Committee to focus my testimony
on my professional experience and my clinical perspective on trauma.
Professional Experience
I obtained a doctorate degree in Clinical Psychology in 2003 from
the University of Nebraska--Lincoln with specialization in the
cognitive-behavioral treatment of anxiety disorders, which at the time
encompassed trauma disorders. My professional practice work has focused
on providing services to trauma-survivors. I am certified in trauma-
focused cognitive behavioral therapy. I have received training in the
Neurosequential Model of Therapuetics (NMT; Perry), a developmentally
sensitive, neurobiology-informed approach to working with at-risk
children; Trust-Based Relational Intervention (TBRI; Purvis), a
therapeutic model that trains caregivers to provide effective support
for at-risk children; and Eye Movement Desensitization and Reprocessing
(EMDR; Shapiro), an intervention approach that helps reduce the long-
lasting effects of traumatic memories.
During my undergraduate and graduate training I received the honor
of becoming a McNair Scholar and then an American Psychological
Association (APA) Fellow. I also received the Indian Health Service
2009 Health Professional of the Year Award for outstanding service and
the American Psychological Foundation 2010 Early Career Award for
providing culturally competent practice techniques for Native Americans
and for developing training programs in rural, underserved areas.
My career began with the Veteran's Administration where I provided
psychological services to traumatized Veterans. During my interim at
the VA, Dr. Arthur McDonald (Ogala Lakota) and I joined forces to
create psychology internship training and services for Native
Americans. Our initial effort was funded by HRSA/BHP. During the 3-year
grant phase we designed and implemented a model for training
psychologists to provide culturally competent and relevant services in
rural Native American communities. From this experience, evolved the
stimulus for a much greater vision to develop reservation-based
internship programs with unique missions to restore the individual and
the collective sense of worth of Native American people by supporting
the belief that the healing of Native Nations lies within the Nations
themselves.
The Standing Rock Psychology Internship and Post-doctoral Program
became the flagship model of our vision. The Program evidenced success
in recruiting and retaining psychology providers for rural Native
American populations and substantially increased accessible mental
health services. Doctorate-level trainees worked collaboratively with
tribal health, schools, and judicial departments. In addition to the
well over 3,000 hours of direct patient care, trainees provided
community education, suicide prevention, and even equine assisted
psychotherapy. One of the highlights of the Program was the mobile
crisis response team that worked to prevent and reduce suicides on the
reservation. The Program was a tribally-driven initiative that provided
an excellent example of Indian self-determination.
Unfortunately, it is difficult to sustain mental health services on
the reservation. Mental health providers in Indian Country are at a
particularly high risk for burnout. We work in an intense and crisis-
oriented environment on a day-to-day basis. We face an unusual array of
highly-stressful conditions including inadequate compensation, safety
issues, lack of basic resources such as supplies and testing materials,
professional isolation, lack of appropriate referral and consultation
resources, excessive time demands, and inadequate funding. In addition,
we serve a patient population that has an unimaginable amount of
emotional trauma and social problems. These conditions cause us to
experience a constant state of physical and mental exhaustion and lead
to feelings of depersonalization and dissatisfaction. It is no surprise
that decreased worker effectiveness and burnout are common among mental
health professional in rural Indian Country.
While my heart still resides in working on Indian reservations, I
have been drawn towards education and advocacy for trauma-survivors
including training local teachers, educating congressional leaders, and
serving as the president of Council for Native American Trauma-Informed
Initiatives which is hosting this afternoon's Roundtable on the Causes
and Effects of Trauma In Native American Communities.
Thus, in 2011, I step away from my clinical work on the reservation
and began work as a private practice and consulting psychologist in
Bismarck, ND. In a very short amount of time my clinic schedule was
full of patients, primarily children in foster care with complex
developmental trauma. Whether it be on, or off the reservation the need
for trauma-based psychological services in North Dakota is immense.
Over the course of my career I have become acutely aware of the
``culture of trauma'' that is overwhelming Indian communities and
inhibiting the traditional ``healing culture'' practices. I will
discuss the culture of trauma first.
The Culture of Trauma
Historical trauma is the cumulative impact of historical losses
caused by European settlers' efforts to exterminate Native Americans
and our culture and transmitted across generations. The assimilation
policies of the federal government, particularly the one that involved
sending young Indian children to boarding schools, continue to have a
tremendous detrimental effect on Indian people. This history has led to
a generational pattern of trauma that perpetuates itself in the form of
abuse, neglect, substance addiction, violence, mental unwellness,
physical illness, and unresolved grief.
Trauma by definition is an unbearable and out of control sensation
in the body. It leaves an imprint on the mind, body and brain and
results in reorganization of the way the mind and brain manage
perceptions. Trauma changes what we think, how we think, and our very
capacity to think. Traumatized people have trouble deciphering what is
going on around them. They superimpose their trauma on everything.
Individuals who become conditioned to adversity come to believe they
have no control over their lives so they give up trying--a response
referred to as learned helplessness. Trauma affects those who are
directly exposed to it as well as those around them. The current
challenges in Indian country, including difficulties with social-
environmental, physiological and psychological functioning, are
evidence that the trauma that occurred long ago continues to impact
Native Americans today.
The therapists in my practice serve hundreds of traumatized
individuals, many of whom are Native American children. The gut-
wrenching impact of trauma on these precious souls is evident in their
persistent hyperarousal and hyperactivity. These children struggle to
regulate their own emotions, attend to stimuli, and their capacity for
learning is often greatly impaired. While they are desperate for love
and affection, their persisting fear-response causes them to perceive
everything as threating, and they are likely to lash out at even the
most loving caregivers. Children who have such complex trauma cannot
become functioning members of society without skillful trauma-focused
intervention.
The Healing Culture
Research shows that helping trauma survivors to describe their
trauma is helpful, but is often not enough. Since trauma is encoded in
the mind and body, for healing to occur, mind-body communication is
needed. Scientists have discovered that individuals can restore their
arousal system through practices such as mindfulness, movement, and
rhythm--principles that have been used by Native American cultures for
centuries. Although Native principles in healing have long been
regarded as nonsense by modern day medicine, we now have scientific
proof that the ability to heal ourselves and our communities lies
within our traditional cultural practices.
Recommendations
Recent scientific studies have developed some practical and
effective interventions for trauma, and we now have a pretty good idea
of what tribes can do to address the causes and effects of historical
and childhood trauma. A comprehensive trauma-informed initiative that
involves every institution on the reservation must be implemented. My
recommendations are provided below.
1. Implement Comprehensive Trauma Informed Initiatives. There
is no one single intervention that every tribe must adopt.
Rather, there are a number of different ones that have been
shown to be effective for a specific area--the schools, the
mental health program, the law enforcement system, and so on.
Each tribe needs to select the approaches that are most
appropriate for its values and culture. The keys are that the
initiative must be comprehensive and the community must be
fully educated about trauma and involved in the initiative. The
problem is that right now there is no place a tribe can turn to
in order to obtain technical assistance in setting up a
comprehensive trauma-informed program. I urge Congress to
appropriate funds to create an institute that would provide on-
going assistance to tribes that are seeking to implement a
comprehensive trauma-informed initiative.
2. Provide funding for the use of interns. There is a
desperate and immediate need for increased human service
resources in order to address childhood and historical trauma.
Although the Standing Rock Program is no longer in operation
its model is universally applicable and has the ability to be
reproduced in other underserved areas. By providing funding to
enable tribes to implement psychology intern programs that
bring pre- and post-doctoral psychologists to reservations we
can expand the mental health workforce in our region.
Conclusion
Mr. Chairman and honorable members of the Committee, childhood and
historical trauma are long-standing issues that have detrimental
effects on our Federal and State budgets, health, and overall well-
being. Indian Country needs maximum mental health power to deal with
the trauma. Money must be allocated for tribal comprehensive trauma
initiatives. I thank you for the time and opportunity to share my
perspective on trauma and mental health challenges in Indian Country.
Senator Heitkamp. Thank you so much, Dr. DeCoteau. Thank
you so much for your leadership and educating me on these
issues. I don't think that I would be nearly as informed
without your assistance, without your persistence. And thank
you to Don Schmitt for helping making this hearing a reality. I
have known Don for many, many years. More years than probably
either one of us want to recognize. There has been no greater
advocate for children in foster care looking for advanced
solutions, and we know so many heroes like this, and it's
important where we do have people who dedicate their life, that
we recognize that.
So I'm going to turn first turn to Senator Hoeven for a
round of questions. I think we're around five minutes, or as
long as you want to go.
Senator Hoeven. Thank you to all of our witnesses. What I
would start out with is the need for a comprehensive approach.
I ask each witness to describe what that comprehensive approach
looks like? Recently the State Department of Human Services had
a workshop in Fargo on the opiods epidemic. We really talked
about--and we had the people work on the prevention, people who
work on treatment, and law enforcement. So the idea was we got
people from the front lines and experts. We had them from all
areas. So we can try to come at the problem in a comprehensive
way. We talked about everything from drug court to making sure
there's education in schools and prevention, so people
understand these drugs are not only addictive but they're
dangerous and they're killing us. And then how law enforcement
has to be able to not just incarcerate but to have treatment
options. So same thing here, how each of you--What's it take to
get that comprehensive approach? And I would start with Miss
Sparks.
Ms. Robinson. Thank you. Thank you for that question. It's
a difficult question to answer, because it's such a difficult
issue for us to tackle and for us to wrap our minds around. As
I mentioned, there are many pathways to be able to treat parts
of the trauma and behavioral health. But what we first have to
understand is what actually are the causes. And I think that
really varies impacting from community to community. We heard
from Dr. Eagle Williams that the Garrison Dam is still
something that's impacting the elders and it's transmitting
down to the youth as well. And I think that each tribal
community will have a similar story as to what is the root
cause. But prevention, intervention, providing services, it's
complicated. Unfortunately I don't have an answer for exactly
what is the comprehensive approach, but I can tell you from
Children and Families' perspective would be that we want to
start early childhood programs. We want to be able to provide
trauma and foster care to the service providers in our head
start and our childcare and our native language programs. We
want to be able to reach the parents that might not only be
suffering from some of the symptoms of trauma but are suffering
from some of the more complex historicals or PTSD or other
adverse childhood experiences and help them get the services
they need. We want to be able to prevent the adverse childhood
experiences before they happen. And if they have happened, how
do we get to the kids where they are to prevent them from being
further traumatized. But, you know, that's just one way of
approaching this particular topic.
Mr. Cruzan. Very interesting. And I realize now that it's
not just a drug and alcohol thing, which is what we see
primarily. We have these activating events. There's law
enforcement and you're dealing with really the symptoms and not
the cause. One of the things we're trying to do within the
Office of Justice Services, you could sort of, which I'm not
sure we'll talk about, it's a thing more than a thing. It's a
series of things, right? But one of the parts of that is a
break in the system of services that are out there. I mean, I'm
sure these people struggling with these issues can be referred
separately, but for us there's an activating event. We're
developing a graded system of services. It's basically a poster
that we're trying to teach our law enforcement folks that you
are a part of this healing process, for lack of better words,
from the very beginning. So we're trying to develop a system
where a police officer gets called to an event where you have
these individuals who are displaying the symptoms of a greater
problem, where you can divert them, maybe have a court option,
but you don't immediately go to that judicial branch. You sort
of have a diversion process where the officers who are dealing
with these folks over and over again--I was just at Standing
Rock yesterday and you look at the board of who is in the
facility, and you can almost go back two years ago and it's
almost the same people. It's the same names over and over
again. So these officers who are dealing with these folks, if
we have an option to divert them out of that judicial process
into some sort of treatment, that would be our first option.
Maybe that works. Maybe it doesn't. If it doesn't, you continue
on this, continue here where now you go to work and Courts now
have more options. Maybe it's adjudication. Maybe it's court
ordered treatment. Maybe it's through drug court. Maybe it's a
number of things. We've got a new system in place, and I think
it's fairly generic. It's post-adjudication pre-sentencing
that--So I'm arrested, I get brought in, I sit down, and I go
through this with a court personnel. It's an assessment that
really begins to ask questions about my likelihood of
reoffending and if it's into where I should probably be. So
maybe court ordered treatment. It maybe jail as opposed to
treatment. So you continue this through these services,
hopefully these off ramps back in the community where they can
live healthy lives. Again, I think we're a part of the
solution. I think it's becoming more and more clear to me that
we could be more active participants in this. But the issues
that these folks that we're dealing with are much deeper, and
I'm not trying to tie this into these issues that--but foster
homes, I can't control. It's in my head and and acting
differently because of it. You know, you go and say, well,
going down that path--You know, these folks that are struggling
with these adverse childhood experiences are dealing with
things that they can't comprehend, they can't control, and you
can't really reason yourself out of it. I'm not saying I
completely can relate, but I can understand, and it makes a
little bit more sense. They are acting out in these ways. It's
more than just alcohol and drug abuse. And we are working with
that and I think for us it's going to diving into the
professionals with our analytical data and our statistics and
our numbers. So I don't know if I have a solution.
Senator Heitkamp. Thank you. Miss Warrington?
Ms. Warrington. Thank you. One of the things that we have
been doing is getting from volume from all our governmental
bodies. So they know what we are doing. We have quarterly
meetings with them and we report to them on what we're doing
for trauma care. We have a casino and we involve all the
players. The police department supports all the businesses. We
involve them all so that they know that this is not going to
wayside. It's not a little thing we're going to play right now.
It's continuing on, and they know this because we also ask them
for money. We have to prove to them what we are doing, because
they do contribute to the foster futures in the trauma group of
people that we continue to work. We have regular meetings, but
we have quarterly meetings as well. So I think it's important
to let them know who is being trained, what kind of training is
going on, but also because--and I've been doing this for three
years, and we are starting the evaluation process now, because
it isn't just, okay, here's what trauma informed care is. It's
going back and saying, are you practicing it? How are you
practicing it? Is it including your agencies? Is it improving
your relationships? So that to us is very important to not to
just be preaching to the choir, but also what are you doing?
Are you actually feeling better about this, and do you have any
ideas? What can we do to make it better? And I think that's the
number one thing, but also reporting out to those agencies so
they can, if they are asked, they can say what it is that
they're doing. It's a core group. We started with eight people,
but we brought in several others involved in these regular
meetings. We also said engagement meetings where we involve
anybody from the community. So that is so important. We're
addressing the youth, bring them in. What are these kids
saying? What do they need? What do they think is going to help
us? So to talk about this we have to have the youth involved as
well.
Dr. Eagle-Williams. Thank you so much. Some of what we're
seeing and what we're doing is very similar. We're very happy
that we are working with our justice center as well as as our
police force in educating them on basically what's happening
also in the homes and the actual psychological effects of the
parent and having the children witness these things, and also
to help the police officers identify that. So we've been
educating them on what we are seeing. And so that I think has
been really helpful in working with the police force. And also
coming from the aspect of, you know, not criminalizing our
addicts. We have to change that mindset. Working in Indian
country, I've worked primarily with women, I evaluated and did
interviews, and when I did that there were 80 to 90 percent of
the women that we treated on an outpatient treatment program,
were molested, raped, had domestic violence in their homes. I
realized that I had all of those risk factors as well, and I
didn't even know, and I'm a professional. So we are working on
educating our communities. We've gone through the Ace study
with some of our staff, and when we did that there wasn't a dry
eye in there of our women and our community members that hadn't
experienced those childhood experiences. So we are working on
educating, and the powers in the community. The thing is, we
don't have enough staff. We have one counselor. You know, it's
just so difficult to find individuals that are able to address
these situations. I have to say, that the other, finding ways
to bringing that culture or peace that's sometimes missing in
these families is very important. And as we're working with
these individuals that are either getting incarcerated or
children who are taken from their home, we have to develop a
reentry program that are allowed to bring those families back
together. Because you could be an alcoholic and still be
extremely supportive of your family and or an addict could
still have that love, but because of that addiction, we cannot
criminalize those individuals because of any experiences that
led them to where they are. The other things we have, or I've
include in my testimony, includes addressing the mental health.
Definitely we need prevention and intervention, the
alternatives to abuses. I actually took my daughter to the ER
two weeks before she died, and she said, ``Mom, I am having
chest pains.'' You know, my heart was pounding. I was like,
``Is she having an anxiety attack? What's going on?'' So I'm
trying to do all these things and ask the right questions, and
we're working on collecting data from the State. It's amazing
how--I can't remember the exact numbers, but we were
identifying people at that point that were having anxiety or
were suffering from depression but were released. That's kind
of where we're at. So, again, thank you. Thank you for
listening.
Dr. DeCoteau. So we know that trauma has horrible impact on
a human being. There's no one single approach that will work.
We need comprehensive initiative from the community and it must
include education of childhood trauma and historical trauma for
all tribal systems and tribal leaders. There needs to be
education on what the science says about intervention, and I
think what tribal communities will find is that these
interventions are very, they are very consistent with their
tribal ways. What research is saying now is that safe,
consistent relationships are a priority in restoring a
traumatized individual, and things like rhythm and movement and
mindfulness. And we've had these in our culture for
generations. So we now understand that what use to be thought
of as nonsense is scientifically proven as a successful
intervention for traumatized individuals. A comprehensive
initiative needs to have technical assistance that the tribes
can reach out to for support, and identify consultants who are
experts in their areas and who can assist the tribe in
developing their own comprehensive initiatives in their
communities. Tribal communities need a workforce, a workforce
of mental health providers who are willing to leave the comfort
of their office and do outreach to the furthest corners of the
reservation. We've got to get to those folks because in my
experience, those are the folks that are the highest risk for
suicide. When I was working on the reservation, the one thing
that was crystal clear to me was when there was a suicide, this
was not somebody I knew. They were not a mental health patient.
We're not reaching the services that they need, and we need to
do a better job in doing that. We need to develop internship
programs. It's hard to get folks to North Dakota. It's hard to
get folks to rural areas to work, but the Veteran's
Administration, other universities have established for decades
that the best way to recruit professionals to our region is to
develop internship training programs. We had that success and
experience in the program at Standing Rock. We know that works.
Thank you.
Senator Hoeven. Follow up questions for the next round.
Thanks to each of you.
Senator Heitkamp. I think the great thing that's here is we
have the person who has been tasked with the challenge of
taking a look, kind of breaking down those silos, and thinking
about emanating programs. So many times we hear we started a
project, we received great results and then the funding was up
and it went away. So one of the concerns that I had about this
issue involved consistency and longevity. So Dr. Robinson is
here. She is tasked with that goal, and I want to just ask the
three health care professionals here to offer some advice to
her on what would be helpful in addressing trauma and making
sure the trauma programs continue on and we continue to see the
success that you're seeing, but what more do you need from HHS
to tackle this process.
Ms. Warrington. We've said it before, and that is like
someone else said, the professional assistance. You know,
having people there that can help, can counsel, and different
programs, pediatric care, whether working with children. What
better way to do that is to start with trauma affecting the
lives and starting from when they are very young, but those
experiences where they need care and they are few and far
between. So having professionals that will go to where you want
them to is very important to our treatment program for
counseling services up there. I think that really that is one
of the biggest things to me is having a professional
availability and resources.
Senator Heitkamp. And you mean not in Washington DC, but
actually on and in the trenches?
Ms. Warrington. Make that a point.
Senator Heitkamp. Next.
Dr. Eagle-Williams. We would like to see training programs
that are accessible and efficient to train our local people as
well as internships and funding that supports traditional
health and wellness. Like Dr. DeCoteau said, why would a 17
year old girl who is extremely healthy, a leader in her school,
and basketball player have to go to the hospital. We're not
seeing those individuals. We're not even seeing the individuals
that are making attempts until we go through 911 calls, and at
that time it's three months later. So we're developing the
referral process, stuff like that, but we'd like to see more
traditional health and wellness. We would also like to see
incorporating the entire family, because obviously this is not
just affecting that individual. It's affecting the entire
family and addressing the domestic violence within our homes.
Just people in general are carrying, you know, historical
trauma. We are carrying the trauma of our parents, our
grandparents, and our children are doing the same.
Dr. DeCoteau. So the first thing that comes to mind is to
provide the infrastructure for the mental health workers. I
agree that we need a workforce, but coming from my own
experience in reservation work, and many of you probably
understand, when you're doing mental health work on the
reservation, you are the receptionist and the director and the
clinician, and a number of other things. So the burnout is
intense, and it's very difficult to sustain that work even if
that's where your heart is. It's exhausting. So we need to
develop an infrastructure that supports the mental health
workers and makes it possible for these individuals to function
and stay in these jobs. Most of the people who do this, that's
where their hearts are, and if they leave, they leave for other
reasons. So we need infrastructure. We need flexible use of
funding. Sometimes when financing a grant for something I have
to shave off the most innovative parts of my project to fit
into what the grant is looking for. We need the ability to use
the funding in flexible ways that make sense for the community
and don't just make sense for the granting agency. We also need
a mandate for collaboration from emergency rooms both on and
off the reservation. I cannot tell you how many times I have
referred a high risk suicidal youth to the emergency room with
burn marks on their neck because of an attempt, and they were
turned away because they told the doctor they weren't suicidal.
It happens over and over and over, and we must collaborate
better with our emergency rooms and doctors need to be
educated, so we can help these individuals and save lives. We
need to develop an ability to bill for services at the Federal
rate, so that we can have sustainable funding sources for this
type of project. We need to develop the ability for providers
to private practice outside of the IHS system to have access to
the same Federal rates when we're doing reservation based work.
Senator Heitkamp. Miss Sparks-Robinson, if you could just
kind of comment on what you've heard. And I'm particularly
concerned, obviously we are at the end of the administration
that has progressed greatly over the last eight years and their
awareness and their willingness to commit, how do we perpetuate
that?
Ms. Robinson. So what I've heard from the listening session
is that definitely the approaches have to be flexible, they
have to be developed from tribal perspectives, they have to
support the local solutions, and there's a critical role of
native language of education, and looking at the health. So
that gives us some parameters on how we should collaborate.
What I will tell you is that the staff is really helpful and is
really dedicated to making sure trauma informed care is part of
our normal practice. Especially for ACF and also at HHS. There
is an HHS coordinating committee that will address trauma, not
just in Indian communities, but across all of our programming.
So this is an education piece that's happening. There's grants
that we are providing specific to Indian Country that hopefully
will provide some flexibility and it also is requiring that
it's done from the tribe perspective. We also have the
methamphetamine/suicide initiative. We have tribal behavior
health grants that we're providing as well. So these are some
of the activities and program funding that will continue to be
available, you know, regardless of who is sitting here next
year in this position. Last, we have to come up with proposals
in the President's budget that will allow for tribal training
assistance center specific to native youth. That will look at
small resources that are needed specific to trauma informed
care.
Senator Heitkamp. Thank you. Just to make a comment, which
is, we have seen with Indian health, and we've had some direct
challenges with the Great Plains district; shutting down
emergency rooms, failure to provid care, and we need to really
examine Indian health in a way that I don't think it's been
examined for awhile. But when we look at outcomes, and we know
that Native Americans, their longevity is not what it is in the
rest of the country. That tells us something. That tells us
even though we're working on beating chronic disease, whether
it's diabetes, whether it's hypertension, we're really only
treating a symptom of something that we need to. Actually we're
finding this out all across the country that we no longer can
afford to ignore mental health. We no longer can afford to
ignore trauma and the things that lead to trauma. You know, one
of the challenges that we have, and I hope you take back, is
CMS needs to be responsive. We need to figure out how we pay to
treat people in ways that actually achieve an outcome, not
just, oh, you know, came and made sure that he had blood
pressure checked, as opposed to why is this person experiencing
hypertension? Why is this person experiencing high blood
pressure? You know, we know that adverse childhood experiences
have a very traumatic effect. Some reports would say 20 years
off your life, we repeat treating the symptoms, and that's
expensive. If we don't start looking at this differently, we
not only will dig our hole deeper, but we're going to continue
to have the same outcomes. So we're just really interested in
how--and especially with Indian health. We need to have greater
access to behavior and mental health services. We've got tribal
chairmen in this room who would tell you that someone who is
suffering from addiction, who is the first responder, the first
responder the family calls is tribal court, BIA police. They
didn't commit a crime, but the emergency room isn't a place
where you're going to go to get help. So the person looks for
help in a church or a precinct. That is not an outcome that
should happen. We've got to figure this out, and the challenge
for me is to provide, you know, some sense that we can change
outcomes. I think so many people have given up. So many people
have given up and said, ``It's never going to change. We just
have to continue to do what we've always done.'' We can change
it. We can change it if we take this great science that's being
done, great talents that are being developed in trauma informed
and trauma based programs, and we start involving communities
and we start involving what makes those communities unique.
That's the critical piece of this, because we cannot fund our
way out of this chronic disease without dealing with this issue
as a potential to make change overall. So I'm committed to
making sure that these programs continue to get attention. I'm
going to turn it over to Senator Hoeven for some last
questions. Thank you so much.
Senator Hoeven. And I just want to follow up. I appreciate
that each of you had very good concepts and ideas to offer. I
just want to follow up on a number of those with you. So I'm
going to start with Miss Sparks-Robinson. You were talking
about early childhood trauma, what is the key component to
impacting outcomes?
Ms. Robinson. Well there is a group who is incredibly
dedicated to improving outcomes for Indian country. I spent
some time with folks, including those that were practitioners
in the community, to come up with what is the action that we
need? What can we do to impact outcomes? And what we found is,
so far, because the book is not done, is that there has to be
screening tools. There has to be culturally specific screening
that's done in our health care center, in our childcare
centers. They have to be developed in partnership with Indian
Health Service to be able to identify what the needs are in
that particular family. It has to be family based. We need
that. When I have these conversations out in Indian country,
both the kids and parents and leaders have all said, ``I wish
someone taught me how to be a better parent. I wish there was
somewhere I could go to to be a better parent.'' The youth are
saying, ``I wish my mom would talk to me. I wish I knew how to
talk to my dad. I wish my parents knew what I needed.'' And
tribal leaders are saying, ``I wish there was a way to provide
this service to our community members.''
Senator Hoeven. Does HHS or IHS have people come in and do
some of the assessments?
Ms. Robinson. So ACF through the tribal program, so ACH
funds that program that's funded through Versa. So we do have
the ability, but you have to come in and apply but then there
is somebody that actually comes out and does prenatal and early
childhood activities. We have someone that teaches them, okay,
this is what you need to be able to deliver a healthy baby. We
need you to destress. We need you to make sure that you're not
being overwhelmed. This is what you need to be able to expect.
Then comes in and does some screenings in the home, which we
can't always expect the patient or the person that's in need to
go to the place where the service is being provided.
Senator Hoeven. Thank you. Mr. Cruzan, you mentioned too,
could you describe a little bit what you think is particularly
effective in North Dakota about the program?
Mr. Cruzan. Absolutely. I think this one initiative in
itself is really an effort, to the government watching in DC,
we're certainly not going to solve anybody's problem by saying,
``This is the way we're going to do it.'' So it is a break in
services, if you will, and it's an effort to give those
services. The people closest to the issue, know the solution.
People that have resources will ask. So I think that's the
effort that's happening right now. Currently they are
developing local plans driven by tribal leadership and the
community and those service providers to tell, basically to
say, ``Here's the direction we want to go.'' There are--One
size doesn't fit all certainly when it comes to that. So I
think that's what we're doing is being very sensitive to the
tribe's developing a plan. And then being flexible with the
funding and saying, ``Well this isn't normal but that sounds
reasonable. So let's do it.''
Senator Hoeven. Thank you. I agree and describing what they
think would help. So I appreciate that. Dr. DeCoteau, you
talked about a comprehensive approach, you talk about education
of childhood trauma. So I wanted you to just describe what that
is? You talked about safe and consistent relationships. You
talked about technical assistance. I just don't understand what
you mean when you say ``technical assistance.'' Then you talk
about outreach and internship programs as a way to resource,
and I'm just wondering how you might structure or how you would
come up with those outreach initiatives?
Dr. DeCoteau. So when I work with parents who are raising
children with complex developmental trauma, one of the first
things I do is I teach the parents how trauma impacts the brain
and what that does to the child's neurochemistry, so the
parents can see that it isn't a behavioral issue. It's a brain
development issue, and that's what education about childhood
trauma needs involve. Whether it be in the school systems or
the parents or other agencies, people need to understand that
the behaviors we see are the behaviors of traumatized children
because they lack brain capacity to put forth the behaviors
that are expected. Until parents and our systems learn to
nurture the brains in the individuals, and have strategies that
are directly targeted to rebuild the brain so we can rebuild
the brain. And I always tell parents, it's a brain development
issue. I think if we had samples of the neurotransmitter panels
of these children, we would see and understand that they are so
disregulated. They cannot function. That helps us respond to
these children in an empathetic way instead of an angry way.
Safe relationships, that's a simple term, but it really means a
lot in terms of how do we help reduce the stress response in
children that are always in a state of fear. We cannot rebuild
a brain that has a constant fear signal, and they will always
react to their environment in ways where they perceive fear. We
don't have a learning brain when there's a fear response in the
brain. So we need to interact with the child in a way that
reduces that fear response, and we have a learning brain and
now we can rebuild the brain. That comes first and foremost
most with safe relationships. And what I've learned is that in
our society loving, nurturing parents need help to know how to
do this especially in traumatized children. So there needs to
be strategies to teach parents how to be mindful with your
child, how to provide healthy touches, how to provide
nurturing, how to correct behaviors in ways that are not
punitive, and build their self esteem, sense of self, which
will, again, trigger their response. When I talk about
technical assistance, I talked about, and I mean that rather
broadly, I mean that in terms of having the kind of
infrastructure support in a system where one person is not
wearing all hats. Also, in terms of an ability to develop some
research to provide timelines and to provide the data that we
need to get the funding. When I was on the reservation a number
of years ago, we had a project that was working to reduce the
suicide rates, and we had a very unfortunate response from the
government. We were able to provide information about how this
program is working and the government officials looked at
myself and the tribal officials as we made our presentation and
said, ``I need to see timelines. This is just antidotal
information, and it's useless to us without data.'' And I
understand that data is required for funding, but the problem
with that in reservation communities is you don't have the
infrastructure to develop a research base. Not that we
couldn't, but we need the assistance to be able to do that. We
need the infrastructure to be able to do that. Outreach and
internship, so there's a difficulty in getting mental health
workers and qualified mental health workers who want to do this
work in Indian country. In my experience what I find is it's
harder to bring in providers who have been working. It's harder
to train those people because what's required is an attitudal
change in how you're going to do your work. But interns and
trainees are fresh, and they're energetic and they want to make
change and they're idealistic and they want to follow your
direction. They are usually younger, and they have a ton of
energy. They come in with the mindset of changing the world. Of
course we can't change the world, but we can do what we can do.
So using those internship models is a way to recruit people
from outside the state, from inside the state, and keep them
here. In fact, the internships that we had at Standing Rock,
more than 30 percent of them came in from outside this state
and stayed in this region.
Senator Hoeven. To me that makes a lot of sense.
Dr. DeCoteau. One important point I would like to make
about that, Senator, is a handful of years ago I worked with
this Committee on the Indian Health Care Reform Bill, and we
made sure there was a specific provision written into that bill
to allow for interns and trainees, not just in the field of
mental health, but in all fields of health, to be billable
providers at the Federal rate. So if we we could bill for those
service and create stainable funding for our service. And these
aren't just, these are doctorate level trained folks. So they
are quality individuals. I don't know anybody that has used
that yet, but it would have provide a system of funding.
Senator Hoeven. Thank you. Chairman Warrington, you
mentioned having the counties more involved. Could you
elaborate on that?
Ms. Warrington. Well a lot of times the counties are the
only ones that are eligible for funding, so they can put--
Senator Hoeven. So you're talking now about State dollars?
Ms. Warrington. Yes. And I know that a lot of tribes can't
get the county to the table to help share those resources to
serve the people. We are a county, so most of them are part of
the tribe. So we have a good relationship, but I know a lot of
them don't. And if we got in there, there's ways that the
government can make them do it. But I think that having that
mandate, I think because they have to pay for some of these
services to tribal members, because the tribe does not have the
funds.
Senator Hoeven. How about some kind of cooperative
agreement? Have you tried anything like that?
Ms. Warrington. I would think that would work, if the
county was willing to do that.
Senator Hoeven. When I was governor we had cooperative
agreements, not necessarily in this area, just in general. Just
asking if you think that might be possible?
Ms. Warrington. I don't know if you would be able to do
that with the county.
Senator Hoeven. And the idea of working together makes
sense.
Ms. Warrington. It does to me, because pulling all those
resources together makes it better.
Senator Hoeven. Right. Combine Federal and State resources?
Ms. Warrington. Yes. So we could apply for resources.
Senator Hoeven. Dr. Eagle-Williams, I am incredibly sorry
for your loss. It takes incredible courage and strength to be
here and talk about his. So I just want to commend you as far
as making a difference for others. I want to bring up the
Indians in the medicine programs and the Indians in the
psychology programs. The reason is because of your testimony
that you know there is obviously a lack with cultural and
experienced trauma. So I think those are programs very good.
Through our university system we're trying to combine the
training, you know, very sophisticated and comprehensive
medical training, and some of these cultural understandings
that we talked about. So I'm just going to ask what we think of
those programs? Are they working? Should they be adjusted? Is
there something more we should do, and how do we build off
those kinds of programs?
Dr. Eagle-Williams. Actually those programs are very
helpful, but we're not necessarily seeing those individuals
come back and return to our home. So it's very difficult. The
other thing is --
Senator Hoeven. Do you mean they don't come back to the
reservation?
Dr. Eagle-Williams. To Fort Berthold. Yes. But the other
thing that we had experienced, we actually had a representative
working very closely with the University of North Dakota and is
actually an employee. Within the years that I had been there,
we only had one graduate of that program. And actually, the
success, it took six years to become a licensed clinical
counselor, and that's a challenge because the policy
requirements in the State of North Dakota. And that's what I'm
saying, there's a need for behavioral health specialists, you
know, policy modifications to allow for sort of the layperson
to receive adequate training to provide services that are
universal. Because we're not seeing a whole lot of people who
are going into the field of medicine. I think we recently only
had one graduate from the college of medicine who is a tribal
member this last past year. I cannot say, we didn't know, but I
believe I was the last one to graduate from medical school in
2002 from the University of Arizona with little to no support
as, I mean, I don't practice medicine because of that. Getting
through the boards and then dealing with all my own trauma, you
know, just trauma being one in five in college of medicine, you
know, that's traumatizing, so.
Senator Hoeven. That's what I was just going to wrap up
with. Dr. DeCoteau, any thoughts on how we get people into
those programs?
Dr. DeCoteau. Yes. So there's three Indian programs in the
psychology programs in the nation. There's legislative law that
will allow for up to five. They are great programs. Part of the
difficulty is that those individuals have an IHS pay back, and
they have difficulty finding jobs in the IHS system. They are
allowed to find jobs in other systems where they serve more
than 50 percent native population, but there's not a lot of
available jobs, and some of those students are in default in
their loans. The other issue is that the pipeline was never, it
was never finished. So graduate school is not less, but you
have to go to internship and you have to go on to post-doctoral
residency. That's where the recruitment is an issue. So if
there's not internship in post-doctoral programs in these rural
communities, they go off to other metro areas. And then they
usually start there careers in other metro areas. So we need to
finish the pipeline.
Senator Heitkamp. I do want to comment that in our presence
today is Dr. Don Warren, who runs the Ph.D. program for public
health at NDSU and working very, very hard on building that
capacity. Because a lot of what we're talking about is
integrating those public health models into the medicine, you
know, just bringing it all together so that we're not just
focused on diabetes and hypertension and, you know, injuries,
but that we're actually looking at bringing a model to the
system in Indian health that treats the whole person and treats
the whole person culturally. So I couldn't let it go by just
talking about those two programs. I think Dr. Warren if you
don't mind just telling us what percentage of your graduate
students now are Native?
Dr. Warren. In my program?
Senator Heitkamp. Yes.
Dr. Warren. Okay. We have the American Indian Public Health
Program at NDSU is what you're referring to, and our students
start, actually tomorrow we have new student orientation, and
we've now got 107 students and of that number 27 are American
Indian. So it's the most American Indians for any school in
that timeframe. Sadly more than any school in our history. But
we focus on health policy issues, cultural context issues, and
recognizing the health disparities are really all the way back
through historical trauma. But many of our students are
planning to work in the tribal population and are wanting to
work in public health, psychology. Essentially we need a public
health focus which is dealing with prevention of a crisis.
Senator Heitkamp. What percentage of your folks that you
graduated are working directly in Indian country?
Dr. Warren. We've had now of the 27 American Indian
students, of that number there's been about seven who have
graduated, and I think we have one who is working for Sanford.
The rest are working in Indian country.
Senator Heitkamp. That's a huge resource for North Dakota.
I would like to make that point.
Senator Hoeven. If I could ask, so kind of that follow up
question that I'd asked for the panel members, how do you
coordinate with the Deans of Medicine in those programs?
Dr. Warren. Yes. So public health is a different field, of
course, than psychology and medicine, but they are integrated
once we get out into the field. So we do have what's called our
coordinating counsel with UND. So we meet quarterly with the
Medical School Dean, their health care program direction, and
other administrators to coordinate efforts.
Senator Heitkamp. I think we have a couple more comments
and then we need to close it out.
Dr. Eagle-Williams. I would just like to say that the
medicine program is actually a Federally funded program that
may be a consideration of the State to implement into their
budget for the next fiscal years.
Dr. DeCoteau. President McDonald has just reminded me that
our Alaska Native relatives are in fact implementing an
internship training program in their community and apparently
they are using the billing to sustain the funding for their
students. So we have a model with our Alaska relatives that we
could look closely into.
Senator Heitkamp. We have a process that we need to follow.
We've had a couple folks tell us that they would like to offer
some comments. Comments, typically, because this is an official
Senate hearing, we have to keep our usual schedule, what we
planned on. So what I intend to do is offer an opportunity for
anyone in this audience to submit written comments. Those
written comments need to be sent to us in two weeks, and they
will become part of the official record. So I'm going to close
this hearing.
[Whereupon, the hearing was concluded.]
A P P E N D I X
Prepared Statement of the Octeti Sakowin youth
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Stephanie Yellow Hammer, Enrolled Member,
Standing Rock Sioux Tribe
I, Stephanie Yellow Hammer an enrolled member and lifelong resident
of the Standing Rock Sioux Tribe and who has worked in the Early
Childhood field here for 15 years, request to have my testimony entered
into the official record for the Senate Indian Affairs Committee Trauma
Field Hearing to be held on August 17, 2016 in Bismarck North Dakota.
Generation after generation our people have endured many historical
traumatic events often one right after another. Each one of our
generations has had to experience some type of traumatic event from the
first contact of the European settlers to the present day event that is
happening right now to the 7th generation with the placement of the
Dakota Access Pipeline less than one mile north of our Standing Rock
Reservation, which you people will refer to as an Adverse Childhood
Experience (ACES) and once again breaking the treaties by placing this
black snake that will carry crude oil from the northwestern part of
North Dakota to Illinois. When this pipeline breaks it will contaminate
not only our water source but all people who depend on the Missouri
River for their water but we will be the first to feel this impact. In
D/Lakota we say ``Mni Wiconi'' water is life; as without out water we
cannot survive.
Our people have never been able to heal and grieve as many of these
traumatic events have been inflicted one right after another and
somewhere in this process we have lost our resiliency as we have had so
much taken from us; Our Land, Our Culture, Our Language, Our Kids
Forced into Boarding Schools, Denied the Right to Practice Our Sacred
Ceremonies, Forced Relocations, we can go on and on about what was
taken from us and what we have lost, but you all know what has happened
to us.
We need funding for housing as many of our families live in doubled
or often tripled up homes, where some are exposed to alcohol, drug and
sexual abuse.
We need funding for Indian Health Services as many of our youth and
children are in dire need of mental health services from the
``effects'' of the historical trauma and ACEs that they experience at
an alarming rate.
We need funding for cultural programs such as the Lakohol'iyapi
Wahohpi and Wichakin Owayawa (Immersion) as we have lost our identity
through all the trauma and grief. Our children need to be exposed to
their culture and language so we can regain our identity that was
stolen from us.
We need more funding for prevention and educational programs so we
can better educate our children and youth so we do not have to function
in a reactive mode.
We need a big push for the importance and need for Tribal Early
Childhood Services so we can build strong children instead of repairing
broken youth.
We need funding for an inpatient treatment facility and addiction
services so we can provide the much needed treatment services that our
youth and adults need.
You can educate people all you want on the Causes and Effects of
Historical Trauma & Adverse Childhood Experiences in Native American
Communities but until you can provide sufficient and adequate funding
for our Tribal Nations you will continue to see the ``Effects'' of the
trauma that the white man has inflicted on us. Hopefully this hearing
will open the eyes of some of the elected officials and shed some much
needed light on the issue.
Wophila Thanka (Thank You) for your time.
[all]