[Senate Hearing 114-112]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 114-112

             DEMANDING RESULTS TO END NATIVE YOUTH SUICIDES

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 24, 2015

                               __________

         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

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                                                                   Page
Hearing held on June 24, 2015....................................     1
Statement of Senator Barrasso....................................     1
Statement of Senator Daines......................................    49
Statement of Senator Franken.....................................    36
Statement of Senator Heitkamp....................................     4
Statement of Senator Murkowski...................................    53
Statement of Senator Tester......................................     2
Statement of Senator Udall.......................................     4

                               Witnesses

Clifford, Hon. Collins ``C.J.'', Tribal Council Member, Oglala 
  Sioux Tribe....................................................    13
    Prepared statement of Hon. John Yellow Bird Steele...........    15
Lafromboise, Teresa D., Ph.D., Professor, Developmental and 
  Psychological Sciences, Graduate School of Education, Stanford 
  University.....................................................    40
    Prepared statement...........................................    43
Mcswain, Hon. Robert G., Acting Director, Indian Health Service, 
  U.S. Department of Health and Human Services...................     5
    Prepared statement...........................................     7
Seki Sr., Hon. Darrell G., Chairman, Red Lake Band of Chippewa 
  Indians........................................................    36
    Prepared statement...........................................    38

 
             DEMANDING RESULTS TO END NATIVE YOUTH SUICIDES

                              ----------                              


                        WEDNESDAY, JUNE 24, 2015


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m. in room 
628, Dirksen Senate Office Building, Hon. John Barrasso, 
Chairman of the Committee, presiding.

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

    The Chairman. Good afternoon. I call this hearing to order.
    Today, the Committee will hold an oversight hearing 
entitled Demanding Results to End Native Youth Suicides.
    Over the past ten years, this Committee has held six formal 
hearings to address the issue of youth suicide. We return to 
this panel issue once again today because youth suicide 
continues to plague too many Indian communities.
    In 2011, the Substance Abuse and Mental Health Services 
Administration identified youth suicide as the second leading 
cause of death for Indian youth between 15 and 24 years of age. 
The U.S. Centers for Disease Control reported Native youth 
suicide to be two and a half times the national average in 
2012.
    Some communities are dealing with daily suicide attempts 
and suicide clusters. Over the last six months, the Pine Ridge 
Indian Reservation in South Dakota has suffered at least 11 
suicides and at least 379 suicide attempts have been reported.
    I was troubled to learn from the testimony submitted by 
President Steele that a youth pastor at the Pine Ridge 
Reservation received word that a group of children had planned 
a group suicide. The pastor sped to the place it was planned 
and found many ropes hanging from the trees.
    Thankfully, the pastor arrived before any of the children 
attempted to hang themselves. He was able to counsel them on 
the spot, undoubtedly saving their lives in the process.
    This is just one reservation. Many communities across 
Indian Country are facing similar tragedies or attempted 
tragedies. Our hearts go out to the families and communities 
for their great losses.
    I will not stand idly by, nor will this Committee. There 
must be a better way of supporting the young people, parents, 
teachers and community leaders that are fighting against 
suicide. We all share the goal of ending youth suicides in 
Indian Country. Achieving this goal requires a comprehensive 
and evidence-based plan that is proactive instead of reactive.
    I am very concerned that the Administration's plan and 
actions so far have been insufficient. The Department of Health 
and Human Services is responsible for the delivery of health 
services to American Indians and Alaska Natives. Its duty is to 
uphold the Federal obligation to promote healthy Indian 
communities and honor tribal governance, but it has failed to 
do so.
    I talked directly with Secretary Burwell last week. She 
shares our concern. Native youth suicide is too significant a 
threat for this Committee to accept anything less than 
measurable results.
    I am very troubled that Federal agencies with 
responsibilities to American Indians and Alaska Natives do not 
seem to be learning from the tribes like the White Mountain 
Apache Tribe and the Menominee Indian Tribe of Wisconsin which 
have actually reduced the number of suicides in their 
communities.
    We will not turn away from this issue until it is resolved. 
The time for finger pointing, lack of coordination and excuses 
is over. This Committee will do whatever it takes legislatively 
and in its oversight capacity to support results.
    Today, we will hear testimony from tribal leaders, a 
subject matter expert and the Administration.
    Speaking of the Administration, a lot of time and energy 
has been spent in preparing for this hearing today. It is 
unacceptable that the Committee only received the 
Administration's testimony late yesterday afternoon.
    I want to welcome our panel and look forward to hearing 
their perspectives.
    Before we hear from the panel, I want to thank Vice 
Chairman Tester for his attention to the issue and invite him 
to make an opening statement.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman. Thank you for 
holding this hearing today.
    I would join you in your resolve to get this issue on youth 
suicide and suicide in Indian Country settled. I appreciate 
anything we can do to work together to truly make some inroads.
    This is a bad issue. My friend and former Chairman of this 
Committee, Senator Dorgan, who retired in 2011, put a good 
amount of time into solving this issue. It still is an epidemic 
among tribal nations across this country.
    As we have heard at our Committee hearings over and over 
again, children in Indian Country face some dreadful realities. 
Late last year, the Department of Justice releases a report 
called Ending Violence So Children Can Survive. Included in 
that report was a finding that Native children experience PTSD 
at the same rate as veterans from the wars in Iraq and 
Afghanistan. We have some problems. To say that this is 
troubling does not even begin to characterize the situation.
    Many of our Native children face hopelessness each and 
every day. They wake up to overcrowded homes with up to 10 or 
15 people living in a two or three bedroom house. Many lack 
access to fresh, healthy food or breakfast because they live in 
food deserts.
    These youths get on school buses sometimes traveling for an 
hour or more to get to schools that are often run down and lack 
available staff to teach and nurture them. We have had hearings 
on this also.
    These are just some of the challenges Native children face 
every day. This is all before lunch.
    There is no single, simple solution. We need to work 
together to improve everything from nutrition to housing to 
health care to public safety. I am grateful to see this 
Administration has formed a Council on Native American Affairs. 
This is a more holistic approach to addressing the needs of 
Native communities. It will help remove the bureaucratic red 
tape that has been in place for far too long.
    We cannot continue to air drop in resources erratically 
when suicides spike in Indian communities and turn around and 
abandon those communities when patchwork funding runs out. We 
need stability, consistency in mental health programs and a 
community effort to remove the stigma associated with mental 
health and mental health treatment.
    In my home State of Montana, sadly, this issue is not new. 
On the Fort Peck Indian Reservation, the tribe was faced with a 
wave of suicides in recent years and has since developed a 
suicide prevention plan.
    That plan includes significant steps to address risk 
factors, implement prevention efforts and develop a crisis 
response plan. Interestingly, many tribes are finding that 
increased access and exposure to culture and language resources 
promotes a positive self image and improves mental health for 
Native youth. Fort Peck's plan also focuses on ways to increase 
community knowledge on how to assess risk in order to refer 
individuals for treatment and increased access to appropriate 
preventative care.
    Tribes know what they need. Many are in the position to 
implement programs to support these efforts. What they lack is 
a sustainable funding source. These efforts are at the heart of 
the trust responsibility our government holds with tribal 
nations.
    Now the Federal Government needs to step up and do what we 
need to do to support tribes in their efforts to stop this 
awful cycle. Unfortunately, this year it seems like we can 
provide more money for defense budgets but we cannot put more 
money into saving lives of Native youth. This is unacceptable 
by anybody's standard.
    I look forward to the testimony of the witnesses today to 
hear what we can do to work together to help end this youth 
suicide epidemic.
    I want to thank the panelists for being here today. I know 
some of you have been through some very difficult times 
recently. You all know this issue inside and out. I look 
forward to your testimony.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Tester.
    Would any other members like to make a statement? Senator 
Heitkamp.

               STATEMENT OF HON. HEIDI HEITKAMP, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Heitkamp. Thank you, Mr. Chairman and Vice Chairman 
Tester.
    Once again, here we are, wringing our hands and telling 
deplorable and horrible stories of situations that should shock 
the Nation's conscience but somehow do not ever seem to filter 
out of this hearing room.
    This is not a new issue. During my time serving as North 
Dakota's Attorney General, we had a high rate of suicide in 
Indian Country but it has become almost epidemic. We cannot 
simply say ``we share your concern.'' It is not enough any 
longer for the Federal Government to say we share the concerns 
of all the tribal entities and all the tribal families and all 
the tribal parents who are losing the next generation of their 
children. We must take action. The unfortunate thing is 
frequently that action we must take involves resources, 
involves community coming together, having enough resources, 
and having a great plan.
    Mr. Chairman, I welcome all of the wonderful witnesses we 
have today here to talk about an extraordinarily difficult 
subject, I am very interested in hearing what successful 
practices and models Dr. Teresa D. LaFromboise has to share, 
because we have to find a solution. We have to find best 
practices and then we have to fund those best practices.
    I want to personally thank Dr. LaFromboise for being here. 
She is of Miami tribal decent and is the proud mother of her 
daughter, Cecily, who is an enrolled member at the Turtle 
Mountain Band of Chippewa located in North Dakota. I think her 
expertise and her commitment will be revealed in her testimony. 
I am particularly anxious to hear what steps we need to take, 
when we need to take them and how we change this dynamic. What 
we have done in the past, taking a look at the rapid increases 
that we have seen, what we have done in the past clearly has 
not worked.
    Thank you, Mr. Chairman. You continue to have my 
participation and my commitment to work with you and with the 
Vice Chairman on a path forward.
    The Chairman. Thank you, Senator Heitkamp.
    Senator Udall?

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

    Senator Udall. Thank you very much, Chairman Barrasso and 
Vice Chairman Tester. I really appreciate your pulling this 
hearing together on this incredibly important subject.
    The loss of one child's life is debilitating for families 
and I think for the entire community. In my home State of New 
Mexico, we have lost far too many young people in our Native 
communities.
    As Senator Heitkamp discussed, when I was Attorney General 
in New Mexico and then a Congressman before I came to the 
Senate, the numbers were way, way too high. Just to throw one 
at you, the New Mexico Department of Health estimates that at 
least 201 Native American youth have died of suicide between 
1999 and 2013.
    There has been evidence of suicide clusters, a series of 
two or three suicides in the community over the course of the 
year or less occurring on the Mescalero Apache Indian 
Reservation and also the Eastern Navajo Nation. It is likely 
that the statistics are significantly under-counting these 
tragedies.
    There are also high concentrations of risk factors in New 
Mexico's Native communities. Last year, in a survey of 1,300 
Native Americans from seven different tribal communities in the 
State, the University of New Mexico researchers found that 29 
percent had been exposed to four or more traumatic experiences 
as children such as alcohol and drug abuse, physical violence 
at home, neglect, abuse, separated or divorced parents or a 
close family member in prison.
    It is critical that we listen to our Native youth and 
remove the stigma from talking about suicide and trauma. We 
must create and sustain opportunities for them to learn the 
value of their cultures and identities.
    We need to make sure they are connected to adequate mental 
health services. We must show them that their lives matter.
    I want to thank the witnesses for being here today and for 
all the hard work they have done in their communities and the 
crises that are occurring around the country. We must do 
better.
    Thank you very much, Mr. Chairman.
    The Chairman. Thank you.
    We will now hear from our witnesses. We have with us today 
the Honorable Robert G. McSwain, Acting Director, Indian Health 
Service, U.S. Department of Health and Human Services, 
Rockville, Maryland. We have the Honorable Collins ``C.J.'' 
Clifford, Tribal Council Member, Oglala Sioux Tribe of Pine 
Ridge, South Dakota. Councilman Clifford is filling in for 
President Steele. We also have the Honorable Darrell G. Seki, 
Sr., Chairman, Red Lake Band of Chippewa Indians, Red Lake, 
Minnesota, and Teresa D. LaFromboise, P.h.D, Professor, 
Developmental and Psychological Sciences, Graduate School of 
Education, Stanford University, Stanford, California.
    I thank you all for being here. I want to remind our 
witnesses that your full written testimony will be made a part 
of the official hearing record. Please keep your statements to 
five minutes so that we may have time for questions. I look 
forward to hearing your testimony, beginning with Mr. McSwain.

          STATEMENT OF HON. ROBERT G. MCSWAIN, ACTING 
DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Mr. McSwain. Mr. Chairman, Vice Chairman and members of the 
Committee, good afternoon.
    I am Robert McSwain, current Acting Director of the Indian 
Health Service. I appreciate the opportunity to testify on 
demanding results to end Native youth suicide.
    I agree, number one, this is a very serious issue. I have 
been talking with Councilman Clifford as we prepared for the 
hearing about how things are going. I have not had a chance to 
talk with President Steele this week but I try to call him 
every week.
    I would just highlight some of the key programs, 
initiatives and investments that we are doing to end youth 
suicide. I look forward to continuing to work with the 
Committee, as you have offered.
    As you know, Indian Health Service, of any group plays a 
rather unique role. We are providing health care and we are 
sitting on the reservation. I have some comments about how we 
can make that even better.
    The mission of the Indian Health Service is to raise the 
physical, mental, social and spiritual health of American 
Indians and Alaska Natives to the highest possible level. That 
is our mission and has been for the last 20 years. I just want 
to restate that.
    You mentioned some statistics and I am not going to go 
through all of those. You are probably well aware of it. I will 
say we have published a new Trends in Indian Health dated 2014. 
It is on our website. We have recited all of those particular 
notations you have made in the case of suicide which is the 
sixth leading cause of death overall for males residing in IHS 
service areas. I think that is a real issue.
    I want to say that when tribal leaders often request help 
from us in many different forms, either funding or during a 
cluster, we generally will respond immediately whether it is 
funding to help locally or if they have asked for deployments. 
We have done that.
    In fact, in the deployments to Pine Ridge, we were able to 
convene a deployment within a week to go to Pine Ridge. We had 
three cycles of folks up there. As you mentioned, Mr. Chairman, 
it was only temporary as we move ahead. We need to do something 
more substantial.
    The most important part I can say today is the fact that 
this year we will launch the Zero Suicide Initiative. The most 
important part of this concept is as patients go through our 
clinics, we have to have our folks trained to identify where 
the at-risk youth are coming to us, know when to see it and 
when to be able to have that conversation. We are a health 
system and they come to us for a lot of reasons. We ought to be 
able to monitor the youth better.
    I would just enumerate the other parts because you have it 
in my statement. We have a Meth Suicide Prevention Initiative. 
That has been going on for six years. We will get the results 
this year. That is community-based.
    There are 130 programs across the Nation. Domestic violence 
is another initiative that is community-based. These are 
important pieces we are putting in place. They had 65 projects 
and certainly the DVPI expands outreach.
    Prioritizing health care for youth is one I am very excited 
about. We are going to jump ahead. It is in the President's 
budget for 2016 but we are going to go ahead and open a 
Pathways program and begin to hire Native youth to work in our 
facilities and service units to get them doing something 
different and perhaps expose them to health care and forming 
youth steering committees so they can get together and begin to 
share.
    There was a comment about lack of integration. We are 
working closely with the Substance Abuse and Mental Health 
Administration. A good example of our response to Pine Ridge is 
that we are working on our health system to improve it and make 
it more responsive and SAMHSA is providing support to help the 
community work their piece of it. This is a two-part process.
    The other part is behavioral health. We have turned on 
Tele-Behavioral Health to Pine Ridge, for example, and to the 
outlying clinics so that we can provide access to care locally 
in some of those health centers.
    I will also mention the biggest challenge we will have in 
rural America is recruit and retention of health care 
providers. We ran up against this at Pine Ridge and immediately 
we had a problem with housing. We did a little work-around. I 
won't go into how we did the work-around, but we were able to 
provide temporary housing for staff that desperately needed to 
be on-site.
    We will do more in this area. I think there will be 
questions about health care professionals that we need in the 
area, certainly behavioral health folks. We are working on that 
very diligently.
    I think we have some pieces that we are putting together 
that will integrate all of the pieces. We have all these 
programs. We just want to have one place where they are all 
working together and not working in silos or separately.
    With that, I will close my oral remarks.
    [The prepared statement of Mr. McSwain follows:]

 Prepared Statement of Hon. Robert G. Mcswain, Acting Director, Indian 
      Health Service, U.S. Department of Health and Human Services
    Chairman and Members of the Committee:
    Good afternoon, I am Robert G. McSwain, Acting Director of the 
Indian Health Service (IHS). Today, I appreciate the opportunity to 
testify on ``Demanding Results to End Native Youth Suicide.''
    Thank you for the invitation to talk about this very serious issue 
of Native youth suicide. It is with a heavy heart that we discuss an 
issue that continues to plague American Indian and Alaska Native (AI/
AN) communities. Most recently, the Oglala Sioux Tribe has faced the 
same tragedy of a suicide cluster that too many other AI/AN communities 
have experienced. Our thoughts go out to the Oglala Sioux Tribe and the 
families and friends who are grieving the loss of their young people. 
Today, I will highlight our key programs, initiatives, and investments 
to end Native youth suicide and we look forward to continuing to work 
with the Committee to address this devastating problem.
    As you know, the Indian Health Service (IHS) plays a unique role in 
the Department of Health and Human Services because it is a health care 
system that was established to meet the federal trust responsibility to 
provide health care to American Indians and Alaska Natives. The IHS 
provides high-quality, comprehensive primary care and public health 
services through a system of IHS, Tribal, and Urban operated facilities 
and programs based on treaties, judicial determinations, and Acts of 
Congress. The IHS has the responsibility for the delivery of health 
services to an estimated 2.2 million American Indians and Alaska 
Natives who belong to 566 Federally-recognized Tribes. The mission of 
the agency is to raise the physical, mental, social, and spiritual 
health of American Indians and Alaska Natives to the highest level. The 
agency goal is to assure that comprehensive, culturally appropriate 
personal and public health services are available and accessible to the 
AI/AN population. Our duty is to uphold the Federal Government's 
obligation to promote healthy AI/AN people, communities, and cultures 
and to honor and protect the inherent sovereign rights of Tribes.
    Two major pieces of legislation are at the core of the Federal 
Government's responsibility for meeting the health needs of American 
Indians and Alaska Natives: The Snyder Act of 1921, 25 U.S.C  13, and 
the Indian Health Care Improvement Act (IHCIA), 25 U.S.C.  1601-1683. 
The Snyder Act authorized appropriations for ``the relief of distress 
and conservation of health'' of American Indians and Alaska Natives. 
The IHCIA was enacted ``to implement the Federal responsibility for the 
care and education of the Indian people by improving the services and 
facilities of Federal Indian health programs and encouraging maximum 
participation of Indians in such programs.'' Like the Snyder Act, the 
IHCIA provides the authority for the provision of programs, services, 
functions, and activities to address the health needs of American 
Indians and Alaska Natives. The IHCIA also includes authorities for the 
recruitment and retention of health professionals serving Indian 
communities, health services for people, and the construction, 
replacement, and repair of healthcare facilities.
Introduction
    We share your deep concern about the tragedy of suicide among 
Native youth. Suicide is a complicated public health challenge with 
many contributing factors in AI/AN communities. Although suicide 
contagion is not unique to AI/AN populations, too frequently, AI/AN 
communities experience suicide that takes on a particularly worrying 
and seemingly contagious form, often referred to as suicide clusters. 
In these communities, the suicidal act becomes a regular and 
transmittable form of expression of the despair and hopelessness 
experienced by some Native youth. While most vividly and painfully 
expressed in close knit AI/AN communities, suicide and suicidal 
behavior and their consequences send shockwaves through the community. 
We at IHS--and at HHS more broadly--try to prevent these suicide 
clusters from beginning and to halt them once they begin occurring.
    However, all too many AI/AN communities are affected by high rates 
of suicide. The recently published IHS ``Trends in Indian Health, 
2014'' reports:

   The age adjusted suicide rate (18.5 per 100,000 population) 
        for the three year period (2007-2009) in the IHS service areas 
        was 1.6 times that of the U.S. all races rate (11.6) for 2008.

   Suicide is the second leading cause of death (behind 
        unintentional injuries) for Indian youth ages 15-24 residing in 
        IHS service areas and the suicide death rate for this cohort is 
        four times higher than the national average.

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

   AI/AN young people ages 15-34 make up 64 percent of all 
        suicides in Indian country.

Responding to Suicide Crises
    Tribal leaders will often request IHS to provide additional support 
and funding to help prevent any further suicides during a cluster. 
Since no two suicide clusters are the same, the IHS response is 
tailored to the needs of the community in crisis. In general, our Area 
Office typically takes the first steps to organize and implement a 
response to a suicide crisis. In particular, the IHS Area Office 
reaches out to tribal leadership to ensure IHS and key Federal 
partners, such as the Substance Abuse and Mental Health Services 
Administration (SAMHSA), are aware of the Tribe's level of need and the 
specific requests for a response. We take steps to work hand-in-hand 
with the tribe, in organizing our response. IHS and SAMHSA coordinate 
to ensure Federal resources are readily available.
    SAMHSA's resources may include existing grants awarded to the tribe 
under the new Tribal Behavioral Health Grant (TBHG) program that is 
focused on preventing suicidal behavior and substance abuse and 
promoting mental health in AI/AN youth or the Garrett Lee Smith State/
Tribal Youth Suicide Prevention program that supports youth suicide 
prevention and early intervention strategies and collaborations among 
youth-serving institutions and systems (i.e., schools, juvenile 
justice, foster care, substance abuse, mental health, and other child 
and youth supporting organizations). Other SAMHSA resources include 
specialized technical assistance centers such as the Suicide Prevention 
Resource Center, National Native Children's Trauma Center, and National 
AI/AN Addiction Technology Transfer Center.
    If the Tribe requests a deployment of healthcare providers, IHS 
takes the lead with the Division of Commissioned Corps Personnel and 
Readiness (DCCPR) to assess and plan for the deployment. A deployment 
team can be on the ground in a matter of days. These short term 
deployment teams are intended to deal with the immediate crisis until 
mid- and long-term solutions can be set in place.
Zero Suicide
    In 2015, IHS will launch the Zero Suicide Initiative, a key concept 
of the 2012 National Strategy for Suicide Prevention. In our current 
system, suicide care has traditionally been provided by individual 
local champions and clinical providers. IHS is moving toward a more 
programmatic system-wide approach by implementing Zero Suicide. IHS' 
commitment to create a leadership-driven, safety-oriented culture 
committed to reducing suicide among people under our care will drive 
the improved patient outcomes we need to see as a result of a 
collective Agency effort. Moving forward, IHS is making the commitment 
to set big goals and improve our approach to inform system changes to 
provide better care for AI/AN individuals at risk for suicide.
    Zero Suicide represents a bold goal for IHS. It is the foundational 
belief that suicide deaths for individuals under our care within our 
health and behavioral health systems are preventable. IHS is committed 
to creating a leadership-driven, safety-oriented culture focused on 
reducing suicide. The approach represents a commitment from IHS to set 
in place an organizational structure where suicidal individuals and 
individuals at-risk will receive coordinated care from a competent 
workforce. The fundamentals of Zero Suicide implementation include: 
leadership's commitment to reduce suicide deaths; training a competent, 
confident, caring workforce; identifying and assessing patients for 
suicide risk; engaging patients at risk for suicide in a care plan; 
treating suicidal thoughts and behaviors directly; following patients 
through every transition in care; and applying data-driven quality 
improvement. To accomplish our commitment, IHS has begun a virtual 
training series through the Tele-Behavioral Health Center of Excellence 
(TBHCE). IHS is also partnering with SAMHSA and the Suicide Prevention 
Resource Center to bring a tailored Zero Suicide Training Academy for 
IHS and Tribal healthcare facilities in 2015. In addition, as discussed 
below, the Fiscal Year (FY) 2016 Budget requests an additional $25 
million to hire additional behavioral health providers through the 
Methamphetamine and Suicide Prevention Initiative (MSPI).
Methamphetamine and Suicide Prevention Initiative
    The MSPI is an IHS nationally-coordinated demonstration project, 
focusing on providing much-needed methamphetamine and suicide 
prevention and intervention resources for AI/AN communities. It is a 
key resource for IHS as we work to prevent youth suicides. It promotes 
the use and development of evidence-based and practice-based models 
that represent culturally-appropriate prevention and treatment 
approaches from a community-driven context.
    The MSPI supports 130 programs across the country. The goals of the 
MSPI are to:

   Prevent, reduce, or delay the use and/or spread of 
        methamphetamine use;

   Build on the foundation of prior methamphetamine and suicide 
        prevention and treatment efforts, in order to support the IHS, 
        Tribes, and Urban Indian health organizations in developing and 
        implementing culturally appropriate methamphetamine and suicide 
        prevention and early intervention strategies;

   Increase access to methamphetamine and suicide prevention 
        services;

   Improve services for behavioral health issues associated 
        with methamphetamine use and suicide prevention;

   Promote the development of new and promising services that 
        are culturally and community relevant; and

   Demonstrate efficacy and impact.

    MSPI projects provide multiple services related to suicide and 
methamphetamine use. The most common focus of funded projects is 
suicide prevention (94 percent), methamphetamine prevention (69 
percent), and suicide treatment and intervention (55 percent). The MSPI 
projects are in the sixth and final year of the demonstration program. 
From 2009-2014, the MSPI resulted in over 9,400 individuals entering 
treatment for methamphetamine use; more than 12,000 encounters via 
tele-health for substance abuse and mental health disorders; over 
13,150 professionals and community members trained in suicide crisis 
response; and more than 528,000 encounters with youth provided as part 
of evidence-based and practice-based prevention activities.
    MSPI projects offer a multitude of evidence-based practices and 
treatments. The most common types of evidence-based practices utilized 
among MSPI programs to prevent suicide are Question, Persuade, Refer 
(QPR); Applied Suicide Intervention Skills Training (ASIST); Safe Tell, 
Ask, Listen, Keepsafe (safeTALK); Mental Health First Aid; and 
Gathering of Native Americans. Evidence-based treatments to prevent 
suicide re-attempts utilized among MSPI programs include Motivational 
Interviewing, Cognitive Behavior Therapy (CBT), and Dialectical 
Behavior Therapy, to name a few. For instance, the White Earth MSPI 
project, called Native Alive, stations mental health professionals at 
reservations schools and maintains a support hotline staffed by health 
professionals trained in ASIST.
    MSPI projects often incorporate cultural elements into their 
programs and activities such as by teaching traditional beliefs, 
smudging, ceremonies, or sweat lodges in collaboration with traditional 
healers. The Absentee Shawnee MSPI project, Following in Our Footsteps, 
utilizes cultural activities such as Native American storytelling, arts 
and crafts, dancing, sweat lodge ceremonies, and positive youth 
activities to promote healthy life choices and positive decision-making 
skills.
    Building on the associations between social connections and lower 
suicide risk, MSPI projects enlist partners to build community-based 
suicide prevention. Partnerships with local schools are key in the MSPI 
for school-based interventions to develop skills to protect against 
suicidal thoughts and behaviors, raise awareness, encourage help-
seeking, and teach positive life and coping skills. Examples of such 
activities at work in MSPI communities include American Indian Life 
Skills, Native Hope, and Project Venture. Youth may not want or may not 
always be able to ask appropriate adults for help and may reach out to 
their peers for assistance. MSPI projects offer training to youth to 
build their intervention skills for such situations. The MSPI funds 
allow projects to expand community-based mental health care into youth-
based settings, increasing access to care for mental health and 
substance use disorders for our Native youth. The funding for MSPI 
funding is not enough to go to every Tribe. Therefore, IHS awards the 
funds on a competitive basis. In FY 2015, IHS will open a new funding 
announcement for a project period to run from September 30, 2015 to 
September 29, 2020, contingent on appropriations.
Domestic Violence Prevention Initiative
    Since the Institutes of Medicine (2002) report \1\ on suicide 
research, there has been much learned about the role of child abuse in 
later suicide risk. According to the Center on the Developing Child at 
Harvard University, a toxic stress response can occur when a child 
experiences strong, frequent, and/or prolonged adversity, such as 
physical or emotional abuse, chronic neglect, caregiver substance use 
and mental health disorders, exposure to violence, and/or the 
accumulated burdens of family economic hardship. These adverse 
childhood experiences can disrupt the development of brain architecture 
and other organ systems, and increase the risk for stress-related 
disease and cognitive impairment, well into the adult years.
---------------------------------------------------------------------------
    \1\ See: http://www.iom.edu/Reports/2002/Reducing-Suicide-A-
National-Imperative.aspx
---------------------------------------------------------------------------
    IHS' primary response to children exposed to violence is through 
the Domestic Violence Prevention Initiative (DVPI). The IHS began the 
DVPI in 2010 with the purpose of better addressing domestic violence 
(DV) and sexual assault (SA), including the pediatric and adolescent 
population, within AI/AN communities. The program has awarded funding 
to a total of 65 projects that include IHS/Tribal/Urban operated 
programs. This initiative promotes the development of evidence-based 
and practice-based models that represent culturally appropriate 
prevention and treatment approaches to DV and SA from a community-
driven context. Types of evidence-based treatment practices provided by 
DVPI projects include CBT, Trauma Focused CBT, Beyond Trauma: Traumatic 
Incident Reduction, and Strengthening Families, a program to improve 
parenting and family relationships. Practice-based practices utilized 
by DVPI projects include elders teaching traditions, talking circles, 
or smudging ceremonies. For instance, Santa Clara Pueblo provides more 
community education activities; in-school services for young witnesses 
of family violence; violence prevention education in schools; and 
counseling for young victims of DV.
    The DVPI expands outreach and increases awareness by funding 
projects that provide victim advocacy, intervention, case coordination, 
policy development, community response teams, and community and school 
education programs. The funding is also used for the purchase of 
forensic equipment, medical personnel training, and the coordination of 
Sexual Assault Examiner (SAE) and Sexual Assault Response Team 
activities. From 2010-2014, the DVPI resulted in over 50,500 direct 
service encounters including crisis intervention, victim advocacy, case 
management, and counseling services. More than 38,000 referrals were 
made for domestic violence services, culturally-based services, and 
clinical behavioral health services. In addition, a total of 600 
forensic evidence collection kits from eight SAE programs were 
submitted to Federal, state, and tribal law enforcement. In the last 
year, DVPI projects referred over 2,000 children and youth to 
behavioral health, cultural services, DV or SA services, shelter 
services, specialized medical care, or to victim advocates.
Prioritizing Behavioral Health Services for Native Youth
    The Administration's 2016 Budget proposes key investments to launch 
Generation Indigenous (Gen-I), an initiative addressing barriers to 
success for Native American youth. This integrative, comprehensive, and 
culturally appropriate approach across the Federal Government will help 
improve lives and opportunities for Native American youth. The HHS 
Budget Request includes a new Tribal Behavioral Health Initiative for 
Native Youth with a total of $50 million in funding for IHS and the 
SAMHSA. Within IHS, the request includes $25 million to expand the 
successful MSPI to increase the number of child and adolescent 
behavioral health professionals who will provide direct services and 
implement youth-based programming at IHS, tribal, and urban Indian 
health programs, school-based health centers, or youth-based programs. 
SAMHSA will expand the Tribal Behavioral Health Grant program to 
support mental health promotion and substance use prevention activities 
for high-risk Native youth and their families, enhance early detection 
of mental and substance use disorders among Native youth, and increase 
referral to treatment. These activities will both fill gaps in services 
and fulfill requests from tribal leaders to support Native youth.
    IHS' Gen-I activities include youth engagement through the 
development of youth steering committees at the local level to inform 
IHS on planning, implementation, and evaluation of its youth health 
programs and services. The information from the local youth steering 
committees will feed into regional and national recommendations to 
operationalize the input received from Native youth. Secondly, IHS will 
provide opportunities through its Pathways Internship Program. Pathways 
is a streamlined program designed to attract students enrolled in a 
wide variety of educational institutions (high school, home-school 
programs, vocational and technical, undergraduate and graduate) with 
paid opportunities to work in agencies and explore Federal careers 
while still in school. This program exposes students to jobs in the 
Federal civil service by providing meaningful ``developmental work'' at 
the beginning of their career, before their ``career paths'' are fully 
established. The flexible nature of the program is to accommodate the 
need to hire students to complete temporary work or projects, perform 
labor intensive tasks not requiring subject matter expertise, or to 
work traditional ``summer jobs.'' The program provides agencies with 
the opportunity to hire interns who successfully complete the program 
and academic requirements into any competitive service position for 
which the Intern is qualified. The IHS Gen-I Pathways Internship 
Program offers Native youth an opportunity to apply for paid summer 
positions at IHS Service Units in their local community. The initiative 
kicked off in May 2015, and we have posted job advertisements at all 
the IHS Areas and have over 80 summer internship positions allocated 
IHS-wide.
    IHS will also provide more funding opportunities geared toward 
Native youth for early intervention and positive youth development 
through its three largest initiatives. In the Special Diabetes Program 
for Indians, grantees will have the option to elect to use FY 2016 
funding to implement the Family Spirit Program, an early intervention 
home visiting program. Family Spirit is an evidence-based and 
culturally tailored in-home parent training and support program. 
Parents gain knowledge and skills to achieve optimum development for 
their preschool aged children across the domains of physical, 
cognitive, social-emotional, language learning, and self-help. The 
program is currently the largest, most rigorous, and only evidence-
based home visiting program ever designed specifically for American 
Indian families. Family Spirit now has randomized controlled trial 
evidence demonstrating that it reduces risk factors associated with a 
number of adverse outcomes, including obesity and substance use.
    The MSPI program will also provide FY 2015 funding for local 
programs to support their Gen-I activities through evidence-based and 
practice-based programming. Examples of such activities include 
implementation of American Indian Life Skills, Model Adolescent Suicide 
Prevention Program, Project Venture, Native HOPE (Helping Our People 
Endure), ASIST (Applied Suicide Intervention Skills Training), and 
cultural activities like Native American storytelling, traditional 
teachings, ceremonies, and other local relevant practices.
Behavioral Health Integration with Primary Care
    The current system of services for treating mental health problems 
of American Indians and Alaska Natives is a complex and often 
fragmented system of tribal, Federal, state, local, and community-based 
services. The availability and adequacy of mental health programs for 
American Indians and Alaska Natives varies considerably across 
communities. The future of AI/AN health depends largely upon how 
effectively behavioral health is addressed by individuals, families, 
and communities and how well it is integrated into community health 
systems. We know that successful and sustained behavioral change will 
require cultural reconnection, community participation, increased 
resources, leadership capacity, and the ability of systems to be 
responsive to emerging issues and changing needs. In 2014, IHS began a 
small pilot project of six sites, the Behavioral Health Integration 
Initiative (BH2I). The goal of the funding was for sites to develop 
rapid cycle improvements of behavioral health integration with primary 
care using the Improving Patient Care (IPC) model. BH2I will continue 
into FY 2016. IHS will host a National Behavioral Health Integration 
with Primary Care Conference in Phoenix, Arizona to disseminate 
integration best practices and lessons learned from BH2I.
    The IPC Program is an outpatient primary care quality improvement 
program designed to assist IHS/Tribal/Urban Indian clinics with 
improving their care delivery and achieving Patient Centered Medical 
Home (PCMH) recognition. The PCMH is a model of care that aims to 
transform the delivery of comprehensive primary care to children, 
adolescents, and adults. The PCMH is best described as a model that is 
patient-centered, comprehensive, team-based, coordinated, accessible, 
and focused on quality and safety. The medical home is focused on the 
needs of patients, and when appropriate, their families and caregivers. 
A significant element of the PCMH is integration of behavioral health 
services into primary care patient visits. This can include screening 
for behavioral health conditions, addressing beliefs about diseases and 
treatments, identifying disorders and initiating treatment, and 
collaboration with behavioral health professionals as part of the 
integrated primary care team.
Training and Tele-Behavioral Health Services
    IHS recognizes the need to support access to services and to create 
a broader range of services linked into a larger network of support and 
care. IHS piloted the use of tele-behavioral health to increase access 
to specialty behavioral health services in the MSPI demonstration pilot 
phase. MSPI projects provided over 6,000 tele-behavioral health 
encounters in the fifth year alone.
    The TBHCE was developed in 2009 to promote and develop tele-
behavioral health services. Working in partnership with the University 
of New Mexico, the TBHCE provides services in a number of settings 
including school clinics, youth residential treatment centers, and 
health centers. The TBHCE has leveraged their ability to use federal 
service providers and provides technical and program support nationally 
for programs attempting to implement tele-health services. IHS programs 
are increasingly adopting and using these technologies with more than 
8,000 encounters provided via tele-behavioral health in FY 2014.
    IHS benefits from the use of telemedicine for the prevention and 
treatment of youth suicide by connecting widely separated and often 
isolated programs of varying sizes together into a network of support. 
For example, small clinics would need to develop separate contracts for 
services such as child and adult psychiatric support, but the TBHCE is 
able to provide more cost-effective specialty care conveniently located 
within the clinic patients utilize for services. Such a system could 
provide 24/7 access to emergency and routine behavioral health service 
in any setting with adequate telecommunications service and 
appropriately trained staff.
    The TBHCE also provides opportunities for mutual provider support. 
For example, currently when psychiatric providers are on leave or are 
attending a training conference there are often no direct services 
available during that time period. Sufficient services could be 
provided via tele-health connections to improve continuity of care with 
providers who are familiar with treating AI/AN patients. IHS also 
encourages families to participate in care through tele-health in 
circumstances when their youth may be transitioning from a treatment 
facility or residential program.
    Providers with particular specialty interests can also share their 
skills and knowledge across a broad area even if they themselves are 
located in an isolated location by videoconferencing, providing 
clinical supervision and working with multidisciplinary teams. 
Universities providing distance-based learning opportunities have 
demonstrated for years that educational activities can be facilitated 
by this technology and reduce burn out due to professional isolation. 
Recruitment also becomes less problematic because providers can readily 
live and practice out of larger urban or suburban areas and are thus 
more likely to continue providing service over time.
    The TBHCE also provides virtual training to primary care providers, 
nurses, and behavioral health providers on current and pressing 
behavioral health topics in an effort to increase the Indian health 
system's capacity to provide integrated behavioral health care with 
primary care. In FY 2014, over 8,000 providers received training.
Recruitment and Retention
    The rural and remote geographical locations of AI/AN communities 
present challenges with recruitment and retention of qualified 
behavioral health providers. Many of the facilities that serve AI/AN 
populations are in what the Health Resources and Services 
Administration (HRSA) has designated as health professional shortage 
areas. \2\ The IHS offers financial incentive programs to recruit and 
retain behavioral health providers. The IHS Loan Repayment Program 
offers financial support in exchange for a service obligation in IHS-
designated facilities upon completion of training and licensure. The 
IHS Indian Health Professions Scholarship Program is designed for AI/AN 
recipients entering the healthcare field. The recipients receive full 
or partial tuition support and a monthly stipend in exchange for a 
service obligation upon completion of training and appropriate 
licensure for placement within IHS-designated facilities located in 
designated shortage areas. The Indians into Psychology grant provides 
funding to colleges and universities for the purpose of developing and 
maintaining American Indian psychology career recruitment programs to 
encourage AI/AN students to enter the behavioral or mental health 
field. Recipients of the program receive tuition, fees, and a monthly 
stipend. Upon graduation with a Ph.D., these professionals are placed 
within IHS-designated facilities.
---------------------------------------------------------------------------
    \2\ See: Health Resources and Services Administration Shortage 
Designation: Health Professional Shortage Areas and Medically 
Underserved Areas/Populations. Available at: www.hrsa.gov/shortage/find
---------------------------------------------------------------------------
    The National Health Service Corps (NHSC), administered by HRSA, has 
both a scholarship program and a loan repayment program. The NHSC adds 
another source of service-obligated providers to IHS, Tribal, and Urban 
Indian health programs, including behavioral health professionals. IHS 
and HRSA collaborated to increase the numbers of IHS, Tribal, and Urban 
Indian health program sites that are eligible for assignment of NHSC 
personnel. The NHSC Loan Repayment Program is another opportunity for 
behavioral health providers to serve in communities with limited access 
to care and have their student loans repaid.
Conclusion
    Suicide prevention needs to be addressed in the comprehensive, 
coordinated way outlined in the National Strategy for Suicide 
Prevention. No one agency or one approach will solve the tragedy of 
suicide in AI/AN communities. Suicide is complex and thus has many 
factors that must be considered. Reducing the number of suicides 
requires the engagement and commitment of people in many sectors in and 
outside government. IHS is committed to being a partner in the response 
to end Native youth suicides. As a central provider of health care for 
American Indians and Alaska Natives, we must do better in reaching 
youth with behavioral health and other help they need. We want to work 
with you to get us closer to the Zero Suicide goal. We all recognize 
that the challenges faced by Native youth run deep--we must all work 
together in offering them hope for a better future.

    The Chairman. Thank you so much, Mr. McSwain.
    Next we have C.J. Clifford, Council Member from Pine Ridge, 
South Dakota. I note that President Steele is not with us 
because he fell ill. Please give him our very best.
    Councilman Clifford.

  STATEMENT OF HON. COLLINS ``C.J.'' CLIFFORD, TRIBAL COUNCIL 
                   MEMBER, OGLALA SIOUX TRIBE

    Mr. Clifford. I would like to say top of the afternoon to 
you, Chairman Barrasso and members of the Committee. Thank you 
for having me here today.
    My name is C.J. Clifford, Council Member for the Oglala 
Sioux Tribe. I am here in place of our tribal president, John 
Yellow Bird Steele, who fell ill. President Steele was very 
disappointed that he could not attend this important hearing.
    Between the week before Christmas and today, the Oglala 
Sioux Tribe has lost 14, to update you with numbers, young 
people to suicide. According to the Indian Health Service, 176 
of our youth attempted suicide in that same period. The IHS 
treated 229 more who had suicidal ideas with plans and intent 
to carry it out.
    Though there is some overlap with IHS, our Tribe's 
Sweetgrass Suicide Prevention Project served 276 young people 
exhibiting suicidal behavior. These are our children and we 
cannot bear to lose any more. When we lose one child, it hurts 
the spirit and soul of every one of our people. I hope the 
hearing today results in action from Congress to assist in 
saving the lives of our youth.
    President Steele issued a proclamation in February 2015 
declaring a state of emergency on the Pine Ridge Reservation 
due to high incidence of suicide of our youth. I would like to 
submit this for the record. This is the second declaration 
since 2010. We are struggling and need to get resources to get 
in front of this problem.
    Our biggest challenge is to combat the hopelessness of our 
youth. We also need to combat the growing normalcy of suicide. 
Some children speak openly about suicide or discuss methods or 
stories at the school or on social media.
    To reiterate the story you mentioned earlier, this year one 
of the youth pastors on our reservation received a tip there 
would be a group suicide that day. He went to the site and 
found ropes hanging from the trees. Thankfully, no one had 
hanged themselves but the youth had begun to gather. This 
intervention saved them at this time.
    Feelings of hopelessness are compounded by the reality of 
living on Pine Ridge. Our poverty rate is more than 50 percent, 
our unemployment is above 70 percent and 60 percent of our 
students do not graduate high school. Life expectancy is around 
50 years of age compared to the U.S. average of 79 years.
    The suicide rate is twice the national average. The latest 
cluster of suicides is almost unprecedented. Our children have 
the outlook that things may not get better for them, that they 
are destined to suffer the same history and injustice as our 
ancestors.
    Black Elk said the nation's circle was broken by Wounded 
Knee; 125 years later, we are still trying to heal. Just for 
your information, I am a direct descendent of Black Elk, the 
holy man.
    We have asked IHS to deploy behavioral health 
professionals. We have asked them to provide debriefing, 
education and individual assessments and to work with our 
schools. We have also asked them to begin home visits for youth 
treated for suicidal ideation, mental health problems or 
attempted suicide.
    IHS has begun to help us but there is so much work that 
needs to be done. We realize that IHS is struggling to provide 
adequate services nationwide due to insufficient funding but we 
are faced with urgent problems in need of immediate attention 
and assistance.
    Congress can help us in concrete ways. Immediate steps 
include: one, to encourage the Secretary to come out to Pine 
Ridge for a youth suicide prevention summit and create a task 
force devoted to accessing Federal resources for suicide 
prevention and intervention; two, to establish a school-based 
community so students can have access to counselors at their 
schools; three, to provide $240,000 through SAMSHA, HRSA or 
elsewhere to install Tele-Health in our schools; four, 
establish and fund a Department of Labor youth opportunity 
program on the Pine Ridge Reservation and make opportunities to 
provide children with safe havens; five, to immediately provide 
surplus Federal housing to address our severely overcrowded 
housing situation which places significant stress on our 
children.
    There are also fundamental overarching steps Congress can 
take to help us. These are detailed in our written testimony.
    I will be glad to answer any questions.
    [The prepared statement of Mr. Yellow Bird Steele follows:]

 Prepared Statement of Hon. John Yellow Bird Steele, President, Oglala 
                              Sioux Tribe


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

   
    The Chairman. Thank you so much for your testimony. It is 
compelling. We are grateful you could be with us today, Mr. 
Clifford.
    Senator Franken, if I could ask you to introduce our next 
witness.

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

    Senator Franken. Thank you, Mr. Chairman.
    It is my honor to introduce Chairman Darrell Seki of the 
Red Lake Band of Chippewa. Chairman Seki has served Red Lake in 
various roles over the past 40 years. He has served over a 
decade as treasurer of the Red Lake Tribal Council and last 
year, he was elected tribal chairman.
    The Red Lake Band is far too familiar with tragedy. Just 
since March when Chairman Seki testified before a House 
committee on this very issue, Red Lake has lost two children to 
suicide.
    Chairman Seki can speak not only to the challenge of 
addressing this immediate crisis but also to the struggle to 
fund services for Indian youth over the long term.
    I am pleased to welcome you, Mr. Chairman, to the Indian 
Affairs Committee. I look forward to hearing your valuable 
perspective on how we can make a sustained effort to prevent 
suicide and how we can create a better future for our young 
people in Indian Country.
    Thank you for being here.

STATEMENT OF HON. DARRELL G. SEKI, SR., CHAIRMAN, RED LAKE BAND 
                      OF CHIPPEWA INDIANS

    Mr. Seki. Thank you to Senator Franken for introducing me.
    [Prayer in Native language.]
    Mr. Seki. Good afternoon, Chairman Barrasso, Vice Chairman 
Tester and members of the Committee.
    Thank you for the opportunity to testify today about ending 
Native youth suicides. I will focus my testimony on youth 
suicide but I would also point out that Red Lake suffers from 
high suicide rates in people over 18 as well. Like our brothers 
and sisters at the Pine Ridge Reservation, the Red Lake Nation 
is experiencing high numbers of youth suicide, attempted 
suicide, suicide ideations and counseling referrals.
    We are happy to hear Pine Ridge received a Department of 
Education SERV grant. Red Lake received a SERV grant and a 
SAMHSA grant 10 years ago after the Red Lake School shooting.
    Operating these grant programs, we learned two big lessons. 
First, was that school counselors can make a huge difference, 
second, we learned programs like this only work if they can be 
financially sustained over many years. It is long, hard, slow 
work.
    Just three months ago, we marked the 10-year anniversary of 
the Red Lake School shooting. Ten people lost their lives that 
day. Five were wounded and many other lives were changed 
forever. Although President George W. Bush promised we would 
not be forgotten, that promise has not endured.
    Last year, Red Lake suffered four youth suicides, two girls 
and two boys. This year, we already have lost two more kids to 
suicide including a 9 year old boy just a few weeks ago.
    Over the last year of school at Red Lake, there were more 
than 75 cases of suicide ideation. School wellness counselor 
intervention resulted in more than 40 students being placed 
under protective watch and sent to appropriate medical 
facilities for care.
    The counselors initiated dozens of safety plans which drove 
us to get assistance when needed. This proves our counselors 
are doing their job. Counselors can and do save lives.
    Because of staffing reductions and other sequestration, we 
are unable to reach all who need help. Anyone who thinks 
sequestration is not bad is dead wrong. Sequestration is a 
nightmare for tribes at Red Lake who must rely on Federal 
funding.
    The current youth suicide intervention process usually ends 
without any continuing care. After the crisis is over, there 
are no financial resources for follow up treatment. That is 
like funding an emergency room with only hospital services for 
performing surgery without any post-op rehab services.
    Students do not get needed after-care because of the Indian 
Health Service's staffing shortage. Often these shortages lead 
to wait times of several weeks for follow up care. This 
frustrates some families and they give up.
    Last fall, my office conducted community meetings across 
our reservation focusing on suicide, drugs and bullying. In 
those meetings, we identified several obstacles to solving our 
suicide problem. Some of those obstacles include loss of our 
traditions in everyday life, lack of nearby facilities, needed 
after care services on reservations, more training in how to 
have difficult family conversations, and perhaps most 
important, parental drug use which includes alcohol. Our 
community members felt that solving drug abuse is critical in 
bringing an end to suicide.
    The solutions we came up with can easily be summed up. We 
simply must restore our sense of community. We have a plan to 
end suicide on our reservation. Components of our plan include 
strengthening our wellness counselor program by doubling the 
number of counselors and social workers; improving the process 
for follow-up care; rebuilding hope by rebuilding our 
infrastructure; getting tough on drug offenders and precluding 
them from our land while building rehabilitative services for 
our members.
    A key in building our rehabilitative services is the Tiwahe 
Initiative. We are very fortunate to have just been selected as 
one of the four tribes to participate in the pilot component of 
BIA's Tiwahe Initiative. The purpose of the Initiative is to 
address the underlying causes of poverty, domestic violence, 
substance abuse and suicide. Tiwahe utilizes integrated 
approaches to service delivery and redesign of the services 
offered by bringing all of our programs together.
    We are going to break down the silos. We are going to find 
ways to implement what works. In building our infrastructure, 
we believe that hope is often fostered by prosperity. We have a 
plan to build our economy at Red Lake. We are focusing on our 
infrastructure like communications, roads, diversifying our 
tribal enterprises and improving local training programs in 
order to build our workforce.
    Congress can help by ending sequestration for tribes. We 
will have more recurring dollars to support our efforts to end 
youth suicides. By supporting the Tiwahe Initiative, we can 
strengthen our social service and rehabilitation programs.
    Congress needs to remove the obstacles imposed on tribes 
through a process of short term grants. Summed up, our big 
message is that only sustained funding of affected programs 
will end youth suicides in Indian Country. Red Lake has a plan 
to do that but we need sustained funding to do so.
    I want to thank the Committee for giving me this 
opportunity to speak on behalf of Red Lake Nation.
    [The prepared statement of Mr. Seki follows:]

Prepared Statement of Hon. Darrell G. Seki Sr., Chairman, Red Lake Band 
                          of Chippewa Indians
    Mr. Chairman, I thank you and the other distinguished members of 
the Committee for this opportunity to provide testimony on behalf of 
the Red Lake Band of Chippewa Indians, and for your attention on the 
problem of native youth suicides. For statistical purposes I will focus 
my testimony on youth under 18, but I would also point out Red Lake 
suffers from high suicide rates in over 18 years as well.
    On behalf of the Red Lake Nation, I want to extend my sympathies to 
my brother Mr. Yellow Bird Steele, and the people of Pine Ridge. The 
Red Lake Nation is also experiencing high numbers of youth suicides, 
attempted suicides, suicide ideations, and counselling referrals. We 
are happy you received a Department of Education SERV grant. Red Lake 
received a SERV grant and a SAMHSA grant 10 years ago after the Red 
Lake School Shooting. Two lessons we learned are that school 
counsellors can make a huge difference and programs like this only work 
if they can be financially sustained over time.
About Red Lake Band of Chippewa Indians
    Red Lake is a fairly large tribe with 12,000 members. Our 840,000 
acre reservation is held in trust for the tribe by the United States. 
While it has been diminished in size, our reservation has never been 
broken apart or allotted to individuals. Nor has it been subjected to 
the criminal or civil jurisdiction of the State of Minnesota. Thus, we 
have a large land area over which we exercise full governmental 
authority and control, in conjunction with the United States. At the 
same time, due in part to our remote location, we have few jobs 
available on our reservation. While the unemployment rate in Minnesota 
is 3.7 percent, ours remains at an outrageously high level of about 50 
percent. The lack of infrastructure such as good roads, communications, 
technology and other necessary infrastructure continues to hold back 
economic development and job opportunities.
Red Lake Suicide Rates and Intervention Process
    Health information laws constrain our ability to consolidate 
suicide data. The School district, law enforcement and our health 
services all collect data in different ways, which makes analysis of 
suicide-related data difficult. Focusing on just health services, the 
data shows that last year we had four youth suicides-two girls and two 
boys-and there were 63 cases of suicide ideation. Due to Wellness 
Counselor interventions, 34 students were placed under protective watch 
and sent to appropriate medical facilities for care. The counselors 
initiated dozens of Safety Plans with students to get assistance when 
needed. This proves the counselors are doing their job, and they can 
and do save lives. But because of staffing reductions under 
sequestration, we are unable to reach all who need help. Anyone who 
thinks sequestration is not so bad is dead wrong. Sequestration is a 
nightmare for tribes who must rely on federal funding.
    The current youth suicide intervention process ultimately ends with 
no lasting service. For example, when a student is having a problem in 
our school, the teacher will contact of a wellness counselor. The 
wellness counselor will first talk with the child and then take the 
child to the school social worker. If the child meets all the signs of 
suicidal behavior the child is taken to the hospital emergency room. 
After a doctor evaluates the child the hospital mental health staff 
will further evaluate to determine whether the child should go to a 
special facility for further treatment and observation. In this 
example, the child visited four separately funded programs, the 
independent school district, Red Lake Comprehensive Health Services, 
Indian Health Services--Emergency and Indian Health Services--
Behavioral Health and if they are forwarded to another facility, it 
represents yet another funding source. At Red Lake, because of staffing 
shortages, it is well documented that Indian Health Service follow up 
care is always backed up by several weeks and children must wait weeks 
in order to be seen for follow up.
The History of Our Suicide Problem
    Last fall, my office conducted community meetings focusing on 
suicide, drugs and bullying. We visited all four of our tribal 
communities and had great attendance and participation from our 
members. From our community meetings our members identified several 
long-standing obstacles to solving our social ills including youth 
suicide. Some of those obstacles include: loss of our traditions in 
everyday life; lack of facilities nearby; no aftercare in our land; 
inability to have ``difficult'' conversations; and perhaps most 
importantly, parental drug use-which includes alcohol. Our community 
members felt that solving drug abuse and bullying are critical needs in 
bringing about an end to suicide. The solutions our community came up 
with can easily be summed up; restore our sense of community.
    The trail to suicide isn't far from lack of job opportunities. A 
lack of employment opportunities results in poverty and disparity. 
Poverty and disparity can lead to drugs and addiction. Drug addiction 
leads to the tear down of our families, which often precipitates high 
suicide rates.
    But drugs are not the only source of our high suicide rate. Just 
three months ago, we marked the 10th anniversary of the Red Lake School 
shooting. 10 people lost their lives that day, 5 were wounded, and many 
other lives were changed forever. Today, a lot of those people are 
still suffering from the horror they faced that day. The story gets 
even more tragic when we consider that President George W. Bush told 
Red Lake the Government would come to our aid, and we would not be 
forgotten. But that promise did not endure.
    I talked about Red Lake's youth suicide problem at the House 
Interior Appropriations Committee last March. Since that time two more 
kids committed suicide, including a nine year old boy just three weeks 
ago. I pointed out during the March hearing that for three years now, 
sequestration took about $1.5 million each year from Red Lake's BIA and 
IHS base programs, and additional amounts from formula-based programs. 
This has made it very difficult for us to provide any sustained 
assistance to combat youth suicide. Grants are very difficult to apply 
for and to manage, and they don't last. Sustained funding is our only 
hope to make a difference.
How Red Lake Can End Suicide on Our Reservation
a. Expanding our Wellness Counselor Program
    Our Tribal Health program funds the Red Lake Schools' Wellness 
Program, which provides counselors to help students when they have 
problems and are thinking of harming themselves. It began after the 
School shooting, with help from a SAMHSA grant. The grant ended two 
years later, so the Tribe has had to pick up the tab ever since. 
Because of sequestration we had to cut the number of wellness 
counselors from 8 to 5, which is not nearly enough to assist hundreds 
of students in four schools. Additionally, we have only two school 
social workers, they are the specialists who usually make the first 
diagnosis of a problem. The wellness counselors and social workers in 
our schools are the critical front-line components of our suicide 
prevention plan. We need to at least double their numbers this year: 
from 5 to 10 wellness counselors; and from 2 to 4 social workers.
b. Attacking Our Drug Problem
    Drugs are a major factor in our suicide rates and we have taken a 
hard line against offenders. Within the last few weeks federal agents 
and our tribal police force arrested 41 people involved in trafficking 
drugs. The traffickers moved drugs such as heroin, methamphetamine and 
prescription pills in to Red Lake. We continue to work with our law 
enforcement partners and the United States Attorney's Office to expand 
on the number of drug busts. And that isn't all, the Red Lake Band of 
Chippewa Indians has also permanently removed many non-member drug 
Dealers from our lands.
c. Large Concentrated Multi-Prong Push
    The Band will take a multi-program rehabilitative approach to 
address suicide and the underlying causes we see in Red Lake. We are 
very fortunate to have just been selected as one of four tribes to 
participate in the BIA's Tiwahe Initiative. The purpose of the Tiwahe 
Initiative is to address the underlying causes of poverty, domestic 
violence, substance abuse, and suicide, by utilizing an integrated 
approach to service delivery, and redesign of the services offered. We 
are bringing all of our programs together, we are going to break down 
the silos, and we are going to find out what works and does not work, 
and we're going to find a way to implement what works. We recently 
formed a suicide prevention task force to better coordinate mental 
health and suicide prevention services.
d. Building Infrastructure
    Hope is often fostered by prosperity. Providing adequate funding 
for governmental functions allows us to spend what little of our own 
money we have on economic development. We have a plan to build our 
economy in Red Lake. We are focusing on things that never leave the 
reservation; our infrastructure like communications and roads, and 
improving local training programs in order to build our workforce.
How Congress Can Help Red Lake to Accomplish Our Plan
    Congress can help tribes reduce suicide by ending sequestration and 
by finding a way to provide additional and sustained funding. Red Lake, 
like many government agencies, suffers from compartmentalization of 
many services, including for mental health and suicide prevention. This 
makes it difficult to coordinate an effective approach to combatting 
the problem. And it makes it difficult for community members to know 
what services are available and where to go for help. 
Compartmentalization is partly the result of the fact that most funding 
to address mental health comes in the form of grants. Silos are created 
because granting agencies have their own unique funding requirements, 
and they award funds to different types of grantees (e.g. Department of 
Education to schools; HHS to health centers; DOJ and SAMHSA to tribal 
governments).
    I have already alluded to it, but one thing we know about Indian 
Country is that grants often do not work. Grants are short term and 
often non-strategic. Further, federal application and reporting 
requirements are cumbersome and require significant resources to 
complete. Our SAMHSA grant was helpful but it only lasted two years.
    The problem with grants is an issue that national scholars have 
noted. Miriam Jorgensen, the editor of ``Rebuilding Native Nations'' 
noted that often, Indian Tribes are unable to set their own development 
agenda--they must pattern it to obtain grants. Further Ms. Jorgensen 
pointed out, ``few dollars come to Native Nations via block grants, a 
mechanism that would place more decisionmaking power in Indians 
hands.''
    Compounding the problems associated with grants, the only recurring 
funding we could count on, from BIA and IHS, has been hammered by 
sequestration and at least 14 different across the board rescissions. 
Congress could aid in reducing our suicide rate by ending sequestration 
in Indian Country, and returning our sequestered funds to us.
    In summary, in order to end suicide in Red Lake we need to better 
understand what we are doing right, and what we are doing wrong. We are 
optimistic that Red Lake's participation in the Tiwahe Initiative will 
serve as the springboard to make changes that will work. Poverty brings 
about hopelessness and despair. Drugs that follow poverty have 
destroyed our understanding of family. The horrors of the school 
shooting still linger, and there is also generational trauma. Our 
community members feel we need to restore our sense of community. 
Sequestration has limited our ability to address our problems. Grants 
are not the answer-they set programs up for failure. Only sustained 
funding of effective programs will end youth suicides in Indian 
Country. Red Lake has a plan to do that, but we need sustained funding 
to do so.
    Thank you for allowing me to provide testimony today on the 
important topic of ending Native Youth Suicides.

    The Chairman. Thank you very much, Chairman Seki.
    Dr. LaFromboise.

     STATEMENT OF TERESA D. LAFROMBOISE, Ph.D., PROFESSOR, 
           DEVELOPMENTAL AND PSYCHOLOGICAL SCIENCES, 
            GRADUATE SCHOOL OF EDUCATION, STANFORD 
                           UNIVERSITY

    Dr. LaFromboise. Good afternoon, Mr. Chairman and members 
of the Committee. I am grateful for the opportunity to present 
testimony on a topic of urgent importance in Indian Country.
    I have been working in the field over American Indian 
suicide prevention since 1989. I began at the invitation of Mr. 
Hayes Lewis, the Superintendent of the Zuni Public School 
District. He made a request to me at Stanford to bring a team 
of educators and health promotion specialists from Stanford 
University to the Pueblo of Zuni to help community experts 
develop a culturally grounded youth suicide prevention 
intervention.
    Over the course of three years, our team worked in Zuni to 
develop a life skills curriculum, to consult with the Zuni 
Board of Education and the Zuni Tribal Council, and conduct an 
outcome study of the curriculum we developed. We compared 
students in the curriculum with those who were not. We found 
those in the curriculum, the Zuni Life Skills Curriculum, 
displayed less suicidal ideation, suicide attempts, less 
hopelessness, greater self-efficacy to manage anger, and 
greater effectiveness in helping a suicidal friend solve 
problems and to go to someone for help.
    Today, I would like to talk a little bit about the 
derivative of the Zuni Life Skills which is the American Indian 
Life Skills. I would also like to talk about four other 
evidence-based interventions used in Indian communities and 
found to be effective in reducing suicide. The evaluations were 
not with Native communities but with communities across 
mainstream society. I think that might provide some help.
    When Mr. Lewis invited us to develop this curriculum, we 
were invited only to do work with the Zuni high school. We did 
not have a lot of experience, although I did teach junior high 
and high school, so I learned a lot about school-based suicide 
prevention.
    The rationale for suicide prevention in schools hinges on 
the recognition that a significant amount of suicidal behavior 
occurs among ostensibly well-functioning students. The idea is 
to do a population-based strategy of exposing all students to 
suicide awareness and skills about suicide so that it can reach 
the greatest number of students who will then help the smaller 
number of students who are at risk.
    These programs primarily target an individual student's 
thinking and behavior. The ultimate goal is to help at-risk 
students receive psychological treatment before they become 
acutely suicidal. The type of approaches then in schools for 
suicide prevention consists of awareness and education 
curricula, peer leadership training, skills training, 
gatekeeper training and screening.
    The Zuni Life Skills was expanded to have examples from a 
number of different tribes so that we could reach a more 
diverse group of people. The emphasis is social skills training 
and intervention that emphasizes the fact that suicide is an 
action and a behavior rather than focusing on it as a mental 
illness.
    This curriculum has seven major themes: building self-
esteem; identifying emotions and stress; increasing 
communication and problem-solving skills; recognizing self-
destructive behavior and finding ways to eliminate it; learning 
information about suicide; helping a suicidal friend go for 
help; and planning ahead for a great future.
    You may say, what is cultural about that? There are a 
number of opportunities for cultural considerations in this 
curriculum but more of the scenarios in it emphasize realistic 
situations that occur in Native communities. We talk about 
culturally appropriate ways to express emotions and grief.
    Tribal community members are encouraged to be the ones that 
deliver the intervention. Tribal community members are invited 
into a number of the sessions to share cultural teachings and 
to model cultural coping perspectives. It is cultural. This has 
been offered in a number of schools but it is also offered in 
cultural camps, local recreation and sports programs, Boys and 
Girls Clubs, Upward Bound, treatment centers, tribal colleges 
and tribal youth employment.
    It has been adapted in recent years for urban and suburban 
settings and in some tribal communities, a few, such as the 
Spirit Lake Dakota Tribe which has adapted it for their local 
community values and norms.
    I have had the opportunity of training community members 
from over 100 reservations that have participated in these 
trainings. Now we are working on internet applications in order 
to provide technical assistance after these trainings.
    I want to talk about four other programs. Basically, the 
reason I selected these four is that they have a history of 
implementation in Indian communities and also have yielded 
outcomes in randomized controlled trials.
    The first one is Sources of Strength. This was a program 
developed out of the United Tribes in Bismarck and later 
adapted for mainstream society. Basically, the emphasis of this 
program is a lot of positive messaging, suicidal awareness and 
training of peer leaders, the idea being that once the students 
identify who are the adults in the school who are really 
supportive of them as mentors and the peer leaders, those at 
risk might go to these peer leaders to get help. At three month 
follow-up, participants in Sources of Strength reported reduced 
suicide attempts and increased knowledge about suicide.
    Another program is called Reconnecting Youth. I learned 
about that because I was looking for a comparative treatment to 
evaluate the American Indian Life Skills. This was already 
being used at a number of reservations.
    The emphasis on this one is to work with at-risk students 
to help them be able to monitor their own substance use and 
monitor their attendance in school. This is like the last stop 
before getting kicked out of school. In this program, basically 
they learn rather than be kicked out for being out of control, 
or poor attendance or coming to school loaded, they learn how 
to manage this.
    I have to say we used this with middle school students. 
Over only 10 months, we saw reduced hopelessness at post-test 
and reduced suicidal ideation. Then at one year follow-up, we 
saw even greater gains.
    Another one is a shorter version of this called CAST, made 
by the same developers. Basically, it is a shortened version of 
Reconnecting Youth.
    Finally, I want to talk about the Good Behavior Game. I 
found out about these when I served on the National Academy of 
Sciences and Institutes of Medicine's task force which 
developed a book, all this is outlined in there, to prevent 
behavioral, emotional and mental disorders in young children.
    The Good Behavior Game has been touted as the most 
effective behavioral vaccine. This is actually not a program; 
it is a strategy where in working with elementary children, 
they learn self-regulation. The teacher basically divides the 
class into teams. Teams are reinforced for staying on task, 
doing the appropriate thing, not talking out of turn, and 
focusing on what they are doing for a while.
    I know it sounds manipulative. What they are learning is 
self-regulation. I have to say this has been used with First 
Nations elementary children and Metis Children in Canada.
    The important results of this is that following these 
elementary school children into adolescence, they were just 
exposed to it in elementary, and by adolescence they had less 
impulsive, disruptive behavior, less substance use, drug 
addiction, lower rates of suicidal ideation and suicidal 
attempts. That is quite a nice long term effect.
    The Chairman. Doctor, if you have any last summation you 
want to make, because I know there are a number of questions.
    Dr. LaFromboise. I am so sorry.
    Basically, I think I would concur in what people have 
indicated as solutions to this. Unfortunately, what we have 
here is a situation where we do not have enough psychologists 
or behavioral health specialists to meet the need.
    In schools, it is very difficult to implement because 
administrators are very concerned about making grade in terms 
of AYP and high stakes testing. It is very difficult.
    I am suggesting that we really turn to looking at Masters 
level people. We have more jobs for Masters level people that 
will supplement the already existing counseling staff in 
schools and help with this kind of work because you can see the 
results. They can work. We just need the staff in order to 
deliver it.
    Thank you.
    [The prepared statement of Ms. LaFromboise follows:]

    Prepared Statement of Teresa D. Lafromboise, Ph.D., Professor, 
     Developmental and Psychological Sciences, Graduate School of 
                     Education, Stanford University
    Good afternoon Mr. Chairman and members of the committee. I am 
grateful for the opportunity to present testimony on a topic of urgent 
importance in Indian Country, that is, the need for effective 
interventions to reduce the exceedingly high rates of Native American 
youth suicide.
    My name is Teresa LaFromboise. I am a Professor of Psychological 
and Developmental Sciences at the Graduate School of Education at 
Stanford University. I have been working in the field of American 
Indian/Alaska Native (AI/AN) youth suicide prevention since 1989.
    The work began in response to a request from Mr. Hayes Lewis, the 
Superintendent of the Zuni Public School District, that I bring a team 
of educators and health promotion specialists from Stanford University 
to the Pueblo of Zuni to help community experts develop a culturally-
grounded youth suicide prevention intervention.
    Over the course of three years we worked in Zuni to develop life 
skills pedagogy and curriculum lessons, consult with the Zuni Board of 
Education and the Zuni Tribal Council, and conduct an outcome study to 
assess the psychological impact of the curriculum (LaFromboise & Lewis, 
2008) . This outcome evaluation demonstrated the following effects: 
less suicidal ideation and suicide attempts, less hopelessness, greater 
self-efficacy to manage anger, and greater effectiveness in helping a 
suicidal friend solve problems and go for help among participants in 
the Zuni Life Skills treatment group as compared to those in the no-
treatment comparison group (LaFromboise & Howard-Pitney, 1995).
    Today, I want to provide a brief overview of ongoing work 
associated with American Indian Life Skills (AILS) and introduce four 
other evidence-based interventions delivered in school settings that 
have produced favorable outcomes in youth suicide prevention. I will 
discuss some of the limitations of interventions that focus solely on 
psychological rather than social, cultural and spiritual issues that 
may be more relevant in Native American youth suicide prevention. 
Finally, I will offer some recommendations concerning how we might more 
effectively reverse the rates of youth suicide within tribal 
communities.
Promising Practices in School Based Suicide Prevention
    When we were invited to develop an intervention in Zuni we were 
only allowed access to the Zuni High School. Thus we learned a lot 
about suicide prevention in schools. The rationale for schools adopting 
suicide prevention programs hinges upon recognition that a significant 
amount of suicidal behavior occurs among ostensibly, well-functioning 
students. School suicide prevention programs try to reach the greatest 
number of students through population-based strategies to identify and 
assist the smaller number of students who are at risk. They primarily 
target an individual student's thinking and behavior. The ultimate goal 
is to help at-risk students receive psychological treatment before they 
become acutely suicidal.
    Presently, there are five main types of suicide prevention 
interventions in schools: (a) awareness/education curricula, (b) peer 
leadership training, (c) skills training, (d) gatekeeper training and 
(e) screening. Awareness/education curricula focuses on increasing 
accurate knowledge about suicide, and encourages self-disclosure among 
peers to develop positive attitudes toward seeking help. Peer 
leadership training assists student leaders in learning to respond to 
suicidal peers and then to refer them to a ``trusted adult'' for 
further referral to treatment. Skills training fosters the growth of 
skills to support protective factors in the prevention of suicide 
(e.g., problem solving, self-regulation). Emphasis is also placed on 
the reduction of risk factors to prevent the development of suicidal 
behavior (e.g., depression, substance abuse, anger regulation). 
Gatekeeper training teaches school staff, students and their parents 
about symptoms of suicide, and additionally provides information 
regarding risk and protective factors in order to improve 
identification and referral of at-risk students to available resources. 
Lastly, screening programs assess suicidal ideation, depression 
symptoms, and other clinical mental health disorders (including 
multiple problems such as depression along with disturbed eating or 
binge drinking) in order to refer students displaying disorder to 
psychological services.
American Indian Life Skills
    The success of the Zuni Life Skills Development Curriculum 
bolstered a more Native American generic version entitled the American 
Indian Life Skills Development Curriculum (AILS) which is available to 
any tribe or community that is searching for adolescent suicide 
prevention and life empowerment programs (LaFromboise, 1996).
    AILS is a universal, community-driven suicide prevention 
intervention emphasizing social cognitive skills training to reduce 
suicidal behaviors . AILS strongly emphasizes suicide as an action and 
behavior rather than the result of mental illness. It emphasizes an 
array of psychosocial skills necessary for effectively dealing with 
everyday life such as: emotional regulation, mindfulness, problem 
solving, and anger regulation. It focuses on 7 main themes: (1) 
building self-esteem; (2) identifying emotions and stress; (3) 
increasing communication and problem-solving skills; (4) recognizing 
self-destructive behavior and finding ways to eliminate it; (5) 
learning information about suicide; (6) helping a suicidal friend go 
for help, and (7) planning ahead for a great future.
    A number of cultural considerations were considered in the design 
of this intervention. The curriculum is full of realistic situations 
that occur in AI/AN communities and homes. Lessons in AILS encourages 
culturally appropriate ways that students can express emotions like 
grief or anger. The preferred interventionist of AILS is a 
professionally trained community member. Additional community members 
are invited into AILS sessions at relevant times to share cultural 
teachings and model cultural coping perspectives.
    Ideally, AILS is offered in a required course such and social 
studies or language arts. However, AILS has been taught in culture 
camps, local recreation and sports camps, tribal youth employment and 
training programs, Upward Bound, treatment centers, and tribal 
colleges. It has been adapted for AI/AN adolescents in urban and 
suburban settings. In addition, tribal communities such as the Spirit 
Lake Dakota tribe have adapted AILS to their local community values and 
norms.
    Community members, teachers and behavioral health specialists from 
over 100 reservations have participated in AILS trainings. Currently, 
we are working on Internet applications for providing on-going 
technical assistance to those who are implementing AILS following an 
initial 3-day Key Leader Orientation training.
Schools as Sites for Suicide Prevention
    From my experience in this field and from systematic review of 
research on school-based suicide prevention programs, I have found a 
growing number of potentially effective mainstream programs that could 
be of help in reducing Native American youth suicide. I selected the 
following evidence-based programs to highlight today because they each 
have some history of implementation in AI/AN communities and they have 
been found to yield outcomes associated with the prevention of 
adolescent suicide with diverse populations (LaFromboise & Hussain, in 
press).
    Sources of Strength (SOS). SOS is a universal program (meaning that 
it is offered to all students in a school) that emphasizes awareness/
education and peer leadership to reduce suicidal behaviors (LoMurray, 
2005). Its curriculum includes suicide awareness, positive messaging, 
empowering activities and screening strategies. Peer leaders are 
trained in responding to students who display risk factors for suicide, 
directing them to a trusted adult for further support. Originally 
designed for youth living in rural areas near United Tribes in 
Bismarck, North Dakota to tackle issues related to suicide, such as 
violence and substance use, SOS was later modified for widespread use 
with students from diverse backgrounds across the United States. At a 
3-month follow up, participants in SOS reported reduced suicide 
attempts and increased knowledge about suicide (Aseltine, James, 
Schilling, & Glanovsky, 2007).
    Reconnecting Youth (RY). RY is a selected intervention utilizing a 
life-skills training approach which targets high school students who 
demonstrate poor academic achievement, are at risk for dropping out of 
school and exhibit maladaptive symptoms like aggressive behavior 
(Eggert & Nicholas, 2004). RY emphasizes the prevention of substance 
use and emotional distress while fostering resilience. Opportunity for 
social bonding is also achieved through intervention activities which 
form connections within the school and encourage parent involvement. 
Native American RY participants have reported reduced hopelessness and 
suicidal ideation immediately following the intervention and at 1-year 
follow up (LaFromboise & Malik, 2012).
    Coping and Support Training (CAST). CAST is a selected prevention 
program adapted from RY that uses a skills-training approach with high 
school students following their referral to the program based upon 
initial screening. CAST consists of 12 sessions given over 6 weeks 
administered by service providers (e.g., teachers, nurses). CAST 
focuses on mood management and school performance and emphasizes 
decreased involvement with illicit substances. Participants of CAST 
have demonstrated increased problem solving skills, perceived family 
support and self-control, and decreased symptoms of depression and 
hopelessness (Thompson, Eggert, Randell & Pike, 2001).
    Good Behavior Game (GBG). GBG is a behavior management approach 
that has evolved into a universal, primary prevention program for 
elementary school students to teach self-regulation skills (Barrish, 
Saunders, & Wolf, 1969). The GBG socializes children into displaying 
cooperative rather than disruptive or aggressive behavior, both of 
which are risk factors for substance abuse and suicide. To play the GBG 
a teacher splits the classroom into two or more teams which are 
rewarded for being adaptive to academic social expectations (e.g., 
being on task for brief periods of time, not talking out of turn). 
Eventually they are expected to be cooperative for longer periods of 
time. The winner of the GBG is the team with the least amount of 
infractions.
    GBG has demonstrated long-term effects (following elementary 
school-age participants on into adolescence) on decreased impulsive/
disruptive behavior, substance use, drug addictions, and lower rates of 
suicidal ideation and suicide attempts (Kellam et al., 2008). By 
incorporating the program into the classroom at an early age, there is 
a high cost-effectiveness ratio.
Lessons Learned
    From having either carefully reviewed, implemented or tested each 
these programs, I found that it is very difficult to influence schools 
to engage in primary prevention. ``School administrators and teachers 
working in public schools serving Indian populations are so bent upon 
meeting the high stakes demands of testing and Adequate Yearly Progress 
(AYP) that they have no time to do more than the minimum expected when 
it comes to responding to the emotional and cultural needs of Native 
American students'' (Testimony of Hayes A. Lewis, Youth Suicide in 
Indian Country, February 26, 2009, p.4). It takes advocacy from 
community champions (e.g., tribal council members, members of 
prevention committees and parents) to influence school administrators 
to adopt programs sensitive to the social emotional needs of youth.
    Most of these interventions rely on the referral of at-risk 
students to psychological treatment before they become acutely 
suicidal. However, many rural AI/AN communities have limited school 
counseling services or behavioral health services. When formal mental 
health services are staffed by AI/AN behavioral health specialists 
those services are in high demand. When they are staffed by service 
providers from outside the community they may be underutilized due to 
the stigma of seeking help from those who seemingly represent the group 
that marginalizes and oppresses them. The ultimate effectiveness of the 
prevention program, to save lives, relies on youth initiating or 
completing care.
    I also found that most individually focused ``off the shelf 
interventions'' do not address key perceived contributions to AI/AN 
suicide such as historical oppression, intergenerational trauma, 
prejudice and discrimination and other forms of collective 
disempowerment. Thus the protocols upon which these interventions were 
tested are either short lived or, in the best case scenario, modified 
to address more relevant social justice issues in Indian Country.
    Finally, those AI/AN communities, who actually implement programs 
such as the ones I have just reviewed and who find them intuitively 
``helpful,'' are often reluctant to engage in further assessment of 
their effectiveness within their own community. I believe that this 
type of assessment would be helpful in guiding decisions about 
modifications to the intervention to better meet local community needs 
and norms or concerning whether or not to continue efforts toward 
sustaining the intervention overtime.
Recommendations
    I respectfully offer the following recommendations to strengthen 
tribal capacity to improve service delivery to prevent Native youth 
suicide based upon my observations, research, and training experiences.
    Expand the number of empirically-validated suicide prevention 
interventions and evaluate their adaptation and implementation in 
diverse AI/AN contexts.
    School-based suicide prevention programs began in 1984 in reaction 
to a significant escalating trend in suicidal behavior among 
adolescents in many Western industrialized countries. Considering the 
relatively new introduction of prevention intervention to this 
complicated problem, issues with customized delivery that target 
specific variables such as ethnic/racial group background, cultural 
involvement, and tribal diversity still need significant innovation and 
evaluation.
    Make a commitment to continue to support the dissemination of 
valued community-driven approaches to suicide prevention across Indian 
Country.
    There is a sense of urgency among tribal leaders to preserve 
cultural ways of knowing before the knowledge keepers are gone. 
Research indicates that communities with higher levels of political and 
cultural engagement have lower suicide rates. Certain individual 
protective factors for Native youth suicide prevention include cultural 
identity and engagement in cultural activities as well as school 
completion. This presents a window of opportunity for collaboration 
between community leaders and prevention scientists to develop services 
that reflect community priorities and practices and to mobilize 
available support systems to prevent suicide.
    Encourage and support research on the interaction of community-
level processes, family systems, and individual psychology that affect 
the well-being and resilience of Native youth.
    Historically suicide prevention has focused on the treatment of the 
individual and that type of intervention should continue but not at the 
cost of ignoring the gestalt of the disorder. Specific efforts have 
evolved for the last decades or two on economically viable, rapidly 
deployed and clinically efficacious efforts to target not only the 
individual but the larger system- from social media to society and 
everything in between. Let us continue that momentum.
    Tribal communities have practiced ``integrated care'' among 
individuals and families for generations but usually without adequate 
resources. Let us support continuation of those cultural practices and 
healing traditions.
    Thank you for providing this opportunity.

    References

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Eggert, L.L., & Nicholas, L. J. (2004). Reconnecting youth. 
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Kellam, S.G., Brown, H.C., Poduska, J.M., Ialongo, N.S., Wang, W., 
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LaFromboise, T.D., & Hussain, S. (in press). School-based adolescent 
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    The Chairman. Thank you so very much.
    I want to thank all of our witnesses for their testimony.
    I will now turn to questions from the Committee, starting 
with Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    I want to go back to you, Teresa. Your Ph.D is in what?
    Dr. LaFromboise. Counseling Psychology.
    Senator Tester. I would ask you to be as concise as you 
possibly can.
    Senator Udall went down the litany of things faced in 
Indian Country in his opening statement: alcohol, drug abuse, 
physical abuse, poor nutrition, poor schools, domestic 
violence, poverty, and overcrowded housing. You know the 
statistics probably better than anyone up here. The rate at 
which Native Americans commit suicide is the highest of any 
minority in the Country. In 15 to 34 year olds, the rate is 
twice that of anybody else.
    What do we do about this? If there is alcohol abuse, drug 
abuse by parents or the potential person who is going to commit 
suicide, combine that with poor nutrition and poor schools, 
where do you start?
    Dr. LaFromboise. First, I understand what you are alluding 
to. You are alluding to all these intense social determinants 
of behavior. Probably you are thinking I am naive to focus on 
the individual.
    Senator Tester. No, no. I want to do to solve the problem.
    Dr. LaFromboise. Here is what I would suggest. All these 
problems need to be solved. One thing we do know about the 
resilience literature is that the children who are resilient, 
meaning they are able to thrive in spite of all this adversity, 
are children who are able to manage their emotions and are able 
to stay detached from situations and are able to have a strong 
identity.
    All these things these kinds of program do. They emphasize 
the protective factors.
    Senator Tester. The resilience is taught where, in school?
    Dr. LaFromboise. Resilience begins as a child.
    Senator Tester. I know, but when you have dysfunction, 
alcoholism, and housing problems, where the hell are they going 
to learn resilience?
    Dr. LaFromboise. They can begin to learn it in school. 
Obviously I am an educator, so I think of school. The schools 
are sanctuaries. For some children, this is the only place they 
get a meal. For some, this is the only place they feel safe.
    That is why I am thinking of this arena as the place where 
we can really marshal some forces to try to help them. There 
are some wonderful programs. I remember Duane Mackey had a 
program a number of years ago called The Heart Room. This heart 
room was in schools.
    Children went into the heart room on Friday for prayer and 
meditation and to prepare for what they were going to have to 
go through over the weekend. They came back into that heart 
room on Monday in order to decompress and be ready to focus in 
school.
    Obviously, we need so much more. It would be nice if we 
could do this kind of work in families. Unfortunately, we 
really did not have access to families.
    Senator Tester. Thank you.
    A month or two months ago, we had a hearing here on schools 
about being subpar, cold, lack of academic materials, and the 
lack of good teachers. We have a lot of problems.
    I want to go over to Mr. McSwain. It is a fact and folks 
have testified here today about recruitment and retention of 
dedicated, high quality health care providers as critical for 
your work at IHS. You indicated four different scholarship and 
loan repayment programs to recruit health care professionals in 
the IHS service areas.
    It is known, it is not a secret, that there is a shortage 
of IHS mental health providers. Why has IHS never employed the 
Indian Health Service Mental Health Prevention and Treatment 
Loan Repayment Program?
    Mr. McSwain. Senator, that is a good question.
    I know we have been working on our own loan repayment, our 
own scholarship program and we have been using the National 
Health Service Corps Loan Repayment Program and using their 
scholars but we have not gone beyond that.
    Senator Tester. To me, it sounds like the perfect program 
to try to get folks into Indian Country who can help. The 
professor talked about more professionals in Indian Country can 
help. Are there any plans to enact it? Do you have the dough to 
do it? What is the problem?
    Mr. McSwain. A good point, because we just recently were 
identifying some vacancies but it was a matter of getting the 
people there in these remote locations. That is a challenge. I 
think Councilman Clifford mentioned that one of the biggest 
barriers to getting people out there is housing.
    Senator Tester. Yes, but you also have to enact that 
program. I was going to ask you the same question I asked the 
Professor. What are some of the programs that work for youth? I 
cannot because I have run out of time.
    I want to say thank you guys very much for your testimony. 
We have to deal with this issue. If we do not deal with this 
issue, it is not going to go away; it is not going to get 
better. It is going to be here and it is going to get worse.
    Whether it is working with the Administration or with 
individual tribes in Indian Country, we have to deal with this.
    I appreciate you guys making the trek to Washington, D.C. 
Once again, this is the start of another conversation that I 
hope ends up in something that will functionally fix the 
problem.
    The Chairman. Thank you, Senator Tester.
    Senator Daines?

                STATEMENT OF HON. STEVE DAINES, 
                   U.S. SENATOR FROM MONTANA

    Senator Daines. Thank you, Senator Tester, for that.
    We both represent the State of Montana. I was meeting with 
four Montanans who came to my office yesterday. Montana has the 
highest per capita suicide rates in the Nation. We are number 
one.
    It is a combination of a lot of factors. Certainly we have 
a high Native population. We talked about that here today. We 
have a high per capita veteran population. There is a crisis in 
our home State.
    Mr. Chairman, thank you for holding this hearing. It is a 
tough topic to talk about but one we cannot ignore.
    Dr. LaFromboise, you mentioned the need for the culturally-
based suicide prevention programs. I was struck with your 
academic biography as a professor at Stanford and working in 
American Indian and Alaska Native youth suicide prevention 
since 1989, for more than 25 years, so we are glad to have your 
expertise.
    I want to thank all of you for your testimonies today. I 
wish there was more time.
    One of my constituents, Dustin Monroe, is the head of a 
group called Native Generational Change in Montana. He is an 
Assiniboine Black Feet tribal member, an Iraq veteran of the 
25th Infantry Division. He is working on preventing youth 
suicide among Natives in rural communities.
    One of the problems he has brought up is the lack of 
programs that adequately address the cultural differences that 
might exist between Indians and non-Indians with regard to 
suicide prevention and counseling. For example, Dustin mentions 
talking about the deceased might be therapeutic to some, but it 
could be very troubling to a Native population.
    How well do you believe our suicide prevention or 
counseling programs take these cultural differences into 
account?
    Dr. LaFromboise. Certainly, the American Indian Life Skills 
has, because at the very beginning, the emphasis is saying that 
people who are doing this know best their own cultural 
teachings and that they should be respected. Therefore, they 
would be the ones to filter the information.
    We do not encourage people to think about the deceased. We 
do have one lesson on grief because we feel that people need to 
think about stages of grief.
    You are absolutely right. We do know from our research that 
people who have a strong cultural identity and strong 
involvement in cultural practices are certainly less likely to 
be involved in suicide. We also know that communities that have 
strong political engagement are in charge of most of what is 
going on in their community and strong practices.
    I am not saying these things should be replaced. One of my 
recommendations would be that we should also increase the 
resources to help support community-driven interventions much 
like the individual you are talking about. I do not think one 
should replace the other. That is why I think it kind of helps 
to keep one in school and the other in the community because we 
are not interfering with each other.
    Senator Daines. Thank you.
    You mentioned expanding the number of empirically-driven 
suicide interventions for school-based programs. I was struck 
by your comments to Senator Tester about how the school, for 
some young people, is the safe place they can go during the day 
and the week.
    Given the limited dollars we have for all these programs. 
Where you look at empirically-based, outcome-based metrics, 
what programs are working, what programs are not working? In 
the zero sum game we face often here in Washington, D.C., what 
programs should we stop and double down on other programs that 
are working? What is not working and what is working?
    Dr. LaFromboise. I think it is very important to have 
gatekeeper training but I think the research would say that it 
does not really impact people as much as we think it does but 
it does help individuals who have already gone through the 
process of asking someone if they are suicidal and helps 
strengthen their skills.
    For individuals that have never asked the question, they 
can go through gatekeeper training and come out and still never 
ask the question. That is one a lot of money is appropriated 
for but I am not really sure how well that works.
    Senator Daines. Before I run out of time, I want to ask 
Councilman Clifford from Pine Ridge a question.
    Yesterday's conversation revolved around having a job, how 
that was a place to go, to work and when you are in poverty, 
the statistics you shared from Pine Ridge are staggering. What 
role does having a job and having employment play in trying to 
reduce suicide?
    Mr. Clifford. It gives a person something to do and also to 
look forward to a paycheck and paying their bills and being 
able to assist. I like your conversation about the cultural 
elements and the academic part. I think that has a lot to do 
with it and ties into being a working person. The cultural 
relevance of it is being able to share with what we grew up 
with and actually knowing.
    The comparison and the so-called scientifically proven 
evidence, the cultural relevancy you cannot scientifically put 
a number on it. We know it works and it is there. It has always 
worked for many years.
    I am reminded of the coffee shop story of a young lady in 
school and having a job. Not long ago, this young lady was 
feeling bad, suicidal tendencies and the ideations that came 
with it. One of the special ed programs took her under their 
wing did some testing and found she was qualified for special 
ed. During that special ed time, she was withdrawn and not 
really functioning right, but as they worked with her, she was 
capable of learning to be responsible for part of the coffee 
shop. It broke her shell and she was able to get up and talk 
about it.
    The other day during our meeting, they brought this young 
lady in and she actually got up and talked. She stuttered at 
the first but then all of a sudden, it just came out. That is 
what jobs and working can do. It is not always about the 
academic part, especially in Indian Country.
    If I could use this arm a little better, I would be able to 
explain because I too am like that, to express myself, to be 
able to show the point the importance of losing our child and 
what is happening today and the help we need. It needs to be 
equal on how it is shared and brought to us. Most important is 
the responsibility of growing up and being able to work and 
able to know that I have someplace to go.
    Senator Daines. Thank you for the great story, Councilman 
Clifford.
    I am out of time. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Daines.
    Senator Heitkamp?
    Senator Heitkamp. Thank you, Mr. Chairman.
    I do not think anyone here thinks that suicide is anything 
other than a symptom of what are clearly conditions that many 
children on the reservation and in Indian Country exist in, 
creating stress. In the last Congress, we held a hearing on 
trauma-based interventions and had some amazing testimony 
relative to altered brain chemistry as a result of stress. I 
want to address some of this with you, Doctor.
    At Johns Hopkins, an institution really close to 
Washington, the researchers think they have discovered a 
chemical alteration in a single human gene linked to stress 
reaction that if confirmed in larger studies could give doctors 
a blood test that may tell them who is at risk and who is not. 
They believe that this genetic mutation caused as a result of 
exposure to stress and trauma is a gene known as SKA-2. By 
looking at brain samples from people who had poor mental health 
and healthy people, the researchers found in that sample from 
people who had died by suicide, levels of SKA-2 that were 
significantly reduced.
    You can go back to the work being done in Montana on stress 
and trauma relative to brain chemistry. I think a lot of what 
we always talk about is treating symptoms. We are going to do 
intervention, we are going to build resiliency, when this 
problem is a systemic-based problem driven by trauma and 
stress. I am not a doctor but I think when you look at these 
issues, I think you have to come to a clear understanding of 
what we are dealing with.
    How can we integrate some of the new brain chemistry 
research that we are seeing now into the programs you are 
talking about? How can we do a better job modernizing the way 
we look at this?
    As the Senator from Utah and I know, because we both served 
as Attorneys General, we were talking about this problem in the 
1990s, we talked about this problem the last decade and we 
still are talking about this problem and guess what? It has not 
gotten any better. It has gotten worse.
    What about a new idea and taking a new look at brain 
research and what we can do to fashion or model better 
intervention programs?
    Dr. LaFromboise. That is a heavy one.
    Basically, here are a few things I would think about. You 
are talking about basically determining whether a person has 
experienced this trauma. It is also the case with screening 
which people are very resistant to but by early screening, you 
would be able to know a lot about a person to begin with.
    Having had a child who experienced language learning 
disabilities, when I was learning about that, I can remember 
one of the people doing the assessments saying after a certain 
point, it does not matter how it happened or the fact it is 
there, it is now what are you going to do. Yes, we do need to 
improve assessment and to be able to determine this, to know 
whether it is there or not.
    Senator Heitkamp. I can tell you stories of children who 
have been involved in anti-suicide programs who have been model 
children who later committed suicide. Sometimes interventions 
are not adequate.
    Dr. LaFromboise. Part of the intervention is also turning 
that around. In terms of even changing brain chemistry, the 
coping aspect of it, because what will you do once you get 
everyone diagnosed? There are still people who are functioning 
every day, carrying on with their lives, that need to keep 
going.
    Some of my colleagues said actually the article, the last 
one cited on my testimony by Wexler, probably the best 
researchers that I know of in Native American suicide, are 
there and we struggle with this all the time.
    Some people will say they think I am na?ve in terms of 
focusing on these interventions. They say we have to change the 
marginalization, the oppression and all these things. Yes, we 
do and we need to treat the people in the meantime.
    It may take three generations, even if we change all these 
things. What do we do with all the people in the meantime that 
do need help and are even mildly exposed to trauma and can 
benefit from these activities?
    Senator Heitkamp. I have just a little bit of time.
    If we keep doing what we are doing right now and do 
everything the way we have done it and we are all here in ten 
years, do you think we have a better result?
    Dr. LaFromboise. We are not doing enough right now. I am 
just highlighting the potential if we were using effective 
programs. We are not doing that now.
    Senator Heitkamp. I think we need to modernize effective 
programs. I think there have been a number of examples, if I 
can take a minute, as we look at this and as we look at some of 
the tribal-based strategies treating trauma, identifying 
historic trauma, identifying some of the neurological issues 
that we have and being able to transition some of that new 
thinking into interventions, and when we look at this being 
done in places like the Menominee who have been able to double 
graduation rates. I just want to bring a broader kind of new 
development and new research into the discussion.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much, Senator Heitkamp.
    Senator Murkowski?

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman.
    It is always interesting listening to my colleague from 
North Dakota because of the issues you raise. The Chairman and 
I were just talking about how many hearings on suicide in 
Indian Country we have had before this Committee. Again, we are 
not seeing the statistics get much better.
    The one thing I have noted is that we are just kind of 
changing the deckchairs here. It used to be that Alaska was 
number one, now it is Montana and Wyoming tied for number one, 
New Mexico tied for number three and Alaska has dropped to 
number four.
    We have not really solved the problems. We are still 
continuing the discussions. In the meantime, we are losing our 
children.
    In addition, to follow up on your line of inquiry about the 
mental trauma and some of the research we are seeing, look at 
our increasing levels of suicide amongst our military, amongst 
our veterans, those who have experienced some level of trauma.
    Again, I am with you. I am not the doctor here but it does 
lead you to conclude that maybe we need to be looking at some 
other areas. I would certainly be interested in working with my 
friend on this.
    I look at where we seem to be having some limited success 
in my State. About four years ago now, we had a town hall on 
suicide in Bethel and brought out as many people who were 
willing to talk about suicide right after a horrible rash of 
suicide in some of the villages up north.
    In fairness, it was much of the same conversation that we 
hear around here until we came to the very end where some of 
the children, the students I had invited from some of the 
villages that had been impacted, rose to speak.
    It was painful listening to them because they stood in the 
center in front of all these grownups and elders and could not 
speak. They were so brave that they would not let themselves 
sit down. They stood for a minute in silence gathering the 
courage to speak about what had happened in their village. One 
young woman made the comment that yes, suicide was kind of a 
normal teenage thing. It ripped at your heart.
    I think it was from that roundtable that we have seen 
within the White Cage Sea, they identified four different 
villages, Hooper Bay, Chevak, Scammon and Alakanuk who have had 
exceptionally high rates of suicide. They began to focus 
specifically on these communities.
    In their message to me, since they have been doing that, 
they have experienced no suicides to this point in time. What 
are they doing? It is the culturally-based programs. It is 
gatherings, pot luck lunches, arts and crafts activities, 
making fish traps, and the talking circles.
    Some of the other things that we look to, there is a 
gentleman from Tanana, Vernon Stickman, Sr., who lost a 
daughter to suicide in 2010. He walks the Yukon River during 
the wintertime, 140 miles from community to community to raise 
awareness.
    Is that helping? I do not know. Is he as one person who 
does not have a program, who does not have a budget, just 
saying I am willing to do whatever it takes to get some 
attention to this, to shine some kind of a spotlight on it, to 
deal with my own personal grief, I think, as a dad.
    I look to where we can be making a difference. I just met 
with some of our leaders in suicide education and prevention 
yesterday. I said, James, what is the one thing we could do 
that would make a difference. It is the mental health 
professionals.
    It seems to me so much that particularly with youth 
suicide, it has to be the kids that are there for one another, 
saying I am there for you. As we talk about these programs, I 
hope that we are not just talking as adults in a room, talking 
about funding, budgets and what the MSPI program is doing to 
make progress.
    I really hope that it is designed to involve the young 
people for their ideas. I think it was not until those young 
people spoke up in Bethel that we really started to talk about 
it. It was not until the young people at AFN two years up ago 
spoke up from Tanana and called out the parents, the adults, 
the elders and said, we are tired of being the victims of 
neglect, sexual assault, violence, and suicide. Wake up, 
grownups. What are you going to do about it? Anything that we 
can be doing that is bringing in our young people for the 
solutions, I think has to be key.
    Mr. McSwain, I want to ask you one quick question regarding 
the MSPI program. We think it is making some progress. We are 
hearing from some of the groups in our State that it is. I have 
been a supporter of it. I think it is culturally relevant. I 
think it is getting us going in the right place.
    I have been told on a few occasions that the overall 
structure and the management currently inhibit the program from 
being used to its full potential. I was told by a group in 
Alaska that some questions they have submitted to the program 
virtually went unanswered. I do not know much more beyond that.
    I am wondering whether it is a lack of resources that is 
complicating effectively running this program or if you are 
aware of any other obstacles that we have faced with regard to 
the MSPI?
    Mr. McSwain. Senator, I believe that the MSPI program is 
doing some great things. I think it is one of those where it is 
at the community level and the community is directing it. In 
all of our programs, whether it is STPI or MSPI, when the 
community has its own design on what they want to do with the 
resources, they know how to move forward. That is what is 
making the progress in that program.
    It has been six years since we have had it in place. We 
will be doing a full review of the six years to see what the 
successes are and what improvements ought to happen. We are 
doing that this year.
    I liked your other comment about the kids. That struck a 
tone with me. The one area we have not done a real good job 
about and we are going to do that, is simply having kids get 
together, having our service units. I recommend to the tribes 
that they do it as well. The tribes are really interested.
    We start talking about the pathways, hiring students as a 
GS-1, GS-2 or GS-3 and having them provide support to us. I 
think a comment was made by Dr. LaFromboise about the schools 
and the security they feel.
    You can imagine what I felt when I was worried about 
suicides and the schools were letting out in the Northern 
Plains. What is going to happen to all those kids? Do they have 
any structure?
    That is a part of it and certainly a conversation we are 
having with all of the MSPI recipients as to what they can do 
for kids. This expansion we have proposed for 2016 in 
Generation Indigenous is about kids. It is building on the 
MSPI.
    If you are having questions, if there are concerns from 
folks from Alaska, ask us and we will look into it.
    Senator Murkowski. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murkowski.
    Senator Udall.
    Senator Udall. Thank you, Mr. Chairman.
    Mr. McSwain, Senator Heitkamp asked about brain research in 
this area, new brain research and the discussion with Dr. 
LaFromboise. Do you have any thoughts on that from the Indian 
Health Service perspective or your work with SAMHSA? Is this a 
fruitful area? Is this something we should be looking into, 
some of those latest things being discovered?
    Mr. McSwain. I do not think we can leave any rock unturned, 
the brain being one of them. I think our health care delivery 
system will be looking to other folks, the professionals, if 
you will, certainly the NIH folks and others that do this kind 
of work for anything that can help.
    It is not going to be as easily magical as that. In my 
view, it is going to be a partnership that happens between the 
Administration and the tribes. That is the partnership that 
will be able to give them the tools.
    Making an observation, some of our communities are just 
paralyzed because of the suicides. We have to do more to help 
them feel they can do something. That is part of our 
administrative responsibility.
    In terms of science, I will leave that to scientists.
    Senator Udall. Thank you. Thank you for your work in this 
area.
    Teresa, thank you for your work with the Zuni Pueblo. 
Longtime Pueblo in New Mexico really care about their young 
people. When they learn what is the right thing to do, they 
really invest in it. It is good to see that you were out there.
    I am wondering, were they able to incorporate these things 
into the schools and other areas in order to make a real 
impact?
    Dr. LaFromboise. It has made a significant difference. I 
think Mr. Lewis testified here in 2008 that they had basically 
reversed the suicide rate and it is seldom happening now. It is 
a required course in the high school.
    I was there a few years ago and actually the families were 
having meetings in the evening because they were doing more 
cultural adaptation of it.
    Senator Udall. What should a community do if they have one 
of these clusters? I have been to several in my tribal 
communities when in a period of weeks they lose two or three of 
their young people. They may not have had this happen before.
    How do you view the steps that should be taken to tackle it 
if they run into that kind of situation?
    Dr. LaFromboise. First of all, I have to defer to people 
who are clinical interventionists on the ground. I have focused 
in recent years more on prevention.
    In essence, I think having a rapid response and bringing in 
people who have dealt with trauma and also communities is 
critical. I am sure that Chairman Seki knows more about that 
from their experience with the trauma that happened years ago 
at Red Lake.
    Basically, there is work in place but there are better 
people to respond to that question.
    Senator Udall. Chairman Seki, would you like to respond?
    Mr. Seki. Are you talking about the trauma?
    Dr. LaFromboise. The suicide clusters.
    Senator Udall. Yes, the suicide clusters.
    Mr. Seki. We suffered high suicide incidents and suicide 
ideation by our children for many years. The major factors 
underlying the suicide rates are long standing substance abuse, 
poverty and generation trauma. This is not a cluster but a 
sustained rise in suicide rates.
    Having more counselors and meeting with the students 
individually is crucial. Right now the ratio is one counselor 
per 290 students. It does not work. We have to have more 
counselors and more social workers to address these issues we 
have in our school system and our reservations.
    It is not easy to fix just like that. It takes time because 
people suffer a long, long time. When it happened in Red Lake, 
people are still suffering at this time. The suicides are 
happening on our reservation.
    Some counselors I talk with say it happens. One happened in 
one area and then there are others, these are friends, saying 
they want to do it, more or less seven or more people doing it 
at the same time. It is work that needs to be corrected by 
adding more counselors and social workers working together.
    Everything starts at home with parental involvement. 
Poverty and no jobs, create more jobs for the families so they 
can address these issues with their children because everything 
leads to drug and alcohol abuse when all this is not in place.
    It is very hard for our people back in Red Lake, what we 
face, to continue trying to address these issues with our 
Native youth because it is a problem all over, not just at Red 
Lake. I heard Pine Ridge and this lady talking about different 
ideas and Mr. McSwain.
    These are the things that you, as elected officials, have 
to come up with ways for us, tribal nations, to invest in 
tribes so they can fix their infrastructure, come up with ideas 
to improve the system and what is happening with our youth on 
our reservations.
    We need help. It is not just us but everyone. Everyone has 
to be involved all the way from the parents. You have to 
listen, as Senator Murkowski said, to the children's ideas. You 
have to listen to the youth, what their ideas are. Pick that up 
and use that as working together to resolve these issues.
    It is not going to happen if we keep cutting funds to the 
reservations because of sequestration. Those are the dollars 
they lose for creating more jobs, for bringing in more 
counselors and social service workers.
    If sequestration is reversed, it could be fixed in six 
months or less if it goes back to 2013. That is not enough, 
there is more to it, to create these programs. We need more 
culturally based programs for our people to understand the 
culture and teach our youth what it is to be a Shanabe person 
because it is not easy. It is hard.
    I am just now chairman for a year and I am very sensitive 
talking about our youth because I know they have problems. I 
like visiting with them, talking to them and finding ways to 
resolve their issues.
    Also bullying is a concern but it leads right back to the 
parents. Parenting needs to be focused because it all starts at 
the home.
    Senator Udall. Mr. Chairman, you are absolutely right. I 
think you are right about the underlying causes. We have to 
tackle those. We have to invest the resources. We should not be 
cutting in terms of the kinds of resources that are there.
    I thank this panel very much and yield back.
    The Chairman. Thank you, Senator Udall.
    Senator Franken.
    Senator Franken. Mr. Chairman, thank you, for what you just 
said.
    When we are faced with the realities, you sort of wonder 
where to begin because whether you begin with unemployment, 
that is a big place to start. I have been to Pine Ridge which 
is I think 75 percent unemployment. What is the unemployment 
rate at Red Lake?
    Mr. Seki. About 50 percent.
    Senator Franken. We talk about trauma. I read a book called 
How Children Succeed, and it talked about adverse childhood 
experiences which lead to trauma. The author talks about 
extreme poverty, alcohol and drug abuse at home, abuse, whether 
it is neglect, physical abuse or sexual abuse, of you 
witnessing domestic abuse when you are a child, and living in a 
dangerous neighborhood where you see violence.
    American Indians, on top of that, have seen cultural trauma 
for generations, so where do you begin? You witness the other 
families' domestic violence when you have poor housing and you 
see drug abuse too, even if your own parents are not using.
    I went to a rehab facility in Bemidji, Oshki Manidoo, a 
White Earth facility. I visited the kids there. Every child I 
talked to had started using with their parents. We have very 
systemic problems here. Where do you start?
    Mr. Chairman, I think you are right. You start with jobs 
but you also start with the funding that we do for programs. 
You are right. It was Buck Jourdain at the time, Buck I know 
longer than you and I apologize that during my introduction, I 
think I said Seki instead of Seki.
    President Bush said, we won't forget you. During the last 
sequestration, there were less funds coming in for school 
counselors and during that time there were suicides. The very 
first thing we can do is fund these professionals.
    Yes, these professionals engage the kids. These 
professionals should be professionals about engaging with 
children. We cannot depend on children to solve this 
themselves. We are the adults. We are supposed to be the 
adults. We are the grownups here. We are the Indian Affairs 
Committee.
    We are supposed to fight for funding for you because which 
other of our colleagues will do that if not us. My challenge is 
to my colleagues on this Committee. We have these hearings in 
which we hear this testimony and our other colleagues in the 
Senate do not even hear this.
    Our job on this Committee is to fight for you, to fight for 
your kids. We are supposed to be the grownups. We cannot put 
this off on the kids. Yes, a good counselor knows how to engage 
kids. A good counselor knows much better than we do how to get 
kids talking to other kids and kids involved in activities 
talking to other kids.
    We have adult responsibilities here. One of our adult 
responsibilities is not to take away school counselors during 
sequestration and not sit here when the Director of the Bureau 
of Indian Affairs has to defend the budget and the numbers are 
woefully lacking and embarrassing.
    I had questions about lots of things but it is our 
responsibility to be funding the things we know work and to 
fight for economic development in your communities, to fight 
for Indian energy, to fight for jobs but to also fight for the 
services that you need.
    I apologize. I can only apologize for myself, that we have 
not been doing enough for your kids and for you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Franken.
    Director McSwain, in briefings with the Committee staff and 
during a visit last week to Pine Ridge by one of our staff, it 
became clear that the agencies within the Department of Health 
and Human Services do not actually sufficiently coordinate with 
each other.
    Regardless of the level of support available, there does 
not seem to be sufficient coordination with each other or with 
agencies and other departments like the Bureau of Indian 
Affairs, the Bureau of Indian Education, to the effect that 
there are devastating consequences.
    What is your plan to fix this coordination and 
communication gap we heard about in last week's visit to Pine 
Ridge?
    Mr. McSwain. I am not so certain I know what you heard from 
Pine Ridge. Certainly from all the calls I have been on leading 
up to it, the coordination has increased. In fact, the Office 
of Secretary has taken a lead role and given us all 
assignments. We are all reporting on those assignments as we 
move forward.
    I think for the first time, as a department, we are all 
together. I know the department is reaching out to other people 
who have the ability to help like Education, DOI and so forth.
    I have seen a marked increase on coordination, particularly 
the ones with whom we work closely like HRSA, SAMHSA and such. 
That coordination has really increased. We just have to make 
sure that it is always there for the next crisis.
    The Chairman. I think it makes a point that it needs to 
always be there. In my discussions with Secretary Burwell last 
week, I got the impression from her that now the focus was 
there but you wish it had been for a long period of time. We 
want to make sure that focus continues, not just in one 
location, but throughout the communities. I am going to call on 
you to please continue that level of focus that is there right 
now but had not been and we cannot let it fall apart.
    Mr. McSwain. Yes, and I would say Secretary Burwell took a 
very personal interest in this. She said, we have to fix this. 
She told us all to step up and step up together. She put the 
Deputy Secretary in charge of making sure we did that.
    The Chairman. She mentioned that too.
    Native suicide is not a new issue. We were dealing with 
this on the Wind River Reservation back on the 1980s. It is 
still not clear to me that the Administration is operating 
under an evidence-based plan to prevent suicide across Indian 
Country. That is not just this Administration. I think we have 
seen this now for decades.
    Is there a plan in effect? If there is a plan in effect, it 
is obviously not working and needs to be reevaluated. As the 
head of the HIS, you are leading the effort. Your goal should 
be, of course, to bring the suicide rate for Native youth to 
zero. Task force meetings and planning sessions are not 
accomplishing that. When can we expect to see real results?
    Mr. McSwain. We have something in the statement that talks 
about Zero Suicide which is really going to enable us to engage 
the system and be able to track certainly a lot better than the 
data we have had so far.
    We actually have relied on our health IT system to tell us 
a lot, but we have to reach out beyond that to be able to know 
what is happening in the community as opposed to just what is 
happening in our clinics.
    As you know, we have always said we are a health care 
provider, we do not get out in the community but we have to 
engage the community and be able to report that as well so we 
can have a complete data picture of what we are doing so we can 
have a baseline and be able to come back to you and say, these 
are the results. We have done that with the trends analysis but 
we need to do more.
    The Chairman. Chairman Seki, in your testimony you outlined 
how Red Lake could end suicide at your reservation. 
Specifically, you highlighted expanding your wellness counselor 
program. The wellness counselors are social workers located in 
the schools and are critical frontline components of your 
suicide prevention plan.
    Can you explain the advantages of having the counselors in 
the schools and how they have actually helped reduce suicides 
at Red Lake?
    Mr. Seki. As I stated before, counselors meet with students 
individually. They have times set aside to talk with the 
students that have problems, talking about suicides or domestic 
issues at home. They address these with them individually, 
giving them a plan on how to resolve this and continue working 
with them.
    Having only two counselors at each school is not enough. 
They need more counselors so the counselors have fewer students 
to speak to regarding the issues happening with our youth.
    It is very important that the agencies funding our youth 
counselors plus our social service people, that they continue 
to invest in them because we need more people, more of those 
counselors, more social workers to address these issues so that 
our students can go to someone when they have problems.
    The wellness counselors and social workers address these 
and help them, help our youth.
    The Chairman. Thank you.
    Councilman Clifford, last week during the visit I mentioned 
one of our staff members made to Pine Ridge, they heard a lot 
about problems with the Rapid City Regional West and Indian 
Health Service facility.
    Perhaps the most concerning was the impression among some 
community leaders that going to that facility did not really 
make a difference for Native youth. We heard that young people 
who are sent to the Regional West for being suicidal or 
attempting suicide often actually committed suicide later.
    I wanted to get kind of a follow-up from you. Some have 
suggested that sexual abuse is a major driving factor of Native 
youth suicide. There was a long editorial and story in the New 
York Times about that specific part of it.
    Based on your experience, could you talk a little bit about 
that, particularly as an educator who is at the front lines and 
helping young people every day? What role do you think sexual 
abuse and domestic abuse play with regard to the youth suicide 
question?
    Mr. Clifford. First of all, whenever you combat whatever 
issue it is, we have to be stirred up and bring the issue 
forward. What happens on the Pine Ridge Reservation locally has 
a lot to do with alcohol and drugs, overwhelmed with them.
    Sexual abuse is amongst some of the crimes committed that 
are not dealt with. It is like getting a cut and it being able 
to fester and you are not taking care of it. Eventually, it is 
going to infect your whole body.
    The same is true of a physical attack on your mind 
emotionally, that festers to the point of where there is 
hopelessness and it is there. The reality of it is that it is 
there. I am here to tell you that the hopelessness is there.
    The lack of funding of different programs, I specifically 
worked in education for a great number of years and I am really 
glad you brought up funding disparities that go on. When we 
talk about counselors, guidance counselors versus a 
psychological counselor, there is a big difference there.
    What use do I have for one of them counselors or both of 
them counselors? I have use for both of them. I have mentioned 
that in dealing with some of these things in our life and 
education, we seem to put an individual education plan forward 
to children identified with special needs.
    In reality, I feel studying all these years, each and every 
young person from K to forever how long they go to school, 
having individual education plans set forth not just for the 
special needs children.
    As we go through our life and place judgment on these 
children, I want to say judgment because that is how we use the 
data that is provided, they are gains, they are individual 
growth gains, not a standard that says all third graders are 
like that, not all seventh graders are like that but an 
individual education plan that would monitor that child and 
young person's self, not rated amongst each other.
    The sexual abuse that does go on does happen on the Pine 
Ridge Indian Reservation and it relates to the poverty.
    I would like to quickly mention the disparity on some 
funding. We are underfunded in all schools nationwide, Indian 
education, operation and maintenance, and transportation. We 
take the ISEP dollars designed for children to learn and the 
title dollars and we use them to fix our schools. We are using 
them to pay our light bill and to pay for propane to keep them 
warm.
    I can go on forever on that. In the case of that, there 
needs to be money there. All of this work is critical.
    I would like to ask that the Committee support our efforts 
to save the lives of our children. We need long term solutions, 
not a quick band-aid today.
    Thank you.
    The Chairman. Thank you very much, Councilman Clifford.
    Do any of you have a short closing comment on the things 
you have heard said today? We are in the middle of roll call 
votes. I think we have a number of them now and the roll call 
vote has already been called so we have to summarize.
    Director McSwain, any last thoughts?
    Mr. McSwain. I think this will require us, as the 
Administration, to work very, very closely with the communities 
and engage the communities where they are engaged on the 
issues. They need the tools and we need to provide the tools to 
be able to address this particular issue.
    Right now we are finding that many of our communities are, 
as I mentioned earlier, rather paralyzed. There is something 
they want to do. In fact, my weekly calls with President Steele 
to be able to see how he is doing and how the tribe is doing, 
as an Administration, we have to do more of that.
    The Chairman. Mr. Clifford?
    Mr. Clifford. I would recommend the following: providing 
emergency funding for substance abuse and suicide prevention 
and mental health care; commit to economic development and 
infrastructure on the Pine Ridge. I ask respectfully to remove 
the jurisdictional restrictions and fund tribal police and 
courts and focus on education for our youth suicide epidemic. 
It would probably be best fought in the schools.
    Lastly, acknowledge the government's treaty obligation to 
fully fund all these programs.
    Thank you.
    The Chairman. Mr. Seki?
    Mr. Seki. Thank you for giving us this opportunity. I want 
to thank the panel here that spoke regarding the suicides.
    The thing I will keep addressing is the sequestration, to 
stop it, to put back the funds for the tribes so they can 
address these suicides happening on our reservations. Pine 
Ridge alluded to grants. That is not the solution. Long term 
funding like SAMHSA and DOG is the solution. Put them through 
the 638 agreements, not short term because short term does not 
work. They only last as long as the grant and then it is over. 
Then we are back to square one again.
    I ask you as the Committee to invest in tribal nations for 
infrastructure, for economic development, for tribes to create 
jobs for our safety and for our generations to come, our youth.
    Thank you.
    The Chairman. Thank you, Mr. Seki.
    Dr. LaFromboise?
    Dr. LaFromboise. In addition to all that has been said, I 
think we need to remember it is very important to strengthen 
the workforce of American Native and Alaska Natives in the 
fields of mental health. We need to look at funding beyond 
psychiatry and psychology with the Indian Health Service to 
include social work and Masters level people. They can work in 
collaboration with the schools to deliver some of these 
programs. There are programs proven to be effective. They just 
need the staffing with which to do that.
    I also realize that I pushed the issue of evidence-based 
but do agree with what has been said today, that there are many 
practices the community knows work. Unfortunately, because they 
have not been proven through scientific methods, they often are 
looked upon as less than and they are not. They are equal to, 
if not more powerful. We just do not have the resources for 
those to continue as much as they should in full force.
    I want to be on record as having said, there is really a 
balance between traditional practices and then some of these 
other more western-based practices that we have proven that do 
work with Native kids.
    The Chairman. Thank you.
    I appreciate your comments. There may be some written 
questions by other members of the Committee who were unable to 
be here with us today. The hearing record will be open for two 
weeks.
    I am going to remind the Administration that our work is 
not complete. I look forward to continued dialogue, including 
Committee briefings, listening sessions, and hearings in the 
weeks to come.
    I want to thank all the witnesses for your time and 
testimony.
    The hearing is adjourned.
    [Whereupon, at 4:12 p.m., the Committee was adjourned.]

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