[Senate Hearing 114-112]
[From the U.S. Government Publishing Office]
S. Hrg. 114-112
DEMANDING RESULTS TO END NATIVE YOUTH SUICIDES
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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
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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
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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.
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\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
Barrish, H.H., Saunders, M., & Wolf, M.M. (1969). Good Behavior Game:
Effects of individual contingencies for group consequences on
disruptive behavior in a classroom. Journal of Applied Behavior
Analysis, 2, 119-124. Retrieved from http://
search.proquest.com/docview/615628148?accountid=14026
Eggert, L.L., & Nicholas, L. J. (2004). Reconnecting youth.
Bloomington, IN: National Educational Service.
Kellam, S.G., Brown, H.C., Poduska, J.M., Ialongo, N.S., Wang, W.,
Toyinbo, P., & Wilcox, H.C. (2008). Effects of a universal
classroom behavior management program in first and second
grades on young adult behavioral, psychiatric, and social
outcomes. Drug and Alcohol Dependence, 95, S5-S28. doi:
10.1016/j.drugalcdep.2008.01.004
LaFromboise, T.D. (1996). American Indian Life Skills Development
Curriculum. Madison, WI: University of Wisconsin Press.
LaFromboise, T.D., & Howard-Pitney, B. (1995). The Zuni Life Skills
Development Curriculum: Description and evaluation of a suicide
prevention program. Journal of Counseling Psychology, 42, 479-
486. doi: 10.1037/0022-0167.42.4.47
LaFromboise, T.D., & Hussain, S. (in press). School-based adolescent
suicide prevention. In L. Bosworth (Eds.). Prevention Science
in School Settings: Complex Relationships and Processes. New
York: Springer.
LaFromboise, T.D., & Lewis, H.A. (2008). The Zuni Life Skills
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prevention intervention. Suicide and Life-Threatening Behavior,
38, 343-353. doi: 10.1521/suli.2008.38.3.343
LaFromboise, T.D., & Malik, S.S. (2012, May). Development of the
American Indian Life Skills Curriculum: Middle School Version.
Poster presentation, Second Biennial Conference of the Society
for the Psychological Study of Ethnic Minority Issues. Ann
Arbor, MI.
LoMurray, M. (2005). Sources of Strength facilitators guide: Suicide
prevention peer gatekeeper training. Bismarck, ND: The North
Dakota Suicide Prevention Project.
Thompson, E. A., Eggert, L. L., Randell, B. P., & Pike, K. C. (2001).
Evaluation of indicated suicide risk prevention approaches for
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Wexler, L., Chandler, M., Gone, J., Cwik, M., Kirmayer, L.,
LaFromboise, T., Brockie, T., O'Keefe, V., Walkup, J., & Allen,
J. (2015). Advancing suicide prevention research with rural
American Indian and Alaska Native populations. American Journal
of Public Health.
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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