1. Shakopee Mdewakanton Sioux Community Building Blocks to a Healthy Life July 21, 2008 Prior Lake, Minnesota Healing Families, Finding Solutions 1

2. 2 One Sky Center

3. 3 Jack Brown Adolescent Treatment Center Alaska Native Tribal Health Consortium United American Indian Involvement Northwest Portland Area Indian Health Board Na'nizhoozhi Center Tribal Colleges and Universities One Sky Center National Indian Youth Leadership Project Cook Inlet Tribal Council Tri-Ethnic Center for Prevention Research Red Road Prairielands ATTC Harvard Native Health Program One Sky Center Partners

4. 4 One Sky Center Outreach

5. 5 Goals for Today An Environmental Scan Behavioral Health Care Issues Fragmentation and Integration Best Practice = Evidence-Based + Indigenous Knowledge You do both Treatment and prevention

6. 6 Six Missions Impossible? How do we: Define ourselves? Define health care? Ask for help? Get Federal and State agencies to work together and with us? Build our communities? Restore what is lost?

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10. Native Health Problems 1.Alcoholism 6X 2.Tuberculosis 6X 3.Diabetes 3.5 X 4.Accidents 3X 5.Poverty 3x 6.Depression 3x 7.Suicide 2x 8.Violence?

11. 11 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

12. 12 Agencies Involved in B.H. Delivery 1. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 2. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 3. Tribal Health 4. Urban Indian Health 5.State and Local Agencies 6.Federal Agencies: SAMHSA, VAMC, Justice

13. 13 Difficulties of Program Integration Separate funding streams and coverage gaps Agency turf issues Different treatment philosophies Different training philosophies Lack of resources Poor cross training Consumer and family barriers

14. 14 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

15. 15 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

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17. 17 Mental Illness: A Multi-factorial Event Edu., Econ., Rec. Family Disruption/ Domestic Violence Family Disruption/ Domestic Violence Impulsiveness Negative Boarding School Hopelessness Historical Trauma Family History Suicidal Behavior Suicidal Behavior Cultural Distress Psychiatric Illness & Stigma Psychodynamics/ Psychological Vulnerability Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Individual

18. 18 Adolescent Problems In Schools School Environment Bullying Fighting and Gangs Alcohol Drug Use Weapon Carrying Sexual Abuse Truancy Domestic Violence Drop Outs Attacks on Teachers Staff Unruly Students Sale of Alcohol and Drugs 12 1. School Admin 2. Law 3. FBI 4. DEA 5. State MH 6. State A&D 7. Courts 8. Child Services

19. 19 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

20. 20 Most Common Emotional Disabilities Among Native Youth Learning Disabilities Post Traumatic Stress Disorder Conduct Disorder Oppositional Defiant Disorder Depression Disorders Anxiety Disorders Substance Use/Abuse Disorders Developmental Disabilities

21. Six behaviors that contribute to serious health problems: Tobacco use Poor nutrition Alcohol and other drug abuse Behaviors resulting in intentional or unintentional injury Physical inactivity Risky sex

22. 22 Suicide: A Native Crisis Source: National Center for Health Statistics 2001

23. 23 Methamphetamine: Epidemiology

24. 24 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

25. 25 Models of Care

26. 26 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

27. 27 Risk  Mental illness  Age/gender  Substance abuse  Loss  Previous suicide attempt  Personality traits  Incarceration  Failure/academic problems Protective  Cultural/religious beliefs  Coping/problem solving skills  Ongoing health and mental health care  Resiliency, self esteem, direction, mission, determination, perseverance, optimism, empathy  Intellectual competence, reasons for living Risk and Protective Factors: Individual

28. 28 The Intervention Spectrum for Behavioral Disorders Case Identification Standard Treatment for Known Disorders Compliance with Long-Term Treatment (Goal: Reduction in Relapse and Recurrence) Aftercare (Including Rehabilitation) Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994. Indicated— Diagnosed Youth Selective— Health Risk Groups Universal— General Population

29. 29 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

30. 30 Effective Family Intervention Strategies: Critical Role of Families Parent training Family skills training Family in-home support Family therapy Different types of family interventions are used to modify different risk and protective factors.

31. 31 Sources of Strength Family Support Positive Friends Caring Adults Positive Activities Generosity/Leadership Spirituality Access to Medical Access to Mental Health

32. 32 Treatment Settings - Social Support: A Native Advantage Tribal Community Family Siblings Peers Individual

33. AI/AN Prevention, Treatment, and Rehabilitation Interventions Story Telling Talking Circles Sweat Lodge Ceremonies and Ritual –Purification –Passages –Naming –Grieving Drumming, Singing, Dancing Vision Quest Flute playing/meditation Reconciliation Mentoring Service Learning Traditional Experiences Preservation 33

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35. 35 Indigenous Knowledge Is local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, which is used as a basis for decision- making for all of life’s needs. Definitions:

36. 36 Traditional Medicine The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health. WHO 2002 Definitions:

37. 37 Evidence-based Practices Interventions that show consistent scientific evidence of improving a person’s outcome of treatment and/or prevention in controlled settings. SAMHSA 2003 Definitions:

38. 38 Best Practices Examples and cases that illustrate the use of community knowledge and science in developing cost effective and sustainable survival strategies to overcome a chronic illness. WHO 2002 Definitions:

39. 39 ID Best Practice Best Practice Clinical/services Research Traditional Medicine Mainstream Practice

40. 40 Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

41. 41 What are some promising strategies?

42. 42 Integrated Treatment Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services Findings: decrease in hospitalization lessening of psychiatric and substance abuse severity better engagement and retention (Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)

43. 43 Comprehensive school planning Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event occurs

44. 44 Community Driven/School Based Prevention Interventions Public awareness and media campaigns Youth Development Services Social Interaction Skills Training Approaches Mentoring Programs Tutoring Programs Rites of Passage Programs

45. 45 Unified Services Plan Case management should address: Mental health Education/vocation Leisure/social Parenting/family Housing Financial Daily living skills Physical health

46. 46 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

47. 47 – Albert Einstein “We cannot solve problems by using the same kind of thinking we used when we created them.”

48. 48 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org