1. 1 Addictions and Mental Health Approaches in Native Populations R. Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD March 2, 2006 Phoenix, Arizona

2. 2 One Sky Center

3. 3 Program Goals Promote and nurture effective and culturally appropriate prevention and treatment Identify and disseminate evidence-based prevention and treatment practices Provide training and technical assistance Help to expand capacity

4. 4 One Sky Center Outreach

5. 5 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

6. 6 Total Female Male Total 11.9 9.814.1 Native American19.823.315.6 Non-Hispanic White11.8 9.913.9 Non-Hispanic Black13.110.216.6 Hispanic – Central American 5.7 4.2 7.7 Hispanic – Cuban 8.2 5.511.4 Hispanic – Mexican12.7 9.215.8 Percentage using any illicit drugs in the past year Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

7. 7 Percentage reporting dependence on alcohol Source: 1999 SAMHSA Treatment Episode Data Set (TEDS). Total Female Male Total3.52.14.9 Native American5.66.84.3 Non-Hispanic White3.42.24.8 Non-Hispanic Black3.42.05.2 Hispanic – Central American2.80.85.4 Hispanic – Cuban0.90.51.3 Hispanic – Mexican5.62.68.4

8. 8 Lifetime History Regier, 1990 Mental Disorder 22.5% Comorbidity 29% 3.1% 1.5% 1.7% 1.1% Alcohol Disorder 13.5% Comorbidity 45% Drug Disorder 6.1% Comorbidity 72%

9. 9 Multiple Diagnoses Increases: treatment seeking use of services poor outcome suicide risk likelihood of no services treatment costs

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11. 11 How is it working? One size fits all goals Different goals Resource silos Activity-driven (Carl Bell, 7/03)

12. 12 We need Collaboration, Integration, and Synergy : Community Mobilization Culturally specific Best Practice Integrating resources Outcome driven (Carl Bell, 7/03)

13. 13 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:

14. 14 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:

15. 15 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:

16. 16 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:

17. 17 World Conference on Science Recommended that scientific and indigenous knowledge be integrated in interdisciplinary projects dealing with culture, environment and chronic illness. 1999 A partnership begins!

18. 18 ID Best Practice Best Practice Clinical/Services Research Traditional Healing Mainstream Practice

19. 19 Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

20. 20 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) P r e v e n t i o n T r e a t m e n t M a i n t e n a n c e 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

21. 21 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

22. 22 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

23. 23 IndividualGenetics Personality Attitudes beliefs Interpersonal Community Parent s Peers SchoolsLocal legal Personal situations Portrayal in media Cultural beliefs Stigma National attitudes Individual Environmental Interpersonal societal Tribal attitudes State attitudes

24. 24 Prevention Primary Risk factors Protective factors Prevent 1st use Secondary Prevent kids who use from continuing Prevent kids who misuse from experiencing use related problems or dependency

25. 25 Implications for Treatment Teach adolescents how to cope with difficulties and adversity Increase their repertoire of coping strategies Cognitive therapy is most effective approach

26. 26 Treatment Settings - Social Support Tribal Community Family Sibs Peers Individual

27. 27 Evidence-Based Practices for Alcohol Treatment Brief intervention Social skills training Motivational enhancement Community reinforcement Behavioral contracting Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2 nd ed., pp 12 – 44). Boston: Allyn & Bacon.

28. 28 Scientifically-Based Approaches to Addiction Treatment Cognitive–behavioral interventions Community reinforcement Motivational enhancement therapy 12-step facilitation Contingency management Pharmacological therapies Systems treatment 1.L. Onken (2002). Personal Communication. National Institute on Drug Abuse. 2.Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

29. 29 Alcohol/Drug Treatment Core Components and Comprehensive Services Medical Mental Health Vocational Educational Legal AIDS / HIV Risks Financial Housing & Transportation Child Care Family Continuing Care Case Management Urine Monitoring Self-Help (AA/NA) Pharmaco-therapy Group/Individual Counseling Abstinence Based Intake Assessment Treatment PlansCoreTreatment Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)

30. 30 Cultural Approach Original Holistic Approach Psychopharmacology Approach The unconscious has always been there Group Therapy Network Therapy Recreational / Outdoors Traditional Interventions Indian is...

31. 31 Unified Services Plan Case management should address: Mental health Education/vocation Leisure/social Parenting/family Housing Financial Daily living skills Physical health

32. 32 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org