Transcript Document

The American Indian/Alaska Native National Resource Center
for Substance Abuse and Mental Health Services
Native Suicide Prevention: Approaches,
Interventions, and Responses For An
International Strategy
Fort Hall, Idaho
July 31, 2006
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
Michelle Singer
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One Sky
Center
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One Sky Center Partners
Cook Inlet Tribal Council
Alaska Native Tribal
Health Consortium
Northwest Portland Area
Indian Health Board
Tribal Colleges
and Universities
Prairielands ATTC
Red Road
One Sky
Center
United American
Indian Involvement
Harvard Native
Health Program
Jack Brown
Adolescent
Treatment Center
National Indian Youth
Leadership Project
Tri-Ethnic Center for
Na'nizhoozhi Center Prevention Research
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One Sky Center Outreach
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Native Aspirations!
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Overview
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An Environmental Scan
Behavioral Health Care System Issues
Fragmentation and Integration
Discuss Suicide, Disaster
Indigenous Knowledge + Evidence Based Knowledge
= Best Practice
• Integrated care approaches are best for suicide
prevention
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Six Missions Impossible?
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How do we define problems?
How do we define disaster?
How do we ask for help?
How do we get Federal and State agencies to
work together and with us?
• How do we build our communities?
• How do we restore what is lost?
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Health Problems
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Alcoholism 6X
Tuberculosis 6X
Diabetes 3.5X
Accidents 3X
Suicide 1.7 to 4x
Physicians 72/100,000 (US 242)
60% Over 65 live in poverty
(US 27%)
American Indians
• Have same disorders as general
population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated
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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
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Disconnect Between
Addictions/Mental Health
• Professionals are undertrained in one of two
domains
• Patients are underdiagnosed
• Patients are undertreated
• Neither integrates well with medical,
emergency, educational, legal, and social
services
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Difficulties of Program
Integration
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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
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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning?
(Carl Bell, 7/03)
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Culturally
Specific
Best
Practice
Outcome
Driven
Integrating
Resources
We need Synergy and an Integrated
System (Carl Bell, 7/03)
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Suicide: A National Crisis
• In the United States, more than 30,000 people die by
suicide a year.1
• Ninety percent of people who die by suicide have a
diagnosable mental illness and/or substance abuse
disorder.2
• The annual cost of untreated mental illness is $100
billion.3
1 The
President’s New Freedom Commission on Mental Health, 2003.
Center for Health Statistics, 2004.
3 Bazelon Center for Mental Health Law, 1999.
2 National
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Our Community Issue
• For every suicide, at least six people are affected.4
• There are higher rates of suicide among survivors
(e.g., family members and friends of a loved one who
died by suicide).5
• Communities are linked to each other via a national
network.
• Healthy communities are stronger communities.
4 National
5 National
Center for Health Statistics, 1999.
Institute of Mental Health, 2003.
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Denise Middlebrook 1-5-2006R. Dale
Walker, M.D., 2003
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Age-Adjusted Suicide Death Rates
CY 1996-1998
U.S. All Races (1997) = 10.6
IHS Adjusted Total - All Areas = 20.2
Nashville
Oklahoma
Adjusted for Race Misreporting
California
Unadjusted
Phoenix
Albuquerque
Navajo
Billings
Portland
Bemidji
Tucson
Aberdeen
Alaska
0
10
20
30
40
50
Rate per 100,000 Population
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Suicide Rates by Age, Race, and
Gender 1999-2001
AI Male
Black Male
AI Female
50
40
30
20
Age Groups
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Source: National Center for Health Statistics
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
0
10-14
10
5-9
Rate/100,000 .
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White Male
Native Suicide: A Multi-factorial Event
Psychiatric Illness
& Stigma
-Edn,-Econ,-Rec
Cultural Distress
Impulsiveness
Substance
Use/Abuse
Hopelessness
Family Disruption
Domestic Violence
Suicide
Family History
Negative Boarding School
Historical Trauma
Douglas Jackobs 2003
R. Dale Walker, M.D., 2003
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
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Current Cluster Suicide Crisis in a Tribal
Community
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300+ attempts in last 12 months
70 attempts since November
13 completions in 12 months
8 completions in 3 months
4 to 5 attempts per week
– Some attempts are adult
• Age range of completions: 14-24 years of age
– Most completed suicides are female
– 80% Alcohol related
– All hanging
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Disaster Defined
• FEMA: A natural or man-made event that negatively
affects life, property, livelihood or industry often
resulting in permanent changes to human societies,
ecosystems and environment.
• NHTSA: Any occurrence that causes damage,
ecological destruction, loss of human lives, or
deterioration of health and health services on a scale
sufficient to warrant an extraordinary response from
outside the affected community area.
• NOAA: A crisis event that surpasses the ability of an
individual, community, or society to control or recover
from its consequences.
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The Intervention Spectrum
for Behavioral Disorders
Case
Identification Standard
Treatment
for Known
Indicated—
Disorders
Diagnosed
Youth
Selective—
Health Risk
Groups
Universal—
General Population
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.
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Interventions
• To date slim data regarding evidence based
suicide prevention
• More studies based on prevention instead of
intervention
• Emphasis is placed on
individual
family/peer
school/community
society
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Promising Practices for Suicide
Prevention
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ASIST
C-CARE/CAST
Columbia University Teen Screen
Means Reduction
Lifelines
Reconnecting Youth
ER intervention for attempters
Signs of Suicide
US Air Force program
Yellow Ribbon Suicide Prevention
American Indian Life Skills
http://www.sprc.org/featured_resources/ebpp/ebpp_factsheets.asp
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Ecological Model
Society
Community/
Tribe
Peer/Family Individual
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Environmental
Interpersonal
societal
Stigma
Community
Tribal
attitudes
Parents
Peers
Personality
National
attitudes
Genetics Individual Attitudes
beliefs
Cultural
beliefs
Schools
Interpersonal
Local
legal
State
attitudes
Personal situations
Individual
Portrayal in media
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Suicide: Individual Factors
Risk
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Mental illness
Age/Sex
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
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Suicide: Peer/Family Factors
Risk
• History of
interpersonal
violence/abuse/
• Bullying
• Exposure to
suicide
• No-longer married
• Barriers to health
care/mental health
care
Protective
• Family cohesion (youth)
• Sense of social support
• Interconnectedness
• Married/parent
• Access to
comprehensive health
care
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Suicide: Community Factors
Risk
• Isolation/social
withdrawal
• Barriers to health
care and mental
health care
• Stigma
• Exposure to
suicide
• Unemployment
Protective
• Access to healthcare and
mental health care
• Social support, close
relationships, caring
adults, participation and
bond with school
• Respect for help-seeking
behavior
• Skills to recognize and
respond to signs of risk
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Suicide: Societal Factors
Risk
• Western
• Rural/Remote
• Cultural values and
attitudes
• Stigma
• Media influence
• Alcohol misuse and
abuse
• Social disintegration
• Economic instability
Protective
• Urban/Suburban
• Access to health care &
mental health care
• Cultural values affirming
life
• Media influence
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ID Best Practice
Best Practice
Clinical/services
Research
Mainstream
Practice
Traditional
Healing
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Circle of Care
Traditional
Healers
Primary Care
A&D
Programs
Best
Practices
Child &
Adolescent
Programs
Boarding
Schools
Colleges &
Universities
Prevention
Programs
Emergency
Rooms
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Partnered Collaboration
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
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WHAT ARE SOME
PROMISING SCHOOLBASED STRATEGIES?
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Comprehensive school
planning
• Prevention and behavioral health
programs/services on site
• Handling behavioral health crises
• Responding appropriately and
effectively after an event occurs
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American Indian Life Skills
Curriculum
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Build self-esteem
Identify emotions and stress
Increase communication, problem-solving
skills
Recognize and eliminate self-destructive
behaviors
Receive suicide information
Receive suicide intervention training
Set personal and community goals
Curriculum three times a week for 30 weeks in
a required language arts class
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Native Aspirations!
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Promising Strategies
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Home visitation
Parent training
Mentoring
Social cognitive
Cultural
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Recommendations
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Make information accessible
Make resources/services more accessible
Increased screening
Target adolescents
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Partnered Collaboration
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
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Potential Organizational
Partners
• Education
• Law Enforcement
• Family Survivors
• Juvenile Justice
• Health/Public Health
• Medical Examiner
• Mental Health
• Faith-Based
• Substance Abuse
• County, State, and
Federal Agencies
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Suicide Prevention Resources
• Suicide Prevention Resource Center http://www.sprc.org/
• Indian Health Service Director’s Initiatives http://www.ihs.gov/
• Office of Juvenile Justice Model Programs
http://www.dsgonline.com/mpg2.5/mpg_index.htm
• One Sky Center http://www.oneskycenter.org/
• Screening for mental health
http://www.mentalhealthscreening.org/
• Jason Foundation http://www.jasonfoundation.com/home.html
• T LaFromboise, The Zuni Life Skills Development Curriculum:
Description and Evaluation of a Suicide Prevention Program.
Journal of Counseling Psychology 42(4):479–86
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Contact us at
503-494-3703
E-mail
Dale Walker, MD
[email protected]
Or visit our website:
www.oneskycenter.org
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