Transcript The American Indian/Alaska Native National Resource Center
The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services
A Strategy for Native Youth Mental Health Treatment and Prevention Services and Programming
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Michelle Singer Oregon Health and Science University Tribal Justice and Safety Regional Conference Mystic Lake, Minnesota March 26, 2007 1
One Sky Center
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One Sky Center Partners
Cook Inlet Tribal Council Tribal Colleges and Universities Alaska Native Tribal Health Consortium Prairielands ATTC Northwest Portland Area Indian Health Board
One Sky Center
Red Road Harvard Native Health Program United American Indian Involvement National Indian Youth Leadership Project Na'nizhoozhi Center Tri-Ethnic Center for Prevention Research Jack Brown Adolescent Treatment Center 3
One Sky Center Outreach
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Goals for Today
• An Environmental Scan • Behavioral Health Care System Issues • Fragmentation and Integration • Discuss Mental Health and Comorbidity • Indigenous Knowledge + Evidence Based Knowledge = Best Practice • Integrated care approaches are best for treatment of these chronic illnesses 6
Five Missions Impossible?
• How do we define problems? • 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? 7
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Ten Leading Causes of Disability in the World
• Unipolar Depression • Iron-deficiency Anemia • Falls • Alcohol Use • COPD • Bipolar disorder • Congenital anomalies • Osteoarthritis • Schizophrenia • Obsessive-compulsive disorder • • • • • • • • • • 10.7% 4.7
4.6
3.3
3.1
3.0
2.9
2.8
2.6
2.2
(WHO, 1997) 11
Juvenile Justice Mental Disorder Rates
Type of disorder Any Listed Conduct Disorder Disruptive Behavior ADHD Affective Anxiety Psychotic Substance Use Males (n = 1,170) Prevalence 66.3
5.4
41.4
16.6
18.7
21.3
1.0
50.7
Chicago Detention Center (Teplin,2002)
Females (n = 656) Prevalence 73.8
3.8
45.6
16.4
27.6
30.8
1.0
46.8
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Most Common Disabilities Among Youth in the JJ System
• Learning Disabilities • Post Traumatic Stress Disorder (higher in girls) * • Conduct Disorder • Oppositional Defiant Disorder • Depression • Anxiety Disorders • Substance Use/Abuse Disorders • Developmental Disabilities 13
Mental Health Needs: Across Juvenile Justice Placements
A study compared mental health needs among a random sample of youth (n=473) within the juvenile justice system found mental health problems in: – 45.9 % of youth on probation, – 67.5% youth incarcerated, and – 88 % youth adjudicated to residential treatment centers (Lyons, Quigley, Erlich & Griffin, 2001) 14
Native Health Problems
1. Alcoholism 6X 2. Tuberculosis 6X 3. Diabetes 3.5 X 4. Accidents 3X 5. 60% Over 65 live in poverty (US 27%) 6. Depression 3x 7. Violence?
American Indians
• Have same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated 16
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
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Disconnect Between Justice/Addictions/Mental Health
• Professionals are undertrained • Patients are underdiagnosed • Patients are undertreated • None integrates well with medical and social services 18
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 19
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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12 10 8 6 4 2
Suicide Among ages 15-17, 2001
Death rate per 100,000 16 14
2010 Target Total Females Males
Source: National Vital Statistics System - Mortality, NCHS, CDC.
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Suicide: A Native Crisis
60 White Male 50 40 30 20 10 0 AI Male Black Male AI Female
Age Groups
Source: National Center for Health Statistics 2001 24
SUICIDE: A MULTI-FACTORIAL EVENT Personality Disorder/Traits Substance Use/Abuse Psychiatric Illness Co-morbidity Neurobiology Impulsiveness Hopelessness Severe Medical Illness Suicide Family History Access To Weapons Life Stressors Suicidal Behavior Psychodynamics/ Psychological Vulnerability
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Adolescent Problems In Schools
1. School Admin 2. Law 3. FBI Fighting and Gangs Alcohol Drug Use Bullying Weapon Carrying 4. DEA 5. State MH 6. State A&D 7. Courts 8. Child Services Sale of Alcohol and Drugs School Environment Unruly Students Attacks on Teachers Staff Drop Outs Domestic Violence Sexual Abuse Truancy
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Key Adolescent Risk Factors
Aggressive/Impulsive Substance Abuse Depression Trauma 27
Comorbidity Defined
“Individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person….at least one disorder of each type can be diagnosed independently of the other.” -
Report to Congress of the Prevention and Treatment of Co-Occurring Substance Abuser Disorders and Mental Disorders
, SAMHSA, 2002 28
Lifetime History
Mental Disorder 22.5% Comorbidity 29% Alcohol Disorder 13.5% Comorbidity 45% Drug Disorder 6.1% Comorbidity 72% Regier, 1990
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Lifetime Psychiatric Diagnoses Among Primary Caretakers (N=207) 40 30 20 10 0 Lifetime Depression Panic Disorder Antisocial Personality Clean Current Depression Confounded R. Dale Walker, M.D. (7/97) Dysthymia 30
Multiple Diagnoses Increase
• Treatment seeking • Use of services • Likelihood of no services • Treatment costs • Poor outcome • Suicide risk
Dual diagnosis is an expectation, not an exception
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The Intervention Spectrum for Behavioral Disorders
Indicated — Diagnosed Case Identification Standard Treatment for Known Disorders Youth Selective — Health Risk Groups Compliance with Long-Term Treatment (Goal: Reduction in Relapse and Recurrence) Universal — General Population 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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Spectrum of Intervention Responses
Thresholds for Action
No Problems Universal/Selective Prevention Mild Problems Moderate Problems Severe Problems Treatment Brief Intervention 34
Ecological Model
Society Community/ Tribe Peer/Family Individual 35
Environmental Stigma Interpersonal societal Community Tribal attitudes Parent s Personality Peers National attitudes Genetics Individual Attitudes beliefs Cultural beliefs Schools Interpersonal Personal situations Local legal State attitudes Individual Portrayal in media 36
Individual Intervention
• Identify risk and protective factors counseling skill building improve coping support groups • Increase community awareness • Access to hotlines other help resources 37
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.
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Implications for Treatment
• • •
Teach adolescents how to cope with difficulties and adversity Increase their repertoire of coping strategies Cognitive therapy is most effective approach
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Behavioral Health Programs Should . . . .
Reduce Risk Factors
ineffective parenting
chaotic home environment
lack of mutual attachments/nurturing
inappropriate behavior in the classroom failure in school performance
poor social coping skills
affiliations with deviant peers
perceptions of approval of drug-using behaviors in the school, peer, and community environments
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Behavioral Health Programs Should . . . .
Enhance Protective Factors
strong family bonds parental monitoring parental involvement success in school performance prosocial institutions (e.g. such as family, school, religious, and tribal organizations) conventional norms about drug use
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Sources of Strength
Access to Mental Health Access to Medical Family Support Positive Friends Spirituality Generosity/Leadership Caring Adults Positive Activities 42
Effective Interventions for Adults
• Cognitive/Behavioral Approaches • Motivational Interventions • Psychopharmacological Interventions • Modified Therapeutic Communities • Assertive Community Treatment • Vocational Services • Dual Recovery/Self-Help Programs • Consumer Involvement • Therapeutic Relationships 43
Effective Interventions for Youth
• Family Therapy • Multisystemic Therapy • Case Management • Therapeutic Communities • Community Reinforcement • Circles of Care • Motivational Enhancement 44
Treatment Settings - Social Support: A Native Advantage
• Tribal • Community • Family • Sibs • Peers • Individual 45
Cultural Approach
• Original Holistic Approach • Psychopharmacology Approach • The unconscious has always been there • Group Therapy • Network Therapy • Recreational / Outdoors • Traditional Interventions • Indian is...
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Possible Treatment/Prevention Activities
• The Talking Circle • Smudging • Story telling • Traditional Healers • Medicine Person • Herbal remedies • Traditional ceremonies • Sweat Lodge • Traditional Experiences Preservation 47
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Definitions:
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.
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Definitions:
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 50
Definitions:
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 51
Definitions:
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 52
ID Best Practice
Best Practice Clinical/services Research Mainstream Practice Traditional Healing
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Circle of Care
Traditional Healers Primary Care Child & Adolescent Programs A&D Programs Best Practices Boarding Schools Prevention Programs Colleges & Universities Emergency Rooms
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What Is Integrative Medicine?
Basic Science Wellness Patient CAM literacy Evidence Centered Based Care Cultural Medicine Power Sensitivity Of the Mind 55
Principles of Integrative Medicine 1. It is better to prevent than to treat later.
2. Recognition of the interaction between body, mind, spirit, and environment. 3. Integrate the best of conventional and traditional medicine.
4. Belief that bodies respond uniquely, so treatment must be customized.
5. Belief in innate healing powers of the body.
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WHAT ARE SOME PROMISING STRATEGIES?
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Promising Strategies
• Home visitation • Parent training • Mentoring • Heroes • Social cognitive • Cultural 58
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.) 59
Comprehensive school planning
• Prevention and behavioral health programs/services on site • Handling behavioral health crises • Responding appropriately and effectively after an event occurs 60
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 61
Unified Services Plan
• • • • • • • • •
Mental health Education/vocation Justice/safety Leisure/social Parenting/family Housing Financial Daily living skills Physical health
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Potential Organizational Partners
• Education • Family Survivors • Health/Public Health • Mental Health • Substance Abuse • Traditional Healers • Elders • Law Enforcement • Juvenile Justice • Medical Examiner • Faith-Based • County, State, and Federal Agencies • Girls/Boys Clubs 63
Partnered Collaboration
State/Federal Grassroots Groups Community-Based Organizations Research-Education-Treatment
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Recommendations
• Develop interagency task forces • Bring in supportive/interested state partners • Reach out to bring in new resources • Be clear, positive, and direct • Remember what this effort is all about 65
Evidence-based coordination– linkage mechanisms • formal agreements among behavioral health, primary health care providers and justice; • case management and primary health care; of behavioral health, justice, • co-location of behavioral health, and primary health care services; • delivery of mental, substance-use, and primary health care through clinically integrated practices of primary and M/SU care providers. 66
Making It Work for Youth and Families Involved in Juvenile Justice • Engage
All
Leaders on all Decisions • Know the decision points in the JJ System At point of arrest/earliest point to divert At point where decisions to charge are made/diversion At intake to juvenile court/diversion • Make information accessible • Make resources/services more accessible • Increased screening • Target adolescents 67
Contact us at 503-494-3703 E-mail Dale Walker, MD [email protected]
Or visit our website: www.oneskycenter.org
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