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The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services

Native Community Disaster Management: Planning, Assessment,

Care, and Follow-up San Diego, California

June 8, 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

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

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

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One Sky Center Outreach

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Presentation Overview

• An Environmental Scan• Behavioral Health and Education System Issues• Fragmentation and Integration• Discuss Suicide as Disaster: planning, care,

assessment, follow up• Integrated care approaches and interagency

coordination are best overall solutions

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Six Missions Impossible?• How do we define health, education, and

social 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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A Quiet Crisis: Federal Funding and Unmet Needs

in Indian Country, July 2003

Funding not sufficient to meet needs for:• Health care• Education • Public safety• Housing• Infrastructure development needed

Native Health/ Educational Problems

1. Alcoholism 6X

2. Tuberculosis 6X

3. Diabetes 3.5X

4. Accidents 3X

5. Suicide 1.7 to 4x

6. Health care access -3x

7. Poverty 3x

8. Poor educational achievement

9. Substandard housing

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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. & Edn1. Indian Health Service (IHS)

A. Mental HealthB. Primary HealthC. Alcoholism / Substance

Abuse2. Bureau of Indian Affairs (BIA)

A. EducationB. VocationalC. Social ServicesD. Police

3. Tribal Education/Health4. Urban Indian Education/Health5. State and Local Agencies6. Federal Agencies: SAMHSA, Edn

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Disconnect Between Education/Behavioral

Health• Professionals are undertrained in one of the

two domains• Students as patients are under diagnosed

and under treated• Students have less opportunity for education• Neither system integrates well with medical,

emergency, legal, and social services

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Difficulties of System Integration

• Separate funding streams and coverage gaps• Agency turf issues• Different philosophies• Lack of resources• Poor cross training• Consumer and family barriers

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How are we functioning? (Dale Walker, Carl Bell, 7/03)

One size fits allOne size fits all

Different goals Different goals Resource silosResource silos

Activity-drivenActivity-driven

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We need Synergy and an Integrated System (Dale Walker, Carl Bell, 7/03)

Culturally Specific

Culturally Specific

Best Practice

Best Practice

IntegratingResources

IntegratingResources

Outcome Driven

Outcome Driven

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Emergency situation

Event where, in order to protect the people, goods and the environment, requires a quick response for which the normal procedures and resources of an organisation are adequate.

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DisasterEvent, endangering the safety of people, goods and the environment, that exceeds the organisation’s normal response capabilities (resources or procedures)

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When Does an Emergency Become a Disaster?

• A disaster depends largely on the community itself. What is it’s size, it’s resources, it’s experience in dealing with a certain hazard.

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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, 2003.2 National Center for Health Statistics, 2004.3 Bazelon Center for Mental Health Law, 1999.

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Our Native 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 closely linked to each other, increasing the risk of cluster suicide.

4 National Center for Health Statistics, 1999.5 National Institute of Mental Health, 2003.

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Suicide Rates by Age, Race, and Gender 1999-2001

Source: National Center for Health Statistics

0

10

20

30

40

50

605-

9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85+

Age Groups

Rat

e/10

0,00

0 .

White Male AI Male Black Male AI Female

Douglas Jackobs 2003 R. Dale Walker, M.D., 2003

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Native Suicide: A Multi-factorial Event

-Edn,-Econ,-Rec-Edn,-Econ,-Rec

Family DisruptionDomestic ViolenceFamily DisruptionDomestic Violence

ImpulsivenessImpulsiveness

Negative Boarding SchoolNegative Boarding School

HopelessnessHopelessness

Historical TraumaHistorical Trauma

Family HistoryFamily History

SuicidalBehaviorSuicidal

Behavior

Cultural DistressCultural Distress

Psychiatric Illness& StigmaPsychiatric Illness& Stigma

Psychodynamics/Psychological VulnerabilityPsychodynamics/Psychological Vulnerability

Substance Use/AbuseSubstance

Use/Abuse

Suicide

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Suicide

“The complexity of causes necessarily requires a multifaceted approach to prevention that takes into account cultural context. Cultural factors play a major role in suicidal behavior.” and its treatment

Violence – A global public health problem, World Health Organization, 2002, p. 206. DeLeo, D. Cultural Issues in suicide and old age. Crisis, 1999, 20:53-55.

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Current Cluster Suicide Crisis in a Tribal Community

• 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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Suicide

“Problems are complex and go beyond the capacity, resources, or jurisdiction for any single person, program, organization, or sector to change or control.” Disaster

Lasker R., Weiss E., Broadening Participation in Community Problem Solving: A Muiltidisciplinary Model to SupportCollaborative Practice and Research. Journal of Urban Health: Bulletin of the New York Academy of Medicine. Vol 80,No 1. March 2003. p.5.

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BIA Schools• 184 elementary and secondary schools and

dormitories (55) as well as 27 colleges• In 23 states • 60,000 total students• 238 different tribes• Majority of the schools are located in Arizona

and New Mexico• Second greatest number of schools in the

states of North Dakota and South Dakota• Third greatest lie in the northwest

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Why should schools be involved?

• When students’ behavioral health problems are barriers to learning and development. From Carnegie Task Force on Education.

• Schools need to take steps to minimize factors that lead to student alienation and despair.

• Schools are in a unique position to promote healthy development and protective buffers, offer risk prevention programs, and help to identify and guide students in need of special assistance.

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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

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Four Phases of Emergency Management

• Mitigation (prevention)• Preparedness• Response• Recovery

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Community Assessment

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Community Assessment

Five parts to a community assessment:

• Description of community

• Assessment of needs

• Assessment of resources

• Community history

• Problem statement(s)

3.1

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Stages of Disaster

The community response in grief.• HEROIC: From impact to about one week

out.• HONEYMOON: Lasts several weeks and

there is a sense of the community “pulling together.”

• DISILLUSIONMENT: One month to even a couple of years. Hype is gone and questions are unanswered.

• RECONSTRUCTION: Final stage with realization of what has been experienced and what they can do to restore the community.

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Prevention Programs Enhance Protective Factors

• strong family bonds • parental monitoring • parental involvement • success in school performance• pro social institutions (e.g. such as family,

• school, and religious organizations)• conventional norms about

• drug use

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Ecological Model

IndividualPeer/FamilySociety Community/Tribe

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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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Stress Management

• Mental health professionals with child/family training

• Information, information, information• Provide energy outlets for kids• Provide parents with time away from kids• Provide best possible sleep environment• Therapeutic play (drawing, role play)

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Comprehensive Behavioral Health/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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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

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Effective Family Intervention Strategies: Critical Role of

Families

• Parent training• Family skills training• Family in-home support• Family therapyDifferent types of family interventions are used

to modify different risk and protective factors.

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Promising Strategies

• Home visitation

• Parent training

• Mentoring

• Social cognitive

• Cultural

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Partnered Collaboration

Research-Education-Treatment

Grassroots Groups

Community-BasedOrganizations

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Potential Organizational Partners

• Education

• Family Survivors

• Health/Public Health

• Mental Health

• Substance Abuse

• Elders,

• Law Enforcement

• Juvenile Justice

• Medical Examiner

• Cultural specialist

• County, State, and Federal Agencies

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Contact us at503-494-3703E-mail Dale Walker, MDonesky@ohsu.eduOr visit our website:www.oneskycenter.org