[Senate Hearing 111-36]
[From the U.S. Government Publishing Office]
S. Hrg. 111-36
YOUTH SUICIDE IN INDIAN COUNTRY
=======================================================================
HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
----------
FEBRUARY 26, 2009
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Printed for the use of the Committee on Indian Affairs
YOUTH SUICIDE IN INDIAN COUNTRY
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COMMITTEE ON INDIAN AFFAIRS
BYRON L. DORGAN, North Dakota, Chairman
JOHN BARRASSO, Wyoming, Vice Chairman
DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona
KENT CONRAD, North Dakota LISA MURKOWSKI, Alaska
DANIEL K. AKAKA, Hawaii TOM COBURN, M.D., Oklahoma
TIM JOHNSON, South Dakota MIKE CRAPO, Idaho
MARIA CANTWELL, Washington MIKE JOHANNS, Nebraska
JON TESTER, Montana
TOM UDALL, New Mexico
_____, _____
Allison C. Binney, Majority Staff Director and Chief Counsel
David A. Mullon Jr., Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on February 26, 2009................................ 1
Statement of Senator Barrasso.................................... 6
Statement of Senator Dorgan...................................... 1
Prepared statement........................................... 2
Statement of Senator Johanns..................................... 60
Statement of Senator Murkowski................................... 52
Statement of Senator Udall....................................... 54
Witnesses
Broderick, Eric B., D.D.S., M.P.H., Acting Administrator,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services........................ 68
Prepared statement........................................... 70
Jetty, Dana Lee, Student, Minnewaukan Public School; Member of
Spirit Lake Dakotah Nation..................................... 14
Prepared statement........................................... 16
LaFromboise, Teresa D. , Ph.D., Associate Professor of Counseling
Psychology and Chair of Native American Studies, Stanford
University..................................................... 47
Prepared statement........................................... 49
Lewis, Hayes A., Director, Center for Lifelong Education,
Institute of American Indian Arts.............................. 37
Prepared statement........................................... 40
McSwain, Hon. Robert G., Director, Indian Health Service, U.S.
Department of Health and Human Services........................ 61
Prepared statement........................................... 63
Moore, Hon. Robert, Member, Great Plains Tribal Chairmen's
Association and Aberdeen Area Tribal Chairmen's Health Board;
Council Member, Rosebud Sioux Tribe............................ 18
Prepared statement........................................... 20
Reid, Hon. Harry, U.S. Senator from Nevada....................... 7
Prepared statement........................................... 11
Walker, R. Dale, M.D., Director, One Sky Center, Oregon Health
and Science University......................................... 24
Prepared statement with attachments.......................... 26
Appendix
Bordeaux, Rodney, President, Rosebud Sioux Tribe, prepared
statement...................................................... 117
Flynn, Laurie, Executive Director, TeenScreen National Center for
Mental Health Checkups, Columbia University, prepared statement 112
Gallanos, James, LCSW Project Coordinator, Office of Prevention
and Early Intervention Services, Division of Behavioral Health,
prepared statement with attachments............................ 129
Gray, Jacqueline S., Ph.D., Assistant Professor, Center for Rural
Health, University of North Dakota School of Medicine and
Health Sciences, prepared statement with attachment............ 79
Hawkins, Jessica, Prevention Program Manager, Oklahoma Department
of Mental Health and Substance Abuse Services, prepared
statement with attachment...................................... 90
Kauffman, Jo Ann, President, Kauffman & Associates, Inc.,
prepared statement with attachment............................. 102
Lewis, Hayes A., Director, Center for Lifelong Education,
Institute of American Indian Arts, prepared statement.......... 122
Not Afraid, Leroy M., Member, Great Crow Nation, prepared
statement...................................................... 120
Oglala Sioux Tribe, prepared statement........................... 115
Patterson, Brian, President, United South and Eastern Tribes,
Inc., prepared statement....................................... 117
Response to Written Questions Submitted to Eric B. Broderick,
D.D.S., M.P.H. by:
Hon. John Barrasso........................................... 206
Hon. Maria Cantwell.......................................... 207
Hon. Byron L. Dorgan......................................... 202
Response to Written Questions Submitted to Hon. Robert G. McSwain
by:
Hon. John Barrasso........................................... 346
Hon. Maria Cantwell.......................................... 348
Hon. Tom Coburn.............................................. 349
Hon. Byron L. Dorgan......................................... 343
Rios, Emilio, Member, Three Affiliated Tribes, prepared statement 196
Whiteman Tiger, Cora, prepared statement with attachments........ 86
Written Questions Submitted to:
Teresa D. LaFromboise, Ph.D.................................. 354
Hayes A. Lewis............................................... 352
Hon. Robert Moore............................................ 349
R. Dale Walker, M.D.......................................... 350
Supplementary information submitted for the record:
A College Suicide Model for American Indian Students......... 230
Article, entitled, Durkheim's Suicide Theory and Its
Applicability to Contemporary American Indians and Alaska
Natives.................................................... 273
Article, entitled, Suicide and Self-Destruction Among
American Indian Youths..................................... 285
Article, entitled, Youth Suicide in New Mexico: A 26-Year
Retrospective Review....................................... 329
Articles from the Argus Leader............................... 303
North Dakota suicide trend charts............................ 334
Letter submitted to Secretary Mike Leavitt by Hon. Tim
Johnson.................................................... 229
Letter submitted to Hon. Byron L. Dorgan and Hon. John
Barrasso by Stephanie Hall and Whitney Osceola............. 227
Mindstreet letter with Psychiatric Times article............. 224
Presentation on Native American Prevention Initiatives in New
Mexico..................................................... 337
Sources of Strength Program information...................... 210
Study paper, entitled, Adolescent Suicide at an Indian
Reservation................................................ 254
Study paper, entitled, An Update on American Indian Suicide
in New Mexico, 1980-1987................................... 261
YOUTH SUICIDE IN INDIAN COUNTRY
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THURSDAY, FEBRUARY 26, 2009
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10 o'clock a.m.
in room 628, Dirksen Senate Office Building, Hon. Byron L.
Dorgan, Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. BYRON L. DORGAN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. I will call the hearing to order. This is a
hearing of the Indian Affairs Committee of the United States
Senate. The subject of the hearing today is an oversight
hearing on youth suicide in Indian Country.
I have an opening statement. I think I will just simply
make a couple of comments and then call on Vice Chairman
Barrasso for a couple of opening comments. Our Senate Majority
Leader is here as our first witness, and I want to get right to
him.
I want to make just a couple of brief comments about this
subject. It is a very sensitive subject. I have held a couple
of hearings on it, one in North Dakota where we had a cluster
of teen suicides on the Standing Rock Sioux Tribe Reservation.
I held a hearing here in Washington, D.C. on it. I acknowledged
when I held the hearing that this is a very sensitive subject,
a very difficult subject.
I have told the story on the floor of the United States
Senate, with the consent of the relatives, of a young woman
named Avis Little Wind. Avis was 14 when she died. Avis Little
Wind apparently felt hopeless and helpless and took her own
life. She laid in a bed at home for some 90 days in a fetal
position and nobody asked about her. Somehow she was never
missed. Her sister had committed suicide. Her mother was a drug
abuser. Her father had taken his own life. And somehow she just
fell through the cracks.
Avis Little Wind was just a 14 year old girl who ended her
life very early. I went to that reservation. I met with the
tribal council. I met with school officials. I met with her
classmates. I was just trying to understand what is happening
and why. What causes this?
Following that, and following discussions at the Standing
Rock Reservation where I went and met just myself with a good
number of high school students to talk to them about their
lives, we put together some legislation to try to make mental
health treatment and counseling more widely and readily
available to young people on Indian reservations, to try to, as
one response, address some of the issue of teen suicides.
Today, we will hear about what those efforts have resulted
in. We are going to hear from a good number of witnesses. We
are going to hear from Dana Lee Jetty, who is a student at
Minnewaukan Public School and a member of the Spirit Lake
Dakotah Nation. Dana's sister took her life. Her parents are
with us today.
We want to hear testimony from a number of members of other
tribes. We are going to hear testimony from the Director of the
Indian Health Service and the Acting Administrator of the
Substance Abuse and Mental Health Services over at the
Department of Health and Human Services.
I want to mention we have a vote that will occur at 10:30
a.m., so we will recess for the vote today. After I call on
Vice Chairman Barrasso for a couple of comments, I am going to
call on our Majority Leader. We are enormously honored that he
has joined us today to be the lead-off witness on this very
important subject.
Prepared Statement of Hon. Byron L. Dorgan,
U.S. Senator from North Dakota
Today, we will hold an oversight hearing on Youth Suicide in Indian
Country. The purpose of today's hearing is to examine the effectiveness
of the current prevention programs in Indian Country.
The issue of suicide is of great importance both to this Committee
and to me personally. As someone who has felt the crushing blow of
suicide by a friend and co-worker, I am aware of the tremendous effect
suicide has on surviving family members, friends and a community.
Indian Country suffers from many health and economic disparities
that have been linked to a higher risk of suicide: alcohol and
substance abuse, depression and mental illness, unemployment, and
domestic violence.
The broken health care system in Indian Country adds to the risk of
suicide in American Indian communities.
The unfortunate result is that the rate of suicide among American
Indian and Alaska Natives is 70 percent higher than the general U.S.
population.
Today, we are focused on our young people in Indian Country and
sadly they are not spared from these trends. [Chart 1] In this chart,
we have listed on the left the 10 states with the highest percentage of
Indians and on the right the 10 states with the highest rates of youth
suicide. As you can see, the correlation is very troublesome.
[Chart 2] This next chart shows the rates of suicide for ages 10 to
24 across numerous racial groups. As you can see, American Indian and
Alaska Native youth have the highest rate of suicide for both males and
females. Young American Indian men have a suicide rate 2 to 4 times
higher than adolescent males and 11 times higher than same-age females
in other racial groups.
In the last decade, Indian Reservations have seen youth suicide
rates reach epidemic levels. In 2005, there were youth suicide clusters
on the Standing Rock, Crow Creek and Cheyenne River Reservations. This
is a crisis that we must address.
I want to show a chart [Chart 3] which depicts the disparity in
youth suicide rates from my home state. The top line shows the rate of
suicide for American Indians, ages 10 to 24. The bottom line shows the
same for Caucasians. Again, the rate for American Indians is incredibly
high, but it also shows a decline over the past two years.
In response to the epidemic in 2005, the issue of youth suicide in
Indian Country gained National attention. Agencies, like the Substance
Abuse and Mental Health Services Administration and the Indian Health
Service, began specific initiatives to deal with the crisis. New grant
funding, like the Garrett Lee Smith grants, were available for youth
suicide prevention and many Tribal communities have received funding
for their own programs.
This Committee held three hearings on youth suicide in 2005 and
2006. Part of what we are doing today is to follow-up on youth suicide
prevention efforts that have occurred since our last hearing.
We will receive an update from the federal agencies responsible for
administering youth suicide programs, experts on the issue and Tribal
leaders who see the impact of youth suicide every day. We will also be
hearing from a longtime advocate for suicide prevention, the honorable
Majority Leader Reid.
I want to end my statement by saying, one youth suicide is one
tragedy too many. This issue is about more than numbers, it is about
the families and communities left behind and the young lives we have
lost. [Chart 4] I want to show you see the face of a beautiful young
woman, Jami, from the Spirit Lake Nation in my home state of North
Dakota. Last November, Jami felt hopeless and decided to take her own
life. Today, her sister, Dana will tell us, on a personal level, what
youth suicide really means for Indian Country. We all need to work to
address this crisis.
I want to thank all the witnesses for being here today and look
forward to your testimony.
Senator Barrasso?
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Well, thank you, Mr. Chairman. Like you,
I have an opening statement, and it is an honor to have Senator
Reid here, so I will submit my opening statement to the record.
But I just want to say that no community is, or ever will
be, immune from the tragedy of suicide. We have to make sure
that the trauma of suicide and its aftermath does not paralyze
the community. With that, I would like for just a few seconds,
Mr. Chairman, to talk about the Wind River Indian Reservation
in Wyoming, home of the Eastern Shoshone and the Northern
Arapaho Tribes. It serves as an example.
You talked about how serious and how sensitive this issue
is. In two short months a number of years ago, nine young
Native American men between the ages of 15 and 25 committed
suicide, with another 88 verifiable suicide attempts occurring
on the reservation within that time frame.
Mr. Chairman, the Wind River Indian community mobilized to
address this crisis, creating a team that included that Bureau
of Indian Affairs, the Indian Health Service personnel, as well
as the traditional and tribal leaders. Mr. Chairman, the
suicides and the suicide attempts soon subsided. Since that
time, the number of youth suicides has been decreasing on the
reservation.
So I am particularly pleased that the Northern Arapaho
suicide prevention team works well with the Fremont County
Suicide Prevention Task Force and know that there are solutions
and we can find them. Working together, we can improve our
efforts even more.
So with that, Mr. Chairman, let me just submit my statement
to the record and welcome along with you, and say what an honor
it is, for all of us to have Senator Reid with us this morning.
Thank you, Mr. Chairman.
The Chairman. Thank you very much.
I did not mention that the rate of suicide among American
Indian and Alaska Natives is 70 percent higher than the general
U.S. population. We have seen very troubling clusters of
suicides, especially among Indian teens. That is what this
hearing is about today.
Senator Reid, we are pleased that you are here. The
presence of the Majority Leader is always an honor. I know that
this issue is something that is very personal to you and that
you have spent significant time working on it as well.
Thank you for being here, and you may proceed.
STATEMENT OF HON. HARRY REID,
U.S. SENATOR FROM NEVADA
Senator Reid. Chairman Dorgan, Dr. Barrasso, it really is a
pleasure for me to be here today. I appreciate your holding the
hearing.
As Chairman Dorgan mentioned, this issue of suicide is very
personal to me. More than a dozen years ago, I attended a
Special Committee on Aging meeting chaired by Senator Bill
Cohen from Maine. At the hearing, Mike Wallace talked about his
emotional problems. This famous man, the anchor for 60 Minutes
for so long, indicated that there were many times that he
wanted to die. He would try to pick assignments hoping that
maybe something would go wrong and he wouldn't be able to come
back.
I was so impressed with his courage being there, his
ability to speak publicly about a problem he had and the
treatment he had received. Basically what he said was, ``I
don't have that problem anymore. I take a little bit of
medicine, talk to somebody once in a while, and I am fine.''
At that time I commended him for his speaking out publicly
about a condition that some associate with weakness, that some
people, and many feel frankly, is a stigma. It was during this
hearing that I came to the conclusion that my own personal
experience in dealing with my dad, is something that I should
talk about publicly. I and my family had kind of kept it to
ourselves. Had we really failed? Why did my dad shoot himself
in the head with a pistol? The whole family, we just kind of, I
guess, pretended it hadn't happened.
But at this hearing on Aging, I said that my dad had killed
himself and that we should hold a hearing on senior suicide,
and we did. I came to the realization that suicide was a
national problem, not my problem, not my family's problem, not
Nevada's problem, but a national problem. I came to the
realization that there were people that needed to be advised
that they were not the cause of someone having killed
themselves.
The people who survive a suicide are many times the victim
themselves. Feelings of guilt persist. So following these
hearings that Chairman Cohen was willing to have, I was
contacted by a married couple from Georgia. There name was
Weyrauch, Georgia and Elsie Weyrauch. They had lost an adult
daughter, who was a physician. They were so proud of her. She
got out of medical school and had a good, successful practice,
but she killed herself. These two wonderful people founded the
Suicide Prevention Advocacy Network to raise awareness about
the issue.
So with their encouragement and that of a wonderful staff
member of mine who became so involved in this, Jerry Reed, who
since has left my office, and gone on to get a Ph.D. He has
worked on suicide since those hearings that we had in the Aging
Committee. He is here today, still working in suicide
prevention.
With their support I proposed S. Res. 84, which declared
suicide to be a national problem and sought to make suicide
prevention a national priority. It passed the Senate. It passed
the House. After Surgeon General David Satcher was confirmed, I
invited him to approach suicide as a national public health
issue, and he did. In 1998, he convened a conference in Reno,
Nevada. The Reno conference brought together experts from all
over the Country to address the problem of suicide. By the time
they were finished, they had come up with a national strategy
for suicide prevention.
There are so many interesting things about suicide. Why are
the leading States of suicide west of the Mississippi? For
those of us in the West, where the air is so clear and the sun
is so bright, and we don't have the dark winters, why is that?
We are trying to figure it out. We don't know even now. But Dr.
Satcher's convening the conference gave the issue some
momentum. In 2001, a couple of years after that, the United
States Department of Health and Human Services published its
national strategy for suicide prevention, which provides a
blueprint for suicide prevention in the United States. In 2002,
a year later, the Institute of Medicine published its report,
Reducing Suicide: A National Imperative.
Now, Committee members, there had been nothing done about
suicide prior to that. No money had been spent to try to figure
out why there is more suicide in the West than the East. And
now, there are studies going on. We need to make sure that they
can continue and it is going to take a little bit of taxpayers
money, but it is important. Because you see, more than 30,000
people kill themselves every year. Now, those are the people
that are reported suicides. There are a lot of suicides that
are car wrecks, hunting accidents, and boating accidents who
really aren't listed as suicides, but they are.
As a result of these calls to action, we have suicide
research centers, suicide hot lines, and the National Suicide
Prevention Resource Center. This center is designed to provide
States and communities with evidence-based strategies for
suicide prevention. Importantly, the center collaborates with
many organizations like the One Sky Center, represented today,
and he will testify here, Dr. Walker, to promote widespread
implementation of a national strategy.
Here in the Senate, one of our members of our Senate
family, Senator Gordon Smith, lost his 21 year old son to
suicide. What a sad story. Garret Lee Smith was his name. And
we all who served with Gordon heard about the love he and his
wife have and had for their boy, who as a college student
killed himself. The Garret Lee Smith Memorial Act became the
first law to address youth suicide, so we are making progress.
Many of us here today, including you, Mr. Chairman,
Senators Akaka, Johnson and Murkowski, sponsored this
legislation because of its potential to help communities and
families save lives. During the last session of Congress, we
made some steps forward. After many, many years of talking
about it, we finally stuck into one of the must-pass bills, the
Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Act. We passed that legislation, and it was important
that we did it.
We have done some other good things. Under your leadership,
Mr. Chairman, the Senate passed the Indian Health Care
Improvements Act last year. It is so important we took care of
that, but we still were unable to get it done, for a lot of
reasons. I hope we try it again. It would have created an
Indian Youth Health Program for suicide prevention,
intervention and treatment efforts. I repeat, it is too bad it
didn't pass.
So I look forward to working with you and your colleagues
to pass this legislation now, this year. If not this year, next
year.
We have made some progress and that is important we talk
about that, since the first hearing we had back in 1996. In
fact, we have really come a long way. It is amazing what a few
Congressional hearings can do to bring attention to such an
important issue. We need to do more. We need to focus on
populations that are particularly at risk, American Indians.
We have 26 separate tribal communities in Nevada. I have
worked hard to try to understand Indian Country. Mr. Chairman,
you know that the suicide rate for Native Americans, who are
between ages 15 and 34, as you have already indicated, is more
than two times higher than the national average. Among this age
group of Native Americans, 15- to 34-year-olds, it is the
second leading cause of death. That is really staggering.
In fact, the rate of suicide among youth on Indian
reservations is three times greater than any other youth
population. It has to be, for lack of a better description, a
crisis.
The one thing that I have heard a number of you talk about,
Mr. Chairman, you and Dr. Barrasso, is multiple suicides in a
family. That is a study. This is not rare. It happens all the
time. We have had instances of where a grandfather, a father
and a son have committed suicide, in the same family. Nevada
has one of the Nation's highest rates of suicide. In fact, I
think we probably are the highest. The data suggests that our
Native Americans in Nevada are even more likely than non-Native
Americans to consider an attempt and to die from suicide, as we
have already established. Outreach and awareness efforts on a
number of Nevada's more remote reservations certainly make this
case.
That is why I support efforts of Federal agencies, public-
private partnerships, tribes and others who develop and provide
suicide prevention treatment programs are vitally important.
The Indian Health Service has partnered with HHS and tribes to
develop and implement a suicide prevention initiative. It is
behind schedule.
In recent years, SAMHSA's direct funding grants in
partnership opportunities have generated research and supported
programs in the field. A few Nevada tribes have received grant
funds to promote prevention and provide treatment within their
communities.
Then there are programs in places like Boys and Girls
Clubs, tribal community buildings, native language nests and
language schools that build community, provide after-school
programming, and strengthen the social fabric.
Mr. Chairman, it doesn't take much. We learned in some of
the hearings we held many years ago that mail carriers, people
who deliver mail, can be trained, especially with certain
populations like senior citizens, to see how patterns change,
they don't pick up their mail, et cetera. In the State of
Washington, they have had a number of programs like this which
have been very successful in preventing people from killing
themselves.
We have one Boys and Girls Club in Nevada, on the Walker
River Paiute Reservation. We also have one youth treatment
center on the Pyramid Lake Paiute Reservation. I suggest we
need more to both successfully address the needs of young
people and tribes.
So Mr. Chairman, members of this Committee, I so appreciate
your commitment and attention to this epidemic. Holding this
hearing is so vitally important, and your dedication to
improving and saving the lives of Native Americans,
particularly our kids. And that is what they are. We have to
understand why it is happening and what we can do to slow it
down and ultimately prevent it.
Thank you, Mr. Chairman.
[The prepared statement of Senator Reid follows:]
Prepared Statement of Hon. Harry Reid, U.S. Senator from Nevada
The Chairman. Senator Reid, thank you so much for being
with us.
I want to put up one chart that amplifies something that
you said that is so important for all of us to understand. You
talked about the States with the highest youth suicide rates.
You will see on these charts, it is very interesting that
almost all of them are Midwest and Western States. You
indicated that no one quite knows why that is the case, but
that is a really interesting chart. It is something I had not
known before I saw this chart yesterday.
Does anyone have questions of Senator Reid?
I know, Senator Reid, that it is intensely personal for you
to speak about these issues, and yet I think your decision
previously to speak out on these issues is enormously
beneficial to our Country and to others who hear your
testimony. I very much appreciate your willingness to come
today.
Senator Reid. Byron, it has been good for my family. It has
been good for the family to confront this issue and not be
embarrassed. No one should be embarrassed about this. No one
should feel it is their fault. There are organizations out
there, lots of them now, who will help people work their way
through this. Whenever I see someone where there is a suicide,
I try to call them and give them organizations that can help.
The Chairman. Well, thank you so much for being here today.
I think it does provide an inspiration to others, so thank you
for being with us.
We have a list of witnesses today. I indicated that there
will be a vote at about 10:30 a.m. We probably will break about
20 minutes to 11 a.m., that is 20 minutes from now, to go vote
and come back. We will have a brief recess.
But I want to call on Ms. Dana Lee Jetty, who is a student
at Minnewaukan Public School and a member of Spirit Lake
Dakotah Nation, Fort Totten, North Dakota; the Honorable Robert
Moore, Member of the Great Plains Tribal Chairmen's
Association, and the Aberdeen Area Tribal Chairmen's Health
Board; Dr. Dale Walker, Director of One Sky Center, Oregon
Health and Science University in Portland, Oregon; Mr. Hayes
Lewis, Director of the Center for Lifelong Education, Institute
of American Indian Arts at Santa Fe, New Mexico; and Dr. Teresa
LaFromboise, Associate Professor at Stanford University School
of Education.
I want to say to our colleagues, the Honorable Robert
McSwain and Dr. Eric Broderick, that normally, I would call you
first. I would like, with your permission, to call you after
this panel so that you have a chance and an opportunity to
listen to this panel, and then respond. So I appreciate your
indulgence and thank you so much for that.
Let me begin with Dana Lee Jetty. Dana Lee Jetty is here
with her family. The circumstances of our inviting her here are
very tragic circumstances. I know how difficult these things
are. It is good of you to come. Dana Lee's sister took her
life. Her sister's name was Jami Rose Jetty. It was just last
November. She is a high-schooler in Minnewaukan, North Dakota,
which is on the edge of the Spirit Lake Nation Reservation. She
has agreed to come with her parents and visit with us today. I
am going to begin with you, Dana Lee. You may proceed.
STATEMENT OF DANA LEE JETTY, STUDENT, MINNEWAUKAN PUBLIC
SCHOOL; MEMBER OF SPIRIT LAKE DAKOTAH NATION
Ms. Jetty. My name is Dana Jetty. I am 16 years old and I
am an enrolled member of the Spirit Lake Tribe of North Dakota.
Before I begin, I would like to thank the Committee for giving
me the opportunity to talk to you about my family and, more
importantly, about my sister Jami.
Jami was 14 years old. She had a lot of friends and was
mature for her age. Jami was open-minded and always asking
questions about anything and everything. She was very caring,
sweet, compassionate and never judged anyone. She saw the world
in black and white, and found pleasure in simple things like
listening to old stories from long ago. Jami was like any other
teenage girl from a middle-class home surrounded by a family
who loved her.
November 3, 2008 started as a day like any other, but it
ended as a day that I will never forget. November 3, 2008 is
the day that my baby sister, Jami Rose Jetty, ended her own
life. My sister and I were home that day and Jami woke me up
about 9:30 in the morning to tell me that she felt sick and
dizzy. I knew my sister had been having problems with
depression, and I asked her if she had taken anything. She told
me she had, so I immediately called my mom at her office. My
mom came to the house right away, but Jami refused to tell her
what she had taken and refused to go to the clinic.
My mom told me to keep an eye on Jami while she went to
make some calls to see what kind of help she could get for my
sister. Of course, my sister was angry with me for calling my
mom, but I talked to her for a while anyway. After Jami talked
for a while, she asked me to leave her alone. I hesitated, but
decided to give her some space.
After I left her alone, I watched TV and made some food. I
decided to clean up and called for Jami to come help me, but
she did not respond. I walked towards the back of the house and
saw that the bathroom door was closed, but the light was on. I
opened it, but she was not in there. I looked towards Jami's
bedroom and her door was also closed. I opened it, and I was
instantly flooded with feelings of fear and shock. It was like
a horrible dream that I cannot wake up from.
I saw my sister with a belt fastened to the bunk bed and
wrapped around her neck. Jami was sitting lifelessly, her body
leaning against the wall. I ran to get my boyfriend and I tried
to get the belt off her neck, but it was too tight. My
boyfriend got a knife and cut her down. All I could do was
yell, why, as I rocked her lifeless body in my arms.
The next thing I recall is my mom and dad running into the
house. I watched as my mom frantically called the police and my
dad desperately tried to perform CPR. Within minutes, the
police and paramedics arrived. Even though the paramedics did
get a slight pulse, my sister, Jami Rose Jetty, was not alive
when she arrived at Mercy Hospital in Devils Lake, North
Dakota.
On November 3, 2008, I lost my sister and my best friend.
On November 3, 2008, my life and my family changed forever.
Suicide has left me feeling lost, lonely and angry. I don't
understand why my sister felt that she had to do this, and I
don't know why she didn't ask me for help or tell me what she
was thinking. Knowing my sister, she would not have wanted to
burden others with her problems, but I wish she would have told
me.
I, along with my family, have turned to our spirituality
and our faith to guide us through this dark time. We have
prayed. We have attended sweat ceremonies, and we have talked
to whoever will listen to share our experience. In the
aftermath of my sister's suicide and in the ceremonies we
attended, we have come away with a message from Jami that we
are now passing along to others: Tell the ones that are trying
to end their lives this way, it is not the way to go.
And so my sister's message has become a mission for my
family. We have attended meetings in our community to tell
anyone that is considering suicide that it is not the way to
go, and that there are people who can help. In talking to our
community, we have found that suicide is a much more common
problem than we ever realized. People in our community have
opened up to us and have shared their feelings of suicide and
have expressed the shame that they feel for having those
thoughts. I never imagined that so many people had these
thoughts and kept them inside out of a sense of shame and
hopelessness.
While I am surprised at how many people feel suicidal, I am
not shocked at the hopelessness they feel. I know that my mom
had concerns about my sister before her suicide. My mom did all
the right things. She took her to the doctor. She talked to
counselors and she was even evaluated by mental health
professionals from Indian Health Services. The mental health
providers dismissed my mom's concerns and diagnosed my sister
as being a typical teenager. I know my mom is angry that these
professional people did not provide the help she needed, and
her strength and ability to forgive is amazing.
Now, our mission has led us to Washington, D.C. Today, I,
along with my family, ask you to support our efforts to prevent
suicide by funding and developing quality programs and health
services in our tribal communities. It is not enough to put a
counselor in a community. We need trained professionals who
really know how to help our communities. We can stop others
from committing suicide if we talk openly in our communities
and if we provide supportive places for people to go when they
need help for themselves or for their family members.
We need to make sure that our communities and our people
know how to reach out for help if they need it, and we need to
make sure that help is there when they ask. We need to share
Jami's message: Tell the ones that are ending their lives this
way that it is not the way to go.
And so today, I am here on behalf of my sister Jami Rose
Jetty to ask for your help. I ask that you support suicide
prevention programs in our tribal communities, and I ask that
when you have your discussions on the issue of suicide, you
remember my sister. She was 14 years old. She was a beautiful,
outgoing teenager with her whole life ahead of her. She was my
sister, and she is what suicide looks like in Indian Country.
Thank you for giving me the opportunity to share Jami's
message with you today. Thank you.
[The prepared statement of Ms. Jetty follows:]
Prepared Statement of Dana Lee Jetty, Student, Minnewaukan Public
School; Member of Spirit Lake Dakotah Nation
My name is Dana Jetty, I am 16 years old and I am an enrolled
member of the Spirit Lake Tribe in North Dakota. Before I begin I would
like to thank the Committee for giving me the opportunity to talk to
you about my family and more importantly about my sister Jami.
Jami Rose Jetty was 14 years old, she had a lot of friends, and was
mature for her age. Jami was open minded and always asking questions
about anything and everything. She was very caring, sweet,
compassionate, and never judged anyone. She saw the world in black and
white and found pleasure in simple things like listening to stories
from long ago. Jami was like any other teenage girl from a middle class
home surrounded by a family who loved her.
November 3, 2008 started as a day like any other but it ended as a
day that I will never forget. November 3, 2008 is the day that my baby
sister, Jami Rose Jetty, ended her own life. My sister and I were home
that day and Jami woke me up around 9:30 in the morning to tell me that
she felt sick and dizzy. I knew my sister had been having problems with
depression and I asked her if she had taken anything. She told me she
had so I immediately called my mom at her office. My mom came to the
house right away but Jami refused to tell her what she had taken and
refused to go to the clinic. My mom told me to keep an eye on Jami
while she went to make some calls to see what kind of help she could
get for my sister. Of course my sister was angry with me for calling my
mom but I talked to her for a while anyway. After Jami talked for a
little while, she asked me to leave her alone. I hesitated but decided
to give her some space.
I left her alone and watched TV and made some food. I decided to
clean up and called for Jami to come and help me, but there was no
response. I walked towards the back of the house and saw that the
bathroom door was closed but the light was on. I opened it but she was
not in there. I looked towards Jami's bedroom and her door was also
closed. I opened it and was instantly flooded with feelings of fear and
shock. It was like a horrible dream that I could not wake up from. I
saw my sister with a belt fastened to the bunk bed and wrapped around
her neck. Jami was sitting lifelessly, her body leaning against the
wall. I ran to get my boyfriend and I tried to get the belt off her
neck but it was too tight. My boyfriend got a knife and cut her down.
All I could do is yell ``Why?'' as I rocked her lifeless body in my
arms. The next thing I recall is my mom and dad running into the house.
I watched as my mom frantically called the police and my dad
desperately tried to perform CPR. Within minutes the police and
paramedics arrived. Even though the paramedics did get a slight pulse,
Jami Rose Jetty, my baby sister, was not alive when she arrived at
Mercy Hospital in Devils Lake, ND.
On November 3, 2008 I lost my sister and my best friend. On
November 3, 2008 my life and my family changed forever. Suicide has
left me feeling lost, lonely and angry. I don't understand why my
sister felt that she had to do this and I don't know why she didn't ask
me for help or tell me what she was thinking. Knowing my sister she
would not have wanted to burden others with her problems, but I wish
she would have told me.
I, along with my family have turned to our spirituality and our
faith to guide us through this dark time. We have prayed, we have
attended sweat ceremonies and we have talked to whoever will listen to
share our experience. In the aftermath of my sister's suicide and in
the ceremonies we attended we have come away with a message from Jami
that we are now passing along to others ``. . . tell the ones that are
trying to end their lives this way that it is not the way to go. . .
''.
And so my sisters' message has become a mission for my family. We
have attended meetings in our community to tell anyone that is
considering suicide, that this is not the way to go and that there are
people who can help. In talking to our community we have found that
suicide is a much more common problem than we ever realized. People in
our community have opened up to us and have shared their feelings of
suicide and have expressed the shame that they feel for having those
thoughts. I never imagined that so many people had these thoughts and
kept them inside out of a sense of shame and hopelessness. While I am
surprised at how many people feel suicidal, I am not shocked at the
hopelessness they feel. I know that my mom had concerns about my sister
before her suicide. My mom did all the right things. She took her to
the doctor, she talked to counselors, and she even had her evaluated by
mental health professionals from Indian Health Services. Those mental
health providers dismissed my moms concerns and diagnosed my sister as
being a ``typical teenager''. I know my mom is angry that these
professional people did not provide the help when she needed it and her
strength and ability to forgive is amazing.
Now our mission has led us to Washington, D.C. and today I, along
with my family, ask you to support our efforts to prevent suicide by
funding and developing quality programs and health services in our
Tribal communities. It is not enough to put a counselor in a community.
We need trained professionals who really know how to help our
communities. We can stop others from committing suicide if we talk
openly in our communities and if we provide safe and supportive places
for people to go when they need help for themselves or their family
members. We need to make sure that our communities and our people know
how to reach out for help if they need it and we need to make sure that
the help is there when they ask. We need to share Jami's message: ``. .
. tell the ones trying to end their lives this way, that it is not the
way to go. . . ''.
And so today, I am here on behalf of my sister, Jami Rose Jetty to
ask for your help. I ask that you support suicide prevention programs
in our tribal communities and I ask that when you have your discussions
on the issue of suicide you remember my sister. She was 14 years old.
She was a beautiful, outgoing teenager with her whole life ahead of
her. She was my sister and she is what suicide looks like in Indian
Country.
Thank you for giving me the opportunity to share Jami's message
with you today.
The Chairman. Well, Dana, thank you very much. You have
given all of us today an opportunity to remember your sister.
My guess is that your little sister would be enormously proud
of you.
Ms. Jetty. Yes.
The Chairman. The tragedy that has visited your family and
the loss of your sister is intensely personal and intensely
emotional to your family. And yet, for all of us to try to find
lessons here that might help others who experience this tragedy
is so important.
I mentioned in the opening statement the death of Avis
Little Wind on the same Indian reservation.
Ms. Jetty. Yes.
The Chairman. She, too, hung herself at age 14. I spent
time going there, talking to everybody I could talk to to
understand what happened there.
Ms. Jetty. Yes.
The Chairman. There are not obvious or easy answers. Often,
it is very complicated. But the one thing that was clear to me
and has always been clear to me, and is true on almost every
Indian reservation, there is not readily accessible treatment
by qualified professionals that are available. It is something
we have to fix. I mean, this is a great tragedy.
So we all appreciate very much your being willing to come
and do something that I know is very, very difficult for you
and your family to do, and that is speak publicly about it. You
heard our colleague, Senator Reid, describe the inclination not
to talk about these things.
But I think your willingness to come to Washington, D.C.
and to speak publicly about these things will help others. So
we appreciate that.
Ms. Jetty. Yes.
The Chairman. What I am going to do, with the permission of
my colleagues, is hear from the other witnesses, and then we
all have a chance to ask Dana questions and other witnesses
questions, if that is permissible. We likely will have to be
interrupted by this recess for a vote.
Let us start with the Honorable Robert Moore, who is a
member of the Great Plains Tribal Chairmen's Association and, a
Council Member of the Rosebud Sioux Tribe
Mr. Moore?
STATEMENT OF HON. ROBERT MOORE, MEMBER, GREAT PLAINS TRIBAL
CHAIRMEN'S ASSOCIATION AND ABERDEEN AREA TRIBAL CHAIRMEN'S
HEALTH BOARD; COUNCIL
MEMBER, ROSEBUD SIOUX TRIBE
Mr. Moore. Thank you, Mr. Chairman. Thank you again. It is
a pleasure to see you as well again.
I am very honored and humbled to be here to represent the
many tribes of the Great Plains, with which you are very
familiar. You mentioned several of your own experiences out
there in hearings and understanding, particularly at Standing
Rock and others, like the story of Jami. There are hundreds of
those stories in our area alone.
In the Aberdeen area, as a matter of fact, when you look at
some of the statistics, the national death rate from suicide is
approximately 10 per 100,000, 17 per 100,000 in the IHS
population and the service area, and in the Aberdeen area
alone, it is over 22 per 100,000.
At Rosebud, we have been sort of identified as the
epicenter of suicide in Indian Country. Recently and just
yesterday, Indian Health Services service unit at Rosebud
released an alarming statistic. In our tribe alone, the suicide
rate is 200 per 100,000 for males ages 15 to 24, which right
now puts us as having the highest suicide rate in the world, in
that little pink rectangle that Rand McNally calls the Rosebud
Sioux Indian Reservation in your atlas.
It is very alarming. There is not a single family member or
tribal citizen at Rosebud that has not been directly impacted
by the overwhelming number of suicides in our area. As a result
of this, and as a result of the growing concern of elected
tribal leadership and the entire community, we responded in a
way that really organized and efficiently and effectively
brought together tribal agencies to respond from all levels,
including areas of law enforcement, alcohol and substance
abuse, our tribal university and others.
As you know, in Indian Country it is very important for us
to have a very holistic approach to not just suicide, but to
the overall wellness of all of our community, which includes
those areas like law enforcement and education. And then we can
be able to more directly address suicide.
I have several recommendations that are, I think, important
for us to talk about. One is we need improved collaboration,
not only with what we currently have experienced, and I have to
extend a great amount of appreciation to Mr. McSwain, Mr.
Broderick and others who have really helped us and joined
together as an overall HHS Department-wide response to our
situation specifically at Rosebud. But we need improved
collaboration, cooperation and data-sharing between IHS and
tribes, and elevating suicide to a very reportable medical
system of reporting so that the information is out there for
tribes and IHS to be more response than they are and have been
so far.
IHS has to change its health care paradigm. Right now, IHS
is really responsible for response to medical situations and to
Medicaid. But in their own mission statement, they have
identified health promotion and disease prevention as one of
their leading missions. So we want to work with them to be able
to shift that whole paradigm so that we are able to really
provide a well and healthy community.
Another area that we need to talk about is early childhood
trauma. I have been asked to represent that point in that a lot
of the suicides that have occurred, at least at Rosebud and in
our area, can be directly identified to an incident that
occurred in early childhood, but we don't have the resources
and mechanisms in place to address that when it actually
happens.
However, in some of our programs, we have done very well at
addressing the mental health needs of children. Our diabetes
prevention program is one. We have had great success in
addressing the mental health of our children who are showing
early onset of Type 2 diabetes. In doing that, it has helped
address and alleviate some of those mental health issues in
those homes, but that is only just a small pocket in our
community.
We also need the resources to really reach out and develop
home-based, community-based response to suicide and to the
behavioral and mental health issues in our tribal communities,
where we have actual citizens engaged in response, actual
citizens engaged in promoting and addressing the self-esteem of
our children. One of the leading causes of suicide is lack of
self-esteem.
So one of the things that we are doing in Rosebud is we
have established the Wiconi Wakan Health and Healing Center. It
means life is sacred. Our faith-based community and our
traditional spiritual leaders have really joined together to
invoke the spiritual life of our tribal citizens at Rosebud,
particularly, as they have around the Country. It is a very
spiritual issue for tribal citizens.
Then finally, as we look at one of the issues that was
mentioned in the earlier testimony from Jami's sister, is
having the appropriate people in place at IHS and other Federal
agencies or other systems of care in Indian Country. That means
cultural competency. A lot of folks would say, oh, Jami's
situation is that of just a typical teen, without fully
understanding some of the cultural life that we have and having
the competency to address that part of our lives in Indian
Country.
You have my written testimony. We will be glad to continue
to work with you and the entire Committee and your staff as we
join together in Indian Country to address this issue one on
one. In fact, this Sunday we have our second Suicide Task Force
meeting, which is conducted with the National Congress of
American Indians. We had our first Suicide Task Force meeting
this last fall in Phoenix. We are joining forces on a national
level to address the situation and to provide resources and
opportunities for tribes to respond.
Thank you.
[The prepared statement of Mr. Moore follows:]
Prepared Statement of Hon. Robert Moore, Member, Great Plains Tribal
Chairmen's Association and Aberdeen Area Tribal Chairmen's Health
Board; Council Member, Rosebud Sioux Tribe
Introduction
Mr. Chairman and other Members of the Committee, thank you for your
hard work to ensure that the appropriate authority and funding for
health care services is available to meet the needs of the 17 Tribal
Nations of the Great Plains, and thank you for the opportunity to
provide this testimony on behalf of the Rosebud Sioux Tribe and all the
Tribal Nations of the Great Plains Tribal Chairman's Association. I am
Robert Moore, Elected Councilman of the Antelope Community, Rosebud
Sioux Tribe of South Dakota. I am here today representing the Great
Plains Tribal Chairman's Association (GPTCA), and the Aberdeen Area
Tribal Chairmen's Health Board (AATCHB) -an Association of seventeen
Sovereign Indian Tribes in the four-state region of SD, ND, NE and IA.
The Great Plains Tribal Chairman's Association is founded on the
principles of unity and cooperation to promote the common interests of
the Sovereign Tribes and Nations of the Great Plains and their
citizens.
Great Plains Region
The GPTCA stands on the Fort Laramie Treaty of 1868 (15 Stats. 635)
Articles IV, V and IX that guarantees that the United States will
provide health care services at the local level to our people and will
reimburse the Tribes for any services lost. It was clearly understood
by the Indian signers of that Treaty that necessary assistance would be
provided to the signatory Tribes by the Indian agent and a local
physician (or Superintendent or the Director of Indian Health Service
in the modern era) and that sufficient resources would be made
available to the physician to allow him to discharge the duties
assigned to him. Indian health care fulfills a fundamental Treaty
obligation and our Tribal people take this obligation very seriously.
It is important to note that as Tribal members, we are the only
population in the United States that is born with a legal right to
health care. This right is based on treaties in which the Tribal
Nations exchanged land and natural resources for several social
services, including housing, education and health care.
The Great Plains Region, aka Aberdeen Area Indian Health Service,
has 21 I.H.S. and Tribally managed service units. We are the largest
land based area served of all the Regions with land holdings of
Reservation Trust Land of over 11 million acres. There are 17 Federally
recognized Tribes with an estimated enrollment of close to 200,000
tribal citizens. The Tribes of the Great Plains are greatly underserved
by the I.H.S. and other federal agencies with the I.H.S. Budget
decreasing in FY 2008 over the FY 2007 amount. This is in spite of
increased population size and worsening health disparities. The GPTCA/
AATCHB is committed to strengthening direct health care systems and all
Federal Programs in a comprehensive delivery to improve the lives of
our enrolled members and in particular our Youth of the Seventh
Generation. In the past few years, unfortunately, our Tribes have
experienced an increase of Suicides.
Health Data and Overview
As documented in many reports, the Tribes in the Great Plains
region suffer from among the worst health disparities in the Nation,
including several-fold greater rates of death from numerous causes,
including diabetes, alcoholism, infant mortality and suicide. For
example, the national infant mortality rate is about 6.9 per 1,000 live
births, and it is over 14 per 1,000 live births in the Aberdeen Area of
the Indian Health Service--more than double the national rate. The life
expectancy for our Area is 66.8 years--more than 10 years less than the
national life expectancy, and the lowest in the Indian Health Service
population. Leading causes of death in our Area include heart disease,
cancer, unintentional injuries, diabetes and liver disease. While the
numbers are heart-breaking to us, as Tribal leaders, these causes of
death are preventable in most cases. They, therefore, represent an
opportunity to intervene and to improve the health of our people.
Additional challenges we face, and which add to our health disparities,
include high rates of poverty, lower levels of educational attainment,
and high rates of unemployment. All of these social factors are
embedded within a health care system that is severely underfunded. As
you have heard before, per capita expenditures for health care under
the Indian Health Service is significantly lower than other federally
funded systems, including the health care provided to Federal
prisoners.
Specifics on Suicide
Unfortunately, youth suicide has had a severe and devastating
impact on the Great Plains tribes. The national death rate from suicide
is approximately 10 per 100,000 population, and it is 17 per 100,000 in
the IHS population. In the Aberdeen Area IHS, the suicide rate is over
22 per 100,000 population-more than double the national rate. Adding to
these disheartening numbers is the fact that suicide is more common
among American Indian and Alaska Native youth, whereas suicide rates
tend to increase with advancing age among the general population.
According to the Centers for Disease Control and Prevention (CDC), from
1999-2005, among youth age 10-19 years nationally, the suicide death
rate was 4.5 per 100,000 population.
In South Dakota, where I am from, among American Indians during the
same timeframe, the suicide rate was over 38 per 100,000 population--
more than eight times the national rate. The result is that not only do
we have a higher percentage of people committing suicide, we have a
higher percentage of young people killing themselves--resulting in an
even greater number of years of potential life lost in our populations.
In addition, the Great Plains region suffers from extreme disparities
in health, educational opportunities, and poverty, and suicide among
our young people is limiting the potential of future generations to
overcome these challenges.
Our young people live in great despair--witnessing the extreme
emotional and social impact of high rates of infant deaths, living with
poverty and often within abusive households, and watching other young
people taking their own lives. The result is that we tend to see
clusters of youth suicides in many of our communities, including my
home in Rosebud, SD.
Over the past several years, the lack of resources, funding and
staffing has taken its toll on our Tribal communities. It takes a
community to raise a healthy child, and when you have school systems
that needs strengthening due to lack of funds, a law enforcement
department that is not operating at full capacity, a health care system
that is inadequate, lacking proper funding and adequate staffing (such
as no mental health care) combined with poverty, substance abuse, lack
of jobs and quality of life, our People suffer. And, our Children
suffer most of all.
The following are words directly from a teenager whose 14 year old
sister committed suicide last November in North Dakota:
Jami was in a sitting position against the wall on her bed with
a belt around her neck. The belt was tied to the bars of the
top of her bunk bed which was leaning against the wall. I ran
into the living room and told my boyfriend what Jami had done,
then I ran back into Jami's room and he followed. I tried to
take the belt off of her neck but it was too tight. Then my
boyfriend cut her down. After that, I called my Mom and Dad. I
sat there holding her till they came. I was crying
uncontrollably talking to her asking her, ``Why?''
I couldn't comprehend what had just happened. Then I heard my
Mom and Dad come running in. My Dad started to do CPR on her,
and my Mom was on the phone calling the Police Department to
get the ambulance here. Then not even five minutes later they
were here. The paramedic worked on her with no response, they
did get a slight pulse at one time, and then they rushed her to
the hospital.
She was already gone by the time they got there. The doctor at
the hospital said if she would've survived she would have been
brain dead.
The experience of losing my sister, best friend, someone I
confided in, is very painful and hard to accept. I feel lost,
lonesome, alone, and sometimes angry because I don't know why
she did this while I was just in the other room. We always told
each other ``everything''. She didn't tell me how she felt. I
know she thought that I had enough of my own problems and
didn't want to burden me with hers, but she still could have
told me.
It's been a few months now and I still feel lost, lonesome, and
alone, but what I have learned from this is; don't keep things
to yourself, talk to someone because there is always someone
there for you who is willing to listen and help you.
Over the last several years in the Rosebud Sioux Tribe alone, we
have witnessed dozens of suicides and hundreds of documented suicide
attempts. The situation became so bad that in 2007 our Tribal President
declared a State of Emergency in order to draw attention and resources
to the problem. This year, 2009, there has already been 1 suicide and
more than a dozen attempts in less than 2 months.
Rosebud Model
Chairman and Members of the Senate Indian Affairs Committee, to
lose one of our Youth hurts our entire Community and Tribe. Our Tribal
Leaders and community health advocates have worked tirelessly to find
out what the roots of the problem are, and to see how we can improve
our situations and prevent more suicides. Several projects have begun
to address the problem of youth suicide. For example, on Rosebud we
have started or expanded several programs, including:
Wiconi Wakan Health and Healing Program
``Safe Schools Project'' in collaboration with Todd County
Schools
Suicide Task Force
White Buffalo Calf Pipe Women's Program
Alcohol and Drug Treatment Program
RST Tribal Health Program (including Tribal Education and
CHR Program), with the support of IHS's ``point man'' for
Suicide Prevention/Intervention, Austin Keith (just arrived
last week) will be able to physically follow up on every
suicide completion and attempt, and begin tracking every
suicide attempt with a Rapid Response Team approach.
Suicide Prevention Grant
Suicide Summits and Meetings with community members and
leadership
The response and efforts conducted in the Rosebud Sioux Tribe have
been remarkable, and we are hoping to have an impact on reducing
suicide permanently in our community. Unfortunately, these efforts were
not started in time to save many of our young people, and in the
sixteen other tribal nations in our region, not enough is being done to
focus on suicide prevention. In addition, we need a well-coordinated
data, surveillance and response plan to meet the needs of all our
communities. Regrettably, most of our communities do not have access to
Area-wide and community-specific data that is managed by the IHS. In
our region, most medical services and datasets are managed by the IHS
at the federal level, and most of our public health programs are
managed by the tribes. We need improved collaboration, cooperation and
data sharing between the IHS and the tribes. According to Dr. Donald
Warne, Executive Director of AATCHB, the Health Board has no reports or
data sets with Area level data specific to suicide. As we attempt to
improve our system of epidemiology related to suicide and mental
health, this is precisely the problem. Although the IHS collects and
maintains administrative and clinical data on patients seen in IHS
clinics, these data are not readily accessible nor useful for the
traditional public health functions of population monitoring,
investigation, program planning, and evaluating the effectiveness,
accessibility and quality of health services.
For suicide, we need to develop a public health care infrastructure
that is capable of supporting a ``Rapid Response'' approach and follow
up to suicide events attempts/gestures and completions in all of our
communities. This implies creating a data collection and monitoring
system that allows ready access to actionable data at a moment's
notice. Such a system cannot rely on passive surveillance alone (i.e.,
voluntary), which is currently the case. Therefore, I would first
recommend that suicidal behavior be elevated to the status of a
reportable event throughout the Aberdeen Area. That means mandated
reporting of all suicidal behavior in a timely manner by all providers
(including first responders). Secondly, surveillance should apply to
all levels of jurisdictional access (community, Tribal, Area) on a
need-to-know basis. Suicidal contagion gives no credence to reservation
boundaries. An electronic, integrated, surveillance system could
accomplish these objectives. Finally, an active suicide surveillance
system could serve as the starting point for the development of a more
extensible infrastructure that supports focused, targeted interventions
and coordination of care through automated analysis of factors relevant
to crisis management and suicide prevention/intervention (i.e. who
intervenes, when they intervene, with whom, and others).
IHS must change its health care paradigm to one of ``Disease
Prevention and Health Promotion'' rather than just treating medical and
behavioral problems after they begin. Our People need wellness
education programs, exercise and healthy foods that are closely
integrated with our traditional belief systems. Our Children need
improved self-esteem and a stronger sense of hope for the future if
they are to live in a healthy way. To achieve these goals, we need more
resources to develop healthy communities. The health of the community
often determines the health of the families and the health of the
children. Suicide is preventable, but we need resources in order to
continue our community healing efforts.
Sufficient Resources
What would it take to give the Indian Health Service (IHS)
sufficient resources to address our health care needs? The current
appropriation for IHS clinical services is about $3.4 billion. Our
estimated funding percentage based on documented level of need is
approximately 50-60 percent of that need. In order to bring IHS up to a
more appropriate level of funding, an additional $2 billion for
clinical service would be needed nationally making our annual Federal
appropriation closer to $5.4 billion. This would be a major increase,
but a small one relative to the $700 billion budget for the Department
of Health and Human Services (DHHS). A significant portion of these
additional resources need to be directed toward behavioral health,
suicide prevention and holistic care that meets the needs of our young
people and our future generations.
Summary
In closing, we do not want to lose any more of our Youth. We seek
to take on directly the terrible disparities that make our population's
health status comparable to a third world country. As the nation takes
on the ideas of health care reform, as President Obama noted in his
address before Congress on Tuesday evening, February 24, 2009, please
ensure that American Indian and Alaska Native communities and leaders
are included its development. Also, please ensure that national efforts
at health promotion take into account the unique needs and health
disparities of our nation's first inhabitants. Thank you, again, for
this opportunity and your attention to these vital matters.
The Chairman. Mr. Moore, thank you very much.
I did not mention in the opening statement, because I
truncated my remarks, that a lot of us have personal
acquaintance with these issues. Mine was pretty profound, and
had a huge impact on my career. I walked in the office of a
friend and a boss in the State Capitol who had just been
elected to a State-wide elected office. He had been a 38 year
old Harvard-trained lawyer from a town of 80 people in North
Dakota. That is some accomplishment, to leave a town of 80
people and get a law degree from Harvard and be elected to a
State-wide office. I walked in his office one day and found him
dead. He had committed suicide.
So I have, and all of us do, I suppose, in various ways
very personal acquaintances with suicide. In this case, it was
a very close friend that I found one morning in his office. I
think it is a tragedy always, but magnified especially by young
people who decide that things are hopeless and helpless and
they must end their life at a very young age.
What I would like to do is recess. The vote started 10
minutes ago. We can vote and come back, and I would expect we
will be back in 15 minutes and continue the hearing.
Thank you very much. We are in recess.
[Recess.]
The Chairman. The hearing will come to order.
Next, we are to hear from Dr. Dale Walker, M.D., Director
of One Sky Center, the Oregon Health and Science University in
Portland, Oregon.
Dr. Walker, thank you for being with us.
We apologize to all of you for the delay, but we must go
vote when the rolls are called here in the Senate. We
appreciate your indulgence.
STATEMENT OF R. DALE WALKER, M.D., DIRECTOR, ONE SKY CENTER,
OREGON HEALTH AND SCIENCE UNIVERSITY
Dr. Walker. Senator, I am happy to hear that business goes
on. That is always good to see.
Indeed, it is an honor to be here with all of you and to
hear the story, Dana, that you have shared with us. I think
that makes us think especially about this problem, and I thank
you for sharing.
I want to first of all, identify the One Sky Center as a
national resource center for American Indian alcohol, drug, and
mental health. We provide an outreach to well over 100
communities, tribes, Indian communities, urban programs, across
the Country. That gives us incredible information and personal
stories about what is happening in our communities.
It is true that we have all personally had these
experiences happen to our families and people in our community.
But within an American Indian community, the loss of a life or
the loss of a cluster of lives is a unique phenomena. In my
view, it is defined very easily as a disaster for that
community. If you have a small community of 3,000 in a
reservation, if you have 8,000, and you have 17 lives that are
lost, teenagers, early 20s, and how that impacts the community
in the short term and the long term, carries with it a major
burden of illness. That burden of illness is complicated by the
multiple problems.
Suicide is a chronic problem, a chronic illness, if you
will, but it is additive. You know, all of the other things
that we have heard about, the addictions problems, the housing
problems, severe domestic violence, community violence, all of
these things together create community moods and community
problems. The feeling of hopelessness and helplessness that you
mentioned within an individual is felt within the community.
I still remember when I did my first evaluation at Standing
Rock. One of the Elders said, we are tired of suffering. We can
suffer and feel no more. We are numb to the losses. That is
when I think of the phrase, disaster. That is when I think that
we need to be really attentive to the problems when they happen
at Rosebud and Wind River and Standing Rock and Alakanuk, and
places that we all know well and we know the difficulties
there.
The One Sky Center has worked in those areas providing
technical assistance, consultation, and probably as important
as anything we do, is gather information to put into tool kits
and information packages that are unique and defined for the
community. That is information they need to help recover from
the problems that they have.
Community mobilization is something that we will hear from
SAMHSA and the Indian Health Service. I can only tell you that
I think that is one of the critical elements of recovery within
a community is for the community to open up, discuss and
understand the difficulties, and begin to make decisions based
upon who they are, the people they are, the culture they have.
Those elements are critical.
Now, the other piece that I don't want to understate is the
need for good quality health care, medical services, mental
health care and delivery within those communities. I have sat
in front of this Committee and said before that not all of the
Indian health need is performed and completed by the Indian
Health Service.
We don't expect that, but we expect the agencies across the
Federal Government to gather together and garner resources in
such a way that people can deal with these health care
problems. We have 13 recommendations and they kind of fit in
six areas. When we went through to think about this, we thought
that the policy administration area was our most critical.
We recommend that two particular items be addressed. I
think that it would be useful that a standing committee or a
task force be developed at the HHS level to help the
collaboration, coordination and cooperation necessary across
agencies to work with Indian people. Money comes at Indian
communities in small silos. Each one has definitions and
special purposes, but they don't work together. That actually
divides the ability of the tribes to make decisions about their
generalized health care because they have to address from 28 up
to 37 grants for mental health care, each one with a project
officer who hasn't been to their reservation.
So we have the difficulty of trying to integrate those
services, helping the tribal councils manage the health care
needs of their communities. I think that is an area that we
really need to think about how we can integrate those services
effectively.
Another issue that can only be stated this year, and that
is that we need to take a serious look at where health care
reform is going nationally in this Country, and hook the stars
of the Indian communities to that change. We need a blue ribbon
task force and we need Indian involvement in health care reform
in this Country. They need to be a part of that and a part of
the reform that would happen.
Now, I have gone through, and I have mentioned other pieces
of information in regards to community competence, youth and
family development, training and education, and clinical
services, but I think if I can leave you with the point that we
have a lot of work to do. We know a lot about the clinical care
and services, but access to care, as someone mentioned here, is
a critical point and a critical element for us to deal with.
I hope that we can do the training and the education, the
outreach and the community mobilization and make things happen.
We need to continue the programs like Native Aspirations, like
Project HOPE, and One Sky Center, so we can continue to do this
work. We are working hard to maintain a permanent relationship
with the health care field.
I will stop now. I know we have so many things to say, but
I always want to tell you that the One Sky Center is a resource
center for the Indian communities, but it is also for you. I
would welcome, and I thank your staff for the outreach and the
wonderful work that you are doing.
[The prepared statement of Dr. Walker follows:]
Prepared Statement of R. Dale Walker, M.D., Director, One Sky Center,
Oregon Health and Science University
Introduction
Mr. Chairman, Vice-Chairman, and members of the Committee, my name
is R. Dale Walker, M.D.. I am the Director of the One Sky Center, the
American Indian/Alaska Native (AI/AN) National Resource Center located
at Oregon Health & Science University in Portland, Oregon. I am a
Cherokee psychiatrist with over 30 years experience in the fields of
substance abuse and mental health. I have worked with native people,
veterans, health & medical professionals, and tribal communities. I am
also a member and immediate past president of the Council of Advocacy
and Public Policy for the American Psychiatric Association, in addition
to being a long-time member of the Association of American Indian
Physicians. Finally, I am a member of the Advisory Council of the
National Institute of Drug Abuse (NIDA).
I thank the Committee for inviting the One Sky Center to testify as
an expert witness on suicide prevention in Indian Country and to
comment on recent trends in youth suicide among American Indian and
Alaska Natives.
It was my great honor to testify in front of this Committee twice
in the 109th Congress on Indian health and suicide prevention. I look
forward to updating my earlier reports to you on the suicide prevention
efforts of One Sky Center and some allied organizations. While suicide
remains a devastating problem throughout much of Indian Country, many
notable culturally appropriate initiatives are also underway.
Current Suicide Prevention Initiatives in the Pacific Northwest
The One Sky Center is allied with other national, regional, and
local entities working on suicide prevention in Indian Country.
Following is an update on One Sky Center and some of the regional
entities not appearing at this Senate Hearing.
One Sky Center
In May 2006, the One Sky Center testified on teen suicide
prevention. As the first National Resource Center for American Indians
and Alaska Natives dedicated to improving substance abuse and mental
health services in Indian Country, the One Sky Center has provided
training, technical assistance, and lent expertise on suicide
prevention affecting American Indian and Alaska Native people and
tribal communities.
The One Sky Center has produced various culturally relevant
resources for tribal communities. (See attachment). One Sky Center
products, available online via our website, include: Motivational
Interviewing Enhancement Curriculum for Tribal Youth with training
guidebooks, culturally appropriate Service Learning Curriculum, a first
of its kind A Guide to Suicide Prevention for American Indian/Alaska
Native Communities with a community assessment tool for American Indian
and Alaska Native youth, a Best Practices in Behavioral Health Services
for American Indians and Alaska Natives monograph, and a Describing
Culture-Based Interventions for Suicide, Violence, and Substance Abuse
monograph.
In addition, the One Sky Center has been involved in two national
initiatives, the ``Native Aspirations Project'' (NA) of Kauffman
Associates, Inc., and the ``Indian Country Methamphetamine Initiative''
(ICMI) of the Association of American Indian Physicians. In these
efforts to reduce suicide and closely related problems, the One Sky
Center provides clinical, programmatic, and research expertise and
assistance in the form of consultation, education, training, and
production of guidebooks, all in a manner appropriate to the need in
Indian Country.
Tribes and tribal organizations with scarce financial resources
look to the One Sky Center to learn from medical and scientific
disciplines and from what is working in other tribal communities. It
has been One Sky's honor to be able to assist.
Many lists of ``Best Practices'', including suicide prevention
programs, have been published. However, the form and success of best
practices depends heavily on tailoring for cultural and local context.
With financial assistance from Substance Abuse and Mental Health
Service Administration's (SAMHSA) Center for Mental Health Services
(CMHS), the One Sky Center reviewed evidence-based suicide prevention
programs developed by, actually adapted to, or potentially useful in
Indian Country, and produced a Suicide Prevention Guide to help
disseminate this information throughout Indian Country. This document
has passed through several phases of review and its approval by SAMHSA
for dissemination is eagerly awaited by Indian Country.
Similarly, the One Sky Center assisted Indian Country experts to
develop and disseminate culturally specific interventions for suicide
and to train others in their application. These include Native Helping
Our People Endure (HOPE); Project Venture; and a Tulalip tribal
adaptation for children of the Canoe Journey/Life Skills program.
The One Sky Center has served as a source of expertise and advocacy
in suicide prevention in Indian Country for government, public, and
private entities. This activity spans awareness raising, coalition
building, motivation enhancement, resource development (such as
inventories of best practice), broad dissemination, training, and
technical assistance.
Northwest Portland Area Indian Health Board
To address American Indian suicide in Oregon, Washington, and
Idaho, the Northwest Tribes, led by the Northwest Portland Area Indian
Health Board (NPAIHB), located in Portland, Oregon, initiated an inter-
tribal action plan in January 2008 to guide program planning and
catalyze effort. A resolution supporting the NW Tribal Suicide Action
Plan was unanimously passed by the 43 members of the NPAIHB in January
2009. Coordinated and concerted effort is extremely important
particularly to suicide prevention because of the systemic nature of
the causes of suicide in Indian Country. For more information, visit
www.npaihb.org/health_issues/suicide/
National Indian Child Welfare Association
Suicide occurs most frequently among adolescents and young adults
with the seeds of the problem sown during childhood. Children are the
principal and strategically important target population for suicide
prevention. The National Indian Child Welfare Association (NICWA),
located in Portland, Oregon, provides technical assistance and training
to tribes, state and federal agencies serving children, removes
barriers to accessing services, increases awareness of the risk factors
that contribute to youth suicide in this population, and develops
policy and strategies for increasing children's services and funding
for tribes.
NICWA provided technical assistance to 49 SAMHSA-funded tribal
communities under the tribal Systems of Care and Circles of Care since
1999. NICWA assisted two tribes in accessing Garrett Lee Smith Grants
in 2008. NICWA has also secured funding from the American Legion Child
Welfare Foundation, Inc. to develop and disseminate the Ensuring the
Seventh Generation: Youth Suicide Prevention Toolkit for child welfare
and mental health programs. The toolkit educates tribal child welfare
workers on the warning signs of suicide, risk and protective factors,
suicide prevention and intervention methods, and when such workers
should seek professional mental health services.
Policy development activities include work on the reauthorization
of the SAMHSA programming to address funding and programming in
children's mental health for AI/AN youth, establishing a specific
authorization for the tribal System of Care and Circle of Care grant
programs, creating direct access for tribes under the Mental Health
Block Grant and supporting the expansion of IHS funding under the
Indian Health Care Improvement Act reauthorization to allow tribes to
utilize System of Care concepts (i.e. child centered services,
promoting systems collaboration and culturally competent) in IHS
programs for youth. For more information, visit www.nicwa.org.
Native American Rehabilitation Association, Northwest, Incorporated
The Native Youth Suicide Prevention project, a three year grant
award funded by SAMHSA for the second time, is a partnership between
Portland, Oregon-based Native American Rehabilitation Association
(NARA) of the Northwest, the nine federally recognized Tribes of
Oregon, and Portland State University. The project increased community
awareness through a media campaign with a focus on risk and protective
factor education, provided evidenced-based gatekeeper trainings at
Tribal and community locations, conducted culturally based prevention
and wellness activities, developed community specific resource cards to
strengthen the referral process, formed a Native American Elders
Council for direction and wisdom, provided technical assistance
including conference planning, identifying resources, coordination of
stakeholder meetings, and evaluated effectiveness and progress of the
project.
Portland State University Native American Community and Student Center
Universities and colleges are strategic points of intervention as
students are at risk as well as being in training for careers that may
include suicide prevention services. Healing Feathers is focused on
American Indian/Alaska Native college students enrolled in Portland
State University. The participants in Healing Feathers developed a
brochure and power point presentation on warning signs of suicide,
actions that individuals can take to provide support, and resources for
referral and support. In the future the program seeks to establish a
summer internship program working with the Native American communities
in Oregon, both urban and rural to promote wellness and suicide
prevention. The project uses community collaboration as a principal
strategy.
Recommendations
Suicide is a devastating event for a family, a community, and a
nation. Although the impact is powerful and widespread, suicide is a
very individual event, often understandable only in retrospect, if
ever. Expert professional intervention is critical for averting suicide
by an individual who may be approaching such an act. A large increase
in the number of such treatment ``slots'' and the expertise of
interveners would avert significant numbers of suicides and reduce the
devastating consequences for survivors.
However, important societal, community, family, and personal
circumstances do affect an individual's propensity to suicide, and are
reflected in the unusually high rates of suicide in some Alaska Native
communities. (These circumstances also adversely affect other ills
including substance abuse, crime, and failure to thrive and prosper.)
Such circumstances can be changed. More programs to improve youth
development; remove pathological community factors; and foster
community self-determination, vision, and hope for the future would
significantly reduce suicide and, further, greatly improve the well-
being and productivity of an entire generation--the youth of today, the
adults of tomorrow.
Carefully assessing individual interventions and community programs
will facilitate continuing improvement of those interventions. However,
we should not look to break-through improvements in behavioral
technology. We already know the technology of suicide prevention pretty
well. We just need a lot more of it, and we need to educate and train
more personnel to deliver those interventions.
Our understanding and efforts are weak on some points. Although we
have lists of best practices and strategic plan documents, the
notorious silo problem, education and training shortcomings, and other
factors have left us with a fractured approach to suicide prevention,
full of working at cross-purposes, duplication, and unnecessary gaps.
We need a systemic vision and inspiring leadership in order to bring
together a concerted, coordinated effort. An emphasis in policy and
investment on comprehensive vision, coordinated programming, and
monitored and enforced collaboration from the highest levels to the
front line would be helpful.
Following are the One Sky Center's observations on the state of
suicide prevention in Indian Country and some more specific
recommendations.
1. Policy and Administration
Findings: American Indian and Alaska Native (AI/AN) health
needs are greater than the purview of the Indian Health Service
or any other single federal agency. Comprehensive vision,
inter-agency communication, coordination, and collaboration are
essential. This is well known and multi-agency strategic plans,
initiatives, agreements, etc., do exist. Interagency task
forces, committees, coordination offices, and cross-agency
staff placements have been employed to improve this situation.
However, comprehensive policy, communication, coordination,
and collaboration are lacking. Fragmentation and dysfunction
include, specifically, management by crisis, unnecessary gaps
in service, duplications, working at cross-purposes, and inter-
organizational competition. Of course, funding and staffing
(``capacity'') are vastly insufficient. At the front line, the
impact of administrative and policy fragmentation is felt
acutely and reflected in less than optimal services
organization.
Recommendation 1.1: We recommend creation of an effective
task force, office, or other at the HHS level to promote,
monitor, and enforce comprehensive policy, communication,
coordination, and collaboration on the federal response to AI/
AN health needs.
Recommendation 1.2: We also recommend that a ``blue ribbon''
committee develop a comprehensive strategic plan for Indian
Health care within the emerging National Health Care Reform
initiative.
2. Community Competence
Findings: Research has demonstrated the ``community
competence'' (ability to master challenges and meet the needs
of community members) and ownership and control of local
institutions and assets have a very large, measurable impact on
suicide rates. These interventions are currently implemented on
a small, pilot basis only.
Recommendation 2.1: We recommend extending and promoting
programs like Native Aspirations (Kauffman and Associates,
Inc.,) Nation-Building (Harvard University), and One Sky Center
to mobilize and improve the strength of community institutions
and leadership in identifying and mastering challenges within
the community.
3. Youth and Family
Findings: Suicide is a chronic illness. The illness often
begins in childhood and develops over years as a vulnerability,
propensity, ability, and, finally, a determination to suicide.
Providing opportunities to develop life skills, commitment to
community service, and involvement with nurturing and shaping
family relationships creates resiliency and capacity to meet
the crises and challenges that otherwise precipitate suicide.
Recommendation 3.1: We recommend extending and promoting
youth development and family strengthening programs across
Indian Country.
4. Clinical Services
Findings: When screening, gate-keeping, school counselors,
social workers, law enforcement/judicial authorities identify
individuals with high suicide potential, they attempt to refer
the suicidal individual to someone able to intervene. In fact,
there is a massive lack of such individuals. Further, the
capacity of staff of multiple agencies to collaborate in the
care of such an individual is limited by lack of policy,
procedure, and infrastructure support.
Recommendation 4.1: Increase the workforce of skilled
clinical staff capable of providing suicide intervention
services. This includes funding additional staff positions as
well as workforce management efforts such as recruitment,
retention, and infrastructure support.
Recommendation 4.2: Promote policy, procedure and
infrastructure support at the community level for interagency
coordination and collaboration in delivering services to
individuals.
Recommendation 4.3: Institute telehealth services to support
community front-line clinical staff with tertiary care
expertise in assessment and treatment planning for suicidal
patients.
5. Training and education of staff
Findings: Physicians, where available, are not always
skilled in suicide risk assessment and intervention. Other
professional staff also lack these skills and knowledge.
Consequently, even those suicidal individuals who do gain
access to professional help may not receive an effective
intervention.
Recommendation 5.1: Establish cultural relevance in
professional training curricula.
Recommendation 5.2: Increase on-the-job continuing education
together with certification for AI/AN health care personnel.
Recommendation 5.3: Institute telehealth training services
for on-the-job continuing education by professional colleges
and universities.
6. Research
Findings: We all feel a profound ignorance in the face of so
shocking an event as suicide. While there is a reasonably good
understanding of the epidemiology and etiology of suicide and
we have a large body of research on preventive and treatment
interventions, a great deal of work is still needed. We lack a
good understanding of Culture-Based Interventions, a very
challenging area of research. We also lack universal,
systematic and continuous evaluation of suicide prevention and
treatment interventions (and, therefore, the ability to
continuously improve those interventions on the basis of such
information).
Recommendation 6.1: We recommend innovative research on
Culture-Based Interventions with mandates and financial support
capable of progress on this challenging area of research.
Recommendation 6.2: We recommend a strong policy commitment
to ongoing evaluation of all prevention and treatment services,
together with utilization of that evaluation in program
improvement. This recommendation is not new: for example, it is
found in many accreditation programs.
Recommendation 6.3: We recommend that the practice of
program evaluation and continuous program improvement be widely
taught in professional schools and in continuing-education
programs.
Conclusion
We commend Senators Dorgan, Barasso, and the Senate Committee on
Indian Affairs for holding this hearing, requesting comment on this
most important issue, and especially to the Oregon Delegation for their
support on these issues, namely former U.S. Senator Gordon Smith (R-
OR).
We would also like to recognize former U.S. Senate Majority Leader
Tom Daschle (D-SD) who consistently fought to improve Indian health,
and along with Senator Smith, crafted the tribal provisions for the
Garrett Lee Smith Memorial Act that is now the authorizing statute for
suicide prevention monies through the Substance Abuse and Mental Health
Services Administration.
I had the good fortune recently to visit briefly with Senator Smith
here in Washington when he was honored by the American Psychiatric
Association and have been in contact with him since then. I informed
him of this opportunity to testify today and although he let me know he
wished he could be here, he passed on these words for me to share with
you on this most important issue to both him and all of us here today:
``The numbers of suicides among our Native American brothers
and sisters, especially among the young, is a national tragedy,
and ought to be a concern to all Americans. The Garrett Lee
Smith Memorial Act is a vital tool in helping tribal
governments to assure that, in the future, there are no more
fallen feathers. The reauthorization and funding for Garrett
Lee Smith Memorial Act couldn't be more urgent and important.
It's part of keeping faith and represents a matter as grave as
life and death.''
The One Sky Center stands ready to assist the Committee on this
issue, and we will hope to exist in our committed work.
Thank you very much. This concludes the written part of my
testimony.
Attachments
The Chairman. Dr. Walker, thank you very much. Thanks for
your work, Dr. Walker, and I appreciate your being here once
again before our Committee.
Next, we will hear from Mr. Hayes Lewis, Director of the
Center for Lifelong Education at the Institute of American
Indian Arts in Santa Fe, New Mexico.
Mr. Lewis, you may proceed.
STATEMENT OF HAYES A. LEWIS, DIRECTOR, CENTER FOR LIFELONG
EDUCATION, INSTITUTE OF AMERICAN INDIAN ARTS
Mr. Lewis. Thank you, Mr. Chairman and members of the
Committee. It is a pleasure to be here.
My name is Hayes Lewis. I am the Director for the Center
for Lifelong Education and from Zuni Pueblo.
I would like to talk today about my experiences as a school
superintendent in the State of New Mexico at the Zuni Pueblo
School District and what we did to overcome the youth suicides
in our tribal community, but also talk about the responsibility
that all community leaders have, as well as tribal colleges, in
assisting tribes to build the capacity and strengthen the
capacity to deal with these kinds of public health issues in
their communities.
As a school superintendent, and one of the reasons why we
created our own school district, was because of many
dysfunctional conditions and the lack of educational
opportunity that was evident as part of the Gallup-McKinley
County School District. So we broke off and in 1980 created our
own system. One of the first things that we addressed was a
long-term condition of youth suicides in our tribal community.
For a while there, we were averaging about two a year, and
it was an emotional roller coaster, particularly when you have
a tribal community where nearly everybody is related by blood
or by clan or by society in some way. So dealing with that, we
called in some assistance from the Indian Health Service,
particularly from Stanford University. Teresa LaFromboise is
one of the key people that helped us.
By putting a focus on youth suicide and by our tribal
council and all the tribal organizations, including the
schools, making the commitment to enhance life and to take the
responsibility of saying this is our problem, you know. We can
have all of the experts come into our tribal communities, but
unless we decide and we own the problem, then nothing happens.
And so we went through the process of mobilizing our
community and developed the school-based program, culturally
based because one of our chief referrals was to tribal
traditional healers. While that is a family responsibility, we
did everything we could to make that a flexible option for
them. But more importantly, the school and the school boards
really decided that this is a priority. These are the kinds of
systems that we are going to put in place, protocols. So our
youth suicides ended for quite a number of years.
But just as Zuni has, as have other tribes, slipped back
into seeing more youth suicides in the community again, I think
this just points to the fact that it is a very fragile
situation and one that always have to be reinforced in a number
of ways by tribal leaders.
So we look forward to the day when tribal leaders, school
leaders, can stand up and say we are going to create safe
schools. We are going to create safe communities so that all
children and people and members will benefit from this. And so
it does take that kind of a commitment.
In terms of tribal colleges, the Center for Lifelong
Education does not receive any monies from, with the exception
of a small $5,000 grant from the State of New Mexico Youth
Suicide Prevention Coalition. But we work in concert and
collaboration with the New Mexico Youth Suicide Prevention
Coalition to provide free technical assistance, workshops. We
use people that have extensive experience in the communities,
to start spreading the story, spreading the news about youth
suicide is preventable. There are certainly resources that are
available nationally and statewide, as well as within our
tribal communities, that can bring to bear their talents and
expertise to deal with this crisis.
So our focus is really in strengthening tribes,
strengthening communities to create the capacity to deal with
these kinds of issues and concerns from the internal, and
strengthening those resources that they know they have within
the community and building relationships so that they can use
others as well.
The recommendations I have listed for you are very
important in my mind, but at the same time, in listening and
thinking about what is going on in New Mexico now, we really
need to look at developing programs at the graduate level as
part of the education for teachers and administrators that need
to really develop and enhance their cultural competency about
particularly Indian situations. But more than that, that they
are there for service to all of the children and that schools
become safe, just as communities become safe.
So I will end my presentation at that. You have my
testimony. I really appreciate the time and the commitment all
of you have made to ending youth suicide in Indian Country.
Thank you.
[The prepared statement of Mr. Lewis follows:]
Prepared Statement of Hayes A. Lewis, Director, Center for Lifelong
Education, Institute of American Indian Arts
The Chairman. Mr. Lewis, thank you very much.
And finally, we will hear from Dr. Teresa LaFromboise,
Associate Professor, Stanford University School of Education.
STATEMENT OF TERESA D. LaFROMBOISE, Ph.D., ASSOCIATE PROFESSOR
OF COUNSELING PSYCHOLOGY AND CHAIR OF NATIVE AMERICAN STUDIES,
STANFORD UNIVERSITY
Ms. LaFromboise. Good morning. Thank you for the
opportunity, Chairman Dorgan and members of the Committee, for
me to be able to present a little of my experience in working
in the area of Indian youth suicide. I am a Professor of
Counseling Psychology, the mother of an enrolled member of the
Turtle Mountain Ojibway Tribe, the developer and evaluator of
the Indian life skills curriculum that Mr. Lewis talked about.
I research in the area of ethnic identity and mental
health, and I was a former elementary and secondary teacher in
urban and reservation schools. So I am glad that there are some
educators at the table, too.
I believe I was asked to talk some about the progress that
I have seen made since the hearings that were held by this
Committee in the past to document the extent of the problem of
Indian youth suicide. I thought that maybe I would be additive
in that way.
As a result of some of the funds that have been
appropriated through the Garret Lee Smith Memorial Act, I was
able to work directly with a few of the SAMHSA programs for
Indian youth suicide: one with Native Aspirations in which we
developed regional training programs. In one year, we trained
groups of three from 30 reservations in Wolf Point, Montana;
Rosebud, South Dakota; Pine Ridge, South Dakota; and Anchorage,
Alaska.
I also worked with the Indian Country Child Trauma Center
at Oklahoma University, where they helped support the
development of a middle school version of the American Indian
Life Skills curriculum, which we field tested on the Omaha
Reservation.
And then finally, the third SAMHSA project I was able to
work with was with the Puyallup Tribe with their Helping Hands
Project, where we worked with the mental health technicians
from the tribal health authority, and six grade teachers from
Chief Leschi School, to facilitate the field testing of the
middle school version of American Indian Life Skills.
So all in all, of these wonderful experiences, I have met
an incredible number of native people who are wonderful
interventionists. I certainly have witnessed the power of
traditional healing when it is used in conjunction with
effective psychological practices. Traditional healing effects
its own power, but it certainly helps accentuate what
psychological services can be done.
I have also encountered a lot of frustration on the part of
tribal leaders at the slowness with which we have been able to
get these programs out. There are a number of programs that are
highlighted in the special report of the Institute of Medicine
and other evaluations of Indian-specific programs for suicide
prevention. Dr. Walker's approach is one. The Zuni Life Skills
Program is another. And there is a wonderful program entitled
The Western Athabaskan Natural Helpers Program where we have
direct evidence of the effectiveness of those programs in
reducing hopelessness and reducing suicidal ideation, and also
strengthening the skills of youth to help their friends talk
about their problems and get them to help. Getting them to
someone for help is the main thing.
But I have also really come to appreciate the fact that
many of these programs privilege traditional ways of knowing.
They encourage youth to be involved in their cultural
practices. They involve tribal leaders and resilient elders in
those practices. And that relationship shouldn't be overlooked
because we do have research that talks about the impact of
being embedded in one's culture, being embedded, and how that
is very positively associated with protective factors, such as
academic success, and negatively associated with depression. So
in other words, it really helps overcome depression.
Now, what I would like to add to this conversation,
perhaps, is the fact that I have just finished working on a
committee at the National Academy of Sciences. As you probably
know, a report has just been shared, and there will be public
dissemination of it very soon, entitled Preventing Mental,
Emotional and Behavioral Disorders Among Young People.
This report emphasizes a number of evidence-based programs
for families, school and community interventions. We know that
a number of the risk factors for suicide are risk factors
common for other kinds of problems such as substance abuse,
unsafe sex, even eating disorders. This report highlights a
number of those.
Unfortunately, most of the studies outlined in the report
have been conducted in mainstream populations and mainstream
society. Some of those interventions have been evaluated in
primarily African American and Latino/Latina populations, but
very few with Native Americans. There is only one with Native
Americans that I know of.
What I am suggesting as a recommendation, when we talk
about advancing funding, is that there be evaluations of the
effectiveness of these interventions in Indian communities. If
they are found not to be generalizable, if they are not generic
enough to be appropriate within Indian communities, then do not
require communities receiving Federal funding to have to use
them.
I am suggesting that technical assistance centers, like the
Institute for American Indian Arts, Center for Life Long
Learning, or the One Sky Center, or even a new one, and the
work that has been done at Native Aspirations, could provide
opportunities for native researchers and clinicians to work
with noted prevention researchers around adapting these
evidence-based interventions so that they will be culturally
sensitive and so that they will be more widely accepted among
communities. I think that tribes do not want the transposition
of one intervention that works supposedly for all onto their
communities.
So that is my major suggestion, that among all these things
that we have to do, that we do pay some attention to the
relevance of evidence-based interventions for the Native
American communities that need to be served.
Thank you.
[The prepared statement of Ms. LaFromboise follows:]
Prepared Statement of Teresa D. LaFromboise, Ph.D., Associate Professor
of Counseling Psychology and Chair of Native American Studies, Stanford
University
Good morning, Honorable Chairman Dorgan and Vice-Chairman Barrasso
and Honorable Members of the Committee. Thank you for your invitation
to personally testify before this Committee and to present my views
concerning progress made in the area of preventing American Indian and
Alaska Native (AI/AN) youth suicidal behavior.
I come before you as a professor of Counseling Psychology, a mother
of an enrolled member of the Turtle Mountain Band of Chippewa, the
developer and evaluator of a suicide prevention program entitled the
American Indian Life Skills, a researcher of ethnic identity and mental
health, and a former elementary and secondary teacher in urban and
reservation schools. I hope that my testimony will assist the Committee
in taking stock of the potential for evidence-based school and
community interventions to prevent AI/AN youth suicide and promote
positive AI/AN mental health.
In the 21st Century, suicide continues to be a vivid manifestation
of distress among Native people. Untimely death accounts for almost one
in five deaths among AI/AN youth 15-19 years of age. This proportion is
considerably higher than that of youth from other ethnic groups or the
general population (Centers for Disease Control, 2006). Completed
suicide is 72 percent more common among AI/AN people than the general
population (Indian Health Service, 2001). The estimated rate of
completed suicides among AI/AN youth ages 5-14 years is 2.1 per
100,000, compared to 0.8 per 100,000 for all U.S. youth in the same age
group; the rate of completed suicides among AI/AN youth ages 15-24
years is 37.4 per 100,000, compared to 11.4 per 100,000 for all U.S.
youth in the same age group (Indian Health Service, 2002).
In recent years federal efforts such as the Surgeon General's Call
to Action and the National Strategy for Suicide Prevention (U.S.
Department of Health and Human Services, 1999, 2001) have reflected
growing concern over youth suicide within the U.S. Hearings on Indian
youth suicide sponsored by this Committee have provided a forum for
citizens to advocate for greater attention and services for those AI/AN
youth who elect not to seek help for suicidal ideation due to stigma or
embarrassment, who seem to lack regard for the deadly consequences of
their behavior, and whose suicidal intent goes unrecognized,
unappreciated, and untreated.
Funds appropriated by the Garrett Lee Smith Memorial Act have
served as a catalyst for the mobilization of suicide prevention
programs in many AI/AN communities at highest risk for suicide. I have
been fortunate to work with three SAMHSA funded programs for AI/AN
youth suicide prevention . I designed a Training of Trainers program
with staff from Native Aspirations (JoAnn Kauffman, PI) to train
community members from 30 reservations in regional training in Wolf
Point, MT, Rosebud, SD, Pine Ridge, SD, and Anchorage, AK. I was also
supported by the Indian Country Child Trauma Center (Dee BigFoot, PI)
to develop and field test a middle school version of the American
Indian Life Skills on the Omaha reservation. As a consultant to the
Helping Hands Project of the Puyallup tribe (Danelle Reed Inderbitzen,
PI), I worked with mental health workers from the tribal health
authority who worked in tandem with 6th grade teachers at their tribal
school to field test the middle school version of AILS. Through these
experiences I worked with some incredible AI/AN interventionists and
witnessed directly the power of traditional healing in conjunction with
effective conventional psychological practices. However, I also
observed the frustration of tribal leaders at the slowness with which
these programs have reached AI/AN communities.
As a psychologist, I realize that the psychological risk for
suicidality includes co-morbidity with psychiatric and substance use
disorders. However, as a counseling psychologist who studies learning
and adaptation, I believe that decisions related to suicidal behavior
among the majority of AI/AN youth may be attributed to direct learning
or modeling influences (e.g., family, peer, extended family suicide
attempts/deaths by suicide) in conjunction with certain contextual
sources (e.g., perceived discrimination, historical trauma,
acculturation stress) and individual characteristics (e.g., depression,
PTSD). I also believe that many risk factors for suicide are similar to
risk factors for other problematic behaviors such as alcohol and drug
abuse or engaging in unsafe sex. When cast from this more social
cognitive perspective, suicide and other forms of risk behavior are
more likely to be preventable.
Suicide Prevention and Treatment for AI/AN Youth
``The goal of most prevention programs is to assist an individual
in fulfilling their normative and developmentally appropriate potential
including a positive sense of self-esteem, mastery, well-being, and
social inclusion and to strengthen their ability to cope with
adversity'' (National Research Council and Institute of Medicine, 2009,
p. 74). Five programs, targeting AI/AN youth suicide, have been
featured in noted reviews of suicide prevention (National Academy of
Sciences, 2002; Goldston, Molock, Whitbeck, Murakami, Zayas, & Hall,
2008). These include: The Zuni Life Skills Development Curriculum
(LaFromboise & Howard-Pitney, 1994), the Wind River Behavioral Program
(Tower, 1989), the Tohono O'odham Psychology Service (Kahn, Lejero,
Antone, Francisco, & Manuel, 1988), the Western Athabaskan Natural
Helpers Program (May, Serna, Hurt, & DeBruyn, 2005), and the Indian
Suicide Prevention Center (Shore, Bopp, Waller, & Dawes, 1972). These
prevention programs incorporate positive messages regarding cultural
heritage that increase self-esteem and sense of mastery among AI/AN
adolescents and focus on protective factors in a culturally appropriate
context. They provide strong grounding for adolescent pro-social
behaviors through close ties with extended family involvement and
resilient elders. They also integrate tribal leaders in the prevention
effort and encourage youth to use traditional ways of seeking social
support (May, et al., 2005).
These programs privilege AI/AN ways of knowing, behavioral
expectations, attitudes and values and encourage youth to be embedded
in cultural practices. For the most part, suicide prevention programs
that incorporate cultural teachings and traditions into the
psychological intervention have been well-received by AI/AN communities
and some are found to have promising outcomes. Research has shown that
enculturation is positively related to protective factors such as
academic success and pro-social behaviors (Whitbeck, Hoyt, Stubben, &
LaFromboise, 2001) and negatively related to depression (LaFromboise,
Albright, & Harris, forthcoming). One of the complexities in
implementing these interventions across tribal groups is the extent of
major cultural differences between more than 560 different tribes.
However, researchers who struggle with the problem of lack of
generalizability of prevention programs are exploring efforts to
identify common elements among tribes with closely related traditions
that could be incorporated into prevention programs on a wide scale
basis (See Mohatt et al., 2004; Allen et al., 2006).
Prevention Intervention in AI/AN Communities
Within mainstream society and a few select cultural groups there
has been considerable evidence for the positive effects of family,
school, and community prevention interventions to increase the
resilience of youth and reduce their risk for mental, emotional, and
behavioral disorders. A recent report just released by the National
Academy of Sciences (2009), entitled Preventing Mental, Emotional and
Behavioral Disorders among Young People, highlights interventions
designed to prevent many of the common correlates of suicidal ideation
(e.g., depression, substance abuse, interpersonal conflict, constricted
thinking). The recommended interventions also focus on strengthening
families, improving social relationships, and reducing aggressive
behavior and school-based violence. I believe that some of the
prevention programs featured in this report could provide a mechanism
for advancing suicide prevention efforts in Indian Country.
I cannot give this testimony without also advocating for the
expansion of social emotional learning in AI/AN schools. I realize that
schools are often overloaded with other academic-related priorities.
However, social emotional development programs in schools have been
found to have a positive impact on academic outcomes, especially among
elementary school-age children. Research by Durlak and colleagues
(2007) indicated that the effects of social and emotional learning
programs were equivalent to a 10 percent point gain in test
performance. Students who also participated in this intervention
research demonstrated improvements in school engagement and grades.
Unfortunately, few of the interventions showcased in the National
Academy report have been implemented in Indian Country. Evidence has
been found for long-term results of a few of the interventions with
African American and Latino-Latina youth. No doubt that given the
unique historical context of AI/AN communities, there is resistance to
the mere transposing of evidence based interventions onto prevention
programs with AI/AN youth. It is essential for AI/AN researchers to
assess whether the relevant recommended prevention interventions
featured in this report are generic enough to be found effective with
AI/AN youth. Furthermore, AI/AN researchers should work to culturally
adapt evidence based interventions while maintaining the critical core
content and dosage of the intervention.
Recommendations
1. Allocate federal funds for a technical assistance center to
provide training in the implementation and evaluation of evidence based
prevention interventions in Indian Country. This center could assist in
improving the cultural competence of service providers in terms of
knowledge of the relevant risk and protective factors for suicide among
AI/AN youth. This center would encourage the expansion of AI/AN
community-based research collaborations.
2. Expand social emotional development activities in AI/AN schools
throughout the course of Kindergarten through 12th grade.
3. Increase the number of AI/ANs in the fields of psychology,
social work, public health, medicine, and education to further
advancement of prevention efforts in Indian country.
References will be provided upon request.
The Chairman. Thank you very much.
I am going to call on my colleagues. I will ask questions
at the end. I did want to mention that Dana Lee Jetty is
accompanied by her parents, who are in the room: James Dean
Jetty, right there, Mr. Jetty, thank you; and Cora Whiteman
Tiger. Thank you for being with us, both of you. We appreciate
your being here.
Senator Murkowski?
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman. And thank you
for convening this hearing.
To those of you who have given testimony this morning,
thank you very much. Ms. Jetty, thank you. Your testimony is
very heartfelt and so very important to be able to be an
advocate in an area that is, as the Chairman has mentioned,
very personally challenging, and the emotional side that you
bring to this issue is heard, and certainly very heartfelt.
I appreciate what you have just given us, Ms. LaFromboise
and Mr. Moore, in terms of the need to tailor the programs so
that we do have the cultural sensitivities, if you will, that
we have programs that are not kind of a one size fits all. If
it works in Akron, Ohio, it is going to work in Alakanuk. Well,
we know that is not the situation. What we need is the
flexibility within the funding that comes available to us in
our communities, whether it is villages in Alaska or out on the
Rosebud Reservation, to craft that so that it works for the
population that we are dealing with.
We have been the recipient up in the Northwest Arctic
Borough. Amenliak has been the recipient of a Garret Lee Smith
grant that has allowed them to really tailor what they are
doing to adopt a more holistic approach that really follows the
Inupiak values. That is going to be important to the success of
the efforts that we do up there.
Mr. Walker, I have just a technical question for you on
your recommendation for a standing committee. I want to ask the
question because I was just in Juneau last week with Dr.
Broderick. SAMHSA was awarding a grant to the community of
Juneau. We heard from a gentleman who had lost his son to
suicide, a 16 year old boy. This was some 10 years or so ago.
In that community, at the time, the stigma on suicide and
talking about it, similar to what the Majority Leader spoke to.
They wouldn't talk about it in the schools, so there was no
reach-out in the schools to the other students. The community
was afraid to talk about it. It was this scar, that somehow or
other our community was not as good as it was because of this
unexpected, absolutely out of the blue suicide of an ``ordinary
young teenage boy.''
Do we still have that resistance in the schools to talk
about it? I have had, coming out of my boy's elementary school,
I have had parents that have suggested to me that we don't want
to have our young kids exposed to these ideas or even knowing
that suicide is out there, because then they might think about
it. To me, I am one who is really focused on prevention.
But how much of a stigma, how much difficulty do we have in
getting out to not the kids in high school, but the kids in
elementary school, this level of awareness and, you know, talk
to one another so that you, Dana, would have known what your
sister was going through. What is the attitude out there right
now? Mr. Walker?
Dr. Walker. You bring up a very important point, because
there is the stigma connected to, if you will, the feeling of
failure and somehow you have let your community down and you
don't want to talk about it. But there is also, it comes so
often, the numbing process that I mentioned, that you really
want to make it go away. That is kind of a natural phenomena
that happens inside all of us, in the pain and intensity. That
is why I think it is a disaster, that people become so numb to
the process they really don't want to respond.
If I could give an example. I visited a community, a tribe,
that had a suicide cluster. It was very difficult for me to
even document how many people had died. The data, you know,
aren't collected. I went to the coroner system. I went to the
medical folks. I went to the State medical examiner trying to
collect the data.
I came to realize that people were, indeed, that
encouragement not to reveal or not to open that up is
systematic. I believe, too, that first of all, it doesn't allow
us to understand the problem. It certainly doesn't allow a
community to work through the grieving process when the
information is not shared.
Now, you ask a tough question. The question has to do with
at what age do we somehow allow these things to happen. There
might be families here who have different views about this, but
I think that it needs to be open. Facts are facts in
communities, and everybody knows when people pass away, and
everybody deals with that in their own way. I can't help but
think that we need to have an openness process to make that
workable and work through.
Having said that, what do you do when the people who are
documenting the suicide are relatives of the person, so they
are in authority to document, but they also are relatives. That
puts them in a very, you have to be a clinician and you have to
be a family member at the same time. That is very difficult.
That is why the workload and the workforce in Indian Country
needs to be thought through in a much more deliberate way.
There are not enough people there, and there is not enough
training. To be able to do what you are wanting to do would
require, wouldn't it be nice if somebody at that school had the
ability to work with family, but when they were involved with
the family, that someone else could back them up. We have no
policies like that anywhere in Indian Country.
Senator Murkowski. You wanted to join in this?
Ms. LaFromboise. Yes, I did, because I wanted to just
mention from a prevention perspective, with the work that we
have done with Zuni Life Skills, American Indian Life Skills,
it is universal intervention in that all students go through
this curriculum, rather than just at-risk youth.
Senator Murkowski. And regardless of age?
Ms. LaFromboise. Well, it has been developed for high
school students. I wanted to answer this question about age as
well. One of the points of it is that we know that youth talk
to their friends, more likely than some of the adults, and we
want them to be able to get their friends to help. We have
found that, part of the goal is to reduce the stigma by
allowing people to have someone that they can talk to about
this.
Now, with the middle school students, people ask about age.
We have gone into communities where people say, well, we don't
really know how active students are in terms of suicide at the
middle school level, but we want to find out. In one of the
schools, and it is in some of the documentation that I have
presented, the middle school students, 19.7 percent of them had
already attempted. Of those, middle school students on a
reservation in the Northern Plains, 10 percent had attempted
more than once.
When we do this, we actually have a series of questions
that we ask, and make clear that we are not talking about just
thinking about it, but have you done something physical to
yourself to end your life. We ask, would you mind telling us
what was going on at that time, with just some lines for open-
ended comments. And the students will tell us. They will write
it on a sheet of paper.
Now, what I have heard in focus groups in some of the
communities, students will talk among themselves. In that
particular study, 97 percent of students had not sought help
because if they seek help, then that means that they might be
moved to a psychiatric hospital hundreds of miles away because
in-patient help isn't there as much as it needs to be locally.
Or there might even be one bed assigned at the hospital and the
charge nurse at that particular time doesn't want to deal with
it and doesn't want the person admitted so they go to the jail
instead of the hospital. So you know how that goes, just to
add.
Senator Murkowski. Mr. Chairman, thank you very much.
Thank you.
The Chairman. Senator Udall?
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. Thank you very much, Mr. Chairman, and
thanks for your leadership on this issue. I think you and your
staff have pulled together a distinguished panel and some very,
very moving testimony here today.
I was impacted a lot by Senator Reid and his testimony
earlier, where he talked about my cousin, Gordon Smith, and
what happened with Gordon's family. I wish Senator Reid was
here for me to just thank him for what he did for my family and
thank him for the support when the family was really in crisis.
Dana Lee, you have helped us by coming forward and talking
about your sister. It is a horrible feeling and you conveyed to
us what you have gone through and what the family has gone
through. But by stepping forward, I think you educate all of us
and allow us to focus on what the issue is and what we can do
about it. So thank you very much for being here today.
As I listen to this panel, I hear you talking about some
very simple things in order to deal with this. I mean, one of
them is just for a young person to be able to have somebody to
talk to about their problems, about their feelings, what they
are going through. Hayes, you mentioned just changing the way
schools approach this in terms of protocols, taking
institutions that are there and making those institutions
reform themselves so that they deal specifically with the issue
of youth suicide in Indian Country.
So the question I want to ask, I guess to Teresa and Hayes
to start with, but happy to have any of the others jump in is,
how much of this is about resources and how much of this is
about realigning the use of current resources? And I think
Teresa you talked about the Garret Lee Smith funds and
utilizing those funds. Is it about resources? Or is it about
taking what is in place and making sure that the people that
are either in schools or other institutions that, tribal
leaders, tribal healers, that they are doing the kinds of
things that you are talking about?
Please, Hayes, go ahead.
Mr. Lewis. Mr. Chair, Senator Udall, in many cases it is
realigning resources that are present within the tribal
communities, including the schools. A lot of our school
organizations are not set up to respond to the variety of
tribal community issues and really have not made schools a safe
place for all children.
By that, if you look at, and I was just in a school
district last week. This is a high school. Kids are coming out
of the classrooms, walking around. Other kids are coming out
during class, walking around. Maybe they went to the rest room
or something, or that is what they told the teacher, but they
are harassing each other in the hallways, text-messaging each
other negative notes and things like that. So there is a lot of
that kind of bullying going on right under the noses of the
school administration and the staff.
That is not to say that they are not trying their best, but
at the same time, I think school resources are sometimes
stressed. But at the same time, you can look within a community
and see what other tribal resources are available, so that you
can start addressing prevention, strengthening children,
providing those kinds of skills that will give them more than
just one option.
Just in a quick response to your question, Madam. In a
tribal community many times we are told you can't talk about
death because you are going to bring on more death. The dilemma
we had was that if we don't talk about death and dying, how are
we going to help the living? And so, it is a circular kind of a
situation that you are involved in.
So we decided we will talk about death and dying, but it is
really a determinant of how you talk about death and dying, and
how you are respectful to younger children. You talk about
death and dying, or you talk about options like strengths, the
cultural strengths that you have, the cultural taboos against
taking your own life, because I think all of the tribes have
that. You are not to take your own life for a number of
reasons, and they vary from tribe to tribe. But at the same
time, if you talk about the strengths of ancestors and the
strength of character and values that we have, then you can
lead into other areas of discussion about death and dying.
But I believe on the resource issue, there still needs to
be a lot of work in that area. In New Mexico, I know there is a
specific account out of the Public Law 81-874 impact aid that
25 percent of it is earmarked for the use for Indian children
for cultural, emotional and academic strengthening of Indian
children. That means programming of different kinds, and many
of our school districts carry that amount across to the next
year, without really investing in programs that will strengthen
and create safe places for all children.
Ms. LaFromboise. I would suggest that we need more
resources. Part of the work that we have done, it seems to me,
is just the tip of the iceberg in terms of what could be done
in training people and working with communities to implement
prevention work. You know, prevention is part of the mission
statement, of IHS, but we know that there isn't much allocated
for that activity, if at all. When we train people, we raise
consciousness. People then try to go back into their
communities to implement the intervention. They are sort of
like the champions of this intervention, but there are no
resources for it, or very little.
In some of the training programs we have done, we have
actually had people where, after a couple of days, I realized
that almost everyone at the table doesn't have a job. Or we
might serve lunch, and people literally leave and take what
they have been given for lunch home and then come back to the
training immediately. So I mean, there is such poverty and such
pervasive hardship that there needs to be more resources in
terms of mental health support and support of social-emotional
development in schools.
The other thing with the work in terms of restrictions, is
the fear in terms of No Child Left Behind of having much in
terms of social-emotional development or mental health
programming in the schools because it might negatively impact
test scores. We do now have research that says that there can
be as much as a 10 point difference in terms of standardized
test scores among students that have received this kind of
work, this kind of training, and more involvement in school.
So I think that it takes actually educating teachers for
them to actually be willing to do some of this work in their
classrooms. And it also takes, some technical assistance for
those people who are para-professionals and community members
who can do so much in terms of this kind of work.
Mr. Moore. If I could also offer an answer. At Rosebud, the
Administration for Native Americans out of HHS, and their
immediate response to our rising and escalating suicide
statistics there, provided resources for us to create some
youth activities this last summer. We trained 150 kids, mostly
young teenagers, young adults, in the community emergency
response team, CERT, training that is offered by FEMA. It gave
them some essential skills, emergency medical response, fire
suppression, et cetera. It trains lay people to be the
immediate first responders in the event of an incident, before
the professional first responders get there. They had this
shared collective experience.
One of the young men who graduated from that program, that
training, ended up protecting a car accident victim from going
into shock until the first responders got there, by his
training there. There were three young girls who were just a
day away from completing their training and getting their
certificate. They were spending the night together.
One of the girls got up and left, and had been gone for
some time. The other two girls went to look for her and they
found her hanging in a closet. With the skills they had just
learned, they revived her. They got her down in time and they
revived her and resuscitated her. So now they have this energy
to become doctors and nurses themselves, and want to respond to
that in a very positive way.
But the resource issue is that now we are without the money
to keep this collective group of young people together in some
way to have ongoing work with them, ongoing development with
them. So the hot shot response provided a base for them, but we
simply don't have the resources to keep the collective going,
and for these kids to continue in activities together, which
has been one of the strengths of that program during that
summer.
Dr. Walker. I would like to respond as well. We do need
more sources, simply stated. I don't want to under-sell that
issue, but I want to go back to why we are having this meeting
today. The core question is, what has happened in the last two
to three years. I think we need to take a serious look at what
has happened at Standing Rock. It is one of the best examples.
They received an emergency grant from SAMHSA. They received
two or three other resources. What I would tell you in a
document that I received from them is that they have more
mental health services readily available across their
reservation. The suicide rate has gone down. They have more
people working within the school system and much more
discussion consequently within the community about these
issues.
So a little bit of money made a difference. I think we
would all want to say that this is a hopeless thing, because
that feeds right in with the issue. We know that when resources
get directed, even though they might be small, Native
Aspirations does not put huge amounts of money into
communities, but they help mobilize and work in the community.
Those systems work.
Indian Health is under-funded. I would say 40 percent
under-funded. I have felt that way for the last 20 years. I
think that we need to really deal with the issues.
Now, a point of hope has to do with what can we do, if we
go out and train these people. Remember the grants only last
three years. I would like to see them increase to five years,
number one. I would also like to see some kind of integration
of grants into continued health care. That would be an
important step.
We can also take a look at tele-health, tele-medicine work
to maintain training and certification of our counselors and
health care providers across Indian Country. One of the
problems we have is in isolated remote areas. Counselors get
their training and certification, but they can't maintain it
over time because they can't receive supervision in their
immediate area.
Now, what that means is they can't bill for Medicare and
Medicaid services. So there are ways that we can actually take
smaller steps in regards to how we educate and maintain the
training of our people in the communities.
The Chairman. Mr. Walker, the point you made that I think
is important is we have full-scale health care rationing on
Indian reservations. It ought to be headline news in newspapers
because it is a scandal. Do you think if there were health care
rationing among U.S. Senators it wouldn't be fixed in a minute?
Health care rationing is something that is almost unbelievable
and it goes on every single day with the most vulnerable
population in this Country, and it is shameful.
And you are right about the 40 percent. Forty percent of
the health care needs of American Indians are unmet. Now, the
President's budget was just released today. It asks $4 billion
for the Indian Health Service. That is approximately $600
million more than fiscal year 2008. That is a good sign, a very
good sign. We need to meet our obligations. We ought to go read
the treaties. We ought to go re-read the treaties, that the
United States Government signed with Indians.
I don't know if you used the term rationing, but it is a
shameful thing that ought to be headline news across this
Country.
Now, I want to ask, and I had invited my colleagues to
inquire first. We have also been joined by Senator Johanns.
What I would like to do is ask a couple of questions. I will
recognize the Senator from Nebraska if he has inquiries. Then
we are going to go to our colleagues who have been very, very
patient this morning. My thanks to them, Mr. McSwain and Dr.
Broderick.
Dana Lee Jetty, I told you I am sure none of us understand
how difficult it is to come some months after losing your
younger sister and talk about it publicly. You are going to
school in Minnewaukan, North Dakota, is that right?
Ms. Jetty. Yes.
The Chairman. What year are you in school?
Ms. Jetty. I am a sophomore.
The Chairman. I have been to the Spirit Lake Nation many
times. In fact, I have been there to have meetings about teen
suicide because there have been other teen suicides there. In
your testimony, you indicated that you knew that your mom had
concerns about your sister before her suicide, and you say your
mom did all the right things. She took her to the doctor,
talked to counselors, and even had her evaluated by mental
health professionals from Indian Health Service. They dismissed
your mom's concerns and diagnosed your sister as being a
typical teenager.
Ms. Jetty. Yes.
The Chairman. So your sister had some issues. Your mother
recognized that, and went to seek out some assistance.
Ms. Jetty. Yes.
The Chairman. And the tragedy at the end of this is your
sister took her life.
As a young Indian teen, are you familiar with others who
have performed, as the professionals call it, ideation, talking
about perhaps ending their life, or those who have actually
made an attempt to end their life?
Ms. Jetty. Yes. I know some people have actually come up to
me and asked me, you know, what should I do? And how can I help
myself? So what me and my family have been doing, we have
actually been going around to different places, to schools, to
jails, where teenagers are, and we tell them that there is help
that they can get out there. Some counselors, like you said,
they just push aside the person's feelings, you know, how they
want to, the help that they want to get. And I don't know.
The Chairman. Dana Lee, I told you that I met with a group
of Indian teenagers at Standing Rock. Just me and a group of
them, no other adults present. I just asked them about their
lives. What is going on in their lives? What do you think? I
talked to them about the cluster of suicides, asked them to
give me their impressions of their classmates and so on. It was
a fascinating discussion, and in many ways, also troubling and
in some ways hopeful.
But one of the things that some of those students told me
was that their acquaintances that had committed suicide, and
some who had tried it, felt that perhaps it wasn't a desire to
be dead, or to actually end up being dead as a result of this.
It was a desire to cry out for help, but without thinking this
is forever, this is final, this is death. Do you sense that
among the young people that talk to you about these issues?
Ms. Jetty. Yes, actually I do. Yes. Some of them, they
think that it is the only way that they can feel better, that
they won't feel the pain that they are feeling. It is really, I
don't know. It is a big concern.
The Chairman. And there is, as all of the professionals on
the panel have described to us appropriately, not one reason
for suicide. You know, there just isn't one reason you can say,
here is what is triggering it. It is a series of emotional
things that, I think in my own view, relates to circumstances
of life and feelings that one doesn't have the same
opportunities and things are tough, and you know, poverty and a
whole range of things. Substance abuse can play a role
sometimes.
So it is tragic when anyone commits suicide. The person
that I found who had committed suicide was an adult, only 40
years old. But to have someone 14 years old take their life is,
as you know, such a tragedy.
So again, let me just thank you for being here. But when
you tell me that you go to jails and schools, you and your
family, and are doing something in your sister's name, I think
your younger sister would be mighty proud of her older sister,
and we appreciate your doing it.
To those of you who have put on the public record here your
experience and your work, I have a number of questions, but I
think I am going to send you these questions. I am going to ask
more specifically about some of the services and, Mr. Walker,
how you are going to disseminate the guide throughout Indian
Country on what your plans are.
And Mr. Hayes, I will ask you to respond about when the
suicide prevention program ceased in your community, when did
you see repercussions of that. I have a number of questions,
but I think what I would like to do is submit them to you and
ask if you could respond for the Committee record in writing so
that I might get the testimony of Mr. McSwain and Dr.
Broderick.
The reason I wanted them to stay was to hear something very
valuable from your testimony, especially you professionals. It
is very important for Indian Health Service and SAMHSA to
understand what it is you say and what it is you do out in
Indian Country across America.
So let me call on my colleague from Nebraska for any
comments or questions you might have.
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Well, let me start out and thank the
Chairman for holding this hearing, a very, very important
topic.
Dana Lee, if I could just inquire. Thinking about your
friends and the very sad case of your sister committing
suicide, do you think there is sometimes a reluctance with kids
to reach out and seek help from, I don't know who, a parent, a
counselor, a teacher? Would that be kind of a stigma? Would
other kids look down on them? Is that a problem? And if you see
that as a problem, could you give us any advice on how we might
think about how to help that situation?
Ms. Jetty. Yes, I think they do look down on them. They see
that other kids are doing it, and they think that is the only
way they know how to deal with them. They really need to talk
to somebody who knows what they are going through and who can
really relate to them and know how to help them. And sometimes,
kids, they go, they talk to counselors, but it is not the stuff
they want to hear. So I think, you know, we can really get to
them by talking to trained professionals who know what to do
and stuff, so.
Senator Johanns. I appreciate your honesty in answering
that. I wonder if it would be helpful to think about an
approach where certainly a trained professional would be
involved, but there would also be your own peers involved. You
know, sometimes you will share things with a friend that you
would, my daughter or my son, would never tell me, but they
really need somebody to talk about it. What would you think
about that kind of idea? Do you think that would help?
Ms. Jetty. Yes, I think that would really help, I think,
you know, like other students. Yes.
Senator Johanns. Okay. I really appreciate you being here.
I think it is very, very helpful to us as we think about how to
fashion an approach to maybe prevent this from happening in
another family. Thank you.
Ms. Jetty. Thank you.
The Chairman. I am going to dismiss the panel, but as I do,
let me again thank Dana Lee's parents, James Dean Jetty and
Cora Whiteman Tiger. Thank you for accompanying your daughter
today and making it possible for her to testify.
And I want to thank especially those of you who have
testified about your programs and the professional work that is
being done. Dr. LaFromboise, we particularly appreciate your
lineage from Turtle Mountain and appreciate your work at
Stanford.
Ms. LaFromboise. Thank you.
The Chairman. And let me thank you for being here. All of
you are welcome to stay and listen to our next two witnesses
from the Indian Health Service and from SAMHSA. Thank you very
much.
Now, Mr. McSwain and Dr. Broderick, I thank both of you for
being so patient with us. This took a while, but I think it
would be enormously helpful for you to hear, so we appreciate
your being here.
Director McSwain, thank you very much. You may proceed,
after which we will hear from Dr. Eric Broderick.
STATEMENT OF HON. ROBERT G. McSWAIN, DIRECTOR,
INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Mr. McSwain. Thank you, Mr. Chairman and members of the
Committee. I, too, enjoyed to a great degree, because I learned
a lot from the previous panel. I made copious notes, and
certainly had a chance to talk with Dana and her experience, so
that it was helpful to understand our system and how our system
interfaces, the clinical system.
You certainly have my statement. I am accompanied today by
Dr. Richard Olson, Director of the Office of Clinical and
Preventive Services, and Dr. Rose Weahkee, Public Health
Adviser, Division of Behavioral Health. And certainly I
appreciate the opportunity today to testify on youth suicide in
Indian Country, recognizing that my predecessors appeared
before you and this Committee before in several parts of the
Country.
As was mentioned, I think it is an important feature of
this hearing is that suicides and suicide-related behaviors do
exact a profound toll on American Indian and Alaska Native
communities. As it was mentioned, suicides just reverberate
through communities, small or large, and affect the survivors
many years after the actual incident.
I won't go through the, you have certainly the data, and I
just want to say that we confirm the data of the suicide rates
that were shared with you earlier. The one thing that tends to
make the numbers a little different when you are talking to a
large organization like SAMHSA or U.S. national numbers is that
remember our focus is on 1.9 million Indian people living in 35
States on or near a reservation. So our numbers are a little
bit smaller in terms of the actual prevalence and the like. So
that understood, there will be some differences in the final
numbers.
You know, suicide is a very complicated public health
challenge. As we talked about it earlier today, certainly there
are a whole lot of factors, and as you said, Mr. Chairman, any
one factor. And clearly, the only pursuit of a multi-targeted
coordinated and persistent effort is acutely aware of the
cultural context. All those issues were shared today.
The total cultural context of suicide blends the best of
traditional American Indian and Alaska Native healing wisdom
and Western public health tools, and is likely to succeed not
only on a community basis, but also on a national basis.
Since this hearing is a follow-up, I would like to simply
highlight some activities that have been occurring since the
previous two hearings. First is in the area of collaboration. I
know that there was concern about the Indian Health Service
collaborating and partnering with the Bureau of Indian Affairs
and what they have going. Clearly, we have had a number of
discussions, and I can assure you that I had discussions with
the Bureau of Indian Affairs this last year until their
leadership changed a bit. But basically, we are still
continuing to focus.
I think the important is that while there may be a sort of
lack of real coordination at a national level, I can say that
there is a lot of activity going on out in the field in the
service units, in the communities, with the Bureau of Indian
Affairs. I think a case in point is that IHS continues to
provide both medical and behavioral health-related services to
BIA-funded youth detention centers. For example, the Chinle
Navajo Nation Youth Detention Center in Arizona was allocated
both a nurse practitioner and regular contacts from the local
IHS alcohol and substance abuse coordinator. That is just one
example of many across the Country. If I don't run out of time
today in my opening, I will talk about some other things that
are going on in other States.
But IHS is fully involved since the last time in a number
of things. We are involved in many statewide suicide prevention
teams, coalitions. There are two Alaska Natives who were
appointed to the Alaska statewide Suicide Prevention Council.
One is also a member of the Suicide Prevention Committee, which
is the IHS prevention committee. An IHS representative sits on
the Arizona State Suicide Prevention Coalition. The Oklahoma
area also cosponsored a suicide prevention conference with the
State of Oklahoma in December.
There are a lot of things happening nationally. My
colleague to my left here, we are working very closely with
SAMHSA, the CDC, NIMH, and the like. Suicide prevention
programming was offered at the annual IHS-SAMHSA meeting last
summer, and we are looking forward to another session with
SAMHSA as we move forward, where there were between 400 and 600
people who were actually at the conference.
We have been working nationally with NCAI and other
national Indian organizations. NCAI has established its Suicide
Prevention Work Group. The Suicide Prevention Resource Center
works collaboratively with Indian Health Service.
On an international level, the department has a memorandum
of understanding with the country of Canada and our
counterpart, First Nations. We are working together for those
common issues. What are they experiencing up there in Canada as
well? And two learning exchange meetings have occurred and are
scheduled to continue.
I just want to mention to you that I know there will be a
question about the $14 million that the Indian Health Service
was appropriated. It was a deliberate process on my part to
establish a national Tribal Advisory Committee where you heard
today, the importance of tribal communities being engaged. I
wanted tribal leaders to be engaged in how best to target the
resources that were given. They have come forward with a series
of recommendations, and I am prepared to deliver on those
recommendations very soon. We are looking at upwards of 60
grants in the committee to begin to address suicide and
methamphetamine abuse. Then, of course, that was the first
charge I gave to the new group as they convened, and said,
look, I want your ideas on best how to target these limited
resources.
Let me close with just a few examples of IHS area-specific
suicide prevention activities. The Aberdeen area has
established a suicide prevention strategic plan. Again, at
least it is on the table and they are working through it. They
have also used the question-persuade-refer training for every
reservation, which is actually referred to as a QPR. And of
course, in the Alaska area, the big news in Alaska is the
behavioral health aids that are being actually trained and
deployed throughout the villages in Alaska. Another event
certainly to address local needs, to go along with the others,
are community health aids, and certainly the dental health aid
therapists that occur in Alaska.
Bemidji began their efforts with applied suicide
intervention skills training, QPR, the North Dakota Project and
American Indian Life Skills training, and they continue to work
throughout the area. There are certainly a number of activities
going on in the Billings area, which includes Wyoming. I am
sorry that Senator Barrasso isn't here, but we have a number of
activities going on in both Montana and Wyoming, and of course
working again with SAMHSA, you will hear more from Dr.
Broderick on some activities there.
The Phoenix area has teamed up with the State of Nevada for
those interested in providing training to reservations in Utah,
Nevada and Arizona. The Portland area, in partnership with the
Northwest Portland Area Indian Health board, has developed an
area-wide suicide prevention plan. And the Navajo Nation has a
strategic plan, a suicide prevention team, and is working with
the tribe with suicide prevention activities. In fact, they
actually have a special project that is referred to as Suicide:
Breaking the Silence, and we have all heard about that today.
Let me just simply say that our successes to date, and that
is whether it has been Colville or Flathead, has been
community-based. I mean, we have gotten into the community and
the community has actually taken up ownership. I think our
successes will continue where American Indian and Alaska Native
communities take ownership and lead the effort, and then we are
helping and supporting them as they move forward.
Mr. Chairman, this concludes my summary statement. Thank
you for this opportunity to discuss youth suicide in Indian
Country, and I will be happy to answer of your questions.
[The prepared statement of Mr. McSwain follows:]
Prepared Statement of Hon. Robert G. McSwain, Director, Indian Health
Service, U.S. Department of Health and Human Services
Mr. Chairman and Members of the Committee:
Good morning, I am Robert McSwain, Director of the Indian Health
Service (IHS). I am accompanied by Richard Olson, M.D., Acting
Director, Office of Clinical and Preventive Services, and Rose Weahkee,
Ph.D., Public Health Advisor, Division of Behavioral Health. Today, I
appreciate the opportunity to testify on youth suicide in Indian
Country.
The IHS has the responsibility for the delivery of health services
to an estimated 1.9 million Federally-recognized American Indians and
Alaska Natives (AI/AN) through a system of IHS, Tribal, and urban (I/T/
U) operated facilities and programs based on treaties, judicial
decisions, and statutes. The mission of the agency is to raise the
physical, mental, social, and spiritual health of American Indians and
Alaska Natives to the highest level, in partnership with the population
we serve. The agency goal is to assure that comprehensive, culturally
acceptable personal and public health services are available and
accessible to the service population. Our duty is to uphold the Federal
government's obligation to promote healthy American Indian and Alaska
Native people, communities, and cultures and to honor and protect the
inherent sovereign rights of Tribes.
Two major pieces of legislation are at the core of the Federal
government's responsibility for meeting the health needs of American
Indians/Alaska Natives: The Snyder Act of 1921, P.L. 67-85, and the
Indian Health Care Improvement Act (IHCIA), P.L. 94-437, as amended.
The Snyder Act authorized regular appropriations for ``the relief of
distress and conservation of health'' of American Indians/Alaska
Natives. The IHCIA was enacted ``to implement the Federal
responsibility for the care and education of the Indian people by
improving the services and facilities of Federal Indian health programs
and encouraging maximum participation of Indians in such programs.''
Like the Snyder Act, the IHCIA provides the authority for the provision
of programs, services, and activities to address the health needs of
American Indians and Alaska Natives. The IHCIA also included
authorities for the recruitment and retention of health professionals
serving Indian communities, health services for people, and the
construction, replacement, and repair of healthcare facilities.
The Department of Health and Human Services (HHS) has been
proactive in raising the awareness of Tribal issues through the process
of Tribal consultation. As such, HHS recognizes the authority provided
in the Native American Programs Act of 1974, and utilizes the
Intradepartmental Council for Native American Affairs to address cross
cutting issues such as suicide and to seek opportunities for
collaboration and coordination among HHS programs serving Native
Americans.
We are here today to discuss youth suicide in Indian Country.
Background
Suicides and suicide-related behaviors exact a profound toll on
American Indian and Alaska Native communities. Suicides reverberate
through close-knit communities and continue to affect survivors many
years after the actual incident.
Using the latest information available, the American Indian
and Alaska Native suicide rate (17.9) for the three year period
(2002-2004) in the IHS service areas is 1.7 times that of U.S.
all races rate (10.8) for 2003. (This information will be
published in the upcoming ``Trends in Indian Health, 2002-
2003'').
Suicide is the second leading cause of death behind
unintentional injuries for Indian youth ages 15-24 residing in
IHS service areas and is 3.5 times higher than the national
average. (This information will be published in the upcoming
``Trends in Indian Health, 2002-2003'').
Suicide is the 6th leading cause of death overall for males
residing in IHS service areas and ranks ahead of homicide.
(This information will be published in the upcoming ``Trends in
Indian Health, 2002-2003'').
American Indian and Alaska Native young people ages 15-34
make up 64 percent of all suicides in Indian country. (This
information will be published in the upcoming ``Trends in
Indian Health, 2002-2003'').
On a national level, many American Indian and Alaska Native
communities are affected by very high levels of suicide, poverty,
unemployment, accidental death, domestic violence, alcoholism, and
child neglect. \1\ According to the Institute of Medicine, an estimated
90 percent of individuals who die by suicide have a mental illness, a
substance abuse disorder, or both. \2\ According to a 2001 mental
health supplement report of the Surgeon General, ``Mental Health:
Culture, Race, and Ethnicity'', there are limited mental health
services in Tribal and urban Indian communities. \3\ While the need for
mental health care is great; services are lacking, and access can be
difficult and costly. \4\
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\1\ Manson, S.M. (2004). Cultural Diversity Series: Meeting the
Mental Health Needs of American Indians and Alaska Natives. National
Association of State Mental Health Program Directors (NASMHPD) and the
National Technical Assistance Center for State Mental Health Planning.
\2\ Institute of Medicine (2002). Reducing suicide: A national
imperative. Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., Bunney,
W. E. (Eds.) Washington, DC: National Academies Press.
\3\ U.S. Department of Health and Human Services. (2001). Mental
Health: Cultural, race, and ethnicity supplement to mental health:
Report of the Surgeon General. Rockville, MD: U.S. Department of Health
and Human Services, Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services, National Institutes
of Health, National Institute of Mental Health.
\4\ Manson, S.M. (2004). Cultural Diversity Series: Meeting the
Mental Health Needs of American Indians and Alaska Natives. National
Association of State Mental Health Program Directors (NASMHPD) and the
National Technical Assistance Center for State Mental Health Planning.
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The system of services for treating mental health problems is a
complex and often fragmented system of tribal, federal, state, local,
and community-based services. The availability and adequacy of mental
health programs varies considerably across communities. \5\ American
Indian youth are more likely than non-Indian children to receive
treatment through the juvenile justice system and in-patient
facilities. \6\
---------------------------------------------------------------------------
\5\ Ibid.
\6\ Ibid.
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The Indian Health Service is most directly responsible for
providing mental health services to American Indians and Alaska
Natives. The purpose of the IHS Mental Health/Social Service (MH/SS)
program is to support the unique balance, resiliency, and strength of
our American Indian and Alaska Native (AI/AN) cultures. The MH/SS
program is a community-oriented clinical and preventive mental health
service program that provides primarily outpatient mental health and
related services, crisis triage, case management, prevention
programming, and outreach services. The MH/SS program provides general
executive direction and recruitment of MH/SS program staff to 12 Area
Offices (regional) that, in turn, provide resource distribution,
program monitoring and evaluation activities, and technical support to
163 Service Units. These Service Units consist of IHS, Tribal, and
urban Indian programs whose MH/SS staff are responsible for the
delivery of comprehensive mental health care to over 1.9 million
American Indians and Alaska Natives.
The most common MH/SS program model is an acute, crisis-oriented
outpatient service staffed by one or more mental health professionals.
Many of the IHS, Tribal and Urban (I/T/U) mental health programs that
provide services in times of crises do not have enough staff to operate
24/7. Therefore, when an emergency occurs, the clinic and service units
will often contract out such services to non-IHS hospitals and crisis
centers. Inpatient services are often purchased from non-IHS hospitals
or provided by State or County mental health facilities. Medical and
clinical social work in the MH/SS program model are usually provided by
one or more social workers who assist with discharge planning and
provide family intervention for child abuse, suicide, domestic
violence, parenting skills, and marital counseling.
The MH/SS program model also includes tele-behavioral health
technology. Tele-behavioral health technology is increasingly adopted
throughout the Indian health system to improve access to behavioral
health services. Currently, over 30 IHS and Tribal facilities in 8 IHS
Areas are augmenting on-site behavioral health services with tele-
behavioral health services. This type of system capacity building
supports not only distance psychiatric services to remote communities
where such services are not available now but can also be used to share
resources more efficiently in urban and semi-urban areas. A National
Telebehavioral Health Center of Excellence is in the planning stages
and should provide increased access to televideoconferencing based
behavioral health services such as telepsychiatry.
Over the last 15 years, most of the behavioral health programs have
transitioned from IHS to local community control via Tribal contracting
and compacting. Over half of the Tribes have administrative control
over the delivery of the majority of mental health and substance abuse
programs through tribal contracts and compacts. Such local programs are
community based and have direct knowledge of their population and what
interventions can be effectively implemented. It is clear then that
Tribes, not IHS, are now primarily providing services to their
communities. IHS now seeks to support those services with programs and
program collaborations to bring resources to the communities
themselves.
Addressing Suicide Among American Indians
Suicide is a complicated public health challenge with a myriad of
contributors in American Indian/Alaska Native communities. Only the
pursuit of a multi-targeted, coordinated, and persistent effort that is
acutely aware of the cultural context of suicide and blends the best of
traditional AI/AN healing wisdom and western public health tools is
likely to succeed on a national basis. The losses caused by suicide
affect us all and so the solutions must come from all of us working
together.
IHS has five targeted approaches for suicide prevention and
intervention:
Assist I/T/Us in addressing suicide utilizing community
level cultural approaches.
Identify and share information on best and promising
practices.
Improve access to behavioral health services.
Strengthen and enhance IHS' epidemiological capabilities.
Promote collaboration between Tribal and urban Indian
communities with Federal, State, national, and local community
agencies.
To address youth suicide in Indian Country appropriately requires
public health and community interventions as much as direct, clinical
ones. Since 2003, the IHS National Suicide Prevention Initiative has
provided a critical framework for addressing the tragedy of suicide in
American Indian and Alaska Native communities. The IHS National Suicide
Prevention Initiative builds on the foundation of the HHS ``National
Strategy for Suicide Prevention'' and the 11 goals and 68 objectives
for the Nation to reduce suicidal behavior and its consequences, while
ensuring we honor and respect our people's traditions and practices.
Traditional knowledge, along with the role of Elders and spiritual
leaders, needs to be respected and validated for the important role
they play in healing and wellness. Understanding and decreasing suicide
in our communities will require the best holistically and culturally
sensitive, collaborative efforts our communities and the agencies that
serve them can bring together. With these principles in mind, we hope
to provide a holistic, cultural foundation to suicide prevention,
building on the strong resilience of AI/AN communities. We will strive
to bridge concepts between AI/AN communities, government agencies, and
non-profit organizations in order to effectively prevent suicide.
The Suicide Prevention Initiative is complemented by the IHS
Behavioral Health Initiative, both of which seek to address suicide
prevention through a holistic, community-centered approach. Two other
focus areas that are closely linked to the Behavioral Health Initiative
are the Chronic Disease Management and Health Promotion and Disease
Prevention Initiatives. All of these initiatives are pertinent to
suicide prevention efforts and seek to address the underlying causes of
poor physical and mental health, rather than just treating the
symptoms. They also stress the empowerment and full engagement of
individuals, families, and communities in health care.
Indian Health Service supports changing the paradigm of mental
health services from being specialty and disease focused to being a
part of primary care and the ``Medical Home''. This offers new
opportunities for interventions that identify high risk individuals
before their actions or behavior becomes more clinically significant.
One primary care based behavioral health intervention is the Alcohol
Screening Brief Intervention for patients presenting after physical
trauma, which our agency is broadly promoting as an integral part of a
primary care based behavioral health program. Studies suggest that this
and similar interventions can dramatically reduce further traumatic
injury as well as alcohol and other substance abuse more generally. The
agency, through our Chronic Disease Collaborative and Innovations in
Primary Care project, is also supporting efforts to integrate
behavioral health providers directly into primary care settings as has
been done successfully in Alaska and in other progressive primary care
sites across the country. This presents a dramatic change from the
usual model of distinct and separate medical and behavioral health
service delivery and we intend to support this practice shift over the
coming years through developing further learning communities, sharing
implementation best practices as they develop, and re-aligning and
supporting the development of primary care-based behavioral health
resources.
We have made substantial efforts over the last several years to
improve our behavioral health data collection in the Resource and
Patient Management System (RPMS). Behavioral health information can now
be integrated with primary care and other clinical information
supporting coordinated care and improved health outcomes. As increasing
numbers of clinics adopt the integrated model, data will become
available that may help identify opportunities for intervention in
medical, behavioral health, and community settings. IHS has developed a
suicide surveillance reporting tool to document incidents of suicide in
a standardized and systematic fashion which is available to all
providers in the RPMS health information system. The Suicide Reporting
Database is beginning to provide a more detailed picture of who is
committing or attempting suicide and identifies salient factors
contributing to the events. Accurate and timely data captured at the
point of care provides important clinical and epidemiological
information that can be used to inform intervention and prevention
efforts. IHS is currently developing an IHS-wide Behavioral Health
``data mart'' to provide IHS leadership with up-to-date information on
suicidal events including suicide completions. The application will
include a number of available reports and will provide the ability to
identify ``cluster'' events to assist in the mobilization and
deployment of available resources. Finally, IHS GPRA measures now
include screening for depression in primary care settings as best
practice in order to assist in identifying patients at risk for
developing suicidal ideation. Tools have been selected to assess
depression, monitor response, track such response over time, and are
incorporated into the IHS Electronic Health Record. IHS has
consistently met or exceeded target goals for this GPRA depression
screening measure. This level of monitoring is key to identifying at
risk populations by providers and ensuring they receive timely and
adequate care.
The IHS Emergency Services Program is supporting AI/AN communities
by utilizing the IHS Emergency Response to Suicide Model to assess
communities with high incidence of suicide, coordinate a response to
the affected community, and augment existing staff, with the goal of
mitigating the emergency and stabilizing the community. For example, in
FY 2008, the IHS Emergency Services staff managed on behalf of HHS the
deployment of Public Health Service mental health clinicians through
the Office of Force Readiness and Deployment (OFRD) to a Tribal
community from January-May 2008 to respond to a suicide ``cluster'' in
that community. Federal and community efforts are still ongoing in that
community. The deployment was directly requested by that Tribal
government, and HHS' response was coordinated through the Office of
Intergovernmental Affairs.
Substantial progress has been made in developing plans and
delivering programs, but it is still only the beginning of a long term,
concerted and coordinated effort among Federal, Tribal, State, and
local community agencies to address the crisis. We have recognized that
developing resources, data systems, and promising programs, as well as
sharing information across the system, requires national coordination
and leadership. In response to the problem, the IHS, with Federal
partners, Tribal, and Urban Indian communities across the country, will
expand ongoing partnerships and formulate long term strategic
approaches to intervene in the suicide crisis and provide suicide
prevention and early intervention activities.
Last year, I established the National Tribal Advisory Committee
(NTAC) on Behavioral Health made up of Tribal Leaders from each IHS
Area. The Committee serves as an advisory body to the Indian Health
Service, providing expertise, guidance, and recommendations on
behavioral health issues affecting the delivery of health care for AI/
ANs. In addition, the National Behavioral Health Workgroup was
established which is comprised of Tribal and Urban behavioral health
service providers. The workgroup provides information to the National
Tribal Advisory Committee on Behavioral Health on issues in Indian
Country.
To help guide the overall Indian health system effort, the National
Suicide Prevention Committee, comprised of suicide prevention experts,
was established. The Committee was tasked with identifying and defining
the steps needed to build on the previous suicide prevention efforts to
significantly reduce the impact of suicide and suicide-related
behaviors on AI/AN communities. Members of the Suicide Prevention
Committee are interdisciplinary and represent a broad geographic
distribution within and outside the Indian health system.
It is the responsibility of the IHS Suicide Prevention Committee to
provide recommendations and guidance to the Indian Health Service
regarding suicide prevention and intervention in Indian Country. This
past year, the SPC developed an Indian Health System National Suicide
Prevention Strategic Plan. The National Suicide Prevention Strategic
Plan is a first step in describing and promoting the accumulated
practice-based wisdom in AI/AN communities. At its best, the plan will
be a living and constantly changing reflection of the collaborative and
focused efforts of the many people throughout American Indian/Alaska
Native communities who are working to reduce the scourge of suicide.
The Methamphetamine and Suicide Prevention Initiative (MSPI) is a
another coordinated program designed to provide prevention and
intervention resources for Indian Country. This initiative promotes the
development of evidence-based practices using culturally appropriate
prevention and treatment to address methamphetamine abuse and suicidal
behaviors in a community-driven context.
The goal is to intervene effectively to prevent, reduce or delay
the use and/or spread of methamphetamine abuse by increasing access to
methamphetamine and suicide prevention services through culturally
relevant services. The $14 million initiative focuses on supporting
promising or model practices for methamphetamine and suicide reduction
programs in Indian Country.
So, taken all together, where are we?
We acknowledge that the complexity of suicide and its close
cousins, violent and accidental death and injury, remains challenging.
At the same time, we believe suicide and suicidal behaviors are
preventable through the engagement of the affected communities and the
application of research-supported public health approaches. Several
Tribal and urban Indian communities have already taken up this
challenge and have been implementing a number of innovative and
culturally sensitive prevention initiatives. For example, Tribal and
urban Indian communities are implementing the Native H.O.P.E.
curriculum, the American Indian Life Skills Development, the Sources of
Strength model, ASIST (Applied Suicide Intervention Skills Training),
QPR (Question, Persuade, Refer), and other promising approaches in
several communities across Indian Country. Increasing access to
services, improving responsiveness of services, developing school and
community level wisdom about how to manage distressed community
members, educating and increasing awareness, and connecting young
people to their culture are all successful approaches in Indian Country
that are beginning to show us the way. However, for many other
individuals and groups, it remains challenging to determine the best
approach to prevent suicide in their own communities.
The initiatives and programs that I have described here are some of
the methods and means to engage individuals and their communities.
These efforts are not sufficient in and of themselves to significantly
change many peoples' living conditions. However, if we can act
together, among agencies, branches of government, Tribes, States, and
communities, I believe that the tide can be turned and hope restored to
those who have lost hope. To that end, I commit to work with you and
anyone else in and out of government to bring services and resources to
that effort.
Mr. Chairman, this concludes my statement. Thank you for this
opportunity to discuss youth suicide in Indian Country. I will be happy
to answer any questions that you may have.
The Chairman. Mr. McSwain, thank you very much.
Next, we will hear from Dr. Eric Broderick from SAMHSA.
Thank you very much for being here.
STATEMENT OF ERIC B. BRODERICK, D.D.S., M.P.H., ACTING
ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Broderick. Good morning, Mr. Chairman and Committee
members. Thank you very much. I appreciate the opportunity to
be here today. I thank you for bringing together survivors of
suicide, professionals from the suicide prevention field, as
well as Mr. McSwain and other Federal partners to talk about
this issue.
No one person has the answer to this. No one organization.
It must be reliant on collaboration, a collaborative effort
that people bring from many different perspectives to address
this very, very serious issue.
SAMHSA has worked very hard over the last three years to
put our resources out into the field in Indian Country to
ultimately help increase the capacity of Indian communities to
address the challenges that mental illness and substance abuse
present to them.
Suicide is a serious public health challenge, as has been
said today, and it is only now beginning to receive the
attention and degree of national priority that it deserves. It
takes huge courage to do what Senator Reid did, what Ms. Jetty
did, and what her family did, what the gentleman that Senator
Murkowski and I heard last week did, to stand up, in spite of
the stigma, in spite of the guilt and the anger and grief that
a family feels, and speak out. Until that happens, the stigma
will remain.
I am very pleased to hear it happening more and more and
more across this Country because that is what will actually
deal with the stigma and deal with the many different emotions
that families confront when confronted with this great problem.
Suicide is a huge problem in this Country, with 32,000
deaths a year. You heard Senator Reid state that statistic. Any
time there is a situation where 900,000 of our youth, 900,000 a
year, plan their own death, and 712,000 of those youth actually
attempt it, that, I would say, qualifies as a public health
crisis. You have very well articulated the needs of this
Country to face this issue.
We have heard the data, and I won't repeat them, but as
seriousness as this condition is across this Country, the
situation is more serious in Indian communities. I have said
that we have made it a priority at SAMHSA to make our resources
available in Indian Country. As we do that, it is critical that
we engage tribes and tribal leaders to help assure that we do
so in a respectful way as partners. I want to mention a few
strategies that we have used to engage tribes in that way.
We have a Tribal Advisory Committee that is comprised of 14
tribal leaders from around the Country, to provide us advice
and guidance. We participate in the HHS Tribal Consultation
Sessions each year around the Country.
We also in 2006 partnered with the Department of Justice to
be responsive to a call from tribal leaders to improve tribal
capacity and infrastructure through training and technical
assistance to tribal communities. That project, now called the
Tribal Justice Safety and Wellness Project, began with a
meeting in California two and a half years ago where 200 people
attended. Mr. McSwain talked about the session that we had in
Billings last summer. The session was convened, by the
Department of Interior, the Department of Health and Human
Services, and the Department of Justice. Over 1,000 people came
together who don't talk to one another including Federal
agencies, to allow tribes the access that they have requested
to talk to individuals from multiple locations across the
Executive Branch of the government.
The partnership now includes the Department of Health and
Human Services, the Department of Justice, the Department of
Interior, the Department of Housing and Urban Development, the
Small Business Administration, and our newest partner, the
Corporation for National and Community Service.
I will tell you at every one of these opportunities, these
venues where tribes come together with Federal staff, suicide
is among the most frequently mentioned issues that is brought
to us along with requests to help tribes address that.
We are making progress. At the start of 2005, SAMHSA had
two suicide prevention grants. Today, we have 110. You have
heard much discussion about the Garret Lee Smith Suicide
Prevention Act. There have been others who talked about the
Suicide Prevention Resource Center that SAMHSA funds. It is a
technical assistance center. What I would add to that is there
are now two tribal affairs specialists employed by the Suicide
Prevention Resource Center specifically there to help Indian
communities with their requests for technical assistance around
suicide.
You have heard some discussions about the Native
Aspirations Project. That project focuses on the 25 communities
with very high risk for suicide clusters. They do wonderful
work. I would add that some of the Native Aspiration
communities have gone on and used that technical assistance and
gone on to become Garret Lee Smith grant awardees.
The situation today at SAMHSA is that fully one-third of
our Garret Lee Smith State and tribal grants go to tribes. We
awarded 30 last year, 12 went to tribes, 18 went to States. And
as Senator Murkowski said, we were in Alaska last week and
presented a $1.5 million Garret Lee Smith grant to the State of
Alaska. One of the first things that they told us was in using
those grant dollars, they will put them in place in communities
where the need exists. They made it very clear that native
communities are among the communities that they will focus on.
So it is very heartening to see resources going out in that way
to communities in very great need.
The last program I would like to talk about is the National
Suicide Prevention Lifeline Network, a network of 135 crisis
centers across the United States that receive calls from a
national toll-free number, number 1-800-273-TALK. Every month,
44,000 people have their calls answered by the lifeline, an
average of 1,439 people a day. Calls are free and confidential
and answered 24 hours a day, 7 days a week. We know this
program saves lives.
The National Suicide Prevention Lifeline American Indian
Initiative has worked to promote access to suicide prevention
hot line services in Indian Country by supporting communication
and collaboration between tribes and local crisis centers, as
well as providing outreach materials customized to each tribe.
Suicide is preventable and help is available. All Americans
have access to the National Suicide Prevention Lifeline during
times of crisis, and we are committed to sustaining this vital
national resource.
These SAMHSA initiatives are an important start, but as we
know, there is much, much more to be done to reduce the tragic
burden of suicide in Indian Country. The problems confronting
the American Indians and Alaska Natives are taking a toll on
these communities now and will in the future. I lived on the
Wind River Reservation when the incident occurred in 1985 that
the Senator talked about a few minutes ago. I will tell you, in
my opportunities to go back there, much has been done to remedy
that situation, but they still live with the outcomes and the
consequences of those 10 or so young people who killed
themselves all those many years ago.
Mr. Chairman, I want to thank you for the opportunity to be
here today. I would be happy to answer any questions that you
might have or the Committee might have. Thank you very much.
[The prepared statement of Dr. Broderick follows:]
Prepared Statement of Eric B. Broderick, D.D.S., M.P.H., Acting
Administrator, Substance Abuse and Mental Health Services
Administration, U.S. Department of Health and Human Services
Mr. Chairman and Members of the Committee, good morning. I am Dr.
Eric Broderick, Acting Administrator of the Substance Abuse And Mental
Health Services Administration (SAMHSA) within the Department of Health
and Human Services (HHS) and Assistant Surgeon General. I am pleased to
have this time to share with you a few highlights of SAMHSA's efforts
and the Agency's important role in improving behavioral health
throughout American Indian/Alaska Native (AI/AN) communities.
In my prior position as SAMHSA's Deputy Administrator and twice now
as the steward of the Agency as Acting Administrator, I have worked
hard to raise the critical issues facing our tribal nations surrounding
behavioral healthcare and its direct relationship to overall health to
a priority level within SAMHSA and among our federal partners. I have
made it a priority to take SAMHSA and its resources directly to AI/AN
communities where much-needed training and dialogue can and has taken
place to further the process of breaking down the barriers to quality
assistance and services.
By participating annually in the HHS Budget Consultation and
Regional Consultation Sessions with Tribal leaders and representatives,
SAMHSA hears first-hand about the top priorities in Indian Country.
Additionally, SAMHSA requires active engagement of our Senior Leaders
in these meetings and has made this a part of all of our performance
plans.
I continue to believe one of my most important responsibilities is
to leave each site visit, training session, consultation session or
other gathering knowing more about what needs to be done in AI/AN
communities than when SAMHSA staff and I arrived. The need for those at
the federal level to continue engaging tribal leaders, organizations
and communities is clear and the response should be held at a high
level of importance.
In particular, over the past two years SAMHSA has gained ground on
a number of accomplishments with our tribal partners including our
partners within the IHS Regional Health Boards. For instance, in 2006
the Department of Justice and SAMHSA began a collaboration to respond
to the call of tribal leaders to improve tribal capacity and
infrastructure through training and technical assistance to tribal
communities. With more federal agencies committing to developing
strategic solutions for American Indians and Alaska Natives, the
collaboration is now a multi-agency endeavor entitled Tribal Justice,
Safety and Wellness Government-to-Government Consultation, Training and
Technical Assistance Sessions. In 2006 about 200 people attended the
first session. By the seventh session, there were over 1,000 people,
which demonstrates that a collaborative approach is working-no one
agency can solve the problems alone.
These Tribal Training and Technical Assistance Sessions provided
many opportunities for tribal leaders to learn about SAMHSA's grant
programs as well as important information regarding grants
administration and financial management, tips for successful grant
writing, overviews of various Federal funding sources and information
on Tribal Drug Courts. There are many federal partners including: the
Department of Health and Human Services through SAMHSA, the Indian
Health Service and the Office of Minority Health; the Department of
Justice through its Office of Justice Programs, Community Orienting
Policing Services, Executive Office of U.S. Attorneys Native American
Issues Subcommittee, Office of Tribal Justice, and Office on Violence
Against Women; the Department of the Interior through its Bureau of
Indian Affairs; the Department of Housing and Urban Development through
its Office of Native American Programs; the Small Business
Administration's Office of Native American Affairs; and our newest
federal partner, the Corporation for National and Community Service.
Many of these and other steps forward taken by SAMHSA are a result
of the agency's dedication to improve services in Indian Country
beginning with the revision of SAMHSA's Tribal Consultation Policy in
2007. SAMHSA has established a Tribal Technical Advisory Committee
comprised of Tribal Leaders who provide guidance and input on critical
issues impacting Indian Country. As we continue to move forward and
continue to make progress, we will stay closely involved in the
critical issues, such as suicide, which continue to face our tribal
partners.
SAMHSA is working to address suicide among American Indians and
Alaska Natives. SAMHSA's efforts correspond with the efforts identified
in the National Strategy for Suicide Prevention (NSSP). The NSSP
represents the combined work of advocates, clinicians, researchers and
survivors around the nation. The NSSP provides a framework for action
to prevent suicide and guides development of an array of services and
programs that must be developed. It is designed to be a catalyst for
social change with the power to transform attitudes, policies, and
services. SAMHSA's agency-wide efforts to address and prevent suicide
continue to be developed around the recommendations of the NSSP.
Suicide--Correlation with Substance Use and Mental Health Disorders
SAMHSA is responsible for improving the accountability, capacity
and effectiveness of the nation's substance abuse prevention,
addictions treatment, and mental health service delivery systems.
Suicide prevention is among our agency priorities.
SAMHSA has a clear role to play in addressing and preventing
suicide, as both substance abuse and mental health disorders can
increase the risk of and contribute to suicidal behavior in several
ways. Two of the leading risk factors for suicide are a history of
depression or other mental illness and alcohol or drug abuse. For
particular groups at risk, such as American Indians and Alaska Natives,
depression and alcohol use and abuse are the most common risk factors
for suicide.
Suicide--A Public Health Issue
Suicide is a serious public health challenge that is only now
receiving the attention and degree of national priority it deserves.
Many Americans are unaware of suicide's toll and its global impact.
Suicides account for up 49.1 percent of all violent deaths worldwide,
making suicide the leading cause of violent deaths, outnumbering
homicide. In the United States, suicide claims approximately 32,000
lives each year. When faced with the fact that the annual number of
suicides in our country now outnumbers homicides by three to two, the
relevance and urgency of our work becomes clear. Additionally, when we
know, based on SAMHSA's National Survey on Drug Use and Health (NSDUH)
in 2003, that approximately 900,000 youth had made a plan to commit
suicide during their worst or most recent episode of major depression
and an estimated 712,000 attempted suicide during such an episode of
depression, it is time to intensify activity to prevent further
suicides. The NSDUH data and the countless personal stories of loss and
tragedy are proof that suicide prevention must remain a priority at
SAMHSA.
Suicide Among American Indian and Alaska Native Youth
Suicide is now the second-leading cause of death (behind
unintentional injury and accidents) for American Indian and Alaska
Native youth aged 10-34. HHS's Centers for Disease Control and
Prevention (CDC) reports that from 1999 to 2004, the suicide rate for
American Indians/Alaska Natives was 10.84 per 100,000, higher than the
overall U.S. rate of 10.75. Adults aged 25-29 had the highest rate of
suicide in the American Indian/Alaska Native population, 20.67 per
100,000. Suicide ranked as the eighth-leading cause of death for
American Indians/Alaska Natives of all ages.
Of significant concern is that in the two most recent years for
which we have data, 2004 and 2005, the suicide rate among American
Indians/Alaska Natives increased. According to CDC's National Vital
Statistics Report, in 2005 American Indian and Alaska Native youth aged
15-24 had a rate of suicide twice as high as youth of that age
nationally. We do not yet know if the 2006 data will show a
continuation of the same tragic trend, but the stories we have heard
lead us to have great concern. What in and of itself is a tragedy to
report is more than one-half of all persons who die by suicide in the
United States, and an even higher number in Tribal communities, have
never received treatment from mental health providers.
SAMHSA's Role in Better Serving American Indian and Alaska Native
Populations
SAMHSA focuses attention, programs, and funding on improving the
lives of people with or at risk for mental or substance use disorders.
SAMHSA's vision is ``a life in the community for everyone.'' The agency
is achieving that vision through its mission of ``building resilience
and facilitating recovery.'' SAMHSA's direction in policy, program, and
budget is guided by a matrix of priority programs and crosscutting
principles that include the related issues of cultural competency and
eliminating disparities. To achieve the agency's vision and mission for
all Americans, SAMHSA-supported services are provided within the most
relevant and meaningful cultural, gender-sensitive, and age-appropriate
context for the people being served. SAMHSA has put this understanding
into action for the American Indian and Alaska Native communities it
serves. SAMHSA has worked to ensure Tribal entities are eligible for
all competitive grants for which States are eligible.
SAMHSA's activity in suicide prevention has increased dramatically
in recent years. For example, at the start of 2005, there were two
competitive grant awards for suicide prevention. At the end of 2005,
there were 46. Currently, there are over 110 suicide prevention grants
going to states, tribes/tribal organizations, territories, and colleges
and universities, and crisis centers across the country. SAMHSA
supports four major suicide prevention initiatives that I will
highlight briefly today. These initiatives are: the Garrett Lee Smith
Youth Suicide Prevention Grant Program; SAMHSA's the Native Aspirations
Project; the Suicide Prevention LifeLine; and the Suicide Prevention
Resource Center.
Garrett Lee Smith Youth Suicide Prevention Grant Program
As a result of the Garrett Lee Smith Memorial Act (P.L. 108-355),
SAMHSA has been working with State and local governments and community
providers to stem the number of youth suicides in our country. In 2005,
we awarded the first cohort of grants, 14 in all, under the Garrett Lee
Smith Memorial Act State/Tribal Suicide Prevention program. These funds
are available to help States/Tribes implement a State-wide/Tribe-wide
suicide prevention network. One of those first set of grants went to
the Native American Rehabilitation Association in Oregon. In addition,
through an Interagency Agreement between the CDC and SAMHSA, the Native
American Rehabilitation Association was one of three Garrett Lee Smith
grantees awarded additional funding to enhance their evaluations to
maximize what we can learn from these important suicide prevention
efforts.
Awards were also made in 2006 and 2007, during which six more
Tribes/Tribal Organizations were awarded grants. These grants are
supporting a range of suicide prevention activities in Indian Country,
such as training community members to recognize the warning signs of
suicide and intervening with youth seen in Emergency Departments who
have attempted suicide. This past August (2008), 12 Tribes/Tribal
Organizations received Garrett Lee Smith grants in addition to the 18
grants made to States, totaling 30 new awards.
Garrett Lee Smith grants to Tribes and Tribal Organizations now
total one-third of the number of grant awards. This is not only a
direct result of outreach and technical assistance, but a true
indication of the resolve of Tribes and Tribal Organizations to
proactively seek RFAs and then put forward strong, viable applications.
Additionally, it is important to note that many of the states that
received grant awards are partnering with and/or reaching out to
include suicide prevention efforts in their local tribal communities.
Among the 18 States that received a grant in 2008 is Alaska. Just last
week, I was able to travel to Juneau to present to the State of Alaska,
with Senator Murkowski in attendance, this $500,000 per year award for
three years, totaling $1.5 million.
Within the newest cohort of grants, the Tribes/Tribal Organizations
awardees are: the Gila River Behavioral Health Authority Youth Suicide
Prevention Project, The Gila River Indian Community, Sacaton, Arizona;
Omaha Nation Community Response Team--Project Hope, Walthill, Nebraska;
Mescalero Apache School Youth Suicide Prevention and Early Intervention
Initiative, Mescalero, New Mexico; Wiconi Wakan Health & Healing
Center, Rosebud Sioux Tribe, Rosebud, South Dakota; Circle of Trust
Youth Suicide Prevention Program, The Confederated Salish Kootenai
Tribes of the Flathead Indian Nation, Pablo, Montana; Preserving Life:
Nevada Tribal Youth Suicide Prevention Initiative, Inter-Tribal Council
of Nevada, Sparks, Nevada; Youth Suicide Prevention, The Crow Creek
Sioux Tribe, Ft. Thompson, South Dakota; Tribal Youth Suicide
Prevention Program, Oglala Sioux Tribe, Pine Ridge, South Dakota;
Wiconi Ohitika Project, Cankdeska Cikana Community College, Fort
Totten, North Dakota; Sault Tribe Alive Youth (STAY) Project, Sault Ste
Marie Tribe Chippewa Indians, Sault Ste Marie, Michigan; Bering Strait
Suicide Prevention Program, Kawerak, Inc., Nome, Alaska; and the Native
Youth Suicide Prevention Project, Native American Rehabilitation
Association, Portland, Oregon, which successfully recompeted for a
second grant.
As of October 2, 2008, a total of 54 states, tribes, and tribal
organizations, as well as 49 colleges and universities, will be
receiving funding for youth suicide prevention through this program.
Again, it is important to note that with the new tribal grantees, one-
third of all of the Garrett Lee Smith State and Tribal grants will be
going to tribes or tribal organizations.
Native Aspirations Project
SAMHSA funds the Native Aspirations project, which is a national
project designed to address youth violence, bullying, and suicide
prevention through evidence-based interventions and community efforts.
Native Aspirations, after consultation with SAMHSA based on data from
IHS, determines the 25 AI/AN communities that are the most ``at risk'',
and the project then helps these communities develop or enhance a
community-based prevention plan. After a community is selected, the
initial step is a visit from Native Aspirations project staff members,
who share information and help community leaders set up an oversight
committee. The second step is a Gathering of Native Americans (GONA), a
4-day event designed to offer hope, encouragement, and a positive
start. GONA events are based on each community's traditional culture
and honor AI/AN values. GONA events are a safe place to share, heal,
and plan for action.
Within a month of a GONA, Native Aspirations staff facilitate a 2-
day planning event. At this point, participants receive training about
prevention plans and decide which model to follow. They outline a
customized plan based on actions that have worked for others. As the
community finalizes and carries out its plan, Native Aspirations
provides training, consultation, technical assistance, and budget
support. A number of tribes who received help through Native
Aspirations were able to build on this to successfully compete for a
Garrett Lee Smith Youth Suicide Prevention grant.
Suicide Prevention Resource Center
Another initiative is the Suicide Prevention Resource Center
(SPRC), a national resource and technical assistance center that
advances the field by working with states, territories, tribes, and
grantees and by developing and disseminating suicide prevention
resources. The SPRC was established in 2002. It supports suicide
prevention with the best of available science, skills and practice to
advance the National Strategy for Suicide Prevention (NSSP). SPRC
provides prevention support, training, and resource materials to
strengthen suicide prevention networks and is the first federally
funded center of its kind.
The Suicide Prevention Lifeline
The National Suicide Prevention Lifeline is a network of 135 crisis
centers across the United States that receives calls from the national,
toll-free suicide prevention hotline number, 800-273-TALK. The network
is administered through a grant from SAMHSA to Link2Health Solutions,
an affiliate of the Mental Health Association of New York City. Calls
to 800-273-TALK are automatically routed to the closest of 135 crisis
centers across the country. Those crisis centers are independently
operated and funded (both publicly and privately). They all serve their
local communities in 47 states, and operate their own local suicide
prevention hotline numbers. They agree to accept local, state, or
regional calls from the National Suicide Prevention Lifeline and
receive a small stipend for doing so.
In the three states that do not currently have a participating
crisis center (Idaho, Hawaii, and Vermont), the calls are answered by a
crisis center in a neighboring state. Every month, more than 44,000
people have their calls answered through the National Suicide
Prevention Lifeline, an average of 1,439 people every day. When a
caller dials 800-273-TALK, the call is routed to the nearest crisis
center, based on the caller's area code. The crisis worker will listen
to the person, assess the nature and severity of the crisis, and link
or refer the caller to services, including Emergency Medical Services
when necessary. If the nearest center is unable to pick up, the call
automatically is routed to the next nearest center. All calls are free
and confidential and are answered 24 hours a day, 7 days a week.
By utilizing a national network of crisis centers with trained
staff linked through a single national, toll-free suicide prevention
number, the capacity to effectively respond to all callers, even when a
particular crisis center is overwhelmed with calls, is maximized. This
also provides protection in the event a crisis center's ability to
function is adversely impacted, for example, by a natural disaster or a
blackout. Further, by utilizing the national number 800-273-TALK,
national public awareness campaigns and materials can supplement local
crisis centers' efforts to help as many people as possible learn about
and utilize the National Suicide Prevention Lifeline. In fact, SAMHSA
has consistently found that when major national efforts are made to
publicize the number, the volume of callers increases and this
increased call volume is maintained over time.
The National Suicide Prevention Lifeline's American Indian
initiative has worked to promote access to suicide prevention hotline
services in Indian Country by supporting communication and
collaboration between tribes and local crisis centers as well as
providing outreach materials customized for each tribe. We are pleased
that we have been able to work together with the AI/AN Communities and
also with the Department of Veterans Affairs to help deliver the
critically important messages that suicide is preventable, and that
help is available. All Americans have access to the National Suicide
Prevention Lifeline during times of crisis, and we are committed to
sustaining this vital, national resource.
SAMHSA Emergency Response Grants
SAMHSA is also committed to assisting communities which have faced
traumatic events through our SAMHSA Emergency Response Grant (SERG)
Program. SAMHSA provides SERG funding in rare emergency situations in
which State and local resources are overwhelmed and no other Federal
resources are available. Applicants must demonstrate that the need is
greater than existing local and State resources, and must explain why
other Federal funding doesn't meet their needs. The SERG is a SAMHSA-
wide program. Funding can be used for emergency mental health services
and disaster-related substance abuse treatment and prevention programs
and can be used to address new substance abuse treatment and prevention
concerns in response to an event or to replace services destroyed by a
disaster.
The SERGs are available in response to those situations in which a
presidential disaster declaration has not been made and are
particularly helpful in cases of emergent and urgent unmet behavioral
health needs of communities such as the Red Lake reservation community.
The Red Lake Band of Chippewa Indians in Minnesota received a SERG in
response to the school shooting there. The SERG assisted in the
establishment of the Wii-doo-kaa-wii-shin (Helping Each Other) Project.
This project provides mental health needs, specialized outreach,
assessment, ongoing support and education, as well as treatment and
services.
The Standing Rock Sioux also received a SERG in response to a
suicide cluster. The grant assisted with the establishment of a
behavioral health network with staffing as well as funding to augment
their suicide prevention program, crisis hotline, healing and support,
as well as training and technical assistance. In addition, the Crow
Creek Sioux received a SERG to assist in their efforts to protect and
heal their community following a suicide cluster as well.
The SAMHSA initiatives described above are important steps to
reduce the tragic burden of suicide in Indian Country. The problems
confronting American Indians and Alaska Natives are taking a toll on
the future of these communities.
Mr. Chairman and Members of the Committee, thank you for the
opportunity to appear today. I will be pleased to answer any questions
you may have.
The Chairman. Dr. Broderick, thank you very much for being
here.
Let me ask briefly about the response to the Rosebud
circumstance in South Dakota. The suicide rates on the Rosebud
Reservation reached epidemic proportions there. I wonder about
the emergency response. What is the level of suicide? What is
the approach you use by which the IHS would implement some sort
of emergency response model that you have? And describe to us
what you did at Rosebud, if you would.
Dr. Broderick. Okay. The situation at Rosebud has been
going on for some time. It is not something that just recently
started. Actually, the Rosebud Sioux Reservation is one of the
communities that is part of the Native Aspirations Project. So
in partnership with the Indian Health Service, we increased the
resources available to that community through Native
Aspirations. There was a deployment of commissioned officers of
the Public Health Service to go and assist that community.
The Chairman. But how did that happen? What was the trigger
that caused it?
Dr. Broderick. The tribe asked. It is a matter of the tribe
asking the Commission Corps. The Indian Health Service was
intimately involved in that request, and Public Health Service
officers from SAMHSA, and quite frankly all across the
Department of Health and Human Services responded to go to
Rosebud for tours of three to four weeks and rotations of
individuals to provide mental health and substance abuse
counseling services to that community over the course of time.
The process continues. It is hard work, because we believe
that the solution to the problem doesn't rest at SAMHSA or
doesn't rest at the Indian Health Service headquarters in
Rockville. It rests in that community. And we stand ready and
committed to provide assistance to the community.
The Department of Health and Human Services also convened
in the Office of Intergovernmental Affairs a cross-agency
collaboration of multiple departments to bring resources to
bear to help that community.
The Chairman. We will know we have made progress when we
see diminished rates of teen suicides on Indian reservations.
The question I have is, with several different initiatives out
there that are being used by SAMHSA and the Indian Health
Service, how are we tracking the effectiveness and the
efficiency of the use of these funds? How do we know what we
are getting for these funds and whether we are making a
difference? And which programs, which initiatives make the
biggest difference?
Dr. Broderick. For SAMHSA, each of our grants, each of our
grant programs, rely on evidence-based practice. We heard some
discussion about that earlier. What can we do when the
evidence-based practices are developed in non-native
communities to make them available? That is a whole other
discussion, but suffice it to say that our grantees, in order
to be successful for a SAMHSA grant, you must demonstrate the
use of evidence-based practice.
We then monitor progress on those grants through the
Government Performance and Results Act and the PART process to
make sure that data are available and that the projects are
successful.
The Chairman. Mr. McSwain?
Mr. McSwain. Thank you, Mr. Chairman. I think Indian Health
Service certainly has two things working. One is that we have
always been there with our clinical folks and the like, so we
are looking at a system of care that begins to identify certain
incidences. Maybe it is depression. We are tracking that on the
clinical side, so we can hand them off, a soft hand-off to our
behavioral health people, and even incorporating the behavioral
health people in.
We have built in the evaluation piece into these grants.
The first $14 million that we got this last year, we will build
it into those and actually begin to measure results as they go
out to the communities with this very thought in mind.
The Chairman. How short are your behavioral health dollars
in order for the reach that you should do? We talked earlier
about rationing. I know these programs exist. I know that both
of you do outreach on certain reservations, they get some help
from you. I also know that is not something that is across the
Indian populations and available to all reservations.
So how short are we of the resources necessary to do the
job you think should be done?
Mr. McSwain. You know, I don't really know. The reason why
I don't know is that because of the fact that there are so many
other factors involved. Health is one piece of it. Until we get
the whole pie built, if you will, the SAMHSAs, the DOJs, and
all the other folks who enter in to helping a community with
suicide, when we get that all together, if we take all the
pieces, then we would have what we would project we would need.
The Chairman. You have heard and you know of the models
that are out there, the work that is being done to train folks
in our schools and so on. There must be some notion of what
kind of additional resources should be made available so that
we better expose all of the populations that are at risk out
there to the kinds of services that are necessary, the kinds of
programs that are necessary.
Would you work to try to give us your assessment of what
that shortage of resources is at this point?
Mr. McSwain. I certainly would give it a big try because it
is a fact that we work so hard on the clinical side. We can
tell you what the numbers are there, but giving you the
behavioral health side will take a little more work, but we can
do that.
The Chairman. Unfortunately, because of the vote and the
recess we felt this would go from 10 a.m to 12 noon. It is
12:20 p.m. The Chair had a 12 o'clock speech that I didn't give
off the Hill, but I have to chair a luncheon in the Capitol
Building.
So what I would like to do for both of you is to submit a
list of questions. I think what we have done today is hear a
lot of information with which we can try to evaluate what is
happening and what works, what doesn't work. We have heard from
a young woman who described these issues in personal terms, and
the reason that is important, especially here in Washington,
D.C. where we describe them statistically. That is not what is
happening in America. This isn't about statistics. It is about
great tragedy that is occurring, not only those who take their
lives and lose their lives, but those who are left behind as
victims of these suicides.
So I want to thank both of you for being willing to sit
through the previous testimony. That is not usual, but I think
it was for good purpose. We will submit a list of additional
questions to you.
I want to thank all of the others who have testified.
Our Committee is going to continue to pay attention to
this, even as we turn now to try to write a new Indian Health
Care Improvement bill that we will introduce. As we do that, we
will pay special attention to this subject, which is part of
that issue.
This hearing is adjourned.
[Whereupon, at 12:20 p.m., the Committee was adjourned.]
A P P E N D I X
Prepared Statement of Jacqueline S. Gray, Ph.D., Assistant Professor,
Center for Rural Health, University of North Dakota School of Medicine
and Health Sciences
Greetings Honorable Chairman Dorgan, Vice-Chairman Barrasso, and
Members of the Committee. Thank you for the opportunity to provide
testimony to this committee and my perspective on the present status
and progress toward preventing American Indian and Alaska Native (AI/
AN) youth suicidal behavior.
I bring to you my perspectives as a Choctaw and Cherokee
descendent, a mental health clinician with 25 years of experience
working with American Indian clients, a faculty member from the Center
for Rural Health at the University of North Dakota focused on rural and
tribal mental health issues, an adjunct faculty in counseling
psychology preparing future mental health professionals, a researcher
of mental health and suicide prevention with American Indians, and a
concerned mother and grandmother. I have worked in suicide prevention
and crisis intervention for 20 years and developed a crisis
intervention model that has been adopted across the state of Oklahoma.
I have worked with Garrett Lee Smith campus, state, and tribal suicide
prevention programs, Native Aspirations (which utilizes Dr. Theresa
LaFromboise's American Indian Life Skills [LaFromboise, 1996]
curriculum), Indian Health Service, and tribal programs focused on
behavioral health. I walk in many worlds with regard to this issue:
Native and Western with my bicultural identity; clinician, teacher,
researcher, and consumer of mental health services; survivor of
suicide; promoter of wellness, and prevention of suicide. I hope my
testimony will assist the Committee in understanding the needs and
potentials related to AI/AN youth suicide and promotion of positive AI/
AN mental health.
You have received statistics from others highlighting the suicide
rates of AI/AN youth as the highest in the nation and escalating in
recent years (Broderick, LaFromboise, McSwain, Reid, Walker, 2009).
Suicide in AI/AN communities is an epidemic and in need of the
attention given a public health epidemic. A great deal has been
addressed in recent years by the Garrett Lee Smith Memorial Act (P.L.
108-355). I have worked with campus, state, and tribal applicants and
awardees of these grants and know the hard work that is being done to
address youth suicide through the funds provided. I have worked with
the Native Aspirations program and know that they are trying to address
suicide prevention in some of the most ``at risk'' AI/AN communities in
the country. I have also worked with the Suicide Prevention Resource
Center and Suicide Prevention Lifeline and the great work they are
doing to provide resources and support for suicide prevention. But this
is clearly not enough.
Services
Mental health services available through Indian Health Service
(IHS) and tribes are already stretched beyond capacity. As more youth
are identified as suicidal or at risk we need more local services to
address those needs. Many times youth must be transported hundreds of
miles from home for inpatient treatment and then lack the aftercare
services needed to transition to outpatient, and follow-up treatment
when returned home.
When writing a grant a few months ago, I worked with Aberdeen Area
IHS Behavioral Health staff to determine the ratio of mental health
providers to AI population in the Aberdeen Area. The results were
overwhelming: one psychiatrist per every 250,000 American Indians; one
psychologist per every 17,000 American Indians; and one social worker
or counselor per every 3,300 American Indians. Every county with AI
reservations has been designated as Mental Health Professional
Underserved Areas through the Health Resources and Services
Administration (HRSA, 2008). The requirements for Mental Health
Provider Shortage designations are 30,000: 1 for geographic areas or
20,000:1 for high need areas. Core mental health providers (CMHP;
clinical social workers, psychiatric nurse specialists, clinical
psychologists, and marriage and family therapists) rations 9,000:1
including psychiatrists or 6,000:1 CHMP and 20,000:1 for psychiatrists
(HRSA, 2009). Indian Health Services behavioral health services are
currently funded at about 25% of the actual need. Solutions to this
problem includes passage of the Indian Health Care Improvement Act,
increased funding for behavioral health services to AI/AN communities,
minimal standards for providers of behavioral health services to ensure
the protection of those receiving services, funding for training
programs to increase the numbers of AI/AN behavioral health service
providers, cultural competence training for providers of health, and
behavioral health services in AI/AN communities. Resources to utilize
American Indians into Psychology trainees and other trained,
credentialed, AI/AN providers on an emergency basis help to assist with
suicide emergency situations. Many of the youth involved in suicidal
behaviors are in need of substance abuse services as well as mental
health services. More funding for dual diagnosis services close to home
for these youth are important in maintaining connection with families
and receiving care for both issues at the same time.
Education/Training
The need for training includes increasing the numbers of AI/AN
licensed mental health providers and trainings on cultural awareness,
competence, and integration into services, prevention, and programs
provided for AI/AN youth. There are approximately 250 AI/AN clinically
trained psychologists (0.3% of 84,883), 865 AI/AN clinically trained
counselors (0.5% of 100,533), and 150 school psychologists (0.4% of
37,893) in the U.S. (SAMHSA, 2004). Currently, there are American
Indian/Alaska Native into Psychology programs at the University of
North Dakota, Oklahoma State University, the University of Montana, and
the University of Alaska-Fairbanks. Utah State University has an
unfunded American Indian Support Project. While these programs increase
the number of AI/AN psychologists, there is a great need for more. The
inclusion of clinical, counseling and school psychology programs would
increase numbers and fill varied roles for mental health providers who
receive the same licensure in states. To fill the gaps in the pipeline,
mentoring programs to support AI/AN students between undergraduate and
graduate programs would increase their competitiveness in applying to
graduate programs and pre-doctoral internship programs; post-doctoral
(pre-licensure) opportunities would provide clinical experiences with
AI/AN clients and give those graduates work opportunities, helping them
to get through the licensure process so they can work at IHS and tribal
facilities.
In addition to training mental health providers, cultural
competence and awareness training needs to be a requirement for all
health service providers in Indian Country. It is critically important
that those providing services can relate to the cultural values of the
people they serve to increase the likelihood of AI/AN people in need of
services seeking out the help that is available. If culturally
appropriate programs, media, and services are not available, the
resources are less likely to be used by those who need them most. In
addition, a strong cultural identity has been found to be protective
against depression (Gray, et. al, 2008).
While the need for services and well-trained professionals is
evident, another area of need is the training of community members,
first responders, and school personnel to recognize, assist, and
support youth prior to reaching a suicidal state. Programs such as
Question, Persuade, Refer (QPR) (Quinette, 1999) have been adapted for
Indian Country and focus on suicidal behavior recognition and
intervention. Mental Health First Aid is a program like a first aid
program focused more generally on mental health issues, recognizing
symptoms, crisis situations, intervening in a crisis, and supporting a
person throughout any treatment or follow-up (MHFA, http://
www.thenationalcouncil.org/cs/press_public/mental_health_first_aid_2/
about_the_program/mhfa_course_description). This program has shown
increased willingness for participants to intervene in the case of a
mental health emergency, greater feelings of confidence in their
abilities to do something in a mental health emergency, and reduced
stigma regarding mental health issues by those completing the training
(http://www.mhfa.com.au). Funding for programs like this in Indian
Country, where there are great distances to travel for services and
need for support locally, can help to increase capacity for supporting
those in crisis within the community.
Research
Although we hear a great deal about evidence-based practices, there
is virtually no research on evidence-based treatment with AI/AN
populations (Miranda, et. al, 2005) and only two suicide prevention
programs being studied to establish their efficacy: American Indian
Life Skills and Sources of Strength (LaFromboise, 1996; LoMurray,
1998). There is very limited research on the assessments used to
measure effectiveness of programs with AI/AN programs. These measures
must be tested before the results of efficacy of programs that utilize
them can be tested to provide accurate information on the use of
programs with AI/AN populations. To give the needed attention to this
work, funds through NIMH, NIDA, and NIAAA are needed to address levels
of research to measure, and provide evidence-based practices in AI/AN
populations. Interfaced data and a national registry through IHS for
suicidal behaviors and treatment, to provide data informing continuity
of care across systems for inpatient, outpatient, dual diagnosis, and
other supportive services, is necessary. Establishing a mandatory
reporting system, such as the kind used for reporting child abuse,
could help to identify troubled youth before they actually attempt
suicide and subsequently get them access to prevention services.
Technology/Infrastructure
In remote areas of Alaska and throughout Indian Country, a
technology infrastructure is needed, from electronic health records
(EHR) that interface across IHS, tribal, Veterans Affairs, private, and
public health systems, to telemental health programs that allow for
services and billing of psychiatric and mental health services across
state lines and licensure jurisdictions. Blue ribbon panels to address
the issues of access across service systems of EHRs, and funds to
support the development of the interface of these systems, are needed.
Demonstration projects in telemental health are needed to find how
these systems can provide better care and address the issues of
licensure and access to services across state lines. Infrastructure
funding is needed to provide adequate technological support for the
distance services, including video and audio connections for youth
located in residential treatment facilities to their families at home
who may not be able to visit them while they are in treatment. This
helps to maintain their connection to family and loved ones during a
stressful time in their lives.
Summary
In summary, my recommendations to this committee cover four general
areas: mental health services, education and training, research, and
technology and infrastructure.
Mental Health Services
1. Passage of the Indian Health Care Improvement Act;
2. Increase funding to Indian Health Service to increased the
number of credentialed mental health professionals providing services
in Indian Country;
3. Increase funding of Indians into Psychology and Indians into
Medicine to increase the numbers of AI/AN providers in Indian Country;
4. Increase funding of loan repayment programs to recruit and
retain qualified mental health service providers in Indian Country; and
5. Fund aftercare treatment programs and circle-of-care services
for transition and follow-up treatment for AI/AN youth.
Education and Training
1. Fund and require cultural competence training for service
providers in Indian Country;
2. Increase funding and scope of Indians into Psychology and
Indians into Medicine programs to more locations and include clinical,
counseling and school psychology programs as part of Indians into
Psychology;
3. Fund enrichment programs for AI/AN students between
undergraduate and graduate programs to make them stronger applicants
for graduate and medical school;
4. Fund clinical placement, internship, and post-doctoral residency
programs for AI/AN students for experiences working with clients in
Indian Country, and jobs in transition while working toward licensure;
and
5. Provide funding for programs such as Mental Health First Aid
that help to build community capacity and reduce stigma related to
mental health issues and crises.
Research
1. Funding for research on assessment materials used to determine
efficacy of treatment programs with AI/AN populations;
2. Funding for research to determine evidence-based treatments for
AI/AN populations;
3. Promote and fund the interface of data and a national registry
through IHS for suicidal behaviors and treatment, to provide data
informing continuity of care across systems for inpatient, outpatient,
dual diagnosis, and other supportive services; and
4. Establish a mandatory reporting system to gather data, plan
programming, and get youth needed services before they complete a
suicide.
Technology/Infrastructure
1. Fund interfacing of electronic health records across IHS,
tribal, Veterans Affairs, private, and public health care systems;
2. Establish a blue ribbon panel to address the issues of access
across service systems, as well as technology-based services across
state lines, and licensure issues;
3. Fund demonstration projects in telemental health to find how
these systems can be of greatest assistance in Indian Country; and
4. Fund infrastructure to connect service providers, families, and
patients for communication and treatment planning with support networks
while in residential treatment.
Attachment
______
Prepared Statement of Cora Whiteman Tiger
______
Prepared Statement of Jessica Hawkins, Prevention Program Manager,
Oklahoma Department of Mental Health and Substance Abuse Services
ODMHSAS Mission
To Promote Healthy Communities and Provide the Highest Quality Care
to Enhance the Well-Being of all Oklahomans.
Oklahoma's Suicide Prevention Initiative
In 2005, Oklahoma Department of Mental Health and Substance Abuse
Services (ODMHSAS) was awarded $1.2 million over 3 years by the
Substance Abuse and Mental Health Services Administration (SAMHSA)--
Center for Mental Health Services, through the Garrett Lee Smith
Memorial Act, to implement youth suicide prevention programs across the
state. Oklahoma proposed to utilize this grant funding to implement
portions of the state plan on youth suicide prevention.
The Oklahoma State Plan on Youth Suicide Prevention was developed
at the request of the Oklahoma Legislature. House Joint Resolution No.
1018, passed in 1999, created the Youth Suicide Prevention Task Force
with the assignment of submitting recommendations to the Legislature on
the prevention of youth suicide. This task force involved physicians,
educators, survivors, mental health professionals, clergy, legislators
and representatives from state agencies including Health, Mental Health
and Substance Abuse Services, Education, and Juvenile Affairs. The
Oklahoma Youth Suicide Prevention Council was formed in 2001 to
implement the plan and also serves as the advisory body for
implementation of the Garrett Lee Smith project.
Oklahoma's grant-funded youth suicide prevention initiative
allocates funds for statewide, evidence-based suicide prevention
strategies including gatekeeper training and screening. The grant funds
five community-based projects, including one with the Kiowa Tribe of
Oklahoma. Kiowa Tribe is located in Southwest Oklahoma. The tribe's
suicide prevention project includes gatekeeper training (QPR), youth
suicide risk screening (Columbia TeenScreen) within Riverside Indian
School, suicide prevention themed Pow-Wow events, and youth leadership
development. Also notable is that Indian Health Service is the major
sponsor of the state's annual Suicide Prevention Conference and serves
as an active participant on the state's Youth Suicide Prevention
Council.
Notable accomplishments in Oklahoma regarding suicide prevention
include:
2000: Oklahoma Legislature made suicide a reportable injury in
2000, leading to the current collection of hospital discharge
data on suicide attempts.
2006: ODMHSAS initiated an important partnership with a large-
scale hospital system in Central Oklahoma to train all
physicians, nurses, and staff in suicide prevention. This
effort has resulted in similar partnership with other large-
scale hospital systems in the state.
2006-2008: ODMHSAS trained 3,125 people as suicide prevention
gatekeepers (number for those completing evaluation surveys; actual
number trained is estimated to be much higher) and 62 people as
certified gatekeeper instructors.
2008: Oklahoma Legislature passed Senate Bill 2000 which expands
the scope of the Oklahoma Youth Suicide Prevention Act from youth-
specific to across the lifespan. In November 2008, the Youth Suicide
Prevention Council will become the Oklahoma Suicide Prevention Council
and will undertake the task of revising the state plan on suicide
prevention to address all populations.
In Spring 2008, ODMHSAS reapplied to SAMHSA to continue the youth
suicide prevention initiative an additional three years. The new grant
would provide additional funding for the provision of suicide
prevention among high risk youth populations, including those in the
juvenile justice system, foster care, and mental health/substance abuse
treatment.
Attachment
______
Prepared Statement of Jo Ann Kauffman, President, Kauffman &
Associates, Inc.
______
Prepared Statement of Laurie Flynn, Executive Director, TeenScreen
National Center for Mental Health Checkups, Columbia University
Thank you for the opportunity to submit testimony on behalf of the
TeenScreen National Center for Mental Health Checkups at Columbia
University (National Center) for the Senate Indian Affairs Committee's
oversight hearing on youth suicide in Indian Country. I commend the
committee for exploring this issue and for continuing to shine a light
on the tragedy of youth suicide within our American Indian and Alaska
Native (AI/AN) communities. Many opportunities exist to help our tribal
young people, yet many challenges remain to actually reach those in
need. The National Center stands ready to help Congress as it considers
ways to identify those in need and improve care to help save lives.
Across our nation, youth suicide remains a significant public
health challenge. Each year, 30,000 Americans die by suicide, while an
estimated 500,000 high school students make attempts. Yet, among our
tribal communities, mental illness and suicide is an even greater
threat. According to the Centers for Disease Control and Prevention, on
our tribal lands suicide is the second leading cause of death for
individuals age 10 to 34. Further, when compared with other racial and
ethnic groups, AI/AN youth have more serious problems with mental
health disorders related to suicide, such as anxiety, substance abuse
and depression.
Today's hearing provides Congress with an opportunity to take
action to improve mental health care delivered to AI/AN populations.
The starting point for this change should be the Indian Health Service
(IHS). Since enactment of the Indian Health Care Improvement Act
(IHCIA) in 1976, the IHS has not kept pace with the modernizations
taking place in the rest of the American health care system. For
example, mainstream American health care is moving out of hospitals and
into people's homes; focus on prevention has been recognized as both a
priority and a treatment; and, coordinating mental health, substance
abuse, domestic violence and child abuse services into comprehensive
behavioral health programs is now standard practice. There is a
critical need for mental health promotion and disease prevention
activities in Indian Country. The National Center strongly encourages
Congress to incorporate coverage of mental health checkups into the
IHS. Making this change will give providers the tools needed to
identify adolescents at risk for mental illness or suicide and take
steps necessary to intervene and provide care.
The availability of mental health services also is severely limited
by the rural, isolated location of many AI/AN communities. Adding to
the difficultly of accessing services, IHS clinics and hospitals are
located on reservations, yet the majority of AI/NAs no longer live
there and only one in five American Indians reports access to IHS
services. Furthermore, AI/AN tribes that are recognized by their state,
but not by the Bureau of Indian Affairs (BIA), are ineligible for IHS
funding. Moreover, there are fewer mental health providers, especially
child and adolescent specialists, in rural communities. The National
Center encourages Congress to take steps to expand and coordinate care
for AI/AN populations not living on or near reservations.
Understanding the nature and the extent to which AI/ANs utilize
mental health services is limited by the lack of research. The 1997
Great Smoky Mountain Study examined mental health service use among
Cherokee and non-Indian youth living in adjacent western North Carolina
communities. Among Cherokee youth with a diagnosable psychiatric
disorder, one in seven received professional mental health treatment.
This rate is similar to that for the non-Indian sample. However,
Cherokee youth were more likely to receive this treatment through the
juvenile justice system and inpatient facilities than were non-Indian
youth. Similarly, in a small study of Plains Indian students in the
North-Central United States, more than one-third of those with
psychiatric disorders used services at some time during their lives.
Two-thirds of those who received services were seen through school; and
just one adolescent was treated in the specialty mental health system.
Among those youth with a psychiatric disorder who did not receive
services, over half were recognized as having a problem by a parent,
teacher or employer.
The National Center was created to advance greater access to mental
health checkups for America's youth. Our screening program is
evidenced-based and was highlighted in the 2003 President's New Freedom
Commission Report. TeenScreen also is included in the Substance Abuse
and Mental Health Services Administration's (SAMHSA) National Registry
of Evidence-based Programs and Practices (NREPP) as a scientifically
verified intervention in the areas of suicide prevention and early
identification of mental illness. I am proud to say that the National
Center is funded entirely by a private, philanthropic family foundation
whose founders had personal experience with suicide and mental illness.
We provide our tools, training and technical assistance at no cost, and
there are no fees to participate in our screening program. Our goal is
to incorporate mental health evaluations as a routine part of medical
care for teens.
To accomplish this goal, the National Center is exploring
partnerships with primary care providers, mental health organizations
and elected officials in the nation's Capitol and state capitols across
this country. The National Center currently has collaborations with
eight primary care entities in six states. These partnerships are
exploring effective models of incorporating teen mental health checkups
into wellness and other health care visits. They include:
Cincinnati Children's Hospital Emergency Department, Ohio
Federally Qualified Community Health Center, New York
ValueOptions, New York and Colorado
GHI, HIP and Emblem Health, New York
Kaiser Permanente, Colorado
Aurora Health Care, Wisconsin
Nevada EPSDT, Clark County Children's Mental Health
Consortium and the Nevada Office of Suicide Prevention, Nevada
The National Center also has community-based mental health
screening programs operating in over 530 communities, 11 of which are
focused on tribal populations. The communities focused on tribal
populations include:
Bena, Minnesota
Juneau, Alaska
Las Cruces, New Mexico (three sites)
Ruidoso, New Mexico
Belocourt, North Dakota (two sites)
Fort Yates, North Dakota
Wakpala, North Dakota
Anadarko, Oklahoma
As Congress considers steps needed to reform our nation's health
care system, we urge you to incorporate much needed changes and
improvements to the care delivered to our AI/NA populations, in
particular the mental health services available to AI/NA youth. One
critically important and cost-effective step Congress can take is to
integrate mental health checkups into the annual exams and medical
visits America's young people, and in particular AI/NA youth, receive.
Doing so will provide the foundation from which to build other
improvements and take the first, and most important step, toward
reducing the rate of suicide within our tribal communities.
Thank you for the opportunity to testify. I stand ready to help the
members of this Committee develop policies that will improve the lives
of AI/NA youth.
______
Prepared Statement of the Oglala Sioux Tribe
______
Prepared Statement of Brian Patterson, President, United South and
Eastern Tribes, Inc.
______
Prepared Statement of Rodney Bordeaux, President, Rosebud Sioux Tribe
Introduction
On behalf of the Rosebud Sioux Tribe in South Dakota, I appreciate
the opportunity to submit written testimony regarding the youth suicide
crisis occurring on the Rosebud Sioux Tribe Reservation. The 877,831-
acre Rosebud Reservation is located in south-central South Dakota
consisting of 20 communities within a four county area (Tripp, Todd,
Mellette and Gregory counties) and borders Pine Ridge to the northwest
corner and Nebraska to the south. Our tribal headquarters is located in
Rosebud, SD. Approximately 19,000 members of approximately 26,000
members are domiciled on the Rosebud Reservation.
I, thank you for convening this important hearing on youth suicide
in Indian Country. Sadly, the Rosebud Reservation has tragically lost
many of our youth and young people to suicide completions. From January
2005 through January 2009 Rosebud has had 37 suicide completions, 617
suicide attempts, and 629 suicidal ideations. Indian Health Service
(I.H.S.) reported 1,272 encounters with different individuals who have
completed, attempted or had suicidal ideation. The Rosebud Sioux Tribe
has the highest suicide rate in the nation for 10-24 year old males.
These are alarming statistics originating from our Reservation. I look
forward to working with you and the Senate Indian Affairs Committee in
addressing and bringing further awareness to this crisis, which is
devastating our communities and Indian Country.
I need to emphasize that Rosebud is working to develop and provide
cultural suicide prevention and youth programs. However, we have an
overwhelming need for resources to provide these programs. We have
developed programs to assist with basic public safety and awareness,
substance abuse and mental health, as well as the Boys and Girls Clubs
on the Reservation. Additionally, we are supporting our families and
communities through our cultural and educational programs.
Wiconi Wakan Health and Healing Center
Rosebud is located in a rural, remote area of Indian Country and
relies heavily on funding from the I.H.S. and Bureau of Indian Affairs
(BIA) to provide services and resources to our tribal members. Due to
I.H.S. and BIA being consistently under-funded, we have turned to our
Congressional delegation for assistance in procuring additional
resources for substance abuse and mental health treatment facilities
and equipment. Rosebud identified a need to create a culturally-based
suicide prevention treatment program and facility specific to our
tribe.
Rosebud has worked diligently for nine years to obtain funding, to
build the current 20-bed treatment facility for mental health, which
has been open for three years. It remains necessary to develop
additional youth programs to assist in recovery and rehabilitation.
Therefore, Rosebud is establishing the Wiconi Wakan (Sacredness of
Life) Health and Healing Center, a place to implement the Tribal Youth
Suicide Prevention and Early Intervention Project plan targeting
Rosebud children and youth (ages 10-24 years old) on the Rosebud
Reservation.
Inherently our youth are sacred and a vital asset to the people of
the Sicangu Lakota Oyate. Suicide has created a destructive ripple in
the very structure of our Lakota Oyate. The effects of suicide will be
felt for generations. The Wiconi Wakan Health and Healing Center will
provide a venue for reviving the life of our people.
The Wiconi Wakan Health and Healing Center will significantly
contribute to the available scientific knowledge on the mental health
status and delivery of services to children and youth on the Rosebud
Reservation regarding Tribal Youth Suicide Prevention and Intervention
and will provide a valuable template for replication by other Tribal
communities throughout the country. Rosebud has developed a Suicide
Prevention plan to advocate and coordinate a culturally comprehensive
community-based approach to reduce suicidal behaviors and suicides in
the Sicangu Lakota communities while facilitating wellness.
The primary purposes of the Wiconi Wakan Health and Healing Center
is to strengthen, implement and develop culturally and linguistically
appropriate youth suicide prevention and early intervention services
for Rosebud tribal members. This level of intervention will include
screening programs, gatekeeper training for ``frontline'' adult
caregivers and peer ``natural helpers,'' support and skill building
groups for at-risk Rosebud youth, and enhanced accessible crisis
services and referrals sources. To be directly informed by parents,
youth, and providers within the Rosebud Reservation. To increase
awareness of the signs of suicide amongst community, parents, and
youth, working collaboratively with other agencies, providers and
organizations sharing information and resources by promoting awareness
that suicide is preventable.
Rosebud will implement the public health approach to suicide
prevention as outlined in the Institute of Medicine Report, ``Reducing
Suicide: A National Imperative.'' This approach focuses on identifying
broader patterns of suicide and suicidal behavior, which will be useful
in analyzing data collected and monitoring the effectiveness of
services provided. Rosebud will focus on methodology research on
suicide and suicide prevention by providing consistent leadership and
monitoring of suicide prevention activities.
Collaborative Effort
Recognizing our overwhelming need, the Department of Health and
Human Services (HHS) deployed officials from the I.H.S. to spend
extended lengths of time on our Reservation and address our youth
suicide crisis.
Dr. Kevin McGuinness, Ph.D., MS, JD, ABPP and Dr. Rose Weahkee
visited the Rosebud reservation for a second time from December 4th to
December 18th 2008. During this visit they worked collaboratively with
Victor Douville, Sinte Gleska University Instructor and Lori Walking
Eagle, MSW, Executive Administrative Officer for the RST--President's
office. Discussions were held regarding systemic influences from the
micro to the macro level within the Reservation systems. The
Consultation process focused on cultural systems of wellness, cross
cultural sharing of knowledge regarding organizational operations and
development of systems with the expertise of Rosebud Tribal leadership
to integrate ``Wolakota'' as a principal intervention that will restore
balance through the tribe and its communities to its most vulnerable
members. The Rosebud Sioux Tribal Council will participate and attend a
retreat which will enhance traditional knowledge.
Wiconi Wakan ``Sacredness of Life'' Suicide Prevention Summit
On July 1-2, 2008, Rosebud hosted the, ``Wiconi Wakan Suicide
Prevention Summit,'' in Mission SD at the Sinte Gleska University.
While I convened the Summit that morning, our community was burying
another youth, which further emphasized the need to discuss and address
this crisis affecting our people and communities. Representatives from
the South Dakota delegation, state, local, and federal government
officials including South Dakota Governor Michael Rounds' Secretary of
the Department of Human Service, the Director of the South Dakota
Indian Health Care Initiative, HHS Director of Office of
Intergovernmental Affairs, and the Substance Abuse and Mental Health
Services Administration (SAMHSA) Administrator as well as other
officials from the I.H.S. and HHS along with tribal leaders, members,
and youth attended and participated, providing experiences and insight
in preventing future youth suicide.
As a result of the Summit, the South Dakota Secretary of the
Department of Human Services, Jerry Hofer, committed the state to
opening more of its SAMHSA grants and resources to Rosebud. The state
currently receives a Garrett Lee Smith Memorial Act grant from SAMHSA,
which is also known as the ``Suicide Awareness Partnership Project,''
from the State/Tribal Youth Suicide Prevention and Early Intervention
Program. For three years, $400,000 is given annually to the state. At
the time of the Summit, Mr. Hofer indicated that the state is in its
2nd year of the grant. The purpose of the Suicide Awareness Partnership
Project is to reduce suicide attempts and completions in South Dakota
for youths aged 14-24 in 25 high schools and two universities. Mr.
Hofer reported that the Todd Country School District and St. Francis
Indian School, both located on the Rosebud Reservation whom serve our
youth, are pilot schools in the project as is the Sinte Gleska
University. Mr. Hofer reported that the state has specifically
contracted with the Sinte Gleska University to provide awareness and
prevention activities on the Rosebud Reservation.
Rosebud is extremely appreciative of the state providing resources
to our schools and youth through the SAMHSA grant. We understand that
the grant will be nearing its three-year term and are concerned as to
how these programs will continue to operate once the grant is
exhausted. We have overwhelming needs in our communities including a
need for additional resources to build upon and expand on these
imperative programs to ensure our youth are given opportunities for
suicide prevention. At Risk Tribes should be allowed to receive block
grants like the states from SAMHSA.
None of the Block Grant funding reaches the tribal government for
program development and suicide prevention efforts. Currently, the Red
Lake Band of Chippewa (Minnesota) are the only federally recognized
tribe included with the States that receive Block Grant Funding.
Regarding our current suicide crisis the Rosebud Sioux Tribe should be
allocated and allowed to receive Block Grant Funding to eliminate
suicides on our Reservation. Because of our Government to Government
relationship which we enjoy with the federal government we should not
be restricted from receiving Block Grant Funding. Due to the high rate
of suicides in Indian Country Block Grants should be available to those
tribes experiencing the loss of their youth to suicides.
Need for Resources to Provide Programs to our Youth
Rosebud has several programs to provide activities and resources to
our youth. However, in each of these areas, funding resources are
continually problematic for the viability and expansion of the
programs. We need a major infusion of funding to serve and support
youth in our communities to further their skill sets and provide for
training and increase opportunities.
I will now outline several programs which have been proven to be
effective for our tribal youth.
Sicangu Nation Employment and Training Program (SNETP)
The Sicangu Nation Employment and Training Program serves' our
youth in the following areas: work experience, on-the-job training, and
classroom training. The SNETP receives approximately $208,148 annually
to serve the Rosebud Sioux Tribe and approximately 20% of the Crow
Creek Sioux Tribe youth.
Additionally, the SNETP has developed and implemented several
unique programs which serve our tribal youth:
Youth Conservation Corp--a collaborative effort with
Rosebud, Yankton, Standing Rock, and Cheyenne River Sioux
Tribes with the U.S. Forest Service--allows our youth to gain
experience in the forestry field while spending time in our
sacred Black Hills area;
Straw Bale Home Initiative--teaches our youth how to build a
straw bale home from start to finish in collaboration with the
SNETP and Sicangu Wicoti Awayankapi (Housing Authority). This
program operates on a ``green works'' concept; serving the dual
purpose of providing for less-expensive homes, and meeting
Reservation housing shortage needs.
Habitat for Humanities--teaches our youth to build a
standard home earning a one-year building credit certificate at
our local university. Upon obtaining the one-year certificate,
our youth are offered full-time employment with the housing
authority;
Penn Foster Online High School Diploma Program--allows our
youth (18 to 21 years old) to obtain their high school diploma
online.
Solar Heat Panel Training and Installation--a collaborative
effort by the SNETP and Sicangu Wicoti Awayankapi teaches youth
a ``green works'' concept that conserves our natural resources
while utilizing solar energy to heat homes.
During the summer of 2008, the SNETP received 689 summer youth
applications only 200 youths could be served due to funding
constraints. Over two-thirds of interested students reaching out for
assistance had to be turned away. Increased funding for the SNETP's
youth employment program could have a major, positive impact on our
tribal youth, especially with the high number of suicides that our
community has experienced in the past few years. Increased funding will
provide for additional resources to extend to the overwhelming number
of youth we have been unable to serve. We strive to keep our youth
occupied by increasing services in the form of employment, incentives
for accomplishments, and supportive services in their endeavors to
overcome barriers.
Community Emergency Response Team (CERT) Training Sessions
Rosebud received funding in 2008 for CERT Training Sessions for our
youth, which were extremely effective in training, providing knowledge
and skill sets regarding emergency medical response and preparedness.
Rosebud held two sessions of CERT training, which trained over 100
youth in our communities. The tribal youth that were trained under this
program developed important set of skills which led to aiding tribal
members in emergency medical situations and prevention. Rosebud has a
major need to continue providing this vital training opportunity for
our tribal youth. The CERT Training prepares our youth for emergencies
and events for when our Emergency Medical Services arrive on the scene.
The training empowers our tribal youth to seek medical positions.
Having trained tribal youth in our communities provides increased
medical and public safety, especially in light of our expansive rural
Reservation. Rosebud greatly supports this program and seeks to receive
additional funding to serve more of our tribal youth.
Boys and Girls Clubs
To be completely effective in helping prevent youth suicide we need
Boys and Girls Club centers in all 20 of our communities. Rosebud has
20 communities on the Reservation, but there are only three small Boys
and Girls Clubs. Despite this fact, the Rosebud Sioux Tribe Boys and
Girls Club plays' an important role in providing activities and a
central place for our youth to gather. To fully reach all of our tribal
youth on the Reservation, we need funding to provide additional
recreational facilities, activities and programs for all of our
communities.
Conclusion
Rosebud understands and has intimately experienced the devastation
youth suicide has on our families, communities, and Tribe. With 37
suicide completions in less than five years, Rosebud is deeply
concerned and focused on preventing suicides on our Reservation.
Although we are working to develop and expand our programs by
incorporating culturally-based components and curriculums, funding and
resources remain a major obstacle. The federal government has a trust
responsibility to Tribes, and Rosebud greatly appreciates the
collaborative efforts among the state and federal government. However,
we still have major needs and funding deficiencies that must be
addressed. To increase the number of highly-trained individuals
specialized in suicide prevention for each of our communities would be
monumental in addressing our crisis.
We need additional resources and flexibility in the use of funding
to provide, create, and maintain programs that incorporate culturally-
based components that connect and are tailored for our youth. Tribes
need access to resources, trained health care professionals, and
prevention programs to adequately address this crisis that continues to
plague our Reservation.
Thank you, for holding this very important hearing for Indian
Country, giving us the opportunity to express our views and concerns
regarding tribal youth suicide.
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Prepared Statement of Leroy M. Not Afraid, Member, Great Crow Nation
My name is Leroy M. Not Afraid! I am a teenage suicide survivor! I
am enrolled member to the Great Crow Nation in Montana! I am also the
Justice of the Peace for Big Horn County, Montana.
The signs of teenage suicide are not always obvious. Often we may
make the mistake that a young person has to be into drugs, gangs, or
other negative behavior's concerning the prerequisites of teen suicide.
My story will give you a different point of view;
In 1989, I was a teenager that was looking for attention in the
realm of education and athletics! I became the ideal student-athlete.
What the public did not see or know behind the show I presented was
hurt, pain, and fear. I was using the glamour of being an outstanding
citizen to hide the anguish I felt as a young person! I did not want
the world to see who I really was. I acquired A's and B's, became
Student Body President, and became the captain of both the basketball
and cross country teams to hide who I really was. A young man with no
other alternative's! I thought being the best in everything would bring
me serenity and hope for the future. It did not, as I would look in the
mirror on a daily basis, ``I was ashamed of who I was and where I came
from!'' I wanted to die!
Then one evening, I was home alone in my bed room. I loaded my 6mm
hunting rifle, put it under my chin and I wanted to pull the trigger! I
thought of my childhood being born and raised on the Crow Indian
reservation. I asked the question(s), ``Why didn't my own parents raise
me? Why did my grandparents raise me? Why are my natural parent's
alcoholics? Why did my natural mother run from me when I tried to take
her home while she lived the on the streets of Skid row? Why does not
my father visit me when he says he is?'' These very same questions are
being asked by today's youth. ``I know'' I visit with them in the
courtroom on a daily basis. I meet with them as I go on the road
throughout Indian country as a motivational speaker on suicide issues.
I understand the loneliness, depression, oppression, and anguish
the young people feel in Indian Country! I am one of them. The signs
are deep and real. We must work together in unity to fight this
horrible situation. Suicide after all is a permanent solution for a
temporary problem.
Today, I look back! By the grace of the Creator I did not pull the
trigger. I got the help I needed! I got into counseling and very
involved in my native spiritual ways! That's what saved my life.
So many young lives have been cut short! Potential lost forever!
The young ones never live their dreams. Leroy Not Afraid has gone on to
become the First Native American elected as Justice of the Peace in
Montana's History! Thank God, ``I did not pull the trigger!''
Thanks for listening! I would love to share my story with members
of congress! AHO!
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Prepared Statement of Hayes A. Lewis, Director, Center for Lifelong
Education, Institute of American Indian Arts
______
Prepared Statement of James Gallanos, LCSW Project Coordinator, Office
of Prevention and Early Intervention Services, Division of Behavioral
Health
Suicide Rates in Alaska
Data
Alaska has recently adopted the Alaska Violent Death Reporting
System (AK VDRS) which is continuing developing itself as a more
reliable system of reporting suicide information. We have three years
of data from 2003-2005 and will continue this grant for at least two
more years. I attached some preliminary reports/PowerPoint slides
above. We also conducted a study, the Alaska Suicide Follow Back Study
between 2003-2006 as well as rates for Alaska Native youth over past
sixteen years (page 13) up to 79 per 100,000 and higher based on other
reports that combine region with race and age. In general . . . Alaska
Natives account for about 16 percent of the state population but
account for 39 percent of all suicides. More recent Vital Statistics
data show a 5 year running balance (srrates 97-06) and seeing a slight
decrease in the Northwest region which is typically highest in the
State. See project below in this region.
Projects
Project Life in Kotzebue. GLSMA SAMHSA youth grant (See description
attached).
Lisa Wexler research on acculturation and Inupiat youth
suicide.
Suicide Prevention Training
Gatekeeper Suicide Prevention Training (statewide training
and train the trainer model)
Youth/children residential treatment training protocols
--Division of Juvenile Justice, trainer, Lindsey Hayes
(PowerPoint) *
* The information referred to has been retained in Committee files
and can be found at www.ncdjjdp.org/resources/policy_manual/
departmental_policies/18_suicide_prevention/DPSP-0014.ppt
---------------------------------------------------------------------------
--Office of Children's Services/Alaska Children's Services
training of residential programs.
Native Aspirations Project
Kaufman and Associates (see testimony) no other information
on outcomes of this independent project.
American Indian Life Skills training (Theresa LaFramboise)
Comprehensive Prevention and Early Intervention Grants (statewide
DHSS program)
http://hss.state.ak.us/dbh/prevention/programs/
suicideprevention/default.htm
The Statewide Suicide Prevention Council (2008 annual report
attached [last slide Ak Native and US incorrectly placed]).
http://www.hss.state.ak.us/suicideprevention/
GLSMA SAMHSA youth suicide prevention State proposal for FY09
See attached abstract.
Attachments
______
Prepared Statement of Emilio Rios, Member, Three Affiliated Tribes
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Eric B. Broderick, D.D.S., M.P.H.
Response to Written Questions Submitted by Hon. John Barrasso to
Eric B. Broderick, D.D.S., M.P.H.
Response to Written Questions Submitted by Hon. Maria Cantwell to
Eric B. Broderick, D.D.S., M.P.H.
______
______
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