[Senate Hearing 111-365]
[From the U.S. Government Publishing Office]
S. Hrg. 111-365
S. 1635, SEVENTH GENERATION PROMISE: INDIAN YOUTH SUICIDE PREVENTION
ACT OF 2009
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 10, 2009
__________
Printed for the use of the Committee on Indian Affairs
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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
AL FRANKEN, Minnesota
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 September 10, 2009............................... 1
Statement of Senator Barrasso.................................... 5
Statement of Senator Dorgan...................................... 1
Statement of Senator Franken..................................... 6
Prepared statement........................................... 6
Statement of Senator Johanns..................................... 4
Statement of Senator Udall....................................... 6
Witnesses
BigFoot, Dolores Subia, Ph.D., Director, Indian Country Child
Trauma Center and Project Making Medicine, University of
Oklahoma Health Sciences Center................................ 19
Prepared statement with attachment........................... 21
Broderick, Hon. 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........................ 13
Prepared statement........................................... 15
Roubideaux, Hon. Yvette, M.D., M.P.H., Director, Indian Health
Service........................................................ 7
Prepared statement........................................... 9
Appendix
Franklin, Reno Keoni, Chairman, National Indian Health Board
(NIHB), prepared statement..................................... 35
Keita, Gwendolyn Puryear, Ph.D., Executive Director, Public
Interest Directorate, American Psychological Association (APA),
prepared statement............................................. 41
National Congress of American Indians (NCAI), prepared statement. 37
Response to written questions submitted by the Committee from Dr.
Ellen Gerrity.................................................. 55
Response to written questions submitted to Dolores Subia BigFoot,
Ph.D. by:......................................................
Hon. Byron L. Dorgan......................................... 44
Hon. Tom Udall............................................... 51
Written questions submitted by the Committee to:
Hon. Eric B. Broderick, D.D.S., M.P.H........................ 58
Hon. Yvette Roubideaux, M.D., M.P.H.......................... 61
S. 1635, SEVENTH GENERATION PROMISE:
INDIAN YOUTH SUICIDE PREVENTION ACT OF 2009
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THURSDAY, SEPTEMBER 10, 2009
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:47 p.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. We will now call the hearing to order.
We are pleased today to have three witnesses join us. This
hearing is on the subject of S. 1635, the Indian Youth Suicide
Prevention Act.
We have the Honorable Yvette Roubideaux, who is the
Director of the Indian Health Service, of the U.S. Department
of Health and Human Services. We very much appreciate your
being here.
The Honorable Eric Broderick, who is the Acting
Administrator of SAMHSA, the Substance Abuse and Mental Health
Services Administration.
And Dr. Dolores Subia BigFoot, Ph.D., Associate Professor,
University of Oklahoma at the Health Sciences Center, who will
testify on behalf of the American Psychological Association.
We appreciate very much your attendance.
Today we are going to hold this hearing to examine S. 1635,
the Indian Youth Suicide Prevention Act. We believe this bill
will help address the high rates of youth suicide on Native
American communities and improve access, especially to mental
health services. Suicide is hitting our Native youth like an
epidemic in some areas of this Country. And it is critical, I
believe, that we move quickly and respond aggressively.
The rate of suicide of Native American youth is not double,
it is three and a half times higher than the general U.S.
population. We have a chart that shows the suicide rates by
race and gender in this Country. You will see the rates of
suicide of American Indians.
Native American male and female teens have a higher rate of
suicides than Asians, Hispanic, African American, Caucasians.
In fact, the rate of Native American male youth is almost
double that of the next highest racial group, which is male
Caucasians. Chart two shows the disparity in the youth suicide
rates in my home State. The top line shows the rate of suicide
for Native Americans 10 to 24. The bottom line shows the rate
for Caucasians. Even when the incidence of Native American
suicide is the lowest, the rate is still more than double that
of Caucasian youth.
These charts show statistics. They fail, however, to show
the cluster of suicides that can impact a community. The
Standing Rock Sioux Reservation, which traverses North and
South Dakota borders, had 53 suicide attempts this year, 10 of
them which were completed. The members of this community are
experiencing extreme trauma and need more resources and help.
This past February, when we held a hearing on teen suicide,
a young woman named Dana Lee testified before this Committee
about the loss of her little sister, Jami Rose. Jami Rose's
picture is here on this chart, a beautiful little 14 year old
girl from the Spirit Lake Nation in my home State of North
Dakota. Last year, Jami took her life. Jami's mom had noticed
that Jami seemed troubled. She took her daughter to the doctor,
had her evaluated by mental health professionals from the
Indian Health Service. The doctors dismissed her mom's concern
and diagnosed her as being a typical teenager.
Jami did not obtain the services she needed last November,
and Dana Lee found her younger sister hanging in her bedroom.
Sadly, Jami's story is one we hear far too often in Indian
Country. I have told the story often on the Floor with the
consent of relatives of Avis Little Wind. Actually, Avis was
from the same reservation. She laid in a bed for 90 days in a
fetal position. Her sister had taken her life, her mother was a
substance abuser, her father had taken his life. And this young
lady sort of dropped out and nobody noticed for three months
that she wasn't in school. She was lying alone in bed in a
dysfunctional family until they found her hanging in her closet
at age 14. Hopeless, helpless, without the ability to get the
services that we would expect for most teenage children in
trouble.
We need to do much better than that, and that is the reason
we have put together legislation to try to address these
issues. This is all too silent an epidemic in this Country, and
we aim to try to address it in a significant way.
I want to, because Senator Johanns has another hearing that
he is supposed to be at, I want to, with the courtesy of my
colleagues, call on Senator Johanns for a statement.
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Mr. Chairman, thank you very much. And to
my colleagues, thank you for the courtesy. I appreciate it. I,
like all Senators, am learning that the biggest challenge we
face is being in two places at once. So I do appreciate this.
I would like to offer a few thoughts on what we are doing
here this afternoon. I think it is enormously important. I
would like to address the challenges of providing mental health
services to our Native American youth. I want to issue my
strongest, without reservation, support of S. 1635, the Seventh
Generation Promise: Indian Youth Suicide Prevention Act of
2009. In my home State, the State of Nebraska, we have four
Native American tribes. They are just the most wonderful
people. I have enjoyed working with them as a Senator and as a
Governor and even as a mayor.
However, the suicide statistics in Indian Country would
have to concern anyone. They deeply concern me. Native American
young people have the highest suicide rate of any population
group in the United States. The charts really do tell the
story.
Alarmingly, the rate of suicide amongst Indian children in
the northern Great Plains is 10 times higher, 10 times higher
than the national average. Ninety percent of all Indian teens
who commit suicide have a diagnosable mental illness at the
time of their death. Yet more than half of these young people
have never seen a mental health professional.
One effective way to reach these youth who are often in
remote locations is through tele-medicine. A trained
professional, through video conference, can do psychiatric
assessments, complete diagnostic interviews, intervene with
crisis counseling and provide needed mental health services. I
could not be more pleased to be a sponsor of this important
legislation. Key provisions of the legislation I believe will
help transform how we deliver mental health services in this
Country.
It is certainly a step in the right direction. For example,
this bill authorizes the Department of Health and Human
Services to carry out a project for tele-mental health services
targeted to Native American youth. The goal is to provide
mental health services to those Indian youth who have expressed
suicidal thoughts, have attempted suicide or who have mental
health conditions that could increase the risk of suicide. The
legislation would also address the barriers Indian tribes and
tribal organizations face when applying for Substance Abuse and
Mental Health Services Administration grants.
The legislation would require that this process be
streamlined and take into account the unique obstacles that
Indian tribes experience when applying for these grants. It
would also give priority for youth suicide prevention grants to
those Indian tribes and tribal organizations that have high
youth suicide rates and prevent them from being disqualified
from the grant application process, because they may not have
the capability to extensively collect the data or have the
advanced infrastructure in place to put that data there.
Finally, the bill would encourage the use of pre-doctoral
psychology and psychiatry interns to provide mental health
services in Indian Country where appropriate. Increasing the
number of interns will help increase access to services, I
believe, and serve as a valuable recruitment tool. My hope is
that somebody who has this experience decides to stay in Indian
Country.
With the impressive advancement technology in tele-medicine
and with the tools that are at our disposal, living in an
isolated rural area, which is oftentimes the case in all of our
States, should not prevent a young person from getting
services. I believe, again, that this is an important step in
the right direction.
Mr. Chairman, I will wrap up and just say, I so appreciate
your leadership on this, and the Ranking Member. I said at the
first hearing I attended on Indian Affairs I thought this was
one of our key issues to work on. I really think that if we can
get started today, this will be a step, an important step in
the right direction. Thank you.
The Chairman. Senator Johanns, thank you very much, and
thanks for your work on and your attention to this issue. It is
very important to this Committee.
I am going to call on others here for any statements. I am
trying to determine, I believe we originally had a vote
scheduled at 3:30. I am trying to determine whether that is the
case. But let me call on Senator Barrasso, the Vice Chairman.
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Thank you very much, Mr. Chairman. These
statistics are tragic. The personal stories compel action. It
is inconceivable to me now that the Indian Health Service is
reporting suicides among children as young as five years old.
I appreciate this legislation which attempts to address the
lack of mental health services for these children, especially,
as Senator Johanns talks about, through the tele-health
services. According to the Indian Health Service, currently
over 30 IHS and tribal facilities in 8 IHS areas are augmenting
on-site behavioral health services with tele-behavioral health
services.
This past spring, the previous director of the Indian
Health Service testified before this Committee regarding the
National Tele-Behavioral Center of Excellence. It was in the
planning stages and was intended to provide increased access to
video-conference-based behavioral health services. I hope, Dr.
Roubideaux, that you can update us on the status of this Center
of Excellence.
I look forward to hearing from all the witnesses on how
this legislation can help provide an accountable system for
addressing and preventing Indian youth suicide.
Thank you, Mr. Chairman.
The Chairman. Senator Barrasso, thank you very much.
Senator Udall?
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. I just wanted to briefly, Chairman Dorgan,
say thank you again for focusing on this issue, and thank you
for focusing our attention on youth suicide in Indian Country.
The figures that you put up on North Dakota, those figures
are very similar in New Mexico. We all know we have a national
tragedy with this problem. Former Senator Gordon Smith, my
cousin, also had a young son, Garrett. Garrett committed
suicide while Gordon was in the Senate. Gordon used that
tragedy to provide leadership and pass the Garrett Lee Smith
Act, which has provided grants and momentum to bring some
really thoughtful approaches to this particular tragedy.
So I thank you again for bringing our attention to this and
really look forward to our leaders here giving us the way they
see it and what they think we need to do. Thank you, Chairman
Dorgan.
The Chairman. Senator Franken?
STATEMENT OF HON. AL FRANKEN,
U.S. SENATOR FROM MINNESOTA
Senator Franken. Thank you, Mr. Chairman.
I have an opening statement that I would like to enter into
the record, without objection. Because I don't want to take any
more time. I, like Senator Johanns, have to leave at a certain
point and I apologize for that, because this is such an
important and tragic subject. It is in Minnesota, as well.
So I would just like to thank the witnesses for being here,
and I want to thank Senator Johanns for introducing the bill
and his role in that, and you, Mr. Chairman, and you, Mr. Vice
Chairman.
[The prepared statement of Senator Franken follows:]
Prepared Statement of Hon. Al Franken, U.S. Senator from Minnesota
Thank you Chairman Dorgan and Vice-Chair Barrasso for holding this
timely and important hearing.
Mr. Chairman, I especially want to thank you--and Senator Johanns--
for your leadership in introducing the ``7th Generation Promise: Indian
Suicide Prevention Act of 2009.''
I look forward to working with both of you, and everyone on this
Committee, to bring this legislation to the floor.
Over the years, this Committee has held a series of hearings on the
issue of Indian youth suicide. I was moved by Chairman Dorgan's
recitation of Dana Lee Jetty's testimony when he introduced the bill on
the Senate floor last month. Ms. Jetty's testimony about the loss of
her 14-year-old sister is just one more sobering reason why this
legislation is so badly needed.
Across the country, American Indian teens commit suicide at a rate
at least twice the national average. The rate is much higher in the
Upper Midwest and Great Plains, where it is five to seven times higher
than the national average.
In 2004--one of the most recent years data is available--three
teens committed suicide on the Red Lake Indian Reservation in
Minnesota; and a shocking 69 teems attempted it.
Even more shocking, in a survey of ninth-grade girls at Red Lake
High school, 81 percent said they had thought about suicide at least
once in their life; and nearly half said they attempted it.
Sadly, this problem is not just limited to a few reservations.
Clearly, it is a complex problem with no easy solution. I look
forward to hearing from our panelists on how to best deal with this.
The Chairman. Senator Franken, thank you very much.
Dr. Roubideaux, I indicated when you took this job, and I
was very pleased to support your nomination, that you inherited
a pretty big task. But I appreciate your doing that, and today
we asked you to come and talk to us about a very sensitive
issue. It is difficult to talk about, and sensitive to talk
about the issue of suicide, youth suicide. In some cases, some
would perhaps sooner not have it discussed publicly. But the
fact is, we must. We can no longer ignore this.
So let me ask you to begin. We appreciate very much your
being here. Your entire statement will be a part of the record,
I would say to all three witnesses. And we would ask that you
summarize.
Dr. Roubideaux?
STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., M.P.H., DIRECTOR,
INDIAN HEALTH SERVICE
Dr. Roubideaux. Thank you, Mr. Chairman, Mr. Vice Chairman
and members of the Committee.
Good afternoon. My name is Dr. Yvette Roubideaux and I am
the Director of the Indian Health Service. I appreciate the
opportunity to testify on S. 1635.
As you know, the Indian Health Service plays a unique role
because it is a health care system that was established to meet
the Federal trust responsibility to provide health care for the
1.9 million American Indians and Alaska Natives it serves.
We are acutely aware that many American Indian and Alaska
Native communities are affected by high rates of suicide. The
most recent IHS data report that American Indian and Alaska
Native suicide rate is 1.7 times that of the U.S. all races
rate. Suicide is the second leading cause of death for Indian
youth age 15 to 24, and is 3.5 times higher than the national
average. American Indian and Alaska Native young people age 15
to 34 make up 64 percent of all suicides in Indian Country.
The current system of services for treating mental health
problems of American Indians and Alaska Natives is a complex
and often-fragmented system of tribal, Federal, State, local
and community-based services. The availability and adequacy of
mental health programs for American Indians and Alaska Natives
varies considerably among tribes. The Indian Health Service
Mental Health and Social Services program is a community-
oriented clinical and preventive mental health services program
that provides primarily outpatient mental health and related
services, crisis triage, case management, prevention
programming and outreach services.
As you know, suicide is a complicated public health
challenge with many contributing factors and barriers to care
in American Indian and Alaska Native communities. There are
many reasons for the lack of access to care. Indian Country is
predominantly rural and remote and local care may be limited.
Rural practice is often isolating and challenging for its
practitioners and even well-seasoned and balanced providers
risk burnout. Many of the IHS tribal and urban mental health
programs that provide services do not have enough staff to
operate 24/7. Therefore, when an emergency or crisis occurs,
the clinics and service units will often contract out such
services to non-IHS hospitals and crisis centers.
Tele-health based behavioral health services are a
promising strategy to address these access to care issues. We
know that these services work and are acceptable to many, if
not all, of our clinic populations. As a system of care, these
services are either being used or are in planning stages in
over 50 Indian Health System sites. Services being delivered
range from settings including clinics, schools, youth and
treatment centers.
We also have the methamphetamine and suicide prevention
initiative, which is another coordinated program designed to
promote the development of evidence-based and promising
practices using culturally appropriate prevention and treatment
to address methamphetamine abuse and suicidal behaviors in a
community-driven context. IHS is using this funding to
establish a national tele-behavioral health center of
excellence to provide technical support nationally to programs
attempting to implement such services.
We have preliminary indications that IHS programs are
increasingly adopting and using these technologies. IHS is
using Recovery Act funding to improve our telecommunications
infrastructure, to increase the reliability and availability of
appropriate bandwidth across the Indian Health system. We are
investing in the infrastructure expansion support and
maintenance needed to keep pace with potential service demands
and to plan for the long-term success of this and any new
Indian tele-mental effort.
We see many benefits of the use of tele-medicine for the
treatment of youth suicide. It can connect many isolated
programs in a web of support with a much larger array of
services that is more cost-effective and convenient for
patients. Such a system could potentially translate into 24/7
access to emergency behavioral health services in any setting
with an adequate telecommunications service.
Such a system has other desirable consequences, such as
filling gaps in provider coverage, allows providers with
specialty interests to share their skills and knowledge with
others in isolated locations, reducing provider burnout and
professional isolation and improves recruitment for providers
that can live and practice in urban areas rather that isolated
locations. Families can also participate in care, even when at
a distance from their youth.
We believe tele-health programs can become an integrated
part of the IHS behavioral health services, strengthen our
clinical expertise and expand access to needed behavioral
health care. The additional services proposed in this
legislation could help facilitate our ability to provide needed
services.
In summary, we look forward to opportunities to work with
this Committee to address the critical problem of youth suicide
in Indian Country.
Mr. Chairman, this concludes my statement. Thank you for
the opportunity to testify. I will be happy to answer any
questions you may have.
[The prepared statement of Dr. Roubideaux follows:]
Prepared Statement of Hon. Yvette Roubideaux, M.D., M.P.H., Director,
Indian Health Service
Mr. Chairman and Members of the Committee:
Good morning, I am Dr. Yvette Roubideaux, Director of the Indian
Health Service (IHS). Today, I appreciate the opportunity to testify on
S. 1635, 7th Generation Promise: Indian Youth Suicide Prevention Act of
2009.
As you know, the Indian Health Service plays a unique role in the
Department of Health and Human Services because it is a health care
system that was established to meet the federal trust responsibility to
provide health care to American Indians and Alaska Natives. The IHS
provides high-quality, comprehensive primary care and public health
services through a system of IHS, Tribal, and Urban operated facilities
and programs based on treaties, judicial determinations, and Acts of
Congress. The IHS has the responsibility for the delivery of health
services to an estimated 1.9 million federally-recognized American
Indians and Alaska Natives. 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 and 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 appropriations for ``the relief of distress
and conservation of health'' of American Indians and 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 includes 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.
Background
Many American Indian and Alaska Native communities are affected by
high rates of suicide. A wide range of general risk factors contribute
to suicide. In the case of American Indian and Alaska Native young
people, they face, on average, a greater number of these risk factors
individually or the risk factors are more severe in nature for them.
Research suggests that there are factors that protect Native youth and
young adults against suicidal behavior. These factors are their sense
of belonging to their culture, strong tribal spiritual orientation, and
cultural continuity.
The soon to be published IHS ``Trends in Indian Health, 2002-2003''
reports:
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 the U.S. all races rate (10.8) for 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.
Suicide is the 6th leading cause of death overall for males
residing in IHS service areas and ranks ahead of homicide.
American Indian and Alaska Native young people ages 15-34
make up 64 percent of all suicides in Indian country.
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 to these
services 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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Addressing Suicide Among American Indians
The current system of services for treating mental health problems
of American Indians and Alaska Natives is a complex and often
fragmented system of tribal, federal, state, local, and community-based
services. The availability and adequacy of mental health programs for
American Indians and Alaska Natives 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\
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\5\ Ibid.
\6\ Ibid.
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IHS and SAMHSA work closely together to formulate long term
strategic approaches to address the issue of suicide in Indian Country
more effectively. For example, IHS and SAMHSA are actively involved on
the Federal Partners for Suicide Prevention Workgroup. In 2001, the
Office of the Surgeon General coordinated the efforts of numerous
agencies, including IHS, SAMHSA, CDC, NIMH, HRSA, and other public and
private partners to develop the first, comprehensive, integrated,
public health approach to reducing deaths by suicide and suicide
attempts in the United States in the National Strategy for Suicide
Prevention. This resulted in the formation of the ongoing Federal
Partners for Suicide Prevention Workgroup.
The Indian Health Service (IHS) is responsible for providing mental
health services to the American Indian and Alaska Native population it
serves. The IHS Mental Health/Social Service (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 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 do not have enough staff to operate 24/
7. Therefore, when an emergency or crisis occurs, the clinic and
service units will often contract out such services to non-IHS
hospitals and crisis centers.
Suicide is a complicated public health challenge with many
contributing factors, and barriers to care in American Indian and
Alaska Native communities. Indian Country has communities every year
where suicide takes on a particularly ominous and seemingly contagious
form, often referred to as suicide clusters. In these communities, the
suicidal act becomes a regular and transmittable form of expression of
the despair and hopelessness experienced by some Indian youth. While
most vividly and painfully expressed in these communities, suicide and
suicidal behavior and their consequences send shockwaves through many
communities in Indian Country, including urban communities. The pain
only deepens when those seeking help for their loved ones in crisis, or
those left behind as emotional survivors of such acts, are unable to
access adequate care.
There are many reasons for a lack of access to care. Indian Country
is predominantly rural and remote, and this brings with it the
struggles of providing support in settings where appropriate local care
may be limited. Rural practice is often isolating for its
practitioners. The broad range of clinical conditions faced with
limited local resources challenge even seasoned providers. Some
providers are so overwhelmed by the continuous demand for services,
particularly during suicide outbreaks, that even well-seasoned and
balanced providers risk burn-out.
For example, there are situations where the appropriate treatment
is known, such as counseling therapy for a youth survivor of sexual
abuse, but there are simply no appropriately trained therapists in the
community. One of our IHS Area Behavioral Health Consultants told me
recently that there was only one psychiatrist in her half of a large
Western state attempting to serve both the Indian and non-Indian
population. Despite years of effort, the IHS Area Office had been
unsuccessful in recruiting a fulltime psychiatrist to serve the tribes
in that region.
Over the years, we have attempted to apply a number of remedies to
these problems including adopting special pay incentives in order to
make reimbursement packages more competitive, making loan repayment and
scholarship programming available for a wide range of behavioral health
specialties including social work, psychology, and psychiatry, along
with active recruitment, development of the Indians into Psychology
program, and emergency deployment of the Commissioned Corps.
Indian Tele-health Based Behavioral Health Services
IHS recognizes the need to support access to services and to create
a broader range of services tied into a larger network of support and
care. As evidenced by the Alaska experience, where there are often no
workable options other than tele-health based behavioral health
services, we know such services work and are acceptable to many if not
all of our clinic populations. As another example, a Southwest tribe
has been providing child and youth-specific tele-behavioral services
for the past two years and has achieved a show rate of >95 percent for
scheduled appointments. This is an outstanding rate when other clinics
with face to face provider availability only achieve a 65-70 percent
show rate.
As a system of care, tele-health based behavioral health services
are either actively being used or in planning stages for over 50 Indian
health system sites (both tribal and federal). They include a range of
programming, from a broad variety of mental health services, to
specific and intermittently available services such as child psychiatry
consultations. Services are being delivered in a range of settings
including clinics, schools, and youth treatment centers. Only within
the past five years has the telecommunications infrastructure, in some
locations, become available and reliable enough to be used routinely
for clinical care. The lack of infrastructure is a significant issue
for most tribal communities.
The Methamphetamine and Suicide Prevention Initiative (MSPI) is
another coordinated program designed to provide prevention and
intervention resources for Indian Country. This initiative promotes the
development of evidence-based and promising practices using culturally
appropriate prevention and treatment to address methamphetamine abuse
and suicidal behaviors in a community-driven context. IHS is using the
MSPI funding to promote adoption of technologies on a larger, system
wide basis. For example, in the California and Oklahoma Areas, programs
will benefit from MSPI grants supporting increased access through tele-
health service delivery.
MSPI dollars in the amount of $863,000 are also being used to
establish a National Tele-Behavioral Health Center of Excellence. An
intra-agency agreement was signed in early August with our Albuquerque
Area Office, which has agreed to take the lead on establishing a
national center to promote and develop tele-health based behavioral
health services. They are working in partnership with a number of
regional entities including the University of New Mexico and the
University of Colorado. The University of New Mexico Center for Rural
and Community Psychiatry is a leader in the use of tele-health
technologies in rural settings. The University of Colorado Health
Sciences Center and the VA Eastern Colorado Healthcare System are
leaders in tele-health outreach to veterans including Indian veterans
in the northern Plains, the State of New Mexico, and the Tribes and
Pueblos of the region. Services are provided to a number of settings
including school clinics, youth residential treatment centers, health
centers, and others. They hope to leverage their ability to use federal
service providers and provide technical and program support nationally
to programs attempting to implement such services.
We have been tracking visits to behavioral health clinics using
tele-health technology, and have preliminary indications that IHS
programs are increasingly adopting and using these technologies. Tele-
behavioral health services require adequate and reliable bandwidth if
they are to be sustainably implemented. Increasing bandwidth
utilization strains the telecommunications infrastructure. IHS was
fortunate to be recipients of ARRA funding to improve our
telecommunications infrastructure to increase the reliability and
availability of appropriate bandwidth across the Indian healthcare
system. Approximately $19 million of our Health Information Technology
ARRA funding will be spent to provide new routers, switches, and basic
telecom infrastructure to ensure current needs are met, as well as
improve our ability to prioritize traffic over the network. ARRA
funding is also supporting a mass procurement of state-of-the-art
clinical videoconferencing equipment that will be distributed to
Tribal, Urban, and Federal care sites depending on need later this
fall. We are working to improve access to videoconferencing and
bandwidth capacity to strengthen our telecommunications infrastructure.
As one of my providers who is active in telemedicine told me, ``My
patients are very patient and are willing to tolerate surprisingly bad
connections. But when my image freezes up with regularity I may as well
be using the telephone.'' We are investing in the infrastructure
expansion, support, and maintenance needed to keep pace with potential
service demands and to plan for the long term success of this and any
new Indian tele-mental effort.
We see many benefits to the use of telemedicine for the treatment
of youth suicide. This technology promises to connect widely separated
and often isolated programs of varying sizes together in a web of
support. Whereas small clinics would need to develop separate contracts
for services such as child and adult psychiatric support, pooling those
needs in a larger pool provides potential access to a much larger array
of services, and does so more cost-effectively and more conveniently
for patients. Such a system could potentially move some clinics that
are available every other Friday afternoon for 4 hours to systems where
clinic time for assessments is available whenever the patient presents.
This could translate into 24/7 access to emergency behavioral health
service in any setting with adequate telecommunications service and
rudimentary clinic staffing.
Such a system has other desirable consequences such as
opportunities for mutual provider support. For example, currently when
psychiatric providers take vacation,are on sick leave, or are training
in places where they are the sole providers, there are often either no
direct services at that clinic for that time period, or a temporary
doctor with limited understanding of the clinic is hired to provide
services. Sufficient services could be provided via tele-health
connections to reduce or eliminate discontinuities in patient care and
do so at significantly less expense. Providers with particular
specialty interests can share those skills and knowledge across a broad
area even if they themselves are located in an isolated location. Burn
out due to professional isolation is also decreased as
videoconferencing readily supports clinical supervision and case
management conferences. Universities providing distance-based learning
opportunities have demonstrated for years that educational activities
can also be facilitated by this technology. Families can participate in
care even when at a distance from their youth, promoting improved
contact and better resolution of home environmental concerns which is
often the key issue in a youth transitioning successfully from a
residential program to home. Recruitment becomes less problematic
because providers can readily live and practice out of larger urban or
suburban areas and are thus more likely to continue in service over
time with sites. The resulting pool of providers accessible for hiring
could also increase because relocation to an isolated location may not
be necessary.
It is important to note that the proposed services would require
behavioral health providers including psychiatrists, psychologists,
clinical social workers, and therapists in addition to the telemental
health technology.
The behavioral health services discussed in my testimony today are
available or will be available to some degree already at 50 federal and
tribal sites, or are otherwise unavailable or irregularly available in
the Indian health care system.
As described in my testimony today, IHS supports and indeed is
already funding many of the activities included in the demonstration
grant program outlined in, S. 1635, the 7th Generation Promise. These
activities, including the National Tele-behavioral Health Center of
Excellence funded by the MSPI, will also help us understand how to
effectively deliver such services, and in particular, will provide more
focused experience in providing services to Indian youth. We believe
tele-behavioral programs can become an integral part of the IHS
behavioral health services, strengthen our clinical expertise in using
tele-health services and expand access to needed behavioral healthcare.
We are working to augment the ability of the IHS Tele-behavioral Health
Center of Excellence to promote and support such services across the
Indian health system. The additional services proposed in this
legislation could help facilitate our ability to provide needed
services.
In summary, we look forward to opportunities to address the
critical problem of youth suicide in Indian Country. We are committed
to using available technologies including our growing national
telecommunications infrastructure to help increase access to sorely
needed behavioral health services. For Indian Health Service, our
business is helping our communities and families achieve the highest
level of wellness possible.
Mr. Chairman, this concludes my statement. Thank you for the
opportunity to testify. I will be happy to answer any questions that
you may have.
The Chairman. Dr. Roubideaux, thank you very much for your
statement and for being here.
Next we will hear from the Honorable Eric Broderick. Dr.
Broderick is the Acting Administrator of the Substance Abuse
and Mental Health Services Administration. Dr. Broderick?
STATEMENT OF HON. 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. Thank you, Mr. Chairman.
Mr. Chairman, Mr. Vice Chairman, members of the Committee,
good afternoon. My name is Eric Broderick. I am the Acting
Administrator of the Substance Abuse and Mental Health Services
Administration within the Department of Health and Human
Services.
Today I am honored to join Dr. Roubideaux as a witness at
this hearing. I have known Dr. Roubideaux for a number of
years, and I look forward to expanding our working relationship
with the Indian Health Service under her leadership to expand
and enhance the well-being of American Indians and Alaska
Natives.
Mr. Chairman, I would like to also acknowledge the
assistance of your staff, specifically John Hart, Erin Bailey
and Rhonda Harjo for the assistance they provided us at SAMHSA
in addressing and engaging issues of concern to Indian Country.
Thank you for the opportunity to testify about suicide in
Indian Country. As you have said, it is an extremely serious
issue. The data are very clear, and bear our close attention.
I regret that since I last testified, as you pointed out,
there has been a tragic cluster of suicide on the Standing Rock
Sioux Reservation. Mr. Chairman, SAMHSA staff, accompanied by
your staff, visited Standing Rock on the 20th of July of this
year, met with Chairman His Horse Is Thunder, as well as
members of the chairman's staff, other tribal leaders,
reservation program coordinators and tribal community members.
Based upon this visit, SAMHSA has submitted a report to this
Committee. The report focuses on issues at Standing Rock and is
consistent with the testimony I provided at previous hearings.
During our visit, the director of the Boys and Girls Club
of the Grand River area of the Standing Rock Reservation
reported that at Standing Rock, there is an unemployment rate
of 74 percent, 85 percent of the tribal members live in
poverty, violent crime is six times the national average and
the high school graduation rate is 49 percent, compared with 76
percent nationally. These statistics provide a glimpse of the
risk factors American Indians and Alaska Native youth face in
their communities. We know that protective factors such as
tribal culture, sports, recreation and academic programs can
mitigate these risk factors. We also know that adequate mental
health services and substance abuse services for those in need
are extremely important.
Unfortunately, in many communities, these protective
factors and essential health services are not always available.
Federal, State and tribal governments must work together to
address this problem, and we at SAMHSA are committed to the
effort.
In order to create an opportunity for systematic feedback
and guidance from elected tribal officials, we at SAMHSA
created and staffed a tribal advisory committee comprised of
elected tribal officials from across the Nation. The committee
has been in place for two years and provides us with valuable
assistance in working with tribal communities and understanding
the issues of importance to Indian Country.
Additionally, over the past three years, SAMHSA has co-
hosted with the Department of Justice Office of Justice
Programs, Office of Violence Against Women, Office of Victims
of Crime and the COPS program, as well as the Department of
Interior, Department of Housing and Urban Development, the
Small Business Administration and the HHS Office of Minority
Health and the Indian Health Service nine technical assistance
and consultation sessions. These tribal justice, safety and
wellness conferences were created at the request of tribal
leadership and provide the opportunity to both consult with
tribal leaders on issues at the nexus of public health and
public safety that are of concern to them as well as to provide
technical assistance aimed at raising tribal grantsmanship
capacity. Youth suicide has been raised as a concern at every
one of these sessions.
I believe that this ongoing commitment to the development
of tribal capacity is largely responsible for the doubling of
SAMHSA grants awarded to tribes between 2006 and 2008. However,
I also believe that much more can be done.
It has been our experience that giving blanket priority to
certain groups, to specific drug types or to specific mental
illnesses in a grant application process often fails to produce
the desired results. As an alternative, I would like to share
with you what has proven effective for us at SAMHSA. We
understand the value of providing tribes and tribal
organizations additional resources to develop infrastructure
needed to submit competitive grant applications and to
administer grants when funds are awarded. For example, in
evaluating the Children's Mental Health Initiative, we have
found that many American Indian and Alaska Native tribes were
unsuccessful in competing for our Systems of Care grants
because they did not have the infrastructure to draft or to
plan for such new programs.
The Children's Mental Health Initiative provides funding to
local communities, including American Indian and Alaska Native
communities, to develop systems to care for children with
serious mental illness. In response to that finding, SAMHSA
developed the Circles of Care grants, which are three-year
discretionary infrastructure grant programs for American Indian
and Alaska Native tribes and tribal organizations to plan for
and develop community-based systems of care for children with
serious mental illness. There have been 16 tribes or tribal
organizations who have received Circles of Care grants. Of
those 16, 12 have been successful in becoming Systems of Care
grantees and implementing the models they have developed as a
result of their Circle of Care grants.
Mr. Chairman, when we consider ways to help tribal
communities prevent youth suicide, I would recommend that we
consider similar strategies to expand tribal capacity.
Currently, fully one-third of our Garrett Lee Smith grants have
been awarded to tribes and tribal communities. Eighteen of 54
grants now go to tribes. They have been successful and very
competitive in that environment.
But to build upon that tremendous success of tribes, I
would suggest that the Circles of Care grant model, relative to
suicide prevention, is one worthy to consider. Creation of
planning grants for suicide prevention would build upon
SAMHSA's Native Aspirations program, as well as to develop
much-needed capacity to develop programming and permit tribes
to successfully compete for grants to implement those programs.
These planning grants should target communities that currently
do not possess the capacity to successfully compete for Federal
grants. Not only would this approach direct resources to
communities of extremely high need, it would also create the
capacity for solid administration and implementation of those
grants.
Thank you for the opportunity to testify, sir. I would be
happy to answer any questions for the Committee.
[The prepared statement of Dr. Broderick follows:]
Prepared Statement of Hon. 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 afternoon. I am
Eric B. Broderick, D.D.S., M.P.H., Acting Administrator of the
Substance Abuse And Mental Health Services Administration (SAMHSA)
within the Department of Health and Human Services and Assistant
Surgeon General.
SAMHSA and the Indian Health Service (IHS) work closely together to
formulate long-term strategic approaches to address the issue of
suicide in Indian Country more effectively. For example, SAMHSA and IHS
are actively involved on the Federal Partners for Suicide Prevention
Workgroup. In 2001, the Office of the Surgeon General coordinated the
efforts of numerous HHS agencies, including SAMHSA, IHS, the Centers
for Disease Control and Prevention, the National Institute of Mental
Health within the National Institutes of Health, and the Health
Resources and Services Administration, along with other public and
private partners to develop the first, comprehensive, integrated,
public health approach to reducing deaths by suicide and suicide
attempts in the United States in the National Strategy for Suicide
Prevention. This resulted in the formation of the ongoing Federal
Partners for Suicide Prevention Workgroup. SAMHSA also helped
facilitate and participated in a Federal Partners Committee on
Telemental Health.
While I am very pleased to be here today to talk about suicide
rates among American Indians and Alaska Natives, I regret that since I
testified the last time, the problem has not improved. I am saddened to
note that we have faced yet another episode of suicides among American
Indians and Alaska Natives, this time on the Standing Rock reservation
where there have been ten recorded suicides, primarily among the
younger population since January of this year.
Along with representatives of the Chairman, we visited the
reservation on July 20 and met with Chairman Ron His Horse is Thunder
as well as members of the Chairman's staff, tribal leaders, reservation
program coordinators and tribal community members. Based on this visit,
SAMHSA submitted a report to the Committee. The report repeats much of
what I and the previous IHS Director have testified about in previous
hearings, except due to the recent increased loss of youth to suicide,
the report is specific to the Standing Rock Sioux Tribe July visit.
Despite the attention that suicide among American Indians and
Alaska Natives deserves and gets, especially from the Committee and the
Department, we, as a nation, continue to experience very high rates of
suicide among Native Americans and Alaska Natives. In the case of
Standing Rock, a cluster of youth suicide completions devastated the
reservation despite suicide specific funding from SAMHSA through the
Garrett Lee Smith (GLS) State/Tribal Suicide Prevention Grants.
Program staff for the GLS grant, known as Oniyape, are deeply
dedicated to their suicide prevention program. Community members told
us that staff supporting this grant have their hands full just trying
to intervene with the large number of youth and families most at risk
for suicide.
Programs that help increase protective factors to offset the risk
factors that exist among the tribe--such as sports, recreation,
cultural, and academic support programs--are scarce on the Reservation.
Where such resources do exist, inadequate financial and human resources
limit outreach and activity level they can provide. During the recent
crisis, the Boys and Girls Club of the Grand River Area of the Standing
Rock Reservation served as the de facto crisis center for the
community. It provided--and continues to provide--support, meetings
with families, and grief counseling to the youth following the recent
suicides. Parents and grandparents approached Club staff at work, on
the street, and at their homes, asking if they could help their child
or grandchild. Club staff made referrals, ensured the youth were
involved in the Club's programs, checked in on the youth, and listened
to and supported the adults.
With the suicide rates so high, tribal members report that many
individuals at risk struggle with:
Maintaining intimate relationships
Trusting and being trusted
Working in teams with others
Persevering when problems arise
Functioning as parents
Holding a job--if jobs exist
Stopping harmful behaviors such as alcohol and drug abuse or
family violence.
These reactions only create a deeper sense of isolation,
depression, and substance abuse which often lead to suicidal thoughts
and actions.
This problem requires a public health approach that works to
decrease risk factors and increase protective factors. This may very
well take a concerted effort by the Federal, State, and Tribal
Governments. It will take time.
In the meantime, we support programs such as the Garrett Lee Smith
State/Tribal Grants and other efforts supported by the SAMHSA and the
Indian Health Service and consider ways of intervening such as finding
ways to support mental health and substance abuse services for American
Indian and Alaska Native tribes and tribal organizations.
We provide technical assistance to tribes and encourage them to
apply for funding. All of our grants, except those that are restricted
by statute, are open to American Indians and Alaska Natives tribes and
tribal organizations, and we have been working hard to increase funding
to American Indian and Alaska Native tribes or tribal organizations.
They may apply directly for discretionary funds without going through
the State, and we have facilitated the application process.
As a result of this effort, the amount of funding to American
Indian and Alaskan Native tribes and tribal organizations, especially
with respect to suicide prevention, now totals over $60 million a year.
Standing Rock has been very successful in competing and receiving grant
funds from SAMHSA. Besides a Garrett Lee Smith State/Tribal grant, they
also have a Circles of Care grant, an inter-departmental (HHS and
Education) Safe Schools/Healthy Students grant, and a Targeted Capacity
Grant for substance abuse treatment.
SAMHSA's Role in Better Serving American Indian and Alaska Native
Populations
SAMHSA provides national leadership for suicide prevention,
consistent with the National Strategy for Suicide Prevention. We have
four major suicide prevention initiatives that I will highlight briefly
today. These initiatives include the Garrett Lee Smith Youth Suicide
Prevention Grant Program, the Native Aspirations Project, the Suicide
Prevention Resource Center, and the Suicide Prevention Lifeline.
Garrett Lee Smith Youth Suicide Prevention Grant Program
As a result of the authorization provided by the Garrett Lee Smith
Memorial Act (P.L. 108-355), SAMHSA has been working with state and
local governments and community providers to further 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.
Awards were again made in 2006 and 2007, during which six Tribes/
Tribal Organizations were awarded grants. In August 2008, 12 Tribes/
Tribal Organizations received Garrett Lee Smith grants, totaling 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 Requests
for Application and then put forward strong, viable applications.
Additionally, it is important to note that many of the states which
received grant awards are partnering with and/or reaching out to
include suicide prevention efforts in their local tribal communities.
Among the newest cohort of grants the Tribes/Tribal Organizations
awardees include: 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.
Overall, 54 states, tribes, and tribal organizations, as well as
more than 50 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.
Through the Native Aspirations project, a total of 25 American Indian
and Alaska Native communities determined to be the most ``at risk''
develop or enhance a community-based prevention plan.
After a community is selected, the first step is an initial visit
from Native Aspirations project staff members, who share information
and help community leaders set up an oversight committee. The second
step is the 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
American Indian and Alaska Native 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 event, 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 ongoing training, consultation, technical assistance, and
budget support.
Suicide Prevention Resource Center
Another initiative is the Suicide Prevention Resource Center (SPRC)
which is 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 last major initiative I will highlight today is the National
Suicide Prevention Lifeline. The National Suicide Prevention Lifeline
is a network of 141 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 141 crisis centers across the country. Those crisis centers
are independently operated and funded (both publicly and privately).
They all serve their local communities in 49 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 Idaho, the only
state that does not currently have a participating crisis center, the
calls are answered by a crisis center in a neighboring state.) Every
month, nearly 52,000 people have their calls answered through the
National Suicide Prevention Lifeline, an average of 1,852 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
American Indian/Alaskan Native Communities and also with the Department
of Veterans Affairs (for veterans using the Lifeline) 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.
In addition to the four funding programs outlined above, SAMHSA has
also provided funding for an expanded evaluation of Garrett Lee Smith-
funded grant activities in the White Mountain Apache tribe, focusing on
Emergency Department interventions and follow up with American Indian
youth who have made suicide attempts. In this innovative approach,
Apache paraprofessionals provide outreach in the community to each
youth who has been reported to attempt suicide or to experience
suicidal thoughts. By electronic means, these outreach workers are
provided remote supervision by a child psychiatrist, psychologist and
clinical team from the Johns Hopkins University Center for American
Indian Health. In addition, last year, SAMHSA sponsored a meeting to
examine the tragedy of suicide clusters in Indian Country.
These SAMHSA initiatives are an important start, but we know there
is much more to be done to reduce the tragic burden of suicide in
Indian Country. The problems confronting American Indian and Alaska
Natives are taking a toll on the future 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.
Next we will hear from Dr. Dolores Subia BigFoot, Director
of the Indian Country Child Trauma Center and the Project
Making Medicine at the University of Oklahoma Health Sciences
Center. She is testifying on behalf of the American
Psychological Association.
You may proceed. Thank you for being with us.
STATEMENT OF DOLORES SUBIA BIGFOOT, Ph.D., DIRECTOR, INDIAN
COUNTRY CHILD TRAUMA CENTER AND PROJECT MAKING MEDICINE,
UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER
Dr. BigFoot. Chairman Dorgan, members of the Committee,
this is both a personal and a professional effort. First,
please allow me to express my appreciation for the opportunity
to speak on behalf of the 150,000 members and affiliates of the
American Psychological Association. My name is Dr. Dolores
Subia BigFoot, and I bring goodwill from the Caddo Nation of
Oklahoma in which I am enrolled, and from the Northern Cheyenne
Tribe in Montana, in which my children are enrolled.
I am a child counseling psychologist by training and have
devoted 35 years to addressing health disparities in its many
different forms within our tribal nations. Thank you for
convening this important hearing to discuss the need to reduce,
to eliminate and to reveal the devastation of suicide within
our American Indian and Alaska Native youth through the
development of Federal legislation.
As the Director of Project Making Medicine and the Indian
Country Child Trauma Center at the University of Oklahoma
Health Sciences Center, I profoundly understand the need for
safety for our youth. There are many diligent and dedicated
people who are concerned and working to address this same need
for safety and to provide appropriate mental health and other
culturally-appropriate interventions that can help prevent
suicide.
Project Making Medicine is funded by the Office of Child
Abuse and Neglect, the Children's Bureau and the Indian Country
Child Trauma Center was funded from 2003 to 2007 by the
Substance Abuse and Mental Health Services Administration as
part of the National Child Traumatic Stress Network. We
currently remain a very active affiliate member of this
network, which is an important Congressional initiative that
works to raise the standard of care for traumatized children
and their families.
It is also important to acknowledge the critical role of
SAMHSA's youth suicide prevention and early intervention
programs created under the Garrett Lee Smith Memorial Act. The
rates of suicide among our youth has been drastically
illustrated by the charts that were shown. They are
disproportionately high and we must work to address these
preventable, yes very preventable, tragedies.
Mr. Chairman, as I am sure you know, given your steadfast
commitment to addressing this tragic problem, high suicide
rates have significant impact on families, siblings, peers, and
the community as a whole. While progress has been slow in
understanding suicide from a cultural perspective, we know that
both historical and current traumatic stressors in Indian
Country affect our youth. I think that by the bill earlier
referenced, regarding violence in Indian Country, it is very
self-evident.
The self-harm responses that youth may exhibit are much
like those of other individuals exposed to collective trauma,
such as our combat veterans that are returning and their high
rate of suicide, such as the first responders, firefighters and
police officers, like those involved in the Oklahoma City
bombing. I am aware of those that committed suicide after that.
And of course, those after 9/11. Tragedy has an impact. Trauma
has an impact.
Despite the challenges facing our American Indian and
Alaska Native communities, we remain optimistic and hopeful.
Organizations such as the National Congress of American
Indians, the National Indian Health Board, National Council of
Urban Indian Health, along with tribes and the Indian Health
Service, has been formulating best practices related to suicide
prevention that will help our youth. These efforts focus on
developing a better understanding of what would lead youth to
consider suicide.
While we know that suicide typically occurs as a single
individual act, suicide cannot be understood in isolation.
Instead, we must consider the various precipitating factors,
including child maltreatment, family violence, mental health
problems, trauma, loss, grief and pain that are associated with
feelings of hopelessness and the lack of safety among our
youth.
Our youth are in desperate need of safe homes, safe
families and safe communities. Chronic under-funding of tribal
and urban programs and a lack of infrastructure and human
resources, as described earlier, create barriers for our youth.
We must provide appropriate resources and opportunities to
immediately empower and support our population to build our
capacity to address the needs of our youth.
Currently, there are insufficient numbers of psychologists
and other mental health providers of Indigenous heritage. Two
vital Federal initiatives in place to help address this problem
are the Indians Into Psychology program and the Minority
Fellowship program, funded by the Indian Health Service and
SAMHSA, respectively. These programs have a strong history of
success and are critical to building the ethnic minority
pipeline. As such, it is important that increased funding is
provided for these initiatives.
At the same time, while we work to build the sufficient
professional workforce, tribal communities require immediate
and innovative resources to meet the urgent needs of our youth
and families. At the University of Oklahoma Health Sciences
Center, we currently utilize a video-conferencing system
through the internet in which we are training via real-time
mental health providers in tribal communities. We have done
this in the State of Washington, we have done it in California
and Utah and Oregon and Alaska and across Oklahoma.
The National Child Traumatic Stress Network is also
developing a sophisticated distance learning system that can
help providers access the specific training they need. I
strongly recommend the continued support and expansion of the
National Child Traumatic Stress Network as an important
resource to ensure that we have a national infrastructure of
child trauma experts and providers who can meet the diverse
needs of our youth.
We appreciate your efforts to develop the Seventh
Generation Promise: Indian Youth Suicide Prevention Act of
2009. How well it is that we should think seven generations
ahead.
This legislation aims to increase and enhance the provision
of mental health care for American Indians and Alaska Native
youth by decreasing disparities in access and improving quality
of mental health care. We look forward to working with
Congress, the Indian Health Service, the Children's Bureau and
SAMHSA as this proposal moves through the legislative process.
We cannot be silent and so I will add, my own family loss,
my beautiful, precious son of 33 years died 10 months ago
today. His death certificate does not say suicide. However, his
self-harm behavior created a situation in which injury resulted
in his death. The outcome was the same. He was traumatized by
someone outside the family that I have no knowledge about until
he informed me as an adult. And by that time, as we tried to
untangle all of the webs that tore at his heart, tore at his
spirit, tore at his mind. It was very difficult.
So his death was a result of self-harm. He chose not to
seek medical care and knew that he would die. There are many of
those in similar situations beyond what we see in terms of the
statistics that are taking their own lives, and it is not
reported as a suicide.
Mr. Chairman, members of the Committee, I am honored. My
family is honored and my tribe is honored by this invitation to
join you today. But especially my son, Bryce Buffalo Man
BigFoot is honored that his mother can voice his cry that help
is so desperately needed. The American Psychological
Association and the Psychology Committee looks forward to
continuing to work with you and the tribal communities to
ensure that our youth receive the mental and behavioral health
care that they urgently need and deserve.
I must also acknowledge and honor the warrior woman that
sits here and her diligence in bringing so much to this table
and to our communities. So I honor you.
I am willing and open and eager to answer any questions you
have.
[The prepared statement of Dr. BigFoot follows:]
Prepared Statement of Dolores Subia BigFoot, Ph.D., Director,
Indian Country Child Trauma Center and Project Making Medicine,
University of Oklahoma Health Sciences Center
Chairman Dorgan, Ranking Member Barrasso, and members of the
Committee, please allow me to express appreciation for the opportunity
to speak on behalf of the 150,000 members and affiliates of the
American Psychological Association. My name is Dr. Dolores Subia
BigFoot and I bring good will from the Caddo Nation of Oklahoma in
which I am enrolled and from the Northern Cheyenne Tribe in Montana in
which my children are enrolled. I am a child psychologist by training
and have devoted 35 years to addressing health disparities in its many
forms within our Tribal Nations. Thank you for convening this important
hearing to discuss the need to reduce, eliminate, and reveal the
devastation of suicide with our American Indian and Alaska Native (AI/
AN) youth through the development of federal legislation.
As Director of Project Making Medicine and the Indian Country Child
Trauma Center at the University of Oklahoma Health Sciences Center, I
profoundly understand the need for safety among our AI/AN youth. There
are many diligent and dedicated people who are concerned and working to
address this same need for safety, and to provide appropriate mental
health and other culturally appropriate interventions that can help
prevent suicide. Project Making Medicine is funded by the Office of
Child Abuse and Neglect, Children's Bureau, and the Indian Country
Child Trauma Center was funded from 2003-2007 by the Substance Abuse
and Mental Health Services Administration's (SAMHSA) National Child
Traumatic Stress Network. We currently remain a very active affiliate
member of this Network, which is an important congressional initiative
that works to raise the standard of care for traumatized children and
families. It is also important to acknowledge the critical role of
SAMHSA's Youth Suicide Prevention and Early Intervention Programs
created under the Garrett Lee Smith Memorial Act.
Physical, mental, and behavioral health problems continue to affect
the AI/AN communities at alarming rates. I am particularly concerned
about the disproportionately high prevalence of mental and behavioral
health problems among our nation's AI/AN population, including suicide
and suicidal ideation. The statistics regarding suicide in the AI/AN
communities are astonishing. Research indicates that American Indians
account for nearly 11 percent of total suicides in the United States.
The suicide rates among youth are also deeply tragic. Of the
approximately five million people who are classified as AI or AN in our
country, 1.2 million are under the age of 18, which comprises 27
percent of this group. This is particularly significant because in
2006, suicide was the second leading cause of death for AI/AN
individuals between the ages of 10 and 34. Furthermore, among AI/AN
youth attending Bureau of Indian Affairs schools in 2001, 16 percent
had attempted suicide in the 12 months preceding the Youth Risk
Behavior Survey.
From 1999 to 2004, AI/AN males between the ages of 15 to 24 had the
highest rates of suicide as compared to other age or ethnic groups,
27.99 per 100,000. This age group accounts for 64 percent of all AI/AN
suicides. Unfortunately, more than half of all persons who die by
suicide in AI/AN communities were never seen by a mental health
provider.
Mr. Chairman, as I am sure you know given your steadfast commitment
to addressing this tragic problem, high suicide rates have a
significant impact on siblings, peers, family members, and communities
as a whole.
It is also important to acknowledge the cultural aspects associated
with suicide in our AI/AN communities. While progress has been slow in
understanding suicide from a cultural perspective, we know that both
the historical and current traumatic stressors in Indian Country affect
our youth. The self harm responses that they may exhibit are much like
those of other individuals exposed to collective trauma, such as
service members/veterans, prisoners of war, and first responders (e.g.,
firefighters, police officers).
Despite the challenges facing our AI/AN communities, we remain
optimistic and hopeful. The National Congress of American Indians,
along with Tribes and the Indian Health Service, has been formulating
best practices related to suicide prevention that will help our youth.
These efforts focus on developing a better understanding of what would
lead youth to consider suicide. While we know that suicide typically
occurs as a single individual act, suicide cannot be understood in
isolation. Instead, we must consider a variety of precipitating
factors, including child maltreatment, family violence, mental health
problems, trauma, loss, grief, and pain that are associated with
feelings of hopelessness and a lack of safety among our youth.
The unfortunate and often forgotten reality is that there is an
epidemic of violence and harm directed towards this very vulnerable
population. AI/AN children and youth experience an increased risk of
multiple victimizations. Their capacity to function and to regroup
before the next emotional or physical assault diminishes with each
missed opportunity to intervene. These youth often make the decision to
take their own lives because they feel a lack of safety in their
environment. Our youth are in desperate need of safe homes, safe
families, and safe communities.
Chronic underfunding of tribal community programs and a lack of
infrastructure and human resources create barriers for AI/AN youth. We
must provide appropriate resources and opportunities to immediately
empower and support our population to build their capacity to address
the needs of our youth. Currently, there are an insufficient number of
psychologists and other mental health providers of Indigenous heritage.
Two vital federal initiatives in place to help address this problem are
the Indians Into Psychology Program and the Minority Fellowship
Program, funded by the Indian Health Service and SAMHSA, respectively.
These programs have a strong history of success and are critical to
building the ethnic minority pipeline. As such, it is important that
increased funding is provided to these initiatives to meet the current
mental and behavioral health needs of our population. At the same time,
while we work to build a sufficient professional workforce, tribal
communities require immediate and innovative resources to meet the
urgent needs of our youth and families.
At the University of Oklahoma Health Sciences Center, we are
currently utilizing a video conferencing system through the Internet in
which we are training via real time mental health providers in tribal
communities in Washington State. In the past, we have trained via
Internet tribal providers located in Alaska, California, Utah, and
across Oklahoma. The National Child Traumatic Stress Network is also
developing a sophisticated distance learning system that can help
providers access the specific training they need when working with AI/
AN youth and families. I strongly recommend the continued support and
expansion of the National Child Traumatic Stress Network as an
important resource to ensure that we have a national infrastructure of
child trauma experts and providers who can help to meet the diverse
needs of our youth.
This past June, we traveled to Anchorage, Alaska to provide a
Mental Health First Aid training for individuals from the villages or
Native corporations who were interested in developing basic skills in
assisting those experiencing mental or behavioral health problems,
including suicide risk. Unfortunately many village providers and other
village helpers who expressed interest in the training were unable to
attend given the lack of transportation resources. With telehealth
capability, such barriers might be overcome to enable the delivery of
critical mental health and suicide prevention education and training in
remote or less accessible areas and to large groups of community
members.
We appreciate your efforts in developing the 7th Generation
Promise: Indian Youth Suicide Prevention Act of 2009. This legislation
aims to increase and enhance the provision of mental health care to AI/
AN youth by decreasing disparities in access and improving quality of
mental health care. We look forward to working with Congress, the
Indian Health Service, the Children's Bureau, and SAMHSA as this
proposal moves through the legislative process.
Mr. Chairman, Ranking Member, and members of the Committee, I am
honored, my family is honored, and my tribe is honored by this
invitation to join you here today. The American Psychological
Association and the psychology community look forward to continuing to
work with you and the tribal communities to ensure that our youth
receive the mental and behavioral health care that they urgently need
and deserve. I would be pleased to answer any questions.
Attachment
The Chairman. Dr. BigFoot, thank you very much for being
with us and for your testimony. I know that the spirit of your
son would be very proud of his mother today for being with us.
I think this issue is so difficult, it is especially more
difficult when it requires a discussion of a loved one. I have,
well, first of all, I have some experience, having walked into
a room and found a friend who had taken his own life. So I know
something about the shock and the trauma of walking into a room
and seeing a friend who has taken his life, something that you
never, ever, ever forget.
It is especially tragic when it is a child, because that is
someone whose life is in front of them and extinguished because
of feelings of helplessness and hopelessness. So what we are
trying to think through is, what causes all of this? We
understand that part of the roots reflect the difficulties of
living in third world conditions. You don't have to go to a
third world country to see third world conditions. It too often
exists here in America on Indian reservations. I have gone to a
reservation where there was a cluster of teen suicides and just
sat around a large table with a group of teenagers, no other
adults present. And I said, just tell me about your lives. Many
of you knew the young kids that took their own lives. Tell me
about them, tell me about what you think.
It is an extraordinary lesson to learn from the mouths and
the minds of young people, to hear about their existence and
their concerns. So there are a number of things, I think, that
play a role here. One of the things that I think is a bright
spot are the youth clubs and the youth centers and so on that
are doing unbelievable work with very little funding and very
little accolades for what they do.
We are trying today to think through, what is it we can do.
Let me just tell you one more story, then I will ask you some
questions. I held a hearing once in Bismarck, North Dakota. It
was on the subject, again, an extraordinarily difficult,
sensitive subject, and that was child sexual abuse. A young
woman testified from one of our reservations. She was in her
mid-twenties. And she had been hired on that reservation to
work on these issues.
And she was the recipient, then, of the complaints. She
began to testify at this hearing. She described that on her
desk was a pile of complaints of child sexual abuse that had
not been investigated by law enforcement. And she began to
describe that just taking one of those complaints and talking
to one of those children and finding a need to take one of
those children to a professional somewhere in a medical
facility, that in order to do that, she had to try to find a
way to beg or borrow a car in order to have the transportation
to get this person to a professional.
At that point in the discussion she just began to sob and
weep, I am talking about the woman on the, in this case, the
Spirit Lake Nation. She just couldn't continue, thinking about
the impossibility of her job. She quit her job several months
later.
But the point is, somewhere stacked in those files was, I
am certain, tragedy occurring with a young child, not even
investigated. So when we ask the question, what leads to this
feeling of hopelessness and helplessness, what leads to
suicide, there are many causes, but not the least of which, in
my judgment, is just the lack of basic resources that exist
routinely and are expected to exist routinely by parents in
most other areas in our society. When someone is missing from
school 90 days, somebody, somebody is going to track them down,
some professional in that school district. But when there are
not enough people around to do that job, kids get lost. That is
what happened to 14-year-old Avis Little Wind.
Dr. Broderick, you indicated that the time previously, when
you testified before this Committee related to fast-forwarding
to this point, there has not been any improvement on the
subject of Indian teen suicide. Can you expand on that and if
that is the case, obviously the question is why?
Dr. Broderick. Mr. Chairman, as you know, it is an
extremely complex topic that requires, I mean, it has taken a
long, long time and much tragedy, much trauma to get there.
Standing Rock is an excellent example. We have worked, we at
SAMHSA and I know the Indian Health Service as well, have
worked closely with the community. They currently have a
Garrett Lee Smith suicide prevention grant and yet they still
experience a suicide cluster, in spite of the investment of
resources. And it tells me that what is needed is a holistic
approach that cuts across both public safety and public health
programs to address the fundamental needs and the fundamental
causes that Dr. BigFoot so eloquently described.
We know that people who have experienced trauma, be it
inter-generational trauma or trauma as children are at
extremely high risk. Unfortunately, children in Indian
communities are oftentimes subjected to such trauma. So I
believe that if we use Standing Rock as a case study, in spite
of the investment of some resources and establishment of close
working relationships with that community, those children still
remain at risk. It speaks to the need for a dedicated effort to
address the multiple causations and the multiple risk factors
that go to contribute to the high rates of suicide that we see.
So I think it calls for not only a redoubling of our
effort, but the need to look at all the causes and all the
complexities that exist in those communities that have existed
there for a long, long time to actually break that cycle.
The Chairman. Dr. Roubideaux, thank you for your testimony.
You are relatively recently nominated and confirmed to your
post. But tell me, do you think the issue is substantially
additional resources? Condense for me your testimony, if you
would, to a couple of paragraphs. What do you think, if you had
your choice today and could make that choice, would be the
couple of things you think would most affect our ability to
reduce the rate of teen suicide on Indian reservations?
Dr. Roubideaux. I think that the first thing that we need
to do is to make sure that we are not all working in isolation
on this problem. We have great partnership with SAMHSA, we have
a great partnership with our tribes. And working with the local
schools, the local justice systems, the local community
programs, I really believe that that is going to be one of the
major ways to address this problem. We can't solve the problem
alone. We have to have partners in this effort.
I am really excited about our new meth and suicide
prevention initiative. Now we have 129 new meth and suicide
prevention initiatives across the Country that involve work
with tribes and the local IHS and other community partners to
try to address this problem.
The other major thing we need is just increased access to
services. Many of our behavioral health programs are staffed
with one clinical psychologist. Many of them have vacancies.
And we really do need to find a way to get more access.
I am pleased that the legislation includes the tele-
behavioral health and the tele-mental health. Because that is a
way that we can increase access to psychiatric and
psychological care through a network of resources using
technology, so that we could potentially provide 24/7 crisis
care if needed. So I think this is an enormously heartbreaking
and complex problem. But I think there are things that we can
do, if we all put our resources together.
The Chairman. Are you fighting inside the institution for
better funding? I mean, you are part of a process by which you
send recommendations up to OMB and then it goes to the White
House and then they decide what you are going to have and then
you have to come here to this table and say, I support this
number, despite the fact it may not be your number at all. You
may strongly, profoundly disagree, but you come to support it.
That is the way the budget process works. But the first side of
that is to be very aggressive, to say, here is what we need to
address these issues, one of them being, for example, teen
suicide, here is the money, the funding we need for these
programs to address teen suicide. You are new to this process,
but I assume you fully understand the early role that you will
play in this budget process?
Dr. Roubideaux. Absolutely. I understand the stakes are
high and that we play an important role in trying to help
understand what resources are needed to adequately and
effectively meet the health needs of this population. I am
proud to say that for the new budget process, we started by
looking at our tribal recommendations for our budget. And I am
really pleased with the support that I am seeing in the new
Administration and in the Department, as people are trying to
understand what our budget needs are. Again, I am also pleased
with the support of the President, with his proposed Fiscal
Year 2010 budget, a 13 percent increase, which is the highest
in over 20 years.
So I am doing my best to be an advocate for the people we
serve.
The Chairman. I should say, Dr. Broderick, thank you for
sending the resources you did down to the Standing Rock
Reservation, along with the staff of this Committee. That was
very, very helpful. We are continuing, and I know with you,
continuing to monitor what is happening there.
Dr. Broderick. I think, if not today then very shortly,
Standing Rock will sign an agreement with the Native
Aspirations program to become one of the communities that are
involved in Native Aspirations. That is a direct result of your
intervention and our trip there. So we are seeing the
dedication of additional resources to that community.
The Chairman. Dr. BigFoot, describe for me, if you would,
the child trauma center that you are directing.
Dr. BigFoot. The child trauma center is hope. What we have
done is we have taken evidence-based practices and culturally
adapted them for the treatment of trauma. We have culturally
adapted Trauma Focus, Cognitive Behavioral Therapy to Honoring
Children, Mending the Circle. We have culturally adapted
Parent-Child Interaction Therapy to Honoring Children, Making
Relatives. The treatment of Children with Sexual Behavior
Problems, we have culturally adapted it to Honoring Children,
Respectful Ways, which has two components. One is a treatment
component, one is a prevention component.
And then we have taken the American Indian Life Skills
Development, in conjunction with Terese LaFramboise, to revise
it for lower grades. Because we also discovered that children
very, very young, in middle school and younger, were having
thoughts of suicide. So we wanted to be able to implement a
curriculum that was for younger ages. Then as part of that, we
have the Honoring Children, Honoring the Future, which is a
suicide intervention and prevention efforts that we have
undertaken through the Indian Country Child Trauma Center,
which includes consultation to tribes and training. It includes
the accessing of resources.
For example, yesterday I was in the State of Washington
where they were having an incredible conference with State and
tribal agreements as part of the innovation center that is
funded by SAMHSA. So I had a presentation on suicide, and one
of the things that I did as part of that presentation was bring
up the Indian Health Service suicide prevention website, and
looked at all the resources that were on there. I had a room
full of tribal members from all different tribes in Washington
State, and they had no idea of the numerous resources that were
available to them, even the simple screening that was on that
website that you can access and get training in.
So being able to help tribes look at what the resources
are, and I think we have numerous kinds of resources, we have
the American Indian Life Skills, we have the different programs
like Native Aspirations, we have multiple different programs.
But a lot of times, tribal communities are not aware.
The other thing that we do is to assist tribal communities
in that healing process so that they can become more proactive.
So we help with healing camps, talking circles, different kinds
of culturally-based interventions that are directed to the
general population. Because one of the things that we need to
recognize is that our tribal communities have always had
healing ways.
And even though I am a trained professional, I still am
highly respectful of the fact that our tribal communities have
ceremonies that are still viable to help to renew and
regenerate and heal some of the loss and grief and some of the
trauma that individuals and tribes have been faced with. And
part of this, in terms of the project Making Medicine funded by
the Office of Child Abuse and Neglect of the Children's Bureau
is to take these evidence-based practices into tribal
communities.
So the culturally-adapted treatment programs were developed
under the Indian Country Child Trauma Center funded by SAMHSA.
But now we have made a wonderful link to be able to deliver
those training interventions to licensed professionals. The
problem we have is that we can train about 20 participants a
year, and we have to do booster training and we need to do
other kinds of things to support. If we only do 20 a year, we
are not doing it very sufficiently. But we really try to help
tribal communities to build their capacity.
The Chairman. Thank you very much. It sounds like a really
important program that is affecting and improving the lives of
a lot of people. Thank you for your work.
I just received a note that a vote is going to start in one
minute on the Floor of the Senate. So it worked out pretty well
that I could have an opportunity to hear all of the testimony
and have all of you be here. We will continue. As you know,
Senator Johanns, Senator Barrasso, myself, Senator Tester and
many others are very concerned about this issue. We wanted to
have an initial discussion today. We intend to proceed with
these discussions on the issue of youth suicide. We will
continue to work with all of you. We would like to get our
legislation enacted this year and try to move forward to make
some significant improvements.
So we thank you for testifying. We will hold the record
open for any additional submissions for two weeks. This hearing
is adjourned.
[Whereupon, at 3:40 p.m., the Committee was adjourned.]
A P P E N D I X