ONE SKY CENTER: Best Practice Behavioral Health Approaches for American Indians and Alaska Natives
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Transcript of ONE SKY CENTER: Best Practice Behavioral Health Approaches for American Indians and Alaska Natives
ONE SKY CENTER:Best Practice Behavioral Health
Approaches for American Indians and Alaska Natives
Elizabeth Hawkins, PhD, MPH
Dale Walker, MD, Patricia Silk Walker, PhD, Douglas Bigelow, PhD, Laura Loudon, MS
Warrior Spirit Conference, Albuquerque, April 22-23, 2004
Overview
Introduction to One Sky Center
Overview of comorbidity issues
AI/AN comorbidity
Comorbidity best practices
Barriers to integrated treatment
Solutions
INTRODUCTION TO ONE SKY CENTER
One Sky Center
Funded by SAMHSA (CSAT & CSAP)
“Envisioned as an innovative NRC dedicated to identification and fostering of effective and culturally appropriate substance abuse prevention and treatment.” -Charles Currie, SAMHSA, July 2003
OSC Goals
Promote and nurture effective and culturally appropriate prevention and treatment
Identify and disseminate evidence-based prevention and treatment practices
Provide training and technical assistance Help to expand capacity and improve
quality in behavioral health care services
National Indian Youth Leadership Project Jack Brown
Adolescent Treatment CenterWhite Bison
Alaska Native Tribal Health Consortium
United American Indian Involvement
Northwest Portland Area Indian Health Board
Eastern U.S. Tribal Consortium
Tribal Colleges and Universities
One Sky Center
OSC Partners
Alaska Native Tribal Health Consortium
ANTHC is a non-profit health organization owned and operated by Alaska Native tribal governments and their regional health corporations.
Provides comprehensive services statewide to Alaska Natives.
Offers: Medical Center specialty services Health and sanitation facility development Training for Alaska Native health professionals Health system statewide network support Community and environmental health services
http://www.anthc.org
Jack Brown Youth Treatment Center
Operated by the Cherokee Nation Health Service and located in Tahlequah, OK Catchment area is primarily Kansas, Oklahoma, and
Texas Number of tribes served 1997-2003: 71
CARF accredited, 20-bed co-educational facility for youth 13-18 years of age
Usual length of stay is between 30 to 120 days Dual Diagnosis approach that targets physical,
mental, emotional, and spiritual growth Special emphasis on art therapy as a means of
health promotion
National Indian Youth Leadership Project
A non-profit organization located in Gallup, NM (founder is McClellan Hall)
Youth development programs include: Service learning Experiential learning Traditional, culturally-derived rites of passage Academic enrichment
Ongoing projects include: Project Venture Walking in Beauty Web of Life 21st Century Learning Center Turtle Island Project Sacred Mountain Learning Center
http://www.niylp.org
United Indian Involvement
A non-profit organization that provides services to the Los Angeles American Indian community. The Los Angeles American Indian Health Project Robert Sundance Family Wellness Center Robert Sundance Workforce Development Program Ah-No-Ven (Healing) Home – Youth Regional Treatment
Center American Indian Clubhouse Seven Generations Child and Family Counseling Center Native Pathways to Healing Circles of Care Program
http://www.laindianhealth.com
White Bison Inc.
An American Indian non-profit organization based in Colorado Springs (founder is Don Coyhis)
Offers sobriety, recovery, addictions prevention, and wellness/wellbriety learning resources
White Bison’s mission is to assist in bringing 100 Native American communities into healing by 2010 The principle underlying White Bison is living in
harmony with natural law Ceremonies are used to help individuals and
communities get back into harmony
http://www.whitebison.org
Sample of OSC Current Projects
SAMHSA portfolio project Best practices consensus panel Needs assessment of IHS Youth Regional
Treatment Centers Alaska Behavioral Health Aide program CAPT and ATTC needs assessment Recruitment and training of AI/AN
professionals Technical assistance Development and dissemination of
prevention and treatment resources
OVERVIEW OF COMORBIDITY ISSUES
Comorbidity Defined
“Individuals who have at least one mental disorder as well as an alcohol
or drug use disorder. While these disorders may interact differently in
any one person….at least one disorder of each type can be diagnosed independently of the other.”
- Report to Congress of the Prevention and Treatment of Co-Occurring Substance Abuser Disorders and Mental Disorders, SAMHSA, 2002
Lifetime History
Mental Disorder22.5%
Comorbidity29%
3.1% 1.5%
1.7%
1.1%
Alcohol Disorder13.5%
Comorbidity45%
Drug Disorder6.1%
Comorbidity72%
Regier, 1990
Prevalence and Pattern of COD
7-10 million Americans are affected each year
Antisocial personality disorder, bipolar disorder, and schizophrenia are most likely to coexist with a substance use disorder
Individuals with COD have a high prevalence of trauma histories and related symptoms
Individuals with COD are more likely to have cardiovascular disease, cirrhosis, or cancer than someone without such a diagnosis
Prevalence and Pattern in Youth
Among adolescents entering substance abuse treatment, 62% of males and 83% of females had at least one emotional/behavioral disorder
Almost 90% of those with a lifetime co-occurring disorder had at least one mental health disorder prior to the onset of a substance abuse disorder
Mental disorder likely to occur in early adolescence, followed by the substance abuse disorder 5-10 years later
Multiple Diagnoses Increase
Treatment seeking
Use of services
Likelihood of no services
Treatment costs
Poor outcome
Suicide risk
Affective Disorders and SUD
56% of people with Bipolar Disorder have a substance use disorder
32% of people with other affective disorders have a substance use disorder
~20% of youth with depression have history of substance abuse
15 – 75% of patients in substance abuse treatment have affective disorder
Use of TCAs and SSRIs show hope for treating affective disorder and reducing alcohol and drug intake
Schizophrenia and SUD
47% have substance use disorders Alcohol use may decrease negative
symptoms (depression, apathy, anhedonia, passivity and withdrawal)
May also decrease positive symptoms of hallucinations and paranoia
Schizophrenics often use and abuse stimulants
Drug-induced psychosis marked by prominent hallucinations or delusions
Anxiety Disorders and SUD
27% have a substance use disorder Anxiety disorders may be treated with TCAs,
SSRIs and Benzodiazepines (with caution) Generalized anxiety disorder: Buspirone
shown to treat anxiety and reduce alcohol consumption
Social anxiety is a big risk factor for alcohol and drug use
With PTSD, people will often use drugs or alcohol to sleep and stop recurrent nightmares, or to reduce anxiety
Disruptive Disorders and SUD
23% of people with ADHD have a substance use disorder
Combination of ADHD and CD place a child at greater risk of substance abuse than either one alone The greater the number of CD symptoms, the
more severe the substance abuse is likely to be When CD precedes substance abuse, youth are
at highest risk for ongoing delinquency and drug use in adulthood
Stimulants are a primary treatment choice but risk of abuse is high
Rates of Treatment by Type and Severity Level of the Disorder
Level of Mental Disorder
Level of Substance
Abuse Disorder
Type of Treatment
12-month serious mental
illness
12-month other mental
illness
12-month substance
dependence
Neither MH nor SA 29% 71%
MH only 49% 25%
SA only 3% 1%
Both MH and SA 19% 4%
12-month substance
abuse
Neither MH nor SA 51% 78%
MH only 49% 19%
SA only 0% 0%
Both MH and SA 0% 3%
COMORBIDITY AMONG AMERICAN INDIANS
AND ALASKA NATIVES
American Indians
Have same disorders as general population
Greater prevalence Greater severity Much less access to treatment Cultural relevance more challenging Social context disintegrated
Mental Health: Culture, Race and
Ethnicity
American Indians: Less likely to receive needed mental health
services Often receive a poorer quality of mental
health care Are underrepresented in mental health
research Have more homelessness and incarceration Have more trauma exposure, suicide,
homicide
Trends among AI/AN Youth
Lifetime substance use rates are similar to non-Indian teens, but AI/AN youth are more likely to: Use tobacco, inhalants, alcohol, and marijuana daily Consume alcohol in a binge-drinking style Engage in high risk behaviors and experience harmful
consequences
AI/AN youth tend to initiate substance use at a younger age
Higher rates of polysubstance use Substance use often does not follow the “Gateway”
model Highest rates of emotional/behavioral problems and
suicide
Alcohol and Other Drug Use
May cause or mimic psychiatric symptoms
May initiate or exacerbate a psychiatric disorder
Can mask psychiatric symptoms May last for days to weeks Drug-induced psychiatric symptoms
may clear spontaneously
Inpatient Psychiatric Care/100,000
Total Male FemaleNational 44 56 32AI/AN 99 78 21Asian 23 13 10Black 171 123 48Hispanic 63 46 21
SAMHSA, 2000
Native American Admissions, 1999
Total Male FemaleAdmissions (Thousands) 43.2 28.2 15.0
Primary Substance (percent) Alcohol 62.2 65.7 55.6Marijuana 12.4 13.0 11.4Opiates 9.0 8.0 10.8Cocaine 6.4 5.0 8.9Stimulants 5.4 4.0 8.2Other 4.7 4.5 5.0Total 100.0 100.0 100.0
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
Past Year Illicit Drug Use
Total Female Male
Total 11.9 9.8 14.1
Native American 19.8 23.3 15.6
Non-Hispanic White 11.8 9.9 13.9
Non-Hispanic Black 13.1 10.2 16.6
Hispanic – Central American 5.7 4.2 7.7
Hispanic – Cuban 8.2 5.5 11.4
Hispanic – Mexican 12.7 9.2 15.8
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
Prevalence of Alcohol Dependence
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
Total Female Male
Total 3.5 2.1 4.9
Native American 5.6 6.8 4.3
Non-Hispanic White 3.4 2.2 4.8
Non-Hispanic Black 3.4 2.0 5.2
Hispanic – Central American 2.8 0.8 5.4
Hispanic – Cuban 0.9 0.5 1.3
Hispanic – Mexican 5.6 2.6 8.4
COMORBIDITY BEST PRACTICES
Best Practices
“Examples and cases that illustrate the use of community knowledge and
science in developing cost effective and sustainable survival strategies to
overcome a chronic illness.”- WHO
Service Planning Guidelines
1. Dual diagnosis is an expectation, not an exception.
Service Planning Guidelines
1. Dual diagnosis is an expectation, not an exception.
2. People with COD can be organized into 4 subgroups for service planning purposes.
Co-occurring Disorders by Severity
IIILess severe
mental disorder/more severe
substance abuse disorder
IVMore severe
mental disorder/more severe
substance abuse disorder
ILess severe
mental disorder/less severe
substance abuse disorder
IIMore severe
mental disorder/less severe
substance abuse disorderA
lco
ho
l an
d o
ther
dru
g a
bu
se
Mental IllnessHigh Severity
Low Severity
High Severity
Service Planning Guidelines
1. Dual diagnosis is an expectation, not an exception.
2. People with COD can be organized into 4 subgroups for service planning purposes.
3. Treatment success involves formation of empathetic, hopeful, integrated treatment relationships.
Service Planning Guidelines
1. Dual diagnosis is an expectation, not an exception.
2. People with COD can be organized into 4 subgroups for service planning purposes.
3. Treatment success involves formation of empathetic, hopeful, integrated treatment relationships.
4. Treatment success is enhanced by providing interventions for both disorders continuously across multiple treatment episodes.
Unified Services Plan
Case management should address:
Mental health Education/vocation Leisure/social Parenting/family Housing Financial Daily living skills Physical health
Service Planning Guidelines
1. Dual diagnosis is an expectation, not an exception.
2. People with COD can be organized into 4 subgroups for service planning purposes.
3. Treatment success involves formation of empathetic, hopeful, integrated treatment relationships.
4. Treatment success is enhanced by providing interventions for both disorders continuously across multiple treatment episodes.
5. Integrated dual diagnosis-specific interventions are recommended.
Service Planning Guidelines
6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change.
precontemplationprecontemplation
relapserelapsecontemplationcontemplation
maintenancemaintenance
actionaction
preparationpreparation
Stages of Change
Service Planning Guidelines
6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change.
7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care assessment methodologies.
Service Coordination by Severity
IIILocus of care:
substance abuse system
IVLocus of care:state hospitals,jails, prisons,emergency rooms, etc.
ILocus of care:
primary health care
settings
IILocus of care:mental health
system
Alc
oh
ol
and
oth
er d
rug
ab
use
Mental Illness
High SeverityLow
Severity
High Severity
Service Planning Guidelines
6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change.
7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care assessment methodologies.
8. There is no single correct dual diagnosis intervention or program. Intervention must be individualized.
Service Planning Guidelines
6. Interventions need to be matched to diagnosis, phase of recovery, stage of treatment, and stage of change.
7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care assessment methodologies.
8. There is no single correct dual diagnosis intervention or program. Intervention must be individualized.
9. Outcomes of treatment interventions are similarly individualized.
Treatment Models
Sequential treatment: First one provider, then the other
Parallel treatment: Two separate providers at the same time
Integrated treatment: Both services provided by same clinician or group of clinicians
Integrated Treatment
“Any mechanism by which treatment interventions for co-occurring
disorders are combined within the context of a primary treatment relationship or service setting.”
-CSAT
Effective Interventions for Adults
Cognitive/Behavioral Approaches Motivational Interventions Psychopharmacological Interventions Modified Therapeutic Communities Assertive Community Treatment Vocational Services Dual Recovery/Self-Help Programs Consumer Involvement Therapeutic Relationships
Effective Interventions for Youth
Family TherapyMultisystemic TherapyCase ManagementTherapeutic CommunitiesCircles of Care
NIDA Recommended Approaches
Contingency Management
Relapse Prevention Therapy
Community Reinforcement Approach
Motivational Enhancement Therapy
BARRIERS TO INTEGRATED TREATMENT
Disconnect Between Systems
Professionals are undertrained in one of two domains
Patients are underdiagnosed Patients are undertreated Neither integrates well with medical
and social service
Difficulties of Integrated Approach
Separate funding streams and coverage gaps
Agency turf issues Different treatment philosophies Different training philosophies Lack of resources Poor cross training Consumer and family barriers
Agencies Involved in Health Services
Indian Health Services
Bureau of Indian Affairs
Tribal health programs
Urban Indian health programs
County and state agencies
Reasons for lack of partnership
Stigma Limited access No critical mass Time Cost Competing priorities Disparate agenda History of unsuccessful collaboration
SOLUTIONS
Identify Best Practices
Best Practice
Clinical/servicesResearch
TraditionalHealing
MainstreamPractice
World Conference on Science
Recommended that scientific and indigenous knowledge be integrated in interdisciplinary projects dealing
with culture, environment and chronic illness.
- 1999
Partnered Collaboration
Research-Education-Treatment
Grassroots Groups
Community-BasedOrganizations
What makes a partnership work?
Trust – do away with stereotypes Real participation at all levels Build in incentives for all stakeholders Education and training of all
stakeholders Dissemination of knowledge Enhanced communication Social to scientific interaction
Circle of Care
Best Practices
Child & Adolescent Programs
Prevention Programs
Primary Care
EmergencyRooms
TraditionalHealers
A&D Programs
Colleges & Universities
Boarding Schools
Resources
National Clearinghouse of Alcohol and Drug Information (NCADI) http://www.health.org
National Institute of Alcohol Abuse and Alcoholism (NIAAA) http://www.niaaa.nih.gov
National Institute of Drug Abuse (NIDA) http://www.nida.nih.gov
National Institute of Mental Health (NIMH) http://www.nimh.nih.gov
Treatment Improvement Protocol (TIP) Series (800) 729-6686
Monitoring the Future Study http://www.monitoringthefuture.org
For more information, contact: Elizabeth Hawkins, PhD, MPH
One Sky National Resource Center 503-494-3703
Visit us online at www.oneskycenter.org