The American IndianAlaska Native National Resource Center for Substance Abuse and Mental Health Serv

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The American Indian/Alaska Native National
Resource Center for Substance Abuse and Mental
Health Services
Best Practices in Native Communities
Strengthening Our System of Care The Forum San
Diego. California June 27, 2005
Dale Walker, MD Patricia Silk Walker, PhD
Douglas Bigelow, PhD Laura Loudon, MS Toma
Timothy Michelle Singer
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• For information, contact us at
• 503-494-3703
• E-mail
• Dale Walker, MD
• onesky_at_ohsu.edu
• Or visit our website
• www.oneskycenter.org

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Best Practices Overview
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Disconnect Between Drug/Alcohol/ Mental Health

• Professionals are undertrained in at least one of
  the domains
• Patients are underdiagnosed
• Patients are undertreated
• None integrates well with medical and social
  service

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Difficulties of Program Integration

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

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Best Practices Historical Evolution

• Agencies IOM, I.H.S., NIAAA, NIDA, NIMH, SAMHSA,
  NIAAA, VAMC
• Businesses Managed care, economics
• Quality care, effectiveness care

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Spectrum of Intervention Responses
Thresholds for Action
No Problems
Mild Problems
Severe Problems
Moderate Problems
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Alcohol/Drug Treatment Core Components and
Comprehensive Services
Medical
Mental Health
Financial
Vocational
Housing Transportation
Educational
Child Care
Legal
Family
AIDS / HIV Risks
Etheridge, Hubbard, Anderson, Craddock, Flynn,
1997 (PAB)
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How Are Evidence-Based Practices Documented?

• Gold Standard
• Multiple randomized clinical trials
• Silver Standard
• Consensus reviews of available science
• Bronze Standard
• Expert opinion based on clinical observation
• (Drake, et al. 2001. Implementing evidence based
  practices in routine mental health service
  settings. Psychiatric Services, 52, 179 182)

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Three Types of Treatment Have Demonstrated
Similar Success Rates
Treatments
Success Rates
At 1 Year

• Cognitive behavior therapy
• Learning skills to cope with situations that
  precipitate drinking
• 12-step programs
• Alcoholism is a disease
• AA involvement
• Motivational-enhancement therapy
• Motivational interviewing outlined in guidebooks

• Abstinent 85 of days (vs. 2030 of days at
  start of study)

At 3 Years

• 2/3 still abstinent

Source Saitz R. Unhealthy Alcohol Use. NEJM.
2005352596-607
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A Selected Sample of Manuals

• Time Out! For Me - Workshop for Women
• Time Out! For Men
• Cognitive Behavior Therapy for Adolescents
• Multidimensional Family Therapy
• Enhancing Motivation for Change
• Mapping New Roads to Recovery

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Nine Steps to Help Prevent Long-Term Disability
from Unhealthy Alcohol/Drug Use

• 1. Gather information
• 2. Express concern
• 3. Provide feedback
• 4. Express empathy
• 5. Offer help

• 6. Know local referral options
• 7. Reinforce self worth
• 8. Assist with a plan
• 9. Follow up

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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

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Agencies Involved in B.H. Delivery

• 1. Indian Health Service (IHS)
• A. Mental Health
• B. Primary Health
• C. Alcoholism / Substance Abuse
• 2. Bureau of Indian Affairs (BIA)
• A. Education
• B. Vocational
• C. Social Services
• D. Police
• 3. Tribal Health
• 4. Urban Indian Health
• State and Local Agencies
• Federal Agencies SAMHSA, VAMC

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American Indians and Alaska Natives

• Have same health disorders as general population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated

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Behavioral Health Issues

• Addiction
• Crow Nation
• Suicide
• Standing Rock
• Red Lake
• Domestic Violence
• Co morbidity
• Across Regions

Chart indicates deaths per 1000 people. Blue
AI, Burgundy U.S. Average
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Different goals
Resource silos
One size fits all
Activity-driven
How is it working?
(Carl Bell, 7/03)
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Best Practice
Culturally specific
Outcome driven
Integrating resources
We need Collaboration, Integration, and Synergy
Community Mobilization
(Carl Bell, 7/03)
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Indigenous Knowledge
Definitions

• Is local knowledge unique to a given culture or
  society it has its own theory, philosophy,
  scientific and logical validity, which is used as
  a basis for decision-making for all of lifes
  needs.

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Traditional Medicine
Definitions

• The sum total of health knowledge, skills and
  practices based upon theories, beliefs and
  experiences indigenous to different culturesused
  in the maintenance of health.
• WHO 2002

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Evidence-based Practices
Definitions

• Interventions that show consistent scientific
  evidence of improving a persons outcome of
  treatment and/or prevention in controlled
  settings.
• SAMHSA 2003

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Best Practices
Definitions

• Examples and cases that illustrate the use of
  community knowledge and science in developing
  cost effective and sustainable survival
  strategies to overcome a chronic illness.
• WHO 2002

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World Conference on Science
A partnership begins!

• Recommended that scientific and indigenous
  knowledge be integrated in interdisciplinary
  projects dealing with culture, environment and
  chronic illness.
• 1999

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ID Best Practice
Best Practice
Clinical/Services Research
Mainstream Practice
Traditional Healing
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Circle of Care
Traditional Healers
Child Adolescent Programs
Primary Care
Best Practices
AD Programs
Boarding Schools
Colleges Universities
Prevention Programs
Emergency Rooms
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Community MobilizationPartnered Collaboration

Community-Based Organizations
Grassroots Groups
Treatment-Education-Research
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