<DOC>
[109 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:27643.wais]
S. Hrg. 109-558
INDIAN YOUTH SUICIDE
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
ON
OVERSIGHT HEARING ON THE TRAGEDY OF INDIAN YOUTH SUICIDE
__________
MAY 17, 2006
WASHINGTON, DC
U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2006
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COMMITTEE ON INDIAN AFFAIRS
JOHN McCAIN, Arizona, Chairman
BYRON L. DORGAN, North Dakota, Vice Chairman
PETE V. DOMENICI, New Mexico DANIEL K. INOUYE, Hawaii
CRAIG THOMAS, Wyoming KENT CONRAD, North Dakota
GORDON SMITH, Oregon DANIEL K. AKAKA, Hawaii
LISA MURKOWSKI, Alaska TIM JOHNSON, South Dakota
MICHAEL D. CRAPO, Idaho MARIA CANTWELL, Washington
RICHARD BURR, North Carolina
TOM COBURN, M.D., Oklahoma
Jeanne Bumpus, Majority Staff Director
Sara G. Garland, Minority Staff Director
(ii)
C O N T E N T S
----------
Page
Statements:
Ashley, Norine, director, Apache Behavorial Health Services,
White Mountain Apache Tribe................................ 17
Curie, Charles G., administrator, Substance Abuse and Mental
Health Services Administration............................. 8
Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice
chairman, Committee on Indian Affairs...................... 1
Eagleman, Chet, acting chief, Division of Human Services..... 4
Gidner, Jerry, deputy director for tribal services,
Department of the Interior................................. 4
Grim, Charles W., director, IHS, Department of Health and
Humane Services............................................ 6
Hubbard, Frederick L., associate director, Community
Relations, White Mountain Tribe............................ 17
Kauffman, Jo Ann, project director, Native Aspirations
Project.................................................... 22
Martin, William E., chairman, Alaska State Suicide Prevention
Council, first vice president, Central Council of the
Tlingit and Haida Tribes of Alaska......................... 19
Maybee, Peter, assistant to the deputy bureau director, Law
Enforcement Services....................................... 4
Murkowski, Hon. Lisa, U.S. Senato from Alaska................ 2
Perez, Jon, director, IHS, Division of Behavorial Health..... 6
Skenandore, Kevin, acting director, Office of Indian
Education Programs......................................... 4
Vigil, Donna, director, Division of Health Programs, White
Mountain Apache tribe...................................... 17
Walker, R. Dale, director, One Sky Center, Oregon Health and
Sciences University........................................ 20
Appendix
Prepared statements:
American Academy of Child and Adolescent Psychiatry and the
American Psychiatric Association........................... 30
American Academy of Pediatrics............................... 37
Bullard, Loretta, president, Kawerak Inc., Nome, AK.......... 40
Curie, Charles G............................................. 40
Gidner, Jerry................................................ 42
Grim, Charles W.............................................. 45
Kauffman, Jo Ann............................................. 55
Martin, William E. (with attachment)......................... 65
McCain, Hon. John, U.S. Senator from Arizona chairman,
Committee on Indian Affairs................................ 29
Vigil, Donna................................................. 164
Walker, R. Dale.............................................. 166
Additional material submitted for the record:
Archambault, Donna, Home School Coordinator, McLaughlin, SD
(letter)................................................... 173
Schmeichel, Patricia, McLaughlin, SD (letter)................ 175
INDIAN YOUTH SUICIDE
----------
WEDNESDAY, MAY 17, 2006
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The committee met, pursuant to notice, at 9:30 a.m. in room
485 Senate Russell Building, Hon. John McCain (chairman of the
committee) presiding.
Present: Senators McCain, Dorgan, and Murkowski.
STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH
DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
Senator Dorgan. Senator McCain is delayed this morning and
has asked that I convene the hearing. He will be here, however,
shortly.
I want to say good morning to everyone and thank all of you
for being here. This is the cOMMITTEE ON Indian Affairs third
hearing on the tragedy of Indian youth suicide. It is a
sensitive subject, one that some perhaps would prefer we not
even discuss, but one I think that we simply cannot ignore.
Today, the committee will hear testimony about what kind of
suicide prevention programs are currently available in Indian
country; what programs exist that may not yet be available to
certain areas in our country; whether there are recommendations
to apply and tailor additional programs or resources to address
the problem of Indian youth suicide on reservations and Alaska
Native village communities.
I want to acknowledge the presence of the Indian Health
Service. Dr. Grim is with us and Mr. Perez, and that of the
Substance Abuse and Mental Health Services Administrator, Mr.
Curie, is with us today. You and your staff have been very
helpful to this committee as we have reflected on a good many
recommendations on these issues.
Others of our witnesses have also provided valuable
experience and insight. This is the third hearing that we will
have held on this subject. Last week, during what was called
Health Week in the United States Senate, the full Senate
approved legislation that I had authored with my colleagues,
Senator McCain, Senator Murkowski, and others, dealing with
telemental health, one avenue to try to deal with this issue of
teen suicide on Indian reservations.
I am very pleased that the Senate has moved that
legislation. I thank Senator McCain, Senator Murkowski, and
others of my colleagues for working with me to put a piece of
legislation together. It was very helpful.
The legislation I think is a positive step, but there is so
much more yet to be done, and that is the purpose of holding
this hearing.
We have a number of witnesses today. The first panel is a
panel that is composed of Jerry Gidner, the deputy director for
tribal services at the Bureau of Indian Affairs, U.S.
Department of the Interior. Mr. Gidner is accompanied by Chet
Eagleman, acting chief, Division of Human Services; Kevin
Skenandore, acting director, Office of Indian Education
Programs; and Peter Maybee, aAssistant to the deputy bureau
director, of the Law Enforcement Services.
We have Dr. Charles Grim, the director of the Indian Health
Service, Department of HHS, accompanied by Jon Perez, the
director of Indian Health Services Division of Behavior Health;
and Charles Curie, administrator of substance abuse, Mental
Health Services Administration.
So we want to thank everyone who has changed their schedule
to be with us this morning. Mr. Curie, I understand that you
were scheduled to be elsewhere, but have changed your schedule
to be with us. Thank you very much.
Why don't we begin? I would like to call on Senator
Murkowski if she has opening comments, and then we will begin
to hear from the first panel.
STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman.
I appreciate your attention, as well as that of Chairman
McCain, to this very important issue. As you have pointed out,
it is an issue that we don't like to talk about. It is
sensitive. It is personal, but it is very, very real.
I am pleased to welcome to the committee this morning First
Vice President, Bill Martin. Bill is Tlingit and Haida. He is
with us today. He is a tribal leader and the chair of Alaska's
Suicide Prevention Council. He has a big job in that role and
we certainly appreciate all the work that he does.
In August 2003, the Centers for Disease Control reported
that the Alaska region of the Indian Health Service had a
higher rate of suicide among Native youth under age 19 for the
period of 1989 to 1998, so a 10-year period, higher than any
other IHS region in the country. Ours was 23.8 per 100,000
population. You can compare that to the next highest, the
Aberdeen region in the plains, they were second at 19.1 per
100,000.
These are statistics that are terrible. These are
statistics that should concern us all. Death by suicide in
Alaska rose 4 percent in 2005 over the previous year. We know.
We don't need to continue to listen to the stories about how
they affect the communities, the families, but it is important
to hear those stories and understand the devastation that the
suicide is causing in too many of our Native villages in our
communities on our reservations.
Mr. Chairman, I want to commend you for your efforts and
all that you have done to bring attention to this issue. The
passage of the Indian Youth Telemental Health bill now pending
in the House of Representatives, I think that is something that
we all want to continue to encourage to make positive steps in
the direction that that legislation leads us.
We have some issues in Alaska that present great
challenges, our distance, our geography, but we share many
characteristics with Indian country in the lower 48. We are
isolated in terms of our road infrastructure. In many cases,
our telecommunications infrastructure needs improvement. We
have serious needs for medical professionals in the areas,
particularly in the behavioral health area. It is tough to get
professionals to move out there to provide the services that we
so desperately need.
We recognize that for the rural telemedicine project, we
can help bridge this gap that is so necessary. The Native
health system in the State I think has proven to be a pretty
innovative. This has been helpful to us, training the community
members as behavioral health aids providing this bridge between
the Native people needing the services and the professionals in
the cities.
So we are making serious headway there, but we recognize
that we have so very hard to go. So I appreciate the good works
of most of you at the table, those of you in the room, that are
focusing on this, and the focus that this committee has placed
on this issue that is such a concern.
With that, Mr. Chairman, I just want to welcome everyone
and look forward to their testimony.
Senator Dorgan. Senator Murkowski, thank you very much.
At a recent hearing dealing with methamphetamine addiction,
we had a tribal chair come to this committee and describe the
devastation of addiction to methamphetamine, but also the
number of attempted suicides on her reservation. As a tribal
chair, she described it in some detail, and it was startling,
absolutely startling. What got me interested in this issue was
a rash of suicide or a cluster of teen suicides on the Standing
Rock Sioux Reservation in North Dakota. Even prior to that, I
have used on the floor of the Senate, with the consent of
relatives, the name of a young woman. I understand it is
sensitive, and that is why I asked the relatives if I could do
it, but a young woman, 14 years old, named Avis Little Wind.
Avis Little Wind killed herself. She was 14. Her sister had
killed herself, taken her own life 2 years before.
At age 14, she had missed 90 days of school, lay in her bed
in a fetal position, with obviously serious emotional issues,
and somehow no one caught it. This young girl lay in her bed
for 3 months, not going to school, at age 14, and it didn't
raise any red flags anywhere, apparently.
And so I went to meet with the school administrators, with
the tribal council. I met with the classmates of this young
women. And then just recently I went to the Standing Rock
Reservation and had a meeting with Indian kids, high school
kids, just us, nobody else was around, just myself and about 1
dozen or 1\1/2\ dozen Indian kids, just talking for about 1
hour about their lives, about what they see in their school,
about the issue of teen suicide, teen pregnancy,
methamphetamine.
What is happening is pretty unbelievable in many areas.
This issue of suicide is so tragic, particularly with respect
to youth. It is young people I think feeling that their life is
hopeless; that they are helpless. They decide that the only way
out is to take their own life. Some young kids have told me
that some of their acquaintances who took their lives really
didn't want to die, they just wanted attention, and they were
trying to get attention, to scream out and beg for attention.
I think as a result of all of this, in our region Indian
teens are 10 times more likely to take their lives than in the
population as a whole. I think my colleague just described the
circumstance in Alaska.
So the purpose of this is not to exploit or to be
sensational. The purpose of this is to see if we can find some
way that is going to save some lives; that is going to say to
these kids that things are not hopeless and there are people
that want to help. That is the purpose of having these
discussions and trying to think through what are the policy
choices for us to address what is a very serious issue.
Let me begin the first panel. Jerry Gidner is the deputy
director for tribal services at the BIA. Mr. Gidner, your
entire statement will be part of the record. You may proceed
with your testimony.
STATEMENT OF JERRY GIDNER, DEPUTY DIRECTOR FOR TRIBAL SERVICES,
DEPARTMENT OF THE INTERIOR, ACCOMPANIED BY CHET EAGLEMAN,
ACTING CHIEF, DIVISION OF HUMAN SERVICES; KEVIN SKENANDORE,
ACTING DIRECTOR, OFFICE OF INDIAN EDUCATION PROGRAMS; AND PETER
MAYBEE, ASSISTANT TO THE DEPUTY BUREAU DIRECTOR, LAW
ENFORCEMENT SERVICES
Mr. Gidner. Thank you, Mr. Chairman, Mr. Vice Chairman,
members of the committee. With your permission, I will put the
testimony in the record and just give a brief statement.
My name is Jerry Gidner. I am the deputy bureau director
for tribal services at the BIA. You mentioned my colleagues who
are here today with me. I did want to mention that Bureau
Director, Pat Ragsdale, is here today in the audience because
of his interest in the topic.
As the committee knows, Mr. Chairman, teen suicide is a
serious problem in Indian country. The suicide rate is 2.5
times greater than the nationwide rate. IHS statistics show
that it is the third leading cause of death in Indian children
5 to 14 years old and the second leading cause of death among
teens and young adults 15 to 24 years old.
Every 2 years, our Office of Indian Education Programs does
a youth risk behavior survey, and that survey shows some fairly
startling results. The last survey results that are available
are those from 2003. Those results show that one-third of
Indian children and teens feel sad or hopeless at some point in
a given year, and that of course is a beginning stage in those
children who might commit suicide.
In high school, the surveys show that 21 percent seriously
considered suicide in the last year and 18 percent actually
attempted, made some attempt in the past year. I invite you to
think about that for just 1 minute. That is a very stunning
statistic. It means that nearly one-fifth of students in BIA
schools or BIA-funded schools made some attempt at suicide.
Senator Dorgan. Mr. Gidner, tell us again where that data
comes from?
Mr. Gidner. That comes from a survey conducted by our BIA's
Office of Indian Education Programs, which is conducted every 2
years in high schools and middle schools. As I said, that data
is from 2003 and I understand the survey was conducted again in
2005. That data is not yet available. In middle school, the
younger children, 26 percent seriously considered suicide and
15 percent actually attempted it. Mr. Chairman, as you pointed
out, the youth of Indian country are crying out for help.
Research shows that many social factors such as poverty,
alcohol, and substance abuse can lead to suicidal behavior and
these social factors as we all know are present in Indian
country. So the question you are rightfully asking is what can
be done about this. Our colleagues here at the table from HHS
provide most of the suicide prevention and treatment behaviors.
The role of the BIA is somewhat less than that. We do work
on some of those societal factors. We help tribes develop the
infrastructure of government, the infrastructure of schools and
law enforcement, where that does not otherwise exist. We
participate in several multiagency efforts. For example, in the
Rocky Mountain region, there is a Native American youth suicide
prevention initiative where we partner with IHS and others in
that effort.
Our law enforcement office, where they have jurisdiction,
are very often the first responders to suicides and investigate
the suicide. We also train our detention center staff,
particularly for the youth detention facilities, in suicide
prevention efforts.
Our Office of Indian Education programs again receives
funding. All bureau-funded schools receive funding through the
Department of Education to operate safe and drug free school
programs, and those are used to prevent violence and substance
and alcohol abuse, which of course can be precursors to suicide
attempts.
In 2004, our education program launched a suicide
prevention initiative using the question, persuade and respond
model, where people are trained to question students that may
be harboring ideas about suicide, persuade them to get help,
and refer them to the appropriate help if they will go. All 184
BIA-funded schools and dormitories received this training, and
the administrators were instructed to ensure that all of their
staff had that training as well.
With that, I will conclude my statement. I will be happy to
take your questions.
[Prepared statement of Mr. Gidner appears in appendix.]
Senator Dorgan. Mr. Gidner, thank you very much for your
testimony.
Next, we will hear from Dr. Charles Grim, the director of
the Indian Health Service at the Department of Health and Human
Services. Dr. Grim, thank you for joining us again.
STATEMENT OF CHARLES W. GRIM, DIRECTOR, INDIAN HEALTH SERVICES,
DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY JON
PEREZ, DIRECTOR, INDIAN HEALTH SERVICE DIVISION OF BEHAVIOR
HEALTH
Mr. Grim. Thank you, Mr. Vice Chairman, and Senator
Murkowski. I continue to appreciate working with this committee
and your willingness to raise issues like this that we in
Indian Health deal with on a daily basis. This is a very
important issue, and we are very appreciative that you have
chosen to hold another hearing about it. I applaud you for
getting the bill that you all introduced passed. I think
telehealth is one of the ways that we are going to be able to
get into some of the most rural parts of the country the kind
of care that you receive in urban areas.
Today, I am accompanied by Dr. Jon Perez, our national
behavioral health consultant, who has been before you as well
today. I am honored to be able to testify on behalf of
Secretary Leavitt on suicide prevention programs in Indian
country.
I am also honored to testify alongside Charlie Curie, a
strong supporter of addressing substance abuse and mental
health issues in Indian country, something that I personally
witnessed and watched him do during his tenure at SAMHSA. It is
also always a privilege for me to testify alongside my
colleagues at the BIA, today Jerry Gidner, because our two
agencies play such a large role in Indian country.
I would ask that my written testimony be made a part of the
record. In it, you will find a much more detailed analysis of
the statistics and some of the partnerships and things going on
in Indian country. Today, I am just going to summarize a few
things in my oral comments.
Suicide in Indian country, as I have said before, in
contrast to most of the rest of the United States, is
characterized by higher rates for younger people, and affecting
entire communities because suicide, much like an infectious
disease, often spreads rapidly among families and peer groups
in what you and others have called suicide clusters in Indian
country.
The latest information that we have, which has been cited
by yourself, Senator Murkowski and the BIA, I won't go through
all those statistics, but suffice it to say they are startling.
I am glad that we, that the Senate, that the tribal leadership
have brought this issue to the forefront and talked about it.
I am also appreciative that the Surgeon General was here at
the last hearing held here in Washington to raise the issue not
only in the Nation, but the high rates in Indian country.
The most important thing to remember is that suicide is not
a single problem. It is a single response to multiple problems.
Neither is it strictly a clinical or an individual problem, but
one that is affected by the entire community. I think the panel
that you have put here today is going to bring all those
perspectives into play.
Let me quote from the Institute of Medicine's landmark 2002
publication called ``Reducing Suicide.'' They stated that
suicide may have a basis in depression or substance abuse, but
it simultaneously may relate to social factors like community
breakdown, loss of key social relations, economic depressions,
or political violence, much of which we know occurs in many of
our Indian communities.
To address it appropriately, we have worked on both public
health and community interventions as much as we have the
direct clinical ones. As you know, much of the Indian Health
Service budget in alcohol and substance abuse and in mental
health goes directly to clinical care.
In late September 2003, I announced the Indian Health
Service National Suicide Prevention Initiative. It was designed
directly to support our Indian Health Service tribal and urban
programs in three major areas associated with suicide in our
communities: First, to mobilize tribes and tribal programs to
address suicide in a systematic evidence-based manner; second,
to expand and enrich research and program bases around suicide
in Indian country, something that is lacking; and third, to
support and promote programmatic collaboration on suicide
prevention.
While we have made progress in developing plans and
delivering programs to Indian country, we all realize that this
is only the beginning of a long-term concerted and coordinated
effort among not only the Federal programs here at the table,
but tribal communities, states, and other local and county
community efforts around the country that we need to address
the crisis.
The initiative that we put together, along with tribal
leadership and tribal providers, addressed all 11 goals around
HHS's national strategy for suicide prevention. That work
represented the combined work of advocates, clinicians,
researchers and survivors of suicide and their families all
around the Nation. It lays out a framework of action to help
prevent suicide and also guide us in the development of an
array of services that we are developing.
In our headquarters office right now, we are currently
working with the areas, tribes and communities, as well as
States, to establish area-wide suicide surveillance and
prevention systems, in collaboration with the BIA and States to
collect information from law enforcement and medical examiner
databases. We are also establishing partnerships between IHS
and BIA to increase access to health and mental health care for
children attending BIA-funded schools, and strengthening
partnerships between State and Federal agencies in the area of
suicide prevention.
We have also been working closely over the last several
years in collaboration with SAMHSA and other HHS agencies and
nongovernmental organizations and States to address and reduce
suicide. We continue to train community members in the QPR
model that was mentioned by Mr. Gidner, to involve American
Indian and Alaska Native youth in suicide prevention efforts
primarily through school products and Boys and Girls Clubs. We
have been utilizing tribal colleges to provide suicide
prevention training and programs that are culturally
appropriate to our population.
For the first time, we have far more accurate data that is
being gathered and shared from our clinicians in our
communities, and those national policymakers and programs, all
of which are extremely important to discuss the prevalence and
the effects of suicide in Indian communities. No longer are we
extrapolating data or estimating data, because we have data now
that we feel is representative of Indian country and the
communities affected.
We are continuing to upgrade those systems. For the first
time, our electronic health record that we have had for many
years is going to be fully integrated with the behavioral
health documentation that many communities keep on suicide and
other behavioral health issues.
Mr. Chairman, I will conclude my statement now by noting
that, as I said earlier, my written statement goes into much
more detail about the efforts that we have done. I want to
thank you and this Committee again for continuing to raise this
issue. I will be happy to discuss any of these issues that we
have brought up today with you during the question and answer.
Thank you.
[Prepared statement of Dr. Grim appears in appendix.]
Senator Dorgan. Dr. Grim, thank you very much.
Finally, we will hear in this panel from Charles Curie. He
is the administrator of the Substance Abuse and Mental Health
Services Administration. Mr. Curie, thank you again for being
here.
STATEMENT OF CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION
Mr. Curie. Thank you, Mr. Chairman and Senator Murkowski.
Good morning. I am Charles Curie, the administrator of SAMHSA,
the Substance Abuse and Mental Health Services Administration
within the Department of Health and Human Services. I am
pleased to be here today to describe how SAMHSA is working to
address the issue of suicide among American Indians and Alaska
Natives.
Senator Dorgan, as you kindly mentioned earlier, I was
scheduled to speak at a suicide prevention conference actually
in Casper, WY today, but I am so personally concerned about
suicide rates, especially in Indian country, and the work that
we must continue to do there, that I wanted to provide this
testimony myself.
It is a privilege also to testify with my friend and
colleague, Dr. Charles Grim, director of the Indian Health
Service [IHS]. SAMHSA and IHS have developed a strong
partnership and a lot of collaborations that we are working on.
It is reflected in our current interagency agreement to work
efficiently and effectively together to help meet the public
health needs of American Indians and Alaska Natives.
It is also a privilege to be here with Jerry Gidner, deputy
bureau director for tribal services at the Bureau of Indian
Affairs [BIA].
Suicide is not only a serious public health challenge, but
it is a tragedy that is only now receiving the attention and
degree of national priority it deserves. As you indicated,
Senator, many people have difficulty discussing this issue and
many times it is easier to put it out of the realm of
consciousness. Many Americans are unaware of suicide's toll and
its global impact.
Suicide makes up 49.1 percent of all violent deaths
worldwide. It surpasses homicide as the leading cause of
violent deaths. In the United States, suicide claims
approximately 30,000 lives each year. When faced with the fact
that the annual number of suicides in our country now outnumber
homicides by 3 to 2, approximately 30,000 and 18,000
respectively, the relevance of our work becomes very clear.
When we know, based on SAMHSA's household survey for 2003, that
approximately 900,000 youth have made a plan to commit suicide
during their worst or most recent episode of major depression,
and an estimated 712,000 attempted suicide during such an
episode of depression, it is time to intensify activity to
prevent further suicides.
The household survey data, the countless personal stories
of loss and tragedy, are why we have made suicide prevention a
priority at SAMHSA.
Last year, as you mentioned, a suicide cluster occurred on
the Standing Rock Reservation in North Dakota; 10 young people
took their own lives, and dozens more attempted to do so. The
Red Lake Indian Tribe in Minnesota is experiencing high suicide
rates following the deaths of 9 individuals at the hand of a
16-year old high school junior. Tragically, many other
reservations have similar stories to tell. Suicide is the
second leading cause of death for American Indian and Alaska
Native youth ages 15-24. In 2003, the suicide rate for this
population was between 2 and 2\1/2\ times the national average,
and the highest among all ethnic groups in the United States,
with a rate of 18 suicides per 100,000 individuals.
SAMHSA's policy is to level the playing field and to ensure
that tribal entities are eligible for all competitive grants
for which States are eligible, unless there is a compelling
reason to the contrary. Currently, SAMHSA consistently is
funding around $34 million of grants to award tribal behavioral
health issues.
In 2005, we made the first cohort of awards, 14 in all,
including a grant to Arizona under the Garrett Lee Smith
Memorial Act. These funds are available to help States and
tribes implement effective suicide prevention networks. One of
those first grants went to the Native American Rehabilitation
Association in Oregon. Today, I am announcing almost $9.6
million in funding for eight new grants, each for approximately
$400,000 per year for 3 years under this program to support
national suicide prevention efforts.
Grants have been awarded to programs in Oregon,
Connecticut, Utah, Wisconsin, and Idaho. In addition, grants
specifically geared to American Indians and Alaska Natives have
been awarded to the Manniilaq Association of Alaska, the United
Indian Involvement, Inc., and the Montana-Wyoming Tribal
Leaders Council. An announcement for a third cohort of grants
under this program closed yesterday. SAMHSA again invited all
tribes to apply and provided technical assistance to tribal
organizations to encourage more applicants.
The Garrett Lee Smith Memorial Act also authorized a
National Suicide Prevention Resource Center. We are requiring
the center to address how they would expand the current youth
suicide prevention technical assistance to go toward tribes and
tribal organizations.
SAMHSA has long supported a national suicide hotline, 1-
800-273-TALK. Funding for the current hotline grantee was
increased by $369,000 in fiscal year 2006, and the grantee has
been asked to submit an application that indicates how they
will expand their access to tribes.
In the Administration's request for the fiscal year 2007
budget, the one currently in front of Congress, SAMHSA is
asking for nearly $3 million for a new American Indian-Alaska
Native Initiative to provide evidence-based programming to
prevent suicide and reduce the risk factors that contribute to
youth suicide and violence.
SAMHSA has also transferred $200,000 to IHS to support
programming and service contracts, technical assistance, and
related services for suicide cluster response and suicide
prevention. One example is the development of a community
suicide prevention tool kit. This tool kit includes information
on suicide prevention, which can be made readily available via
the web.
SAMHSA also has issued emergency response grants in the
aftermath of suicides, both on the Standing Rock Reservation as
well as at Red Lake. Those dollars are still available to those
two entities and we are still working in close collaboration to
ensure those dollars are used in the best way possible.
SAMHSA is proud of what we have done, while knowing that
this is not nearly enough. There is much more to do. The
problems confronting American Indian and Alaska Native youth
are taking their toll on the future of tribal communities.
I ask also that my written testimony be made part of the
record, which does go into much more detail. I want to thank
you again for the opportunity to appear today and I would be
pleased to answer any questions you may have.
[Prepared statement of Mr. Curie appears in appendix.]
Senator Dorgan. Mr. Curie, thank you very much.
The Senate now has a vote in progress. I understand there
are about 6 minutes remaining, so I think we will have no
choice but to have a brief recess. We do want to ask some
questions, and I believe Senator McCain will be joining us as
well. But I think in the interest of time here, we will take
about a 10-minute recess, and we will reconvene, we expect, at
10:15.
[Recess.]
Senator Dorgan. The hearing will come to order again.
Let me thank the panel for their testimony, and let me ask
a few questions, if I might.
The hearings that I have held and the discussions that I
have had paint a pretty dismal picture in most areas and with
most reservations. The resources available, for example, when I
went to the Spirit Lake Nation Tribe and talked to the school
administrators, the tribal council, parents, students, and
others, what I discovered with respect to the death of Avis
Little Wind and others who had committed suicide is that they
had very few resources. Mental health resources were virtually
nonexistent. To the extent that they were accessible, they were
accessible only with great difficulty, only then if you were
able to borrow a vehicle from someone, if someone would loan
you a vehicle that you could use, then the transport. It was
unbelievable to me to see how few resources area available.
Now, Mr. Curie, today you have described grants and I
appreciate your announcement today of those grants. I think it
is going to be helpful. But I would like all three of you to
tell me, you know, you have told us what is happening; tell us
what isn't happening that has to happen in order for us to
fully address this.
Let me describe why I say that. Dr. Grim, you talked about
the resources that are important in rural areas to address
this. But you know, the President's budget recommends zeroing
out the Indian Urban Health Centers in urban areas, zero them
out. So even in urban areas, we have problems with the
resources.
So I appreciate all that you say that you are doing. Tell
me, as professionals, and as people who visit reservations and
understand these issues, what is not being done that has to be
done in order to really address this issue? Mr. Curie, would
you go first?
Mr. Curie. Yes; I will. Senator, I couldn't agree with you
more that the issue around resources and accessibility to care
is really part of the fundamental problem that we are seeing
here. In fact, when we take a look at suicide rates, whether it
is in Indian country or in general, untreated depression, lack
of intervention many times is the root cause.
I think when we look at Indian country, we look at the
remoteness of many of the reservations we see especially in
Alaska with the Alaska Native villages, and this is an ongoing
problem. We need to be thinking in terms of how to have the
resources available to people where they live. There are models
that are now being developed.
One, I would point out, is at the University of Alaska in
which individuals who are from the tribe, young people in
particular who are looking for a potential career, are trained
as behavioral health, mental health, substance abuse aides and
have the supervision, then, of a graduate degree professional
that they would be connected with. We think this offers a
pathway that we need to examine and see how we can expand and
bring that to some sort of systemic level. Because again, when
you have virtually hundreds of miles to go before you find a
professional, it is unlikely that the interventions are going
to be timely and appropriate.
This is tied, I think, to the greater workforce development
issue that is facing the field as a whole, both in mental
health and substance abuse, attracting people, keeping people
in the field. Then again it is compounded even further when you
are talking about rural frontier remote areas, and we are
talking about Indian country.
So we need to be thinking in terms of how individuals
themselves can be engaged and get the training and support they
need.
I think it is also very critical for us to do what we can
in collaboration with agencies that work not only on the
treatment end of things, but in helping the young people in
those villages find both an anchor, and I was discussing this
with Senator Murkowski earlier, and a line of sight of where
they are going to end up being someday.
I think those villages where we have seen a real focus on
getting a sense of their cultural heritage, having strong youth
initiatives to give them a sense of family, heritage,
tradition, and helping them see what their future can hold, are
establishing clear protective factors that can help address
these risk factors. So we believe a public health model in
identifying risk factors and increasing protective factors also
will be critical in this process.
Senator Dorgan. Thank you.
Dr. Grim.
Mr. Grim. I would agree with everything Charlie said. Let
me just start out by saying that. Second, since we focus on
direct clinical and preventive, as well as public health care
in our settings, we need to continue to do that. We need to
have those sorts of services available. I think the expansion
of, and we are doing this in telehealth, the expansion of tele-
mental health capabilities. We don't have that across all of
our areas yet. I think that will also lead to some increase in
services.
We face the same thing that Charlie said at a national
level, you know, the recruitment and retention of the right
types of health care professionals. But also I think I want to
play up the partnership issue a lot. I don't think any one
agency right now has the full answer to this, nor has all the
money that they need to address it. But I think we are seeing a
lot of partnerships emerge around this issue.
A lot of it is coming from the Administration, asking the
Indian Health Service and SAMHSA and BIA to work together. A
lot of it is coming from the Congress in stimulating activity
through funding or through bills like you all just passed. I
think the partnerships that we have with SAMHSA, with BIA right
now, are critically important partnerships.
We have also worked with Canada. My counterpart from
Canada, the Director for First Nations and Inuit Health Branch,
they have a very similar problem up there. We had a recent
meeting in Albuquerque, New Mexico where their National
Institute of Health Research, our National Institute of Mental
Health, people from Indian Health Service, and First Nations
and Inuit Health Branch, the Wisdom Keepers and traditional
healers from communities, all got together.
We partnered to come up with a research agenda in Indian
country over the next 5 or so years. We know there is a lack of
information about, as Charlie said, some of the risk factors,
as well as the protective factors. Ever since Charlie and I
have been in our positions, we have held a joint meeting
between the State block grant coordinators, the Indian
programs, and the Indian Health Service and SAMHSA staff. That
meeting has continued to grow in both importance, as well as in
attendance. We are even having people from other countries come
now. There is a part that spins off on that about suicide to a
work group.
So I think partnerships with others beyond just the ones I
mentioned, because the socially complex factors of housing,
education, safety in the communities, all those are part of it.
It is just such a complex issue that we have to have more
partnerships, I believe.
Senator Dorgan. Mr. Gidner.
Mr. Gidner. Thank you. I would agree with Dr. Grim and Mr.
Curie as well. From the BIA perspective, on the micro level, I
would say there are not enough trained people on the ground to
observe and work with the youth, to identify those who may be
thinking about suicide, and to get them into the appropriate
health model to prevent that. BIA does have a cadre of social
workers throughout the country. They are spread very thin and
spend most of their time working with child abuse and
adoptions, foster care, things of that nature.
On the macro level, though, I would suggest that what needs
to happen is there has to be a way to give these children hope
that there is some better future for them. That would involve
more job creation, better law enforcement, other things that
are going to improve the health of their community so that they
know there is something waiting for them, and that they have a
reason to live.
Senator Dorgan. Mr. Chairman, welcome. We are just
finishing up the first panel. Senator Murkowski has not yet
asked questions.
I have to be down at an Appropriations hearing in a few
minutes with the Defense Secretary to question him. I just
wanted to make a point at the end of this panel. I think these
partnerships are important. I especially appreciate the fact
that you are all providing focus to this. I also think that we
have to provide funding as well.
For example, we have an Indians in Psychology Program
trying to encourage Indians into psychology in colleges. That
gets zeroed out every year by the Administration and they are
zeroing out the Urban Indian Health Centers. So we do have to
provide funding. We need youth centers. We need trained mental
health professionals and so on.
I have been sensitive to this issue of suicide for a long,
long time. I walked in one morning and found a very close
friend of mine had taken his life, a co-worker. I found him at
his desk at 8 o'clock in the morning. With him, as it is, you
say, with Indian youth, it is the single act in response to
multiple causes, almost always the case regardless of age.
But especially with respect to Indian youth, there is a
very serious problem, and I appreciate the partnerships. We
need the funding. We need strategies. I appreciate Chairman
McCain also providing focus to this issue with this committee,
and Senator Murkowski's attention and interest in it as well. I
look forward to continuing to work with you and exchanging
views with you and developing strategies with you to address
it.
Mr. Chairman, thank you very much.
The Chairman. Thank you very much, Senator Dorgan. Thank
you for your leadership. Thank you for your attention and your
continued commitment to this issue.
I know that a lot has been covered. I just wanted to ask,
Mr. Curie, I keep hearing from Indian country that
methamphetamine is having a significant effect on this issue,
not just suicide, but on a whole lot of other aspects of Indian
country. Can you comment specifically on the epidemic of
methamphetamine and how it has affected this specific issue?
Mr. Curie. Yes, Mr. Chairman; Methamphetamine is
undoubtedly from what we have seen the most dangerous drug that
has been on the street and available. In terms of its addictive
quality, one use and addiction can occur. In terms of the
devastating impact it has on the individual, in terms of their
brain. Their whole life begins to get focused on one thing, and
that is the desire to have more methamphetamine.
The challenge and why it is in many parts of the country,
while national prevalence data shows that actually opiates and
painkillers are growing at a faster rate overall nationally,
there are places in the country, in Indian country and rural
and frontier areas in Western and Midwestern States where
methamphetamine is the number one problem. That is because of
the accessibility of the ingredients to make meth. It is
available, of course, readily available in hardware stores, in
various retail outlets, and there are recipes, of course,
available through the Internet today.
The Chairman. And some of it is coming across our Indian
reservations from Mexico?
Mr. Curie. Yes; and that is also another factor.
Absolutely. So there is accessibility to it. And there is an
undeniable link between substance abuse, especially when we
talk about how dangerous meth is, and suicide. A high
percentage of suicides are linked to drug and alcohol use.
So to approach this, we believe that it has to be a
multifaceted approach to the suicide problem, that we have to
consider our substance abuse treatment and prevention efforts
to be part of the suicide prevention efforts. We need to be
working specifically with tribes in the context of their
culture and the context of what their needs are to identify
those risk factors that continue to contribute to the substance
abuse problem, and to develop protective factors. We are
finding many of them are the same that relate directly to the
suicide problem and issue. So they do go hand in hand.
We are looking very closely now in California, where the
tribal organization, the California Rural Indian Health Board,
received one of our access to recovery grants in which vouchers
are being used and to expand their capacity for substance abuse
treatment. We are going to be looking very much at the link
there in terms of the impact that additional resource is having
in helping address this issue.
The Chairman. Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
Mr. Gidner, you mentioned in your testimony this high
school, middle school youth risk behavior survey, where you
have gotten some pretty compelling data about what our young
people are contemplating. What do you do with that data once
you receive it? I understand how these surveys work and the
confidentiality aspect of the survey, but if you have
statistics coming out of a middle school that show a
disproportionate number of our young people are contemplating
suicide, is there any opportunity through the BIA or for the
school itself to have some kind of an intervention with a group
of young people that are clearly at risk because they have
indicated to you, they are asking for help. What do you do with
the information?
Mr. Gidner. What we have done, Senator, is launch, I
believe I mentioned, the question-persuade-response model,
where all the bureau-funded schools are trained, the
administrators and staff, to intervene on behalf of individual
students when they observe problems and to try to talk to those
students and persuade them to get help and to refer them to the
appropriate place to get that help.
Senator Murkowski. But you are dealing with, again, you are
not able to pinpoint who your students are. You just have a
recognition that in this particular school we have an issue.
With these surveys, you have a lag time between the time the
students respond and the data is compiled and the results then
get back. Are these surveys helping us do something? Or are
they just an indicator of how bad the situation may be getting?
Mr. Gidner. I actually don't know the answer to that
question. I will have to make inquiries and find out exactly
what we do do with that information.
Senator Murkowski. I think when we ask our kids how they
are feeling and how they are thinking, we need to be in a
position to then respond and not respond eight or nine months
after the fact in some generic way. These surveys have value,
but we do want to know that we are able to get to the kids,
particularly when you have statistics coming back that say one-
fifth of our high schoolers have contemplated suicide at some
point in time.
Mr. Curie, you mentioned a grant to Manniilaq Association,
which we greatly appreciate. Can you tell me the terms of that
grant, what we are talking about, and exactly how you
anticipate that we will be able to utilize that to stem the
suicide rate?
Mr. Curie. Absolutely, Senator. It is a total of $1.2
million over a 3-year period, $400,000 per year. It is to be
utilized to begin to implement evidence-based suicide
prevention strategies that are community-wide types of
strategies. Again, more clearly identifying what risk factors
are contributing to the suicide issue, risk factors such as
students not having enough activity, young people and families
not being fully engaged. There are going to be a variety of
those types of risk factors.
And then developing strategies and begin to put into place
evidence-based programs that reflect the protective factors
that can begin to address those particular risk factors, and of
course a required evaluation of that over the 3-year period as
to how effective it is working.
Again, it is to put in a prevention framework and have it
be community-based engaging all elements of the community.
Senator Murkowski. Which is the appropriate response, the
appropriate way to proceed in my opinion. We had an opportunity
to speak a little bit during the break about, it is a societal
issue. It is an economic issue. There are so many things that
come into it.
When I have asked young Alaskans out in the villages, are
you happy, what would make your life better, it is some very
simple responses. They are bored; we are looking for something
to do; we have no community meeting place.
And yet when we try to address that by providing for a Boys
and Girls Club or some form of a community center, that doesn't
necessarily fit your model in terms of where grant funding
goes. We need it to be in some form of a service, and yet we
need the flexibility to work with the communities.
Manniilaq has, I was out there over the Easter break, and
they have an incredible program out in the remote area where
literally the whole family is taken out to be treated for
substance abuse and other issues. But the family as a whole is
addressed, not just the one individual that is suffering from
the addiction or the depression. I don't know if we are set up
to deal with a response in this broad a manner, but when we are
looking at statistics like we are seeing now, it seems to me we
have to do something different. The Manniilaq approach
hopefully will shed some light there.
Mr. Curie. I think that type of model has a lot of merit
and applicability. In fact, I think one of the challenges and
barriers that we have found in Alaska in particular is the fact
that when treatment is offered that someone is taken out of a
village, around 200, 300, or 400 miles to residential treatment
centers, spends a period of maybe a few months there even, but
goes right back. There has been very little intervention for
the family or the community. The results are not good.
Senator Murkowski. The results are predictable.
Mr. Curie. Exactly. So what we need to do is find resources
within the community and have the supports put in place so that
people have an anchor to rely on. They need, again, to be
community-based. It should be no surprise to us. We believe in
community-based care throughout this Nation in what we are
doing. We find that those give the best results. The same would
be true in Indian country.
Senator Murkowski. One question for you, Dr. Grim, and then
you can comment here. As far as Alaska's behavioral health aid
program, it is something that has been working in the State. Do
you see this perhaps as a model to be used in other areas of
Indian country? And if you would comment on what Mr. Curie and
I were talking about.
Mr. Grim. If you would permit me, Senator Murkowski, to
respond to his question first. I wanted to say that I think the
tack that SAMHSA is taking is a very appropriate on, too. One
of the things I talked about in our partnerships together that
we have with them. They are taking and asking communities to
use evidence-based sorts of practices and try to put them in
place in real life communities and see how they work.
One of the things the Indian Health Service is doing with
some of our resources is to go to the community level and ask
them what needs to be done. We have been targeting communities
that have some of the highest need. So we are doing basically
what you said. SAMHSA is attacking it from one direction. We
are using some of our resources to attack it from just the
direction you said. We go into an individual community and say,
okay, what is it you think you need; we have specialists that
help; that can help guide the process. Then we try to tailor it
for that community.
So I think, again in combination with multiple agencies
working together, we are trying to tackle it from different
perspectives.
To be more direct to your second question or your question
to me, I have watched in awe and respect as Alaska has
continued to push the frontier to try to deal with some of the
issues that they have to deal with in their communities. I
think the next step, the community behavioral health aid
therapist that they are looking at is going to be another model
program. As Charlie said, we are looking at shortages in many
of the professional areas.
He also noted, as I noted, that I think we have under-
diagnosed mental health issues, depression and others, in many
of our communities, not just Indian communities around the
country. Now that mental health care is becoming more
acceptable, people are willing to seek it out. We are starting
to see more chronic diseases that are being affected by some of
the underlying mental health conditions people have. I think we
are all becoming much more aware of it and the role that it is
playing in not just mental health issues and suicide, but in
chronic disease issues as well.
Senator Murkowski. I appreciate your support.
Thank you, Mr. Chairman.
The Chairman. Thank you very much.
I thank the witnesses. I appreciate your prioritizing this
very important issue. We look forward to working with you.
Thank you.
Our next panel is Donna Vigil, who is director of the
Division of Health Programs at the White Mountain Apache Tribe,
Whiteriver, AZ. She is accompanied by Dr. Norine Ashley, who is
the director of the Apache Behavioral Health Services. William
E. Martin is chairman of the Alaska State Suicide Prevention
Council and First Vice President of the Central Council of the
Tlingit and Haida Tribes of Alaska. Dr. Dale Walker is director
of One Sky Center, Oregon Health and Science University. Jo
Anne Kauffman is the project director of Native Aspirations
Project in Spokane, WA.
Welcome to our witnesses. Ms. Vigil, welcome. We are glad
to see you. Please proceed with your statement.
STATEMENT OF DONNA VIGIL, DIRECTOR, DIVISION OF HEALTH
PROGRAMS, WHITE MOUNTAIN APACHE TRIBE, ACCOMPANIED BY NORINE
ASHLEY, DIRECTOR, APACHE BEHAVIORAL HEALTH SERVICES; AND
FREDERICK L. HUBBARD, ASSOCIATE DIRECTOR, COMMUNITY RELATIONS
Ms. Vigil. Good morning, Mr. Chairman and members of the
committee. My name is Donna Vigil. I represent the White
Mountain Apache Tribe. I am the executive director of the
Division of Health Programs. I have with me here Dr. Norine
Ashley.
The Chairman. Welcome
Ms. Vigil. She is the director of the Apache Behavioral
Health Center.
The White Mountain Apache Tribe has 17,000 members with
15,000 members living on the reservation. Before I go any
further, I would like to say that Ronnie Lupe, chairman of the
White Mountain Apache Tribe, sends his highest regards to all
the members of the committee, especially to his friend,
Chairman McCain. He considers all the members of the committee
friends to the Apache people.
The Chairman. Thank you.
Ms. Vigil. Suicide is a great challenge to the White
Mountain Apache Tribe, particularly among children and young
adults. With very little outside funding, the White Mountain
Apache Tribe has come together to address this issue. We
started up in 2001 with a suicide task force established by the
tribal council. It is headed by a community member who is an
IHS employee and a member of the tribe. This committee, the
suicide task force, has worked with Johns Hopkins University.
It is working on research through the NARCH program, which
stands for Native American Research Center for Health.
Through that, the tribal council passed a resolution to
begin a registry of suicides, and through the suicide registry
our mental health center, Apache Behavioral Health Center, sees
all the people who are suicidal, or who are at high risk.
Within a 1-year period, there were 300 referrals from the task
force. We have two tribal members who are working on the task
force, assisting and helping with case management.
Another committee we have formed is the High Risk Response
Alliance through the Apache Behavioral Health Services. The
Behavioral Health Alliance is really an effort to get community
members involved in our efforts with suicide prevention.
With that, we started a Ministers Alliance. You know, as
Apache people, we are deeply spiritual, and we wanted to
include spirituality in our suicide prevention program, so the
Apache Behavioral Health Center did incorporate a component of
spirituality. We have over 60 Christian denominations on our
reservation. The ministers had a walk recently and had prayer
services in a location where we had several suicides.
Another part of the Alliance is the traditional part, our
traditional healers. They formed a group and are planning a
ceremony for the reservation.
These are only some of our efforts. We have limited funds
and are trying whatever we can to work on the suicide issue,
but we have some barriers. I am going to mention them quickly
because they are very important. One is that there are not
enough professionals and paraprofessionals who can provide
training or skills to respond to suicidal persons. Apache
Behavioral Health Services is partly funded by Public Law 93-
638. It also receives funding from third-party billing, through
Medicare [which is Medicaid of Arizona].
But we fear that we may not be able to continue billing for
our Native American counselors, those who are not doctors. They
are good workers who go out into the community and help the
people in crisis. Yet our Medicaid program is in jeopardy
because of the certifications and degrees that are required. So
we ask that this doesnt happen; that we are able to continue to
bill for services provided by these non-professional people.
This is very important for the continued success of our suicide
prevention program.
Another thing we need is a 24-hour response center. That
would allow us to have a place where people can call any time.
Underlying our challenge with suicide is the main problem
of substance abuse. Without any culturally sensitive centers to
which we can send our young Apache people, it is difficult to
work on the problems that they have. So we are asking that we
get funds for culturally sensitive substance abuse prevention
centers, to provide this much-needed service for our youth.
In conclusion, our needs are great, and our resources are
few. Our suicide rate is among the highest in this country. So
I am very happy and I am grateful that the Senate Committee on
Indian Affairs has taken an interest in hearing about suicide
in the hopes that you will help us to implement and fund
suicide prevention programs.
Thank you.
]Prepared statement of Ms. Vigil appears in appendix.]
The Chairman. Thank you very much.
Mr. Martin, welcome.
STATEMENT OF WILLIAM E. MARTIN, CHAIRMAN, ALASKA STATE SUICIDE
PREVENTION COUNCIL, AND FIRST VICE PRESIDENT, CENTRAL COUNCIL
OF THE TLINGIT AND HAIDA TRIBES OF ALASKA
Mr. Martin. Chairman McCain, Senator Murkowski, other
members of the committee, thank you for inviting me to testify
at this hearing.
My name is William Martin and I am chairman of the State
Suicide Prevention Council in Alaska. I am also first vice
president of Tlingit and Haida Indian Tribes of Alaska.
The State Suicide Prevention Council serves in an advisory
capacity to the Governor with respect to what actions can be
taken to improve health and wellness; broaden the public's
awareness of suicide; enhance suicide prevention services and
programs; develop healthy communities; and develop and
implement a statewide suicide prevention plans, copies of those
plans I have brought with me and have distributed to your
aides; and to strengthen existing and build new partnerships
between public and private entities that will advance suicide
prevention efforts in the State.
Let me briefly outline the magnitude of our problem and
then report on what seems to be working at preventing suicide.
For the past decade, Alaska has had the second highest rate of
suicide in the United States, twice the national average.
Alaska Natives commit suicide two to three times that of non-
Natives in Alaska. In my written testimony is an even more
startling statistic.
Our Suicide Prevention Council has offered the workplans to
prevent suicide. We distribute it within many diverse
communities throughout the State. With no one answer that fits
our many cultures, we believe there are tools that make suicide
preventable. Our workplan combines analysis of the problem with
words of wisdom from our Alaskan elders. It sets 13 prevention
goals that a community can use to meet its specific suicide
prevention needs.
I submit with my written testimony a copy of our workplan
and ask that it be included in the record of the hearing.
The Chairman. Without objection, it will be made part of
the record.
Mr. Martin. Our Suicide Prevention Council has increased
its suicide prevention and awareness efforts through a media
campaign and through effective use of the Gatekeeper program.
Gatekeeper programs reduce suicide rates by training first
responders such as emergency personnel, public safety officers,
clergy and others who may be approached in a suicidal crisis,
but who typically lack specific suicide prevention experience.
The Gatekeeper program results in much more effective
crisis intervention. We could do far more Gatekeeper training
if we could gain greater access to Federal funding for these
programs. This cost-effective approach works and deserves more
financial support.
As an Alaska Native leader, I have become convinced that my
people must go back to study the lessons of our ancestors. They
lived in a time before alcohol was introduced to our
communities. Suicide then was an unheard of event, typically in
rare cases where one has grievously shamed his family or has
caused despicable hurt upon others. Although my stance may not
make me very popular, I am convinced that tribal leaders should
set an example to our people by abstaining from alcohol.
Whether or not alcohol is a problem for us as individuals, we
leaders need to demonstrate to our people that alcohol is the
cause of most of our social problems.
Suicides in a community tend to go in streaks and I think I
know why. I believe that there is a copycat effect that is
encouraged by how we talk about people after they kill
themselves. For example, at a funeral for someone, we never say
bad things about a person who has died, but there may be a
person listening in the audience, a young person who might
think to himself that this is all I need to do to gain respect
for my family and my friends and for my elders. So it starts a
compounding effect.
We need to talk to our young people before this happens. We
need to praise their good qualities while we are living.
Natives don't usually openly demonstrate day to day affection
and love for our children because of some of our cultural ways.
We just don't do that. We need to change this. Our Native
cultures are living entities that need to be shaped by Natives
alive today.
To change this culture, to change our ways, we need to find
funds from outside our own private communities to support
suicide prevention programs that assist our elders and leaders
in changing the attitudes of our people. Native communities
simply cannot compete on the same playing field for funds from
SAMHSA and from the Centers for Disease Control.
One of our regions hit hard by suicide is the Yukon-
Kuskokwim Delta. Through the Association of Village Council
Presidents, a plan has been organized which in Eskimo means
``securing a future for our children.'' This mission is to
create a well community in which all entities work together
under the direction of elders to restore healthy communities,
strong in culture and language.
Like my own community in Juneau, the Tlingit and Haida
community has developed a modest program that involves Native
teachers in button-blanket making, weaving, and carving to pass
on this knowledge to our youth. This has shown to be a great
success in bringing back Native pride and Native values, the
key defense mechanisms against hopelessness and depression that
can lead to suicide.
To fund a program such as this in the Juneau area requires
funding of approximately $15,000 to $20,000. Funds like this
should be made available to our smaller communities that could
bid on plans and programs that we can use to discourage
suicide.
Mr. Chairman, my time has expired and I would be happy to
answer questions and will be available for that.
[Prepared statement of Mr. Martin appears in appendix.]
The Chairman. Thank you very much, Mr. Martin.
Dr. Walker.
STATEMENT OF R. DALE WALKER, DIRECTOR, ONE SKY CENTER, OREGON
HEALTH AND SCIENCES UNIVERSITY
Mr. Walker. Thank you very much, Mr. Chairman. It is a
pleasure to be here.
Senator Murkowski, I also appreciate being here as a
witness for you.
My name is Dale Walker. I am a psychiatrist. I am also a
Cherokee. I direct a program called the One Sky Center. The One
Sky Center is the only national resource center for American
Indian alcohol, drug and mental health in the country. In the
last year, we have been at 59 different sites. We are a small
group. We have partners across the country who work closely
with us.
We have heard a little bit about the discussion of
interagency support and coordination, and I would tell you that
the development of partnerships at the level of a resource
center is a critical next step in trying to do these issues as
well.
We have been at many sites, first looking at alcohol and
drug issues, but everywhere we went, it was the issue of family
violence, suicide, disorganization, and disconnection with
culture that were issues of great concern. You have heard
already today the fact that these issues are interrelated, that
indeed trying to wrestle with this issue in a pointed directive
way is not as effective as working with the tribe and getting
an overall plan on how to deal with the many circumstances that
lead to the problems.
You have heard some discussion also about indigenous
knowledge or traditional knowledge about how to keep the family
intact and about how to restore values. All of these are
critical and quite important. Evidence-based work is also
critical, but community-based treatment and management requires
that the values within the community are a part of the care.
We have been looking and working with areas also and
finding out that you don't do a visit, a consult or technical
assistance once; that when you visit, you stay. You work with
the tribes continuously through the process.
Sometimes, that is not in sync with the funding cycles of
how programs work within the system, so we are very interested
in if things are set up to help develop. By the way, I want to
add, you already know that there is underfunding of mental
health, addictions, and education. There are three reports, two
from Congress, about the underfunding. You are aware of the
disparities that exist in these areas.
In order to address those, we know there needs to be more
bottom-line funding to help with these problems. Then when you
develop special programs with grants, you can actually advance
the best practices for a community so that everybody can learn
together.
Our experience has been that if we can work with and train
people, the behavioral health aide program in Alaska is a very
good example, they are able, the community is empowered to
select their people. They decide who gets the training for
triage assessment and follow-up after-care in their programs.
That empowers the community to be involved.
They also have the trust and that kind of goes quickly with
the process of care. We support that. I think it is a
remarkable next step in training for IHS programs, as well as,
frankly, third world programs that are in the same situation.
These efforts are quite important.
In the proposed bill, we took a serious look at the
training issues and maintaining the expertise out in the field.
How you get the care there, and how you maintain the care
becomes critical. You have to maintain the care for licensure
so that billing and work under the logical health care
circumstances. That maintenance of license and certification to
do the training is very difficult if you are in a remote area.
We think that the telemedicine is not only for clinical
care, but it is for training of the people who go out into the
area. It would be wonderful to have in place modules for
training in addictions and mental health and suicide so that
people could take courses on Web sites and be able to do that.
We are working with the tribal colleges and universities to
help establish that kind of approach.
The other position I would just mention is that the
interagency task forces and partnerships work if the people
understand that we have to look at the total funding across
agencies and get together to figure out how to focus the
dollars as a group. If you look at it as individual silos, that
is what you get.
We have much else to say in the discussion, but I am going
to end the conversation here.
Thank you very much.
[Prepared statement of Dr. Walker appears in appendix.]
The Chairman. Thank you very much, Dr. Walker.
Ms. Kauffman, welcome.
STATEMENT OF JO ANN KAUFFMAN, PROJECT DIRECTOR, NATIVE
ASPIRATIONS PROJECT
Ms. Kauffman. Thank you, Mr. Chairman. I want to thank you
and Vice Chairman Dorgan for your work on this issue, and also
thank you, Senator Murkowski for your presence here and your
interest in this very difficult topic.
My name is Jo Ann Kauffman. I am a member of the Nez Perce
Tribe. I have been involved in Indian health issues for the
last 30 years. I have a master's in public health from the
University of California at Berkeley.
I was invited here to testify today as a contractor for
SAMHSA and the work that we are doing currently on their behalf
to bring evidence-based interventions to high risk communities
in prevention mode.
I must say, first of all, that this hearing is important
and it was interesting coming on the heels of Mother's Day. I
spent the weekend thinking about the importance of what can
come out of this hearing and the work that you are doing to
bring resources to communities, and my heart goes out to all of
those parents for whom this issue is very personal.
We were asked last year by the Substance Abuse Mental
Health and Services Administration to consider an emergency
contract. As a Federal contractor, we prepared a response for
them, specifically to look at nine of the highest risk
communities across the United States in Indian country for
purposes of preventing some of the disasters that we saw last
year with regard to youth violence in Minnesota and some of the
suicide clusters across the Plains States.
We pulled that together primarily as a prevention model to
prevent youth violence, youth bullying and suicide. We targeted
those communities most at risk through a quantitative
assessment. We are engaging those nine communities in a
grassroots, bottom up planning approach, and bringing the
curriculum or the evidence-based interventions to those
communities to implement according to their wishes over the
remainder of this contract which runs until March 2007.
The nine communities that were selected include, well first
of all, in selecting the nine communities that was a
quantitative analysis of mortality data related to violence for
Indian youth in comparison with behavioral health funding and
poverty rates. We looked at three areas primarily: The Aberdeen
area, the Alaska area, and the Billings area. Then we did a
series of interviews with professionals in each of those areas
to identify three communities within each area to come up with
the nine.
In the Aberdeen area, we have agreements to work with the
Cheyenne River Reservation, Crow Creek Reservation, and the
Pine Ridge Reservation. In Alaska, we will be working with the
Native Village of Alakanuk, the Noorvik Native community, and
the Native village of Savoonga. In the Billings area, we will
be working with Fort Belknap Indian Reservation, Fort Peck
Indian Reservation, and the Wind River Reservation in Wyoming.
Because youth violence is a complex historical, cultural
and family issue that has economic and geographic and access to
care kinds of issues overlaying that, our effort really is to
reduce risks by promoting supportive and protective factors
within each of those communities, and to allow each community
to identify its own strategy.
We did conduct a review of evidence-based interventions and
I want to note that the National Registry of Evidence-Based
Programs and Practices, known as NREPP, is provided through
SAMHSA as a registry of evidence-based interventions. It
contains only two Native American-focused evidence-based
interventions that have received that seal of approval by
NREPP.
There are a host of other interventions that are called
practice-based interventions. And then as you heard earlier,
there are many cultural-based interventions that bring forward
the traditions and values and ceremoneys of particular tribes
and cultures as a way to protect Indian youth and to prevent
violence.
I am happy to report that last week, we conducted our first
two community engagements. We worked with the communities at
Pine Ridge and at Cheyenne River. Each of those communities
conducted their own planning process. They learned about the
evidence-based interventions. What emerged from that was their
own very unique application of cultural knowledge and values
and tradition and ceremony to come up with a plan for this next
year for working within their school districts and their
communities to prevent youth violence.
All nine communities are very motivated. This effort is, as
I described, is an emergency effort of a prevention mode to
prevent further incidents like we heard of last year. But it is
a short-term effort and each of the communities has been very
active in seeking additional alternative resources through
their States, through the Garrett Lee Smith opportunities for
funding, and through other resources.
So in closing, Mr. Chairman, I have a few recommendations.
First, that the committee consider expanding support for tribal
communities seeking assistance through SAMHSA or IHS. It is
difficult for short-term demonstration efforts to have time to
prove results. Second is that in looking the quantitative data,
it is clear that many more communities require this type of
preventive assistance through whatever channels are available.
Third is that the NREPP process of sanctioning certain
evidence-based interventions may inadvertently be leaving out
many traditional tribal or practice-based interventions. That
is important only because it seems that funding now is being
tied closer and closer to that status of NREPP evidence-based
interventions, including Medicaid reimbursement at the State
level.
So it would be important to provide whatever support to get
more tribally based or culturally based interventions through
that status.
I support everything that has been said already with regard
to workforce development in the paraprofessional field and
increased access to services.
In closing, Mr. Chairman, thank you very much for this
time.
[Prepared statement of Ms. Kauffman appears in appendix.]
The Chairman. Thank you very much.
I would like to ask the witnesses how serious in the
overall issue of suicide is the issue of methamphetamine, the
accompanying epidemic of methamphetamine. I will begin with
you, Ms. Vigil.
Ms. Vigil. Well, in the last year we have noticed a 30-
percent increase of methamphetamine use. When we recently
tested our regular employees who work for the tribe there was a
30-percent use.
The Chairman. What percent?
Ms. Vigil. Thirty percent. In the past, there was no
methamphetamine abuse on the reservation; there was just
alcohol. And now methamphetamine abuse is climbing even among
the work force of the tribe. Methamphetamine abuse is related
to alcohol abuse, and substance abuse is related to more than
50 percent of the suicide cases.
The Chairman. Mr. Martin.
Mr. Martin. Mr. Chairman, it is a huge problem in Alaska
because it is easily made. It can be made any place. Also, the
effects of it are quicker in bringing down barriers in people,
even more so than alcohol. It is a problem we are focusing hard
on in villages, but without law enforcement in remote villages,
it is very difficult. And besides, with the secrecy involved in
each of those communities, it makes it very difficult to bring
it out in the open and expose it to the law enforcement people.
The Chairman. Dr. Walker.
Mr. Walker. If suicidal intent and alcohol are a crisis,
suicidal intent coupled with methamphetamine is a disaster. I
say that in studying and working on suicide issues, 90 percent
of the time substance use is a part of the suicide attempt, so
it is a huge connection. The fact is that methamphetamine now
is more and more available, and most kids use what is
available. There is not a staggered way of doing it. They use
what is available. Methamphetamine is everywhere in every
Indian reservation. Therefore, it is used.
The reason I say it is a disaster is that methamphetamine
also causes psychosis. You actually lose control of your
ability to use your own logical thinking.
The Chairman. And there is a period of exhilaration and a
period of depression.
Mr. Walker. That's right. And so with all of that
connected, the psychosis and the depression and the loss, all
of those feelings are magnified, making risk for suicide much,
much higher.
The Chairman. Dr. Walker, before I leave you, is most of
this in Indian County manufactured in Indian country? We know
how easy it is to obtain the materials. Or is it like in the
rest of the country, where you have really this flood of
Mexican methamphetamine, which is even cheaper than making it
yourself?
Mr. Walker. What I hear across the country is the import,
the bringing in from out of the country and out of the area.
There are users, and many times by the way, the manufacturing
is not by Indians out in isolated areas. It is by other people
who know that is a good place to hide.
The fact is, though, there is a huge problem with the
movement of methamphetamine and other drugs into Indian country
from out of this country.
The Chairman. Now, we all know that the suicide rate is up,
right?
Mr. Walker. Yes.
The Chairman. How much of that would you attribute to the
methamphetamine problem?
Mr. Walker. Difficult question. I would quickly tell you
that we need to understand what is happening out in our Indian
communities with methamphetamine. There is actually very little
science. There are lots of facts and experience. But to answer
your question, to make that relationship, I think it is a
wonderful point that needs to be addressed. It reminds me that
another recommendation we had is that perhaps in this bill some
support from the National Institutes of Health might be useful
to actually study these problems much, much more thoroughly.
The Chairman. Maybe we can seek for that to happen. I think
that is a very good recommendation.
Ms. Kauffman.
Ms. Kauffman. Thank you, Mr. Chairman.
I think the only thing that I would add here with regard to
methamphetamine is what we have heard is the difficulty in
treatment of individuals who are addicted to methamphetamine,
and that it is much more difficult and intense than I think the
treatment programs that have evolved around alcohol addiction
or even drug addiction. And so that we are hearing from drug
treatment providers.
The other thing that we have also heard is the difficulty
in terms of law enforcement if there is ever jurisdictional
ambiguities, I guess, that tend to work in favor of those who
are hiding underneath the radar screen of law enforcement.
The Chairman. Thank you very much. We are in agreement on
lack of funding. We are in agreement there needs to be more
interagency coordination and effort. What else do we agree on,
Dr. Walker?
Mr. Walker. Well, first of all, I think that the
consistency of three hearings in 1 year is raising the
visibility and the ability for communities to talk about the
issues. If I could give a very, very direct comment, it would
have to do with how we maintain connections with our
communities when we do technical assistance and do the kinds of
work in providing best practices in those communities. That
connection is so critical to maintain. Letting the communities
alone or letting them drift is not an effective way, and we
know that.
I think that the integration and support that we have seen
from SAMHSA has been marvelous; the fact that we try to put, as
you well know, if you talk about addictions and mental health,
and prevention and treatment, those can also become isolated
from each other. The fact that Mr. Curie states there is one
SAMHSA is a wonderful message. The people are now starting to
work together to move those things in partnership with the
community.
The partnership, by the way, starts with the leadership of
the tribe. We need much, much more influence and ability to
provide information so the tribal councils can actually make
decisions about their own health care.
The Chairman. Ms. Kauffinan.
Ms. Kauffman. Thank you, Mr. Chairman.
One of the points that Dale just made with regard to tribal
leadership we use with our communities, it is called a
community readiness model to assess where a community is before
coming in with interventions or assistance. Across the board so
far, it has been too little awareness on the issue, too vague
awareness on the issue. I think that so much energy and
resources are taken responding to tragedies and events, as they
should be, but so much more needs to be done with regard to
prevention and awareness and training at the local level.
The Chairman. Mr. Martin.
Mr. Martin. We agree that we need to get the programs into
the villages, but more with the cooperation of the people in
the villages. Sometimes there is a stigma involved where they
feel that we are coming in and telling them how to do things,
when in effect we should be able to be working with them, with
the leaders of the villages, along with the elders. We already
have the commitment from the elders, who are always standing by
ready to assist in the youth programs, but we need to be able
to work from the, like in our case, central council. Tlingit
and Haida needs to work with the individual communities to be
able to set up programs.
The State Suicide Council is also willing to adapt its plan
to any of the villages that would require assistance in setting
up how to customize it for each individual village.
The Chairman. Ms. Vigil.
Ms. Vigil. I think we all agree that we need more
paraprofessionals and professional Native Americans who can
provide services. We need Medicaid of our State to continue to
pay us for providing those services because that is one of the
major sources of funding for us.
Another thing we agree on is that treatment for Native
Americans should be tailored specifically for them, to address
all their issues.Thank you.
The Chairman. I want to thank the witnesses. Senator Thune
had some records that need to be included as part of the
hearing record. The letters are from South Dakota Native
Americans who have lost relatives to suicide, to be made part
of the record.
I want to thank the witnesses. I appreciate your commitment
to trying to address this terrible and tragic issue. I am very
grateful for the leadership and conunitment of Senator Dorgan
and other members of this committee. We will not quit, nor will
you, and hopefully we can make some progress over time and
bring more attention to this ongoing national tragedy.
Thank you. This hearing is adjourned.
[Whereupon, at 11:25 a.m., the committee was adjourned, to
reconvene at the call of the chair.]
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A P P E N D I X
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Additional Material Submitted for the Record
=======================================================================
Prepared Statement of Hon. John McCain, U.S. Senator from Arizona,
Chairman, Committee on Indian Affairs
This is the third hearing in the 109th Congress that this committee
has held on youth suicide among Native Americans. At a field hearing
Senator Dorgan chaired in North Dakota last year, and at a subsequent
hearing here, we learned that the suicide rate for Native Americans
continues to escalate and is many times the national average for other
population groups. The tragedy of young people taking their own lives
has particularly impacted various native communities around the country
that have experienced ``clusters'' of suicides among their school-aged
children.
Legislation has been introduced to try to address the problem.
Senator Dorgan introduced, and I co-sponsored, S. 2245, the Indian
Youth Telemental Health Demonstration Project Act of 2006, which passed
the Senate just last week. The bill authorizes a demonstration project
to test the use of telemental health services in suicide prevention,
intervention, and treatment of Indian youth. S. 1057, the Indian Health
Care Improvement Act of 2006, which has been reported out of the
committee but which has not yet passed the Senate, includes the
development of a comprehensive behavioral health prevention and
treatment program for Indian Behavioral Health Services; an assessment
of the scope of the suicide problem; and a grant program to provide
research on the multiple causes of Indian youth suicide.
Today, the committee meets to examine how suicide prevention
programs and resources that exist outside of Indian country might be
applied to American Indians and Alaska Natives. To this end, committee
staff has put together draft legislation to add a native component to
existing Federal suicide prevention and related programs, and I welcome
witnesses' comments today on these proposals.
I am pleased that representatives from the White Mountain Apache
Tribe could be here today. Last year, committee staff traveled to White
Mountain to meet with Apache Behavioral Health Services, where they
learned that, in the tribe of about 15,000 members, there had been over
500 attempted suicides in 1 year. Even accounting for the different
ways in which suicide attempts are counted, this number is both
shocking and heart rending. I am pleased that the thoughtful and
informed, if overwhelmed, people who helped to educate my staff in
December are here today to again share their experience.
Again, I commend the vice chairman for his leadership on this
issue, and look forward to the testimony of the witnesses.
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Prepared Statement of Loretta Bullard, President, Kawerak Inc.
Kawerak, Inc. is encouraging the Senate Indian Affairs Committee to
introduce and support passage of language that would dedicate funds for
tribal suicide prevention programs.
Kawerak is a tribal consortium and non-profit in northwest Alaska.
We provide services throughout the Bering Straits Region. Our region
encompasses 26,000 square miles, has 16 distinct communities and 20
federally recognized tribes. We have very few roads in the region, so
most in-region travel is by small airplane, snow machine in winter, or
small boats in the summer. We are authorized by resolution to provide
BIA services to 18 of our tribes and 2 of our tribes compact
independently. Our Board consists of the presidents of each of the 20
tribal councils in the region, two elder representatives and the chair
of Norton Sound Health Corporation, a tribally authorized health
consortium.
The incidence of suicide in the Bering Strait Region is staggering.
The regional population is about 9,000 individuals of which 7,500 are
Alaska Native. All suicides in the Bering Straits Region have been
Alaska Native. The Bering Straits Region suicide rate is double the
rate in Alaska and is six times the national rate. Suicide accounts for
17 percent of all deaths in the Bering Straits Region. Our population
is small, but our problem is large. In regions such as ours, we know
the individuals that commit suicide. They are our relatives, our
friends, our tribal members, our children and young adults. Because our
population is small and we know each other, I believe the suicides have
a cumulative impact on our young people. In the last 3 years [2003-05],
20 people committed suicide in 11 of our 16 communities. The majority
of individuals who committed suicide were between the ages of 15-29
years old. At least 122 individuals took their own lives from 1979-2004
[1991 statistics were not available]. 75 other individuals attempted
suicide between 2003-05, and it is reported that 175 individuals talked
about taking their own lives. [These are individuals who went through
Norton Sound Health Corporation's Behavioral Health On Call system and
do not include the number of attempts that went unreported or
individuals who did not call for help.]
Nome Public Schools conducted a Youth Risk Behavior Survey in 2005
for ages 12-18 year old junior high and high school students and
compared them to the same survey in 1999. To put this in perspective,
there were only 203 students in the survey group. Fifty-three students
[26 percent] who responded to the survey said they had seriously
thought of killing themselves and 29 [14 percent] actually tried to
kill themselves at one time.
Behavioral health providers in many rural areas of Alaska are
either in short supply or are less than optimally trained for their
duties [or both]. There is also a high turnover. It is difficult to
provide comprehensive services in so many communities. Training local
service providers would be an effective solution but funds are needed
to do so.
Kawerak is recommending funds be set aside for tribal suicide
prevention programs because of the epidemic proportions of suicide
among our youth. Tribes and tribal consortiums currently compete with
the States for SAMHSA's suicide prevention grant funds. When Kawerak
talked to State Behavioral Health Services Division Suicide Prevention
staff, we were encouraged not to apply for the SAMHSA grant because the
State was going after the same grant funds. Statewide suicide
prevention efforts tend to focus on broad planning and prevention
activities that have had limited success in village Alaska. The State
of Alaska has made funds available for some communities to hire village
suicide prevention coordinators. This has been more successful.
Suicide is a serious problem in our rural villages. It is going to
take time and money to address. We would like to design and implement a
grass roots, hands problem--in keeping with the unique cultures and
conditions in northwest Alaska.
We encourage this committee to make funds available such that we
can begin to reduce the high rate of suicide among our youth.
For further information, contact:
Loretta Bullard, president, Kewerak Inc., PO Box 948 Nome, AK
99762, Phone: 907-443-5231 Fax: 907-443-4452
______
Prepared Statement of Charles G. Curie, Administrator, Substance Abuse
and Mental Health Services Administration
Mr. Chairman and members of the committee, good morning. I am
Charles G. Curie, M.A., A.C.S.W., Administrator of the Substance Abuse
And Mental Health Services Administration [SAMHSA] within the
Department of Health and Human Services. I am very pleased to be here
today to describe how SAMHSA is working to address suicide among
American Indians and Alaskan Natives.
I was scheduled to speak at a suicide prevention conference in
Casper, WY today, but I am so personally concerned about suicide rates
especially among American Indians and Alaskan Natives that I wanted to
provide this testimony myself.
It is a privilege to testify along with Dr. Charles Grim, director
of the Indian Health Service [IHS] this morning. SAMHSA and IHS have
developed a strong partnership reflected in our current Intra-Agency
Agreement to work efficiently and effectively together to help meet the
public health needs of American Indians and Alaska Natives. It is also
a privilege to be with Jerry Gidner, Deputy Bureau Director for Tribal
Services at the BIA.
It was just over a year ago that Kathryn Power, Director of
SAMHSA's Center for Mental Health Services, testified before this
committee on my behalf, and Ulonda Shamwell, Director of Policy
Coordination at SAMHSA, testified at a field hearing in North Dakota on
suicide and violence among American Indians and Alaskan Natives. We
have accomplished a great deal since then that I want to share this
with you today.
Suicide
Suicide is a serious public health challenge that is only now
receiving the attention and degree of national priority it deserves.
Many Americans are unaware of suicide's toll and its global impact.
Suicides make up 49.1 percent of all violent deaths worldwide, making
suicide the leading cause of violent deaths, outnumbering homicide. In
the United States, suicide claims approximately 30,000 lives each year.
When faced with the fact that the annual number of suicides in our
country now outnumbers homicides by three to two--approximately 30,000
and 18,000, respectively--the relevance of our work becomes clear. When
we know, based on SAMHSA's National Survey on Drug Use and Health
[NSDUH] for 2003, that approximately 900,000 youth had made a plan to
commit suicide during their worst or most recent episode of major
depression and an estimated 712,000 attempted suicide during such an
episode of depression, it is time to intensify activity to prevent
further suicides. The NSDUH data and the countless personal stories of
loss and tragedy are why I have made suicide prevention a priority at
SAMHSA.
Suicide Among American Indian and Alaska Native Youth
Last year, a suicide cluster occurred on the Standing Rock
Reservation in North Dakota and South Dakota. Ten young people took
their own lives, and dozens more attempted to do so. The Red Lake
Indian Tribe in Minnesota is experiencing high suicide rates following
the deaths of nine individuals at the hand of a 16-year-old high school
junior. Tragically, many other reservations have similar stories to
tell. Suicide is now the second leading cause of death (behind
unintentional injury and accidents) for American Indian and Alaska
Native youth aged 15-24. In 2003, the suicide rate for this population
was almost twice the national average. American Indian youth have the
highest rate of suicide among all ethnic groups in the United States,
with a rate of 18.01 per 100,000 as reported in 2003. What is sad to
report is that more than one-half of all persons who commit suicide in
the United States, and an even higher fraction in tribal communities,
have never received treatment from mental health providers.
SAMHSA's Role in Better Serving American Indian and Alaska Native
Populations
SAMHSA focuses attention, programs, and funding on improving the
lives of people with or at risk for mental or substance use disorders.
Consistent with President Bush's New Freedom Initiative, SAMHSA's
vision is ``a life in the community for everyone.'' The agency is
achieving that vision through its mission ``building resilience and
facilitating recovery.'' SAMHSA's direction in policy, program, and
budget is guided by a matrix of priority programs and crosscutting
principles that include the related issues of cultural competency and
eliminating disparities.
To achieve the agency's vision and mission for all Americans,
SAMHSA supported services are provided within the most relevant and
meaningful cultural, gender-sensitive, and age-appropriate context for
the people being served. SAMHSA has put this understanding into action
for the American Indian and Alaska Native communities it serves.
SAMHSA's policy is to level the playing field in order to ensure that
Tribal entities are eligible for all competitive grants for which
States are eligible unless there is a compelling 4 reason to the
contrary.
Since CMHS Director Power testified before the committee last year,
and as a result of the Garrett Lee Smith Memorial Act [Public Law 108-
355], SAMHSA is now working with State and local governments and
community providers to stem the number of youth suicides in our
country. In 2005, we awarded the first cohort of grants, 14 in all,
including a grant to Arizona, under the Garrett Lee Smith Memorial Act
State/Tribal Suicide Prevention program. These funds are available to
help States/Tribes implement a Statewide/Tribe-wide suicide prevention
network. One of those first set of grants went to the Native American
Rehabilitation Association in Oregon.
Today I am announcing almost $9.6 million in funding for 8
additional new grants [each for approximately $400,000 per year for 3
years] under this program to support national suicide prevention
efforts. Grants have been awarded to programs in Oregon, Connecticut,
Utah, Wisconsin, and Idaho, and grants specifically geared to American
Indians and Alaskan Natives have been awarded to:
<bullet> \\\\\\Manniilaq Association of Alaska to provide a variety
of suicide 5 prevention approaches to a region that has one of
the highest youth suicide rates in the world;
<bullet> \\\\\\United Indian Involvement, Inc. to implement a Youth
Suicide Prevention and Early Intervention Project targeting
American Indian and Alaskan Native children and youth ages 10
to 24 in Los Angeles County; and
<bullet> \\\\\\Montana Wyoming Tribal Leaders Council to provide
suicide prevention efforts to six Montana and Wyoming American
Indian reservations, serving Blackfeet, Crow, Northern
Cheyenne, Fort Peck, Fort Belknap, and Wind River populations.
An announcement for a third cohort of grants of $400,000 per year
for 3 years under this program closed yesterday. SAMHSA again invited
all American Indian and Native Alaskan tribes to apply for these
grants. In an effort to increase the number of applicants from American
Indian and Alaskan Native tribes, we provided technical assistance
specifically for them.
The Garrett Lee Smith Memorial Act also authorized a National
Suicide Prevention Resource Center, and for fiscal year 2006 we
received an additional $1 million in supplemental funds for the center.
We recently requested an application from the existing center for use
of these supplemental funds, requiring them to address how they would
expand the current youth suicide prevention technical assistance to
tribes and tribal organizations.
Though not a part of the Garrett Lee Smith Memorial Act, SAMHSA has
long supported a national suicide hotline--1-800 273-TALK. Funding to
the current hotline grantee was increased by $369,000 in fiscal year
2006, and the grantee has been requested to submit an application that
indicates how they will expand access to American Indians and Alaskan
Natives.
The Administration's request for fiscal year 2007 for SAMHSA asks
for nearly $3 million for a new American Indian/Alaska Native
initiative, which provides evidence based programming on reservations
and Alaskan Native villages to prevent suicide and reduce the risk
factors that contribute to youth suicide and violence. We plan to
continue our collaboration with IHS as we have done in the past in this
initiative.
SAMHSA has also transferred $200,000 to IHS to support programming
and service contracts, technical assistance, and related services for
suicide cluster response and suicide prevention among American Indians
and Alaska Natives. One example is the development of a community
suicide prevention toolkit. This tool-kit includes information on
suicide prevention, education, screening, intervention, and community
mobilization, which can be readily available to American Indian and
Alaska Native communities via the Web and other digitally based media
for ``off the shelf'' use.
SAMHSA is proud of what we have done while knowing that this is not
nearly enough. The problems confronting American Indian and Alaskan
Native youth are taking their toll on the future of American Indian and
Native Alaskan tribes.
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.
______
Prepared Statement of Jerry Gidner, Deputy Bureau Director for Tribal
Services, BIA, Department of the Interior
Mr. Chairman, Mr. Vice Chairman and members of the committee, my
name is Jerry Gidner and I am the deputy bureau director for tribal
services in the Bureau of Indian Affairs [BIA] at the Department of the
Interior. I am pleased to be here today to provide the Department's
testimony on suicide prevention programs and their application in
Indian country. Several of my BIA colleagues accompanied me today. They
are Chet Eagleman, acting chief, Division of Human Services; Kevin
Skenandore, acting director, Office of Indian Education Programs
[OIEP]; and Peter Maybee, assistant to the deputy bureau director, Law
Enforcement Services [OLES]. Each is a member of a federally recognized
tribe, is a senior BIA program manager, and has invaluable field
experience.
I would like to take the opportunity to share the BIA's concern
about Indian teen suicide and the emotionally wrenching impact it has
on Indian country.
Teen suicide is a serious long-standing problem in Indian country.
Research has shown that social factors such as poverty, alcoholism,
gangs, and violence contribute in the manifestation of suicidal
ideation, suicidal behavior and suicide attempts by Indian children and
teenagers.
The Indian Health Service [IHS] data document that suicide is the
third leading cause of death in Indian children age 5-14, and the
second leading cause of death in Indian teenagers and young adults age
15-24. In addition, the IHS data indicate that Indian teenagers/young
adults' suicide rate is 2.5 times greater than the nationwide U.S.
rate. Young Indian men are more at risk to completed suicides, whereas
young Indian women are more at risk to suicide ideation or thoughts.
In addition, data from the biennial BIA High School and Middle
School Youth Risk Behavior Surveys [YRBS] provide insight into the
progression Indian children and teens go through from feeling sad or
hopeless, to seriously considering suicide, to making a suicide plan,
to actually attempting suicide, to incurring serious injury requiring
treatment by a medical professional. The data demonstrate that
approximately one-third of Indian children and teens feel sad or
hopeless, in a given year, which is an early stage in a suicidal event.
The most recent BIA YRBS data for Indian students enrolled in 2003 show
that for Indian high school students:
<bullet> \\\\\\21 percent seriously considered attempting suicide in
the last year, and
<bullet> \\\\\\18 percent actually attempted suicide one or more
times in the last year.
For Indian middle school students, the data show that:
<bullet> \\\\\\26 percent seriously considered attempting suicide, at
some time in their life, and
<bullet> \\\\\\15 percent had attempted suicide.
Furthermore, statistics from the 2002 Annual Report of the Alaska
Bureau of Vital Statistics show that between 1990 and 1999, Alaska
Native teens committed suicide at a rate of 110 per 100,000 or over 5
times greater than the rate of 20 per 100,000 non-Native teenagers in
Alaska.
Although national hard data are not available on Indian country
residents, the professional literature strongly suggests a close
association between parental alcohol and drug abuse, child abuse
[whether emotional, physical, or sexual], domestic violence and suicide
in children and teens. Often suicide may be the only way a child or
teen sees of extricating him/herself from a hostile or threatening
environment. However, the following can help prevent suicide in Indian
country:
<bullet> \\\\\\Improved housing conditions.
<bullet> \\\\\\Increased prevention and treatment services.
<bullet> \\\\\\Increased identification of at-risk individuals and
families and referral to services.
<bullet> \\\\\\Enhanced community development and capacity building
through technical assistance and training for tribal leaders
and staff.
BIA programs assist tribal communities to develop their natural and
social-economic infrastructures [that is, tribal governments, tribal
courts, cultural vitalization, community capabilities, et cetera] or
provide services to fill infrastructure gaps [that is, education, law
enforcement, social services, housing improvement, transportation, and
so on]. For the BIA, suicidal events significantly impact law
enforcement personnel since they are the most likely first responders
and have a significant impact on BIA/tribal school teachers and
students when the suicidal individual is a child or teenager.
BIA's Law Enforcement, Education, and Tribal Services programs
continually seek ways to collaborate and to support activities directed
at suicide prevention and services coordination. An example of this
type of coordination is the BIA Rocky Mountain Region [Montana and
Wyoming] Native American Youth Suicide Prevention Health Initiative
developed and presented by BIA, IHS, and Indian Development and
Education Alliance [IDEA]. The region also hosted a workshop on Native
American Youth Suicide Prevention Training of Trainers in 2005, which
included ``natural healers'' to provide referral and support.
Within the BIA's OIEP school system all Bureau-funded schools
receive supplemental program funds, through the U.S. Department of
Education, to operate a Safe and Drug-free School program. Schools use
these funds to address a myriad of issues to make their schools safe
places for students and staff. BIA schools receive about $92 per
student enrolled and use these funds to address a myriad of issues to
make their schools safe places for students and staff. Past initiatives
included the Comprehensive School Health Program where OIEP partnered
with IHS and the National Centers for Disease Control to assist schools
in developing plans that brought together the involvement of their
community partners such as local law enforcement, social services, and
mental and physical health providers.
OlEP is committed to ensuring a safe and secure environment for our
students. Our focus is the implementation of suicide prevention
strategies. The OIEP's Center of School Improvement launched a Suicide
Prevention Initiative using the IHS endorsed scientifically researched
based Question Persuade Respond [QPR] model. QPR is an aggressive
intervention program focused on suicide prevention. An initial training
in QPR was held in Denver, CO. in August 2004 and provided training on
the QPR model to all 184 BIA funded schools and dormitories.
Administrators at the school and dorm level were instructed to complete
100 percent training in the QPR suicide prevention model for staff at
their respective schools. Additional sets of training material have
been distributed to the schools and dorms through the Education Line
Offices on an annual basis. In 2004, OIEP provided training
opportunities for schools to establish crisis intervention teams to
address potential suicide incidents, using the QPR model.
OIEP has provided training almost yearly on prevention of risky
behaviors as well as preparation required to address almost any
emergency situation. Most recently OIEP sponsored a nationwide event
whereby students were dismissed for the afternoon while staff met to
review their policies and procedures addressing emergency situations.
Just last week, the majority of Bureau funded schools attended a 2-day
``Safe Schools'' training in Denver, CO. The focus of the training was
on emergency preparedness for any type of emergency situation that
would include what to do in an attempted suicide or suicide incident.
In summary, the BIA, IHS, Substance Abuse and Mental Health
Services Administration, other Federal agencies, and Indian tribes must
continue to work together to address all aspects of suicidal events--
both before and after the event happens. Because most Indian programs
fall within the respective missions of the BIA or the IHS, it is
essential that the programs, in each respective agency, that directly
or indirectly relate to suicidal events are coordinated and function
collaboratively. BIA invites other Federal, state and tribal
organizations and agencies to contact BIA regarding programmatic
information, to coordinate efforts and resources, and to collaborate in
addressing suicidal Indian children, teens and young adults.
This concludes my statement. I want to thank you for your concern
for the wellbeing of Indian children, teens and young adults. My BIA
colleagues and I will be happy to answer any questions you may have.
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Prepared Statement of Donna Vigil, Executive Director, Division of
Health Programs, White Mountain Apache Tribe, Northern Arizona
My name is Donna Vigil, I represent the White Mountain Apache Tribe
in northern Arizona in my capacity as executive director of the
Division of Health Programs. I am a member of the White Mountain Apache
Tribe, being born and raised on the reservation. I have here with me
Dr. Noreen Ashley, director of the Apache Behavioral Services. Our
tribe has approximately 17,000 members, of which close to 15,000 live
on the reservation.
Before I go any further, I would like to say Ronnie Lupe, chairman
of the White Mountain Apache Tribe sends his highest regards to all of
you, especially to his close friend Senator McCain. He considers all
the members of the U.S. Senate Committee on Indian Affairs as friends
to the White Mountain Apache people.
Suicide is one of the greatest challenges facing our people,
particularly our children and young adults. Our rates of attempted and
completed suicide are 17 times higher than those of all other races in
the United States, and five [5] times higher than all other American
Indian and Alaskan Native tribes. Attempts among our youth have
increased 11 percent in 1 year. In 2001, our tribe experienced the loss
of four young people to suicide in a very short time period. Each
suicide attempt or completion sends a ripple through our small tribal
community of incalculable suffering, grief and years of productive life
lost. I often wonder what would happen if Falls Church, VA were to
suddenly experience an unemployment rate of over 50 percent, a high
school drop out rate of over 54 percent, a substance abuse rate
reaching epidemic proportions, and a suicide rate over 17 times the
national average. What kind of Federal and State support would be
forthcoming?
With little Federal support, our community has come together to
address the issue of suicide on many fronts. Showing considerable
foresight, the tribal council appointed a Suicide Task Force in 2001.
The task force is headed by an employee of Indian Health Service who is
a community member and a member of the tribe. The Suicide Task Force
worked with Johns Hopkins University to obtain a NARCH grant to do
research on suicide. Through the encouragement of the Task Force and
NARCH the tribal council passed a resolution to establish a suicide
registry. Those who have been identified as being at high risk are
provided with referrals to our mental health facility for treatment and
periodic case management. In a 1-year period, there have been over 300
referrals to two full time workers, who are monitoring and providing
assistance.
In addition to the Suicide Task Force, a High Risk Response
Alliance was established in October 2005 through the tribe's mental
health clinic, Apache Behavioral Health Services. This was a grassroots
effort to involve the community in responding to the suicides.
Our mental health center has attempted to tap into the cultural and
spiritual underpinnings of Apache life to suicidal people. They have
sponsored a Minister's Alliance, a group of ministers and pastors from
the 60 churches on our reservation. One recent activity organized by
the Minister's Alliance was a community prayer walk that focused on
visiting the places where people had successfully killed themselves.
More recently, a Traditional Alliance has formed and is in the process
of planning a reservation-wide ceremony to engage those Tribal members
who adhere to traditional beliefs. As Apaches, we are deeply spiritual
people all efforts to combat suicide must include spirituality to be
successful. As you have-heard, we are taking steps to address our
suicide problem. However, our efforts are limited due to several
critical barriers.
First, there are not enough professional and paraprofessional
health care providers trained and skilled in suicide response that is
also familiar with the Apache way of life and Native spirituality. Our
desire is to train and employ more tribal members to meet this need. We
need Apache speakers, people who know the culture and the community to
work with our suicidal tribal members. Thus, we want to train more
Apache people to reach out to our suicidal family members, friends and
neighbors. Unlike the majority culture, we do not have a professional
class to do this work. We must do it ourselves. Our mental health
center, Apache Behavioral Health Services, is partially funded by a
Public Law 638 contract agreement with Indian Health Service. It is
also supported though third-party billing of Arizona's Medicaid
programs. We are fearful that because of new professional and
educational certification requirements in counseling and substance
abuse treatment, our paraprofessional workers will eventually lose
their ability to receive reimbursement for their good work. This must
not happen. Even though he or she may not possess a doctorate in
psychology, a well-trained Apache mental health outreach worker with a
high school diploma who visits suicidal people in the field can often
do more to decrease the risk of suicide of an Apache person than any
doctor-degreed non-Apache person. Therefore, we must retain our ability
to bill Medicaid programs for services provided by qualified, non-
degreed paraprofessional mental health workers.
Second, we need to develop a 24-hour crisis response center whereby
family members, friends and any concerned person can contact a trained
crisis response professional or trained volunteer to provide immediate
assistance. By necessity, this center would need to have satellite
locations throughout the 1.7 million acre Fort Apache Reservation in
order to be able to provide the rapid response needed when persons are
considering suicide as a solution to their immediate problems.
Third, substance abuse is a major underlying causal factor of
suicide among our people. Data indicates that more than 30 percent of
White Mountain Apache adults abuse drugs and more than 50 percent abuse
alcohol. This is also related to the high morbidity and mortality rates
among the WMAT people. Fundamentally, we need resources to expand
outpatient and residential substance abuse treatment on our
reservation. The current system for substance abuse treatment in the
State of Arizona cannot meet the unique needs of White Mountain Apache
adults and youth requiring services. In fact, it is nearly impossible
to locate a culturally appropriate residential substance abuse center
for Native American adults and teenagers in Arizona.
In conclusion, our needs are great and our resources are few. Our
suicide rates are among the nations' highest and continue to escalate.
While we have made great strides in responding to suicide attempts, we
lack the resources to implement wide-scale prevention. Specifically, we
need Federal support to:
1. Provide 24-hour culturally competent crisis intervention for
youth and adults suffering with suicide ideation;
2. Create community-based substance abuse prevention and early
intervention initiatives;
3. Establish a culturally competent substance abuse treatment
facility on the reservation for adults and youth; and
4. Ensure Medicaid reimbursement for qualified, non-degreed
paraprofessionals working in suicide response.
The White Mountain Apache Tribe and I are grateful that the U.S.
Senate Committee on Indian Affairs has taken the time to investigate
the needs of our people in the area of suicide prevention. It is our
hope that this testimony has served to help define what measures must
be enacted to assist us in reducing the number of suicide attempts and
completions amongst Native American people.
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