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Addictions and Mental Health Approaches in Native Populations

R. Dale Walker, MD

Patricia Silk Walker, PhD Douglas Bigelow, PhD

Bentson McFarland, MD

March 2, 2006

Phoenix, Arizona

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One Sky Center

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Program Goals

• Promote and nurture effective and culturally appropriate prevention and treatment

• Identify and disseminate evidence-based prevention and treatment practices

• Provide training and technical assistance

• Help to expand capacity

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One Sky Center Outreach

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American Indians

• Have same disorders as general population

• Greater prevalence• Greater severity• Much less access to Tx• Cultural relevance more challenging• Social context disintegrated

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Total Female Male

Total 11.9 9.8 14.1

Native American 19.8 23.3 15.6

Non-Hispanic White 11.8 9.9 13.9

Non-Hispanic Black 13.1 10.2 16.6

Hispanic – Central American 5.7 4.2 7.7

Hispanic – Cuban 8.2 5.5 11.4

Hispanic – Mexican 12.7 9.2 15.8

Percentage using any illicit drugs in the past year

Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

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Percentage reporting dependence on alcohol

Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

Total Female Male

Total 3.5 2.1 4.9

Native American 5.6 6.8 4.3

Non-Hispanic White 3.4 2.2 4.8

Non-Hispanic Black 3.4 2.0 5.2

Hispanic – Central American 2.8 0.8 5.4

Hispanic – Cuban 0.9 0.5 1.3

Hispanic – Mexican 5.6 2.6 8.4

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Lifetime History

Regier, 1990

Mental Disorder22.5%

Comorbidity29%

3.1% 1.5%

1.7%

1.1%

Alcohol Disorder13.5%

Comorbidity45%

Drug Disorder6.1%

Comorbidity72%

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Multiple Diagnoses Increases:

• treatment seeking• use of services • poor outcome• suicide risk• likelihood of no services• treatment costs

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How is it working?

One size fits all

Different goalsgoals Resource silosResource silos

Activity-driven

(Carl Bell, 7/03)

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We need Collaboration, Integration, and Synergy : Community Mobilization

Culturally specific

Best Practice

Integratingresources

Outcome driven

(Carl Bell, 7/03)

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Indigenous Knowledge

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

Definitions:

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Traditional Medicine

• The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health.

WHO 2002

Definitions:

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Evidence-based Practices

• Interventions that show consistent scientific evidence of improving a person’s outcome of treatment and/or prevention in controlled settings.

SAMHSA 2003

Definitions:

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Best Practices

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

WHO 2002

Definitions:

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World Conference on Science

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

1999

A partnership begins!

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ID Best Practice

Best Practice

Clinical/ServicesResearch

TraditionalHealing

MainstreamPractice

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Circle of Care

Best Practices

Child & Adolescent Programs

Prevention Programs

Primary Care

EmergencyRooms

TraditionalHealers

A&D Programs

Colleges & Universities

Boarding Schools

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The Intervention Spectrum for Behavioral Disorders

CaseIdentification Standard

Treatmentfor KnownDisorders

Compliancewith Long-TermTreatment(Goal: Reduction inRelapse a nd Recurrence)

Aftercare(Including

Rehabilitation)

Prev

entio

n

TreatmentM

aintenance

Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

Indicated—Diagnosed Youth

Selective—Health RiskGroups

Universal—General Population

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No No ProblemsProblems

Universal/Selective Universal/Selective PreventionPrevention

Brief InterventionBrief Intervention

TreatmentTreatment

Mild Mild ProblemsProblems

Moderate Moderate ProblemsProblems

Severe Severe ProblemsProblems

Thresholds for ActionThresholds for Action

Spectrum of Intervention Responses

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Ecological Model

IndividualPeer/FamilySociety Community/Tribe

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IndividualGenetics

Personality

Attitudesbeliefs

Interpersonal

Community

Parents Peers

Schools Local legal

Personal situations

Portrayal in media

Culturalbeliefs

Stigma

National attitudes

Individual

Environmental Interpersonal societal

Tribalattitudes

Stateattitudes

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Prevention

• Primary

• Risk factors

• Protective factors

• Prevent 1st use

• Secondary

• Prevent kids who use from continuing

• Prevent kids who misuse from experiencing use related problems or dependency

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Implications for Treatment

• Teach adolescents how to cope with difficulties and adversity

• Increase their repertoire of coping strategies

• Cognitive therapy is most effective approach

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Treatment Settings - Social Support

• Tribal

• Community

• Family

• Sibs

• Peers

• Individual

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Evidence-Based Practices for Alcohol Treatment

• Brief intervention• Social skills training• Motivational enhancement• Community reinforcement• Behavioral contracting

Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd ed., pp 12 – 44). Boston: Allyn & Bacon.

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Scientifically-Based Approaches

to Addiction Treatment• Cognitive–behavioral interventions• Community reinforcement• Motivational enhancement therapy• 12-step facilitation• Contingency management • Pharmacological therapies• Systems treatment

1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse.

2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

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Alcohol/Drug Treatment Alcohol/Drug Treatment CoreCore Components Components and and ComprehensiveComprehensive Services Services

MedicalMedicalMental Mental HealthHealth

VocationalVocational

EducationalEducational

LegalLegalAIDS / HIV AIDS / HIV

RisksRisks

FinancialFinancial

Housing & Housing & TransportationTransportation

Child CareChild Care

FamilyFamily

Continuing Care

Case Management

Urine Monitoring

Self-Help(AA/NA)

Pharmaco-therapy

Group/Individual Counseling

AbstinenceBasedIntake

Assessment

Treatment Plans

CoreCoreTreatmentTreatment

Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)

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Cultural Approach

• Original Holistic Approach• Psychopharmacology Approach• The unconscious has always been there• Group Therapy• Network Therapy• Recreational / Outdoors• Traditional Interventions• Indian is...

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Unified Services PlanCase management should address:

• Mental health• Education/vocation• Leisure/social• Parenting/family• Housing• Financial• Daily living skills• Physical health

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Contact us at503-494-3703E-mail Dale Walker, MDonesky@ohsu.eduOr visit our website:www.oneskycenter.org