Addictions and Mental Health Approaches in Native Populations

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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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Native Communities
Advisory Council / Steering Committee
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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Percentage using any illicit drugs in the past
year
Total Female Male Total
11.9 9.8 14.1 Native American 19.8 23.3 15.6 N
on-Hispanic White 11.8 9.9 13.9 Non-Hispanic
Black 13.1 10.2 16.6 Hispanic Central
American 5.7 4.2 7.7 Hispanic Cuban
8.2 5.5 11.4 Hispanic Mexican 12.7 9.2 15.8

Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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Percentage reporting dependence on alcohol
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.
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Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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Lifetime History
Mental Disorder 22.5 Comorbidity 29 3.1
1.5 1.7 1.1
Alcohol Disorder 13.5 Comorbidity 45
Drug Disorder 6.1 Comorbidity 72
Regier, 1990
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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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Different goals
Resource silos
One size fits all
Activity-driven
How is it working?
(Carl Bell, 7/03)
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Best Practice
Culturally specific
Outcome driven
Integrating resources
We need Collaboration, Integration, and Synergy
Community Mobilization
(Carl Bell, 7/03)
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Indigenous Knowledge
Definitions

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

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Traditional Medicine
Definitions

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

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Evidence-based Practices
Definitions

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

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Best Practices
Definitions

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

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World Conference on Science
A partnership begins!

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

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ID Best Practice
Best Practice
Clinical/Services Research
Mainstream Practice
Traditional Healing
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Circle of Care
Traditional Healers
Child Adolescent Programs
Primary Care
Best Practices
AD Programs
Boarding Schools
Colleges Universities
Prevention Programs
Emergency Rooms
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The Intervention Spectrum for Behavioral
Disorders
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Source Mrazek, P.J. and Haggerty, R.J. (eds.),
Reducing Risks for Mental Disorders, Institute of
Medicine, Washington, DC National Academy
Press, 1994.
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Spectrum of Intervention Responses
Thresholds for Action
No Problems
Mild Problems
Severe Problems
Moderate Problems
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Ecological Model
Individual
Peer/Family
Society
Community/ Tribe
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Interpersonal societal
Environmental
Stigma
Community
Tribal attitudes
Parents
Peers
National attitudes
Personality
Attitudes beliefs
Individual
Genetics
Cultural beliefs
Schools
Local legal
Interpersonal
State attitudes
Personal situations
Individual
Portrayal in media
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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

• Cognitivebehavioral interventions
• Community reinforcement
• Motivational enhancement therapy
• 12-step facilitation
• Contingency management
• Pharmacological therapies
• Systems treatment
• L. Onken (2002). Personal Communication.
  National Institute on Drug Abuse.
• Principles of Drug Addiction Treatment A
  research-based guide (1999). National Institute
  on Drug Abuse

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Alcohol/Drug Treatment Core Components and
Comprehensive Services
Medical
Mental Health
Financial
Vocational
Housing Transportation
Educational
Child Care
Legal
Family
AIDS / HIV Risks
Etheridge, Hubbard, Anderson, Craddock, Flynn,
1997 (PAB)
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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 Plan

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

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Contact us at 503-494-3703 E-mail Dale Walker,
MD onesky_at_ohsu.edu Or visit our
website www.oneskycenter.org