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1
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, [email protected] visit our website:www.oneskycenter.org