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group 757Between 2009 and 2011, two tribal communities located approximately 3,000 miles apart—an American Indian tribe on a reservation in New Mexico and a group of closely knit Alaska Native villages in western Alaska—experienced clusters of youth suicides. Across these communities, 25 young people, all American Indian or Alaska Native (AI/AN), took their own lives. At least 28 others attempted suicide, 19 of whom were hospitalized, and more than 60 other young people were identified as being suicidal. Many other reservations and tribal villages have experienced, and continue to experience, similar

tragedies, including an Alaskan village in the same region, where nine young people attempted suicide in 2013.

Researchers note that one of the most distinctive features about suicide clusters is that they occur almost exclusively among teenagers (Gould, 2003; Hazel, 1993). While suicide clusters are relatively rare events, accounting for fewer than 5 percent of all suicides in teenagers and young adults (Gould, Wallenstein, and Kleinman, 1987; Gould, 2003), one study found that the relative risk of suicide following exposure to another individual’s suicide was 2 to 4 times higher among 15- to 19-year-olds than among other age groups (Gould et al., 1990). Similar age-specific patterns have been reported for clusters of attempted suicides (Gould et al., 1994). Some researchers report that, compared to adults, youth are more susceptible to suicide behavior modeling, social norming of suicidal behavior (often described as “contagion”), and imitating suicide methods (Haw et al., 2013). This susceptibility has been described as particularly acute among higher risk subgroups of youth such as AI/AN young people (Brave Heart & DeBruyn, 1998; Bechtold, 1988; Wissow, Walkup, Barlow, Reid, & Kane, 2001), especially those who live in small, intense social networks in remote villages or on rural reservations (Goldston et al., 2008). Researchers found that American Indian youth who spent two-thirds or more of their lives on a reservation were at higher risk for suicidal ideation and suicide attempts compared to American Indian youth who spent the majority of their lives in an urban area (Freedenthal & Stiffman, 2004). While additional research is needed to understand the contributing factors, some research has pointed to considerable exposure that AI/AN youth have to suicide on isolated reservations and in rural villages (Bender, 2006).

Within a number of tribal communities experiencing clusters, including some in New Mexico and Alaska, local and regional leaders have declared states of emergency and dispatched crisis response teams to contain and prevent additional suicides. The teams provide support for families and community members as they work toward recovery. Local and regional leaders have also intensified efforts, in partnership with state and federal governments, to direct suicide prevention funding and programming

to disproportionately impacted communities, many of which are located in isolated, rural areas with limited health infrastructure and crisis response resources.

The purpose of this report is to learn about suicide clusters and responses in tribal communities; identify strength-based approaches to prevention, response, and recovery; explore existing and needed resources for prevention, response, and recovery; and provide recommendations for tribal communities, and for federal, state, and partners.

The authors of this report used a qualitative methodology to learn more about the events and responses within the two tribal communities in Alaska and New Mexico that experienced clusters between 2009 and 2011. The principal sources of information were community members identified through their involvement with SAMHSA-funded programs (i.e., Native Aspirations or Garrett Lee Smith Youth Suicide Prevention and Early Intervention Program), recommended by tribal/village leadership, or both.

Individuals chosen to be interviewed reflected a variety of perspectives and included elders; tribal leaders; teachers and school personnel; mental health and other youth service providers; young people who lost peers to suicide; and mothers, fathers, grandparents, and other tribal members who lost family members to suicide. The categories are not mutually exclusive, with many interviewees providing multiple perspectives.

This report includes:

 Background information based on research literature, media reports, and surveillance data regarding suicide rates in the affected communities; clusters and contagion; risk and protective factors in tribal communities; and contextual information about the regions where the cluster events occurred. This includes the local health service infrastructure and access to behavioral health resources, as well as the impact and response to the clusters in each community;

 A description of data sources used for this report, including interviews and document reviews;

 Findings related to the impact of clusters on individuals and communities, community response and recovery, suicide prevention strategies, and existing and needed community resources; and

 A discussion of the findings as they relate to future resources to prevent and respond to suicide clusters in AI/AN communities.


National Backdrop

Suicide is a significant public health problem in the United States, with the rates of suicide within some populations being particularly high. Suicide is the second- leading cause of death for AI/AN youth and young adults aged 10–24 years (NCHS,

Exhibit 1. Suicide Rates among Youths Aged 10 to 24, by Race/Ethnicity and Sex, United States, 2005–2011*

2011a). The suicide rate for this group is two to four times the rate of other Americans in this age group (NCHS, 2011b; Exhibit 1). While the suicide rate decreased slightly for AI/AN people in the United States between 2010 and 2011, this population continues to experience one of the highest suicide rates of all racial and ethnic groups tracked by the Centers for Disease Control and Prevention (CDC; NCHS, 2011b). Within some states, overall suicide rates are much higher than the national average, with the highest rates occurring in Alaska, the Rocky Mountain states, and in the Southwest region, including New Mexico (NCHS, 2011b; American Foundation for Suicide Prevention, 2014; Exhibit 2). In general, states in the West consistently experience higher suicide rates than states in the Northeast, Southeast, and Midwest. For example, between 2005 and 2011, five western states had average age-adjusted rates that were more than 19 per 100,000: Alaska (21.24), Montana (21.01), Wyoming (20.88), New Mexico (19.40), and Nevada (19.06). This is nearly double the overall U.S. age-adjusted rate of 11.57 per 100,000, over the same time period (Exhibit 2).

Exhibit 2. National Suicide Rates

*Age-adjusted suicide rates per 100,000 population by state, 2005-2011 (NCHS, 2011b)

In Alaska and New Mexico, suicide rates among AI/AN youth are significantly higher than rates among youth from other cultural or ethnic groups. Suicide is currently the leading cause of death for AI/AN youth aged 15–24 living in Alaska (NCHS, 2011a), with a rate more than nine times that of all youth within that age range in the United States (98.88 and 10.04 per 100,000, respectively). At 152.83 per

100,000, the suicide rate for AI/AN males aged 15–24 years in Alaska is nearly nine times that for all males aged 15–24 in the United States (16.23 per 100,000). Young AI/AN females in Alaska die by suicide 11 times more often than all U.S. females in that age group (41.02 and 3.53, respectively; NCHS, 2011b).

While youth suicide rates are lower in New Mexico than in Alaska, New Mexico nevertheless exhibits a similar trend. The suicide rate for AI/AN youth aged 15–24 years is more than three times the rate for all youth within that age group in the United States (33.03 and 10.04 per 100,000, respectively). For young AI/AN males, the rate is 49.15 per 100,000, over three times the rate for all males that age in the United States. For young AI/AN females, the rate is 16.44 per 100,000, over four times the rate for all females that age in the United States (NCHS, 2011b).

Suicide Clusters and Contagion

A suicide cluster can be defined as “a group of suicides or suicide attempts, or both, that occur closer together in time and space than would normally be expected on the basis of statistical prediction or community expectation” (CDC, 1988; Gould, Jamieson & Romer, 2003). There are two main types of suicide clusters: point and mass (Haw, Hawton, Niedzwiedz, & Platt, 2013; Joiner, 1999; Rezaeian, 2012). Point clusters are close in both location and time, occur in small communities, and involve an increase in suicides above a baseline rate observed in the community and surrounding area (Haw, Hawton, Niedzwiedz, & Platt, 2013; Joiner, 1999; Rezaeian, 2012; Cox et al., 2012). Mass clusters involve a temporary increase in suicides across a whole population, close in time but not necessarily location.

Mass clusters have been documented following suicides of high-profile celebrities or others who receive considerable media attention (Cox et al., 2012; Joiner, 1999).

In her literature review of the impact of media coverage on suicide, Gould provides evidence that extensive newspaper coverage of suicide is associated with a significant increase in the rate of suicide, with the magnitude of the increase proportional to the amount, duration, and prominence of media coverage (2001). Young people appear to be particularly susceptible to heightened risk brought about by certain types of media reporting of suicide (Gould, Jamieson, & Romer, 2003). A retrospective, case- control study of suicide clusters in young people in the United States between 1988 and 1996 (before the arrival of social media) indicated an association between certain kinds of newspaper reports about suicide and the beginning of clusters (Gould et. al., 2014). Story characteristics involving front-page placement, headlines containing the word suicide or a description of the method used, and detailed descriptions of the suicidal person appeared more often for cluster-related suicides than non-cluster suicides (Gould et al., 2014).

While the mechanisms underlying suicide clusters are unclear, it has been proposed that point clusters may result from a process of “contagion,” whereby one person’s suicidal thoughts and behaviors are transmitted from one victim to another through social or interpersonal connections (Cox et al., 2012; Joiner, 1999). According to some researchers, a suicide contagion is similar to the spread of infectious disease (Haw, Hawton, Niedzwiedz, & Platt, 2013). Just as flu is most likely to affect individuals with weakened immunity, in poor health, and in close contact with someone who is sick, suicide is more likely

to affect individuals with a history of mental illness, who are close friends or relatives of the person who died by suicide, and who are experiencing poor mental health (Haw, Hawton, Niedzwiedz, & Platt, 2013). Other researchers have cautioned that suicide contagion has yet to be clearly defined (Joiner, 1999).

The suicide clusters discussed in this report are point clusters that occurred in two tightly knit and geographically isolated communities. The affected Alaskan villages are not on the road system and are accessible only by small plane, which forces a higher level of self- and communal reliance. Most individuals are related through blood or marriage. In the case of the Alaska community, extended family and relations live in nearby villages that essentially function as a single community. Thus, when a suicide occurs in one village, it immediately impacts residents in neighboring communities.

Risk and Protective Factors

Suicide risk factors among AI/AN youth are well-known and have been widely reported. Many AI/AN youth face poverty, isolation, historical trauma, discrimination and racism, disrupted family units, previous suicide attempt(s), access to lethal means, exposure to others who have died by suicide, physical or sexual abuse, barriers to care, high rates of alcohol and drug use, and interpersonal violence (Alakanuk Community Planning Group et al., 2009; BigFoot, 2007; Borowsky, Ireland, & Resnick, 2001; Borowsky, Resnick, Ireland, & Blum, 1999; Christman, 2012; Duran & Duran, 1995; Yoder, 2006).

Growing up in two cultures that have very different world views can create cumulative stresses that may increase susceptibility (LaFromboise & BigFoot, 1988). Moreover, the estimated probability of attempting suicide dramatically increases as the number of risk factors to which youth are exposed increases (Borowsky et al., 1999; Borowsky et al., 2001).

Haw and colleagues (2012) reviewed the literature on suicide clusters to describe the risk factors and proposed psychological mechanisms underlying point clusters. The authors identified two kinds of literature: (1) papers describing individual suicide clusters, which included characteristics of cluster victims and environmental risk factors; and (2) papers hypothesizing the mechanisms underlying cluster formation and, which in a few cases also provided empirical data testing a specific hypothesis. The review found that risk factors for suicide clusters are similar to risk factors for suicide in general. The authors conclude that nearly all cluster studies were uncontrolled and involved relatively small numbers of suicides, and that further research is needed to improve understanding of the mechanisms involved.

group 59“Circles of vulnerability” (Exhibit 3) is a model that may provide insight into mechanisms of suicide clusters. Developed to assess community trauma, the model considers geographical proximity, psychosocial proximity, and population at risk (Lahad & Cohen, 2006; Zenere, 2008, 2009).

Geographical proximity is the physical distance from the initial suicide; psychosocial proximity is the closeness of the relationship with the person

Exhibit 3. Circles of Vulnerability

who died; and population at risk refers to an individual’s risk factors, such as mental illness, history of trauma, substance misuse, and history of suicidal thoughts and behaviors (Zenere, 2008, 2009). The intersection of the three circles reflects the point of highest vulnerability.

Through the lens of this model, the risk profile of Native youth is often quite high. Community members typically live in close proximity and are related to one another; adolescent social networks are small and intense (Goldston et al., 2008); and individual risk factors (e.g., alcohol use, depression, the death of family and friends by suicide) tend to mount and multiply (BigFoot, 2007). While youth connectedness to family and community is generally a protective factor, it can also become part of the contagion process if young people begin to perceive suicidal behavior as normal among their peers or people they admire (Action Alliance, 2014).

A social ecological model is also useful for understanding risk and protective factors across four levels: individual, relationship, community, and societal (U.S. HHS and NAASP, 2012). Some factors are at the individual level, but many transcend the person and are influences of the larger community. As Gone and Alcántara (2007) state in a paraphrase of Felner and Felner’s (1989) transactional ecological framework, the “roots of pathology can be and often are outside of the person.” Categorizing risk and protective factors within the model’s levels shows the factors’ complexity, the interaction and relationship between and across such levels, and possible strategies and entry points for prevention and intervention.

Consideration of community- and societal-level risk factors is particularly important for AI/AN populations, as “indigenous suicide is associated with cultural and community disruptions, namely, social disorganization, culture loss, and a collective suffering” (Wexler & Gone, 2012, p. 800). Among the risk factors for suicide unique to AI/AN youth, these communities continue to be impacted by historical trauma stemming from colonization and loss of connection to spiritual and cultural practices (Brave Heart, Chase, Elkins, & Altschul, 2011).

rectangle 58group 54Historical trauma is the “cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma experiences” (Brave Heart, 2003). A primary feature of historical trauma is that “the psychological and emotional consequences of the trauma experience are transmitted to subsequent generations

through physiological, environmental and social pathways resulting in an intergenerational cycle of trauma response” (Sotero, 2006). Suicidal ideation and behavior, substance misuse, depression, anxiety, low self-esteem, anger, and difficulty recognizing and expressing emotions have all been identified as components of the historical trauma response (Brave Heart, 2003).

Efforts by the United States to assimilate American Indians into the European-American mainstream culture and “to end the tribe as a separate political and cultural unit” (Cohen, 1982 ed., p. 139) are well- documented and include polices such as criminalizing traditional tribal governance and cultural

practices, such as funeral procedures and specific dances and ceremonies (Cohen, 1982 ed., pp. 128- 145). Efforts to use boarding schools to force assimilation of Native children spanned from 1790 through 1920 (Hoxie, 1984). Children were removed from traditional families (including extended family and clan system cultures) and from other traditional forms of social organization and sources for identity development, to live in boarding schools, where they were often verbally, physically, and sexually abused (Napoleon, 1996). Brave Heart (1999) discusses the process of boarding schools depriving families of traditional Native parenting role models, “impairing their capacity to parent within an indigenous health cultural milieu.” The cultural anchors that should have served to ground and enhance healthy development—from childhood through adulthood and parenthood—were missing, and, in many cases, dysfunction was left in its place.

A number of studies have also looked at protective factors among American Indian and Alaska Native youth. Perceived connectedness to family; discussing problems with friends or family; consistent, healthy attachment to family and school; traditional cultural values and practices; emotional health and well-being; and access to mental health services have all been identified as protective against suicide attempts (Borowsky et al., 1999; Borowsky et al., 2001; Kral et al., 2011). Similarly, Wolsko and colleagues (2009) found that tribal members who follow a more traditional way of life reported greater happiness, more frequent use of religion and spirituality to cope with stress, and less frequent use of drugs and alcohol to cope with stress. Garroutte et al. (2003) found “a strong and persistent protective association between cultural spiritual orientations and [lifetime self-reported] suicide attempts” (p.

1576), even when risk factors such as substance misuse and psychological distress are experienced. They defined “Cultural spiritual orientations” not as belief systems, but as “ways of encountering and interpreting self, world, and experiences….[that] reflect American Indian cultural views of the connectedness of humans to all other physical and transcendental entities” (Garroutte et al., p. 1573). Moreover, connectedness is protective when it occurs within and between multiple levels of the social ecology—between individuals, families, schools and other organizations, neighborhoods, cultural groups, and society as a whole (Action Alliance, 2014).

Preventing and Responding to Suicide Clusters

group 49One of the most widely cited documents about preventing and managing suicide clusters is CDC’s “Recommendations for a Community Plan

for the Prevention and Containment of Suicide Clusters” (CDC, 1988). The recommendations underscore the critical importance of developing community plans before suicide clusters occur and they guide community leaders and stakeholders in developing specific strategies. This helps accelerate prevention efforts and facilitates swift, coordinated, and effective response in the event of a cluster. The document

suggests that such a response plan should be implemented in two circumstances: (1) when a suicide cluster occurs in the community or (2) when one or more traumatic deaths1 occur in the community, especially among adolescents or young adults, who may be at higher risk for contagion. Related to the second circumstance, CDC notes that “several clusters of suicides or suicide attempts (have been) preceded by one or more traumatic deaths—intentional or unintentional—among the youth of the community” (CDC, 1988, p. 5).

CDC’s recommendations are based on the experts’ experiences and lessons learned assisting various local communities in addressing suicide clusters. One key example is the fact that community leaders responding to an evolving suicide cluster face the simultaneous tasks of attempting to prevent the cluster from expanding, while also managing the existing crisis (Askland, Sonnenfeld & Crosby, 2003; Office of Safe and Drug-Free Schools, 2007). To ensure the timeliest reaction possible, the recommendations urge that the response plan and roles of each participant be developed, agreed upon, and understood by all relevant participants before the onset of a crisis.

The recommendations emphasize the need for including all sectors of the community (e.g., public health, mental health, education, local government, clergy, parent groups, the media, community organizations) in planning and the implementing the prevention and response effort. With the goal of building a coordinated, collaborative initiative, CDC urges that “[e]very effort should be made to promote and implement the proposed plan as a community endeavor.… No single agency … has the resources or expertise to adequately respond to an evolving suicide cluster” (CDC, 1988, p. 3). The document stresses the need to include representatives of the local media in developing the plan, to ensure that the “legitimate need for information” can be satisfied without the kind of sensationalized reporting that has been shown to contribute to suicide contagion.

group 45Overall, the document presents a set of broad principles and sequentially ordered steps that local communities can undertake to prevent and plan for clusters as part of their overall suicide prevention planning process. The recommendations emphasize that community prevention and response plans must be adapted to the particular needs, resources, and cultural characteristics of the community.

A 2012 literature review aimed at understanding effective prevention and

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1 Traumatic death refers to any death in the community that is not the result of old age or sickness.

postvention2 strategies for suicide clusters (Cox et al.) found that few studies actually documented response strategies and only one evaluated its efforts. However, the authors identified a number of strategies that show promise, including six common approaches to cluster containment frequently adopted by communities and schools (see text box).

Suicide Settings of Focus: Cluster Locations and Responses

Tr i b e i n N ew M e xi c o

In New Mexico, the suicide cluster occurred on a tribal reservation3 located in the U.S. Indian Health Service’s (IHS’s) Albuquerque Area. The Albuquerque Area, which extends over most of New Mexico and all of Colorado, provides health services to American Indians in numerous tribal groups, each with their own history, language, and culture (IHS, n.d.). In the New Mexico portion of the Albuquerque Area (Exhibit 4), the tribes served include the 19 Pueblos, the Jicarilla and Mescalero Apaches, and the Alamo, Canoncito, and Ramah chapters of the Navajo Nation. While the previous generations of the affected tribe were nomadic hunters and gatherers, tribal members now fish, hunt, manage ranches, and support an active tourist industry (IHS, n.d.).

Exhibit 4. New Mexico IHS Albuquerque Service Area and Tribal Lands

In response to the suicide cluster, which involved not only multiple deaths but many attempts and expressions of suicidal ideation (strong thoughts of engaging in suicidal behavior), the community

formed a crisis response team to determine priorities, strategies, and steps for prevention and containment. Consistent with CDC recommendations, the response reflected broad collaboration among tribal, local, county, state and federal programs and partner agencies. Examples of actions included providing assessment training and support for emergency medical service providers, Bureau of Indian Affairs law enforcement officers, tribal conservation officers, and medical providers. Law enforcement officials agreed to notify and involve the IHS within 24 hours of any suicide attempt or threat. The crisis response team planned suicide prevention awareness trainings in schools and other community settings. The community provided outreach to tribal youth in tribal and public schools

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2 Suicide postvention is defined as “Response to and care for individuals affected in the aftermath of a suicide attempt of suicide death” (U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention, 2010, p. 141). The goals of postvention may include (1) supporting the bereaved survivors, (2) preventing imitative suicides by identifying other individuals at risk for self-destructive behavior and connecting them to intervention services, (3) reducing survivor identification with the deceased, and

(4) providing long-term surveillance (Gould & Kramer, 2001).

3 The specific location of the clusters and related details will not be disclosed in this document to maintain the confidentiality of interview participants.

across four communities, offering health services, mental health services, and suicide prevention activities, including evening events.

Just prior to the cluster, the tribe had begun developing a suicide prevention team with federal grant funding from the Substance Abuse and Mental Health Services Administration (SAMHSA). As the cluster evolved, the team implemented numerous suicide prevention programs, including a peer-to-peer program modeled after “Natural Helpers,” which had been previously used with success in a tribal community (May et al., 2005). Serna describes Natural Helpers as a “peer-helping and leadership development program based on the premise that within every school an informal ‘helping network’ exists among peers. Students with problems seek out other students whom they trust.” (2011) In adapting the program to their community, the New Mexico tribal suicide prevention team surveyed students to understand sources of distress in their lives and identified “natural” peer supporters among students. The team taught the peers how to mentor students who were struggling, encourage them to talk with their support networks, and seek out adult counseling. The team also integrated social media to reach youth and identify students at risk of suicide.

The tribe falls within the IHS Albuquerque Area, which is divided into ten service units, each of which provides services at the community level (IHS, n.d.). The local IHS Service Unit includes inpatient and outpatient services, as well as field health programs. Specialized services (e.g., surgical and orthopedic care) are referred to contract hospitals in the region. At the time of the cluster, the IHS Service Unit mental health clinic employed two independently licensed counselors. Other mental health resources, including clinical psychologists, psychiatrists, social workers, etc. were more than 200 miles from the tribal setting for this cluster—not an uncommon scenario for rural, tribal communities. Access to behavioral health services was further limited because several tribal substance use provider positions were vacant.

When the cluster developed, the IHS director, in concert with the tribe, requested and received a 90-day deployment of United States Public Health Service mental health teams to stabilize and address the high number of attempted and completed suicides. The teams worked with four school districts and communities, providing counseling services to students and staff, and implementing processes to track and monitor suicide-related data (e.g., numbers of suicide attempts, the age of the person, whether drugs or alcohol were involved). Additionally, IHS instituted a telebehavioral health service to connect local residents with behavioral health staff in other areas.

V i ll ag e s in W e s te rn A l a sk a

This report focuses on three Yup’ik or Cup’ik communities located on the Bering Sea coast, with populations ranging from 530 to 1,100.

The high rates of suicide—beyond what would be expected—across many villages in the Yukon- Kuskokwim (YK) Tribal Health Region (Exhibit 5) mean that there are almost continual suicide clusters in the region. Often referred to as the YK Delta, this area has one of the highest suicide rates (58.2 per 100,000) in the state and the country. The rate is nearly 3 times higher than Alaska as a whole (21.28)

and more than 5 times higher than the United States (11.38) (Alaska Bureau of Vital Statistics, 2002— 2011; NCHS, 2011b).

The YK Tribal Health Region covers approximately 58,000 square miles and is home to 58 federally recognized Yup’ik, Cup’ik, and Athabascan tribes (Yukon-Kuskokwim Health Corporation [YKHC], n.d.). The region’s 25,555 residents, 82 percent of whom are Alaska Native, live in 50 villages ranging in size from 6 to 1,100 residents (U.S. Census Bureau, 2012; YKHC, 2011 – 2014). All of the villages within the region are accessible only by small plane or by snow machine trails in winter.

The town of Bethel serves as the regional hub community and is home to 6,080 residents (U.S. Census Bureau, 2012). Various air taxis provide

Exhibit 5. Yukon-Kuskokwim Tribal Health Region

regular, albeit expensive, service between Bethel and the villages. Round-trip tickets between Bethel and the villages cost between $200 and $700, depending on the distance (ERA Alaska, 2014).

In the Yup’ik or Cup’ik communities impacted by continual suicide clusters, the region’s main health care provider (YKHC) deploys a crisis response team of behavioral health providers. The team provides mental health counseling (including talking circles4) for families who lose loved ones to suicide, and debriefing and postvention services for first responders. YKHC and federal and state programs, including suicide prevention programs, have worked with the communities to develop prevention plans that engage youth and limit high-risk behaviors such as alcohol and drug use. Village schools take an active role in community response by increasing their emphasis on the social and emotional well-being of students. The schools positively acknowledge youth and implement the Natural Helpers peer-to-peer program.

Village tribal councils respond to suicide clusters by calling community meetings to discuss the impact of suicide, its relation to historical trauma and to drug and alcohol use, and contemporary and traditional ways to heal. In direct response to the high numbers of suicide that affected the region in 2010, Alaska Senator Lisa Murkowski convened a summit, a joint effort involving the governor, members of the Alaska Suicide Prevention Council, the SAMHSA tribal affairs advisor, and members of the U.S. Senate Indian Affairs Committee. Summit participants discussed the high rates of suicide in western Alaska and heard from young people about ways to better address the problem (DeMarban, 2010).

The YKHC, located in the hub community of Bethel, is the regional tribal health consortium and main health care provider for the villages in the YK service area (Exhibit 6), provides hospital, dental, and

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4 The talking circle is a traditional way for tribal people to solve problems. There is no beginning nor end in a circle; thus, no one person is in a position of prominence. The talking circle creates an environment where people can speak freely, air their differences, and resolve problems.

behavioral health care; health promotion and disease prevention; and environmental health services (YKHC, 2014). YKHC also provides basic health services within the villages, through clinics staffed by Community Health Aides (CHAs). These local individuals are the frontline of medical care and support within their villages. CHAs are certified at the CHA I, II, III and Practitioner (CHAP) levels and are selected by their communities to receive training for their roles. For each level, the training lasts approximately 3 weeks (Alaska CHAP, n.d.). CHAs operate in an established referral relationship with mid-level providers, physicians, and the regional hospitals (Alaska CHAP, n.d.). Within the YK Delta, there are also five subregional clinics, each of which serves the villages within its subregion. Subregional clinics offer a higher
Exhibit 6. Yukon-Kuskokwim Service Area

level of service than the village clinics and include preventative and urgent care, as well as laboratory and X-ray services. The subregional clinics are staffed with at least one mid-level provider, typically a nurse practitioner or physician assistant. Subregional clinics provide ancillary services (e.g., dental, behavioral health), often in the form of traveling care to the handful of villages in their sub-region.

Comprehensive mental health and substance use services (including inpatient and outpatient services) are available at the YKHC in Bethel. However, access to comprehensive behavioral health services requires leaving the village via bush plane.

To increase access to mental health services in villages, in 2004 the Alaska Native Tribal Health Consortium (ANTHC) collaborated with IHS to institute a statewide behavioral health workforce model that was similar to the CHA. By 2008, the Behavioral Health Aide (BHA) program had been incorporated into the federally recognized Community Health Aide Program. The existing Community Health Aide Certification Board Standards and Procedures were amended to include standards for Behavioral Health Aides (BHA I, II, III and Behavioral Health Practitioner (BHP) certification and practice (ANTHC, 2005– 2014). Like CHA/Ps, BHA/Ps’s have a limited scope of practice and serve as health educators and advocates within their communities (ANTHC, 2005–2014; van Hecke, 2012). Practicing under the supervision of licensed clinicians based in the regional hubs, BHAs I, II and III provide case management, referral, community education, and prevention services; BHPs also provide treatment planning and community evaluations (van Hecke, 2012).

While every western Alaska village does not have a BHA program, those that do select residents of their own village, fluent in the culture of the community, who is a welcoming and familiar face. However, given the close-knit nature of the communities, concerns about confidentiality and shame about behavioral health may limit service utilization. Community members are often reluctant to seek care from individuals they have known, in many cases, their entire lives (van Hecke, 2012).

Available in some villages for 10 years, telebehavioral health is an alternative venue for receiving care and may help allay privacy concerns. But even with the addition of the BHA program and access to telebehavioral health, access to behavioral health care is extremely limited and simply out of reach for many Alaska Natives.

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