[Senate Hearing 111-610]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 111-610

THE PREVENTABLE EPIDEMIC: YOUTH SUICIDES AND THE URGENT NEED FOR MENTAL 
                HEALTH CARE RESOURCES IN INDIAN COUNTRY

=======================================================================

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             March 25, 2010

                               __________

         Printed for the use of the Committee on Indian Affairs





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                      COMMITTEE ON INDIAN AFFAIRS

                BYRON L. DORGAN, North Dakota, Chairman
                 JOHN BARRASSO, Wyoming, Vice Chairman
DANIEL K. INOUYE, Hawaii             JOHN McCAIN, Arizona
KENT CONRAD, North Dakota            LISA MURKOWSKI, Alaska
DANIEL K. AKAKA, Hawaii              TOM COBURN, M.D., Oklahoma
TIM JOHNSON, South Dakota            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           MIKE JOHANNS, Nebraska
JON TESTER, Montana
TOM UDALL, New Mexico
AL FRANKEN, Minnesota
      Allison C. Binney, Majority Staff Director and Chief Counsel
     David A. Mullon Jr., Minority Staff Director and Chief Counsel










                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on March 25, 2010...................................     1

Statement of Senator Dorgan......................................    10
Statement of Senator Franken.....................................     1

                               Witnesses

Clayton, Paula J., M.D., Medical Director, American Foundation 
  for Suicide Prevention.........................................    15
    Prepared statement with attachment...........................    17
Grinnell, Randy E., Deputy Director, Indian Health Service, U.S. 
  Department of Health and Human Services; accompanied by Rose 
  Weahkee, Director, Division of Behavioral Health...............     2
    Prepared statement...........................................     4
Mangas, Coloradas, Sophomore, Ruidoso High School, Mescalero 
  Apache Reservation, NM.........................................    11
    Prepared statement...........................................    13

Listening Session held on March 25, 2010.........................    21

Binney, Allison C., Majority Staff Director/Chief Counsel, Senate 
  Committee on Indian Affairs; accompanied by Rhonda Harjo, 
  Deputy Chief Counsel...........................................    21

                               Witnesses

Flynn, Laurie, Executive Director, TeenScreen National Center for 
  Mental Health Checkups, Columbia University....................    21
    Prepared statement...........................................    23
Genia, Hunter, Administrator, Behavior Health Services, Saginaw 
  Chippewa Tribe.................................................    29
    Prepared statement with attachment...........................    32
Goklish, Novalene, Senior Program Coordinator, White Mountain 
  Apache Youth Suicide Prevention Program........................    35
    Prepared statement...........................................    37

                                Appendix

McCartney, Kevin, Senior Vice President of Government Relations, 
  Boys & Girls Clubs of America, prepared statement..............    68
Response to written questions submitted by Hon. Byron L. Dorgan 
  to:
    Paula J. Clayton, M.D........................................    79
    Novalene Goklish.............................................    84
    Randy E. Grinnell............................................    74
    Hunter Genia.................................................    82
Response to written questions submitted by Hon. Al Franken to:
    Paula J. Clayton, M.D........................................    82
    Novalene Goklish.............................................    89
    Randy E. Grinnell............................................    78
Response to written questions submitted by Hon. John Barrasso to:
    Paula J. Clayton, M.D........................................    81
    Novalene Goklish.............................................    88
Watkins, Julia M., Executive Director, Council on Social Work 
  Education (CSWE), prepared statement...........................    68
Weiler, Mary J., Board Chair, American Foundation for Suicide 
  Prevention, North Dakota Chapter, prepared statement with 
  attachment.....................................................    70
Zapol, Dr. Warren, Commissioner, U.S. Arctic Research Commission, 
  prepared statement.............................................    65

 
                    THE PREVENTABLE EPIDEMIC: YOUTH 
   SUICIDES AND THE URGENT NEED FOR MENTAL HEALTH CARE RESOURCES IN 
                             INDIAN COUNTRY

                              ----------                              


                        THURSDAY, MARCH 25, 2010


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:37 a.m. in room 
628, Dirksen Senate Office Building, Hon. Byron L. Dorgan, 
Chairman of the Committee, presiding.

             OPENING STATEMENT OF HON. AL FRANKEN, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Franken. [Presiding.] I call the hearing to order.
    The Chairman, Senator Dorgan, will be here shortly. This is 
a hearing on a topic of great importance to our American Indian 
communities in Minnesota and across the Country. On behalf of 
the Minnesota tribes, I want to thank the Chairman for his 
leadership in getting the Indian Health Improvement Act 
included in the health reform law.
    American Indian teens commit suicide at rate nearly three 
times the national average, and the rate is much higher in the 
Upper Midwest and the Great Plains, five to seven times higher 
than the national average.
    Each suicide is an unspeakable tragedy from which families 
and communities will never recover. We must learn from these 
tragedies. We must find models and fund programs that work to 
prevent suicide in Native communities.
    As you may know, this month is the fifth anniversary of the 
Red Lake massacre, and so I want to share with you an example 
of how the learning continues in the Red Lake community even in 
the face of ongoing challenges.
    Last spring, Red Lake High School tragically lost another 
student to suicide. Based on the changes at the school 
following the 2005 tragedy, the school immediately brought in 
what is called a CBTS team, Cognitive Behavioral Trauma in 
School, following the suicide. The CBTS team of mental health 
providers from Montana has a history with tribal communities 
and worked with the school to assess the community's needs 
following the suicide.
    During the assessment, mental health workers discovered 
that there was a suicide pact, that six other students had 
plans to take their own lives. Fortunately, the team was able 
to intervene and get students appropriate treatment. And now 
these six students are back in school. Clearly, this model 
worked by intervening early and minimizing more damage, and 
clearly we have a problem as long as any suicide is occurring 
among our youth.
    I look forward to hearing from today's witnesses. I thank 
you all for being here today and sharing your wisdom. I look 
forward to hearing from you about other models that are working 
in tribal communities and how we can get them the resources we 
need to turn this tide.
    The Chairman will be here any minute now. Unfortunately, we 
are going to have to go for a vote fairly early. And so I read 
all your written testimonies last night, and thank you for 
those. I think what we are going to do today is, if you can 
keep your testimony brief right now, we have your written 
testimony. I think that the Chairman will be here any second, 
but we will start the testimony now. And at a certain point, 
all the Members of the Committee who either come, will have to 
leave to go to the Floor to vote on the business before us.
    Again, I just want to thank you all. I want to thank you 
for your wisdom and your stories. And why don't we just begin 
with Mr. Grinnell?

       STATEMENT OF RANDY E. GRINNELL, DEPUTY DIRECTOR, 
  INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN 
 SERVICES; ACCOMPANIED BY ROSE WEAHKEE, DIRECTOR, DIVISION OF 
                       BEHAVIORAL HEALTH

    Mr. Grinnell. Thank you, Senator.
    Good morning. I am Randy Grinnell. I am the Deputy Director 
for Indian Health Service. I am accompanied today by Dr. Rose 
Weahkee. She is the Director for the Division of Behavioral 
Health.
    Today, I appreciate the opportunity to testify on youth and 
the need for mental health care resources in Indian Country. 
Mental health care services are crucial for the well being of 
American Indian and Alaska Native communities.
    As you know, the IHS plays a unique role in the Department 
of Health and Human Services because it is a healthcare system 
established to meet the Federal trust responsibility to provide 
healthcare for American Indians and Alaska Natives.
    Good morning, Mr. Chairman.
    The IHS, in partnership with Indian tribes, provides high 
quality comprehensive care in public health services through a 
system of IHS, tribal and urban-operated facilities and 
programs based on treaties, judicial determinations and acts of 
Congress to an estimated 1.9 million federally-recognized 
American Indians and Alaska Natives.
    Our duty is to uphold the Federal Government's obligation 
to promote health among American Indian and Alaska Native 
people, communities and cultures to honor and protect the 
inherent sovereignty of tribes.
    This week, the President signed the Patient Protection and 
Affordable Care Act, the health insurance reform bill passed by 
Congress. This new law permanently authorizes the Indian Health 
Care Improvement Act. In addition to the many improvements made 
in the Indian health system, this law authorizes a 
comprehensive youth prevention effort as part of the behavioral 
health services.
    I would like to acknowledge Chairman Dorgan's leadership on 
this issue and the Committee's effort to improve access to 
healthcare for American Indians and Alaska Natives.
    Suicide is a complicated public health challenge, with many 
contributing risk factors. American Indians and Alaska Natives 
face a greater number of these risk factors. Indian Country has 
communities where suicide can take on a contagious form often 
referred to as suicide clusters. The suicide act becomes a form 
of expression of the despair and hopelessness experienced by 
some Indian youth. Suicide and suicidal behavior and their 
consequences send shock waves through many tribal and urban 
communities.
    The current system of services for treating mental health 
problems is a complex and often fragmented system of tribal, 
Federal, State, local and community-based services. American 
Indian youth are more likely than non-Indian children to 
receive treatment through the juvenile justice system and 
inpatient facilities.
    IHS and SAMHSA are working closely together to formulate 
long-term strategic approaches to address the issue of suicide 
and mental health care in Indian Country. IHS and SAMHSA are 
actively involved on the Federal Partners for Suicide 
Prevention Work Group. In partnership with tribes, IHS is 
currently developing two five-year strategic plans, one to 
address suicide and one to address behavioral health. These two 
plans will foster collaboration among tribes, tribal 
organizations, urban and other key community resources, and 
provide the tools and framework for the next five years.
    The IHS Mental Health Program provides primary community-
oriented outpatient mental health and related services, case 
management, prevention programming and outreach services. Many 
IHS tribal and urban mental health programs do not have staff 
to operate 24/7. Some providers are so overwhelmed by the 
demand for services, particularly during suicide outbreaks, 
that even well-seasoned providers become at risk for burnout.
    Strategies to remedy these problems include special pay 
incentives, loan repayment and scholarships, active 
recruitment, development of the Indians Into Psychology 
Program, and emergency deployment of commissioned officers.
    IHS first received $13.7 million in 2008 and now receives 
recurring funding of $16.3 million to develop pilot projects 
for model practices for meth and suicide reduction in Indian 
Country. The Methamphetamine and Suicide Prevention Initiative, 
or MSPI, marks a significant milestone in suicide prevention 
efforts in Indian Country that embraces the President's 
direction for tribal engagement and partnership.
    IHS worked closely with tribes and tribal leaders over some 
time to craft this model. MSPI now supports 127 community 
programs targeted at prevention and intervention pilot 
programs, the first of its kind in Indian Country, and 
represents a shift from Federal to tribally based program 
delivery. Local communities determine needs and establish 
programs to meet those needs.
    Tele-behavioral health services are being used or in 
planning stages at over 50 tribal and IHS sites. In Alaska, 
where often there is no other options, tele-health based 
behavioral health services have worked. A Southwest tribe 
currently provides youth and child tele-behavioral health 
services and now shows an appointment rate of over 95 percent 
being kept.
    Services are also being delivered in schools and youth 
treatment centers. In some locations, only within the past five 
years, has the telecommunications infrastructure been reliable 
enough for clinical care.
    We are targeting $19 million of the health funding to 
provide hardware for basic infrastructure development and also 
to acquire state of the art videoconferencing equipment for the 
tribal, urban and Federal sides to improve access for 
videoconferencing.
    The 2011 budget request for mental health is $77 million, 
an increase of over $4.2 million above the 2010 enacted level. 
The 2011 budget request for alcohol and substance abuse is $205 
million, an increase of over $11 million from the 2010 level, 
and includes an increase of $4 million to hire additional 
qualified behavioral health counselors and addiction 
specialists.
    In summary, we look forward to the opportunity to address 
this urgent need for mental health care services in Indian 
Country.
    Mr. Chairman, that concludes my statement. Thank you for 
the opportunity to testify and we will be happy to answer any 
questions.
    [The prepared statement of Mr. Grinnell follows:]

Prepared Statement of Randy E. Grinnell, Deputy Director, Indian Health 
 Service, U.S. Department of Health and Human Services; accompanied by 
         Rose Weahkee, Director, Division of Behavioral Health
    Mr. Chairman and Members of the Committee:
    Good morning, I am Randy Grinnell, Deputy Director of the Indian 
Health Service (IHS). I am accompanied by Rose Weahkee, Ph.D., 
Director, Division of Behavioral Health. Today, I appreciate the 
opportunity to testify on youth and mental health care resources in 
Indian Country. Access to mental health care services is an important 
component of fostering well-being in American Indian and Alaska Native 
communities.
    As you know, the Indian Health Service plays a unique role in the 
Department of Health and Human Services because it is a health care 
system that was established to meet the federal trust responsibility to 
provide health care to American Indians and Alaska Natives. The IHS 
provides high-quality, comprehensive primary care and public health 
services through a system of IHS, Tribal, and Urban operated facilities 
and programs based on treaties, judicial determinations, and Acts of 
Congress. The IHS has the responsibility for the delivery of health 
services to an estimated 1.9 million federally-recognized American 
Indians and Alaska Natives. The mission of the agency is to raise the 
physical, mental, social, and spiritual health of American Indians and 
Alaska Natives to the highest level, in partnership with the population 
we serve. The agency goal is to assure that comprehensive, culturally 
acceptable personal and public health services are available and 
accessible to the service population. Our duty is to uphold the Federal 
government's obligation to promote healthy American Indian and Alaska 
Native people, communities, and cultures and to honor and protect the 
inherent sovereign rights of Tribes.
    Two major pieces of legislation are at the core of the Federal 
government's responsibility for meeting the health needs of American 
Indians and Alaska Natives: The Snyder Act of 1921, P.L. 67-85, and the 
Indian Health Care Improvement Act (IHCIA), P.L. 94-437, as amended. 
The Snyder Act authorized appropriations for ``the relief of distress 
and conservation of health'' of American Indians and Alaska Natives. 
The IHCIA was enacted ``to implement the Federal responsibility for the 
care and education of the Indian people by improving the services and 
facilities of Federal Indian health programs and encouraging maximum 
participation of Indians in such programs.'' Like the Snyder Act, the 
IHCIA provides the authority for the provision of programs, services, 
functions and activities to address the health needs of American 
Indians and Alaska Natives. The IHCIA also includes authorities for the 
recruitment and retention of health professionals serving Indian 
communities, health services for people, and the construction, 
replacement, and repair of healthcare facilities.
    This week, the President signed the Patient Protection and 
Affordable Care Act, the health insurance reform bill passed by 
Congress. This new law permanently authorizes the IHCIA. In addition to 
the many improvements made to the Indian health system, the law 
authorizes a comprehensive youth suicide prevention effort as part of 
the behavioral health services. I want to acknowledge Chairman Dorgan's 
leadership on this issue, and the Committee's effort to improve access 
to health care for American Indians and Alaska Natives.
Background
    Suicide is a complicated public health challenge with many 
contributing risk factors. In the case of American Indians and Alaska 
Natives, they face, on average, a greater number of these risk factors 
individually or the risk factors are more severe in nature for them. 
Every year, several communities in Indian Country experience crisis 
episodes during which suicides take on a particularly ominous and 
seemingly contagious form, often referred to as suicide clusters. In 
these communities, the suicidal act becomes a regular and transmittable 
form of expression of the despair and hopelessness experienced by some 
Indian youth. While most vividly and painfully expressed in these 
communities, suicide and suicidal behavior and their consequences send 
shockwaves through many communities in Indian Country, including urban 
communities. Access to adequate care is critical for those seeking help 
for their loved ones in crisis, or those left behind as emotional 
survivors of such acts.
    IHS ``Trends in Indian Health, 2002-2003'' reports:

   The American Indian and Alaska Native suicide rate (17.9) 
        for the three year period (2002-2004) in the IHS service areas 
        is 1.7 times that of the U.S. all races rate (10.8) for 2003.

   Suicide is the second leading cause of death (behind 
        unintentional injuries) for Indian youth ages 15-24 residing in 
        IHS service areas and is 3.5 times higher than the national 
        average.

   Suicide is the 6th leading cause of death overall for males 
        residing in IHS service areas and ranks ahead of homicide.

   American Indian and Alaska Native young people ages 15-34 
        make up 64 percent of all suicides in Indian Country.

    On a national level, many American Indian and Alaska Native 
communities are also affected by very high levels of poverty, 
unemployment, accidental death, domestic violence, alcoholism, and 
child neglect. \1\ Significant health disparities among American 
Indians and Alaska Natives exist across the spectrum of substance abuse 
problems. The most current IHS health data statistics indicate:
---------------------------------------------------------------------------
    \1\ Manson, S.M. (2004). Cultural Diversity Series: Meeting the 
Mental Health Needs of American Indians and Alaska Natives. National 
Association of State Mental Health Program Directors (NASMHPD) and the 
National Technical Assistance Center for State Mental Health Planning.

   Alcohol-related age-adjusted mortality rate (43.7) for years 
        2002-2004 for AI/AN in the IHS service areas as compared to the 
        U.S. all races rate (7.0) for the year 2003. \2\
---------------------------------------------------------------------------
    \2\ U.S. Department of Health and Human Services. Indian Health 
Service. Trends in Indian Health, 2002-2003 Edition. Washington: 
Government Printing Office, Released October 2009. ISSN 1095-2896. p. 
91.

   Drug-related age-adjusted mortality rate (15.0) for years 
        2002-2004 for AI/AN in the IHS service areas as compared to the 
        U.S. all races rate (9.9) for the year 2003. \3\
---------------------------------------------------------------------------
    \3\ U.S. Department of Health and Human Services. Indian Health 
Service. Trends in Indian Health, 2002-2003 Edition. Washington: 
Government Printing Office, Released October 2009. ISSN 1095-2896. p. 
196.

   NOTE: Rates are per 100,000 population and are adjusted to 
        compensate for misreporting of American Indian and Alaska 
---------------------------------------------------------------------------
        Native race on the state death certificates.

    According to a 2001 mental health supplement report of the U.S. 
Surgeon General, ``Mental Health: Culture, Race, and Ethnicity'', there 
are limited mental health services in Tribal and urban Indian 
communities. \4\ While the need for mental health care is great, 
services are lacking, and access to these services can be difficult and 
costly. \5\ The current system of services for treating mental health 
problems of American Indians and Alaska Natives is a complex and often 
fragmented system of tribal, federal, state, local, and community-based 
services. The availability and adequacy of mental health programs for 
American Indians and Alaska Natives varies considerably across 
communities. \6\ American Indian youth are more likely than non-Indian 
children to receive treatment through the juvenile justice system and 
in-patient facilities. \7\
---------------------------------------------------------------------------
    \4\ U.S. Department of Health and Human Services. (2001). Mental 
Health: Cultural, race, and ethnicity supplement to mental health: 
Report of the Surgeon General. Rockville, MD: U.S. Department of Health 
and Human Services, Substance Abuse and Mental Health Services 
Administration, Center for Mental Health Services, National Institutes 
of Health, National Institute of Mental Health.
    \5\ Manson, S.M. (2004). Cultural Diversity Series: Meeting the 
Mental Health Needs of American Indians and Alaska Natives. National 
Association of State Mental Health Program Directors (NASMHPD) and the 
National Technical Assistance Center for State Mental Health Planning.
    \6\ Ibid.
    \7\ Ibid.
---------------------------------------------------------------------------
Addressing Mental Health Care Resources in Indian Country
    IHS and Substance Abuse and Mental Health Services Administration 
(SAMHSA) work closely together to formulate long term strategic 
approaches to address the issue of suicide and mental health care in 
Indian Country more effectively. For example, IHS and SAMHSA are 
actively involved on the Federal Partners for Suicide Prevention 
Workgroup. In 2001, the Office of the Surgeon General coordinated the 
efforts of numerous agencies, including IHS, SAMHSA, Centers for 
Disease Control and Prevention (CDC), National Institute for Mental 
Health (NIMH), Health Resources and Services Administration (HRSA), and 
other public and private partners to develop the first, comprehensive, 
integrated, public health approach to reducing deaths by suicide and 
suicide attempts in the United States in the National Strategy for 
Suicide Prevention. This resulted in the formation of the ongoing 
Federal Partners for Suicide Prevention Workgroup.
    Currently, in partnership with tribes, IHS is developing strategic 
plans to address suicide and behavioral health for the Indian health 
system. These strategic plans will foster collaborations among Tribes, 
Tribal organizations, Urban Indian organizations, and other key 
community resources. These collaborations will provide us with the 
tools we need to adapt the shared wisdom of these perspectives, 
consolidate our experience, target our efforts towards meeting the 
changing needs of our population, and develop the framework that will 
serve to pave the way over the coming years to address suicide and 
behavioral health in Indian Country.
    The IHS is responsible for providing mental health services to the 
American Indian and Alaska Native population it serves. The IHS Mental 
Health/Social Service (MH/SS) program is a community-oriented clinical 
and preventive mental health service program that provides primarily 
outpatient mental health and related services, crisis triage, case 
management, prevention programming, and outreach services. The most 
common MH/SS program model is an acute, crisis-oriented outpatient 
service staffed by one or more mental health professionals. Many of the 
IHS, Tribal, and Urban (I/T/U) mental health programs that provide 
services do not have enough staff to operate 24 hours/7 days a week. 
Therefore, when an emergency or crisis occurs, the clinic and service 
units will often contract out such services to non-IHS hospitals and 
crisis centers.
    There are many reasons for a lack of access to care. Indian Country 
is predominantly rural and remote, and this brings with it the 
struggles of providing support in settings where appropriate local care 
may be limited. Rural practice is often isolating for its 
practitioners. The broad range of clinical conditions faced with 
limited local resources challenge even seasoned providers. Some 
providers are so overwhelmed by the continuous demand for services, 
particularly during suicide outbreaks, that even well-seasoned and 
balanced providers become at-risk for burn-out.
    For example, there are situations where the appropriate treatment 
is known, such as counseling therapy for a youth survivor of sexual 
abuse, but there are simply no appropriately trained therapists in the 
community. One of our IHS Area Behavioral Health Consultants told me 
recently that there was only one psychiatrist in her half of a large 
Western state attempting to serve both the Indian and non-Indian 
population. Despite years of effort, the IHS Area Office had been 
unsuccessful in recruiting a fulltime psychiatrist to serve the tribes 
in that region.
    Over the years, we have attempted to apply a number of remedies to 
these problems including adopting special pay incentives in order to 
make reimbursement packages more competitive, making loan repayment and 
scholarship programming available for a wide range of behavioral health 
specialties including social work, psychology, and psychiatry, along 
with active recruitment, development of the Indians into Psychology 
program, and emergency deployment of the United States Public Health 
Service Commissioned Corps.
Methamphetamine and Suicide Prevention Initiative
    The IHS received an appropriation in the amount of $13.782 million 
in FY 2008, an increase of $2.609 million in FY 2009, and $16.391 
million in FY 2010 for a national initiative to support the development 
of pilot projects for model practices for methamphetamine and suicide 
reduction programs in Indian Country.
    The Methamphetamine and Suicide Prevention Initiative (MSPI) 
implemented by IHS and its tribal partners nationally, marks a 
significant milestone in suicide prevention efforts in Indian Country 
as well as tribal/federal partnerships for health that embraces the 
Administration's commitment to tribal engagement and partnership.
    MSPI now supports 129 community developed prevention and 
intervention pilot programs across the country. Each program represents 
partnerships between tribal communities and programs and the IHS, to 
develop, implement, and disseminate promising prevention and treatment 
service programs nationally.
    To create the overall MSPI approach, IHS engaged in close 
collaboration with Tribes and Tribal Leaders over the course of almost 
a year. During this time, we crafted a model, and the IHS accepted all 
of the Tribal Leaders' recommendations for approaches and funding 
allocations with only minor adjustments for disbursement methodologies. 
It was and remains a creation of close collaboration and partnership 
with Tribes.
    It is a new program focusing on suicide and substance abuse in 
Indian Country. The program is completely community driven from 
conception through execution for each program in each community. Indian 
communities decide what they need and establish programs to meet those 
needs.
Indian Tele-health Based Behavioral Health Services
    IHS recognizes the need to support access to services and to create 
a broader range of services tied into a larger network of support and 
care. As evidenced by the Alaska experience, where there are often no 
workable options other than tele-health based behavioral health 
services, we know such services work and are acceptable to many if not 
all of our clinic populations. As another example, a Southwest tribe 
has been providing child and youth-specific tele-behavioral health 
services for the past two years and has achieved a show rate of >95 
percent for scheduled appointments. This is an outstanding rate when 
other clinics with face to face provider availability only achieve a 
65-70 percent show rate.
    As a system of care, tele-health based behavioral health services 
are either actively being used or in planning stages for over 50 Indian 
health system sites (both tribal and federal). They include a range of 
programming, from a broad variety of mental health services, to 
specific and intermittently available services such as child psychiatry 
consultations. Services are being delivered in a range of settings 
including clinics, schools, and youth treatment centers. Only within 
the past five years has the telecommunications infrastructure, in some 
locations, become available and reliable enough to be used routinely 
for clinical care. The lack of infrastructure is a significant issue 
for many tribal communities.
    MSPI dollars in the amount of $863,000 are also being used to 
establish a National Tele-Behavioral Health Center of Excellence. An 
intra-agency agreement was signed in early August 2009 with our 
Albuquerque Area Office, which has agreed to take the lead on 
establishing a national center to promote and develop tele-health based 
behavioral health services. They are working in partnership with a 
number of regional entities including the University of New Mexico and 
the University of Colorado. The University of New Mexico Center for 
Rural and Community Psychiatry is a leader in the use of tele-health 
technologies in rural settings. The University of Colorado Health 
Sciences Center and the VA Eastern Colorado Healthcare System are 
leaders in tele-health outreach to veterans including Indian veterans 
in the northern Plains, the State of New Mexico, and the Tribes and 
Pueblos of the region. Services are provided to a number of settings 
including school clinics, youth residential treatment centers, health 
centers, and others. They hope to leverage their ability to use federal 
service providers and provide technical and program support nationally 
to programs attempting to implement such services.
    We have been tracking visits to behavioral health clinics using 
tele-health technology, and have preliminary indications that IHS 
programs are increasingly adopting and using these technologies. Tele-
behavioral health services require adequate and reliable bandwidth if 
they are to be sustainably implemented. Increasing bandwidth 
utilization strains the telecommunications infrastructure. IHS was 
fortunate enough to be the recipient of ARRA funding to improve our 
telecommunications infrastructure which will increase the reliability 
and availability of appropriate bandwidth across the Indian healthcare 
system. Approximately $19 million of our Health Information Technology 
ARRA funding will be spent to provide new routers, switches, and basic 
telecommunications infrastructure to ensure current needs are met, as 
well as improve our ability to prioritize traffic over the network. 
ARRA funding is also supporting a mass procurement of state-of-the-art 
clinical videoconferencing equipment that will be distributed to 
Tribal, Urban, and Federal care sites depending on need later this 
fall. We are working to improve access to videoconferencing and 
bandwidth capacity to strengthen our telecommunications infrastructure. 
As one of our providers who is active in telemedicine told us recently, 
``My patients are very patient and are willing to tolerate surprisingly 
bad connections. But when my image freezes up with regularity I may as 
well be using the telephone.'' We are investing in the infrastructure 
expansion, support, and maintenance needed to keep pace with potential 
service demands and to plan for the long term success of this and any 
new Indian tele-mental health effort.
    We see many benefits to the use of telemedicine for the treatment 
of youth suicide. This technology promises to connect widely separated 
and often isolated programs of varying sizes together in a web of 
support. Whereas small clinics would need to develop separate contracts 
for services such as child and adult psychiatric support, pooling those 
needs in a larger pool provides potential access to a much larger array 
of services, and does so more cost-effectively and more conveniently 
for patients. Such a system could potentially move some clinics that 
are available every other Friday afternoon for 4 hours to systems where 
clinic time for assessments is available whenever the patient presents. 
This could translate into 24/7 access to emergency behavioral health 
service in any setting with adequate telecommunications service and 
rudimentary clinic staffing.
    Such a system has other desirable consequences such as 
opportunities for mutual provider support. For example, currently when 
psychiatric providers take vacation, are on sick leave, or are training 
in places where they are the sole providers, there are often either no 
direct services at that clinic for that time period, or a temporary 
doctor with limited understanding of the clinic is hired to provide 
services. Sufficient services could be provided via tele-health 
connections to reduce or eliminate discontinuities in patient care and 
do so at significantly less expense. Providers with particular 
specialty interests can share those skills and knowledge across a broad 
area even if they themselves are located in an isolated location. Burn 
out due to professional isolation is also decreased as 
videoconferencing readily supports clinical supervision and case 
management conferences. Universities providing distance-based learning 
opportunities have demonstrated for years that educational activities 
can also be facilitated by this technology. Families can participate in 
care even when at a distance from their youth, promoting improved 
contact and better resolution of home environmental concerns which is 
often the key issue in a youth transitioning successfully from a 
residential program to home. Recruitment becomes less problematic 
because providers can readily live and practice out of larger urban or 
suburban areas and are thus more likely to continue in service over 
time with sites. The resulting pool of providers accessible for hiring 
could also increase because relocation to an isolated location may not 
be necessary. Such services would require behavioral health providers 
including psychiatrists, psychologists, clinical social workers, and 
therapists in addition to the tele-mental health technology.
    Activities, including the National Tele-Behavioral Health Center of 
Excellence funded by the MSPI, will also help us understand how to 
effectively deliver such services, and in particular, will provide more 
focused experience in providing services to Indian youth. We believe 
tele-behavioral programs can become an integral part of the IHS 
behavioral health services, strengthen our clinical expertise in using 
tele-health services, and expand access to needed behavioral 
healthcare. We are working to augment the ability of the IHS Tele-
Behavioral Health Center of Excellence to promote and support such 
services across the Indian health system.
IHS FY 2011 Budget Request for Mental Health Services
    The FY 2011 budget request for Mental Health is $77,076,000; an 
increase of $4,290,000 over the FY 2010 enacted level. This increase 
represents: increases of $748,000 for Federal and Tribal pay increases; 
increases of $748,000 for non-medical inflation of 1.5 percent; 
population growth increases of $1.092 million, and increases of 
$1,702,000 for staffing/operation costs for new/expanded facilities. We 
strive to support American Indian and Alaska Native communities 
eliminating behavioral health diseases and conditions by: (1) 
maximizing positive behavioral health and resiliency in individuals, 
families, and communities; (2) improving the overall health care of 
American Indians and Alaska Natives; (3) reducing the prevalence and 
incidence of behavioral health diseases; (4) supporting the efforts of 
American Indian and Alaska Native Communities toward achieving 
excellence in holistic behavioral health treatment, rehabilitation, and 
prevention for individuals and their families; (5) supporting Tribal 
and Urban Indian behavioral health treatment and prevention efforts; 
(6) promoting the capacity for self-determination and self-governance, 
and; (7) supporting American Indian and Alaska Native communities and 
service providers by actively participating in professional, 
regulatory, educational, and community organizations at the National, 
State, Urban, and Tribal levels.
IHS FY 2011 Budget Request for Alcohol and Substance Abuse Services
    The Alcohol and Substance Abuse Program (ASAP) exists as part of an 
integrated behavioral health team that works collaboratively to reduce 
the incidence of alcoholism and other drug dependencies in American 
Indian and Alaska Native communities. The FY 2011 budget request for 
Alcohol and Substance Abuse is $205,770,000; an increase of $11,361,000 
over the FY 2010 enacted level. This increase represents: increases of 
$1,840,000 for Federal and Tribal pay increases; increases of 
$2,605,000 to fund the costs of providing health care and related 
services; population growth increases of $2,916,000, and; increases of 
$4,000,000 for a grant program to expand access to and thereby improve 
the quality of treatment for substance abuse treatment services by 
hiring additional qualified and trained behavioral health counselors 
and other addiction specialists to enhance substance abuse care in 
Federal, Tribal, and Urban facilities. The purpose of the IHS Alcohol 
and Substance Abuse Program is to raise the behavioral health status of 
American Indians and Alaska Natives to the highest possible level 
through the provision of preventive and treatment services at both the 
community and clinic levels. These programs provide alcohol and 
substance abuse treatment and prevention services within rural and 
urban communities, with a focus on holistic and culturally-based 
approaches. The Alcohol and Substance Abuse Program exists as part of 
an integrated behavioral health team that works collaboratively to 
reduce the incidence of alcoholism and other drug dependencies in 
American Indian and Alaska Native communities.
SAMHSA's Role in Addressing Youth Suicides
    American Indian and Alaskan Native tribes also look to SAMHSA for 
help is addressing youth suicides. Through its Garrett Lee Smith State 
and Tribal Grants, 20 American Indian and Alaskan Native tribes or 
tribal organizations have received grants ranging from $400,000 to 
$500,000 a year to prevent suicide. This represents 31 percent of all 
grants given out in the last four years under this program. In addition 
SAMHSA:

   Funds the Native Aspirations project which is a national 
        project designed to address youth violence, bullying, and 
        suicide prevention through evidence-based interventions and 
        community efforts. Through the Native Aspirations project, a 
        total of 25 American Indian and Alaska Native communities 
        determined to be the most ``at risk'' develop or enhance a 
        community-based prevention plan.

   Supports the Suicide Prevention Resource Center (SPRC) which 
        is a national resource and technical assistance center that 
        advances the field by working with states, territories, tribes, 
        and grantees and by developing and disseminating suicide 
        prevention resources.

   Funds the National Suicide Prevention Lifeline, a network of 
        141 crisis centers across the United States that receives calls 
        from the national, toll-free suicide prevention hotline number, 
        800-273-TALK.

         The National Suicide Prevention Lifeline's American Indian 
        initiative has worked to promote access to suicide prevention 
        hotline services in Indian Country by supporting communication 
        and collaboration between tribes and local crisis centers as 
        well as providing outreach materials customized for each tribe.

    In summary, we look forward to opportunities to address the mental 
health care needs in Indian Country. We are committed to using 
available technologies including our growing national 
telecommunications infrastructure to help increase access to sorely 
needed behavioral health services. For the Indian Health Service, our 
business is helping our communities and families achieve the highest 
level of wellness possible.
    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to testify. I will be happy to answer any questions that 
you may have.

              STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    The Chairman. [Presiding] Mr. Grinnell, thank you very 
much. We appreciate your work and your testimony. I apologize 
for being delayed just a bit because of traffic. My colleague 
opened the hearing. I appreciate that very much.
    I wanted to mention as we begin now hearing from other 
witnesses that we are going to have to do things a little 
differently this morning. I will explain it. We were in 
session, I think until close to three a.m. this morning with 
votes, and are coming back at 9:45. You just heard the buzzer. 
The first votes will likely start at 10 o'clock and last--10-
minute votes until 2 o'clock this afternoon. So we will be 
voting for four hours. Because they are 10-minute votes, we 
won't be able to leave the Floor.
    We probably will not have to leave here until 10:10 because 
the first vote will be the only vote that is a 20-minute vote. 
So what I would like to do is, we will go ahead and hear as 
many witnesses as we can before we have to leave. I want to 
make certain that all of the testimony is a part of the 
permanent record.
    Then I am going to ask that we adjourn the hearing, and we 
are going to have the remainder of what is now a hearing, 
become a listening session. The Staff Director, Allison Binney, 
and the Deputy Staff Director on the minority side, Rhonda 
Harjo, will assume our places and receive the remaining 
testimony, and it will still be a part of the permanent record.
    This is a very important subject, very important. And we 
have Coloradas Mangas, a sophomore in high school on the Apache 
Reservation in New Mexico; Dr. Clayton, Medical Director, 
American Foundation for Suicide Prevention in New York City. 
Doctor, thank you for being with us and thanks for your work.
    And Ms. Laurie Flynn, Executive Director, TeenScreen 
National Center for Mental Health Checkups at Columbia. We 
thank you very much for being here.
    Mr. Hunter Genia, Behavioral Health Administrator, Saginaw 
Chippewa Indian Tribe, Mt. Pleasant, Michigan; and Ms. Novalene 
Goklish, Senior Research Coordinator, Celebrating Life Youth 
Suicide Prevention Program, White Mountain Apache Tribe.
    I know that Senator Franken and I have both had experience 
with these issues on our reservations. I have a note in front 
of me about a young man who took his life this week on the 
Standing Rock Reservation, and I will call his parents sometime 
later today.
    I spoke this weekend with the Tribal Chairman at the Spirit 
Lake Nation, where Avis Little Wind took her life and who I 
have spoken about often. The late Avis Little Wind was 14 years 
old, and her brother took his life just within recent weeks.
    We have clusters of suicides, teen suicides especially, 
that are very troubling. We are trying to everything we can to 
recognize it, put a spotlight on it, and understand how to 
address it in order to save the lives of some, particularly 
young people who think things are helpless and hopeless, and 
choose this way of responding.
    It is not the right way to respond, and the work, Mr. 
Grinnell, that your organization does is very important. We 
just, as you know, had a crew be dispatched to Standing Rock a 
while back.
    So let me thank all of you. I just wanted to say that as a 
way of explanation, I am pleased you are here. There was some 
talk of having to cancel the hearing. I said, we have people 
that have traveled here. We want to begin this hearing and do 
the best we can, after which we will convert this to a 
listening session, but we want to continue it and have a formal 
hearing record because many of you have taken great pains to be 
here.
    With that, I want to hear the next witness, Coloradas 
Mangas. I have read your statement and it is a poignant 
statement. I so appreciate your being here and talking to us 
about what this is like through the eyes of a high school 
student. You have seen a lot and experienced a lot at this very 
young age.
    Coloradas Mangas, you may proceed.

STATEMENT OF COLORADAS MANGAS, SOPHOMORE, RUIDOSO HIGH SCHOOL, 
                MESCALERO APACHE RESERVATION, NM

    Mr. Mangas. Good morning, Mr. Chairman and Mr. Franken and 
other distinguished guests. It is a great honor and privilege 
to testify on a public health and social justice issue that has 
disproportionately affected Indian communities throughout my 
country.
    My testimony is dedicated in honor to those whose voices 
will never be heard and who continue to suffer in a culture of 
silence and shame.
    [Greeting in native language.]
    Mr. Mangas. How are you? My name is Coloradas Mangas. My 
mother is CriCri Mangas and my father is Carl Mangas. I have 
two sisters who are Danielle and Kiana Mangas. I am Chiricahua 
Apache from the Mescalero Apache Indian Reservation in New 
Mexico. I am 15 years of age and currently a sophomore at 
Ruidoso High School in Ruidoso, New Mexico.
    I am here due to my past and I am a survivor of teen 
suicide. It is my sincere hope that my words will inspire 
change and help address these serious situations. Allow me to 
begin by telling you about my past.
    The first time I had to deal with teen suicide was when my 
sister Danielle's friend killed himself. I was in the seventh 
grade and it was hard for me to see my sister in that stage. 
The second time was when my sister Kiana's friend killed 
himself about two years ago. Next was in September of 2009 at 
the beginning of the school year. That is when it really had 
taken a hard toll. My friend killed himself. He was a good 
helper and a person to all. He was a fire and rescue worker and 
had seen it all, things I could never imagine. No one saw it 
coming.
    My friend is Larry Anjotti who is the 19 year old posted on 
the left hand side to you and on this side to these people.
    Two weeks later, my sister Kiana's other friend killed 
herself. That was a hard one, not only for her, but for a lot 
of youth on the reservation as she was a friend to all. Her 
name is Brandy Little. She is the 17 year old on the bottom of 
the poster board on this side and on this side.
    My grandmother passed into the next life right after she 
killed herself. After that, another two weeks went by and my 
other friend killed herself. Another two weeks later, my other 
friend killed herself. That night, I didn't know what to do and 
I had no one to run to or to talk to.
    These two people, one of them is Kayla Sheff, who is the 17 
year old on the top of the board. My mother I couldn't get a 
picture of her, so I am sorry that I couldn't be able to put 
her on there.
    The only thing I could do was go to church. It was the one 
thing, and I attend youth group regularly at our Reformed 
Church. As I was at church, I got a message I never thought I 
would get, a text message from my friend saying she loved me 
and that I will always have a place in her heart. I didn't know 
what to do. The only thing I could do was call the police, who 
didn't respond. I went and I walked in the woods from 9 o'clock 
p.m. to midnight. I looked everywhere, every tree, and I found 
her. It was a good thing I found her when I did. Otherwise, she 
would have been gone forever.
    I knew that this issue was bigger than I could handle by 
myself. I made an appointment with the psychologist at the 
mental health clinic. It was nice having someone who listened 
and understood what I was going through. I am more of an 
exception than the rule because most youth would not go to the 
mental health clinic. The stigma and shame keeps people away.
    When I look at the resources that our neighbors have in the 
town of Ruidoso, I can't help but notice how limited our IHS 
hospital is when it comes to basic care and, more importantly, 
mental health services. We have a mental health clinic with 
only one full-time psychologist, one psychologist to serve a 
community of 4,500 children, youth and adults. It is my 
understanding that she is currently on administrative leave 
indefinitely. With her gone, we have a huge gap in the 
continuity of care.
    What troubles me is that law enforcement and the court have 
a larger role to play during an attempt or completed suicide 
compared to our mental health clinic. Most attempters don't 
seek help and some are court-ordered to attend therapy. This 
role of the courts and law enforcement criminalizes their 
behavior and makes their recovery seem less important.
    I applaud our community, though. The tribal administration 
finally understands that our community-based services are not 
connecting in a vital way to meet the challenges of children 
and youth with serious mental health needs and their families. 
With this said, our tribe has recently applied for the SAMHSA 
Systems of Care Grant. It is my hope that we can fundamentally 
change the way our services are delivered.
    Due to the most recent rash of suicides, a new program 
started in the community called Honor Your Life Program. It is 
a SAMHSA Garrett Lee Smith-funded program that is designed to 
implement and evaluate a comprehensive early intervention and 
suicide prevention model.
    A new program that is supposed to change attitudes and 
beliefs about suicide can be culturally taboo, because in our 
culture, we do not talk about death. When it comes to suicide, 
talking about death and dying is the only way to break the 
culture of silence that is taking the lives of so many of my 
friends and other youth.
    I believe in change. I believe that we can meet the needs 
on our reservation. First, we need to increase program 
awareness and cooperation, targeting both youth and adults to 
get involved in these programs. Second is by helping the mental 
health clinic become fully staffed, getting faster hiring 
approval for these clinicians, and ensuring faster Medicaid 
approval for persons referred to residential treatment centers.
    Having more providers is vitally important. We have four 
providers at our school I attend and it seems unjust that we 
only have one provider for our community on the reservation. We 
need more than one psychologist so more people can be seen more 
regularly. Having one provider means that most people are 
operating in a crisis mode between long visits. We could also 
help by getting providers to work with the law enforcement 
during suicide attempts or completions to immediately provide 
family-based aftercare.
    Other things that I believe would prevent suicide is by 
giving the youth more things to do so it would get them away 
from drugs, alcohol and idle trouble. We need more leadership 
activities to inspire our youth to change their life courses. 
Sometimes I think our community forgets that a tribe's legacy 
rests in its children and not in how well the tribe's 
enterprises operate.
    We desperately need a shelter for our youth if they need a 
place to stay at certain times when the home life becomes very 
toxic. We have heard from other youth that if they just had a 
place to go for the night, they would not have made an attempt 
on their life.
    I am very thankful to have the opportunity to share these 
ideas that other youth in Mescalero also have. I am also from a 
new generation of young men and women who believe in breaking 
the silence and seeking help. I come from people whose pride 
runs deep, but I also understand that sometimes pride can keep 
us from asking for help.
    So lastly, I would like to thank not only my friends, but 
also the people that believe in me and mostly mainly all of you 
for your time in listening to me. And I would also like to 
thank everybody for helping me take another step towards my 
plans of becoming a future leader of not only my people on the 
reservation, but people across the Country.
    And in my native language, Ixehe'. Thank you.
    [The prepared statement of Mr. Mangas follows:]

Prepared Statement of Coloradas Mangas, Sophomore, Ruidoso High School, 
                    Mescalero Apache Reservation, NM
    Good Morning Honorable Members of the Committee on Indian Affairs 
and other distinguished guests. It is a great honor and privilege to 
testify on a public health and social justice issue that has 
disproportionately affected Indian communities throughout the country. 
My testimony is dedicated in honor of those whose voices will never be 
heard and who continue to suffer in a culture of silence and shame.
    [Introduction in Apache Language] English Translation: My name is 
Coloradas Mangas. My mother is Cri-Cri Mangas and my Father is Carl 
Mangas. I have two sisters: Danielle and Kiana Mangas. I am Chiricahua 
Apache from the Mescalero Apache Indian Reservation in New Mexico. I am 
15 years of age and currently a sophomore at Ruidoso High School in 
Ruidoso, New Mexico.
    I'm here due to my past and I'm a survivor of teen suicide. It is 
my sincere hope that my words will inspire change and help address this 
serious situation. Allow me to begin by telling you about my past.
    The first time I had to deal with teen suicide was when my sister 
Danielle's friend killed himself, when I was in the seventh grade. It 
was hard for me to see my sister in that stage. The second time was 
when my sister Kiana's friend killed himself two years ago. Next was in 
September of 2009 at the beginning of the school year. That's when it 
really started to take a hard toll. My friend killed himself. He was a 
good person and a helper to all. He was a Fire Rescue worker and he had 
seen it all. Things I could never imagine. No one saw it coming.
    Two weeks later, my sister Kiana's other friend killed herself. 
That was a hard one. Not only for her, but for a lot of youth on the 
reservation as she was a friend to all. Right after she killed herself. 
my grandmother passed into the next life. After that, another two weeks 
went by and my other friend killed herself. Two weeks later, my other 
friend killed herself. That night I didn't know what to do. I had no 
one to turn to or talk to.
    The only thing I could do was go to church. It was a Wednesday 
night and I attend youth group regularly at our Reformed church. As I 
was at church, I got a message I thought I never would get. A text 
message from my friend saying she loved me and that I'll always have a 
place in her heart. I didn't know what to do. The only other thing I 
could do was call the police--who didn't respond. I went and walked in 
the woods from 9 p.m. to midnight. I looked everywhere, every tree, and 
I found her. It was a good thing I found her when I did, otherwise she 
would be gone forever.
    I knew that this issue was bigger than I could handle by myself. I 
made an appointment with the psychologist at the mental health clinic. 
It was nice having someone who listened and understood what I was going 
through. I am more of an exception than the rule because most youth 
won't go to the mental health clinic. The stigma and shame keeps people 
away.
    When I look at the resources that our neighbors have in the town of 
Ruidoso, I can't help but notice how limited our I.H.S. hospital is 
when it comes to basic care and more importantly, mental health 
services. We have a mental health clinic, with only one full time 
psychologist. One psychologist to serve a community of 4,500 children, 
youth and adults. It is my understanding that she is currently on 
administrative leave--indefinitely. With her gone, we have a huge gap 
in the continuity of care.
    What troubles me is that law enforcement and the court have a 
larger role to play during an attempt or completed suicide compared to 
our mental health clinic. Most attempters don't seek help and some are 
court ordered to attend therapy. This role of the courts and law 
enforcement criminalizes their behavior and makes their recovery seem 
less important.
    I applaud our community though. The tribal administration finally 
understands that our community-based services are not connecting in a 
vital way to meet the challenges of children and youth with serious 
mental health needs and their families. With this said, our tribe has 
applied for the SAMHSA Systems of Care grant. It is my hope that we can 
fundamentally change the way our services are delivered.
    Due to the most recent rash of suicides, a new program started in 
the community called the Honor Your Life Program. It is a SAMHSA funded 
program that is designed to implement and evaluate a comprehensive 
early intervention and suicide prevention model.
    A new program that is supposed to change attitudes and beliefs 
about suicide can be culturally taboo, because in our culture, we don't 
talk about death. When it comes to suicide, talking about death and 
dying is the only way to break the culture of silence that is taking 
the lives of so many of my friends and other youth.
    I believe in change. I believe that we can meet the needs on our 
reservation. First, we need to increase program awareness and 
cooperation--targeting both youth and adults to get involved in these 
programs. Second, by helping the mental health clinic become fully 
staffed, getting faster hiring approval for these clinicians, and 
ensuring faster Medicaid approval for persons referred to residential 
treatment centers.
    Having more providers is vitally important. We have four providers 
at the school I attend and it seems unjust that we only have one 
provider for our community on the reservation. We need more than one 
psychologist so more people could be seen more regularly. Having one 
provider means that most people are operating in a crisis mode between 
long visits. We could also help by getting providers to work together 
with law enforcement during suicide attempts or completion to 
immediately provide family based aftercare.
    Other things that I believe would help prevent suicide, is by 
giving the youth more things to do so it would get them away from 
drugs, alcohol, and idle trouble. We need more leadership activities to 
inspire our youth to change their life course. Sometimes I think our 
community forgets that a tribe's legacy rests in its children and not 
in how well tribal enterprises operate.
    We desperately need a shelter for the youth if they need a place to 
stay at certain times when the home life becomes very toxic. We have 
heard from other youth that if they just had a place to go for the 
night, that they would not have made an attempt on their life.
    I am very thankful to have the opportunity to share these ideas 
that other youth in Mescalero also have. I am also from a new 
generation of young men and women who believe in breaking the silence 
and seeking help. I come from a people whose pride runs deep, but I 
also understand that sometimes, pride can keep us from asking for help. 
Lastly, I would like to thank my friends and the people that believe in 
me and mostly for your time. In my Native language, Ixehe' [Thank you].

    The Chairman. Coloradas Mangas, you are wise beyond your 
years. Thank you for your testimony and for being here. We 
appreciate that very much.
    And Dr. Paula Clayton is with the American Foundation for 
Suicide Prevention. We appreciate that work.
    Dr. Clayton, I should tell you that many of us have had 
experience with this issue of suicide. I walked in and found a 
friend of mine who had taken his life one morning, and it is a 
moment you never, ever, ever forget. I mean, it is as if it 
happened 10 seconds ago.
    So I thank you for the work and for the work of the 
Foundation and appreciate your being here. We will take your 
testimony and then see if we can get Ms. Flynn's testimony. A 
vote has started, so we will have about 10 minutes before 
Senator Franken and I will have to leave and then we will have 
the Staff Directors continue the rest of the listening session.
    Dr. Clayton?

         STATEMENT OF PAULA J. CLAYTON, M.D., MEDICAL 
           DIRECTOR, AMERICAN FOUNDATION FOR SUICIDE 
                           PREVENTION

    Dr. Clayton. Good morning, Senator Dorgan and Senator 
Franken.
    My name is Paula Clayton. I am a physician and I do serve 
currently as the Medical Director of the American Foundation 
for Suicide Prevention.
    Suicide is the 11th leading cause of death in the United 
States, and the third leading cause of death in teens and young 
adults from the ages of 15 to 24. In one study of a well-
monitored tribe, which are here today, the suicide rate in 
young adults, rather than being nine per 100,000 was 128.5 per 
100,000. It was 13 times the rate of the rest of the youth of 
the United States.
    In this single tribe, there were 25 deaths of teens and 
young adults in a year. And the thing is that they did very 
excellent monitoring. And so that is one thing we need. We need 
suicide attempt and suicide completion monitoring on all these 
tribes and pueblos.
    Suicide is the result of unrecognized and untreated mental 
disorders. In more than 120 studies of a series of completed 
suicides across the world, at least 90 percent of the people 
who died by suicide were suffering from a mental illness at the 
time of their death. The most common is major depression, 
followed by alcohol abuse and drug abuse, but all psychiatric 
disorders have an outcome of suicide.
    So the major risk factors for suicide are the presence of 
an untreated mental disorder, a history of a past suicide 
attempt, and a family history of suicide or suicide attempts. 
That has to be taken into account.
    The most important interventions, then, are recognizing 
these disorders and treating them. Every culture has a bias 
against doing that. These must be identified in each of these 
cultures and overcome.
    One such effort to present youth suicide to the general 
population is two films AFSP has developed. It is in this 
little package called, More Than Sad. The first is about 
depression and is for the teens in the high school. And the 
second is a companion film to help teachers recognize the 
mental illnesses that teens suffer from that may lead to 
suicide. Both deal with recognition and treatment.
    The first one for the teens depicts four teenagers with 
different types of depression who are referred to treatment by 
four different people. One is a parent. Another is peers and 
the guidance counselor. The third is the kid himself. And the 
fourth is the primary care physician.
    The package is currently being used in more than 1,000 
schools across the United States, and I am sure it is in North 
Dakota, and has recently been adopted by the State of Alabama 
to show in every high school in that State.
    A similar film could and should be made for and about 
Native American teens. Although the film would need clinicians 
and a filmmaker who are culturally sensitive, the messages are 
the same: depression is a medical illness; it is not your 
fault; it is okay to seek help; and treatments can make you 
well.
    A second approach being used in the general population is 
screening for early detection and referral, and this is best 
exemplified by TeenScreen, which you will hear about. For young 
adults, AFSP has an anonymous online screening program that is 
evidence-based and approved by the Suicide Prevention Resource 
Center. It involves having a counselor available to respond 
quickly to an email questionnaire that the troubled young 
person submits to engage them sort of in a dialogue in order to 
finally convince the person to come in for an evaluation. It is 
proven to engage people who are not known to the health system 
because it is anonymous and online.
    The third, but extremely important aspect of suicide 
prevention is to train nurses, other health personnel and 
primary care physicians to recognize disturbed kids and begin 
treatment early. I would think that this should entail getting 
the entire tribe or pueblo involved. There are many public 
health models of para-professionals being the first source of 
recognition.
    Those people who do not respond to the initial treatment 
then need to be referred to mental health services or substance 
abuse specialists. The referral process, which is apparently 
not always the same, needs to be clear and simple. Substance 
abuse treatment should start with self-help groups. There are 
proven short-term psychotherapy interventions for suicide 
attempters and for people with depression in the general 
population. Money needs to be invested in these treatment 
programs that are developed for Native American youth.
    Finally, AFSP believes that suicide postvention behavior is 
an important part of prevention. So we have multiple ways to 
interact with survivors. AFSP has already done two suicide 
support group training programs in South Dakota, which included 
Native American participants. AFSP is writing a postvention 
instruction for middle and high school personnel to guide them 
in their plans in the aftermath of a suicide. Our Web site 
contains many other resources that for someone who has lost 
someone to suicide that could be used or modified.
    Suicide in Native American youth is rising and is in 
crisis. Depression can be fatal. Excessive drinking and drug 
use can be fatal. The fatality is mainly suicide. Culturally 
sensitive, but sustained efforts, with multiple approaches 
offer the best hope.
    Obviously, if there is a shortage of treatment resources, 
which there seems to be, then dollars need to be allocated to 
develop innovative treatments for Native Americans. We must 
reduce this fatal outcome.
    Thank you.
    [The prepared statement of Dr. Clayton follows:]

    Prepared Statement of Paula J. Clayton, M.D., Medical Director, 
               American Foundation for Suicide Prevention
    Good morning Chairman Dorgan, and Ranking member Barrasso, and 
members of the Committee. Thank you for inviting the American 
Foundation for Suicide Prevention (AFSP) to provide testimony on Youth 
Suicides and the Urgent Need for Mental Health Resources in Indian 
Country. My name is Paula Clayton. I am a physician. I currently serve 
as AFSP's medical director. My responsibilities include overseeing and 
working closely with the AFSP's scientific council to develop and 
implement directions, policies and programs in suicide prevention, 
education and research. I also supervise staff assigned to the research 
and education departments within AFSP.
    Prior to joining AFSP I served as professor of psychiatry at the 
University of New Mexico School of Medicine in Albuquerque. I also 
currently serve as professor of psychiatry, Emeritus, for the 
University of Minnesota, where I was a professor and head of the 
psychiatry department for nearly twenty years. My research on bipolar 
disorder, major depression and bereavement allow me to understand some 
of the antecedents of suicide and to appreciate medical research and 
public/professional education programs aimed at preventing it.
    AFSP is the leading national not-for-profit organization 
exclusively dedicated to understanding and preventing suicide through 
research, education and advocacy, and to reaching out to people with 
mental disorders and those impacted by suicide. You can see us at 
www.asfp.org.
    To fully achieve our mission, AFSP engages in the following Five 
Core Strategies, (1) Funds scientific research, (2) Offers educational 
programs for professionals, (3) Educates the public about mood 
disorders and suicide prevention, (4) Promotes policies and legislation 
that impact suicide and prevention, (5) Provides programs and resources 
for survivors of suicide loss and people at risk, and involves them in 
the work of the Foundation.
    I have provided the committee staff with a Power Point presentation 
I recently delivered here in Washington, DC on March 8, 2010, entitled, 
``Suicide Prevention--Saving Lives One Community at a Time.'' * I also 
included a copy of AFSP's 2010 Facts and Figures on Suicide. Both 
documents will provide Committee members and their staff an overview on 
the issues associated with suicide in America today, along with some 
examples of programs and services to prevent this major public health 
problem.
---------------------------------------------------------------------------
    * The information referred to has been retained in Committee files 
and can be found at www.afsp.org/index.cfm?page_id=598DA610-DC4C-A681-
45A4701729BA0C93.
---------------------------------------------------------------------------
    Suicide is the 11th leading cause of death in the United States and 
the third leading cause of death in teens and young adults from ages 
15-24. The suicide rate in this younger group is about 9/100,000. In 
one study of a well monitored tribe the rate was 128.5/100,000 or more 
than 13 times that of all other US young people. In this single tribe 
there were 25 deaths in one year. Monitoring of suicide attempts and 
suicide is an essential first step.
    Suicide is the result of unrecognized and untreated mental 
disorders. In more than 120 studies of a series of completed suicides, 
at least 90 percent of the individuals involved were suffering from a 
mental illness at the time of their deaths. The most common is major 
depression, followed by alcohol abuse and drug abuse, but almost all of 
the psychiatric disorders have high suicide rates.
    So, the major risk factors for suicide are the presence of an 
untreated psychiatric disorder, the history of a past suicide attempt 
and a family history of suicide or suicide attempts. The most important 
interventions are recognizing and treating these disorders. Every 
culture has strong biases against doing that. These must be identified 
and overcome.
    One such effort to present youth suicide to the general population 
is two films AFSP developed. The first is about depression and is for 
teens and the second is a companion film to help teachers recognize the 
mental illnesses in teens that may lead to suicide. Both deal with 
recognition and referral. The first depicts four teens with different 
types of depression who are referred for treatment by four different 
people (parent, peers and a guidance counselor, the kid himself and a 
primary care physician). The package is currently being used in more 
than 1,000 schools across the country and has recently been adopted by 
the State of Alabama to show in every high school in the state. A 
similar film could and should be made for and about Native American 
teens. Although such films need clinicians and a filmmaker who are 
culturally sensitive, the messages should be the same: depression is a 
medical illness, it is not your fault, it is OK to seek help and 
treatments can make you well.
    A second approach being used in the general population is screening 
for early detection and referral. An approach best exemplified by Teen 
Screen. For young adults AFSP has an anonymous online screening program 
that is evidenced based and approved for use by the Suicide Prevention 
Resource Center. It involves having a counselor available to respond 
quickly to an e-mail questionnaire that the troubled young person 
submits to engage them in a dialogue in order to finally convince the 
person to come for an evaluation. It is proven to engage young people 
who are not known to the health system.
    A third, but extremely important aspect to suicide prevention is to 
train nurses, other health personnel and primary care physicians to 
recognize disturbed kids and begin treatment. I would think this should 
entail getting the entire tribe or pueblo involved in the endeavor. 
There are many public health models of paraprofessionals being the 
first source of recognition. Those young people who do not respond to 
initial treatments need to be referred to mental health and substance 
abuse specialists. The referral process needs to be clear and simple. 
The substance abuse treatment should also start with self help groups 
on the reservations. There are proven short term psychotherapy 
interventions for suicide attempters and for people with depression in 
the general population. Money needs to be invested to develop such 
therapies for Native Americans.
    Finally, AFSP believes that suicide postvention behavior is 
important in suicide prevention, so we have multiple ways to improve 
this aspect of care. AFSP has already done two suicide support group 
training programs in South Dakota that included Native American 
participants. AFSP is writing postvention instructions for middle and 
high school personel to guide them in their plans in the aftermath of a 
suicide. AFSP's website contains many other resources that those who 
have lost someone to suicide can review and use or modify.
    Chairman Dorgan, Ranking member Barrasso, suicide in Native 
American youth is rising and is an absolute crisis. Depression can be 
fatal. Excessive drinking or drug use can be fatal. The fatality is 
mainly by suicide. Culturally sensitive but sustained efforts with 
multiple approaches offer our best hope to get students into 
treatments. Obviously, if there is a shortage of treatment resources, 
than dollars need to be allocated to develop innovative new treatments 
for Native American youths. We must reduce this fatal outcome. The 
American Foundation for Suicide Prevention is ready and willing to 
offer our expertise and advice to this Committee and to all members of 
Congress as you make the important decisions on how to reduce suicide 
in the Indian nations.
    I will be happy to answer any questions you and your colleagues 
might have. Thank you.
    Attachment

    
    

    The Chairman. Dr. Clayton, thank you very much.
    There are four minutes remaining in the vote, so Senator 
Franken and I will have to depart shortly.
    Laurie Flynn, I would like to have our staff connect with 
you after this hearing with respect to the TeenScreen Program. 
It appears to me TeenScreen is something that perhaps could be 
very helpful for us to collaborate with you and try to move it 
in a much more significant way nationally. I had a chance to 
review a bit of what you have written, and it seems to me very, 
very inspiring.
    So two things: number one, we apologize for the 
inconvenience of this short hearing; number two, all of the 
statements will be part of the permanent hearing record; number 
three, the hearing record will remain open for two weeks, and 
we will submit written questions and would like to complete the 
hearing record with questions from the Senators.
    In the meantime, I want to adjourn the hearing and then 
begin a listening session with our Staff Director and the 
Deputy Staff Director on the minority side for the remaining 
testimony.
    We thank you very much for being here.
    The hearing is adjourned and the listening session will 
begin. And I would hope Ms. Binney and Ms. Harjo will come up 
and take their chairs.
    [Whereupon, at 10:12 a.m., the Committee proceeded to other 
business.]


 LISTENING SESSION ON THE PREVENTABLE EPIDEMIC: YOUTH SUICIDES AND THE 
     URGENT NEED FOR MENTAL HEALTH CARE RESOURCES IN INDIAN COUNTRY

                              ----------                              


                        THURSDAY, MARCH 25, 2010


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The listening session began at 10:12 a.m. in room 628, 
Dirksen Senate Building, Allison Binney, Majority Staff 
Director/Chief Counsel and Rhonda Harjo, Deputy Chief Counsel 
of the Committee, presiding.

        STATEMENT OF ALLISON C. BINNEY, MAJORITY STAFF 
          DIRECTOR/CHIEF COUNSEL, SENATE COMMITTEE ON 
         INDIAN AFFAIRS; ACCOMPANIED BY RHONDA HARJO, 
                      DEPUTY CHIEF COUNSEL

    Ms. Binney. Good morning. I am Allison Binney. I am the 
Staff Director for Chairman Dorgan on the Senate Committee on 
Indian Affairs. And with me is Rhonda Harjo, the Deputy Chief 
Counsel for the Vice Chairman.
    So as Chairman Dorgan said, we are going to go ahead and 
continue on with the listening session, so this listening 
session will continue to be broadcast via the website, and it 
is still available for people to watch it. We are still going 
to continue with the transcript that will then be available to 
all the Committee Members.
    With that, let's go ahead and begin with Ms. Laurie Flynn 
from the TeenScreen Project.
    Thank you, Ms. Flynn.

   STATEMENT OF LAURIE FLYNN, EXECUTIVE DIRECTOR, TEENSCREEN 
NATIONAL CENTER FOR MENTAL HEALTH CHECKUPS, COLUMBIA UNIVERSITY

    Ms. Flynn. Thank you and good morning. Again, I want to 
join my colleagues in thanking the Senator, the Chairman for 
organizing this hearing and session, and I want to thank you 
very much for gathering the wonderful group that you have to 
share information about how we address this very, very 
significant public health problem.
    I am very honored to be here this morning. My name is 
Laurie Flynn. I am the Executive Director of the TeenScreen 
National Center for Mental Health Checkups at Columbia 
University. I have been at Columbia University working with 
this program since 2001.
    The TeenScreen National Center's mission is to prevent 
adolescent suicide and reduce the disability associated with 
mental illness by mainstreaming mental health checkups as a 
routine procedure for adolescents in healthcare, in schools and 
other youth-serving settings.
    We are able to provide our tools, our training, our 
technical assistance and support to communities throughout the 
Country at no cost because we have been very generously funded 
by a family philanthropy.
    As a parent whose oldest daughter made a very serious 
suicide attempt at age 17, I want to thank the young man to my 
right, Carlos Mangas, for his lovely testimony, very moving. 
And I really think that having the photographs of these young 
people here with us really helps to keep our minds directed to 
the ultimate goal, and it is to step up to this problem for our 
youth in Native American and Alaska Native communities.
    We have heard from Dr. Clayton and we have heard from our 
colleagues at the Indian Health Service the significant 
statistics that surround the tragedy of adolescent depression 
and youth suicide. And what I want to share with you very 
briefly is one part of an effort at solution.
    We know that suicide in adolescents nearly always is an 
outgrowth of depression and other serious mental illnesses. And 
we know that 20 percent of adolescents suffer from a mental 
disorder at some point during their youth. We know that about 
10 percent or 11 percent of those youngsters have a disorder 
significant enough to seriously impair their functioning. These 
are the youth at great risk.
    And yet only about one-fifth of youngsters with mental 
illnesses are identified and receive services, and we have 
reason to believe that in Indian Country that number may even 
be smaller.
    Yet we know there is a window of opportunity of perhaps two 
to four years between the onset of the first symptoms of mental 
disorder and the development of the full-blown disorder which 
can then create severe outcomes, including death.
    Screening for mental illnesses can be accomplished. We have 
been doing this now for a number of years using a variety of 
evidence-based screens that can be safely and effectively 
administered in a wide range of settings.
    Screening for mental illness with an evidence-based tool in 
primary care settings, physicians' offices and clinics, has 
been proven much more effective than informal interviews, which 
tend to miss over 50 percent of youth at risk. We know that by 
identifying youngsters with signs of mental illness early, we 
can begin to provide the range of supports to the family, to 
the community, and to the youngster that can make a lifesaving 
difference.
    These are not just my opinions. Screening is based in over 
20 years of solid science led at Columbia University. Mental 
health screenings or mental health checkups, as we call them, 
have been safe and effective. The Institute of Medicine in its 
national report last week recommended regular screening for 
adolescents for mental disorders.
    The U.S. Preventive Services Task Force has recommended 
annual depression screening and primary care for all of our 
teens. Our program is recognized by SAMHSA in its national 
registry of evidence-based practices. We know that mental 
health checkups can be administered safely in a variety of 
ways. In schools, and we have had a lot of experience in Indian 
Country with the Gila River Schools, with Turtle Mountain 
Schools, and with the Riverside Indian School.
    For many years, we have seen in a variety of Indian Country 
settings, as well as working with Alaska Native sites, that 
these mental health checkups can be administered in ways that 
are culturally sensitive and surround the youngster with the 
immediate help and support if they need it.
    In schools, we provide a service that trains the guidance 
counselor, the school nurse or a visiting health professional 
to work with the youngster, to provide the checkup which is 
self-administered. It is a brief screen.
    Let me just give you an example of what it looks like. This 
is the one we use most frequently in doctors' offices. It is 
this simple. It is an evidence-based checkup. It can be given 
on a clipboard while the youngster is in the waiting room 
waiting for his appointment with his primary care physician or 
with the health practitioner.
    It can be scored within a minute and it can indicate 
whether or not the youngster has problems that require further 
counseling, further probing or referral if necessary if there 
is a real crisis at hand. We always work to engage the family 
and the community because we know that health and healing will 
require the engagement of all the youngsters' close 
connections.
    We do know, too, that for youngsters who have the most 
severe depression and are at greatest risk for suicide, it is 
essential that programs like tele-medicine and the program that 
has been active in the situation in New Mexico can make the 
difference.
    We believe that early detection, identifying the youngsters 
who need the help, and being able to sort out quickly which 
ones are at the greatest risk will help us use our limited 
resources most effectively. And in combination with community 
supports, efforts to increase the availability of appropriate 
mental health resources, and tele-medicine, we can make a real 
difference for youngsters in Indian Country.
    We are delighted to offer our program to officials at the 
Indian Health Service, to various tribal councils, and to 
Members of this Committee so that we can work with you as 
partners to reduce this ongoing tragedy, to implement mental 
health checkups, to identify those youth who are in trouble who 
need support, and to help them get lifesaving assistance.
    Thank you.
    [The prepared statement of Ms. Flynn follows:]

  Prepared Statement of Laurie Flynn, Executive Director, TeenScreen 
    National Center for Mental Health Checkups, Columbia University
    Good morning Chairman Dorgan, Ranking Member Barrasso, and members 
of the Committee. I am honored to appear before you today to present 
testimony about the tragic and ongoing problem of youth suicide in 
Indian Country. My name is Laurie Flynn and I am executive director of 
the TeenScreen National Center for Mental Health Checkups at Columbia 
University. I have served in this capacity since January 2001, and I am 
pleased to share information about our program and our role in 
addressing adolescent suicide.
    The mission of the TeenScreen National Center is to prevent 
adolescent suicide and reduce disability associated with mental illness 
by mainstreaming mental health checkups as a routine procedure for 
adolescents in health care, schools, and other youth-serving settings. 
From our beginning, we have provided tools, training and technical 
assistance at no cost, and we now support mental health screening in 
more than 900 sites in 43 states, including tribal settings.
    We are fortunate to be funded by a generous family foundation. Our 
benefactors share our dedication to reducing the devastating impact of 
undetected depression and other serious mental health problems on 
adolescents and their families. As a parent whose oldest daughter made 
a very serious suicide attempt at age 17, I can understand the ongoing 
pain of families in Indian Country as they struggle to find help and 
hope for their children.
Depression and Suicide among Native American and Alaska Native Youth
    Today's hearing is important because youth suicide remains a 
significant public health challenge in the United States. Suicide is 
the third leading cause of death for all youth 11 to 21 years of age, 
and it accounts for approximately 12 percent of all deaths in this age 
group. As alarming as these statistics are, we know that the problem is 
much worse among American Indian and Alaska Native youth. The suicide 
rate for American Indian and Alaska Native youth is almost twice that 
of young people generally, and suicide is the second leading cause of 
death among 15- to 34-year-olds in these populations.
    Unfortunately, suicide rates do not capture the full extent of the 
problem. According to data cited by the Centers for Disease Control and 
Prevention (CDC), there are approximately 100 to 200 suicide attempts 
for each completed suicide among young people 15 to 24 years of age. 
Among American Indian and Alaska Native youth attending Bureau of 
Indian Affairs schools, a 2001 Youth Risk Behavior Survey found that 16 
percent had attempted suicide in the preceding 12 months.
    Despite these alarming numbers and widespread recognition of the 
epidemic of youth suicide among American Indian and Alaska Native 
youth, we are still not doing enough to identify and assist young 
people suffering from depression and mental illness. National Institute 
of Health (NIH) research shows that more than 90 percent of all 
individuals who commit suicide are suffering from diagnosable mental 
illness in the year preceding their death. Yet, according to the 
Substance Abuse and Mental Health Services Administration (SAMHSA) more 
than half of all persons who die by suicide have never received 
treatment from a mental health provider. Once again, the picture is 
even worse in tribal communities, with even fewer individuals receiving 
treatment.
    This epidemic of preventable suicide among young people has been 
exacerbated by shortfalls in funding for the Indian Health Service 
(IHS), provider shortages, and the difficulty of providing services in 
rural, isolated locations. Each year, funding shortfalls within IHS 
limit referrals for medically necessary contracted health services. The 
vacancy rate for physicians in the IHS is approximately 20 percent, and 
27 percent of the IHS workforce--nearly one-third--will be eligible for 
retirement in 2011. And the rural nature of Indian Country provides 
additional hurdles for both patient access and provider recruitment.
    Despite these challenges, there are effective and efficient ways to 
improve the early identification and treatment of mental illness and 
reduce needless deaths by suicide. Mental health screening can identify 
youth most at risk and provide intervention early, when it is most 
effective.
Defining Mental Health Screening
    Mental health screening, also referred to as a mental health 
checkup, refers to the administration of a standardized, evidence-based 
mental health questionnaire, such as the Pediatric Symptom Checklist 
(PSC) or the Patient Health Questionnaire 9 Adolescent (PHQ-9A). These 
mental health screens include between 9 and 35 questions and take 5 to 
10 minutes to complete. The questionnaire is then scored to determine 
whether additional follow-up is necessary. It is important to note that 
a positive mental health screen is not a diagnosis of mental illness. 
Rather, a positive score on a mental health screen is an indication 
that further evaluation by a health or mental health provider is 
necessary. Whether provided in a school, community, or medical setting, 
the TeenScreen mental health checkup involves providing assistance with 
referral for mental health evaluation or treatment to interested youth 
and their families, who may accept or decline to receive services. In 
school and community settings, where a formal referral network like 
those in many medical settings may not exist, active steps to engage 
parents and assist them in linking to services are encouraged.
    While some have raised concerns about whether mental health 
screening might increase thoughts of suicide, research published by 
Gould et al. in the Journal of the American Medical Association 
demonstrated that there is no increased risk posed by mental health 
screening. Inquiring about mental health status, suicidal ideation and 
previous suicide attempts does not increase distress or suicidal 
thoughts in youth. The research also found beneficial effects for 
depressed youth and previous suicide attempters post-screening. 
Anecdotal evidence suggests that many young people are relieved to have 
the opportunity to discuss their mental and emotional concerns in a 
confidential setting.
Why Screen for Depression--Science and Research Support
    The importance of early detection, through screening of mental 
illness, has been well documented through medical research and by 
governmental entities. In 1999, the Surgeon General released both The 
Surgeon General's Call to Action to Prevent Suicide and Mental Health: 
A Report of the Surgeon General. These publications highlighted mental 
health screening as an effective tool for suicide prevention and 
suggested that primary care providers and schools could provide 
effective settings for the detection of mental illness. In 2003, the 
President's New Freedom Commission on Mental Health recommended an 
increase in early identification efforts by primary care providers. 
More recently, the Institute of Medicine (IOM) and National Research 
Council (NRC), in their report Preventing Mental, Emotional, and 
Behavioral Disorders Among Young People: Progress and Possibilities, 
recommended that the federal government make preventing mental, 
emotional and behavioral disorders, and promoting mental health in 
young people a national priority. Medical panels and professional 
groups have also recommended mental health screening for adolescents, 
including the United States Preventive Services Task Force (USPSTF), 
the American Academy of Pediatrics (AAP), the American Academy of 
Family Physicians (AAFP), and the American Medical Association (AMA).
    A mental health checkup using an evidence-based, standardized tool 
should be incorporated into the annual well-child visit for all 
adolescent youth as part of routine preventive care. We now know that 
in youth up to age 21 there is a window of opportunity of two to four 
years, between the first symptoms and the onset of the full-blown 
diagnosable disorder, when treatment is most effective at reducing the 
severity of specific disorders.
    However, we also know that primary care providers often rely on 
informal, unproven mental health screening methods and that mental 
health issues are sometimes not addressed at all. Further compounding 
the problem, many young people do not receive regular preventive care 
visits. This is especially true for American Indian and Alaska Native 
youth in rural settings, where the closest pediatrician may be several 
hours away. In fact, according to the AAP, the average number of well-
child visits within the American Indian and Alaska Native populations 
has dropped more than 35 percent over the last decade. As a 
consequence, it is important to incorporate mental health screening 
into a wider array of youth serving programs, such as those offered in 
school and community-based settings.
TeenScreen Schools and Communities--Our Work with Tribal Communities
    The TeenScreen Schools and Communities program has been affirmed as 
an evidence-based method of addressing youth suicide. The TeenScreen 
Schools and Communities program is included in the Best Practices 
Registry for Suicide Prevention put out by the Suicide Prevention 
Resource Center (SPRC). The program is also included in the SAMHSA 
National Registry of Evidence Based Programs and Practices (NREPP). 
TeenScreen has assisted a number of school and community based sites in 
providing mental health screening and referral to youth in Indian 
Country. Together, these programs have offered mental health screening 
to thousands of young people. I would like to highlight a few of these 
programs.
    A number of Garrett Lee Smith grantees have chosen to incorporate 
TeenScreen into their suicide prevention efforts. Signed into law on 
October 21, 2004, the Garrett Lee Smith Memorial Act (GLSMA) was the 
first federal suicide prevention program targeted toward youth and it 
created grants for states and tribal organizations to create and 
implement statewide/tribal suicide prevention plans. In all, at least 
13 grantees in 12 states have incorporated TeenScreen into their 
suicide prevention programs, including both campus and state/tribal 
grantees.
Gila River Behavioral Health Authority
    One such grantee is the Gila River Behavioral Health Authority 
Youth Suicide Prevention Project in Sacaton, Arizona. This program 
serves the Gila River Indian community, which includes a population of 
14,000 located on 372,000 acres south of Phoenix. The Gila River grant-
funded services include TeenScreen.
    The Gila River Regional Behavioral Health Authority began providing 
mental health screening to youth in schools within the region during 
the 2007-2008 school year. In the first year of screening, they were 
able to provide just 80 screenings, due to a low rate of parent 
consent. They also noted that a lack of good communication channels has 
made implementing large scale programs, such as TeenScreen, more 
challenging.
    With continued effort and by building trust in the community, the 
Gila River Regional Behavioral Health Authority was able to increase 
their screening rate considerably during the 2008-2009 school year, 
with a total of 455 youth screened. This was an increase of more than 
400 percent, and the program has trained 11 teachers, counselors and 
staff at four sites to implement the TeenScreen program and promote its 
sustainability.
    Among students screened in the program, 87 youth (approximately 19 
percent) screened positive due to risk of suicide or need for early 
intervention services. All youth identified were referred for some type 
of support services: 74 youth were referred for mental health services 
and 13 were referred for non-mental health services, such as social 
support services.
    The Gila River program is continuing its screening program in the 
2009-2010 school year, and the grant funding is currently authorized 
through September 2011.
Turtle Mountain Schools of Belcourt, North Dakota
    In 2002, Paul Dauphinais, Ph.D., a practicing school psychologist 
employed by the Turtle Mountain Community School District, learned of 
the TeenScreen Program and decided to work to bring mental health 
screening to Turtle Mountain Schools. The schools are located in 
Belcourt, North Dakota and on the Turtle Mountain Chippewa Indian 
Reservation.
    At the onset, Dr. Dauphinais knew that community support would be 
critical to the success of the screening program. By educating 
community members and giving presentations on the subject to key 
stakeholders, he was able to garner support from the Tribal Chairman, 
parents, school administration, and area treatment providers who would 
provide clinical interviews and referral resources for youth identified 
through the screening process.
    By 2004, Dr. Dauphinais developed a screening plan that would 
enable him to offer screening in Turtle Mountain's middle and high 
schools. He developed and strengthened relationships with local 
entities and staff that would participate in administering and 
supporting the screening program. Eventually, his screening team was 
comprised of school personnel, Indian Health Service (IHS) clinicians, 
community treatment providers and one case manager, whose position was 
funded by a Safe and Healthy Students Grant. (This position was first 
funded during the program development phase of the project, and has 
continued to be funded in each subsequent year.) Coordination with IHS 
staff and clinicians provided a unique opportunity for collaboration, 
which benefited the families that both the schools and IHS exist to 
serve. The well-orchestrated screening program also ensured that no 
single system was overwhelmed with referrals at any given time, and 
that each youth and family, starting with the most critical cases, 
received appropriate referral services and case management.
    During the 2004-2005 school year, fewer than one hundred students 
participated in the program. Despite seeing lower numbers than the 
screening team anticipated, this first year allowed the team and 
supporting organizations to familiarize themselves with the screening 
process and work to best utilize the community's limited resources for 
the youth who required follow-up interviews and referral services. Over 
two hundred youth (225 total) were invited to participate in the 
program during the 2005-2006 school year. One hundred twenty-five youth 
received parent consent and were screened. Of those youth, 33 scored 
positive on the screening instrument, requiring a clinical interview 
with program staff.
    Unfortunately, personnel difficulties and a lack of funding 
resulted in a stalled program, i.e. they were no longer able to provide 
screening, in 2008.
Riverside Indian School of Anadarko, Oklahoma
    Riverside Indian School (RIS) is a federally operated off-
reservation boarding school located in Anadarko, Oklahoma. RIS is the 
largest Bureau of Indian Affairs boarding school in the United States, 
with an enrollment of 600 students in grades four through 12 and 
students from more than 100 different tribes across the United States. 
The student population is 100 percent American Indian.
    Gordon Whitewolf is a school therapist and counselor at RIS. Mr. 
Whitewolf provides counseling and therapeutic services for students 
experiencing variety of behavioral and mental health problems. He is an 
Oklahoma Licensed Behavioral Practitioner, and an Internationally 
Certified Alcohol/Drug Counselor.
    By 2002, Mr. Whitewolf was well into his tenure at RIS and 
witnessed first-hand the alarming rates of mental illness, substance 
abuse and suicide risk among his students. He felt that through his 
work at RIS, he and his colleagues could proactively identify youth who 
might be at the highest risk for suicide or other mental health 
concerns. Mr. Whitewolf found that many students came to RIS with a 
variety of mental health problems that were not previously identified. 
Some youth were struggling with depression and suicidality; others were 
dealing with anxiety-related disorders, associated with separation from 
their family and friends, and learning to adjust to a new environment.
    Mr. Whitewolf set out to identify a program or intervention that 
would enable the RIS counseling and medical staff to identify students 
in need of immediate intervention, as well as those students who would 
benefit from additional support throughout the school year. A colleague 
presented him with preliminary information about a new mental health 
checkup program being offered by Columbia University. After collecting 
information on the program and presenting it to the Director of Student 
Services, he was granted permission to bring the TeenScreen Program to 
RIS during the 2002 school year.
    ``Native American's have survived centuries of historical trauma 
and infirmity,'' Whitewolf says. ``Today, Native American youth face 
similar discord constructed by society such as violence, racism, 
substance abuse, and mental health problems. These problems impact 
youth in different ways, and may bring about a feeling of hopelessness 
or worthlessness. That is why Riverside Indian School implemented the 
Columbia University TeenScreen Program. The Program helps staff 
identify those students showing evidence of suicidal ideation, previous 
suicide attempts, possible mood disorder, as well as substance use.''
    In the program's first year, Mr. Whitewolf and the counseling team 
offered screening to the entire student body. The screening team 
consisted of two school therapists who administered the screening 
questionnaire and provided clinical interviews, and a nurse 
practitioner who provided case management services. In addition, close 
consultation and cooperation with Parent Liaison staff and Medical 
Center staff ensured that every element of the student's care and well-
being was considered.
    The results of the screening in the first year were telling: staff 
found that 17 percent of youth screened reported suicidal ideation or a 
previous suicide attempt; 20 percent reported problems with substance 
abuse; and 19 percent reported symptoms of depression. Mr. Whitewolf 
and RIS counseling staff assisted youth at highest risk immediately, 
and provided follow-up assessments (and treatment when necessary) for 
all students who screened positive. With such a large segment of the 
student population suffering from mental health and substance abuse 
problems, screening allowed the counseling team to provide triage 
evaluations to all students, and identify youth at highest risk, 
ensuring that cohort of students receives the critical care they need.
    Since his initial success in 2002, Mr. Whitewolf and colleagues 
routinely offer mental health screening to all new students at the 
beginning of each school year. ``The TeenScreen Program provides an 
opportunity for therapeutic intervention for students in need of 
services, and the ability to assist each student both at school and 
when they return to their respective tribal community upon completion 
of the school year,'' Mr. Whitewolf has explained. In addition, he has 
stated that screening has allowed counseling staff to communicate more 
effectively with the medical unit on campus, creating a unique system 
that fosters better over-all care for RIS students.
Lessons Learned
    These case studies highlight both the successes and the challenges 
of reaching at-risk youth in Indian Country through mental health 
screening. Thousands of young people have received a screening, and 
hundreds have been connected to needed support services. More 
importantly, for many youth, the screenings serve as an opportunity to 
start a conversation about mental and emotional health.
    However, much as in medical settings, we cannot reach all young 
people through these screening programs. Funding shortfalls often lead 
to the end of a screening program; when a grant runs out, the program 
stops. We also know that some of the most at-risk young people cannot 
be reached in a school setting. Mental illness is the leading cause of 
disability-related school dropout, and youth suffering from mental 
illness are much more likely to leave school before graduation. In 
fact, a 2010 report from the University of California, Los Angeles 
(UCLA) Graduate School of Education and Information Studies found that 
fewer than 50 percent of American Indian and Alaska Native youth in the 
Pacific and Northwest of the United States graduate from high school.
Recommendation--Integrate Screening into Multiple Youth Serving 
        Settings
    In order to provide comprehensive services and reach as many at-
risk youth as possible, it is imperative that we provide opportunities 
for prevention and early intervention in all youth-serving settings 
where appropriate supports can be arranged. This may include, but is 
not necessarily limited to, medical, school and community settings.
    In American Indian and Native American communities, cultural 
programs can play an important role in promoting and providing access 
to mental health screening. TeenScreen site coordinators in Indian 
Country have repeatedly stressed the importance of engaging tribal 
leaders to communicate about the importance of mental health screening 
and to build trust within the community. Many suicide prevention 
programs incorporate initiatives to celebrate and preserve Native 
culture into their efforts, and these settings should play a role in 
helping to identify at-risk youth through screening.
    The health care reform bill signed into law by President Obama on 
Tuesday will go some way to helping to expand mental health screening 
in the medical setting. The language includes provisions to provide 
United States Preventive Services Task Force recommended services 
without cost-sharing in benefit plans, which includes annual depression 
screening for adolescent youth ages 12 to 18. However, we know that 
mandating coverage of a service does not always translate into the 
service being provided in clinical practice. Therefore, we must 
continue to work to raise the visibility of the need for mental health 
screening as we expand access in multiple youth-serving settings.
Recommendation--Expand Telemedicine With Focus on Mental Health of 
        Youth
    Identifying youth in need of mental health services through 
screening is of little utility if we are unable to connect them to 
necessary services. As we referenced earlier, the IHS suffers from a 
provider shortage for all types of providers, and child and adolescent 
psychiatrists are in short supply, not just in the IHS, but the system 
more generally. Furthermore, the rural and often isolated locations in 
which many American Indian and Alaska Native youth reside contribute to 
the difficulty of connecting them to appropriate mental health 
providers.
    An important solution to addressing these challenges has been the 
expansion of the use of telemedicine services, including 
telepsychiatry. For example, the University of New Mexico's Center on 
Rural Mental Health has been providing telepsychiatry services, also 
referred to as tele-behavioral health services, to the Mescalero tribe 
and others in New Mexico. Through a contract with the IHS and the State 
of New Mexico, the Center is able to offer patient diagnosis, 
treatment, and supervision services. The Center is also able to help 
address the workforce shortage by providing additional training and 
supervision to mental health providers, such as social workers.
    The success of such programs has spurred an increased investment in 
tele-behavioral health services. The Methamphetamine and Suicide 
Prevention Initiative (MSPI) included funding to establish a National 
Tele-Behavioral Health Center of Excellence, and at least 50 IHS and 
federal sites are using or in the process of creating tele-behavioral 
health services. The American Recovery and Reinvestment Act of 2009 
(ARRA) also provided funding to expand the infrastructure necessary to 
support telemedicine.
    The health care reform legislation signed into law earlier this 
week also includes provisions that will help expand access to services 
for American Indian and Alaska Native youth. New grant moneys for 
telepsychiatry projects are included in the legislation, as well as 
provisions targeted toward addressing IHS workforce recruitment; 
improving rural health services; reducing health disparities; and 
expanding access to preventive services.
    These are all steps in the right direction, but we remain far from 
being able to serve all youth who are in need of mental health services 
adequately. We must continue to address the shortage of services 
through common-sense, proven approaches such as telemedicine.
TeenScreen National Center as a Resource
    Thank you for the opportunity to testify. The TeenScreen National 
Center stands ready to serve as a resource, and I look forward to 
working with the members of this Committee as you develop policies to 
improve the lives of American Indian and Alaska Native youth.

    Ms. Binney. Thank you, Ms. Flynn.
    Next, we will hear from Hunter Genia, who is the Behavioral 
Health Administrator at the Saginaw Chippewa Tribe in Michigan.

   STATEMENT OF HUNTER GENIA, ADMINISTRATOR, BEHAVIOR HEALTH 
                SERVICES, SAGINAW CHIPPEWA TRIBE

    Mr. Genia. Good morning. [Greeting in native language.]
    My name is Hunter Genia. I am the Behavioral Health 
Administrator for the Saginaw Chippewa Indian Tribe. I would 
like to thank the other panelists that have spoken. Probably 
unlike many of them, except for the young man that spoke, I 
don't work on a Federal level. I actually work in our tribal 
community on the ground level and kind of see what is going on 
for our nation.
    I also work with a collaboration of tribes in Michigan that 
are recipients of a SAMHSA grant called Access to Recovery. I 
believe that was originally started under the Bush 
Administration and has continued hopefully under the Obama 
Administration. I want to talk about that briefly as well.
    I also recognize that where I come from, the Odawa and 
Ojibway Nation in Michigan that I descend from Pontiac, who 
back in the 1700s was a leader among the Great Lakes tribes 
that tried to thwart the expansion of Western Civilization 
because his fear was that we would adopt too many of the non-
native ways and we would lose ourselves and become lost.
    And I think what we are seeing here in Indian Country is a 
deep psychological wound that has not healed for many, many 
generations and hundreds of years. We have seen this through 
the Indian boarding schools that often goes untalked about here 
in America in our history books. And we have not recovered as 
an Indian people in this Country as a result.
    A lot of people believe that the Indian boarding schools 
was only from the 1870s to the 1930s. But in Michigan, we had 
one Indian boarding school that remained open until the early 
1980s. And my own brother and my own sister attended these 
schools. And if you want to talk about trauma, it has only been 
disclosed in recent years that sexual abuse, physical abuse, 
emotional abuse has occurred in these Indian boarding schools, 
often led by a lot of the church institutions and missionaries.
    But as the Administrator, I have been asked to try to 
address some of the lack of resources that we have in our 
community regarding mental health services. So for the last 
four years, I have been the Saginaw Chippewa Behavioral Health 
Administrator, and prior to that for six years, our Clinical 
Mental Health Director. Prior to that, for 10 years I worked in 
the American Indian urban population where there is virtually 
zero dollars for Indian healthcare for the majority of the 
American Indian population that live in non-reservation 
communities.
    The Saginaw Chippewa Behavioral Health Program and the 
Saginaw Chippewa Indian Tribe is providing nearly 70 percent of 
our funding just to operate our own programs. So the amount of 
dollars coming from Indian Health Service or other grant 
funders is much less than that. So I just want to point that 
out.
    So right now, our tribe is putting over $1.5 million into 
just our behavioral health services. We offer an outpatient 
mental health, substance abuse, residential program, but we are 
very unique as a tribe. And I also want to point out that the 
majority of gaming tribes are not profitable. The majority of 
gaming tribes are in the red and can't do what we are doing and 
providing. So in Michigan, our tribe is very unique.
    One of the things I want to point out about the Access to 
Recovery grant is that it also recognizes our cultural and 
spiritual beliefs and our teachings and our ceremonies, and 
that they are actually utilized in our efforts in recovery. So 
whether we are working with adolescent children or adults or 
elders, the majority of our people are asking that traditional 
and cultural practices be a part of their treatment process.
    And that is one of the beautiful things about the Access to 
Recovery grant, which is under SAMHSA, is that it actually 
acknowledges and respects who we are as an indigenous people 
here in this Country.
    And I just want to point out and remind people that it 
wasn't until 1978 that the American Indian Freedom of Religion 
Act was even passed in this Country, which took a special act 
by Congress. So until then, many of our people have had to live 
in generations of hiding and privatize, really, who we are as 
an indigenous people. And I just want to point that out because 
I think a lot of these programs are great, but it is not really 
talking about where a lot of these wounds are originating from.
    And so oftentimes what we have are band-aid approaches to 
addressing American Indian health needs, especially the mental 
health needs.
    During the 2008 and 2009 fiscal years, at any given time we 
have had an average number of up to 60 tribal members, 
community members waiting to access our behavioral health 
services. During this time, they could wait up to an average of 
three months before they could even see a counselor of a 
clinician. And I just point that out because if we had more 
funding, we could add more staff to our programs and our 
resources and be able to address some of those needs.
    The Saginaw Chippewa Indian Tribe also made a decision to 
build our own residential treatment facility. Before we even 
laid the first brick down to build this facility, we had phone 
calls from all of the other Michigan tribes asking if our 
residential facility will be open to their tribes. And 
unfortunately, they are not. And some of that has to do with 
some of the Indian Health Service policies regarding funding 
and some of the access to care.
    But one of the reasons why we built the residential 
treatment center on our own reservation is because other than 
our tribal residential program, our community members had to 
travel at least six to eight hours or out of State to even 
access culturally sensitive treatment facilities and programs. 
Otherwise, it would go to non-native programs that oftentimes 
were not sensitized to our values, our traditions and our 
culture. And therefore, a lot of the non-native approaches to 
treating our people were often utilized and a lot of our people 
were discriminated against or biased in those treatment 
settings that they were non-native.
    So I think since we opened up our own residential program, 
over 250 of our own tribal members have gone through our 
residential program. And if that residential program was not 
there, probably the majority of them would have never even gone 
into treatment at all.
    So one of the things I want to point out is, our tribe is 
footing the bill for most of our Indian health care, not the 
United States or the Federal Government or Indian Health 
Service, for that matter. We are very fortunate that all the 
tribes of Michigan are part of the Access to Recovery grant 
under SAMHSA, but it still is not adequate funding to provide 
the level of services and care that we need in our tribal 
communities.
    I am 40 years old. I got my master's in social work from 
Grand Valley State University. I don't drink. I don't do drugs. 
I don't smoke. But I am very much in a non-conceited way unique 
in that regard.
    I was talking to a young man here earlier before the 
meeting started that is from Pine Ridge. I think the difference 
is that somebody along the way said that I could be somebody 
and had an opportunity. And I think we can call it mental 
health illnesses and things of that nature, but the fact is 
that the majority of American Indian youth in this Country 
don't see the opportunity. They are not given a chance to see 
what dreams that they can aspire to.
    If you look across the Nation here, how many of our people 
do you see that are in politics? How many do you see that are 
in sports? How many do you see that are in entertainment? 
Virtually none. Until we are able to place our own people in 
places of leadership that our young people can turn on the 
radio or look on TV and see, all they see is what is there on 
our reservation communities. And they don't understand coming 
to Washington, D.C. is a possibility for them, you know, to be 
a Governor, to be a Senator, to be a Congressman. It is very 
far and few in between.
    And I think what we are trying to do and address in our 
community, I will give you two examples. Last October, we had 
GONA, Gathering of Native Americans. It is a four-day training 
actually facilitated by our own people, which initially started 
under SAMHSA. And it brought all of our community together in a 
good way, in a good place to talk about things that we needed 
to do to heal as a community.
    Because that is one thing that we all have as universal 
truths in Indian Country is that there is a lot of walking 
wounded people in our community that have not healed from post-
traumatic historical trauma. And until we address some of those 
things and give it a name and acknowledge those, I am not sure 
that all the programs in the world are going to help. We need 
to focus on healing and wellness in our tribal communities and 
look at those kinds of things that are generated from multi-
generational traumas.
    The other thing that happened in our community is that with 
the assistance of White Bison, is that we have the Journey for 
Forgiveness hosted in our community. And that, for the first 
time in the Mt. Pleasant community, addressed the impact that 
Indian boarding schools had on our people. And as you know, 
Indian boarding schools was very good at taking away our 
language, our culture and our traditions, and basically their 
goal was to Americanize us.
    So I think a lot of what is happening in Indian Country is 
that we have big who am I cultural identity issues that are 
going on among a lot of our young people. Where do we belong? 
How do we fit in? Are we invited to the table? Are we 
important? I think a lot of our young people don't feel that.
    And so a lot of the things that we are trying to do in our 
community is to let them know that they are important and to 
help programs set up like that.
    But I will say that the majority, 60 percent to 70 percent 
of our behavior health funding is because our tribe made it a 
priority, the Saginaw Chippewa Indian Tribe. If we were to rely 
on Indian Health Service's funding or the Federal Government, I 
mean, we would not have a majority of our programs available to 
our own community.
    And so we need more funding. We need more resources. We 
need more American Indian Native American leaders to step up 
and be a part of our tribal communities and lead these efforts 
and be seen and be visible in this Country in our communities.
    So that is basically my main message that I wanted to bring 
here. And I thank you for the opportunity, and I hope that in 
the future years that more funding and resources will be 
available to our tribal communities. But I also know that we as 
native people have to take the leadership role in making that 
happen.
    [Phrase in native language.]
    [The prepared statement of Mr. Genia follows:]

  Prepared Statement of Hunter Genia, Administrator, Behavior Health 
                    Services, Saginaw Chippewa Tribe
    Ahnii, Giwesinini Ndihzinkaaz, Wabezhenshi dodem, Mt. Pleasant, MI 
ndojibaa. My name is Hunter Genia and I am the administrator for the 
Saginaw Chippewa Indian Tribe Behavioral Health Services in Mt. 
Pleasant, MI., approximately one hour north of Lansing, our state 
capitol. The Saginaw Chippewa Indian Tribe behavioral health services 
provides mental health services to all eligible Native Americans of any 
federally recognized tribe residing in a five county district in the 
central lower peninsula of Michigan. The Saginaw Chippewa Tribe has 
over 3,400 tribal members with roughly 50 percent of our population 
being under the age of eighteen.
    I have been the administrator here for 4 years and prior to that, 
the mental health director of our program for six years. Upon my 
employment here we were an outpatient mental health, substance abuse, 
and prevention program providing clinical mental health services to 
over four hundred fifty open clients, with no residential services. In 
2005, we opened up our own residential treatment center, funded solely 
by the Saginaw Chippewa Indian tribe.
    During my tenure as the Administrator and Clinical Director, the 
Saginaw Chippewa Indian Tribe has carried the burden financially for 
providing the Behavioral Health care for our tribe. The Saginaw 
Chippewa Indian Tribe is providing 66 percent of our operational budget 
in this current fiscal year which equates to roughly 1.9 million 
dollars. The Saginaw Chippewa Indian Tribe Behavioral Health Program 
during the last four years has provided over 8 million dollars to 
support Behavioral Health Services; this figure does not include any 
Indian Health Service funding.
    During the 2008 and 2009 fiscal years at any given time we had an 
average number of sixty tribal members waiting to receive services. The 
average waiting time to receive services once on the waiting list could 
be up to three months before they could receive any type of counseling 
services. The Saginaw Chippewa Indian Tribe made a decision to build a 
residential treatment center here on our reservation. The primary 
reason for this was so that our tribal community members could access 
this care without having to travel several hours, or out of state to 
receive Native American residential services. Distance to residential 
treatment provided a barrier for a lot of our tribal members to access 
services when needed. The closest Native American residential program 
was located over eight hours away, which made it virtually impossible 
for family members to participate in the treatment process. Since we 
have opened up our residential services we have provided care to over 
250 Saginaw Chippewa Tribal Members. The residential treatment center 
operational costs are solely funded by the tribe. The majority of 
Native Americans receiving residential cares with us have had a 
combination of mental health and substance abuse disorders, known as 
co-occurring. Many of our tribal members have preferred to remain on 
our waiting list with our tribal services instead of seeking behavioral 
health services with other agencies and programs.
    During my employment with the Saginaw Chippewa Indian Tribe, 
barriers to providing appropriate behavioral health care in our tribal 
community have been; inadequate staffing levels, lack of available 
psychiatrist for adults and children, adult and child psychologist to 
see clients in need of specialized treatment and assessments, cultural 
competency, Native American staff, and funding. Other issues include 
inadequate prevention, education, and screening for early 
identification of youth or adults at risk for suicide. In order for 
these barriers to be addressed effectively adequate funding is needed.
    Many of our tribal community children are faced with enormous 
challenges that can be barriers to success in their lives. Higher 
prevalence of physical, emotional, sexual abuse and neglect are 
experienced by children and adolescents in our tribal communities. Our 
community's children are more likely to experience a higher prevalence 
of substance abuse, domestic violence, mental illness, neglect and or 
have witnessed such before they reach the age of eighteen than any 
other racial ethnic group. Due to these higher rates of behavioral 
health issues roughly 40 percent of our clients we see are children and 
adolescence.
    The substance abuse and mental health issues we face and see in our 
community can be traced back to multigenerational trauma experienced by 
their parents, elders, and grandparents before them. A lot of the 
trauma can be traced directly to federal policies and practices like 
the Indian Boarding Schools. I am not surprised by this comparison 
which has gone severely unaddressed in tribal communities due to a lack 
of resources, funding, and staffing. Our tribal community has begun to 
address the mental health devastation that past federal government 
practices and policies have contributed to our people. Mental health 
issues we are addressing such as historical trauma, relocation, grief 
and loss, foster placement, physical, sexual, emotional, spiritual 
abuse, reactive attachment disorder, and trauma in tribal communities 
is enormous. This is what we see everyday coming into our clinic. This 
also means that specialized treatment and care is called for along with 
the acknowledgment and respect for cultural, traditional, and spiritual 
practices that were outlawed thirty years ago prior to 1978's American 
Indian Freedom of Religion Act. Also prior to this, the 1975 Indian 
Child Welfare Act was passed which protected our tribal children from 
being erroneously removed from their homes and community. These acts 
took special legislation and acts of Congress to protect our tribal 
community and our most precious resource, our youth.
    As an American Indian raised in an large urban American Indian 
population in Grand Rapids, MI and also on my reservation in Mt. 
Pleasant, Michigan, I can tell you that in both respects, it comes down 
to financial and people resources. Unmet needs are still very rampant 
today for the American Indian population who need access to substance 
abuse and mental health care that are appropriate for their level of 
needs. Often times in my experiences, the city, county, and state 
levels do not want to work cooperatively with the tribal governments 
and communities to ensure that we are able to access this care 
equitably.
    I thank you for allowing me to be here this morning.
Attachment




    Ms. Binney. Thank you, Mr. Genia.
    Next, we will hear from Novalene Goklish, who is the Senior 
Research Coordinator for Celebrating Life Youth Suicide 
Prevention Program, White Mountain Apache Tribe/Johns Hopkins 
Center for American Indian Health, Celebrating Life/Johns 
Hopkins Project.
    Thank you.

         STATEMENT OF NOVALENE GOKLISH, SENIOR PROGRAM 
  COORDINATOR, WHITE MOUNTAIN APACHE YOUTH SUICIDE PREVENTION 
                            PROGRAM

    Ms. Goklish. Thank you. Good morning. My name is Novalene 
Goklish. I direct the suicide prevention efforts of my tribe, 
the White Mountain Apache.
    Youth suicide, as you have heard, is the single biggest 
human loss a family or community can experience. It is 
destroying American Indian and Alaska Native communities. When 
you think of other behavioral health problems that affect 
youth, drug abuse, obesity, diabetes, some believe our Indian 
communities tend to see what is to come for other U.S. 
populations unless interventions are developed to stop these 
tragedies.
    In the United States, suicide is the third leading cause of 
death for youth ages 15 to 24. Within the White Mountain Apache 
Tribe, our rates of death for this age group are 13 times the 
U.S. average and six times the all-Indian rate. In the United 
States, up to 500,000 persons a year require emergency 
department care as a result of a suicide attempt.
    On our reservation alone, with a population of 15,500 
members, our Indian Health Service hospital treats more than 
200 youth a year for suicide attempts. The White Mountain 
Apache Tribe is devastated, but not broken by our problems of 
suicide. We see it as an obstacle we must overcome in order to 
share lessons learned with the world.
    We choose research as our tool, with the help of our long-
time partners, Johns Hopkins Center for American Indian Health. 
We have tackled past health disparities by producing public 
health interventions that now save more than 3 million lives a 
year worldwide. Today, we are turning our research focus on a 
range of interventions to prevent youth suicide. We are 
designing this research so that it can be reproduced across 
Indian Country and in rural and indigenous communities across 
our Nation and our world.
    I want to share with you the important elements of our 
work. The White Mountain Apache Tribe, with technical support 
from Johns Hopkins, has developed the first tribally mandated 
suicide surveillance and follow-up system in the United States. 
In 2001, our tribe mandated that all health and human service 
providers and tribal members report suicidal behaviors to the 
Centralized Suicide Prevention Task Force.
    These behaviors include suicidal ideations, attempts, 
deaths, binge drinking, drug use and cutting, which are also 
forms of self-injury in our community. Johns Hopkins assists in 
managing date, tracking quarterly patterns in suicidal 
behaviors and reports the information back to all tribal 
departments.
    Along with Johns Hopkins, we have trained and employed a 
team of case managers who follow-up on every incident reported 
through the suicide surveillance system. The case managers 
assist youths at risk for suicidal death and triage youth and 
their families to available care. Prior to this, very few 
youths who attempted suicide, less than 25 percent, ever 
received treatment due to numerous treatment barriers. This the 
first community-based follow-up and triage system of its kind 
in this Country.
    We are grateful for grants from SAMHSA, Garrett Lee Smith 
Youth Suicide Prevention Program and the Native American 
Research Centers for Health, managed by NIH and IHS. With this 
support, we are now developing evidence-based prevention 
interventions, including the following.
    First, we have adapted an emergency department intervention 
of youth who have attempted suicide and their family members. 
Apache case managers meet with the youth and their families to 
help them develop a safety plan to keep the youth alive. We are 
now developing a research trial to prove the effectiveness of 
this intervention.
    Second, we have adapted a life skills curriculum to be used 
in home outreach by Apache case managers with at-risk youth and 
their families. The curriculum teaches conflict resolution, 
coping and problem solving skills. We are planning a randomized 
control trial of this intervention in the near future to prove 
its effectiveness.
    Third, we have trained and certified two Apache case 
managers to conduct gatekeeper trainings in our community, and 
that is myself along with my colleague Francene Larzalere-
Hinton, who is sitting behind me.
    Fourth, we have developed an Elders Advisory Council. Our 
elders are focusing on promoting traditional protective 
factors. They are speaking in elementary and middle schools and 
taking groups of at-risk and healthy kids on field trips to 
sacred sites on our reservation. They are teaching the youth 
the core strengths of our Apache heritage and are creating 
media campaigns to promote protective factors on our 
reservation.
    Native communities have tremendous resiliency. We have 
survived untold adversity by blending our traditional wisdom 
with new technologies. Culturally appropriate research is a 
great example. We must harness the power of traditional 
understanding and rigorous scientific research to stop youth 
suicide.
    Tribal and university partnerships that are built on trust 
and long-term commitment, such as the White Mountain Apache 
Tribe and Johns Hopkins, are the most powerful means for 
achieving renewed health.
    Federal funds are well spent in the arena of suicide 
prevention to reduce the high toll of medical costs and human 
suffering to ensure our most precious asset, which is our 
youth, so that they can live to their full potential. In our 
belief system, every human life serves a purpose to maintain 
the health and well being of Mother Earth.
    We must find the means to re-learn as a human race that 
life is sacred, that life is precious, that life is meant to be 
lived out serving our greater common purpose.
    Thank you.
    [The prepared statement of Ms. Goklish follows:]

  Prepared Statement of Novalene Goklish, Senior Program Coordinator, 
        White Mountain Apache Youth Suicide Prevention Program *
---------------------------------------------------------------------------
    * DISCLAIMER: None of the opinions expressed within are those of 
Johns Hopkins University.
---------------------------------------------------------------------------
    Mr. Chairman and Members of the Committee, good morning. I am 
Novalene Goklish. I direct the suicide prevention efforts of my Tribe, 
the White Mountain Apache.
    Youth suicide is the single biggest human loss a family or 
community can experience, and it is destroying American Indian and 
Alaska Native communities. When you think of other behavioral health 
problems that affect youth--drug abuse, obesity, diabetes--some believe 
our Indian communities tend to see what is to come for other U.S. 
populations, unless interventions are developed to stop these 
tragedies.
    In the United States, suicide is the third leading cause of death 
for youth ages 15-24. Within the White Mountain Apache Tribe, our rates 
of death for this age group are 13 times the U.S. average, and 6 times 
the All Indian rate. In the U.S., up to 500,000 persons a year require 
Emergency Department care as a result of suicide attempt. In our 
reservation alone, with a population of 15,500 tribal members, our 
local Indian Health Service hospital treats more than 200 youth a year 
for suicide attempts.
    The White Mountain Apaches are devastated but not broken by our 
problems of suicide. Rather, we see it as an obstacle we must overcome 
in order to share lessons with the world. We choose research as our 
tool. With the help of our long-time partners, Johns Hopkins Center for 
American Indian Health, we have tackled past health disparities by 
producing public health interventions that now save 3 to 5 million 
lives a year worldwide. Today, we are turning our research focus to a 
range of interventions to prevent youth suicide. We are designing this 
research so that it can be reproduced across Indian country and in 
rural and indigenous communities across our nation and our world.
    I want to share with you the important elements of our work:
    The White Mountain Apache Tribe, with technical support from Johns 
Hopkins, has developed the first tribally mandated suicide surveillance 
and follow-up system in the United States. In 2001, our Tribe mandated 
that all health and human service providers and tribal members report 
suicidal behavior to a centralized suicide prevention task force. These 
behaviors include: suicidal ideation, attempts, deaths, as well as 
binge drinking, drug use and cutting, which are also forms of self-
injury in our community. Johns Hopkins assists in managing data and 
tracking quarterly patterns in suicidal behaviors and reports the 
information back to all tribal departments.
    In addition, with Johns Hopkins' help, we have trained and employed 
a team of Apache case managers who follow-up on every incident reported 
through the suicide surveillance system. The case managers assess 
youth's risk for suicidal death and triage youth and their families to 
available care. Prior to this, very few youth who attempted suicide 
(<25%) ever received treatment due to numerous treatment barriers. This 
effort is the first community-based follow-up and triage system of its 
kind in the country.
    Our tribe has been fortunate to receive federal funding for our 
suicide prevention research. We are grateful for grants from SAMHSA's 
Garrett Lee Smith youth suicide prevention program and the Native 
American Research Centers for Health, managed by NIH and IHS. With this 
support, we are now developing evidence-based prevention interventions. 
What has been accomplished to date is state-of-the-art, and includes 
the following:

   First, we have adapted an Emergency Department intervention 
        for youth who attempt suicide and their immediate family 
        members. Apache case managers meet directly with the youth and 
        their families to help them develop a safety plan to keep youth 
        alive; we also help them connect to available services and 
        follow-up to ensure they go. More than anything, we teach them 
        that their suicide attempt was very serious and taking one's 
        life is not the Apache way. We are now doing a research trial 
        with 30 White Mountain Apache youth who've attempted suicide to 
        prove the effectiveness of this intervention.

   Second, we have adapted a life skills curriculum to be used 
        in home outreach by Apache case managers with at-risk children 
        and their families. This curriculum, originally called the 
        American Indian Life Skills Curriculum, was previously designed 
        for schools. We have found that many of our youth who are at 
        risk do not regularly attend school. Nor are their families 
        involved with their schools. The curriculum, which we have 
        named, ``Re-Embracing Life,'' teaches conflict resolution, 
        coping and problem-solving skills. It serves as extra support 
        as the Apache case managers work to get youth and families to 
        available mental health treatment on the reservation. We are 
        planning a randomized controlled trial of this intervention in 
        the near future, so we can prove its effectiveness.

   Third, we have trained and certified two Apache case 
        managers to conduct ASIST gatekeeper training in our community. 
        We as Apaches have renamed this intervention ASIST 
        ``caretaker'' training. The training educates adults who work 
        with at-risk youth to recognize signs of suicide and connect 
        youth to care. The Apaches are planning to culturally adapt the 
        ASIST training to be more relevant to Native peoples.

   Fourth, we have developed an Elders advisory council. Our 
        elders are focusing on promoting traditional protective 
        factors. They are speaking in elementary and middle schools, 
        and taking groups of at-risk and healthy kids on field trips to 
        sacred sites. They are teaching youth about the core strengths 
        of their Apache heritage. Elders and youth are also creating 
        media campaigns to promote protective factors on our 
        reservation.

    Some unique highlights of our work include:

   The Apache community-based suicide surveillance system is 
        the first of its kind in the country. We hope it becomes a 
        resource to other tribal nations across North America, and will 
        strengthen culturally specific responses to suicide prevention 
        and treatment.

   The training and employment of Apache case managers to 
        increase the safety net and community connections for suicidal 
        youth is completely unique. It has great potential for solving 
        current barriers to mental health care on reservations and in 
        other indigenous communities worldwide.

   Johns Hopkins and the Apaches have had a 30-year 
        relationship developing evidence-based public health 
        interventions that have been disseminated across the globe. The 
        suicide prevention work is being designed accordingly, to have 
        relevance in populations worldwide.

   The interventions we are designing are low cost and tap and 
        strengthen our local human resources. Much of the prevention 
        and post-intervention is focused on connecting youth to caring 
        adult family members and to community treatment resources. The 
        latest data from the CDC demonstrates that bridging connections 
        to families is the most powerful prevention strategy.

    Native American communities have tremendous resiliency. We have 
survived untold adversity by blending our traditional wisdom with new 
technologies. Culturally appropriate research is a great example. We 
must harness the power of traditional understanding and rigorous 
scientific research to stop youth suicide. Tribal-university 
partnerships that are built on trust and long-term commitment--such as 
the White Mountain Apache Tribe and Johns Hopkins--are the most 
powerful means for achieving renewed health. Federal funds are well 
spent in the arena of suicide prevention to reduce the high toll of 
medical costs and human suffering and to ensure our most precious 
asset--our youth--live to full maturity and potential. In our belief 
system, every human life serves a purpose to maintain the health and 
well-being of Mother Earth. We must find the means to re-learn as a 
human race that life is sacred; that life is precious; that life is 
meant to be lived out serving our greater common purpose.

    Ms. Binney. Thank you.
    So we are in a listening session right now, and as I said 
earlier, it is continuing to be webcast, so a lot of people in 
Indian Country watch our hearings via webcast, so we wanted to 
continue to do that. And there is a transcript that is still 
being taken that will be given to each of the Members of this 
Committee afterwards.
    We thought that it would be helpful to go ahead and engage 
in a dialogue about this issue since you are all here, and 
maybe ask some questions. I know some of you have to leave, 
though, I think particularly Mr. Grinnell, you might have 
another function to go to. So feel free to leave when you need 
to, but we thought it would be nice to ask some questions and 
engage in a dialogue.
    As part of the Indian Health Care Improvement Act that just 
was signed into law, there was a smaller bill that was 
basically aimed at youth suicide prevention in Indian Country 
that Chairman Dorgan sponsored and several Members of this 
Committee on both sides of the aisle sponsored as well.
    And our hope is that that will make some progress in the 
prevention of youth suicides in Indian Country, but we know it 
won't solve the problem. And that is why we are holding the 
hearing today is to basically learn what are some other ideas 
that are working out there already that we can try to inject 
into the system nationally.
    And with that, I would like to go ahead and ask some 
questions, Rhonda and I, and start with Coloradas Mangas.
    Mr. Mangas, you mentioned in your testimony that there is a 
stigma with suicide among some Indian youth your age. And I 
grew up in a Native American community and am part Native 
American, and I agree with that, but I don't fully know where 
it comes from.
    And since you are in the midst of it now, I was wondering 
if you had some thoughts about why there is a stigma with it?
    Mr. Mangas. This is kind of hard for me.
    Ms. Binney. We can start with someone else, too.
    Mr. Mangas. Most youth won't go to our mental health clinic 
because there is stigma of shame that keeps people away. It is 
because they are afraid of getting talked about.
    Myself, I know that by going to the mental health clinic, 
that I would be talked about by other Native American youth and 
by many other Native American people that I live with on the 
reservation. But I took that chance of going to the mental 
health clinic to get myself help.
    I believe that most people really won't go because the 
problems that they have are big and then by adding on more 
problems of other people talking about them, it makes it even 
harder for them. So it is like most people want to seek help, 
but they won't do it because of the shame that is there of 
getting talked about or by having other people put you down 
because you did go these mental health clinics, or because you 
did show your face at one of these faces that most people won't 
even dare be seen walking out of a building like that.
    And most of our youth that did do this, I believe that if 
they did go and get help, that yes, they would have got talked 
about, but the help that they would have received would have 
really helped them in a way that they wouldn't have made these 
attempts on their life or completed these attempts.
    And it is hard for a lot of youth to get talked about. I 
mean, it is like just every little thing you do, you get 
criticized for what you did or you get placed a name on you 
that you don't really appreciate or something. And like for me, 
many of these children that I go to school with, they all like 
to talk about each other, and I knew that from the minute being 
seen walking out of this building, I was going to get talked 
about. But I was willing to take that risk just to get myself 
help.
    And it was hard for me to get talked about because many of 
these people are like, oh, we have seen you walking out of this 
building, and I am, like, well, it is because I needed help. I 
really think that I needed help at the time. That is why I 
seeked it.
    I wasn't afraid of getting talked about by these people or 
by other children, and I just put all that aside from the 
minute I walked into the building, thinking, well, this is 
going to help me and this is going to help my future because 
it's not something that I should be doing is making an attempt 
with my life. That is why I seeked help.
    And the shame that is there for many of these children, 
they can't overcome it because it is too big on some people. I 
mean, if our people weren't afraid of going or being seen 
walking out of this building, I am pretty sure that many of the 
kids that did complete suicide would still be here with us 
today.
    And I think it is just a shame that comes from being seen 
walking out of this building is what is kind of helping these 
kids stay away from this building because of not wanting to be 
seen or not wanting to be talked about.
    And that is what I think is kind of leading to some of 
these suicides is that these children are seeking help, but 
they do not want to be criticized for seeking that help or 
being seen walking out of this building and get talked about.
    Ms. Binney. Yes. Thank you.
    So in light of those comments, Ms. Flynn, do you run into 
any problems using the TeenScreen questionnaire? Because if 
there is a stigma in Indian Country amongst the youth to kind 
of have a little bit, have shame if you go into a building and 
seek help. It seems to me that there might be a similar stigma 
or thoughts of shame if you are filling out a form and a 
questionnaire specifically about suicide and whether you are 
high risk. So have you run into that?
    Ms. Flynn. One of the keys, I think, is to try to bring 
mental health checkups into as many settings as is possible. So 
we have found that making mental health checkups available in 
schools, maybe as part of a health class or a science class, as 
part of a larger discussion about health and what we are 
learning about our emotions and the mind/body interaction. It 
can be built into that sort of a discussion in schools.
    We also find that by inserting it into the routine sports 
physical as part of the basic checkup with your primary care 
physician in the clinic, just continuing to have it as a 
component of total health. It enables us to bring it forward 
and talk about it in the way that we, there are a lot of things 
we didn't use to talk about, a lot of disorders and diseases 
where the stigma has slowly eroded because we bring them 
forward. We explain and we talk about them openly.
    It is also, I think, very important to pick up on what we 
have heard about these significant cultural components, and 
even the spiritual and historical components that are 
particular to Alaska Native and American Indian communities. 
And here again, where we see mental health checkups endorsed 
and supported by youth development organizations, by tribal 
elders, by leaders in the health community, it becomes 
something that is seen as part of healing the nation and 
supporting the youth.
    We have also, frankly, heard in individual interactions 
from youngsters that although it may be difficult and awkward 
at the beginning for these kinds of issues and conversations to 
begin, but once they start, just as we heard from Coloradas, 
youngsters are relieved to have a safe and confidential place 
to go to deal with the concerns they have, to ask for the help 
that they need. Sometimes all they need is an opportunity for 
that open conversation to begin.
    Ms. Binney. Thank you.
    You mentioned the need to, as Mr. Genia was talking about, 
incorporate cultural and traditional aspects of Native American 
life. Does the questionnaire do that?
    Ms. Flynn. The questionnaires themselves, and we didn't 
invent these questionnaires. They are science-based screening 
tools and there are a variety of them. They are standard. What 
makes them appropriate is how they are explained; how they are 
administered; the education and support that surrounds the 
setting and the individual who is part of that. But they 
themselves are, just as with any physical health check-up, they 
are just basic questions that enable us to determine whether 
someone is at great risk for suicide; is beginning to show 
symptoms of depression or not.
    The really important thing is to make them comfortable and 
culturally sensitive to the community in which they are being 
implemented.
    Ms. Binney. Dr. Clayton, were you going to add something?
    Dr. Clayton. I just wanted to add that, that the good thing 
about our film that I am recommending that you make with Native 
American youths in it. This was a film that the State of New 
York paid us to make. They asked us to make a suicide 
prevention film and we gathered a group of experts, and they 
were child psychiatrists and psychologists. And they said, we 
don't want to talk about suicide. You have to teach kids to 
talk about depression, and they didn't want kids to talk about 
themselves. They wanted them to show what it looks like to be 
depressed.
    So we wrote 17 scripts. It took us two years. And then we 
hired a company and these are acted. So there are two girls and 
two boys, and one of them is a very good student. One of them 
is kind of, she is slowed by her depression. One of the kids, a 
boy, drinks too much and is irritable and pushing away his 
friends. And the fourth one is bullied on the computer. And so 
they all have different depressions and they get into treatment 
differently. It is 26 minutes, and we did test it, focus group 
test it on kids. And then we show it now in high schools, and I 
said it may be in 2,000 high schools around the Country.
    And it does help the stigma. That is the whole idea of the 
film. It helps the stigma so that in school, there is a teacher 
guide, and the teacher is taught how to show the film in 
school. And it starts the conversation, we got feedback. I got 
feedback this week from a teacher who showed it in her school 
and she said afterwards two kids came up to her and talked 
about their own problems and she could then refer them. We talk 
about what to do next, which in this film is to refer to the 
guidance counselor, but each school has its own sense of where 
to go next.
    But it really is a de-stigmatization film. We actually are 
going in May to win the American Psychiatric Association award 
for the best de-stigmatization film for this year.
    So I really think there are scripts that have to be written 
so you have to know the culture and know what these kids 
present as. But once that is done, it is an amazing way to de-
stigmatize depression in the school and drinking. We actually, 
because there was so much drinking, there is a party and there 
is all this other stuff, and beer bottles. And we had to get 
permission from the State school psychologist. They also looked 
at it, the head of the New York State School, to make sure that 
it wasn't excessive, the drinking and that. But they said, oh, 
no, that is the way it is. It is okay to do that.
    So I mean I think a film is a really powerful way to begin 
to go. Then because we made this one film for kids, the State 
of New Jersey had passed a law that all teachers needed a two-
hour training program in suicide prevention before they can be 
recertified. So we then went on and made a second film for 
teachers, and it shows clips of the kids, but it also has 
teachers talking about what they have seen in kids in school.
    So again, you could do it with Native American teachers in 
Native American schools. So I really think it is a powerful 
tool that you should investigate.
    Ms. Harjo. Thank you.
    I have a couple of questions that I wanted to direct to Mr. 
Grinnell before you have to leave. And then, of course, there 
are a few that could apply to the entire panel. So if anybody 
wants to respond after Mr. Grinnell, please feel free to do so.
    First of all, as you know, healthcare services are 
important to treatment and screening for mental health issues 
and other risk factors that face Indian youth. But as we have 
heard from testimony today and in prior hearings, health 
providers are not the only element that is important in 
reducing suicide attempts and ideation.
    Could you elaborate a little bit more on the partnerships 
that you referenced in your written testimony, not only with 
other Federal health agencies, but also with other components 
of the tribal community like law enforcement, the courts and 
schools?
    Mr. Grinnell. Yes. The first partnership I would like to 
talk about is actually under Dr. Roubideaux, our Director, her 
first priority has been consultation with tribal leaders. Under 
her tenure, she has actually established the National Tribal 
Advisory Committee for Behavioral Health. It is composed of 
tribal leaders across every area of IHS and there has been 
ongoing consultation with them about the strategic plans, as 
well as the funding that we receive for MSPI, for the 
Methamphetamine and Suicide Prevention Initiative, as well as 
other funding within behavioral health.
    And so first and foremost, the Indian Health Service is 
reaching out and having consultation with tribal leaders, and 
that is the direction that the Director wants to go.
    Secondly, the ongoing partnerships and collaboration that 
is taking place now, especially with SAMHSA and with other 
agency heads. Dr. Roubideaux has met with Pamela Hyde, the new 
Administrator for SAMHSA, as well as staff. Dr. Weahkee and her 
staff have been meeting with her colleagues at SAMHSA as well.
    And she currently sits on a number of Federal committees, 
and I will let her elaborate on some of the other partnerships 
and activities that are underway.
    But Dr. Roubideaux is fully committed to engaging with 
tribal leadership. She fully believes also that the success 
that we will have with these programs in behavioral health will 
be at the local level. They will be tribally managed. They will 
be tribally administered. They will establish the priorities. 
They will be culturally sensitive as well.
    So I would like Dr. Weahkee to also talk about some of the 
other collaborations and partnerships that are underway as 
well.
    Ms. Weahkee. Thank you. So a couple of the other 
partnerships I represent IHS on are the Federal Partners for 
Suicide Prevention Workgroup. And there are a number of Federal 
agencies that sit on that workgroup, including SAMHSA, CDC, the 
V.A., Department of Defense, a whole range of Federal agencies.
    And we meet on a monthly basis to, one, share what we are 
doing in terms of addressing suicide prevention in the 
populations that we serve, but also to figure out ways where we 
can collaborate.
    One of the things that we did collaborate on was that CDC, 
IHS and SAMHSA sponsored a meeting on suicide among American 
Indian and Alaska Natives and Hispanic Latino adolescents last 
September, where we invited national suicide prevention 
organizations such as the Suicide Prevention Resource Center 
and other Federal agencies and tribal leaders to provide input 
and recommendations on how we should address suicide.
    In addition to that, as Mr. Grinnell mentioned, we are 
working very closely with SAMHSA in terms of coordinating our 
suicide prevention efforts. Also recent discussions occurred 
with the Veterans Administration in terms of outreach to Native 
veterans and their families of suicide prevention. So we are 
working very closely with their Suicide Prevention Office.
    And also in addition to that, working with BIA and BIE, the 
Bureau of Indian Education and Bureau of Indian Affairs, on how 
we coordinate our suicide prevention efforts in Indian Country.
    So these are all in the planning stages in terms of 
implementing specific strategies. And again, working with our 
National Tribal Advisory on Behavioral Health to ensure that we 
are including the tribal voice in what we are implementing.
    A few of the other national organizations that we work with 
are the National Suicide Prevention Lifeline, of the hotline, 
in terms of outreach and making sure that Indian Country is 
aware of that resource. We also have a relationship with Health 
Canada, the First Nations and Innuit Health Branch. And again, 
we share information on best practices and the strategies that 
both of our countries are engaging in to address suicide in 
Indian Country.
    Ms. Harjo. Thank you.
    Mr. Grinnell, we received testimony today from Ms. Flynn 
regarding some of the multiple activities they are conducting 
at Riverside Indian School, for example. Have you all been able 
to examine those types of activities and whether this is 
something that you could import into your strategies that you 
are working with with the BIA and BIE?
    Mr. Grinnell. I would like Dr. Weahkee to address that, if 
I could.
    Ms. Weahkee. In terms of a national perspective, we haven't 
looked specifically at the TeenScreen, but definitely in terms 
of screening. She mentioned the Institute of Medicine report 
and the National Preventive Task Force and that they do promote 
screening among adolescents.
    As an agency, one of our performance measures is screening 
for depression and we are expanding that into addressing 
screening for adolescents. So in terms of implementing that 
within our system, promoting integration of behavioral health 
in the primary care system, including screening for such issues 
as depression, is an important element that we are promoting 
nationally and that we are training on nationally all of our 
providers in our system.
    Ms. Binney. Just to follow-up on that, one of the things 
is, Senator Dorgan has been personally impacted by suicide. And 
so one of the things that happens in Indian Country is many 
times when there is a suicide in Indian Country, we hear about 
it. He gets a note about it and he tries to call the family 
because it is a personal issue to him.
    But one of the things that seems to be lacking is sort of a 
database on the amount of suicides that are going on in Indian 
Country. It seems that if we had better data, we could sort of 
better figure out where the crises are and where more funding 
or emergency funding needs to be sent out to.
    And Ms. Goklish over at White Mountain Apache Tribe, they 
have implemented a mandatory surveillance and follow-up system. 
And I wonder if that is something, what your thoughts are if 
that could be implemented nationally in Indian Country. As 
Congress considered that, we would probably be going through 
the Indian Health Service to implement that.
    Ms. Weahkee. We do have a suicide surveillance tool. It is 
called a suicide reporting form that we use in our system. It 
is part of our resource and patient management system. So it 
does collect information in terms of the gender, whether the 
person has attempted, whether there has been a death by 
suicide, if there is ideation, a plan, a means.
    And so that is the tool that we do utilize, so we do 
collect that information currently. However, this is for the 
programs who actually are using the resource and patient 
management system. As you may know, many of our tribal programs 
choose to use another clinical information system and so their 
data may not necessarily be captured on our system. We do have 
some of that data.
    One of the projects that we are currently working on is 
developing what we call a behavioral health data mart so that 
we can capture that information in one place. And someone, for 
example, myself could look at the data not only nationally, but 
all the way down to the service unit level and perhaps see the 
top 10 communities where there are suicide completions.
    And hopefully, in terms of implementing that system, that 
we can, like you are saying, intervene much earlier by 
identifying when there are a high number of suicide attempts or 
suicide completions in a community.
    Ms. Binney. Is the reporting mandatory or voluntary?
    Ms. Weahkee. It is part of our performance measures, one of 
our GPRA performance measures, so that is something that is 
promoted. We do train all of our providers in terms of 
utilizing that system. The different programs can also generate 
their own reports, so it is useful in that way. But we still do 
have a long way to go in terms of improving our system to make 
sure that all of our providers are properly trained, know the 
tool is there, and actually enter that data into the RPMS 
system.
    And the other piece of that is just working in terms of the 
partnership with CDC on suicide surveillance. They will be 
coming out with a published report on suicide surveillance 
definitions, so we will be looking at that in terms of 
improving our system.
    Ms. Harjo. I think that data is really important, but that 
only applies to people who actually present or stop in to IHS 
or the tribal health facilities. What about the children that, 
I guess for lack of a better term, fall through the cracks, who 
don't show up to IHS? Or as Mr. Mangas referenced, will not go 
into the behavioral health center or have dropped out of 
school?
    We don't have those youth-serving settings applying to 
those children. How do we reach out to those kids so that we 
can provide them with appropriate interventions and prevention 
services? And this is for the entire panel.
    Dr. Clayton. I think the study that has mandatory 
surveillance, that Novalene talked about, is the answer. I 
mean, it is an amazing outreach where they train para-
professionals, people in the community to collect the data once 
the police or the health center or the E.R. has notified them. 
And they have a form they fill out. And they get pretty 
complete data on both attempters and completions, but it 
depends on the community and these para-professionals who fill 
in all this information.
    She can tell you more about it, but it is very impressive.
    Ms. Binney. Does it also depend on where there are mental 
health providers on the reservation? I mean, do you need them? 
Because I know in many Indian reservations, there is a 
significant vacancy in the mental health providers out there. 
So do you need to have those there in order to do the mandatory 
surveillance?
    Ms. Goklish. No, our surveillance system, because spikes 
that we had on the reservations was implemented by the Tribal 
Council. And we do know that we have a shortage of mental 
health providers. And so the Tribal Council decided that we as 
a community needed to take our own action by doing something, 
and therefore they implemented the mandatory reporting and they 
also established the Prevention Task Force. And they started 
working with Johns Hopkins to establish some type of protocol 
so that we had the reporting system plus also a follow-up 
system so that, like what Rhonda said earlier, where they fall 
through the cracks.
    We have a lot of that, where they don't go to the Indian 
Health Service. Of if they do, like for some of the examples 
that we have, a young lady went to the hospital because she 
wanted them to check her neck. She said her neck was hurting. 
She wasn't feeling well. And she explained to them that she was 
having thoughts of suicide. So in their system, it is put in 
there as her having ideations.
    Once we receive the form and then our case managers, para-
professionals follow-up with the young lady, she told us that 
it was an actual attempt. She hung herself. Her mom took her in 
to have her checked, but they never explained to the medical 
provider, the doctor, that her mom found her hanging and cut 
her down.
    And so our data that we get, it is from a large range of 
different departments on the reservation. We work very closely 
with all the schools on the reservation. We also get self-
referrals because we do a lot of in-services, so therefore a 
lot of community members are aware of the surveillance system 
that we do work on.
    And it is not restricted to age. Our age group that is at 
high risk is 15 to 24, but the people that we receive a yellow 
form on is whomever. And so the youngest child that we have 
followed up with was only three years old and they were in the 
preschool program. And once we received this form the staff was 
shocked because of the age. And our oldest that we have ever 
followed up with is in their 70s.
    And so, it is not restricted to age. Suicide is not 
restricted to anybody. It goes after whoever regardless of what 
your wallet looks like. And so we feel as a community that if 
we don't take action ourselves that it is not going to stop. 
And by us being able to follow-up with the youth, myself and 
Francene, we are also the ones that follow-up. We are out there 
doing these follow-up visits along with the other staff that we 
work with.
    And it is hard to do this on a regular basis. Monday 
through Friday, we are constantly following up with individuals 
who have suicidal behaviors. But more than 80 percent of them 
will never receive treatment. So we know that, if we at least 
talk to them, at least somebody is talking to them. If they are 
not going to get help from our Behavioral Health Program or the 
hospital, at least someone is talking to them.
    We have also started an outreach program with the churches. 
We have quite a bit of churches on our reservation. One day I 
decided to go ahead and call all of the churches to see if they 
would be willing to meet with some of the community members who 
attend their churches because that is a request we were 
getting.
    And so once I started talking to them and explaining why I 
was asking these questions and if they would be willing to talk 
to some of their members from their congregation, and they 
agreed that they would be willing to do that. But if the person 
needed further help, that we could also provide them with some 
referral forms so that they could get more assistance.
    Our whole purpose of the reporting system is so that we can 
connect them to services to try to get them some type of help. 
And if they are really at high risk, then we try to keep 
following them until we get them something. But we hold on to a 
lot of our forms and we follow them. We have a long tracking 
system, so we follow them and try to find them and we have a 
90-day window. Once we receive the form, we have the form for 
90 days until we find them.
    We receive over 500 referrals, the yellow forms that we 
call them because it is on yellow paper, the referral form. We 
have over 500 a year that come through our office and we 
follow-up with more than 80 percent of that. And we are able to 
enter that and track that. And so we know exactly what is going 
on, why it happened, if they were using drugs or alcohol, if 
they got into an argument or a fight.
    So we ask a variety of questions to better understand what 
is going on, to better understand why our youth are doing what 
they are doing, why are they taking their lives. So that is why 
we said coping skills. They need some type of skills to help 
them get through this. And so it allows us to look into that 
further and to try and develop the program that we are also 
working on.
    Thank you.
    Ms. Harjo. I want to follow-up with you on your program out 
there, but I want to grab Randy Grinnell before he leaves. I 
guess this will be sort of my last two questions.
    We often hear and have heard today about the 
intergenerational trauma that faces Indian people and youth in 
particular. What kind of research is out there or has been 
conducted on that issue?
    Mr. Grinnell. I will let Dr. Weahkee address the research 
questions.
    Ms. Weahkee. Yes, there has been quite a bit of research. 
Marie Yellow Horse Braveheart, Bonnie Duran, all of those 
individuals, Joseph Gone, have focused on historical trauma and 
its impact in terms of the mental health issues that we are 
seeing today in Indian Country and how important it is to not 
only address the current traumas that many native communities 
are experiencing such as domestic violence and sexual assault 
and all of these issues that we hear about, but also to address 
the issues around historical trauma.
    And as Hunter mentioned, until we acknowledge that this is 
also playing a role and a factor in Indian communities, we 
really won't begin that healing process. So I think by 
acknowledging historical trauma, the boarding school experience 
and what impact that has had on Indian Country, then we can 
move forward and begin to heal.
    And you see that as part of components of the programs in 
Indian Country such as GONA, the Gathering of Native Americans, 
where they acknowledge historical trauma. But thankfully, now 
we have a lot more native researchers who are focusing on that 
issue.
    Ms. Harjo. Do you think fetal alcohol disorders play a role 
in some of the mental issues of the youth today?
    Ms. Weahkee. Yes. Fetal alcohol spectrum disorders 
definitely play a role. As you know, alcohol abuse and 
substance abuse are huge issues in Indian Country, and so that 
is something that as an agency we also focus on to ensure that 
we are educating communities about that issue, training our 
physicians and healthcare personnel in terms of screening and 
identifying early when that is an issue, and also having that 
as one of our performance measures, making sure that we are 
screening woman of childbearing age so that we can intervene 
earlier. So, yes.
    Ms. Binney. It seems that, and Mr. Mangas has probably seen 
this in his community, several times in 2009, including on the 
Mescalera Apache Reservation, one or two suicides sets of a 
string, and you end up with a cluster. And I know that both 
Indian Health Service and SAMHSA try to be helpful in 
responding to those situations.
    But it seemed like there was a lack of resources. And every 
department is being pulled in hundreds of directions, and we 
are in our economy and our Country is in a deficit right now. 
But when it comes to lives, particularly of youth, Indian 
youth, do you feel that there are enough resources available to 
address the problem, not just funding-wise, but mental health 
providers, resources, materials, research?
    Mr. Grinnell. As far as resources, and I am definitely not 
the expert on suicide, but it takes an effort of more than just 
the community. When you talk about a local community, then you 
talk about the larger community that it takes in order to 
really have an impact and prevent this major health issue.
    The health aspect is just one component of it. Rhonda 
mentioned about justice and the importance of it. One of the 
things that has been pointed out, especially in some of the 
communities, is public safety is a major issue. That is 
something that has a tremendous impact on it.
    I know that in some of the work that we have been involved 
in, such as at Rosebud and so forth, the youth said it is an 
issue about hope. And that comes into, as I mentioned in my 
written testimony about poverty in some of the places. In the 
reservations, there is high, high poverty, unemployment, these 
other factors that really come into play. We have heard about 
the issues about kids in schools concerned about their safety 
and bullying and all those things.
    And so it is going to take more resources than just within 
the health arena. It is going to take all the partners working 
with the tribes. And the key to this, and I really believe the 
success of this is really going to be at the local level. It is 
going to be the tribal leadership and their ability to 
establish their infrastructure and to maximize the resources 
that are available. And I think it is up to us and it is 
incumbent on us to help them to identify those resources and 
try to find ways to get those resources to those communities.
    I know that one of the things that Secretary Sebelius has 
been since she has been in her position is really reaching out 
to tribal leaders to have consultation with them, to have true 
consultation about what is going on within HHS, about the 
programs that they have, and trying to improve the access of 
those resources for tribes.
    And I think it is going to take a collaborative effort 
among everybody to really make sure that the resources are out 
there, they are effective, and they are there when they are 
needed.
    Ms. Harjo. Well, one of the resources that was mentioned 
today in written testimony was having more youth shelters, 
particularly when the home life becomes toxic. According to the 
testimony, for some youth if they had a place to go for the 
night, they would not have made an attempt on their life. And 
that is very disturbing to hear, I think.
    But for the entire panel, what kind of recommendations do 
you have for engaging the parents and the families so that 
these youth can feel secure at home?
    Mr. Genia. I just want to share a little bit. Some of the 
things that Novalene and Coloradas have pointed out is tribes 
being able to take ownership in their own direction for 
wellness and well-briety on our reservations. And again, I want 
to point out that over 80 percent of the American Indian 
population live off-reservation and oftentimes a lot of our 
efforts are directed towards on-reservation.
    And so when we are talking about funding and resources, we 
need to remember our people that are in the cities and urban 
areas that don't have any Native American health centers and 
oftentimes struggle with going to local community mental health 
agencies. There is a big trust and fear factor there.
    I think one of the things that I see that has happened 
here, the success of White Mountain Apache is that they took 
ownership in developing their own program. In our residential 
treatment program, nobody directed us to do that except for our 
own Tribal Council. Now that we have opened it and increased 
access to it, over 250 of our own tribal members have gone 
through our own residential treatment program in just a little 
over four years.
    If they were to go to Wisconsin, Minnesota or out west to 
where the Native American treatment centers are, I would guess 
probably over 200 of them wouldn't have gone at all. And so we 
need to put the dollars directly into the tribal communities 
and let us take our own direction and ownership with that.
    And like what Mr. Grinnell had said is support us. Don't be 
a roadblock for us and make it harder with a lot of the red 
tape that prevents those dollars from coming directly to the 
tribal behavioral health centers.
    Now that we have had a lot more of our own people go 
through residential treatment, we have more of our own people 
saying, you know what? It is okay to get help. They are in 
recovery. They are sober. When I go to tribal membership 
meetings, I can sit down and talk to our people that said, a 
year ago I mean they didn't want to even show their faces. 
Their heads were covered, their hats low in shame. And now, 
they are bright. I mean, they are going to tribal college. They 
have jobs. They are working for our tribe.
    And I am hoping that for our residential treatment program 
that a lot of them that have gone through recovery and are 
staying sober will actually come back and work for our own 
treatment center so that they can help those that are coming up 
behind them.
    So when we are talking about reducing stigma and making it 
okay is that we need to feel good about it is okay to get 
treatment; that it is actually a cultural warrior value of 
courage and bravery, not one of weakness and shame.
    And that is kind of what is happening in our community. We 
have had a lot of initiative towards wellness, well-briety, of 
all the things, of putting a name to it. Nobody liked to talk 
about how much sexual abuse has gone on in Indian Country 
because it was shameful to talk about it. It was the secrets 
and nobody wanted to talk about it and where it happened.
    Now, we have a lot more people that are coming out and 
talking about it. And now that that they begin to talk about 
it, it makes it okay that it is, you know what? I don't have to 
feel ashamed of that anymore. So I think the same thing applies 
to alcohol and drug treatment, any kind of mental health, you 
know, issues or disorders.
    And we have a lot of our spiritual leaders, our traditional 
people that are involved in our treatment care. Behind our 
Behavioral Health Center, we have a 55-foot longhouse and we 
have a sweat lodge and we have a teaching lodge. And we have 80 
percent of our people or more that are asking for those 
approaches to be a part of their treatment. They are asking for 
it.
    So we are just able to provide it, but they are the ones 
that when they come into treatment and are part of that intake 
and assessment process, they are saying, I want to learn more 
about language. I want to learn about my clan. I want to learn, 
I want to meet with a traditional healer.
    And the funding source is, whether it be SAMHSA, IHS or 
other organizations, they need to recognize and acknowledge 
that that is who we are as tribal people, instead of saying, 
you know what? We are not going to pay for that type of service 
because we don't value and recognize that those are valid 
methodologies to helping our people, when we are that it is, 
and our people are getting better slowly.
    We have a lot more work to do, but they are getting better 
and more people are saying, you know what? I feel good about 
being native and being sober and well. So I think those are 
some of the things that we need to take a look at is reducing 
the roadblocks to recognizing that there are more than just 
Western methodologies to treatment and care.
    Ms. Binney. And it sounds like it goes--your statements 
just now go to Coloradas' statement of a stigma, and your tribe 
was basically able to break the stigma. But it sounds like that 
was only possible for, and I am wondering which one is the most 
important. It sounds like the Saginaw Chippewa Tribe made this 
a priority, mental health. And it sounds like as part of making 
it a priority, the Tribal Council decided to invest a 
significant amount of its own money into the effort.
    The Saginaw Chippewa Tribe is fortunate in that it is one 
of those few tribes that do have a successful Indian operation. 
If you didn't have that, I wonder if you would be able to be as 
successful with it.
    So given the resources and given the Tribal Council making 
it a priority, and maybe Novalene can discuss it too. I mean, 
to really go after breaking the stigma in the community, I 
mean, it sounds like it needs to be raised to the level of a 
top priority with the entire tribal community, particularly the 
leadership.
    Mr. Genia. I would say absolutely. I mean, in the saying 
of, you can't give away what you don't have. I mean, so if we 
as a native people are not well, how are we going to give away 
wellness? How are we going to give away positive mental health 
if we are not well ourselves?
    And we can have all the experts come in and tell us how to 
do it, but really it is up to us as a tribal community to take 
ownership in saying, you know what? Can we share with you what 
we think will work for our people? And can you help us that way 
and not the other way around?
    And I think we are seeing a change and we are seeing a 
shift, but it is just in recent years where they are actually 
listening to the local tribal communities in helping us to not 
make getting funding such a red tape and bureaucratic process.
    So definitely if--and I want to restate the Saginaw 
Chippewa Tribe is the exception when it comes to gaming and 
making money, the resources a priority to our tribal community. 
Most of the tribal communities in Michigan are not in that 
position. And when we go to tribal behavioral health quarterly 
meetings in Michigan, you are right. There are a lot of 
vacancies. There are a lot of position. I mean, we get 
recruited to go work for their tribes because they cannot fill 
those positions and we don't have enough of our own tribal 
people going into the counseling, social work, mental health, 
behavioral health fields.
    So we have to come up with examples like what Nova in her 
community is doing, is by empowering our own people, our 
elders, our parents, peer to peer type of programs to invest in 
that way.
    Ms. Binney. And it sounds like partnerships with research 
institutions, educational institutions are helpful. It seems 
like that is a hard partnership, maybe, to establish, coming 
from a Native American community myself, because there are a 
lot of distrust issues that are multi-generational because of 
multi-generational trauma.
    And so I was wondering, Ms. Goklish, how did the White 
Mountain Apache Tribe develop the partnership with Johns 
Hopkins?
    And I know, Ms. Flynn, that TeenScreen works with several 
tribes and I wonder how those partnerships came about.
    Ms. Goklish. Our relationship with Johns Hopkins started in 
the early 1980s when we were having problems with diarrhea on 
the reservation and a lot of fatalities due to that, with 
infant fatality death. The tribe reached out and asked for 
assistance, and Johns Hopkins was the university that 
responded.
    And Dr. Mathuram Santosham was the physician that came out, 
who is sitting behind me, and he came out then. And he was to 
work on the reservation with the tribal community for one year 
on the oral rehydration solution that was being developed at 
that time, which we now know as Pedialyte. And so that was the 
first time that they ever did that in any community and it was 
being done on our reservation.
    It started in October of 1979, and Dr. Santosham came out 
and he was scheduled to be there for one year. He lived on the 
reservation for six years, working as a physician, and Johns 
Hopkins was able to establish a relationship with the tribe and 
also the Indian Health Service to start this research study 
program so that they could develop the oral rehydration 
solution.
    And from there, they remained on the reservation and we 
have had a 30-year relationship with them since. They have 
never left. We have always had an office there. I have been 
working with Johns Hopkins for 13 years, and worked on several 
different programs. And a lot of our community members, some of 
them feel that certain programs we shouldn't be doing, but a 
lot of the programs that are developed under Johns Hopkins are 
not programs that are decided by Johns Hopkins. It is the 
tribal community that decides on what we are going to work on 
as a community, and then that is then taken before our local 
health board members and our Tribal Council.
    And we usually have meetings with them on a regular basis 
to decide on what different areas we also need to look at. Like 
recently, binge drinking is now an issue on our reservation. We 
are having a lot of problems with binge drinking. This past 
year in 2009, we have had 10 suicides on our reservation. I 
already named the population size that we have, so that is 
really high.
    And then in October, the school suspended over 50 kids from 
the local high school for binge drinking at school. So the kids 
are actually going to school and they are drunk. They are 
already intoxicated by 10 o'clock in the morning. And so the 
schools are reaching out. And so now, they are reaching out for 
help to the tribe and the tribe is gearing them towards us and 
saying, we want you guys to focus on this.
    And so that is why the relationship is really strong. They 
reach out and they tell the staff that they have at the Center 
for American Indian Health with Johns Hopkins exactly what they 
want Johns Hopkins to focus on and that is how we have been 
able to work with them.
    And when Dr. Santosham was there, he was able to build a 
strong relationship with the tribal leaders and it was a 
relationship that has continued to this day. He has worked with 
a lot of the delegates that were in office then who are in 
office now. And so, we are able to move forward and establish 
different programs and protocols that we have to follow that 
the tribe wants us to abide by.
    And so, yes, we are the ones, we work directly under Johns 
Hopkins, but we are tribal members and we work directly in our 
community. And we also are the ones who maintain the data and 
tracking system of all the projects that are there, and all the 
data belongs to the tribe. And whenever Johns Hopkins wants to 
utilize the data for whatever reason, they still have to go 
back to the tribe and ask their permission to use whatever they 
need, even though they are the ones that found the funding to 
work on certain programs and design different data templates 
for us to collect different data that we are working on.
    And so it has been a long relationship. But it is because 
they took the commitment to stay and remain in our community. 
That is why the relationship is still strong.
    Ms. Binney. Thank you.
    Ms. Flynn, how did the tribal partnerships develop with 
Columbia University?
    Ms. Flynn. In our case, in each of the areas where we have 
worked, one of the members of the tribal leadership reached out 
to us. And I think why we were able to continue and move 
forward was because we made very clear that we wanted to learn 
from them and with them as we moved forward with 
implementation; that we didn't have a particular point of view 
about how the screening needed to be implemented; that we 
wanted to learn what was appropriate within that cultural 
context in that specific community; and that we were there to 
provide support and help. But again, it was, as you have heard, 
it was their leadership. It was their program. It is their 
youth. And I think that that fit very well with the general 
context in Indian Country, and so our program has been well 
received.
    The other thing, I think, was that we felt and continue to 
feel very strongly that respect for the family and for the 
parents and engaging them as part of recovery is a very 
important component. So we really emphasize in all of our 
settings the significant importance of reaching and educating 
and engaging and helping families. Because parents want to do 
what is the very best thing for their children. Even parents 
who are impaired care deeply about their children. And whatever 
strength they can bring needs to be tapped because the health 
professionals and the programs have a tendency to fade away, 
but family remains, just as the tribal culture and community 
remains.
    So we have always emphasized the importance of the family. 
And I think that, too, fit within the values framework of the 
tribal communities that we have been working with.
    Ms. Binney. Dr. Clayton, does the American Foundation for 
Suicide Prevention have any partnerships with tribal 
communities?
    Dr. Clayton. The only partnerships we have had are in our 
postvention works. And we have this training program to teach 
people to run support groups after there has been a suicide. 
And so we do it all over the Country. It is a day and a half 
program. And in South Dakota, we have done it twice in two 
different communities, and Native American people have come.
    Now, I did not ask our survivor leader what the follow-up 
on that was because we do collect follow-up data. Have you 
actually held support groups in your home or in your church? 
You can do it wherever you please. So I don't know if, we have 
those data, but I don't know it.
    And we have also reached out to V.A. hospitals, too. And 
had meetings in V.A. for survivor training. Again, it is all 
this postvention training that we have been involved in.
    Ms. Binney. And it does seem that a movie, like you said, 
with Native American actors would probably resonate with Indian 
communities.
    I don't know what you think about that, Mr. Mangas, being 
able to go into a classroom and kind of see your own peers, 
other Native Americans in the movie about suicide, and sort of 
how to respond to that.
    Mr. Mangas. I think it would really help a lot of the youth 
that are on the reservation because, like, many of us don't 
really have nobody to look up into these movies or stuff. All 
we mainly see is white actors or Mexicans or any other people 
except Native Americans.
    And what if Native American actors being in like a suicidal 
movie or something like that, like showing what Native 
Americans really actually do go through, it would help a lot of 
the Native American youth, knowing that they are not the only 
ones out there that are going through this, and there are other 
reservations across the United States that do go through these 
suicidal attempts or suicidal completions like this.
    And having other Native American youth from my reservation, 
like, seeing these movies or stuff, it would kind of help them 
not only knowing that they were not the only ones out there 
suffering with this kind of stuff, but knowing that there is 
help out there besides what we do have on the reservation. And 
they could go to our Council and kind of ask them to refer 
these people to come to our reservation and to help us not only 
with the suicide and drinking and stuff like that, but like 
with depression and with problems at home that would lead to 
these suicides, and that would lead these children to like 
using drugs or alcohol or getting into trouble.
    It kind of, to me, it would kind of help the youth 
understand that there is help and that they don't always have 
to make an attempt on their life to get this help. They could 
as easily just go out there and ask a teacher or another person 
if they could see if they could try and help this youth to get 
this help to the reservation so that everybody could have it 
and not just people from different reservations like here in 
the East or out on the West Coast.
    Because there are many reservations that are right in the 
middle of the United States that really don't seek this help 
because of, like, the shame and stuff that comes with it. 
Seeking this help is too great on some of the people. There is 
such a great honor of not even needing this help or anything, 
that they are too afraid or too shameful to seek it at the last 
minute.
    And by having Native American actors in movies or stuff 
like this, then it would kind of help the youth to understand, 
well, we can seek this help because other Native Americans out 
there are seeking this help, and they are not ashamed of it, so 
we shouldn't be ashamed of it.
    Ms. Harjo. You had referred to the film as helping the 
students, the Indian youth. But what would you say to the 
service providers, to the teachers, to the doctors and other 
people out there in the community? What do they need to be 
doing to help these young people who will not seek out help?
    Mr. Mangas. They need, like, some of the people need to 
kind of put these cultural values into some of the youths' 
heads because many of the youth where I come from don't really 
respect their culture. They don't want nothing to do with it. 
And by having these, like our elders or like our Tribal Council 
leaders or just mainly their parents, having them put these 
cultural values into their head, and having them understand, 
well, this isn't what our Native American people used to do 
when they were having problems way back when, or they wouldn't 
use to use these ways of having people see that they need help.
    They would have, it would kind of help the youth to 
understand, well this isn't what we should be doing because it 
is not what our people would want for us. And it is not what 
our people went through way back when to get us to where we are 
today.
    And by having the elders put these cultural values in some 
of these people's heads or the youths' heads, it would kind of 
really help some of the youth to understand, well, my people 
did this for me, and I should be trying to help my people 
instead of trying to bring all this depression and all this to 
my people. I should be out there making an effort to help other 
youth better going through this and helping them to get through 
this so that they won't make these attempts on their life or 
make these completions with their life.
    It would kind of really help a lot of youth because on our 
reservation, the thing about death is that whenever you do 
something to your body and you die, that is the way you are 
going to go into the next world. If you hang yourself, there is 
going to be a rope around your neck when you go into the next 
world. If you shoot yourself and you shoot your head off or 
something like that, that is how you are going into the next 
world.
    And some of these youth don't understand, well, that is 
what our people used to believe way back when and that is why 
they wouldn't make these attempts or completion of suicide. 
That is why they would be out there fighting for their lives or 
fighting against other people.
    And it would kind of really help a lot of youth to 
understand, well, maybe this is true. Maybe we will go into the 
next world looking like that. And some of these youth are so 
high on their horse that they want to look so perfect and 
everything, and then they do make this attempt on their life 
they are not understanding, well, what if this is really what 
is going to happen to me in the next life? What if I do come 
out looking like that?
    And I believe that some of these kids don't really 
understand what their cultural values are and what is being 
taught to them. And so I think that if the elders and the 
Tribal Council would get out there and teach these children, 
well, this is what is going to happen in the next world. This 
is what you are going to look like if you do this to yourself 
in the next world.
    I think it would help a lot of youth to understand, well, 
maybe I shouldn't do that because I want to look the same way 
for the rest of my life, even in the next world. And I think 
that would kind of help a lot of the youth to understand, well, 
we shouldn't make these attempts on our life or we shouldn't 
make these completions on our life about suicide.
    Ms. Binney. That is such an interesting point, in light of 
Mr. Genia talking about a lot of the people who have now gone 
through the residential program are asking about their culture 
and wanting to get more in touch with their culture.
    Mr. Genia. I want to kind of comment on that, too, because 
we built our own behavioral health facility, which has our 
prevention program, outpatient, residential. We have a domestic 
violence emergency shelter. Prior to that, where our program 
was, we had people that requested to come into the side of the 
building or behind the building to their appointments because 
receiving services for mental health and substance abuse was 
like, they didn't want anybody to know.
    And slowly that has started to change, where we have had 
people in leadership within our tribe actually go through our 
residential program. And I am just, I am really so proud of 
them for doing that and taking the courage and that step to get 
help for themselves. Now other people can see that and say, you 
know what? It is all right. It is a good thing to do that to 
try to help myself.
    But one of the things I wanted to mention, and I will 
mention this again, is that over half or half of our Native 
American population are under the age of 18. So probably your 
experiences and like mine going through secondary education is 
that oftentimes we were the only Native American student in our 
college or graduate courses.
    And one of the things that I had done when I went through 
Grand Valley State University is that they were sending all 
these students these opportunities to go and study about other 
cultures from other countries. And I was thinking why are they 
putting so much money into sending people to Europe, to 
wherever, anywhere but tribes.
    And so about six years ago, I had approached the master's 
in social work program about having their students come up to 
stay with us on the reservation for two weeks, and it is going 
on its sixth year. And I can tell you, in that short two weeks, 
they have learned more than they will ever learn in public 
school education through college education about who we are as 
a people, as a culture, our values, our history, why we deliver 
treatment services, mental health services the way that we do.
    Now it is a very popular program, but we can't do that for 
all the universities and their social worker counseling 
programs. Unfortunately, we have no minimum standards here in 
America about what outcomes they need to learn about Native 
Americans in this Country.
    So there is this population of populations graduating not 
knowing who we are, and there is a lot of ignorance. So I 
really think we need to somehow address some of the education 
standards so that people really still refer to us as those 
people, that we are still part of the invisible population here 
in America.
    And until we do really look at some of those core things, I 
mean, I think we are always going to be kind of the minority 
and feel that way. Anyway.
    Ms. Harjo. Earlier, in previous hearings as well as this 
one today, we have received testimony that many of the cultural 
practices need to be incorporated into treatment for behavioral 
health. But we also received testimony today that there perhaps 
should be some of the behavioral health methodology 
incorporated into some of the cultural settings, like 
screening, for example.
    Ms. Goklish and Mr. Genia, what do you think about that as 
tribal health providers, the recommendation that screening 
ought to be incorporated in some of the cultural settings?
    Mr. Genia. I would definitely agree. Actually, in our 
behavioral health program, we have a cultural healer that is a 
part of our behavioral health staff. And so when we have 
ceremonies, actually, we have substance abuse treatment groups 
that actually meet in our longhouses and some of the groups 
actually go into sweats and our other cultural practices. So 
that is already happening in our setting.
    And I would also say that because we don't have enough 
Native Americans in the field of counseling and social work, 
that a lot of the non-native staff actually stay on to work 
with us because there is something different than they have 
ever experienced in a non-native organization with their 
spiritual practices and cultural practices. So it is really 
kind of a unique thing that is happening.
    But to get to your question is I definitely believe that we 
need our traditional healers, our spiritual leaders, our faith. 
She mentioned working with the churches and stuff. I mean, 
everybody has to come on board and this has to be a multi-
disciplined, multi-faceted approach to addressing health issues 
in our tribal communities, including suicide prevention. It has 
to be okay to talk about. It has to be okay to receive help. 
And the more of our people that are in different disciplines 
within a tribal community, even if they are just non-working 
tribal members and staff, I think that is great. And we need to 
do that. And we are doing that somewhat already in our tribal 
community.
    Ms. Goklish. For us, we really don't have a lot of our 
culture and tradition tied into, like, the behavioral health 
services that are provided. They do offer assistance if 
somebody would like a medicine man to do a prayer for them or 
if they would like to speak with a medicine man. If they can't 
provide the financial means that, the behavioral health 
services would be able to assist with that.
    We feel that on our reservation, that a lot of our, not 
just our youth, but a lot of our tribal members feel a sense of 
loss. They don't have a sense of belonging because they really 
don't know the traditional setting. They don't know our 
culture, the language. We are losing our language, like a lot 
of other tribes are.
    And so for us, being able to incorporate a lot of the 
cultural aspects into a lot of the questionnaires that are 
being asked, or like I don't know what type of surveys they 
have or what type of intake assessments they do, but in there, 
maybe ask information on how or what type of questions they can 
ask that would be culturally appropriate.
    And then also to work directly with them to see what other 
things they would do, maybe they can incorporate sweats or 
other things that would make them feel more like they can be 
comfortable being native and then going and getting help for 
the mental problems that they might be having. We don't have a 
lot of that on our reservation. That is where we started 
working with our Elders Council. And the unique thing about our 
Elders Council is the majority of our Elders Council are very 
traditional, and the other half have a strong Christian faith. 
But that doesn't cause conflict with anything that we are doing 
with the youth because it is not about our elders. It is about 
our youth.
    And so when our elders come together, when we first started 
this, we thought that we would have a problem with that because 
of their belief system and because they are older and you have 
to, we are very respectful of our elders. But working with 
this, our Elders Council that we have established, we have been 
able to do a lot with them. We have been able to work with the 
youth and the elders have been able to talk to them about what 
it means to be White Mountain Apache and that in order for them 
to be complete, what they need to understand.
    And so we haven't reached out to a lot of kids, but the 
ones that we have been able to touch, we know that we have been 
able to make a difference just with our elders working with 
them, taking some of the kids to the sacred sites. When we took 
some of them to a couple of the sacred sites, some of the kids, 
they didn't even know that we were still on the reservation. 
They thought we had actually left.
    So that is sad because they don't even know how big the 
land is. They don't know where it ends. They thought that we 
were going somewhere, on this big field trip off the 
reservation. We never left the reservation. The whole time, we 
were taking them on these field trips so they could better 
understand who they are and where they come from.
    And so I think that the more we include things like that 
into the behavioral health, the mental health, that it is going 
to help them better understand who they are, accept who they 
are, and then it will make them even stronger so that they can 
become healthy again.
    Ms. Harjo. Part of the testimony today indicated that the 
Federal dollars spent on Indian youth suicide prevention or 
Indian suicide prevention in general reduces a lot of the 
medical cost that is associated with the treatment and 
aftermath.
    Mr. Grinnell or any of the panel, Ms. Goklish, is there any 
estimates about how much we are actually saving?
    Mr. Grinnell. No, I don't think we could come up with that 
information right now. I am not sure that we are able to 
capture that because that is a prevention aspect. I can ask 
some of our staff to look into it and we can get back with you.
    Ms. Harjo. That would be really helpful.
    Ms. Goklish, you elaborated on several aspects of the 
mandatory surveillance system. Of course, that being mandatory, 
could you describe, what are some of the teeth to that system 
out there? How do you require people to actually report?
    Ms. Goklish. Well, the teeth in it is the resolution 
itself. And so the tribe did pass the resolution mandating all 
tribal departments, health providers and tribal members to 
report suicidal behavior. So the teeth in itself is the 
resolution that was passed.
    And I think the backbone behind it is the staff that are 
working directly on it, which is us. And you know, us providing 
in-services on a regular basis to all departments on the 
reservation, reminding them that this is mandated by the tribe, 
and that when the tribe, considering that they are a sovereign 
nation, that they make their laws and that that is one of the 
laws that they have passed.
    And so we work closely with the Police Department and other 
departments on the reservation, along with the Indian Health 
Service. We have a really strong relationship with the Indian 
Health Service and our Tribal Council on implementing this with 
all departments.
    If we feel resistance from any department, we don't go back 
to the Tribal Council and let them know. We don't do that. We 
work directly with that department to make sure that they 
understand that this is something that the tribe wants and the 
community has accepted this, as part of our responsibility as 
natives, what we need to do to take better care of ourselves 
and also to step up and say that, yes, either I am suicidal or 
I do have a family member who is suicidal and that they do need 
help. I would rather have that person mad at me than that 
person gone.
    And so we do have family members that will fill out a form 
on another family member, a friend will fill it out on another 
friend, or another individual will fill it out on themselves, 
saying that, yes, I do need help. I do recognize that I am 
suicidal.
    And when we first started doing this, we had a hard time 
because speaking about suicide, it is a taboo. We were told, 
you don't speak about it because it is going to happen. You 
don't need to advertise it.
    And so when we first started doing this, it took us a long 
time to get where we are at. So we have been working and doing 
this for nine years. It started in 2001, but actually the 
tribe's been really struggling with suicide for 19 years. And 
so it has been a long time that we have been trying to get 
help. And when we first had the spike on our reservation, I was 
in high school then. And so a lot of my cousins, my friends 
died from suicide. There are a lot of names out there.
    And so, with the 19 years, there comes a lot of numbers of 
the people that have passed by suicide. And so with us, it is 
the tribes that put in those policies and we are enforcing it, 
but with permission from the tribe. We are tribal members, but 
we do work for an outside agency or department, which is Johns 
Hopkins.
    But we are tribal members and I think that is what gives us 
strength and that we speak in our language and that we can 
explain to the community the importance of us doing this. And 
that, yes, it is taboo for a lot of our elders, but since we 
have established our Elders Council, they have told us that 
even though it is taboo, it needs to be spoken of because if we 
don't speak about it, it is going to continue and it is going 
to continue to take lives on our reservation.
    And so with that, we were able to produce a DVD that we 
use, which we call New Hope. Our production crew is native and 
our actors are native. And so the DVD that we produced is 
geared towards youth who have made an actual attempt to make 
them realize that the impact that it has on their family and 
the community. One attempt that we have has a big impact 
because the first responders who are going out there are also 
community members and so it affects them. And so they deal with 
that, and we explain that to the youth.
    And the core purpose of that particular DVD is for them to 
understand that they do need help and that their attempt was 
serious and that it wasn't a joke. And that they could have 
ended their life and they wouldn't be here today. And so that 
was a DVD that we also produced.
    Ms. Binney. That sounds similar to your guys' movies as 
well, Dr. Clayton.
    Ms. Flynn. Could I just add one comment. I searched through 
my papers in response to your question. I do have some 
information about how screening of youth can save healthcare 
dollars. And I have just a quick from the field story to share. 
It did not occur with American Indian population, but it did 
occur recently. And it is why we are working as well in 
emergency departments because so often that is a primary care 
spot for many youth.
    With the advent of electronic medical records at Cincinnati 
Children's Hospital, a young girl came in, age 16, and her name 
was typed in for the first time as the electronic record came 
online. They saw over 35 previous entries. She had been seen in 
the emergency room for ear ache, headache, stomach ache, back 
ache, a whole panoply of symptoms. She had had all kinds of 
tests, MRIs. She had had all kinds of blood tests. She had been 
admitted overnight twice for all kinds of procedures.
    Finally, on this 37th or 40th admission, she was screened 
for depression, which indeed she was found to have very 
significant and severe symptoms of depression, showing up as 
physical health symptoms. Perhaps because of stigma, she didn't 
want to discuss these other issues.
    When she was asked about it, she readily acknowledged this 
was a problem. And indeed, now they have been able to address 
what was really driving all of these repeated visits for 
symptoms that were in fact symptoms of untreated depression.
    I think it is not a rare example. We hear from emergency 
departments across the Country that this is a component that 
brings youngsters into the emergency room.
    Ms. Harjo. So from that experience, one, is it perhaps a 
recommendation or something that needs to be evaluated as to 
the training for other providers, the rest of the community as 
the White Mountain has done in identifying these types of 
issues and symptoms?
    Ms. Flynn. I think absolutely. As we see integration of 
mental health, physical health, we look at the whole health of 
the youngster. And we realize that it is in adolescence that a 
lot of these significant mental health issues first arise. This 
is when we can first find the symptoms, but we do need 
colleagues across healthcare to learn about this, to be part of 
identifying and then connecting youngsters who need help to the 
treatment and supports they need. I think that is where we have 
to work together.
    Mr. Genia. Can I just add? A lot of the research and stuff, 
too, shows that when at the impact or onset that someone has 
been traumatized, a lot of their developmental emotions, 
maturity levels kind of are thwarted at that age.
    And if you take a look at what has happened a lot in Indian 
Country is that a lot of, whether women, parents that are at 
that age now have been victimized or traumatized in some way in 
their own tribal communities or wherever they grew up at, in 
their adolescence or teen years or younger.
    And I guess the point I am trying to make really is that a 
lot of our efforts as far as putting money more into the 
prevention, the youth, adolescent ages is kind of where we need 
to be directing a lot of our monies. I mean, we do have 
treatment programs and stuff, and that is good to see. But we 
know that the majority of our youth, again, are under the age 
of 18. And if we can develop them, help them, nurture them and 
help them grow that hopefully this cycle will continue to stop.
    So, and you had asked about the behavior, the money put 
into prevention versus medical care. And one of the statistics, 
Jessica, who is on the National Indian Health Board kind of 
pointed this out, too, was that for about every dollar that is 
spent in prevention, we save about three dollars in medical 
care costs or more.
    So it makes a lot of sense if direct a lot of those efforts 
in Federal funding towards those efforts. We could be saving a 
lot more in healthcare costs down the road.
    Dr. Clayton. I would just like to comment one more thing 
about the film, and then something else. I think the film is 
also useful, they have used in schools for the parents, too, at 
PTAs, to show them that kids can get depressed. And this isn't 
just a growing pain or bad behavior or a bad patch they are 
going through. It really could be depression.
    So I think if you make a good film, that it can be used in 
multiple places. And the way we make sure it is used well is to 
have a very, very complete facilitator guide for the teacher, 
hopefully with a mental health worker, but when it is 
presented. So I think it has a lot of depth to it.
    But I would like to say a couple of other things. Senator 
Franken opened by talking about a tribe in Minnesota who had 
another set of copycat suicides. And so they called in a team 
from Montana, he said, to help them evaluate the situation. And 
they did discover that there was some kind of pact in that 
particular community.
    So I think another thing that should be done is that you 
ought to have some crisis intervention teams because contagion 
is a problem for adolescent suicide. There is a contagion thing 
that we have been involved with now on the campus at Cornell. 
And there is a contagion in Palo Alto, California in the high 
school.
    So it is really a problem for youth because they are 
depressed, drinking and impulsive, and then this happens. So 
you need some well-trained intervention teams, I think, to go 
to other reservations when something like that starts to occur. 
You have to do it immediately.
    And then I still think there are now very good short-term 
therapies for depression. There are psychotherapies. I mean, 
there are many drugs that are good. There are drugs for the 
treatment of alcoholism that have been used, I am told, in New 
Mexico successfully in Native American populations.
    But there are good short-term psychotherapies. And there is 
one for suicide attempters that was developed by Tim Beck in 
Philadelphia, in the heart of the city. And 40 percent of the 
people in the study were men, which is very unusual, and 40 
percent of them were black. So it was really in the 
neighborhood of downtown Philadelphia.
    And they have used that same therapy now for the elderly. 
They have to adjust it. And I think you need to invest money in 
developing a kind of psychotherapy, a CBT therapy for Native 
American youths who are depressed or who make suicide attempts. 
I think a suicide attempt specific psychotherapy, while you are 
there, while the person is there, with focus groups. It is a 
complicated process to develop a psychotherapy, but it is 
proven to be effective. So I think it would be a mistake not to 
invest in those kinds of things.
    And then finally, the V.A. in order to solve its problem 
with suicide attempts, it took a long time to work out, but 
they got the Crisis Hotline, which is all over the United 
States, to press 1 if you are a veteran, and then it goes to 
your community of veterans hospitals and that.
    And I think you have talked about the Crisis Hotline some, 
but I think you should have a way to partner with this national 
Crisis Hotline so that Native American communities could also 
use it specifically.
    I don't know. Those are just my thoughts on it.
    Ms. Binney. So basically it would be like a, press 2 if you 
are a Native American?
    Dr. Clayton. I think you have to press 1 if you are a 
veteran and then I think 2 if you are just--it was developed as 
a crisis hotline for the whole Country, not by age or anything. 
And so then when the veterans presented with this enormous 
increase in suicides, the first thing they did, it took about a 
year to partner with them. And so it would be press 3 if you 
are something, or 2, I don't know how they do it, but I think 
you need kind of a national crisis hotline.
    Ms. Binney. I think you are right in that suicide, 
particularly among youth, can be contagious. And the studies 
and the stories and the anecdotes have shown that. And I think 
our hope and our Senators' hope is that having strong leaders 
in the community like Coloradas and Hunter and Novalene to sort 
of break away the stigma, that that becomes contagious to where 
people feel like they can talk about these issues openly and 
comfortably.
    Also there are good young leaders who obviously are very 
proud of their culture and where they come from and of being 
Native American, and that becomes contagious as well.
    We thank everybody for being here. We are going to wrap up, 
but I wanted to remind you all that with the hearing, the 
record will stay open for two weeks, as Chairman Dorgan 
mentioned. And that him and other Members of the Committee, 
because they couldn't be here and couldn't be here for the full 
time, will submit written questions to you for the record, and 
we will give you some time to respond to those questions as 
well.
    I just want to thank everybody for being here on behalf of 
Chairman Dorgan, Vice Chairman Barrasso and all the Members of 
our Committee. We appreciate your coming for the hearing. We 
are sorry it got cut short, and we really appreciate your 
staying around for the listening session and engaging in 
dialogue with us.
    I don't think this Committee is going to stop holding 
hearings on this issue. They have been holding a number of 
hearings on this issue over the last seven years, and I think 
it is going to continue until we can really decrease the number 
of youth suicides that are occurring in Indian Country.
    So again, thank you for being here.
    [Whereupon, at 12:05 p.m., the listening session was 
adjourned.]
                            A P P E N D I X

   Prepared Statement of Dr. Warren Zapol, Commissioner, U.S. Arctic 
                          Research Commission

    Good morning, Chairman Dorgan, Vice Chairman Barrasso and 
Members of the Committee on Indian Affairs. I am pleased to 
submit testimony on Youth Suicide in Indian Country as part of 
the Committee's March 25, 2010, hearing. My testimony focuses 
specifically on youth suicide in the Arctic and on the goals of 
the U.S. Arctic Research Commission, which I represent as a 
commissioner.
    I am the Director of The Anesthesia Acute Care Laboratories 
at Massachusetts General Hospital (MGH) and the Reginald Jenney 
Professor of Anesthesia at Harvard Medical School in Boston. I 
received my undergraduate education at Massachusetts Institute 
of Technology, attended the University of Rochester School of 
Medicine, and after graduation, served in the Public Health 
Service (1967-1970) at National Institutes of Health as a staff 
associate of the National Heart Institute. I currently serve as 
a commissioner for the U.S. Arctic Research Commission, 
representing academics and research while focusing on human 
health. It is in my capacity as the ``human health'' 
commissioner that I submit my comments.
    The Federal Government, Congress and the Supreme Court have 
all determined that the Federal Government has a fiduciary 
responsibility to provide for the health, safety and wellbeing 
of Alaska Natives and American Indians. With youth suicide 
rates, especially in Alaska Native males, drastically exceeding 
the national average--the Arctic Human Development Report 
states that Alaska Native males are 80 percent more likely to 
commit suicide than the general American population--the 
Federal Government is not fulfilling this trust responsibility. 
Millions of dollars have been provided to stem these deaths, 
but youth suicide rates among Alaska Natives are increasing and 
continue to drastically outpace the American population, 
generally. We owe it to our Alaska Native populations to ensure 
that the federal funding provided for their health and 
wellbeing is used to promote maximized benefits--reductions in 
youth suicides.
    Currently, the Federal Government does not know which 
programs work or which programs work most effectively to reduce 
youth suicides in Indian Country. It is critical that the 
Federal Government study these programs to determine how best 
to fulfill its fiduciary responsibility--without this, the 
Federal Government will continue to fund prevention and 
intervention programs, without regard to the programs' 
effectiveness in reducing youth suicides. This is not fair to 
our Alaska Native populations.
    In recent years, there has been significant improvement in 
the general health of the Arctic resident populations, but 
significant behavioral and mental health disparities persist, 
especially between indigenous and non-indigenous populations of 
the Arctic. These disparities include unintentional injuries, 
suicide, homicide, infant mortality, and in part, account for a 
shorter life expectancy and increased mortality related to 
suicide and accidents in Arctic residents, as compared to 
residents in more temperate climates.
    Although Alaskans face the same behavioral and mental 
health issues faced by communities in other states, the 
severity of many of the problems is often greater and there are 
special challenges posed by the remoteness of many Alaskan 
communities. Some of the health problems of greatest concern 
include, but are not limited to, elevated suicide prevalence, 
child abuse/neglect, sexual assault, alcohol use, high 
prevalence of Fetal Alcohol Spectrum Disorders, and 
unintentional injuries. Additionally, the rates of smoking and 
obesity are higher in the Alaskan Natives, compared to non-
Natives, and there has been a rapidly rising incidence of 
diabetes.
    As described in the Arctic Human Health Assessment 
Program's 2002 report, the younger age structure, and 
predominantly remote locations of the majority of the Alaskan 
Native populations makes the State's communities particularly 
vulnerable to these disparities; however, it also provides an 
opportunity for establishing culturally specific, community-
based intervention programs that emphasize resiliency and 
preventive measures for behavioral and mental health promotion. 
Many agencies and organizations have recognized the need to 
invest in further research and improve current services. There 
is also increased attention to the issue of culturally 
appropriate training of community-based health care providers. 
It is believed that coordination of these efforts will provide 
a maximal benefit to the affected communities.
    The indigenous populations and other residents of the high 
northern latitudes disproportionately face a variety of mental 
and behavioral health and health-related social issues. 
Although many of these issues parallel those faced by residents 
of other rural areas, and are similar to those faced by other 
Native American populations in the lower 48 states, the 
problems in Alaska are compounded by the challenging physical 
environment (including extreme cold and photoperiod changes) 
and limited availability of and access to health services, and 
aggravated by the rapid social changes of the past few decades.
    The Arctic Research and Policy Act, passed in 1984 (P.L. 
98-373) and amended in 1990 (P.L. 101-609) was enacted to 
establish national policy, goals, and priorities for Arctic 
research. The Act established the Arctic Research Commission 
and an Interagency Arctic Research Policy Committee (IARPC). 
The Commission publishes a report on goals and objectives every 
two years to help guide the activity of the IARPC and its 
member federal agencies. In its 2009 report, the Commission 
outlined several research program recommendations. In addition 
to studies of the Arctic Region, Bering Sea Region, and 
research on resource evaluation and civil infrastructure, the 
Commission has called for a review of Arctic health research.
    The Commission's recommendation for a research program on 
Arctic health calls for a focus on mental health in the Arctic 
since behavioral problems such as alcoholism, drug use, suicide 
and accidents are among the most frequent causes of ill health 
and death in Arctic populations (USARC, 2009). The Commission 
recommended that IARPC begin planning an interagency program to 
coordinate and emphasize research on mental health concerns in 
the Arctic, with the National Institutes of Health as the focal 
point for the effort. In response, a meeting on Arctic Mental 
Health was held under joint sponsorship of the NIH Fogarty 
Center and USARC in Anchorage on June 2 and 3, 2009. After a 
thorough review of the problems with extensive representation 
from Alaskan Native groups, federal organizations (NIMH, NIAAA, 
NIDA, Fogarty Center, CDC, etc.), State of Alaska agencies 
(Dept. of Health, CMO of AK, etc.), state legislators, and 
voluntary agencies (Mental Health Trust), it became clear that 
the problem was both difficult and chronic and little progress 
is being made toward reducing the suicide rate.
    It was also believed that it would take extensive research 
to identify successful interventions, rigorously test them, 
scale them up, sustain them, and evaluate their effectiveness. 
The complete discussions of that meeting were published in 
December 2010 as a supplement to the International Journal of 
Circumpolar Health and are available on our website 
(www.arctic.gov).
    It should be noted that, although a great number of 
northern residents are at risk and experience disportionate 
mental and behavioral health complications, there are also 
Arctic inhabitants who are resilient to these risk factors. 
These differences can be seen not only between individuals, but 
between communities or villages, suggesting an important socio-
cultural component to resilience. It is unclear what makes some 
individuals or villages more resilient to the same factors that 
put so many others at risk. With few exceptions, there is no 
current, compelling framework to guide development of a primary 
prevention approach for mental illness or addictive disorders 
in the Arctic. That is, it is not known which societal 
strategies are the most effective at fundamentally lowering 
incidence and prevalence of these disorders. Strategies might 
include modifications in housing, socioeconomic status, 
education, environmental hazards, behavior and violence.
    In Alaska, multiple federal, state and local agencies are 
involved in promoting, preventing and treating mental and 
behavioral health disorders. In some cases, these agencies 
collaborate with international partners in the pan-Arctic such 
as the Canadian Ministry of Health. Each of these agencies 
comprises a critical piece of the infrastructure that supports 
and maintains the health of Alaskans. For example, within the 
Federal Government there are at least five agencies active in 
providing assistance, including the Indian Health Service, 
Centers for Disease Control, National Institutes of Health, 
National Science Foundation, and the Health Resources and 
Services Administration. In addition there are well over 20 
non-federal agencies providing behavioral health services in 
Alaska. A coordinated effort among the various agencies and 
organizations is needed to provide the most effective 
prevention and intervention services.
    Researchers in the behavioral and social sciences are 
exploring resilience factors that allow better coping, 
recovery, and resiliency to social and physical trauma. 
Research in neuroscience is identifying mediators and 
mechanisms of altered brain functioning and behavior. 
Community-based researchers are employing educational programs 
to teach cultural values and traditions, within the context of 
the modern society that may be successful in reducing youth 
suicides. Additionally, medical research is finding new 
approaches to diagnose and pharmacologically treat depression.
    Focused research is desperately needed to identify more 
effective and comprehensive strategies for promoting resilience 
and recovery in individuals who live in the northern 
communities as well as to facilitate effective coordination 
among federal, state and local agencies. Despite many trials of 
intervention or ``pilot programs'' there is little 
effectiveness testing of interventions and no interventions 
have been scaled up to a statewide level. The mental health 
research agenda for northern residents is much broader than can 
be accommodated by a single agency. Despite the enormity of the 
problem, a minuscule amount of funds are devoted to mental 
health research in Alaska.
    The U.S. Arctic Research Commission recommends that $1.2 
million be made available for the Institute of Medicine (IOM) 
of the National Academies of Science to review what research is 
needed to improve the health of Alaskan Natives. This study 
will examine the science base, gaps in knowledge, and 
strategies for the prevention and treatment of mental and 
behavioral health problems faced by populations in Arctic 
regions, with a focus on Alaska. Specifically, the IOM research 
would:

        1. Summarize the scope and nature of mental and 
        behavioral health among residents of Arctic regions, 
        with special emphasis on Alaska.

        2. Assess the infrastructure for research into the 
        mental and behavioral health issues in Alaska to 
        determine if current mechanisms and resources are 
        appropriate to facilitate progress in the field. This 
        should include an analysis of which federal agencies 
        are funding research programs and the mechanisms used 
        to review research proposals.

        3. Describe factors that contribute to promoting 
        resilience and recovery among Arctic residents. Learn 
        if any of these have been robustly tested for 
        effectiveness. Learn if any of these have been scaled-
        up for large scale implementation. Have any scaled-up 
        programs been tested?

        4. Provide recommendations for strategies of 
        implementation and testing of programs designed to 
        increase resilience in the affected populations and 
        reduce health disparities.

        5. Describe and assess the infrastructure for 
        prevention and treatment of mental and behavioral 
        health in Alaska; including federal- , state- and 
        community-based programs. This should include 
        examination of collaborative efforts and discussion of 
        ways to improve coordination between the multiple 
        public and private agencies involved in promoting 
        improved mental and behavioral health. The testing of 
        pilot programs for effectiveness will be emphasized, 
        and the scaling potential of pilot therapeutic efforts 
        will be examined.

        6. Identify steps that could be taken in the short- , 
        medium-, and long-term to improve the mental and 
        behavioral health of Arctic residents, including 
        research needed to understand the impact of abrupt, 
        Arctic climate change and rapid social changes on 
        mental and behavioral health, improvements in community 
        infrastructure directly related to improved health, 
        changes in prevention and treatment programs, and 
        mechanisms to improve selection and training of 
        personnel for mental and behavioral health care 
        services. Special emphasis will be made on the use of 
        telepsychiatry to augment these efforts.

    The U.S. Arctic Research Commission understands the 
widespread needs for funding of behavioral mental health 
services in Alaska for Alaskan Natives. In this vein, it is 
vital that the Federal Government carry out an IOM-based report 
of our knowledge and knowledge gaps to learn which strategies 
for sustainable interventions and prevention might most 
effectively and efficaciously be developed to optimize the use 
of these federal dollars and achieve the most beneficial 
effects. Only through rigorous examination and testing can 
evidence-based, sustainable interventions reduce the complex 
set of factors that influence mental and behavioral health in 
the Arctic, especially in Alaska Native youth. Thank you so 
very much for the opportunity to present this testimony before 
the Senate panel.
                                ------                                


Prepared Statement of Julia M. Watkins, Executive Director, Council on 
                      Social Work Education (CSWE)

    Dear Chairman Dorgan and Ranking Member Barrasso: On behalf 
of the 3,000 individual members and 650 graduate and 
undergraduate programs of professional social work education 
comprising the Council on Social Work Education (CSWE), I 
respectfully submit the enclosed report, Status of Native 
Americans in Social Work Higher Education, * to the official 
Committee record for the hearing that took place on March 25, 
2010 on Youth Suicides and the Urgent Need for Mental Health 
Care Resources in Indian Country.
---------------------------------------------------------------------------
    * The information referred to has been retained in Committee files 
and be found at www.cswe.org/File.aspx?id=25694
---------------------------------------------------------------------------
    CSWE is a nonprofit national association representing 
graduate and undergraduate programs of professional social work 
education. Founded in 1952, this partnership of educational and 
professional institutions, social welfare agencies, and private 
citizens is recognized by the Council for Higher Education 
Accreditation (CHEA) as the sole accrediting agency for social 
work education in the United States. Social work education 
focuses students on leadership and direct practice roles 
helping individuals, families, groups, and communities by 
creating new opportunities that empower people to be 
productive, contributing members of their communities.
    In 2007, CSWE formed a Native American Task Force to 
examine the current state of Native Americans in social work 
education. The report, finalized in late 2009, takes a close 
look at the disparities that exist with respect to Native 
Americans in higher education, focusing primarily on social 
work education. It examines the extent to which social work 
programs have been successful in recruiting and retaining 
social work students and faculty, as well as the extent to 
which all social work students are taught core competencies 
needed to serve the mental health needs of Indian Country. A 
primary finding of the report is that social work graduates 
(regardless of whether they are American Indian/Alaska Native 
or not) need to have baseline knowledge of Native American 
culture in order to effectively practice. The report also 
discusses social work programs across the country that have 
been successful in recruiting American Indian/Alaska Native 
students and faculty and suggests that these programs could 
serve as models for other social work programs.
    As you will see by reading the report, and as was discussed 
during the March 25 hearing, capacity building can be a 
challenge for professions responsible for providing mental 
health services, especially to Indian Country. CSWE is 
committed to addressing the severe shortfalls plaguing the 
social work profession by implementing the recommendations made 
in the report to recruit and retain Native American students 
and faculty into social work programs, and to integrate Native 
American content into social work curriculum.
    I hope you will take a moment to read the attached report. 
If CSWE or the Native American Task Force can ever be of 
assistance to the Committee, please do not hesitate to contact 
CSWE's government relations staff, Ms. Wendy Naus.
                                ------                                


    Prepared Statement of Kevin McCartney, Senior Vice President of 
  Government Relations, Boys & Girls Clubs of AmericaWhat do we know 
                  about adolescent suicide in America?

   One adolescent attempts suicide every minute.

   Boys are 4 times more likely to successfully commit 
        suicide than girls; however, girls will attempt suicide 
        4 times more frequently than boys.

   For every completed suicide, there are 100 kids who 
        attempt it.

   There are 500,000 to 1,000,000 attempted suicides 
        each year.

   There will be 100 suicides a week, 14 a day this 
        year.

    Suicide is common to all people, not just a particular 
ethnicity or socioeconomic group. There are many different 
reasons for suicide such as loss of a boyfriend/girlfriend, 
feelings of hopelessness or powerlessness, poor self-esteem, 
pressure to succeed, stress, family or school problems, abusive 
situations, depression, loneliness, and sometimes no visible 
cause at all. As front-line youth development professionals, 
Clubs are often first-responders to kids in crisis and in 
regions where suicide attempt and completion rates have 
skyrocketed, Clubs have established programs and protocol to 
address the issue. Two examples follow.
Alaska
    When the Boys & Girls Clubs of Southcentral Alaska launched 
an outreach program for Native youth, they began in remote 
village of Tyonek. This tiny community of approximately 150 
Athabascan Indians had been plagued by alcoholism and a 
terrible teenage suicide problem, averaging more than one such 
death every year. The problem was so bad that tribal elders 
constructed a Suicide Wall to list the names of the young 
victims.
    Since the Boys & Girls Club opened in 1993, not one child 
has taken his or her own life, and the Suicide Wall has been 
removed. Today, every youth in the village is a member of the 
Club, and names are now being added to the Youth of the Month 
Wall, which recognizes positive contributions by the young 
people in the village.
    Alaska has the highest suicide rate in the nation and 
Alaskan youth are nearly four times more likely than youth 
nationwide to commit suicide. In response to this phenomenon, 
Boys & Girls Clubs launched a statewide suicide prevention 
initiative, Project LEAD, in 2002. Project LEAD (Leadership, 
Education, Acceptance, and Determination) is targeted toward 
at-risk youth in Clubhouse communities throughout urban and 
rural Alaska. Project LEAD builds protective factors in youth 
through academic and leadership programming, along with alcohol 
and substance abuse prevention programming. In the project's 
first year, sixteen youth suicide interventions took place. To 
date, 60 suicide interventions have occurred; three 
interventions were suicide pacts involving a total of nine 
young people.
    The five-year $930,000 project, championed by key 
legislators, funded an Instructor in each community to network 
with mental health and medical providers, school counselors, 
cultural leaders, churches and parents to identify and serve 
at-risk and in-crisis youth. As a result of the initiative, 
over 150 front-line Club professionals in 30 communities are 
trained in suicide intervention skills, and provide watchful 
support to over 15,000 children and teens statewide. These 
trained eyes and ears have identified 312 youth who exhibited 
one or more warning signs and are now building ``profiles'' on 
these youth. Profiles are a paper trail of each youth's 
progress in academic and job performance, peer and family 
relations, and counseling referrals.
North Dakota
    Boys & Girls Club of the Three Affiliated Tribes forged a 
critical partnership with the State of North Dakota and the 
Garrett Lee Smith Memorial Fund in January 2008 to address the 
devastating trends of suicide among Native American youth. 
Clubs approached the initiative as a way to change the culture 
of hopelessness among teens. Clubs worked with health 
professionals to insert the Sources of Strength curriculum in 
Clubhouses and school-based afterschool programs to reach 
children as young as age five. Sources of Strength is a suicide 
prevention and health promotion program designed to prepare 
diverse students to be capable ``Peer Leaders'' for focused 
suicide prevention activities with ongoing adult mentoring. The 
program raises awareness and uses protective factors (sources 
of strength) that help all students be resilient. The program 
focuses on positive strengths and resources that help students 
to overcome problems in their lives.
    The Clubs' suicide prevention efforts are supported with a 
$40,000 grant, as well as in-kind services with Three 
Affiliated Tribes, Tribal Mental Health, Indian Health Service, 
five school districts on the Fort Berthold Indian Reservation, 
the Gerald Fox Justice Center and the University of North 
Dakota. To date, 1,364 students are enrolled in at least one of 
our suicide prevention programs or activities. The program is 
evaluated by the State of North Dakota on a quarterly basis.
Other Efforts
    Boys & Girls Clubs in New Mexico, Arizona, Oklahoma and 
Colorado are also meaningfully engaged in teen suicide 
prevention.

        New Mexico

   Navajo, NM and AZ--Club professionals participate in 
        community-based suicide prevention task forces; the 
        Native HOPE curriculum is utilized in four schools that 
        partner with Boys & Girls Club.

   Mescalero Apache, NM--The community has a grant 
        through the school that uses the Native HOPE curriculum 
        in a community center. There are Club members that 
        attend this program.

    The Native HOPE curriculum by Dr. Clayton Small focuses on 
strengthening adult-youth relationships and community action 
planning. Key elements include: (1) Culturally competent 
activities incorporating spirituality, humor, and important 
values such as belonging, mastery, interdependence and 
generosity; (2) Teaching team building, adult/youth trust, 
communication and team effectiveness; and (3) Providing 
advocates with information, skills and abilities needed to 
develop and maintain an active community team committed to 
creating an action plan to implement prevention and wellness 
activities to increase youth resiliency.

        Oklahoma

     Tahlequah, OK--The school district has a three-
year grant for drug and alcohol prevention, and suicide 
prevention. The grant supports three therapeutic counselors at 
the high school, and Clubs have access to this resource.

     Chelsea, OK--County-wide counseling services are 
available in one Club facility.

        Southern Ute, CO--The Club partnered with the county in 
        its training of 60 gatekeepers in the ASSIST program; 
        Clubs intend to seek support to train kids in the 
        ASSIST program, too.
                                ------                                


Prepared Statement of Mary J. Weiler, Board Chair, American Foundation 
              for Suicide Prevention, North Dakota Chapter

    Thank you for the opportunity to provide written testimony 
for this committee hearing. My name is Mary Weiler--I am a 
survivor of suicide loss. On October 6, 2005, I lost my young 
daughter, Jennifer, to suicide.
    This shining star graduated with honors, was an 
accomplished musician, an avid environmentalist, a loving and 
attentive daughter/sister, an advocate for the poor and 
disadvantaged--yet struggled with chronic depression and 
anxiety for over a decade.
    Over time, I've come to learn that more than 90 percent of 
people who die by suicide have an illness such as depression, 
bipolar disorder, schizophrenia, or substance abuse at the time 
of their death--sometimes diagnosed, sometimes not. And after 
reading the letter that my daughter left for us, I have also 
come to understand that death by suicide is not intentional--it 
is a result of many complicated factors. I found out that due 
to the stigma that surrounds mental illness, she lived in fear 
and isolation and felt she was a burden. At the core, suicide 
is an escape from psychic pain or distress by a person who 
cannot--at the specific moment in time--find another way to 
cope. What I learned is that her experience with depression was 
totally remote from a normal experience, the horror induced by 
depression took on the quality of real physical pain that 
ultimately became unbearable for her.
    I have also learned that suicide is influenced by biology, 
personal and social psychology, roles and relationships, and 
issues about the very meaning of each of our lives. Many 
factors come together in a multitude of different combinations 
to make a death by suicide. The more factors or types of mental 
distress or illnesses that one experiences, the stronger the 
state of vulnerability. I have learned that just as people can 
die of heart disease or cancer, they can die as a consequence 
of mental illness. It has been established with reasonable 
certainty that such severe depression is chemically induced 
amid the neurotransmitters of the brain, probably as a result 
of systemic stress, which for unknown reasons causes a 
depletion of certain chemicals in the brain.
    I've also learned that I'm hardly alone: research shows 
that more than 60 percent of us will lose someone we know to 
suicide during the course of our lifetime; more than 20 percent 
of us will lose a family member. Nevertheless, the historical 
stigma surrounding suicide persists, leaving many survivors of 
suicide loss feeling misunderstood and abandoned, yearning for 
comfort and understanding.
    Survivors of suicide are also often victims of stigma--
people feel awkward and don't know what to do or say to 
surviving family members. It is stigma that continues to keep 
suicide from the public's eye. People are afraid of the word, 
and worse, too often unwilling to be open to talk about the 
topic. If we can't get through the stigma, we struggle to be 
able to educate. It is only when we get beyond the stigma that 
education will be possible and suicide prevention a reality. 
The stigma issue is so important and critical to suicide 
prevention that over the last several years the American 
Foundation for Suicide Prevention (AFSP) has dedicated over 12 
Million dollars to research alone and continues to be committed 
to funding research projects in the future.
    North Dakota loses someone to suicide every four (4) days. 
Suicides rates of American Indian youth are the highest in the 
nation and escalating in recent years. There is still a great 
deal of work to be done to bring mental services to the local 
community to end the stigma and reduce the number of suicides 
on our reservations.
What Mental Health Care Resources Are Needed
1. Better Data and Definitions--See Attached Public Policy Brief
    Fund demonstration projects in tele-mental health to find 
how these systems can be of greatest benefit in Indian County 
and fund infrastructure to connect service provides, families, 
and patients for communication and treatment planning with 
support networks while in treatment.
    Promote and fund the interface of data and a national 
registry through IHS for suicidal behaviors and treatment, to 
provide data informing continuity of care across systems for 
inpatient, outpatient, dual diagnosis and other supportive 
services.
    Collecting statewide data and establishing a mandatory 
reporting system to gather data; plan programming, and get 
youth needed services before they complete suicide.
    Establishing Uniform definitions--collecting all the types 
and causes in injuries in emergency rooms is needed to develop 
uniform definitions (undetermined). Some drowning and single 
motor vehicle deaths are ``misclassified'' as natural or 
accidental when suicide would be more correct. Misclassifying 
of such deaths contributes to under reporting of official 
numbers.
2. National and State Research
    Encouraging research to develop new treatment initiatives 
aimed at reducing suicide by:

   Examining the relationship of domestic violence and 
        child violence on suicide rates.

   Implementing Suicide Screenings Tools for our 
        adolescents and college students such as the 
        Interactive Screening Program through AFSP.

   Improving fire arms storage practices.

   Funding for research to determine evidence-based 
        treatments for American Indian (AI) and Alaskan Native 
        (AN) populations. Seek grant from AFSP.

3. Mental Health Services
    Increase funding to Indian Health Service (IHS) to 
increased the number of credentialed mental health 
professionals providing services in Indian country.
    Increase funding of Indians into Psychology and Indians 
into Medicine to increase the number of American Indian (AI) 
and Alaskan Native (AN) providers in Indian Country.
    Increase funding of loan repayment programs to recruit and 
retain qualified mental health service providers in Indian 
County.
    Fund aftercare treatment programs and circle-of-care 
services for transition and follow-up treatment for Indian 
youth. Explore Post-vention program offered by AFSP.
4. Education and Training
Providing Training Opportunities
    Require cultural competence training for service providers 
in Indian Country. Providers must relate to the cultural values 
of the people they serve.
    Fund clinical placement, internship, and post-doctoral 
residency programs for AI/AN students for experiences working 
with clients in Indian Country.
    Provide training for selected community members to begin 
Survivor of Suicide Loss Support Groups on the reservations.
5. Focusing on Protective and Prevention Factors
    Provide Skill Building tools for our young people--problem 
solving, conflict resolution, non-violent ways of handling 
disputes and new coping mechanisms.
    Foster and celebrate connectedness and strengths with 
family and friends. Enlist the family members and friends in 
the plan for a young person who is struggling with coping. 
Explore Sources of Strength--Peer Resiliency Model.
    Restricting access to lethal means of self-harm (i.e. 
firearms is still the leading method of suicide death).
    Develop ``hope kit'' for our young people to increase their 
social supports--who to call; knowing the triggers of their 
depression then having a support person or action to deal with 
the trigger.
    Provide appropriate funding for mental health care programs 
such as ``Mental Health First Aid'' that help to build 
community capacity and reduce stigma related to mental health 
issues and crises.
6. Advocacy and Collaboration
    Although suicide is clearly a clinical issue, it is also a 
public health issue. This necessitates a shift in focus from 
prevention and treatment at the individual level to prevention 
and treatment at the community level. Therefore, suicide 
prevention should no longer be solely the concern of mental 
health professionals but also that of the entire community.
    The AFSP-ND Chapter has been fortunate to be able to 
collaborate with:

        The ND Coalition for Suicide Prevention
        The Gay Lesbian Bisexual Transgender community
        The ND Department of Health and ND Department of Human 
        Services
        The Veterans Administration for Suicide Prevention
        Survivors of Suicide Loss Support Groups
        Mental Health America-ND
        Law Enforcement and First Link
        Prairie St. John's--Psychiatric Hospital
        R.S.V.P Older Adults Volunteer Program
        Public and Private School Districts
        Universities and Colleges
        Community Churches

    In closing, what I have found is that individuals who are 
suffering from depression are not helped by lectures or by 
hearing all the reasons they have to live. What they need is to 
be reassured that they have someone to whom they can turn--be 
it family, friends, school counselor, physician, or teacher--to 
discuss their feelings or problems. It must be a person who is 
very willing to listen and who is able to reassure the 
individual that depression and suicidal tendencies are very 
treatable. Seventy-five percent of all suicides give some 
warning of their intentions to a friend or family member. All 
suicide threats and attempts must be taken seriously. Treatment 
is of utmost importance, and may involve medications, talk 
therapy or a combination of the two.
    The American Foundation for Suicide Prevention is the only 
national not-for-profit organization exclusively dedicated to 
understanding and preventing suicide. AFSP promotes research, 
awareness and education and reaches out to people with mood 
disorders and those affected by suicide. In May 2007, the AFSP 
North Dakota Chapter was formed to engage in the following five 
core strategies:

   Funds scientific research
   Offers educational programs for professionals
   Educates the public about mood disorders and suicide 
        prevention
   Promotes policies and legislation that impact 
        suicide and prevention
   Provides programs and resources for survivors of 
        suicide loss and people at risk, and involves them in 
        the work of the Foundation

    The work of suicide prevention must continue to occur at 
the community level where human relationships breathe life into 
public policy. The mindset should always be to improve mental 
health and get the best value (saving lives) for our spending--
NOT just saving money!
    If we provide mental health resources to the right people 
at the right time we can actually save money but most 
importantly we are SAVING LIVES.
Attachment



                                ------                                


   Response to Written Questions Submitted by Hon. Byron L. Dorgan to
                           Randy E. Grinnell

    Question 1. Can you describe how IHS becomes aware of and 
responds to these tragedies?
    Answer. Most of the time, IHS becomes aware of these 
suicides from IHS Service Unit staff, Tribal health providers, 
or Tribal leadership. Our experience in responding to these 
types of events has taught us that our effectiveness hinges on 
a coordinated community response involving Tribal government; 
the local Health Departments; Emergency Medical Services; law 
enforcement; schools; faith-based institutions and spiritual 
leaders; and pertinent State and Federal offices. Proactive 
coordination of services and a designated point of contact are 
particularly important to reduce confusion in the community and 
increase the effectiveness of each partner's activities, as 
well as the effectiveness of the overall response. The more we 
can get people and agencies to work together collaboratively, 
the more likely the crisis can be managed quickly. A clearly 
defined intervention plan, consisting of adherence to a unified 
message and crisis response is important for those needing 
immediate assistance and support.
    Primary support comes through the IHS Area Office. The IHS 
Headquarters supports the Area Office in their efforts to 
assist the Tribal community. The Area Office works closely with 
the Tribal community to help coordinate IHS resources in the 
response. ``In the case of self-government Tribes additional 
funding and resources maybe provided to assist in responding to 
a crisis in their communities.''
    While most responses are handled by the communities 
themselves, there are times when a crisis can be of such great 
magnitude that local response capacity may be inadequate or 
temporarily overwhelmed. In some of these situations, we may 
also be able to help coordinate emergency community 
stabilization assistance utilizing the U.S. Public Health 
Service Commissioned Corps Emergency Response Mental Health 
Teams. The IHS Emergency Response Model design responds both to 
the individual(s) in crisis and the community affected. This 
model is designed to assist all American Indian or Alaska 
Native communities in mitigating the immediate crisis, and 
stabilizing the community so that long-term solutions 
(planning, prevention, and implementation plans) can be 
developed by the community.

    Question 1a. Do each of these communities have a mental 
health provider?
    Answer. These communities often have a mental health 
provider. However, when there are vacancies or limited 
behavioral health providers, this can have a negative impact on 
access to behavioral health care. For example, a Tribal 
community may have difficulty recruiting certain disciplines 
such as psychiatrists and psychologists while, in other 
communities, there may be only one or two behavioral health 
providers. So, when there is a vacancy or a staff person takes 
time off, the community may not have access to behavioral 
health services. The availability and adequacy of mental health 
programs for American Indians and Alaska Natives varies 
considerably across communities.

    Question 1b. How do you think Tribes, the Indian Health 
Service, and Congress could best work together to improve youth 
suicide prevention efforts and increase the availability of 
mental health resources?
    Answer. The key strategy that IHS employs to address Indian 
youth suicide is to work in partnership with Tribes to bring 
services and resources together to focus on mental health needs 
and reduce the rate of suicide within American Indian and 
Alaska Native (AI/AN) communities. Tribes must be involved at 
every step of developing and implementing suicide prevention 
strategies within their communities. The IHS is currently 
working with Tribal leadership to coordinate programs, 
services, and resources to address this problem. This focus on 
Tribal collaboration marks only the beginning of a much larger, 
long-term process.
    There also needs to be continued collaboration between 
Federal partners (such as IHS with SAMHSA, NIMH, DOJ, BIA 
etc.). This is not only beneficial but it is necessary. 
Continued coordination of resources across numerous agencies 
will allow the development and implementation of a 
comprehensive, integrated, public health approach to reducing 
deaths by suicide and suicide attempts. IHS plays a key role 
along with Tribal leaders in this collaboration.
    The IHS National Suicide Prevention Initiative has five 
targeted approaches for suicide prevention and intervention 
that we continue to implement including assisting IHS, Tribal, 
and urban Indian programs and communities in addressing suicide 
utilizing community level cultural approaches, identifying and 
sharing information on best and promising practices, improving 
access to behavioral health services, strengthening and 
enhancing IHS' epidemiological capabilities, and promoting 
collaboration between Tribal and urban Indian communities with 
Federal, State, national, and local community agencies.

    Question 2. Does the IHS track the number of mental health 
care providers in Indian Country?
    Answer. IHS can generate reports that look for certain job 
categories, but there are limitations to the amount and type of 
data that can be generated. This information will only provide 
a ``snapshot in time'' because there is a great deal of 
turnover among mental health providers in tribal communities. 
In addition, behavioral health disciplines may not be clearly 
defined in data collection tools (e.g., ``psychiatrists'' fall 
under the general ``medical officer'' series); so, it may be 
difficult to ascertain which of those medical officers are 
psychiatrists. With over 50 percent of the Mental Health 
program and over 85 percent of the Alcohol and Substance Abuse 
program under tribal management, the IHS does not have access 
to tribal and urban Indian health mental health care provider 
data.

    Question 2a. If so, how many mental health care providers 
work in Indian Country?
    Answer. The numbers of mental health providers in the IHS 
civil service system are as follows:

        Social Sciences (0101) = 93
        Social Sciences Aid/Technician (0102) = 54
        Clinical Psychologist (0180) = 60
        Social Worker (0185) = 92
        Social Services Assistant/Aid (0186) = 41
        Social Services (0187) = 14
        Medical Officer-Psych (0602) = 24
        Psych Nurse (0610) = 5
        Practical Nurse-Psych (0620) = 4

    These numbers only represents IHS' federal service and does 
not take into account Tribal and Urban Indian mental health 
care provider data.

    Question 2b. What is the vacancy and turn-over rate?
    Answer. Although this information may be collected for IHS 
the vacancy and turn-over rate for mental health providers is 
currently unavailable. In order for IHS to be generated both a 
vacancy and turn-over rate, it (the number of vacancies and 
number of turn-over) would have to be monitored over a period 
time. The data for Tribal and Urban Indian programs are 
unavailable.

    Question 2c. How many tribes have mental health providers?
    Answer. This is a difficult question to answer given the 
increasing contracting/compacting of mental health programs by 
tribes and tribal programs, and their having no obligation 
under P.L. 93-638 to report such information to the federal 
government for programs they themselves operate. Subsequently, 
it is difficult to give an answer that accurately reflects all 
tribes and programs, so while we can report federal staff as in 
the question below, we are unable to do so for tribal programs. 
It is our experience and understanding, however, that the vast 
majority of tribally contracted/compacted programs do have 
their own providers. For some, most often smaller or more 
isolated programs, there are tribal consortia that pool 
resources and providers for their programs and communities. For 
higher level services as in intensive outpatient, residential, 
and hospital care, many tribes and tribal programs share 
resources or utilize contract health services to access 
providers.

    Question 2d. And what is the breakdown of between 
psychiatrists, psychologists, social workers, and other mental 
health care providers?
    Answer. We do not have a breakdown of behavioral health 
providers for Tribal and Urban Indian health programs. However, 
for the IHS federal civil service providers, the breakdown is 
as follows:

        Social Sciences (0101) = 93
        Social Sciences Aid/Technician (0102) = 54
        Clinical Psychologist (0180) = 60
        Social Worker (0185) = 92
        Social Services Assistant/Aid (0186) = 41
        Social Services (0187) = 14
        Medical Officer-Psych (0602) = 24
        Psych Nurse (0610) = 5
        Practical Nurse-Psych (0620) = 4

    Question 3. Do you think the current funding for mental 
health and suicide prevention is adequate?
    Answer. The President's FY 2011 budget request for an 
increase of $4 million will help support AI/AN communities in 
eliminating behavioral health diseases and conditions which 
include early identification of factors contributing to 
suicide. The President's total FY 2011 budget request for 
Mental Health of $77,076,000 is approximately 13.8% over the 
Omnibus FY 2009 budget of $67,748,000, and approximately 5.9% 
over the FY 2010 enacted budget of $72,786,000. This is in 
addition to the $11.3 million increase for the Alcohol and 
Substance Abuse program which includes funding for the 
Methamphetamine and Suicide Prevention Initiative (MSPI) 
program. These increases reflect the President's commitment to 
addressing the ongoing need for mental health and alcohol and 
substance abuse programs servicing Indian Country.

    Question 3a. What kinds of resources and funding do you 
think is necessary?
    Answer. Funding provided for the Methamphetamine and 
Suicide Prevention Initiative, is now, for the first time, 
offering community developed and delivered direct services and 
support in 127 programs across Indian Country. These programs 
were developed and are now being delivered by the communities 
themselves, and are acting as pilot projects and community 
laboratories for innovations that will hopefully be able to be 
utilized across systems and communities.
    Current program funding has been used to develop a suicide 
surveillance reporting tool which documents incidents of 
suicide in a standardized and systematic fashion. This tool 
captures data related to specific incidents of suicide which 
are essential to accurate data analysis. Through programs like 
the surveillance reporting tool, IHS can better target 
resources both now and in the future. In addition, funding for 
the Methamphetamine and Suicide Prevention Initiative, is now, 
for the first time, offering community developed and delivered 
direct services and support in 127 programs across Indian 
Country. This program is being implemented by communities 
acting as pilot projects and community laboratories for 
innovations that will hopefully be utilized across systems and 
communities. These types of programs and initiative maximize 
current resources and target current funding to where it is 
most needed.

    Question 3b. Of the funding going to tribes for mental 
health services, how much is devoted to suicide prevention or 
related activities?
    Answer. IHS does not have data on how much of the total 
funding going to tribes for mental health services is 
specifically dedicated to suicide prevention. What we do know 
is that in FY 2010, $16.3 million of the IHS alcohol and 
substance abuse budget is dedicated to the Methamphetamine and 
Suicide Prevention Initiative.

    Question 4. What do you think is the biggest barrier to 
data collection in the Indian health system?
    Answer. We have made substantial efforts over the last 
several years to improve our behavioral health data collection 
in the Resource and Patient Management System (RPMS) and will 
continue these efforts. The biggest barrier to data collection 
is that not all tribes utilize this electronic method of data 
collection although it is increasingly being used across our 
Indian health system. The data from tribes that do not utilize 
RPMS may or may not be integrated into the larger RPMS data 
set, dependent upon the tribal program. In addition, tribes can 
elect to not transmit their data to the IHS national data 
warehouse. Inconsistent data collection does not provide a 
complete picture of the health issues in Indian Country.

    Question 4a. Do you think improvements in tracking and 
collecting youth suicide statistics would be helpful in 
preventing youth suicide?
    Answer. Yes. In order to address the suicide epidemic in 
Indian Country, data collection and analysis are pertinent 
components to developing a comprehensive public health response 
to the problem. The greater the levels and quality of 
information available from the point of care through to 
national programs, the better Indian health programs and health 
systems can track and trend needs, then target limited 
resources and services to where they are needed most. The 
better the data, meaning the better the nature and quality of 
health information, the better the systems of care can then 
respond to health needs.

    Question 4b. In the past, has IHS looked at implementing a 
mandated reporting system like the one being used on the White 
Mountain Apache Reservation?
    Answer. IHS has already developed and implemented a suicide 
surveillance reporting tool to document incidents of suicide in 
a standardized and systematic fashion which is available to all 
providers in the RPMS health information system. The suicide 
surveillance tool allows clinicians to document incidents of 
suicide, including ideations with intent and plan, attempts, 
and completions. It captures data related to a specific 
incident of suicide, such as date and location of act, method, 
contributing factors and other useful epidemiological 
information. With the expansion of suicide data collection to 
the primary and emergency care settings, IHS will have more 
comprehensive and reliable information about these occurrences. 
The data will be used to better understand the prevalence of 
suicide in the populations served by IHS, Tribal, and Urban 
Indian healthcare facilities and to inform intervention and 
prevention activities.
    Most patients with serious suicidal ideation or attempts 
present first to providers in primary or emergency care. The 
availability of the RPMS suicide surveillance tool for all 
providers in IHS, Tribal, and Urban Indian healthcare settings 
will promote standardized and systematic documentation of 
suicide events. Suicide data can be analyzed locally through 
RPMS reports and is exported nationally, so that we can develop 
a better understanding of this important public health problem.
                                ------                                


     Response to Written Questions Submitted by Hon. Al Franken to
                           Randy E. Grinnell

    Question 1. Mr. Grinnell, we have a serious shortage of 
mental health providers in Minnesota, especially on the 
reservations. In your testimony, you describe the challenges 
that these providers face in Indian country and some of the 
remedies that IHS has tried. Your description of telehealth 
services seems like a point of light and I'd like to see them 
expanded. Have other remedies have been effective?
    Answer. There have been other promising approaches to 
address access to and quality of mental health care. IHS is 
promoting the integration of behavioral health services into 
the general healthcare delivery system through the spread of 
primary care-based behavioral health services following models 
already successfully implemented by the Veterans Healthcare 
Administration and branches of the Department of Defense. A 
good example of such activities coordinated across the 
healthcare system is the nation-wide promotion of the Alcohol 
Screening Brief Intervention model, which has been demonstrated 
to reduce trauma recidivism by up to 50% in some settings. Such 
models recognize the complex interrelationship of medical and 
behavioral health concerns and offer opportunities for early 
intervention rather than waiting for the development of fully 
manifested mental health disorders. The IHS is also working to 
improve the psychosocial care delivered to patients with 
chronic illnesses such as diabetes and improve their long-term 
outcomes through recognition of and attention to intertwined 
behavioral health concerns.

    Question 1a. What can we do to attract mental health 
providers to Indian Country and keep them there?
    Answer. Over the years, we have attempted to apply a number 
of remedies to attract mental health providers such as adopting 
special pay incentives in order to make reimbursement packages 
more competitive, making loan repayment and scholarship 
programming available for a wide range of behavioral health 
specialties including social work, psychology, and psychiatry, 
along with active recruitment, development of the Indians into 
Psychology program, and emergency deployment of the United 
States Public Health Service Commissioned Corps mental health 
teams. Increasing access and availability to these programs is 
necessary to attract additional mental health providers. For 
example, this year the IHS scholarship program received 
approximately 1,200 applicants while only a little over 100 
will be selected. Increasing staff self-care, clinical 
supervision, and support will also serve to reduce staff 
burnout and isolation.
    Intern programs allow Indian Country to utilize mental 
health providers still in training that can see patients under 
the supervision of a licensed health professional. The 
initiation of pre-doctoral intern programs will help increase 
the number of patients accessing care and serve as a 
recruitment tool for psychologists and psychiatrists. Standing 
Rock has implemented a pre-doctoral psychology intern program 
and has been able to triple their patient load as a result. In 
addition, multiple interns have agreed to stay on and continue 
to practice mental health on the reservation when they are 
licensed. The IHS Albuquerque Area Office has funded an 
American Indian psychology intern program since 1993. The 
Albuquerque Area Office is part of the Southwest Consortium 
Pre-doctoral Psychology Internship program, which includes IHS, 
the Albuquerque Veterans Healthcare Administration Medical 
Center, the University of New Mexico Hospital, and Forensic 
Health Services. The interns work in numerous sites across the 
Albuquerque Area. They have trained numerous American Indian 
psychologists, many of whom now work in Indian Country.
    The potential for expanding these types of programs is a 
way to improve health care and recruit mental health providers. 
Without psychology internships in rural and underserved areas, 
there is a failure to complete the ``pipeline'' of training 
needed to recruit and retain mental health providers in Indian 
Country. IHS will continue to make every effort to support and 
expand psychology internship programs. The President's FY 2011 
budget request for over $41 million for Indian Health 
Professions contributes to this effort.

    Question 2. What are the challenges that arise when people 
have to attend non-tribal facilities?
    Answer. Although providers in these facilities may be well-
trained in medicine and healthcare and are eager to practice 
and serve American Indian and Alaska Native patients, they lack 
knowledge and understanding about this population. This can 
hinder their communication with their patients. We know from 
the Institute of Medicine that effective provider-patient 
communication can build respect and trust, resulting in better 
patient outcomes. We also know that patient-centered care is 
essential for quality care and, ultimately, more equitable care 
for all. It is important that providers understand the cross-
cultural aspects of mental illness in American Indian and 
Alaska Native patients so that they can effectively evaluate 
and manage these disorders. Providers who understand the 
differences between Western and traditional Indian perspectives 
in the role of culture in mental health and how these 
perspectives may influence the types of mental disorders seen 
in American Indian and Alaska Native patients can be more 
effective in treating their patients.

    Question 3. Can you please discuss what IHS mental health 
programs do to help families, not just individuals with regard 
to mental health and substance abuse?
    Answer. We strive to support American Indian and Alaska 
Native individuals, families, and communities by: (1) 
maximizing positive behavioral health and resiliency in 
individuals, families, and communities; (2) improving the 
overall health care of American Indians and Alaska Natives; (3) 
reducing the prevalence and incidence of behavioral health 
diseases; (4) supporting the efforts of American Indian and 
Alaska Native communities toward achieving excellence in 
holistic behavioral health treatment, rehabilitation, and 
prevention for individuals and their families; (5) supporting 
Tribal and Urban Indian behavioral health treatment and 
prevention efforts; (6) promoting the capacity for self-
determination and self-governance, and; (7) supporting American 
Indian and Alaska Native communities and service providers by 
actively participating in professional, regulatory, 
educational, and community organizations at the National, 
State, Urban, and Tribal levels.
    Specifically for families, IHS supports the development of 
locally-driven initiatives that aim to lessen the impact of 
risk factors while enhancing those factors that are known to 
protect against suicide, mental health conditions, and alcohol 
and substance abuse issues. Families provide the essential 
support and nurturing for individuals, thus supporting families 
is critical to supporting individuals, and vice versa. The vast 
majority of mental health programs offer services for both 
individuals and families. In fact, in most tribal communities 
and programs it is difficult to separate families and 
individuals in overall provision of direct services. Indeed, 
particularly for youth, standard treatment includes regular 
family involvement. Additionally, traditional knowledge, along 
with the role of elders, spiritual leaders, and extended 
family/clans needs to be respected and validated for the 
important role they play in healing and wellness. In this 
regard, family, again, is central and integral. Increasing 
protective factors, as in utilizing traditions and family, are 
equally or more effective than decreasing risk factors in terms 
of reducing suicidal risk, mental illness, and alcohol and 
substance abuse. Family, culture, and tradition are 
cornerstones to providing effective behavioral health services. 
IHS works to use practice based interventions that can 
integrate these to increase their effectiveness in Indian 
Country. We have found that programs that integrate them are 
more effective within the communities and with our youth, 
families, and communities.
    Nurturing of children and promoting their safety are the 
most basic aspects of American Indian and Alaska Native 
cultures. Protection of children against harm is embedded in 
cultural and spiritual beliefs, child-rearing methods, extended 
family roles, and systems of clans, bands, or societies. 
Traditional family values bring strength to community-driven 
efforts to prevent suicide, mental health conditions, and 
alcohol and substance abuse among youth, families, and 
communities. Every community member including families, 
businesses, community leaders, and others have a role to play 
in keeping children and youth safe. Community members can 
promote protective factors by ensuring their programs include 
spiritual beliefs, traditional values and healing methods, 
spiritual and cultural continuity, and ensuring that their 
young people have a valued role in preserving their heritage.
                                ------                                


  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                         Paula J. Clayton, M.D.

    Question 1. The American Foundation for Suicide Prevention 
(AFSP) organization has 32 community-based chapters focused on 
grassroots suicide prevention, including an active chapter in 
the state of North Dakota. How many of the AFSP state chapters 
of work with tribal communities? Do you think there are ways 
for AFSP to get more involved and assist in youth suicide 
prevention activities in Indian Country?
    Answer. AFSP currently has 40 chapters, many of which are 
on the East Coast, fewer on the West Coast and fewest in-
between. As you indicated, our firmest connection with tribal 
communities is in North Dakota, but an additional two or three 
chapters have some connections with Native American groups. I 
believe, however, that if more suicide prevention materials 
specifically addressing these populations were available, other 
AFSP chapters would reach out to tribal communities.
    We currently have three programs that might be applicable 
to these communities. One is the award-winning More Than Sad 
film series that I brought with me to the hearings, which 
include a film on teen depression designed to be shown to high 
school-aged youth, and another on youth suicide prevention for 
teachers and other school personnel. More information about 
these products is available on the website, http://
morethansad.org. With the necessary financial resources, these 
films and the accompanying educational materials could be 
adapted to specifically address youth depression, drug use, and 
suicide in Native American communities. We would recommend 
using Native American teens as the actors and actresses in the 
teen film, establishing an advisory committee to guide the 
effort that includes both adults and youth from tribal 
communities and focus group testing all products while in draft 
form to assure that they will be readily accepted by the 
intended audiences and effectively convey the intended 
messages. The More Than Sad films have been well-received by 
schools in general but I should note that they are expensive to 
make. Our funding came from a grant from the New York State 
Office of Mental Health, which was supplemented by gifts from 
several additional donors and by proceeds from our Out of the 
Darkness community walks. If a parallel package of educational 
materials were available for teens and educators in tribal 
communities, I can envision our chapters reaching out, as they 
do so well, to bring them to the appropriate communities across 
the country.
    The second project is a DVD on Depression and Bipolar 
Disorder that educates patients with mental illness and their 
families about these illnesses. Like the previously discussed 
films, this DVD was made for a general population, but may be 
informative for Native Americans communities. Again, its 
relevance and resonance should be focus group tested with 
appropriate community members. In this case as well, developing 
a parallel product that specifically addresses these illnesses 
and perhaps others having high prevalence in tribal communities 
would be ideal, although would require special funding. I would 
like to emphasize that well-developed, appealing materials is 
in the long run a cost-effective way of educating and engaging 
youth, their parents, teachers, community leaders and other 
adults around the topic of suicide prevention. Investing in the 
development of culturally appropriate materials would represent 
a major step toward encouraging treatment for depression and 
other mental disorders and reducing suicidal behavior in these 
communities.
    Third, AFSP has developed an anonymous, online interactive 
screening program for persons aged 18 and older, which would be 
extremely helpful for those Native Americans who have access to 
the Internet. It is possible it could also be accessed through 
use of online chat rooms. This program screens for stress, 
depression, alcohol and substance use, anxiety, eating 
disorders and suicide, and is currently being expanded to 
include PTSD and other conditions prevalent among veterans. Its 
purpose is to engage an individual through an anonymous online 
discourse that will lead to in-person evaluation and treatment. 
As part of this program, AFSP staff work closely with the 
schools, workplaces, veterans facilities and other sites that 
are using it, and would welcome the opportunity to discuss with 
tribal leaders how the program might be adapted to Native 
American communities.

    Question 2. In your testimony you described the research 
and suicide prevention work of the AFSP and also your extensive 
work on youth suicide prevention and mental health issues.
    Most of the AFSP efforts you discussed seem to be focused 
on screening and early detection. Once you have identified a 
child that should be referred to a mental health professional, 
how difficult is it to get that child into treatment?
    Do you think a dramatic increase in access to mental health 
providers and other resources could help to turn around the 
tragic rates of suicide in Indian Country?
    Answer. You note, rightly, that most of AFSP's efforts are 
on screening and early detection but you wonder about entry 
into treatment. As I read the testimony from various tribes 
that were sent to me before the committee hearing, I was struck 
by the complexity of getting a referral. In some tribes the 
route of the referral has to be approved by the governing 
council. It seems to me that the simplest thing for the tribes 
to consider is to refer all suspected problems to the 
individual's primary care doctors, who would be trained how to 
detect depression, substance abuse and other problems, how and 
when to treat and when to refer. Multiple studies indicate that 
when primary care doctors are taught to recognize and treat 
depression, the suicide rate goes down, significantly, in the 
community being studied. Other primary care providers such as 
nurse practitioners and physician assistants could also benefit 
from such training. I am sure each tribe has different 
resources, so it will vary. Certainly, as was told in the 
hearing, it would prevent the provider from not appreciating 
the seriousness of a distressed young woman with rope burns on 
her neck from attempted hanging and from only giving her a 
cursory evaluation and no treatment before sending her home.
    I am also not clear why there are not AA and DA groups on 
the reservations. Clearly, that treatment is as successful as 
almost any we have for alcohol and substance abuse. I believe I 
was told by Jeremiah Simmons from The Mescalero NM tribe that 
they had an association with UNM medical school to give a 
medication for alcohol abuse to those members who have an 
addiction problem in their tribe and that it may be working.
    I would think before one considers a dramatic increase in 
mental health resources to the tribes, one should do pilot 
testing of such a plan in two or three very different tribes. 
It may be that just having one full time mental health nurse 
practitioner in each site is the best answer. And unless the 
tribes are willing and able to tackle the alcohol and drug 
abuse problems that run in families, it may be that the problem 
cannot be solved.

    Question 3. Today we heard testimony about the lack of data 
collection of both the incidence of youth suicide and 
prevention activities in Indian Country. In your testimony, Dr. 
Clayton, you emphasized the importance of collecting youth 
suicide data. Do you think the Indian Health Service and tribes 
should have more data collection activities as a part of youth 
suicide prevention efforts? How do you think they could improve 
this data collection?
    How does the availability of data on suicide and 
availability of mental health services in Indian Country 
compare to non-tribal communities?
    Answer. I absolutely believe that improvements are needed 
in collecting data on attempted and completed suicide in tribal 
communities, starting with mandated suicide surveillance in 
every tribe. The data from cancer registries and registries for 
other serious medical illnesses show that registries are 
important first steps in identifying the problem. These help to 
calculate trends and identify high risk groups as well as 
evaluate interventions. They provide a vital resource to 
estimate the incidence of known risk factors (such as mental 
illness, access to firearms, access and use of alcohol or other 
drugs, previous attempts) and protective factors (like whether 
a family member was available, they were brought in by police, 
what are their social supports). Unless we know the extent of 
the problem, we cannot begin to tackle it and we cannot measure 
a change if an intervention is initiated.
    Although U.S. law requires that all sudden deaths are 
reviewed by a medical examiner or comparable official, I 
understand the law does not apply to Native American tribes. In 
all other deaths that are not sudden, a doctor must certify the 
cause of death. I do not know how Native Americans handle this. 
Anyway, that makes it possible to track suicides across the 
nation, region by region. Although there are undetermined 
deaths also, only a portion of them are probably suicide. And 
the CDC has designated 17 states (we are lobbying for funds for 
all 50 states) be trained to assess and record all violent 
deaths and acts of unexplained injury, including suicide 
attempts that occur in these states. The system is called the 
National Violent Death Reporting System (NVDRS). In most states 
this includes toxicology tests on the deceased. Such a system 
would greatly benefit Native American tribes. It would help to 
de-mystify the event, reduce stigma and call attention to the 
problem, both for individuals, families and caretakers 
responsible for them. The collaboration between Johns Hopkins 
and the White Mountain Apache Tribe is an example of how it can 
be done.
    When I was young, some people thought cancer was contagious 
and avoided anyone with the diagnosis. As it became clear this 
life threatening medical illness was not contagious and 
registries were developed to help identify the problem and test 
newly developed treatments, the myths about the illness ended. 
We must do the same for the brain disorders that lead to 
suicide.
                                ------                                


   Response to Written Questions Submitted by Hon. John Barrasso to 
                         Paula J. Clayton, M.D.

    Question 1. Your written testimony suggests that young 
people who do not respond to initial treatment for mental 
health issues need to be referred to mental health and 
substance abuse specialists.
    How would reach those young people who are referred to 
these specialists but refuse to go?
    Answer. In all communities, non-compliance with 
recommendations regarding mental health treatment is an issue. 
Our experience is that young people are more likely to be 
willing to get treatment for depression, substance abuse and 
other mental disorders when they understand them to be medical 
problems rather than character disorders, and are supported to 
seek help by their peers and by respected adults in their 
community. Thus, broad educational efforts, aimed at changing 
attitudes as well as providing scientifically-grounded 
information, are necessary in the effort to increase the 
willingness to get specialized treatment for mental health 
problems. Linking distressed youth to caring adults in the 
community can also be an effective way of cultivating support 
for help-seeking for mental health problems.
    Compliance with recommendations from a primary care 
provider to seek specialized treatment is also furthered when 
treatments for physical and mental disorders are provided under 
the same roof, thus facilitating patients' access to services 
and communications among care providers, and reducing the shame 
associated with seeking psychiatric treatment.
    Anonymous online screening tools, such as AFSP's 
Interactive Screening Program, are also useful in engaging 
reluctant young patients to seek mental health treatment. Our 
evaluation data show that for many such youth, anonymous online 
conversations with a local counselor were effective in 
addressing and resolving negative attitudes about treatment, 
fears of being stigmatized and other factors that pose barriers 
to help-seeking.

    Question 2. The Committee has received testimony 
recommending more youth shelters, in particular, as places for 
young people to go when their lives at home become toxic. 
According to the testimony, for some youth, if they had had a 
place to go for the night, they would not have made a suicide 
attempt.
    Do you have any other recommendations, such as ways in 
which to engage parents or other family members, so that Indian 
children feel secure in their homes?
    Answer. Although I know little about youth shelters, the 
idea of creating them sounds solid. Here again, however, it 
would take a tribal commitment to make the use of them 
acceptable to the teens in the community. Since shame is always 
a problem, they would have to be presented as a wise choice for 
the teens that need help. Again, if there were suicide 
surveillance, it would be possible to learn whether more 
suicide attempts occur on weekends and then perhaps begin by 
making it available and acceptable first on weekends. Maybe the 
tribe could even encourage non-distressed youth to be present 
during the early months after it opened. Of course, there would 
also have to be appropriate physical and mental health 
assistance for those who come in, or at least the same familiar 
and wise counselor.
                                ------                                


     Response to Written Questions Submitted by Hon. Al Franken to 
                         Paula J. Clayton, M.D.

    Question 1. I learned a sobering statistic recently--a 
study of American Indian teens in Minnesota found that more 
than one-quarter believed they had only a 50 percent chance of 
living to age 35, compared to 10 percent of white teens. This 
statistic seems to show how difficult life is overall for these 
teens.
    Dr. Clayton, can you please discuss the role of poverty in 
the youth suicide problem?
    Answer. As you know, poverty contributes to access to 
health care, quality of health care, quality of education, and 
unemployment. All of those may shorten life span so if young 
people live in poverty, their assessment of the future may not 
be unfounded. The most important factors that can change that 
future for youth who are born into poverty are a first-rate 
education and access to first-rate health care. This must 
include mental health care. But as AA informs, in addition, the 
individual must also take responsibility for themselves and 
admit he or she needs help. In the case of teens, it is the 
family, the community, or an appropriate substitute for the 
family that needs to make that decision. Certainly, 
surveillance that includes the school teachers, police force 
and designated adults would also provide a valuable network to 
engage these teens in treatment.
    The American Foundation for Suicide Prevention (AFSP) would 
like to thank each of you, as well as all members the Senate 
Committee on Indian Affairs for your interest and leadership on 
suicide prevention in Indian Country. Our entire AFSP team at 
our national headquarters in New York City, in our Washington 
DC public policy office and all of our Chapters throughout this 
great nation pledge our support to do whatever we can to assist 
you and our tribal communities to prevent suicide through 
education, research and treatment.
                                ------                                


  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                              Hunter Genia

    Question 1. In your written testimony you discussed the 
Tribe's mental health program in great detail and the extensive 
behavioral health programming available through the Tribe. When 
did the Tribe begin supplementing the mental health program 
with tribal funds? Do you still find that more mental health 
resources are needed in your community?
    Please describe the activities specific to youth suicide 
prevention that are ongoing on the Reservation.
    Answer. The Saginaw Chippewa Indian Tribe was supplementing 
the mental health program since at least the year 2000 if not 
longer. I began working for the Saginaw Chippewa Indian Tribe 
in the year 2000.
    More mental health resources are certainly needed in the 
way of prevention and residential services for our young 
people. Our Behavioral Health program provides an expansive 
amount of resources and outreach to our community that could be 
deemed youth suicide prevention. This occurs on the prevention, 
intervention, and treatment levels in our program. There is 
also a saying in Indian Country, ``Culture is Prevention'' we 
believe that to be true as well here on our reservation. Having 
pride and self esteem is also in direct correlation with a 
strong healthy cultural identity. An emphasis on prevention and 
mental health occurs year around with a tremendous amount of 
community activities. The Saginaw Chippewa Indian Tribe has 
made a commitment to doing what we can for our community 
members. However, there are still too many health issues to 
address without proper funding.

    Question 2. What is the biggest contributing factor to the 
high need for mental health services and how can it be 
prevented in the future?
    Answer. I believe we haven't recovered as an Indian 
community or tribe from some of the policies and practices that 
have contributed to the traditional values and roles that 
governed our families and tribes. We are talking one to two 
generations removed from our families who attended the boarding 
schools that assisted in stripping away our traditional 
practices, languages and families. As a race of people who have 
had to adapt to another cultures values, this created a 
hardship for many families and communities where it tore apart 
intact tribal communities and systems. What replaced these 
cultural and traditional rich values were unhealthy behaviors 
that turned into alcoholism, depression, trauma, violence, 
helplessness, and hopelessness. These are the same health 
issues we are still dealing with today.
    Our biggest challenge in recruiting mental health care 
providers is the low number of Native Americans in the field of 
social work and counseling. With 50% of the total US Native 
American population being adults only a small percentage move 
onto seek a higher degree education. A small percentage of that 
are going into the social work and counseling fields. We are 
very fortunate that we have a small turnover of mental health 
providers for our tribal program. This can be attributed to the 
tribe's generosity and care towards the workers health and 
wellness.

    Question 3. What resources would a tribe need to develop a 
Youth Treatment Center in their community?
    Answer. We do not operate a youth treatment center. We do 
have an adult residential substance abuse treatment program. A 
youth treatment center is an idea the tribe is looking at 
providing as well. If we were to operate a youth treatment 
center I believe we can model after the traditional Native 
American (Ojibway, Ottawa, and Potawatomi) values of the Seven 
Grandfather Teachings. These seven teachings promote love, 
respect, honesty, bravery, courage, humility, and truth. We 
would surround the youth with these teachings and provide 
activities that promote the Medicine Wheel which reinforces the 
development of positive physical, emotional, mental, and 
spirituality of an individuals being.
    Funding for staffing and an appropriate facility would be 
instrumental to making a youth treatment center a reality. 
Health leadership internally within the tribe is also very 
important. A shared and supported vision within the tribal 
leadership is very important. The latitude, respect, and 
recognition of modalities and cultural processes that promote a 
healthy cultural self esteem and identity are desired is needed 
from funding administrators and grantors. The access to 
recovery (ATR) grant, which is a SAMSHA grant, is a great 
example of recognition of cultural processes that are valued 
within a grant process.

    Question 4. What can we do for American Indian you to 
prevent mental health and substance abuse issues before they 
begin?
    Answer. I believe in short that healing and wellness is 
needed in every tribal community. Universal truths within 
tribal communities means that trauma, substance abuse, mental 
health, domestic violence, sexual assault, and many more health 
disparities are so elevated in most tribal communities. 
Community member participation is needed in order to be able to 
identify risk and protective factors. Native Community wellness 
initiatives such as Gathering of Native Americans (GONA) should 
occur on every reservation in order to scratch the surface of 
issues in a fun, friendly, safe, and culturally sensitive 
manner. This would be followed by a strategic planning on a 
grass roots community level that community members would need 
to buy into and follow through with action steps. Resources on 
a federal level need to cut back on the red tape for acquiring 
such resources and make them accessible for tribes. The healing 
of tribes needs to come from within each tribe. Assistance from 
outside the tribes can occur on a complimentary level but the 
control, pace, and solutions need to be identified with the 
tribal community members at the table. Native American tribes 
need to be at the helm of solutions and allow us to control our 
own destiny.
                                ------                                


  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                            Novalene Goklish



   Response to Written Questions Submitted by Hon. John Barrasso to 
                            Novalene Goklish


     Response to Written Questions Submitted by Hon. Al Franken to 
                            Novalene Goklish