American Indian and Alaska Native
Best Practices in Behavioral Health
IHS/SAMHSA National Behavioral Health Conference
Billings, Montana, August 22, 2008
Paulette Running Wolf, PhD, (Blackfeet)
Secretary Treasurer
Founding Executive Director
First Nations Behavioral Health Association (FNBHA)
Recent Meeting
• The Center for Mental Health Services (CMHS), SAMHSA, and
FNBHA sponsored an expert panel meeting, May 3-4, 2008, in
Portland Oregon.
• The panel included American Indian/Alaska Native
researchers, providers, and family advocates
• Discussions included rural reservation, urban Indian, and
Alaska Native perspectives
• Recommendations from the meeting are to be disseminated
in several venues
Purpose of the meeting
• CMHS seeks to reduce disparities in the
behavioral health system of care available to
American Indian and Alaska Native (AI/AN)
communities by:
• increasing knowledge about mental health
issues among AI/AN communities and,
• increasing the effectiveness of those services
by reducing cultural barriers
Expert Panel Meeting Agenda
• To identify culture based engagement
• Barrier reduction
• Service utilization
• Service arrays
• Sustainability partnerships
• Implementation strategies for dissemination
of tribal behavioral health best practices,
including website updates.
Expert Panel Participants
• Shannon Crossbear,
• Holly Echohawk,
• Jill Shepard Erickson,
• Joseph P. Gone,
(Gros Ventre)
• Jeff King,
(Muscogee Creek)
• Jackie Mercer,
• Deb Painte, (Arikira)
• Alan Rabideau, (Ojibwe)
• Catherine Reimer,
• Paulette Running Wolf,
• Pam Thurman,
Participants set the stage by
personalizing the need:
• The system can be disrespectful to families
(e.g., black-out period on entering treatment)
• Some tribes are still recapturing traditions to
increase self esteem and positive identity.
• Ceremonies can teach self discipline to
• There is no consistent standard for suicide
Personalized need continued
• Storytelling and participation in crafts can be
important to establishing trust with families, as
opposed to 50 minute office visits.
• Cultural identity also involves identification with the
land and subsistence activities, i.e., fish camps in
• Indian Country has potentially explosive issues
around blood quantum, “color”, and levels of
• The Medicaid billing code for targeted case
management supports home based wraparound,
and is consistent with tribal values.
Personalized need continued
• CMHS funded Circles of Care and Systems of Care
(SOC) grants with tribes have revealed a common
value that children are sacred.
• Urban Indian youth may hide their cultural identity for
safety if surrounded by a gang culture.
• Tribal sovereignty must be a recognized component
for all research initiatives.
• Current epidemic rates of suicide in Indian Country
have promoted federal (CMHS/SAMHSA) recognition
& support for the integration of culture based
traditional healing practices with western treatment.
Joseph Gone, PhD,
• Title: Mental Health Services for Native Americans in
the 21st Century United States, 2004, (Journal:
“Professional Psychology: Research & Practice”)
• Legal, political and institutional contexts for mental
health services for tribal people and their
communities, and
• The possibility for neo-colonial subversion of
indigenous thought and practice.
• “Are we only dressing up conventional therapy in
beads and feathers?”
Dr. Gone Continued
• There are currently two divergent movements in the field
emphasizing evidence based practices (EBP) and culturally
specific treatments (CST).
• At worst, mainstream treatment may assimilate you into a
quasi-healthy “white person”.
• Establishing an EBP requires randomized clinical trials,
difficult in small population/culturally diverse tribal
• The Native American Research Centers for Health (NARCH)
are health research grants co-sponsored by IHS and NIH.
• Native community psychology involves ethno-psychological
analysis, attention to narrative, and facilitation of
• Mainstream psychology involves talk therapy,
putting feelings into words
• Tribal ceremonies often do not emphasize
verbal self-expression, and there are ethical
issues around taking ceremonies and using
them elsewhere.
• Rigorous studies of medicine men and their
practices may not be possible, but
communities have their own way of
Discussion Continued
• Panelists stated that it is not so much the
actual practice but the healing and
community support.
• The unique goal of tribal behavioral health
services is to preserve the essence of cultural
strengths while strengthening the tribal
person’s ability to respond to changing
external factors.
Evidence Based Practices and Tribal
• SAMHSA maintains a National Registry of
Evidence-Based Programs and Practices,
(NREPP) to treat substance abuse or mental
health disorders, with 3 minimum
– One or more positive outcomes
– Published in a peer reviewed journal
– Documentation of the intervention and
implementation in manuals, tool kits, etc.
Priority Points for NREPP approval:
• Primary targeted outcome fits SAMHSA’s
current priority areas.
• Evaluated using a quasi-experimental or
experimental study design:
– Pre/post design with comparison or control
group, or
– Longitudinal/time series design with three preintervention or baseline measures and three postintervention or follow up measures
Two tribal programs in NREPP
• American Indian Life Skills Development, Zuni Pueblo,
New Mexico. A school based suicide prevention
initiative designed by Teresa
LaFromboise, Ph.D., (Miami).
• Project Venture, an outdoor experiential youth
development program originated in the Navajo
Nation by McClellan Hall, M.Ed., (Cherokee)
• Both programs have been replicated widely in tribal
and other settings.
• Panelists indicated that the fidelity measures
required for EBP administration often prohibit
cultural adaptations.
• The historical trauma issues often vocalized
by tribal communities refers to forced
assimilation from generations of boarding
school experiences outlawing indigenous
languages, and culture which followed the
years of warfare and moves to reservations,
often manifested in violent behaviors today.
EBP Discussion
• Panelists agreed that culture can not just be added
to EBP’s, and that treatment as usual harbors the
potential to hurt, not help tribal communities.
• Traditional practices vary widely, are specific to tribal
cultures, and would be devalued if subjected to
evaluation, measurement, and used by persons of a
different culture. (Some pan-Indian ceremonies have
been replicated and exploited by non-Indian
Practice Based Evidence (PBE)
• Community accepted healing approaches
• Evaluation of the PBE & “certification” of the
provider is provided by the community!
• Western-based mental health practices must
be integrated into the culture (PBE) rather than
the reverse (adding culture to the EBP).
Modern cultural issues
• Youth gang cultures, pop culture, and technology/You Tube/My
Space etc.
• Social issues resulting from casino’s & gaming
• FAS/FAE youth with impulse control & legal issues
• Dramatic increase & misuse of prescription drugs
• New populations of veterans with potential for PTSD impacting
family relationships
• Racism and violence a reality in rural reservation communities
Barrier reduction strategies
• Workforce training, of tribal members with
expertise in both mental health and cultural
nuances specific to the community, involving tribal
colleges and universities.
• Expand and support community-based counselor
training programs (e.g., UAF’s Village Based
Counselor training program).
• Scheduled clinical supervision and cultural
consultation agreements between
paraprofessional and licensed staff, possibly with
telemedicine for remote locations.
Barrier reduction strategies (continued):
• Honor family choice for support system, spiritual,
extended family, tribal, IHS, or mainstream
programs and churches for increased anonymity.
• Staff training to emphasize strength-based
assessments & treatment planning & inclusion of
cultural supports.
• Multidisciplinary family led treatment planning,
with strict HIPPA compliance.
Culture-Based Engagement Strategies:
• Consultation on the local protocols for approaching
elders for cultural and spiritual advice
• Due to boarding schools and relocation policies, urban
families and some reservation families may be relearning and building cultural identity and practices.
• Circles of Care grantees redefined Serious Emotional
Disturbance (SED), to a local definition of a well child,
based on tribal values.
• Lakota and Athabascan assessment scales have been
developed during System of Care (SOC) projects.
Culture-based Engagement Strategies (cont.):
• Urban programs & some acculturated tribal communities
are recreating traditional ceremonies & practices helping youth & families to learn tribal history, language
& culture.
• Re-introduce tribal rites of passage ceremonies to reduce
teen pregnancies and support sobriety.
• 12 Step programs encourage spiritual education &
• Equine therapy fits well with tribal culture.
• Many tribes are using their own resources for cultural
immersion programs, i.e., fish camps in Alaska
FNBHA: Mission
First Nations Behavioral Health Association
(FNBHA) was established in September 2003
to provide an organization for Native
Americans to advocate for the mental well
being of Native Peoples by increasing the
knowledge and awareness of issues impacting
Native mental health
Objectives of FNBHA
• To promote and support development of policies, programs, and
initiatives that educate and address the needs of tribal consumers,
families, communities, and service providers,
• To promote and support research for improving American Indian and
Alaska Native behavioral health services,
• To promote and support quality, comprehensive and effective services for
tribal communities,
• To provide awareness and input to mental health and substance abuse
commissioners, governors, legislators, Board, communities, consumers
and families regarding system needs, and
• To provide other forms of technical assistance regarding the Association
mission as may be indicated by the Board of Directors and/or
• The purpose of FNBHA is to provide national
leadership to all groups, institutions and individuals
that plan, provide and access Native American
behavioral health services
• Initial funding was provided by the Center for Mental
Health Services, SAMHSA, and Indian Health Service
FNBHA Effective Practices, 2005
• American Indian Life Skills
• Project Venture
• Positive Indian Parenting,
• Community Readiness Scale,
Tri-Ethnic Center
• Gathering of Nations (GONA)
• Nanizhoozhi Center, Inc.
• Rural Human Service Program,
• Sacred Child Program,
(SOC, ND tribes)
• Sault Ste. Marie Tribe,
(SOC program)
• Wakanyeja Pawicayapi, Inc,
(SOC program, Oglala Sioux
Past Initiatives of FNBHA
• 2003: Foundational “Think Tank”, 32 providers,
researchers, students, family representatives,
representatives of IHS and SAMHSA.
• 2005: Joint meeting with National Alliance of MultiEthnic Behavioral Health Associations, to identify
culturally respectful practices.
• www.fnbha website established.
• 2006: Subcontract with Suicide Prevention Research
Current Board of Directors
• President: Jeff King, PhD,
(Muscogee Creek)
• Vice President: Pam Thurman,
PhD, (Cherokee)
• Secretary Treasurer and Founding
Executive Director:: Paulette
Running Wolf, PhD, (Blackfeet)
• Public Information Officer: Holly
Echohawk, MS, (Pawnee)
• Family Representative: Shannon
Cross Bear (Ojibwe)
• Founding President: Dale Walker,
MD, (Cherokee)
• Dolores Subia Bigfoot, PhD,
• Candace Fleming, PhD,
• Joseph P. Gone, PhD, (Gros
• Ethleen Iron Cloud-Two Dogs,
MS, (Oglala Lakota)
• Carolyn Thomas Morris, PhD,
• Deborah Painte, MPA, (Arikira
• Alan Rabideau, (Ojibwe)
• Catherine Swan Reimer, EdD,
• Warren Skye Jr., MSW, (Seneca)
• Executive Director: Jill Shepard Erickson,
MSW, (Dakota/Athabascan)
• PO Box 55127
• Portland, OR 97238
• 503-953-0237

First Nations Behavioral Health Association