Richard T. McKeon Ph.D.
Lead Public Health Advisor
Suicide Prevention Team
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services (HHS)
H.O.P.E. for the Future: Helping Our People Engage to Protect Our Youth
Committee on Indian Affairs
United States Senate
Saturday October 22, 2011
Chairman Akaka, Ranking Member Barrasso and Senator Murkowski, thank you for inviting me to testify at this important hearing on protecting Alaska Native (AN) youth. I am Dr. Richard McKeon and I serve as the lead Public Health Advisor on suicide prevention at the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). The problem of suicide among the American Indian (AI) and AN population is a shared concern and efforts to reduce suicide and suicide attempts among AI/AN youth must be a shared effort. The shared effort includes ensuring linkages between behavioral and physical health, education, social services, parents, siblings, community leaders and many others.
SAMHSA has played an integral role in the nation’s efforts to reduce suicide among the AN community. Today, I will share with you some of the efforts SAMHSA is undertaking to reduce suicide and suicide attempts in the AI/AN population both through SAMHSA-led programs, as well as work we conduct in conjunction with other Federal, State, and tribal partners. As you know all too well, the rate of suicide among AI/AN individuals is higher than the national average. In 2008, suicide was the second leading cause of death for AI/AN youth aged 10 – 24 with rates of suicide significantly higher for AI/AN youth aged 15 - 24 ( 22.95 per 100,000) than for the national average (10.01 per 100,000) (CDC, 2011.) Injuries and violence account for 75% of all deaths among Native Americans ages 1 to 19 (Wallace, 2000). Overall, according to unpublished Indian Health Service (IHS) data, suicide mortality is 73% greater in AI/AN populations in IHS service areas compared to the general U.S. population.
SAMHSA’s number one strategic initiative is Prevention of Substance Abuse and Mental Illness. Included in this initiative is the prevention of suicide and suicide attempts. The prevention of suicide is a public health issue and necessitates a public health approach that works at the primary, secondary and tertiary levels. In line with SAMHSA’s Prevention strategic initiative, the Administration is addressing AI/AN youth suicide through a range of efforts including: the National Action Alliance for Suicide Prevention; a proposed Tribal Behavioral Health formula grant program; grants to tribes through the Garrett Lee Smith Memorial Act (GLSMA) youth suicide prevention program; implementation of the Indian Health Care Improvement Act; the Native Aspirations program; technical assistance by the Suicide Prevention Resource Center (SPRC); 24/7 crisis support through the National Suicide Prevention Lifeline; the recently signed Memorandum of Agreement between HHS (with SAMHSA as the lead coordinating agency), the Department of Justice (DoJ) and the Department of the Interior (DoI) as required by the Tribal Law and Order Act; and inclusion of a request that States engage in tribal consultation as part of their plans submitted in conjunction with the new Uniform Mental Health and Substance Abuse Block Grant Application.
Alaska Area Action Summit for Suicide Prevention
The Alaska Area Action Summit for Suicide Prevention, which will be held October 25-27 in Anchorage, is the second Summit to be supported by SAMHSA, DoI’s Bureau of Indian Affairs and Bureau of Indian Education, and the Indian Health Service in calendar year 2011. The first Summit was held in Phoenix, AZ , August 2-4, 2011 and was national in scope with participation from Indian Country. The planning for these two Summits stemmed from information gathered at10 regional listening sessions held November 2010 through February 2011. The Alaska Area Action Summit for Suicide Prevention will offer Alaska Natives the same type of high caliber workshops and presentations as the lower 48 Summit. The events are free and open to tribal leaders, tribal service providers, school personnel, law enforcement and all others committed to addressing suicide and substance abuse issues. Both Summits support the work of the National Action Alliance for Suicide Prevention AI/AN task force.
National Action Alliance for Suicide Prevention
On September 10, 2010, the National Action Alliance for Suicide Prevention (NAASP) was launched by the U.S. Department of Health and Human Services Secretary, Kathleen Sebelius, and former Defense Secretary, Robert Gates. The NAASP has a private sector Co-Chair, former U.S. Senator Gordon Smith (R-OR), and a public sector Co-Chair, Army Secretary John McHugh. Members of the NAASP include, but are not limited to, the Surgeon General, Regina Benjamin; the SAMHSA Administrator, Pamela Hyde; Department of Interior Assistant Secretary of Indian Affairs, Larry Echo Hawk; HHS Assistant Secretary for Health, Dr. Howard Koh; and National Indian Youth Leadership Project Executive Director, McClellan Hall. In addition, the IHS Director, Dr. Yvette Roubideaux, serves as an ex officio Member of the NAASP. Mr. Echo Hawk, Mr. Hall and Dr. Roubideaux serve as the leaders of the NAASP AI/AN Task Force which will establish specific priorities for Tribal youth regarding suicide prevention, intervention, and postvention strategies, including positive youth development. The Task Force also helped develop the agenda and strategy for the Alaska Suicide Prevention Summit for AI/AN communities, leaders, service providers, educators, and law enforcement.
Garrett Lee Smith Grants
Since passage of the GLSMA (P.L. 108-355) in 2004, 19 tribes have received multi-year grants to address suicide prevention among tribal youth, with 22 additional tribal grants to start this year. This number represents 39% of the total State and Tribal Youth Suicide Prevention Grants authorized by the GLSMA. These grants have provided the tribes funding to help implement a tribe-wide suicide prevention network. The first tribal grantee was the Native American Rehabilitation Association in Oregon, which was one of three GLSMA grantees in the first cohort to be awarded additional evaluation funding. They will use the funding to enhance their evaluations to maximize what could be learned from their important suicide prevention activities.
In September, HHS Secretary Kathleen Sebelius announced $52.9 million in new grant awards for FY 2011 to States and tribes for youth suicide prevention programs during a visit to Tanana Chiefs Conference in Fairbanks, Alaska. The grants support State and tribal efforts to prevent suicide by bringing together public and private sector organizations that touch the lives of young people and putting into place a network of services that can help in a time of crisis. Fiscal Year 2011 Alaskan grantees include: $480,000 to Kawerak, Inc in Nome, Alaska; $480,000 to Tanana Chiefs Conference in Fairbanks, Alaska; $480,000 to Southeast Alaska Regional Health Consortium in Juneau, Alaska; and $469,916 to Bristol Bay Area Health Corporation in Dillingham, Alaska.
SAMHSA also awarded $6.2 million in FY 2011 grants to 21 colleges and universities to assist in their efforts to prevent suicide and enhance mental health services for students in crisis. The grants are designed to enhance services for students with mental and behavioral health problems, such as depression and substance abuse, which may put them at risk for suicide and suicide attempts. Funds will be used by the grantee to develop training programs for students and campus personnel, create on-campus networks, conduct educational seminars, prepare and distribute educational materials and promote the National Suicide Prevention lifeline. In addition, 5 GLSMA grants were awarded through the Affordable Care Act’s (ACA) Prevention Fund. The University of Alaska was awarded $306,000 through the Prevention Fund for a fully funded three year grant.
One of the Nation’s most innovative systems for intervening with youth at risk for suicide, the White Mountain Apache's suicide prevention program (funded by SAMHSA through the GLSMA grant program), includes the evaluation of two culturally adapted interventions that target youth who have attempted suicide. These interventions are linked to a unique tribally mandated suicide surveillance system that identifies youth who have exhibited suicidal behavior. The interventions focus on in-home follow-up with youth who have attempted or thought of attempting suicide and were treated and discharged from emergency departments. The first intervention, New Hope, is an emergency department–linked intervention conducted over one to two sessions. The sessions are comprised of a locally produced video and workbook curriculum that develops a safety plan for the youth and problem-solves barriers to their engagement in treatment. The second intervention, Re-Embracing Life, was adapted from the American Indian Life Skills Development Curriculum and consists of nine curricular sessions conducted weekly in home or office settings. The intervention targets problem solving, anger/conflict management, self-destructiveness, emotional regulation, coping, social interactions, and help-seeking behaviors.
Implementation of the Indian Youth Suicide Prevention Provisions of Indian Health Care Improvement Reauthorization and Extension Act of 2009
On March 23, 2010, as part of the ACA, President Obama also signed into law the Indian Health Care Improvement Reauthorization and Extension Act of 2009. Title VII, Subtitle B includes provisions related to Indian Youth Suicide Prevention. SAMHSA is dedicated to undertaking measures to improve the process by which Indian tribes and tribal organizations apply for grants. One such example is that SAMHSA does not require tribal entities applying for agency grants to do so electronically.
In the FY 2011 cohort of GLSMA State/Tribal grantees, 21 of 37, or 57%, grantees are tribes, tribal organizations, or entities that have indicated the grant will be used specifically for AI/AN youth suicide prevention activities. SAMHSA has made significant efforts to take into consideration the needs of Indian tribes or tribal organizations. Furthermore, SAMHSA does not require any Indian tribe or tribal organization to apply through a State or State agency for any of the agency’s grant programs.
Behavioral Health – Tribal Prevention Grants
The President’s FY 2012 Budget for SAMHSA proposed a new grant program titled Behavioral Health – Tribal Prevention Grant (BH-TPG), which is intended to increase SAMHSA’s efficacy in working with tribes and tribal entities. The BH-TPG represents a significant advancement in the Nation’s approach to substance abuse and suicide prevention, based on recognition of behavioral health as a part of overall health. The program would focus on the prevention of alcohol abuse, substance abuse and suicides in the 565 Federally-recognized Tribes. Recognizing the Federal obligation to help Tribes deal with physical and behavioral health issues, SAMHSA would work in consultation with Tribes, establishing a single coordinated mental health and substance abuse program for all Federally-recognized Tribes. SAMHSA also would consult and work closely with Tribes and Tribal leaders to develop a comprehensive, data-driven planning process to identify and address the most serious behavioral health issues in each Tribal community.
Tribes would be allowed to use a set percentage (determined after consultation with Tribes) of the BH-TPG funds for a combination of service and service-related activities, development and dissemination of prevention messages, and provider development and linkage building to support the Tribes in achieving outcomes. Funding for infrastructure activities will enable the Tribe to build service capacity. The Tribe would present data to support how the allocation will support infrastructure and/or provision of services. In carrying out these activities, the Tribe would be required to use comprehensive, evidence-based programming, and/or proven successful programming, based on either mainstream science or proven Tribal traditions. Up to 20 percent of the grant funds could be used to fund key support and development activities, such as operation of a Tribal prevention advisory group, support for a Tribal community coalition, access to an epidemiological work group, training and technical assistance to communities, data collection and evaluation, and oversight and monitoring of activities. The details of the funds distribution would be determined in consultation with Tribes.
SAMHSA appreciates the support that many of this committee’s members have expressed relating to this proposal. However, the Senate FY 2012 Labor, Health and Human Services, Education and Related Agencies appropriations bill did not include funding for this program when it was passed by the full Senate Appropriations Committee in September.
Native Aspirations Program
SAMHSA has funded 49 tribal communities through Native Aspirations (NA), a national project designed to address youth violence, bullying, and suicide prevention through evidence-based interventions and community efforts. NA is unique among SAMHSA suicide prevention programs in that it is based on the concepts and values that reflect the AI/AN community: that solutions to AI/AN youth violence, bullying, and suicide must come from and be embraced by the community; leadership must be involved and invested in the solution; it is up to the community to determine the approaches that would be most effective for them; traditional approaches that are used in non-AI/AN communities in America don’t always work in AI/AN communities; and that the community Elders are crucial to the success of the project.
To date, nearly 200,000 Tribal members in 20 communities and 2,100 Alaska Natives in five villages have been provided specialized technical assistance and support in suicide prevention and related topic areas for these communities. In addition, over 750 community members were trained in prevention and mental health promotion in these communities.
Suicide Prevention Resource Center
SAMHSA funds the Suicide Prevention Resource Center (SPRC), which provides prevention support, training, and resources to assist organizations and individuals to develop suicide prevention programs, interventions and policies, and to advance the National Strategy for Suicide Prevention. SPRC supports the technical assistance and information needs of SAMHSA State/Tribal Youth Suicide Prevention and Campus Suicide Prevention grantees and State, Territorial, and Tribal (STT) suicide prevention coordinators and coalition members with customized assistance and technical resources. SPRC has two senior tribal prevention specialists available to provide technical assistance to those seeking information, evidence-based programs and awareness tools specifically geared for suicide prevention among AI/AN individual. Included on SPRC’s Web page dedicated to AI/AN suicide prevention is a SAMHSA funded guide titled, “To Live To See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults.” In addition, SPRC recently released a fact sheet titled “Suicide Among Racial/Ethnic Populations in the U.S.: American Indians/Alaska Natives.”
National Suicide Prevention Lifeline
The National Suicide Prevention Lifeline (Lifeline) 1-800-273-TALK (8255) is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress. By dialing 1-800-273-TALK, the call is routed to the nearest crisis center in our national network of more than 150 crisis centers. The Lifeline’s national network of local crisis centers, provide crisis counseling and mental health referrals day and night.
The Lifeline has a Native American Initiative that includes objectives such as:
- Establishing and maintaining working relationships between crisis center staff and key stakeholders in tribal communities.
- Developing and delivering cultural awareness and sensitivity trainings as per the direction of the designated tribal community for crisis center telephone workers.
- Strengthening the effectiveness of the local Reservation referrals for suicide prevention supports by identifying relevant, available resources in the tribal community.
- Promoting culturally sensitive social media and educational materials in tribal communities, as determined by tribal stakeholders.
Identifying similarities and differences that can inform serving Native American communities on a national level in a culturally and respectful manner.
Tribal Law and Order Act
SAMHSA Administrator Pamela Hyde was pleased to testify before this committee in reference to the agency’s role in implementing the Tribal Law and Order Act of 2010 (TLOA). Through the TLOA, as you are aware, Congress sought to engage new federal partners to build upon previous efforts in addressing alcohol and substance abuse in the AI/AN population. As a result, the Secretary of Health and Human Services, the Secretary of the Interior, and the Attorney General, recently signed a Memorandum of Agreement (MOA) to, among other things:
- Determine the scope of the alcohol and substance abuse problems faced by American Indians and Alaska Natives;
- Identify the resources and programs of each agency that would be relevant to a coordinated effort to combat alcohol and substance abuse among American Indians and Alaska Natives; and
- Coordinate existing agency programs with those established under the Act.
The MOA takes into consideration that suicide may be an outcome of, and has a connection to, substance abuse. To accomplish the above stated goals, SAMHSA sought to establish an Interdepartmental Coordinating Committee (Indian Alcohol and Substance Abuse Committee) to include key agency representation from SAMHSA, IHS, Office of Justice Programs, Office of Tribal Justice, BIA, BIE, and the Department of Education. The Administration on Aging and Administration for Children and Families within HHS are also represented on the IASA Committee. The IASA Committee has created an organizational structure to include workgroups to carry out its work.
Uniform Block Grant Application
On July 26, SAMHSA announced a new application process for its major block grant programs the Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant (MHBG). The change is designed to provide States greater flexibility to allocate resources for substance abuse and mental illness prevention, treatment and recovery services in their communities. One of the key changes to the block grant application is the expectation that States will provide a description of their tribal consultation activities. Specifically, the new application’s planning sections note that States with Federally-recognized tribal governments or tribal lands within their borders will be expected to show evidence of tribal consultation as part of their Block Grant planning processes. However, tribal governments shall not be required to waive sovereign immunity as a condition of receiving Block Grant funds or services.
Included within the MHBG application SAMHSA notes that States should identify strategies for the MHBG that reflect the priorities identified from the needs assessment process. Goals that are focused on emotional health and the prevention of mental illnesses should be consistent with the National Academies – Institute of Medicine report on "Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities." More specifically, they also should include Strategies that implement suicide prevention activities to identify youth at risk of suicide and improve the effectiveness of services and support available to them, including educating frontline workers in emergency, health and other social services settings about mental health and suicide prevention. Finally, the uniform application requests that States attach to the Block Grant application the most recent copy of the State’s suicide prevention plan. It notes that if the State does not have a suicide prevention plan or if it has not been updated in the past 3 years, the State should describe when it will create or update its plan.
Thank you again for this opportunity to share with you the extensive efforts SAMHSA is undertaking with respect to AI/AN youth suicide prevention specifically, as well as other efforts relating to tribal behavioral health issues. I would be pleased to answer any questions that you may have.
Last revised: December 20, 2011