News

The following article was written by and from the perspective of Northern Public Affairs contributors.

International circumpolar policy leaders are now paying attention to Indigenous youth suicide. In a recent report by the Arctic Council’s Sustainable Development Working Group (2015), they note the global burden of suicide, and write:

“Nowhere, however, does suicide have such an impact and social burden as among indigenous populations, particularly those in circumpolar regions. Historically, Indigenous Peoples in circumpolar regions had very low rates of suicide deaths. Unfortunately, suicide rates in the Arctic are currently among the highest in the world. Youth are especially at risk.”

The high rates of Indigenous youth suicide coincide with the rapid, imposed social changes, forced settlement, rapid modernization and national policies of cultural assimilation of the past several decades (Allen, et., al., 2011; Fraser, et al., 2015; Hicks, 2007; Kral, 2012; Kvernmo & Heyerdahl, 2003). Now, Indigenous youth suicide is an all-too-common tragedy disproportionately impacting Indigenous communities across the Arctic (Ragnhild Broderstad, et al., 2011; Oliver, et al., 2012).

Although this picture is grim, Indigenous communities are responding in innovative and impactful ways. In Northwest Alaska, from 1990 to 2000, Iñupiat young people—aged 15 to 19—had a suicide rate of 185 per 100,000 (10-year average for 1990 thru 2000), significantly higher than the rate for the United States as a whole of 10.7 per 100,000 (Wexler, Hill, Bertone-Johnson, & Fenaughty, 2008). After the tribal health organization, school district, for-profit Tribal Corporation and others initiated and sustained a variety of community-based, self-determined programs and activities focused on young people, recent statewide data shows a significant drop in youth suicides in the last five years. Although the link between these programs and reduced rates of suicide is only correlational, this article briefly highlights several initiatives informed by research and led by local, predominantly tribal institutions to address suicide in Northwest Alaska over the past decade. Northern Public Affairs believes that these programs are contributing to the reduced suicide rates we now see in the region. This reduction in suicide rates is promising, and is conceptually linked by other studies documenting similarly hopeful trends after sustained and multi-level suicide prevention efforts (May, et.al., 2005). The marked drop in youth suicide rates in Northwest Alaska corresponds with these various prevention efforts, and is not found in other, similar regions, which strengthens this belief. We hope this catalogue of activities will inspire other communities to take self-determined, strategic actions to prevent and reduce suicide.

Context

Located mostly north of the Arctic Circle, Northwest Alaska has approximately 40,000 square miles of tundra, mountains, and two main inland rivers: Noatak and Kobuk (see Figure 1). There are 11 communities with no roads connecting them, accessible by small commuter aircraft year-round, by boat in the summer months, and snow machine for 7 to 8 months of the year. The regional hub community, Kotzebue, is home to about 3,000 people, over 70% of whom are Alaska Native (State of Alaska, 2010). The outlying small villages range in population from 90 to 1000, with over 95% of the people living in these communities being Iñupiat. Alaska has a unique tribal political structure compared to other Indigenous peoples in North America. Alaska’s tribal health services have a comparatively sovereign structure, which operate under compact agreements with the U.S. federal Indian Health Service in order to provide self-determined, tribally-governed services to their beneficiaries (Warne & Frizzell, 2014).

Wellness and suicide prevention

Community-based and clinical initiatives focused on wellness, resilience and suicide prevention have been sustained in Northwest Alaska since 1999. We describe some of these recent efforts below, emphasizing two important considerations. First, local community members sought out, developed and championed these efforts, often using available resources such as research, clinical protocols, and/or community infrastructure to make them work. These endeavours reflect local sensibilities, community strengths and traditional culture, and underscore self-determination in conceptualizing and implementing community wellness initiatives. The second important element in these programs and events is that they are informed by research and engage many people and various sectors of the community in doing different levels of prevention work. In reflecting on these efforts, we believe these two aspects – local control and multiple institutional, family and individual involvements – are paramount to sustainable and effective suicide prevention in Arctic Indigenous communities.

Multiple efforts within the region and communities

Maniilaq Association, the tribal health and social service nonprofit organization serving Northwest Alaska, initiated a variety of the wellness and suicide prevention efforts occurring in the region over the last two decades. The organization developed the first-recorded tribal suicide surveillance system in an Indigenous region, starting in 1990 (Wexler, et al., 2008). This system documents suicidal behaviour and correlates, and has shaped targeted, clinical interventions, as well as sparked community programming (Hill, et al., 2007; Hagan, et al., 2007; Wexler & Graves, 2008). Supported by the federal Substance Abuse and Mental Health Administration (SAMHSA), the Indian Health Service (IHS) and the Department of Justice (DOJ) over the years, this programming includes media campaigns promoting culturally-specific messages about the importance of life, family, responsibility to tribe, and young people as valuable community members, as well as the more typical prevention message about the importance of help-seeking (and giving) (Fishbein, et al., 2002; U.S. DHHS, 2001). The universal media campaigns focused on messages of prevention and hope evolved to support a region-wide, annual Walk for Life, where community members create signs or just walk to show solidarity and commitment to wellness, suicide prevention and appreciating life. These events are supported by all of the major regional organizations with growing participation over the years.

Although turnover of health professionals continues to plague Maniilaq Association in ways that are similar to other rural and remote regions, the organization has developed several innovative approaches to suicide prevention through clinical care. Replicating Motto and Bostrom’s (2001) supportive, post-suicide crisis letter-writing campaign, Maniilaq initiated and implemented supportive correspondence between health and wellness staff members and those who attempted suicide from 2007-2010 (Wexler, 2010), and more recently, is developing a process to reach out through text messaging to those who exhibit suicidal behaviour. Maniilaq clinical staff are trained in cultural-specific risks for suicide that are based on the local surveillance system as well as cultural strengths, idioms and practices that clinicians need have in mind.

Local leadership development and self-determination of village communities is a priority in all the wellness activities. Since 2009, village leaders have attended retreats for healing, inspiration and leadership training, and they return to their communities to develop local wellness teams and initiatives. Maniilaq Association’s Wellness Program supports these village-based efforts with resources, which include regular village gatherings, community-wide potlucks, recovery support groups, and subsistence opportunities for people who do not have access to boats, camps or snow machines.

More recently, Maniilaq’s regional efforts support local facilitators who bring together representatives from local, village health, law enforcement, religious, and educational institutions to participate in learning circles to decipher “what we know” from suicide prevention research in order to assess and apply it to their local context. The program, called PC CARES (Promoting Community Conversations About Research to End Suicide), aims to translate research to strategic, locally-determined personal and collective actions for prevention (Wexler, et al., 2016; Wexler, et al., 2017). The “bite-size” research information shared in these learning circles includes findings from local research (Wexler & Goodwin, 2006) as well as general injury prevention information (e.g., lethal means restriction) (Roscoät et al., 2013) (see pc-cares.org) (Wexler, et al., 2016).

In a unique partnership, NANA Native Corporation resource technicians made up the bulk of local facilitator teams, making good on the organization’s commitment to “promoting healthy communities with decisions, actions, and behaviours inspired by our Iñupiat Ilitqusiat values consistent with our core principles.” Preliminary evaluation results from this program show participants gained knowledge and skills and increased their prevention activities on personal and professional levels (Wexler, et al., 2017).

Youth-focused programming through the years includes opportunities for reflection and self-expression through digital storytelling. Maniilaq wellness staff traveled to the 11 villages of the region plus Point Hope to offer week-long digital storytelling workshops for young people. From 2007-2014, youth crafted over 500 digital stories that highlight the multi-faceted reasons for living, cultural expression and pride, and commitment to family (Wexler, et al., 2012; Wexler, Eglinton, Gubrium, 2014). Community-wide screenings feature these digital stories. Through follow-up interviews, we know that young digital storytellers shared their stories with important adults and Elders in their lives, thus strengthening intergenerational support. Such support fosters a sense of mentorship, cultural identity and continuity: all of which are protective factors for suicide (Alcántara & Gone, 2007).

The Northwest Arctic Borough School District has also been involved in suicide prevention through a peer leadership program in the area’s schools. Begun in 2008, the Teck John Baker Youth Leaders Program takes a primary prevention approach to reduce risks of substance abuse and bullying through peer-led education and bystander training. The program also aims to increase protective factors of school attendance and engagement, academic success, and personal and cultural identity development. School personnel, community members and students tend to agree that the program is positive for those involved and for the schools in which youth leaders function. Outcomes from an evaluation of the program suggest increases in protective factors for suicide. More specifically, an evaluation of the program showed that participants believe they matter to others, feel positive about themselves, think they can make a difference in their community and school, and very rarely do drugs and drink alcohol. Additionally, they have higher grades and attendance than their peers. All of these factors are known to protect against suicide (Wexler et al., 2017).

Independent village efforts focused on suicide prevention and wellness include hosting youth conferences that bring together Elders and young people to learn, engage in mentoring and learn leadership skills. One village, Kiana, created a group – Opt-In – which initiated a multi-village event to empower young people to take leadership within their communities (Frost, 2017). Another initiative, sponsored by the Kotzebue Tribal Council, invited young people to initiate inquiry with their Elders to learn about leadership, culture and community (Weinronk, 2017). Also, two villages in the region successfully competed for federal suicide prevention funding to create their own suicide prevention activities, which are in development now.

Several village communities run traditional summer camps for youth each year, and regional camps are offered to younger and older youth. Camp Pigaaq, run by Maniilaq Wellness, is a week-long subsistence camp for young people aged 13-18 typically involving 15 at risk Iñupiat youth from the region. Camp Sivuñiġvik offers four, week-long sessions to young people ages 8-16 from the region. Aqqaluk Trust, a nonprofit foundation aimed at “empowering the Iñupiat through language, culture and education” offers this experience as well as scholarships to Iñupiat young people to go to college.

Change in suicide rates

Due to the complexity of the issue, preventing suicide takes time and multiple kinds of efforts before showing an impact (White, 2012). Although there have been concerted and strategic efforts to prevent suicide in Northwest Alaska as catalogued here, the correlated aimed-for outcomes are just now discernable. This finding offers reason to celebrate. The multifaceted efforts undertaken by Northwest Alaska seem to be having a positive impact on youth suicidal behaviour in the remote and rural, Iñupiat region. This reduction in suicide rates between these two, five-year periods stands out in marked contrast to the suicide rates of other, similar regions.

To illustrate, the State of Alaska Department of Health Analytics and Vital Records compiled age-adjusted rates of suicide per 100,000 from 1995 to 2014 in five-year periods. Northwest Arctic Borough (NAB) showed a significant reduction in suicide rates from 2005-2009 to 2010-2014 based on a 95% confidence interval (See Figure 2). This trend was compared to other rural and remote regions in Alaska with historically similar suicide rates including the Nome Census Area, North Slope Borough, and Yukon-Koyukuk Borough, combined. Our analysis found no significant differences in suicide rates between time points within similar northern regions combined or in the state overall (95% confidence interval).

Alaska Native youth under the age of 25 appears to be driving this reduction in suicides in the Northwest Arctic Borough (See Figure 3), and corresponds with the local and regional efforts outlined above. These findings contribute to a hopeful perspective that Indigenous communities, in partnership with service providers and researchers, can make a significant impact on the seemingly intractable problem of youth suicide. This recent reduction in youth suicides between these timeframes is noteworthy particularly because this age group experiences much higher rates of suicide in Indigenous circumpolar communities (Ragnhild Broderstad, et al., 2011; Oliver, et al., 2012; Lehti, et al., 2009). Continuing to monitor suicide rates will help to determine if ongoing multi-level suicide prevention efforts in Northwest Alaska are able to bring about a lasting and sustained decrease in suicide deaths over time, particularly among Alaska Native youth and young adults who are at highest risk.

Conclusions 

Although suicide is complex and the result of a myriad of structural, historic, social and psychological issues, this regional example offers some reason for hope. Although causal assertions cannot be made, the correlation between this rural region’s reduced suicide rates and their consistent, multilevel programming and self-determined practices is promising. Standing out as a hopeful example, Northwest Alaska has sustained a myriad of evidence-informed and self-determined suicide prevention initiatives for over 10 years, and is now showing a reduction in youth suicide rates. Interestingly, similar multi-level approaches to suicide prevention in Indigenous communities elsewhere have shown decreases in suicidal behaviour (May, et al., 2005). The correlation is promising and can offer other regions a hopeful perspective to spur multi-level and self-determined efforts. We believe other Indigenous communities may find inspiration in this example, and policy makers can find evidence for sustaining support of multiple kinds of community-driven prevention and intervention programming.

Read more on NorthernPublicAffairs.ca.

The following was written by and from the perspective of Dr. Shawn Ginwright, Associate Professor of Education, and African American Studies at San Francisco State University and the author of Hope and Healing in Urban Education: How Activists are Reclaiming Matters of the Heart.

From time to time, researchers, policy makers, philanthropy and practitioners all join together in a coordinated response to the most pressing issues facing America’s youth. I’ve been involved with this process for long enough to have participated in each of these roles. I recall during the early 1990s experts promoted the term “resiliency” which is the capacity to adapt, navigate and bounce back from adverse and challenging life experiences. Researchers and practitioners alike clamored over strategies to build more resilient youth.

The early 2000’s the term “youth development” gained currency and had a significant influence on youth development programming, and probably more importantly how we viewed young people. Youth development offered an important shift in focus from viewing youth as problems to be solved to community assets who simply required supports and opportunities for healthy development. Since that time, a range of approaches have influenced how we think about young people, and consequently our programmatic strategies. I have, for the most part, attempted to nudge and cajole each of these approaches to consider the unique ways in which race, identity and social marginalization influence the development of youth of color.

More recently, practitioners and policy stakeholders have recognized the impact of trauma on learning, and healthy development. In efforts to support young people who experience trauma, the term “trauma informed care” has gained traction among schools, juvenile justice departments, mental health programs and youth development agencies around the country. Trauma informed care broadly refers to a set of principles that guide and direct how we view the impact of severe harm on young people’s mental, physical and emotional health. Trauma informed care encourages support and treatment to the whole person, rather than focus on only treating individual symptoms or specific behaviors.

Trauma-informed care has become an important approach in schools and agencies that serve young people who have been exposed to trauma, and here’s why. Some school leaders believe that the best way to address disruptive classroom behavior is through harsh discipline. These schools believe that discipline alone is sufficient to modify undesired classroom behavior. But research shows that school suspensions may further harm students who have been exposed to a traumatic event or experience (Bottiani et al. 2017). Rather than using discipline, a school that uses a trauma informed approach might offer therapy, or counseling to support the restoration of that student’s well-being. The assumption is that the disruptive behavior is the symptom of a deeper harm, rather than willful defiance, or disrespect.

While trauma informed care offers an important lens to support young people who have been harmed and emotionally injured, it also has its limitations. I first became aware of the limitations of the term “trauma informed care” during a healing circle I was leading with a group of African American young men. All of them had experienced some form of trauma ranging from sexual abuse, violence, homelessness, abandonment or all of the above. During one of our sessions, I explained the impact of stress and trauma on brain development and how trauma can influence emotional health. As I was explaining, one of the young men in the group named Marcus abruptly stopped me and said, “I am more than what happened to me, I’m not just my trauma”. I was puzzled at first, but it didn’t take me long to really contemplate what he was saying.

The term “trauma informed care” didn’t encompass the totality of his experience and focused only on his harm, injury and trauma. For Marcus, the term “trauma informed care” was akin to saying, you are the worst thing that ever happened to you. For me, I realized the term slipped into the murky water of deficit based, rather than asset driven strategies to support young people who have been harmed. Without careful consideration of the terms we use, we can create blind spots in our efforts to support young people.

While the term trauma informed care is important, it is incomplete. First, trauma informed care correctly highlights the specific needs for individual young people who have exposure to trauma. However, current formulations of trauma informed care presumes that the trauma is an individual experience, rather than a collective one. To illustrate this point, researchers have shown that children in high violence neighborhoods all display behavioral and psychological elements of trauma (Sinha & Rosenberg 2013). Similarly, populations that disproportionately suffer from disasters like Hurricane Katrina share a common experience that if viewed individually simply fails to capture how collective harm requires a different approach than an individual one.

Second, trauma informed care requires that we treat trauma in people but provides very little insight into how we might address the root causes of trauma in neighborhoods, families, and schools. If trauma is collectively experienced, this means that we also have to consider the environmental context that caused the harm in the first place. By only treating the individual we only address half of the equation leaving the toxic systems, policies and practices neatly intact.

Third, the term trauma informed care runs the risk of focusing on the treatment of pathology (trauma), rather than fostering the possibility (well-being). This is not an indictment on well-meaning therapists and social workers many of whom may have been trained in theories and techniques designed to simply reduce negative emotions and behavior (Seligman 2011). However, just like the absence of disease doesn’t constitute health, nor the absence of violence constitute peace, the reduction pathology (anxiety, anger, fear, sadness, distrust, triggers) doesn’t constitute well-being (hope, happiness, imagination, aspirations, trust). Everyone wants to be happy, not just have less misery. The emerging field of positive psychology offers insight into the limits of only “treating” symptoms and focuses on enhancing the conditions that contribute to well-being. Without more careful consideration, trauma informed approaches sometimes slip into rigid medical models of care that are steeped in treating the symptoms, rather than strengthening the roots of well-being.

What is needed is an approach that allows practitioners to approach trauma with a fresh lens which promotes a holistic view of healing from traumatic experiences and environments. One approach is called healing centered, as opposed to trauma informed. A healing centered approach is holistic involving culture, spirituality, civic action and collective healing. A healing centered approach views trauma not simply as an individual isolated experience, but rather highlights the ways in which trauma and healing are experienced collectively. The term healing centered engagement expands how we think about responses to trauma and offers more holistic approach to fostering well-being.

The Promise of Healing Centered Engagement

A shift from trauma informed care to healing centered engagement (HCE) is more than a semantic play with words, but rather a tectonic shift in how we view trauma, its causes and its intervention. HCE is strength based, advances a collective view of healing, and re-centers culture as a central feature in well-being. Researchers have pointed out the ways in which patients have redefined the terms used to describe their illnesses in ways that affirmed, humanized and dignified their condition. For example, in the early 1990s AIDS activists challenged the term “gay-related immune deficiency” because the term stigmatized gay men and failed to adequately capture the medical accuracy of the condition. In a similar way, the young men I worked with offered me a way to reframe trauma with language that humanized them, and holistically captured their life experiences.

A healing centered approach to addressing trauma requires a different question that moves beyond “what happened to you” to “what’s right with you” and views those exposed to trauma as agents in the creation of their own well-being rather than victims of traumatic events. Healing centered engagement is akin to the South African term “Ubuntu” meaning that humanness is found through our interdependence, collective engagement and service to others. Additionally, healing centered engagement offers an asset driven approach aimed at the holistic restoration of young peoples’ well-being. The healing centered approach comes from the idea that people are not harmed in a vacuum, and well-being comes from participating in transforming the root causes of the harm within institutions. Healing centered engagement also advances the move to “strengths-based’ care and away from the deficit based mental health models that drives therapeutic interventions. There are four key elements of healing centered engagement that may at times overlap with current trauma informed practices but offers several key distinctions.

• Healing centered engagement is explicitly political, rather than clinical.

Communities, and individuals who experience trauma are agents in restoring their own well-being. This subtle shift suggests that healing from trauma is found in an awareness and actions that address the conditions that created the trauma in the first place. Researchers have found that well-being is a function of control and power young people have in their schools and communities (Morsillo & Prilleltensky 2007; Prilleltensky & Prilleltensky 2006). These studies focus on concepts such as such as liberation, emancipation, oppression, and social justice among activist groups and suggests that building an awareness of justice and inequality, combined with social action such as protests, community organizing, and/or school walk-outs contribute to overall wellbeing, hopefulness, and optimism (Potts 2003; Prilleltensky 2003, 2008). This means that healing centered engagement views trauma and well-being as function of the environments where people live, work and play. When people advocate for policies and opportunities that address causes of trauma, such as lack of access to mental health, these activities contribute to a sense of purpose, power and control over life situations. All of these are ingredients necessary to restore well-being and healing.

• Healing centered engagement is culturally grounded and views healing as the restoration of identity.

The pathway to restoring well-being among young people who experience trauma can be found in culture and identity. Healing centered engagement uses culture as a way to ground young people in a solid sense of meaning, self-perception, and purpose. This process highlights the intersectional nature of identity and highlights the ways in which culture offers a shared experience, community and sense of belonging. Healing is experienced collectively, and is shaped by shared identity such as race, gender, sexual orientation. Healing centered engagement is the result of building a healthy identity, and a sense of belonging. For youth of color, these forms of healing can be rooted in culture and serves as an anchor to connect young people to a shared racial and ethnic identity that is both historical grounded and contemporarily relevant. Healing centered engagement embraces a holistic view of well-being that includes spiritual domains of health. This goes beyond viewing healing only from the lens of mental health, and incorporates culturally grounded rituals, and activities to restore well-being (Martinez 2001). Some examples of healing centered engagement can be found in healing circles rooted in indigenous culture where young people share their stories about healing and learn about their connection to their ancestors and traditions, or drumming circles rooted in African cultural principles.

• Healing centered engagement is asset driven and focuses well-being we want, rather than symptoms we want to suppress.

Healing centered engagement offers an important departure from solely viewing young people through the lens of harm and focuses on asset driven strategies that highlight possibilities for well-being. An asset driven strategy acknowledges that young people are much more than the worst thing that happened to them, and builds upon their experiences, knowledge, skills and curiosity as positive traits to be enhanced. While it is important to acknowledge trauma and its influence on young people’s mental health, healing centered strategies move one step beyond by focusing on what we want to achieve, rather than merely treating emotional and behavioral symptoms of trauma. This is a salutogenic approach focusing on how to foster and sustain well-being. Based in positive psychology, healing centered engagement is based in collective strengths and possibility which offers a departure from conventional psychopathology which focuses on clinical treatment of illness.

• Healing centered engagement supports adult providers with their own healing.

Adult providers need healing too! Healing centered engagement requires that we consider how to support adult providers with sustaining their own healing and well-being. We cannot presume that adulthood is a final “trauma free” destination. Much of our training and practice is directed at young peoples’ healing but rarely focused on the healing that is required of adults to be an effective youth practitioner. Healing is ongoing process that we all need, not just young people who experience trauma. The well-being of the adult youth worker, also is a critical factor in supporting young peoples’ well-being. While we are learning more about the causes and effects of secondary on adults, we know very little about the systems of support required to restore and sustain well-being for adults. Healing centered engagement has an explicit focus on restoring, and sustaining the adults who attempt to heal youth- a healing the healers approach. Policy stakeholders should consider how to build a systems that support adult youth worker’s well-being. I have supported organizations in creating structures like sabbaticals for employees, or creating incentives like continuing education units for deeper learning about well-being and healing.

A Note for Practice and Policy

Marcus’s comments during our healing circle “I am more than what happened to me” left with me with more questions than answers. What blind spots do we have in our approaches to supporting young people who experience trauma? How might the concepts which are enshrined in our language limit rather than create opportunities for healing? What approaches might offer “disruptive” techniques that saturate young people with opportunities for healing and well-being? The fields of positive psychology and community psychology offers important insight into how policy makers, and youth development stakeholders can consider a range of healing centered options for young people. Shifting from trauma informed care or treatment to healing centered engagement requires youth development stakeholders to expand from a treatment based model which views trauma and harm as an isolated experience, to an engagement model which supports collective well-being. Here are a few notes to consider in building healing centered engagement.

• Start by building empathy

Healing centered engagement begins by building empathy with young people who experience trauma. This process takes time, is an ongoing process and sometimes may feel like taking two steps forward, and three steps back. However, building empathy is critical to healing centered engagement. To create this empathy, I encourage adult staff to share their story first, and take an emotional risk by being more vulnerable, honest and open to young people. This process creates an empathy exchange between the adult, and the young people which is the foundation for healing centered engagement (Payne 2013). This process also strengthens emotional literacy which allows youth to discuss the complexity of their feelings. Fostering empathy allows for young people to feel safe sharing their experiences and emotions. The process ultimately restores their sense of well-being because they have the power name and respond to their emotional states.

• Encourage young people to dream and imagine!

An important ingredient in healing centered engagement is the ability to acknowledge the harm and injury, but not be defined by it. Perhaps one of the greatest tools available to us is the ability to see beyond the condition, event or situation that caused the trauma in the first place. Research shows that the ability to dream and imagine is an important factor to foster hopefulness, and optimism which both of which contributes to overall well-being (Snyder et al. 2003). Daily survival and ongoing crisis management in young people’s lives make it difficult to see beyond the present. The greatest casualty of trauma is not only depression and emotional scares, but also the loss of the ability to dream and imagine another way of living. Howard Thurman pointed this out in his eloquent persistence that dreams matter. He commented, “As long as a man [woman] has a dream, he [she] cannot lose the significance of living” (p. 304). By creating activities and opportunities for young people to play, reimagine, design and envision their lives this process strengthens their future goal orientation (Snyder et al. 2003). These are practices of possibility that encourage young people to envision what they want to become, and who they want to be.

• Build critical reflection and take loving action.

Healing and well-being are fundamentally political not clinical. This means that we have to consider the ways in which the policies and practice and political decisions harm young people. Healing in this context also means that young people develop an analysis of these practices and policies that facilitated the trauma in the first place. Without an analysis of these issues, young people often internalize, and blame themselves for lack of confidence. Critical reflection provides a lens by which to filter, examine, and consider analytical and spiritual responses to trauma. By spiritual, I mean the ability to draw upon the power of culture, rituals and faith in order to consistently act from a place of humility, and love. These are not cognitive processes, but rather ethical, moral and emotional aspects of healing centered engagement.

The other key component, is taking loving action, by collectively responding to political decisions and practices that can exacerbate trauma. By taking action, (e.g. school walkouts, organizing peace march, or promoting access to healthy foods) it builds a sense of power and control over their lives. Research has demonstrated that building this sense of power and control among traumatized groups is perhaps one of the most significant features in restoring holistic well-being.

Read more on Medium.com

The following was written by and from the perspective of clinical psychologist Dr. Inger E. Burnett-Zeigler.

Ms. T., 75, came to see me for therapy after a man stole her purse. He was in a car and lured her over under the guise of asking directions. Then he grabbed her bag and stepped on the accelerator. She was dragged halfway down the block before she let go. When I saw her a month later, she was still in physical pain from her injuries and emotional pain from having endured a traumatic experience.

Ms. T. had raised three successful children as a single mother, while enjoying a prosperous career as the head of a social services agency. She had gone through difficult times before, but she’d always been able to overcome them. Now she was embarrassed that she hadn’t been able to “get over” what had happened. She didn’t want to show her adult children her “weakness” and lean on them for support. She believed in therapy, in theory, but was ashamed to be the one who needed it. She no longer saw herself as the “strong black woman” she had once been.

This Strong Black Woman is a cultural icon, born of black women’s resilience in the face of systemic oppression that has dismantled families and made economic stability a formidable challenge. She is self-sufficient and self-sacrificing. She is a provider, caretaker and homemaker. And often, she is suffering.

I provide therapy to people from all socio-economic and racial backgrounds. I am the only black female clinical psychologist on the faculty of the department of psychiatry at Northwestern University, and black women often come to me in secret, feeling alone and embarrassed. They come despite friends and family telling them to “just pray.” They come because they are “desperate” and “can’t take it anymore.” I often get requests for informal consultation via email, LinkedIn, even Facebook. They’re skeptical about mental health treatment. They don’t want therapy, just to talk, and maybe get some advice.

Even in the confidential safe space of therapy, they cling to their public image of strength. They don’t realize that there is a secret community of Strong Black Women who share their distress.

Many — myself included — wear the badge of Strong Black Woman with honor. We are proud of our tenaciousness and never let the world see us crack. But we are suffering silently with the mental and physical health consequences of carrying the burden of family, work and community responsibilities, compounded by personal experiences of trauma and loss, all in an environment of pervasive racial and gender discrimination.

Black women are more likely than white women to have experienced post-traumatic stress disorder resulting from childhood maltreatment and sexual and physical violence. They are more likely to have stress related to family, employment, finances, discrimination or racism and safety concerns associated with living in high crime neighborhoods. Black women are more likely to be depressed and when they are, their symptoms are more severe, last longer and are more likely to interfere with their ability to function at work, school and home. Black women are more likely to have feelings of sadness, hopelessness and worthlessness.

And yet fewer than 50 percent of black adults with mental health needs receive treatment. Shame is a key barrier. Black women also often prefer a black mental health care provider, and there are too few black social workers, psychologists and psychiatrists. In low-income communities, mental health services are scarce and waiting lists are long. And finally, more than 16 percent of black women are uninsured, and many can’t afford treatment.

Meanwhile, the psychological wear and tear of being a Strong Black Woman takes a toll on the mind and body.

Traditionally, black women have garnered strength from God. The church provides a place for fellowship, social support and spiritual guidance. However, the black church has not always condoned secular mental health care and churchgoers may feel that their faith is called into question if they seek extra help.

In lieu of therapy, some people cope with their distress through eating unhealthy foods and overeating, smoking, drinking alcohol and spending excessive time in bed or watching television. While these behaviors may provide temporary relief, stress and depression can emerge in the form of irritability, anger, physical pain and chronic illness.

Stress and depression are closely linked to chronic health conditions such as obesity, diabetes and hypertension — all more prevalent among black women. Their life expectancy is three years shorter than that of white women (81 versus 78 years).

Ms. T. reminded me of my grandmother, who moved to Chicago from Montgomery, Ala., as a single mother to escape an abusive relationship with an alcoholic husband. She lived in the Jane Addams housing projects, worked as a seamstress by day and attended Herzl Junior College at night. She worked her way off public assistance, earned bachelor’s and master’s degrees, and saved enough money to pay for my Ivy League education. She, too, had once been robbed and came home with the straps of her purse as evidence of the struggle. My grandmother was the quintessential Strong Black Woman.

But what about her struggles, her sadness and fear? I’m sure she experienced them. But we never talked about it.

Many of us have been conditioned to believe that we must be strong to survive. But we cannot hold up the strength of black women without acknowledging the stress that comes with it. Otherwise, we set unreasonable expectations for what black women should be able to endure.

There has recently been a shift in this direction. Groups like Black Girl in Om and GirlTrek are raising awareness about the importance of self-care and providing outlets for living a healthy lifestyle.

We must let go of the singular narrative of what it means to be a Strong Black Woman. Black women have harnessed their strength out of the necessity to support themselves and their families when no one else would — and that should be applauded. But there is also strength in vulnerability, comfort in seeing that you are not alone and power in knowing when to ask for help.

Read more on NYTimes.com.

A newly opened center hopes to improve the health of the local Marshallese community, keep the changes going for generations with education and outreach, and share what it learns to help Pacific Islanders everywhere.

The Center for Pacific Islander Health started July 1 at the University of Arkansas for Medical Sciences Northwest. The program is building off research under way at the school, said Pearl McElfish, director of the medical school’s research department and co-director of the center. “The center will allow us to expand the methods and programs we develop in Northwest Arkansas to the rest of the U.S. and the U.S.-affiliated Pacific Islands,” she said.

The center’s scope includes health disparity research, disease prevention and management programs and training for health care providers and community health workers.

Countries include the U.S. trust territories of American Samoa, Guam and the Commonwealth of the Northern Mariana Islands; Federated States of Micronesia, the Republic of the Marshall Islands the the Republic of Palau.

This isn’t the first U.S.-based center to include Pacific Islanders, but it is the first dedicated to that population. Nia Aitaoto, the center’s co-director, said other centers tend to focus on Asians and Native Hawaiians.

She said Northwest Arkansas’ large Marshallese population and the state’s central location will help the center grow. The medical school estimates the Northwest Arkansas Marshallese population is between 10,000 and 14,000 and growing. “Then we had our first trip here, and we had the feeling that it just felt right. In our culture, we plan five generations down,” said Aitaoto, who is Samoan. “When you look at the census of where people are moving, this is the fastest growing.”

Kathy Ko Chin, president and CEO of the Asian & Pacific Islander American Health Forum, said medical care is a big issue. “I think the issue is Pacific Islander is a relatively small population, even aggregated. They often don’t get the kind of attention they well deserve,” she said.

The U.S. Census Bureau estimates 1.4 million residents were Native Hawaiian or other Pacific Islander, either alone or in combination with one or more additional races, in 2013. Native Hawaiians accounted for 560,488 residents, followed by Samoans at 175,589 and Guamanian or Chamorro at 120,706.

Chin said she looks forward to the centers working together.

Medical research

The research department asked what their biggest health concern was when it decided to work with the Marshallese, McElfish said. It discovered between 30 and 50 percent of Northwest Arkansas’ Marshallese residents have Type 2 diabetes, a rate 400 percent higher than the general U.S. population.

The medical school got a $2.1 million grant last year from the Patient-Centered Outcomes Research Institute, a nonprofit organization focused on identifying best health care practices, to study ways to teach diabetes self-management skills in coordination with care provided through the North Street Clinic.

The clinic opened at 1125 College Ave. in November and primarily offers diabetes testing and treatment for Marshallese patients using UAMS faculty and student volunteers.

Research is examining whether a family-based approach is more effective than traditional doctors’ office visits. This includes going into the patients’ homes to teach practices such as healthy cooking.

The research department has a three-year, $2.99 million grant from the federal Centers for Disease Control and Prevention to study health disparities in the Marshallese and Hispanic communities in Benton and Washington counties.

The university also received a $250,000 grant from the Patient-Centered Outcomes Research Institute that will help Pacific Islanders interested in health research connect with experienced researchers. The program will include 20 participants creating 10 teams. Marshallese community members will learn how to recruit and retain study participants, partner with communities and design a study.

The Marshallese also suffer higher rates of Hepatitis B, tuberculosis, leprosy, cancer, heart disease and obesity. Chin said eight of the 10 countries across the globe with the highest obesity rates are in the Pacific. “They have among the highest health disparities in the world,” Chin said of Pacific Islanders.

Radioactive fallout from the U.S. testing nuclear bombs in the Marshall Islands between 1946 and 1962 is blamed for high cancer rates there, but a report by the U.S. Centers for Disease Control and Prevention shows the rate is declining, partly because people directly affected by the fallout are dying.

The report states there is a need for more promotion of effective preventive, therapeutic and palliative care services to improve islanders overall health.

Carmen Chong Gum is the consulate general in Arkansas for the Republic of the Marshall Islands and she said the center will have a broad reach. The consulate office opened in downtown Springdale in 2008.

“We look at all the needs, from head to toe,” she said, such as health, soul and culture. “UAMS is identifying the needs of the community.”

Reaching out

Two more center priorities are educating medical workers nationwide on how to treat and interact with Pacific Islanders and teaching members of the islander communities about research.

It’s important to get the Marshallese community involved in promoting the center, said Dr. Sheldon Riklon. He is the University of Hawaii’s Department of Family Medicine and Community Health clerkship director and a frequent visitor to Arkansas. Riklon is one of two U.S.-trained Marshallese physicians. “The concept of Western research is taboo in the islands,” he said.

Riklon said having Marshallese community members visit their friends and neighbors shows its OK to participate. “It helps break down the barriers,” he said.

Anita Tomeing-Iban has lived in Springdale for 19 years and has diabetes. She said Marshallese people are reserved. “Distrust is part of our nature,” she said.

The idea is to learn best practices, a technique or methodology that through experience and research has proven to lead to the best result. Aitaoto said she worked on Pacific islands for 15 years and best practices there don’t exist such as care for cancer survivors. “We found there are a lot of survivors, but no plan to help them make a better life,” she said.

A group of eight people from the islands are traveling to Northwest Arkansas on Aug. 17 to learn about programs and will develop a plan to use back home for cancer survivors, she said.

The Center for Pacific Islander Health hopes to build on practices in use at the Community Clinic offices. Kathy Grisham, the clinic’s executive director, said its physicians train on working with the Marshallese patients, and she has five Marshallese employees. The nonprofit clinic has nine sites across Benton and Washington counties, including medical and dental clinics and school-based centers. Low-income patients can qualify for a sliding fee scale.

The Community Clinic saw 2,230 Marshallese patients last year, a 30 percent increase from the year before.

“It steadily grows every year, about 12-15 percent every year,” Grisham said. “I don’t think many other community members see a lot of Marshallese patients, but training will be great for our hospital workers,” she said.

Aitaoto said the center will work with people from beyond Arkansas’ borders. “To us, it is a broader plan and a lot of the things we are doing are innovative,” she said. “Programs and research are needed together and our programs are research.”

Read more on ArkansasOnline.com.

Learn About Minority Mental Health Month

“Once my loved ones accepted the diagnosis, healing began for the entire family, but it took too long. It took years. Can’t we, as a nation, begin to speed up that process? We need a national campaign to destigmatize mental illness, especially one targeted toward African Americans…It’s not shameful to have a mental illness. Get treatment. Recovery is possible.”

–Bebe Moore Campbell, 2005

Bebe Moore Campbell National Minority Mental Health Awareness Month

In May of 2008, the US House of Representatives announced July as Bebe Moore Campbell National Minority Mental Health Awareness Month (NMMHAM).

The resolution was sponsored by Rep. Albert Wynn [D-MD] and cosponsored by a large bipartisan group to achieve two goals:

• Improve access to mental health treatment and services and promote public awareness of mental illness.
• Name a month as the Bebe Moore Campbell National Minority Mental Health Awareness Month to enhance public awareness of mental illness and mental illness among minorities.

About Bebe Moore Campbell

Bebe Moore Campbell was an author, advocate, co-founder of NAMI Urban Los Angeles and national spokesperson, who passed away in November 2006.

She received NAMI’s 2003 Outstanding Media Award for Literature. Campbell advocated for mental health education and support among individuals of diverse communities.

In 2005, inspired by Campbell’s charge to end stigma and provide mental health information, longtime friend Linda Wharton-Boyd suggested dedicating a month to the effort. 

The duo got to work, outlining the concept of National Minority Mental Health Awareness Month and what it would entail. With the support of the D.C. Department of Mental Health and then-mayor Anthony Williams, they held a news conference in Southeast D.C., where they encouraged residents to get mental health checkups.

Support continued to build as Campbell and Wharton-Boyd held book signings, spoke in churches and created a National Minority Mental Health Taskforce of friends and allies. However, the effort came to a halt when Campbell became too ill to continue.

When Campbell lost her battle to cancer, Wharton-Boyd, friends, family and allied advocates reignited their cause, inspired by the passion of the life of an extraordinary woman.

The group researched and obtained the support of Representatives Albert Wynn [D-MD] and Diane Watson [D-CA], who co-signed legislation to create an official minority mental health awareness month.

Get Involved

There are multiple ways to get involved in NMMHAM! 

• Follow the Bebe Moore Campbell NMMHAM facebook page for information about minority mental health and mental health disparities throughout the month of July
• Learn the facts about minority mental health
• Share your story to help cure stigma
• Find graphics and resources from NAMI
• Spread the word with these social media messages and more!

Learn more on NAMI.org.

Visit the NNED National Minority Mental Health Awareness Month page to find resources, watch webinar recordings and spread the word!

The National Institute on Drug Abuse (NIDA), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), has recently released a Request for Information (RFI) for the HEALing Communities Study, part of National Institute of Health (NIH)’s Helping to End Addiction Long-term (HEAL) Initiative in response to the opioid crisis.

NIDA, in partnership with SAMHSA, is exploring options for conducting a multi-site national research effort in up to three communities to develop and test approaches for the systematic implementation and sustainability of an integrated set of evidence-based interventions across healthcare, behavioral health, justice systems, state and local governments, and community organizations to prevent and treat opioid misuse and OUD.  The goals are to decrease fatal and non-fatal overdoses, decrease the incidence of OUD and related infectious diseases (e.g. Hepatitis C and HIV), increase the number of individuals receiving medication-assisted treatment (MAT), increase the proportion retained in treatment beyond 6 months, and increase the number of individuals receiving needed recovery support services.  This research would be a part of the NIH Helping to End Addiction Long-term (HEAL) Initiative. The HEALing Communities Study will test the implementation of an integrated set of addiction prevention and treatment approaches in an array of settings in up to three communities affected by the opioid crisis. Through this study, NIDA and SAMHSA aim to define effective strategies to reduce opioid overdose and overdose death, while increasing the number of individuals receiving medication-assisted treatment and the number retained in treatment and receiving needed recovery support services. 

Despite the availability of multiple effective evidence-based interventions and practices, most Americans at risk for or suffering from an OUD do not receive appropriate prevention and treatment services. Simultaneously, opioid overdose rates continue to increase.

This Request For Input (RFI) seeks input on the design, study outcomes, and necessary partnerships and infrastructure for this multi-site research effort. The RFI is focused on the use, misuse, abuse of opioids and Opioid Use Disorders (OUD).  Opioids include prescription and illicit opioids, such as heroin, illicitly manufactured fentanyl, and related analogs.  Opioid Use Disorder (OUD) refers to the clinical diagnosis defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

This RFI solicits input from the extramural research community and public stakeholders.  NIDA and SAMHSA especially seek input on study elements such as, but not limited to: 

Study Design:

• Definition for “heavily affected communities” be defined, including geospatial/geopolitical definitions to provide consistent boundaries for a multi-site study
• Research designs that might be appropriate to accomplish the overall goals of the study
• Estimating effect size and effect size expected in relation to candidate outcomes: rates of non-fatal and fatal overdose; prevalence and incidence of opioid misuse, OUD and Hepatitis C; percent of patients screened for opioid misuse and OUD and who received a brief intervention or were referred to treatment; percent of patients initiated on MAT and retained in medication treatment beyond 6 months; rates of naloxone distribution and overdose reversals; opioid analgesic and benzodiazepine prescription rates; and implementation of prevention programs
• Baseline data that should be captured, existing sources for this data, and challenges that might exist with quality of existing data
• Length of integrated set of evidence-based interventions needed to be in place before expecting a meaningful change in outcomes, and which combination of interventions should be implemented in communities with different characteristics 
• Confounding variables that need to be considered
• Potential threats to internal and external study validity and the strategies that could be deployed to mitigate threats
• Strategies that can help the Coordinating Center overcome barriers to the facilitation of collaboration and coordination activities across Research Centers with regard to data harmonization, collection, integration, cleaning, analyses, and creating datasets for sharing with the research community at large 

Outcomes:

Target metrics feasible for outcomes,  candidate outcomes could include, but are not limited to those listed above: rates of non-fatal and fatal overdose; prevalence and incidence of opioid misuse, OUD and Hepatitis C; percent of patients screened for opioid misuse and OUD and who received a brief intervention or were referred to treatment; percent of patients initiated on MAT and retained in medication treatment beyond 6 months; rates of naloxone distribution and overdose reversals; opioid analgesic and benzodiazepine prescription rates; and implementation of prevention programs 

•  Best ways to gather reliable data related to candidate outcomes listed above>

Integrated Evidence-based Interventions:

• Essential interventions for an evidence based integrated approach to opioid prevention and treatment services, including policies and practices
• Definition for How could “evidence based or evidence informed”
• Measuring and assuring fidelity to an evidence-based integrated approach to opioid prevention and treatment services, including policies and practices
• Strategies and resources necessary, including training and technical assistance, to have meaningful penetration of the evidence-based integrated approach to opioid prevention and treatment services in a single community 

Health Economics:

• Economic questions included as part of the study to inform systems and policy change

Implementation Research:

• Implementation research questions included to develop best practices for replication in other communities impacted by the opioid crisis
• Data collected to help develop metrics for determining the quality of an integrated approach to opioid prevention and treatment services, including policies and practices
• Examples of prior implementation research studies that highlight implementation tools that can be used to replicate and scale up integrated approaches

Infrastructure, Partnerships, Collaboration:

• Research, prevention, and treatment infrastructure and partnerships are needed to support a community-based pragmatic trial assessing the impact of an evidence-based integrated approach to opioid prevention and treatment services
• Best approach to fostering collaboration and meaningful participation between state, county, and local governments; community stakeholders; medical/clinical service providers; and researchers
• Construction a research initiative with the highest likelihood of having sustainable prevention and treatment services
• Data would be of most interest to state and community partners

Submit your responses no later than July 20!

Learn more about this RFI and how to submit input.