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Methamphetamine & Suicide Prevention Initiative

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Current Prevention and Treatment Practices Implemented in the MSPI

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Prevention Practices Implemented within
the MSPI Project

In a national effort towards accountability and effectiveness of health care, the use of evidence-based practices (EBP) is becoming the standard for clinical care. Every health discipline has examples of “historical treatment approaches” (i.e., we’ve always done it this way) without real evidence that it works. The same trend is occurring in the area of prevention as the United States begins the shift from high cost interventions to preventative care. Unfortunately, the historical treatment and prevention approaches are not always effective and have, at times, resulted in no-improvement at best in some cases and fatalities at worst. The Methamphetamine Suicide Prevention Initiative (MSPI) framework developed by the National Tribal Advisory Committee (NTAC) and support by the Indian Health Service (IHS) provided the funded recipients the flexibility to choose from the spectrum of best/promising practices to evidence based practices within the field of prevention and treatment to combat the impact of suicide and methamphetamine use within their respected communities.

Many communities were creative to maximize the prevention and treatment resources. Communities and local leaders made decisions on the implementation of the local MSPI project and an array of services were dedicated across Indian Country to address the impact of suicide and meth within Indian Country. Determining what practices are “evidence-based” or “practice-based” can be challenging. This is primarily due to the fact that there multiple definitions and criteria for determining each have been proposed, without universally accepted consensus. To add to the confusion, the terms “best practices” and “promising practices” have been added to the discussion without good, clear, universally accepted definitions. Much of the work in conceptualizing the range of practices within prevention has taken place within the Substance Abuse and Mental Health Services Administration (SAMHSA).  For the purposes of this Promising Prevention Practices Guide the following SAMHSA accepted definitions will be used:

• Evidence-Based Practices: Practices that integrate the best research evidence with clinical expertise and patient values.
• Practice-Based Evidence: A range of treatment approaches and supports that are derived from, and supportive of, the positive cultural of the local society and traditions.
• Best practices: Most often is used to describe guidelines or practices driven more by clinical wisdom, guild organizations, or other consensus approaches that do not necessarily include systematic use of available research evidence.
• Promising Practices: Clinical practices for which there is considerable evidence or expert consensus and which show promise in improving client outcomes, but which are not yet proven by the highest or strongest scientific evidence*.

Here is a list of the Evidence based Practices, the Practiced Based Evidence, Best Practices and Promising Practices currently being implemented in the MSPI project:

Evidence-Based Practices for Suicide specifically for AI/AN:

Nationally, there is only one suicide prevention program specifically for AI/AN communities that have met the requirements of SAMHSA’s National Registry of Evidence-based Practices and Programs (NREPP).

• American Indian Life Skills Development (previously called the Zuni Life Skills Curriculum) is a curriculum which was originally developed in partnership with the Zuni Pueblo in New Mexico (LaFromboise & Hayes, 2008) to reduce suicide risk and improving protective factors among American Indian adolescents 14 to 19 years old. The program is school-based designed for youth to prevent suicide.  The program has 28 to 56 lesson plans delivered over 30 weeks with sessions 3 times a week. The lessons cover a wide range of topics such as self-esteem, emotions and stress, communications and problem-solving, self-destructive behavior, and setting personal and community goals. Lessons are interactive and incorporate situations and experiences relevant to American Indian adolescent life, such as dating, rejection, divorce, separation, unemployment, and problems with health and the law. Most of the lessons include brief, scripted scenarios that provide a chance for students to employ problem solving and apply the suicide-related knowledge they have learned.
  
  Web Resource: http://nrepp.samhsa.gov/ViewIntervention.aspx?id=81

Evidence-Based practices for Substance Abuse specifically for AI/AN:

Nationally, there is only one EBP’s program specifically for AI/AN communities that have met the requirements of SAMHSA’s National Registry of Evidence-based Practices and Programs (NREPP).

• Project Venture is an outdoor experiential youth development program designed primarily for 5th- to 8th-grade American Indian youth focused on preventing alcohol and other substance use. It aims to develop the social and emotional competence that facilitates youths' resistance to alcohol, tobacco, and other drug use. Based on traditional American Indian values such as family, learning from the natural world, spiritual awareness, service to others, and respect, Project Venture’s approach is positive and strengths based. The program is designed to foster the development of positive self-concept, effective social interaction skills, a community service ethic, an internal locus of control, and improved decision making and problem-solving skills. The central components of the program include a minimum of 20 1-hour classroom-based activities, such as problem-solving games and initiatives, conducted across the school year. The project also includes weekly after-school, weekend, and summer skill-building experiential and challenge activities, such as hiking and camping. Finally, the program includes 3- to 10-day immersion summer adventure camps and wilderness treks and community-oriented service learning and service leadership projects throughout the year.
  
  Web Resource: http://www.niylp.org/projects/Project-Venture-Model-Program.pdf

Below are the Evidence Based Practices currently being implemented within the MSPI with adaptations for a cohesive fit within the respected communities:

• The Matrix Model is an intensive outpatient treatment approach for stimulant abuse and dependence that was developed through 20 years of experience in real-world treatment settings. The Matrix Model is designed for delivery in a treatment program with adults ages 18 to 55 focusing on stimulant abuse and dependence. The intervention consists of relapse-prevention groups, education groups, social-support groups, individual counseling, and urine and breath testing delivered over a 16-week period. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, become familiar with self-help programs, and are monitored for drug use by urine testing. The program includes education for family members affected by the addiction. The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behavior change. The interaction between the therapist and the patient is realistic and direct, but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient’s self-esteem, dignity, and self-worth.
  
  Web Resource: http://nrepp.samhsa.gov/ViewIntervention.aspx?id=87

• Motivational Enhancement Therapy (MET) is an adaptation to motivational interviewing and serves as supplement to other forms of treatment. MET is an intervention for adults ages 18-55 who have not yet fully committed to participate in treatment to reduce alcohol and/or substance abuse behavior. The focus of MET is to elicit intrinsic motivation within an individual to make a commitment to change (i.e., replace substance abuse with pro-social behaviors). MET is a client-centered intervention in which the therapist provides direct but non-confrontational feedback about the person’s current situation and assists the individual in exploring and resolving their ambivalence to change so that the person can achieve lasting changes for a variety of problem behaviors. At the end of MET the individual should have resolved any ambivalence they might have had toward making change and achieved an internal motivation to change their problematic behavior. MET is primarily used for changing alcohol and other drug abuse but has been used for a variety of behaviors (such as increasing exercise, changing diet, etc). Both MET and motivational interviewing has been evaluated with AI/AN populations with positive outcomes.
  
  Web Resource: http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

National Registries of Evidence based Practices:

NREPP (National Registry of Evidence-Based programs and Practices): NREPP is a searchable online registry of more than 190 interventions supporting mental health promotion, substance abuse prevention, and mental health and substance abuse treatment. We connect members of the public to intervention developers so they can learn how to implement these approaches in their communities. NREPP is not an exhaustive list of interventions, and inclusion in the registry does not constitute an endorsement.

Web Link: http://www.nrepp.samhsa.gov/

OSCAR (Online Search, Consultation, and Reporting System):  The Indian Health Service (IHS) is creating an inventory of Best (i.e., Evidence-Based) Practice, Promising Practice, Local Effort (BP/PP/LE), Resources, and Policies occurring among American Indian/Alaska Native (AI/AN) communities, schools, work sites, health centers/clinics, and hospitals. The purpose of this inventory is to:

• Assist our AI/AN communities with getting the information and health services they need;
• Form an IHS database of Best Practices, Promising Practices, Local Efforts, Resources, and Policies that can be easily accessed on the IHS website;
• Improve informed consultation with Tribal and Urban programs by facilitating transparency in IHS and IHS supported activities; and,

Web Link: http://www.ihs.gov/OSCAR/

Practiced Based Programs:

MPSI communities are implementing interventions that are not on SAMHSA’s evidence-based-practice list, but are manualized in such a way that they have been replicated in other communities. Many of these practices have shown positive outcomes but have not been as rigorously evaluated to be included in the Evidence-Based-Practice list. Two of these interventions represent what is referred to as “gatekeeper training” in which both professionals and the general community are trained to understand the risk factors for suicide, assess an individual for suicidal risks, and appropriately intervene to refer someone for treatment. The term “gatekeeper” promotes the idea that caring individuals in the community can effectively navigate at-risk people into the “gate” for treatment. It is important to note that, although no gatekeeper training programs have yet been established as evidence-based-practices, the majority of MSPI communities are using gatekeeper training programs, speaking to the need for community training on suicide prevention.

Manualized Practice-Based Evidence’s programs for Suicide:

• The ASIST program is an internationally recognized youth suicide prevention program developed by LivingWorks Education, Inc. ASIST is a gatekeeper and skills building training program the community to prevent suicide and can be used with youth, adults, and elders. Although it is not yet considered an EBP, ASIST is included on the Suicide Prevention Resource Center’s Best Practices Registry. ASIST training prepares participants to integrate intervention principles into everyday practice.  The skills based, two day workshop provides principles that can be applied to young people, middle age adults or elders. The ASIST curriculum has five learning sections: Preparing, Connecting, Understanding Assisting and Networking.  Skills and principles are illustrated with case studies presented in videos and live dramatizations, role-play simulations, discussions and in the Suicide Intervention Handbook. The workshop prepares participants to be able to: reduce attitudinal barriers which hinder the ability to be direct and comfortable with suicidal situations; dispel myths about youth suicide; identify the indicators and access suicidal risk; intervene with youth suicide; and engage in efforts to build collaborative resource networks for suicidal youth.
  
  Web Resource: http://www.yspp.org/training/asist.htm

• QPR stands for Question, Persuade, and Refer, three simple steps that anyone can learn to help save a life from suicide. People trained in QPR learn how to recognize the warning signs of a suicide crisis and how to question, persuade, and refer someone to help. QPR can be learned in the Gatekeeper course in as little as one hour. According to the Surgeon General’s National Strategy for Suicide Prevention (2001), a gatekeeper is someone in a position to recognize a crisis and the warning signs that someone may be contemplating suicide. Gatekeepers include parents, friends, neighbors, teachers, ministers, doctors, nurses, office supervisors, squad leaders, foremen, police officers, advisors, caseworkers, firefighters, and many others who are strategically positioned to recognize and refer someone at risk of suicide. A QPR-trained Gatekeeper will be trained to: recognize the warning signs of suicide; know how to offer hope; and know how to get help and save a life
  
  Web Resource: http://www.qprinstitute.com

• SafeTALK is a 3 hour video training that prepares people over the age of 15 to identify persons with thoughts of suicide and connect them to suicide first aid resources. Most people with thoughts of suicide look for help to stay safe. Alert helpers know how to use these opportunities to support that desire for safety. A safeTALK-trained suicide alert helper will be able to: move beyond common tendencies to miss, dismiss or avoid suicide; identify people who have thoughts of suicide; and apply the TALK steps (Tell, Ask, Listen and KeepSafe) to connect a person with suicide thoughts to suicide first aid, intervention caregivers.
  
  Web Resource: http://www.livingworks.net/training/map

• Patient Health Questionairre-9 (PHQ-9), while not mentioned as often, by MSPI programs as a new practice, is being utilized to assess depression. The PHQ-9 is easy to administer and has been validated across several cultural/ethnic groups.  It is an evidenced-based and validated tool for assisting with:  diagnosis of depression, treatment selection, and treatment monitoring.  The PHQ-9 can be measured and tracked over time, and is easily followed in an Electronic Medical Record.
  
  Web Resource: www.ncbi.nlm.nih.gov/pubmed/11556941

Practiced-Based Evidence program for Suicide:

• Nohwi' Ida' Bagoue' the "Life is Precious" program reaches out to suicidal individuals in their homes, places of work, medical settings, the Tribal jail, and other community settings to provides counseling and referral services.  Unfortunately, experience has shown that many people at risk of suicide avoid contact with prevention outreach workers and suicide prevention counselors.  In these cases, the families of those at risk receive services designed to help them understand the nature of suicide, how they might respond to suicidal behaviors, and how to support their family members in getting the services that will best help them deal with their suicidal feelings (i.e. counseling, traditional healing, substance abuse treatment, etc.).
  
  Web Resource: http://ihs-mspi.jbsinternational.com/pdf/report_01_arnett.pdf

Practiced-Based Evidence programs for Substance Abuse:

• Keeping It Real is a program developed by Arizona State University in collaboration with youth from the Maricopa area.  The program is a 10-week youth supportive early intervention substance abuse 10 week program.
  
  Web Resource: Coming Soon

• Gathering of Native Americans (GONA) is a three-day youth substance abuse prevention curriculum that is based on four core principles of Belonging, Interdependence, Mastery, and Generosity. The GONA provides workshops focused on understanding historical trauma and facilitates open discussions among youth about the current state of substance abuse in the community. The GONA curriculum provides the framework for sensitive discussions and activities and is integrated with local rituals, customs, and practices to provide healing support. The GONA has been implemented widely throughout Indian Country and is often uniquely adapted to address other health related topics including suicide, bullying, and violence. Further, adult GONAs have been increasing in frequency as the curriculum promotes healing and sharing among community members. Although no center exists to support training trainers in facilitating the GONA, the founder of the curriculum provides training to interested communities.
  
  Web Resource: http://www.whitebison.org/wellbriety_movement/index.html

Bridging the Gap: Promising Practices

There is much to be learned from both Evidence-based-practices and Practice-based-Evidence approaches. While EBP allows for accountability to consumers, their families, and the communities in which they live, PBE allows for the cultural context and characteristics that represents those consumers, families, and communities.  While EBP moves toward the replicability of practices so that they are more consistently implemented, PBE allows for practices that match the community context. These two approaches to clinical care are more than just two ends of the same coin, but rather, represent two differing orientations to what is viewed as effective and helpful aspects within specific parameters, with ultimately the same goal- improving the lives of those served. Finding a way to advance both EBP and PBE simultaneously as well as understanding how each compliments the other will be critical for addressing health disparities for American Indian and Alaska Native people.

The concept of “Promising Practices” can serve as such a mechanism to bridge the gap between these two competing approaches for several reasons. First, the entire concept of a promising practice allows us to accelerate the information dissemination process by releasing practices that have “promising evidence” prior to examining the outcomes more systematically. Ongoing information dissemination is critical given the current disparities within American Indian and Alaska Native communities and the real need for prevention practices now. Second, the concept of Promising Practices allows for grassroots, community, or culturally-based interventions to be recognized. As discussed in the section on Practice-Based-Evidence, tribal communities rarely have access to the appropriate research dollars to document evidence of practices that have been used in many communities for centuries. While there may be hesitant and general concern about the application of researching culturally and spiritually based practices, the focus on assessing what is the outcome is important.  For example, the content of prayers and ceremony may not be for public dissemination, but the understanding of why the prayers or ceremonies are important can be appreciated.  The actually spiritual ceremony may be held in private but the frequency of participation, the supportive nature, the length of time, the number of participants, or self-talk before and after the ceremony can be assessed. Finally, as defined, a Promising Practice show promise in improving client outcomes, but the “promising” part can either be research (academia) or expert consensus (community). This allows for both Evidence-Based interventions and Practice-Based interventions to be included.

• Red Road to Recovery by Medicine Wheel Inc. utilizes the "Red Road Approach" concept integrating Native American healing methodologies, philosophy and values with contemporary methods of chemical awareness, education and chemical addiction therapy processes.
  
  Red Road Approach is holistic in concept and uses prayer as the basis of all healing. There needs to exist a relationship of mutual respect for the afflicted, the medicine (therapy) and the healer (facilitator) before the healing takes place. Native American psychology is essential to reach the inner person (spirit) using specific sound, movement and color. All these essences are present in the Medicine Wheel, which is innate to Native Americans. To insure that healing continues after spiritual awareness, mental cognition, physical recovery and emotional release, the individual must have a lifestyle (culture) that is harmonious with self, community, and the cosmos. The traditions and values of the Native American People ensure balance by living these cultural traditions through the Red Road.
  
  Web Resource: http://redroadapproach.com/index.html

• White Bison: White Bison is a proud facilitator of the Wellbriety Movement. Wellbriety means to be sober and well. Wellbriety teaches that we must find sobriety from addictions to alcohol and other drugs and recover from the harmful effects of drugs and alcohol on individuals, families and whole communities. The "Well" part of Wellbriety is the inspiration to go on beyond sobriety and recovery, committing to a life of wellness and healing every day. White Bison's mission is to assist in bringing 100 Native American communities into healing by 2010. This mission is being realized by means of the many Wellbriety resources, Wellbriety conferences, specialized community training events, Wellbriety coalitions, and the popular grass roots Firestarters circles of recovery groups across the nation.
  
  Web Resource: http://whitebison.org/about-white-bison/about-white-bison.htm

• Warrior Down is a community based support program to help those returning from prison, from treatment, and from military combat zones to reenter the community.  Warrior Down is based upon the Native American Medicine Wheel and 12 Step program developed by White Bison.  The concept behind the Warrior Down is that reentering the community is a process that needs to be supported by members of the community. Mutual support networks (people helping people) can make sure that individuals receive the support they need in order to maintain a healthy and sober lifestyle.    If you want to start a Warrior Down program in your community please contact White Bison, Inc.   If you would like to see how a Warrior Down program has been implemented in one community see Wellbriety for Prisons.   
  
  Web Resource: http://www.whitebison.org/welbriety-training-programs/documents/WarriorDown.pdf

• Sources of Strength: Sources of Strength was originally developed in the late 1990’s by founder Mark LoMurray with tribal and rural suicide prevention partners in North Dakota.  From 2000-2004 the program was used extensively in a statewide campaign through the North Dakota Adolescent Suicide Prevention Project with encouraging reductions in teen fatality numbers and Youth Risk Behavior Survey markers. In 2009 Sources of Strength was listed on the National Best Practices Registry by the Suicide Prevention Resource Center (SPRC) and The American Foundation for Suicide Prevention (AFSP). Sources of Strength has expanded into many states working with urban, rural and tribal settings, with school-based programs in middle school, high school and colleges, with community, faith-based, and cultural programs. 
  
  Web Resource: http://www.sourcesofstrength.org/about-us/history.html

• Planting Seeds of Hope: The mission of the PSOH Project is to improve access to suicide prevention services across all Montana and Wyoming’s tribal communities, while identifying and reducing barriers to care and health disparities as they apply to American Indian Youth and their communities.
  
  The Montana Wyoming Tribal Leaders Council (MT WY TLC) Planting Seeds of Hope (PSOH) Suicide Prevention Project focuses on decreasing suicide attempts and completions among American Indian/Alaskan Native youth age 10-24 on 8 reservations throughout the state of Montana and Wyoming. Planting Seeds of Hope build resilience in Native American youth and build capacity for suicide prevention on the reservations by: 1) Promoting Awareness; 2) Training Gatekeepers; 3) Implementing Screening and Brief Intervention in universal settings; 4) Building protective factors for youth and veterans; 5) Implementing interventions for youth who have attempted suicide; 6) Helping families who have lost someone to suicide; 7) Strengthening coordination and collaboration across sectors.
  
  Web Resource: http://www.mtwytlc.org/tlc-programs/planting-seeds-of-hope.html

• Native H.O.P.E. (Helping Our People Endure) – offers a training of facilitators program. The purpose of the Native H.O.P.E. Training of Facilitators (TOF) manual is to prepare American Indian/Alaska Native/First Nations individuals to strengthen their Facilitation and Leadership skills so that they can replicate the curriculum successfully in their communities and reduce suicide among our most precious and sacred resource, our children and youth. The overall goal of the Native H.O.P.E. Training of Facilitators (TOF) is to strengthen the capacity of American Indian/Alaska Native/First Nations teens and young adults to help each other, their families, schools, and communities by using their “Sources of Strengths,” including culture and spirituality, to break the “Code of Silence,” and unhealthy multigenerational cycles. The overall outcome of the Native H.O.P.E. Training of Facilitators (TOF) is to create a “Call-to-Action” among Native youth and adults from their communities to develop and implement a Strategic Action Plan that greatly reduces suicide and the contributing factors including depression, substance abuse, violence and exposure to trauma.
  
  Web Resource: http://www.oneskycenter.org/pp/documents/
  NativeHOPEYouthTrainingManualCoverandIndex.pdf

 

 

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