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. The focus on evidence and data is also seen in the area of prevention, as communities begin to shift from high cost interventions to preventative care. The Methamphetamine Suicide Prevention Initiative (MSPI) framework, developed by the National Tribal Advisory Committee (NTAC) and supported by the Indian Health Service (IHS), provides the funded recipients the flexibility to choose evidence-based practice, practice-based evidence, best practices or promising practices, or a combination of these prevention and treatment practices, to address the issues of methamphetamine use and/or suicide.
Determining what practices are “evidence-based” or “practice-based” can be challenging. This is primarily due to the fact that there are multiple definitions and criteria being used. To add to the confusion, the terms “best practices,” “promising practices,” and “common practices” have been added to the discussion without a general consensus on the terms’ 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 Prevention Practices Guide, the following 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*.
- Common Practices: Practices for which there is little evidence of effectiveness, however replicability and acceptability has been shown through popular uptake of the practice by multiple, non-related programs or sites.
*Bigfoot, D., Bartgis, J, 2010, Healthy Indian Country Initiative Promising Prevention Practices Resource Guide.
Evidence-based Practices, Practiced-based Evidence, and Best, Promising, and Common Practices that may be of interest to MSPI projects or others working to address methamphetamine use or suicide:
Evidence-Based Practices for Suicide and Substance Abuse, specifically for American Indian/Alaska Native:
The Model Adolescent Suicide Prevention Program (MASPP) is a public health-oriented suicidal-behavior prevention and intervention program originally developed for a small American Indian tribe in rural New Mexico to target high rates of suicide among its adolescents and young adults. The goals of the program are to reduce the incidence of adolescent suicides and suicide attempts through community education about suicide and related behavioral issues, such as child abuse and neglect, family violence, trauma, and alcohol and substance abuse. As a community-wide initiative, the MASPP incorporates universal, selective, and indicated interventions and emphasizes community involvement, ownership, and culturally framed public health approaches appropriate for an American Indian population.
Central features of the program include formalized surveillance of suicide-related behaviors; a school-based suicide prevention curriculum; community education; enhanced screening and clinical services; and extensive outreach provided through health clinics, social services programs, schools, and community gatherings and events. In addition, neighborhood volunteers of various ages are recruited to serve as "natural helpers." These individuals en-gage in personal and program advocacy, provide referrals to community mental health services, and offer peer counseling (with guidance from professional mental health staff) to youth who may prefer to seek assistance from trusted laypersons in a less formal setting.
Web resource: http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=251
- American Indian Life Skills (AILS, the currently available version of the former Zuni Life Skills Development program) is a school-based suicide prevention curriculum designed to address and reduce suicide risk and improve protective factors among American Indian adolescents 14 to 19 years old.
The curriculum includes anywhere from 28 to 56 lesson plans covering topics such as building self-esteem, identifying emotions and stress, increasing communication and problem-solving skills, recognizing and eliminating self-destructive behavior, learning about suicide, role-playing around suicide prevention, and setting personal and community goals. The curriculum typically is delivered over 30 weeks during the school year, with students participating in lessons 3 times per week. 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.
- 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.
Evidence- Based Practices for Suicide and Substance Abuse:
- Cognitive Behavior Therapy (CBT), is a form of psychotherapy in which the therapist and the client work together as a team to identify and solve problems. Therapists use the Cognitive Model to help clients overcome their difficulties by changing their thinking, behavior, and emotional responses. Cognitive therapy has been found to be effective in more than 1000 outcome studies for a myriad of psychiatric disorders, including depression, anxiety disorders, eating disorders, and substance abuse, among others, and it is currently being tested for personality disorders.
- Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. "Dialectical" refers to the issues involved in treating patients with multiple disorders and to the type of thought processes and behavioral styles used in the treatment strategies. DBT has five components: (1) capability enhancement (skills training); (2) motivational enhancement (individual behavioral treatment plans); (3) generalization (access to therapist outside clinical setting, homework, and inclusion of family in treatment); (4) structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and (5) capability and motivational enhancement of therapists (therapist team consultation group). DBT emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients.
- Lifelines: A Suicide Prevention Program is a comprehensive suicide prevention program that includes the entire education community (administrators, faculty and staff, parents, and students). While the instruction is about youth suicide, it’s meant to help members of the education community recognize suicidal behavior and how to best help a student in distress. The research based program is one of the first school based suicide prevention programs in the country.
Lifelines offers four different training options. The first option covers all three training components briefly through a one day training. One day trainings are also available for each of the three trainings: prevention, intervention, and postvention. Lifelines also has Training of Trainers for large State or County initiatives.
- 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.
- Motivational Enhancement Therapy (MET) is an adaptation of motivational interviewing (MI) that includes one or more client feedback sessions in which normative feedback is presented and discussed in an explicitly nonconfrontational manner. Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve their ambivalence and achieve lasting changes for a range of problematic behaviors. This intervention has been extensively tested in treatment evaluations of alcohol and other drug use/misuse. MET uses an empathic but directive approach in which the therapist provides feedback that is intended to strengthen and consolidate the client's commitment to change and promote a sense of self-efficacy. MET aims to elicit intrinsic motivation to change substance abuse by resolving client ambivalence, evoking self-motivational statements and commitment to change, and "rolling with resistance" (responding in a neutral way to the client's resistance to change rather than contradicting or correcting the client).
- Motivational Interviewing (MI) is a goal-directed, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence. The operational assumption in MI is that ambivalent attitudes or lack of resolve is the primary obstacle to behavioral change, so that the examination and resolution of ambivalence becomes its key goal. MI has been applied to a wide range of problem behaviors related to alcohol and substance abuse as well as health promotion, medical treatment adherence, and mental health issues.
- Signs of Suicide (SOS) is a secondary school-based suicide prevention program that includes screening and education. Students are screened for depression and suicide risk and referred for professional help as indicated. Students also view a video that teaches them to recognize signs of depression and suicide in themselves and others. They are taught that the appropriate response to these signs is to use the ACT technique: acknowledge that there is a problem, let the person know you care, and tell a trusted adult. Students also participate in guided classroom discussions about suicide and depression. The program attempts to prevent suicide attempts, increase knowledge about suicide and depression, develop desirable attitudes toward suicide and depression, and increase help-seeking behavior among youth.
Practice-Based Evidence and Promising Practices for Suicide and Substance Abuse, specifically for American Indians/Alaska Natives:
- 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.
- 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. 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. 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.
- Native STAND is adapted from STAND—Students Together Against Negative Decisions—a multi-session, peer educator curriculum developed for youth. It is theoretically based – using both the Stages of Change and the Diffusion of Innovations Model – and was evaluated in four Bureau of Indian Education schools. Its approach is comprehensive and skills-based, and includes STD, HIV, teen pregnancy prevention, drug and alcohol use, and dating violence. Sessions focus on positive personal development, including team building, diversity, self-esteem, goals and values, decision making, negotiation and refusal skills, peer educator skills, and effective communications.
- Red Road Approach to Wellness and Healing integrates Native American healing methodologies, philosophy and values with contemporary methods of chemical awareness, education and chemical addiction therapy processes.
The Red Road Gathering evolved from the Red Road Approach enterprises of Medicine Wheel Inc., a partnership with the Student Counseling Center at the University of South Dakota and members of the Wase Wakpa community. Although the efforts of Medicine Wheel Inc. and its Red Road concepts are still at the foundational sharing of the conference, it has grown to be a globally diversified approach to recovery, health and healing.
- White Bison is a facilitator of the Wellbriety Movement. The Wellbriety Movement is a multi-dimensional program created and designed by White Bison, Inc. 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. Wellbriety resources and events include conferences, specialized community training events, Wellbriety coalitions, and the popular grass roots Firestarters circles of recovery groups across the nation.
Practice-Based Evidence and Promising Practices for Suicide and Substance Abuse:
- Applied Suicide Intervention Skills Training (ASIST) is an internationally recognized youth suicide prevention program developed by LivingWorks Education, Inc.
ASIST is a gatekeeper and skills-building training program that aims to prevent suicide by raising awareness of societal attitudes about suicide; enhancing communication, identification, and intervention skills; and increasing knowledge of resources for both caregivers and people at risk. 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 two day workshop provides principles that can be applied to young people, middle age adults or elders.
- Meth 360 is a methamphetamine prevention program uniting law enforcement, treatment professionals and prevention professionals to deliver meth prevention education presentations to local communities. The audience learns about all aspects of meth from experts with diverse perspectives on the issue–a true "360-degree" view. Informative and motivational, Meth360 also challenges concerned citizens to educate themselves about the dangers of meth and take action to stop the spread of this dangerous drug.
- Question, Persuade, Refer (QPR) outlines 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.
- 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.
Common Practices for Methamphetamine and Suicide Prevention Programming:
- NIHB worked with MSPI providers across Indian Country to develop a brief on what are the practices that are shared and common across multiple partners. This brief seeks to capture and share this information.
Common and Shared Practices Brief (PDF)
Behavioral Health Inquiries:
Robert Foley, M.Ed.
Acting Director of Public Health Programs
National Indian Health Board
926 Pennsylvania Ave, SE
Washington, DC 20003
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