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S. HRG. 114–446 

ADDRESSING TRAUMA AND MENTAL HEALTH 

CHALLENGES IN INDIAN COUNTRY 

FIELD HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

AUGUST 17, 2016 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

JOHN BARRASSO, Wyoming, Chairman 

JON TESTER, Montana, Vice Chairman 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

JOHN HOEVEN, North Dakota 

JAMES LANKFORD, Oklahoma 

STEVE DAINES, Montana 

MIKE CRAPO, Idaho 

JERRY MORAN, Kansas 

MARIA CANTWELL, Washington 

TOM UDALL, New Mexico 

AL FRANKEN, Minnesota 

BRIAN SCHATZ, Hawaii 

HEIDI HEITKAMP, North Dakota 

T. MICHAEL ANDREWS, Majority Staff Director and Chief Counsel 

ANTHONY WALTERS, Minority Staff Director and Chief Counsel 

(III) 

C O N T E N T S 

Page 

Field hearing held on August 17, 2016 .................................................................. 1 

Statement of Senator Heitkamp ............................................................................. 1 

Statement of Senator Hoeven ................................................................................. 2 

WITNESSES

Cruzan, Darren, Director, Office of Justice Services, Bureau of Indian Affairs, 

U.S. Department of the Interior ......................................................................... 13 

Prepared statement .......................................................................................... 17 

DeCoteau, Tami, Ph.D., Clinical Psychologist, DeCoteau Trauma—Informed 

Care and Practice, PLLC ..................................................................................... 35 

Prepared statement .......................................................................................... 39 

Eagle-Williams, Kathryn R., M.D., CEO/Quality Care Director, Elbowoods 

Memorial Health Center, Mandan, Hidatsa and Arikara Nation .................... 28 

Prepared statement .......................................................................................... 30 

Robinson, Hon. Lillian Sparks, Commissioner, Administration of Native 

Americans—Administration for Children and Families, U.S. Department 

of Health and Human Services ........................................................................... 3 

Prepared statement .......................................................................................... 9 

Warrington, Hon. Myrna, Chairwoman, Health and Family Committee, Menominee Indian Tribe of Wisconsin .................................................................... 19 

Prepared statement .......................................................................................... 24 

APPENDIX

Octeti Sakowin youth, prepared statement ........................................................... 55 

Yellow Hammer, Stephanie, Standing Rock Sioux Tribe Member, prepared 

statement .............................................................................................................. 58 

(1) 

ADDRESSING TRAUMA AND MENTAL HEALTH 

CHALLENGES IN INDIAN COUNTRY 

WEDNESDAY, AUGUST 17, 2016 

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Bismarck, ND. 

The Committee met, pursuant to notice, at 9:30 a.m. at the Lewis 

Goodhouse Wellness Center, United Tribes Technical College, Hon. 

Heidi Heitkamp, U.S. Senator from North Dakota, presiding. 

OPENING STATEMENT OF HON. HEIDI HEITKAMP, 

U.S. SENATOR FROM NORTH DAKOTA 

Senator HEITKAMP. Good morning. We’re calling this hearing to 

order. I want to first thank all the tribal leaders, activists, providers, and community members for joining us today to discuss this 

critical issue. I want to thank the UTTC for hosting. I also want 

to recognize the staff of the Senate committee on Indian Affairs 

who have worked so closely with my office to make this field hearing happen. Today the Committee will examine, ‘‘Addressing Trauma and Mental Health Challenges in Indian Country’’. I am so 

honored to be hosting the field hearing in North Dakota to discuss 

how we can work together to address trauma in American Indian 

and Alaska Native communities. The U.S. and National Library of 

Medicine found implications of trauma on health, academics, and 

economic outcomes are significant. The average lifetime cost for a 

child exposed to non-fatal child maltreatment is over $200,000. 

This creates a significant cost and a need for services when 22 percent of Native American children suffer from post-traumatic stress. 

The costs are not only financial but impact Native American communities as a whole. Adults experience trauma in racism, poverty, 

poor nutrition, alcoholism, and suicide. In 2005 to 2008 data, the 

suicide rate for American Indians and Alaska Natives was 14.68, 

higher than the overall U.S. rate of 11.15. To mitigate the effects 

of trauma, the Department of Health and Human Services designated 4,000 mental health professionals to professional shortage 

areas across the country, many of which include Native American 

and Alaska Native communities. This shows that primary care providers generally have limited training in recognizing and diagnosing mental health disorders. Of the 53 counties in North Dakota, only six are identified as not having a mental health professional shortage. Of the 53 counties in North Dakota, only six have 

enough mental health providers. I hope that today we find some attainable proposals that will achieve Native American and Alaska 

2 

Native Communities that will benefit them across the nation, as 

well as focus on intervention models from the traumatic experience. 

I’m pleased and actually thrilled that I’m on this Committee, which 

I think speaks volumes to the history that we have in the Senate 

of Senators from North Dakota believing that this is an important 

issue. Senator John Hoeven has joined me here today to listen to 

this important testimony, provide questions, and take the message 

along with me back to Washington D.C. I turn now to Senator 

Hoeven for remarks. 

STATEMENT OF HON. JOHN HOEVEN, 

U.S. SENATOR FROM NORTH DAKOTA 

Senator HOEVEN. Thank you, Senator Heitkamp. I’m pleased to 

be here with you. Thanks to all of you for attending. Thanks to our 

witnesses and UTTC for hosting this event on a very, very important subject. The purpose of the hearing is to discuss how Federal 

agencies can coordinate to provide services to Native American 

children who suffer from trauma and mental health issues. Trauma 

is defined as a series of events that cause physical and psychological stress reactions. Native American children experience abuse 

and neglect at higher rates than non-native children. As a result, 

they are more likely to experience trauma due to depression, substance abuse, homelessness, and poverty. Native Americans suffer 

from PTSD, post-traumatic stress disorder, at twice the rate of the 

general population in North Dakota. Between the years of 2006 

and 2010 the suicide rate among Native American people was twice 

that of non-natives. As we all know, the devastating effects of trauma are all too common to Native American communities, specifically among the children. I’m committed to doing all I can to work 

with my colleagues and Senator Heitkamp to address this very serious concern. I believe the most effective way to address trauma 

in Native American communities is to prevent it from happening 

in the first place, especially for children. So we’re working on trying to prevent trauma, and one example is the Native American 

Children Safety Act that ensures that foster children on the reservation are placed in safe homes. We need to take this step and 

other steps in a comprehensive way. Let’s hear from our witnesses 

as to how we can address the very important issue and comprehensive approach working together. Thank you to Senator Heitkamp 

for organizing this very important discussion. Thank you. 

Senator HEITKAMP. Thank you so much, Senator Hoeven. I want 

to now turn to our witnesses, some of whom we’ve seen many times 

in front of our committee in Washington D.C, I dare say this, 

maybe a little more friendly than what you’ve seen in the past. But 

I also want to thank those of you who have traveled from so far 

to provide this testimony at this field hearing and to open up this 

discussion that we did a couple years ago on trauma and realize 

that this is not a one off. This isn’t something that we talk about 

today and not realize we need to continue that dialogue well into 

the future. Our first witness is Lillian Sparks Robinson. She is 

Commissioner of the Administration of Native Americans—Administration for Children and Families within the U.S. Department of 

Health and Human Services. I am pleased that she is here with us 

3 

today. I remind you your testimony is five minutes. I will introduce 

each of you before you speak. 

STATEMENT OF HON. LILLIAN SPARKS ROBINSON, COMMISSIONER, ADMINISTRATION OF NATIVE AMERICANS— 

ADMINISTRATION FOR CHILDREN AND FAMILIES, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Ms. ROBINSON. Senator Heitkamp and members of the Senate 

Committee on Indian Affairs, it is my honor to testify before this 

Committee on behalf of the Department of Health and Human 

Services (HHS) on the important topic of Addressing Trauma and 

Mental Health Challenges in Indian Country. 

I am a member of the Rosebud Sioux Tribe, which is located in 

South Dakota. I serve as the Commissioner for the Administration 

for Native Americans, which is part of the Administration for Children and Families (ACF), as well as the Chair of the 

Intradepartmental Council on Native American Affairs (ICNAA). 

Development of HHS-Wide Policy to Address Trauma. In my role 

as chair of the ICNAA, I have led meetings involving leadership 

from ACF, the Indian Health Service (IHS), and the Substance 

Abuse and Mental Health Services Administration (SAMHSA) to 

discuss how we may better lead collaborative efforts on an intradepartmental level to support improved outcomes in the health and 

emotional well-being of American Indians and Alaska Natives (AI/ 

AN) and others in tribal communities. ACF, SAMHSA, and IHS 

were highlighted in the Committee’s December 17 letter requesting 

HHS develop and implement an integrated and coordinated Federal approach to addressing complex trauma, including historical 

trauma in Indian communities and are the primary agencies bringing a trauma-informed lens to this work. We have examined the 

causes and effects of trauma, including historical and childhood 

trauma, with an intentional view toward better understanding and 

highlighting steps tribes themselves are taking to prevent and address the effects of trauma. We believe developing a comprehensive, integrated, and trauma-informed HHS-wide policy that is sustainable over the long-term requires collaboration not only across 

the health and the human services components of HHS, but also, 

with other Federal agencies and our AI/AN partners. 

We are actively engaged in the development of an HHS-wide policy and are planning on releasing and implementing it within this 

calendar year. We are currently soliciting input from our tribal 

partners as well as incorporating substantive material from HHS 

Operating Divisions contributing to the Department’s comprehensive trauma-informed policy. The policy will focus on moving tribal 

health promotion forward as well as learning from and incorporating AI/AN models of prevention, care, and healing in partnership with tribal leaders, experts, and communities. 

Recently, I invited tribal leaders to a listening session held on 

August 9 to solicit input and recommendations to inform this important work. This listening session was held in Portland, Oregon 

in conjunction with the 2016 IHS American Indian/Alaska Native 

Behavioral Health Conference. We are tentatively planning additional listening sessions. 

4 

In addition, guidance and recommendations of tribal leaders in 

the development of the National Tribal Behavioral Health Agenda 

(TBHA), led by SAMHSA, has greatly informed the on-going development of our HHS-wide policy addressing trauma. The process for 

development of the TBHA was the result of SAMHSA’s months of 

information gathering, discussion, analysis, validation, sharing, 

and revalidation of input received from Indian tribes and tribal 

leaders in coordination with the Indian Health Service’s Office of 

Clinical and Preventive Services (OCPS) and the National Indian 

Health Board (NIHB). Development of the TBHA has been a strong 

collaborative effort among Indian tribes, national and regional tribal leaders, SAMHSA regional administrators and staff, and numerous Federal partners. 

As you know, tribal leaders have consistently asked for support 

in addressing behavioral health issues affecting their communities 

as part of broader discussions of health and wellness. To bring a 

targeted focus to such issues at the outset of our work to develop 

Department-wide policy, in March 2016, we solicited and tribal 

leadership provided, through the HHS’s Secretary’s Tribal Advisory 

Committee (STAC), their recommendations on how we could approach the development of a comprehensive, integrated departmental policy to address complex trauma in AI/AN communities. 

Among the input we received were recommendations that we not 

only identify and understand the root causes of trauma, but that 

we make specific efforts to ensure that Federal partners are educated about models and approaches developed from tribal perspectives to more effectively prevent and address trauma in tribal communities including trauma affecting AI/AN children, youth, and 

families. Based on this and other feedback from tribes, we are encouraged to move beyond a deficits-based perspective and to reflect 

in our policy emphasis on protective factors and positive youth development strategies aimed at promoting resilience, which, we believe may have a larger impact on prevention than risk reduction 

strategies alone. Further, since the most effective trauma-informed 

activity is to prevent trauma from occurring, we are working to 

identify and promote interventions, such as home visiting, which 

address the intergenerational transmission of trauma and build on 

the strengths of young parents. 

With our tribal partners, we are moving forward to develop approaches that focus on cultivating, strengthening, and lifting up the 

Native assets and cultural resources found in AI/AN Communities. 

One of the recommendations we heard through the STAC members 

was that our policy should acknowledge tribal elders as assets and 

resources. At a STAC meeting in June, we discussed the critical 

role of tribal elders in the development and implementation of policies addressing trauma, including strategies to foster resilience. 

Our colleagues in the Administration for Community Living (ACL), 

whose mission includes working with seniors and tribal elders, will 

be indispensable in our work to fully reflect tribal elders’ roles in 

addressing trauma. 

At the Departmental Fiscal Year (FY) 2018 Tribal Budget Consultation, Ms. Mirtha Beadle, the Director of the Office of Tribal 

Affairs and Policy at SAMHSA shared with tribal leaders that in 

HHS we take trauma and its effects very seriously and that it is 

5 

something that informs our work every day as part of an all-HHS 

commitment to Native Americans. 

Beyond our work to develop a written HHS policy to effectively 

address trauma in AI/AN communities, others in the Department 

and I are working with Federal agency partners through the White 

House Council on Native Americans Affairs, an interagency body 

established to improve coordination of Federal programs, to develop 

a Federal Government-wide approach to improve our capacity, coordination, and collaboration in addressing the wellness of AI/AN 

communities. 

Ongoing Work to Address Trauma—Since receipt of the Committee’s letter, my colleagues and I have worked hard to reach across 

agencies to identify trauma-informed work already being done in 

the Department and ways we as champions for AI/AN children, 

youth, families, and communities, can coordinate this work better. 

We are focused on ways we can more effectively take advantage of 

the Department’s health and human services assets. 

I would like to share with the Committee and participants in this 

field hearing the three-pronged framework HHS is pursuing. 

Increase Awareness and Understanding. The initial step is to improve information available to key staff across HHS about the extent and impact of trauma in tribal communities and opportunities 

to more effectively improve well-being. This prong will be supported by increasing Federal staff access to webinars and informational materials and encouraging greater engagement with tribal 

leaders and representatives. Resources and discussions are intended to build staff knowledge about cultural, practice, and evidence-based opportunities for creating and/or supporting systems 

that are trauma-informed. 

Among some examples of specific HHS activities to increase Federal staff awareness and understanding of trauma and its effects 

are: 

The development of the ACF Principles for Working with Federally Recognized Indian Tribes; a set of principles designed and intended to foster AI/AN well-being by providing a framework for 

Federal leadership, partnership, and compassionate and effective 

human services delivery. These principles are intended to guide the 

internal management of ACF in its partnership with people in Federally-recognized tribes. 

The launching of the ACF Trauma Network, which is a community of practice for ACF staff designed to share lessons learned and 

promising practices and to strengthen the agency’s ability to support trauma-informed programmatic work. The ACF Trauma Network will host an internal training on issues of trauma and resilience in AI/AN communities, currently scheduled for October 2016. 

This program will address research on protective factors and positive youth development strategies that may have a larger impact 

on prevention of negative health outcomes than risk reduction 

strategies. Representatives from the Center for American Indian 

Health of the Johns Hopkins School of Public Health will share 

with ACF leadership and staff strength-based interventions developed and evaluated with the White Mountain Apache and Navajo 

communities; interventions that have now been scaled to 75 tribal 

communities across 15 states, and two non-Native communities. 

6 

Each year, SAMHSA, through its Tribal Training and Technical 

Assistance Center, hosts a training program focused on improving 

the Agency’s work with AI/AN people. The training includes experiential exercises to assist SAMHSA staff gain greater awareness 

and understanding of intergenerational and historical trauma and 

their effects on tribal communities. The training is delivered in a 

format that allows SAMHSA staff at all levels to participate during 

the three-day program. Webinars are also offered throughout the 

year to improve knowledge about trauma-related issues in tribal 

communities and opportunities for addressing them. 

Home visiting helps expectant families and those with young 

children provide stimulating learning environments and nurturing 

relationships. Beginning in 2013, the IHS Community Health Representatives Program also partnered with the Center for American 

Indian Health of the Johns Hopkins School of Public Health to implement Family Spirit, an evidence-based, culturally tailored homevisiting program as a core strategy to support young families. Six 

pilot sites received intensive on-site training and technical assistance. Using lessons learned from the pilot project, IHS and Johns 

Hopkins will expand Family Spirit for implementation in other 

tribal communities beginning in 2016. Since 2010, ACF has been 

operating the Tribal Home Visiting Program, part of the Maternal, 

Infant, and Early Childhood Home Visiting Program. The Tribal 

Home Visiting Program is an unprecedented expansion of culturally responsive services for vulnerable AI/AN families and children. The program serves some of the most vulnerable families who 

experience multiple challenges often attributed to historical trauma. The program has served a total of 1,523 families and provided 

nearly 20,000 home visits through 25 funded grantees in 14 states. 

There are currently 15 rural grantees, three urban grantees, and 

seven grantees in a mix of rural and urban settings. 

IHS provides comprehensive training options to build a workforce 

that is trauma-informed and responsive. Topics cover historical 

trauma, adverse childhood experiences, early screening and assessment of trauma, treating complex trauma, trauma informed care 

services and programming, and many others. Training is available 

online through the IHS TeleBehavioral Health Center of Excellence. 

This year’s IHS AI/AN National Behavioral Health Conference 

was planned around the theme, Creating Trauma Informed Systems in AI/AN Communities. The conference was held in Portland, 

Oregon, from August 9–11, 2016, with 550 registrants over 35 

breakout sessions, 90 presenters, and more than 45 continuing education hours offered at no cost to participants. 

Improve Coordination and Collaboration. HHS is developing a 

comprehensive, integrated policy on actions that support healing 

from trauma and advance trauma-informed practices through programs that contribute to improving the health and well-being of 

tribal communities. As part of our work with the other agencies on 

these issues, we are developing a template for creating complementary policies across Federal agencies that support trauma-informed 

practices. The intent is to: (1) strengthen support systems across 

health, behavioral health, education, child welfare, justice services, 

environmental, and other Federal programming; (2) improve acVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 S:\DOCS\22689.TXT JACK
7 

tions to recognize and address the impacts of adverse childhood experiences among AI/AN populations; and (3) to the extent possible, 

better align programs to address trauma, prevent additional trauma, and support trauma-informed services that are continuous 

across systems. 

Examples of specific HHS activities to improve coordination and 

collaboration include: ACF, in collaboration with the Centers for 

Disease Control and Prevention, Health Resources and Services 

Administration, IHS, and SAMHSA, is leading work to support improved social-emotional and behavioral health for children and 

families in tribal communities. The agencies hosted a one-day Tribal Experts Workgroup Meeting on February 25. The meeting included tribal leaders, community members, researchers, and advocates, as well as representatives from Federal agencies including 

HHS, the Department of Justice, and the Office of Management 

and Budget. The goal of the meeting was to learn from experts and 

discuss how we can better work together to: (1) raise awareness of 

challenges that pre-school children face in tribal populations with 

high rates of adult mental health and substance abuse issues; (2) 

provide tools and effective strategies for caregivers to support improved social-emotional and behavioral health outcomes for children and their families in tribal communities; and (3) develop policy recommendations to address funding and service delivery challenges. Development of a comprehensive ACF Native American 

Child and Youth Policy Agenda to highlight the ongoing work of 

ACF program and staff offices to support thriving, resilient, safe, 

healthy, and economically secure children, families, and communities. The focus areas for this Policy Agenda are: (1) quality early 

childhood development and learning; (2) the role of self-determination and nation-building in strengthening families; (3) fostering 

child and youth well-being and resiliency in the face of trauma and 

adversity; (4) financial and economic security; and (5) building a 

new narrative with data. The ACF Policy Agenda is intended to 

both function as a structure for innovative policymaking to guide 

stronger and more effective programming and to lift up successful 

tribal models across the identified five focus areas. The Policy 

Agenda is very much an action-oriented roadmap we hope will provide AI/AN parents, caregivers, leadership, and children and youth, 

and federal staff with the tools they need to ensure improved child 

and youth outcomes. 

IHS, in collaboration with SAMHSA, developed the FY 2016 

funding opportunity for the Methamphetamine and Suicide Prevention Initiative Generation Indigenous. The funding opportunity is 

framed around addressing trauma by focusing on the following objectives: increasing positive youth development, building resiliency, 

and promoting family engagement. Newly awarded projects will 

have the opportunity to hire behavioral health providers to implement trauma informed services and programs, including the option 

to increase the number of paraprofessionals serving children, adolescents, and families. 

SAMHSA established the Federal Partners Committee on 

Women and Trauma that is co-chaired by the Department of Labor. 

The Committee’s work has been guided by the recognition that the 

impact of violence and trauma on women is a public health probVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 S:\DOCS\22689.TXT JACK
8 

lem with profound consequences for many different Federal departments and agencies. Initial efforts focused on identifying the impact of trauma on the mission and activities of each agency, raising 

awareness about trauma across government, and promoting evidence-based public health practices. The Committee includes more 

than 100 members from 40 divisions of 13 Federal departments 

and agencies. An objective is to build a trauma-informed Nation 

through effective practices and cross-agency, systemic efforts at 

governmental levels. The Committee hosted a trauma event that 

reached an estimated 2,000 individuals each day, over the course 

of two days. Given the impact of the Committee’s work and significance of trauma-informed approaches for AI/AN women. 

Discussions are underway on opportunities for leveraging these 

efforts as Federal partners work to support trauma-informed efforts for tribal youth, families, and communities build Federal and 

Tribal Capacity through On-Going and Coordinated Technical Assistance. HHS will continue to provide dynamic and collaborative 

technical assistance solutions that are evidence- and practice-informed, culturally relevant, and designed to help agencies and organizations build their capacity to improve and expand quality 

services to tribal communities. Examples of HHS work in this area 

include: ACF, in partnership with other HHS agencies and offices, 

is currently developing toolkits to assist human services programs 

bring a trauma-informed lens to programs serving children, youth, 

and families, including focused resources tailored to the needs of 

programs serving AI/AN individuals and communities. To assist 

managers and administrators of HHS-supported human services 

programs, the HHS Behavioral Health Coordinating Committee’s 

Subcommittee on Trauma and Early Intervention, which is co-led 

by ACF and the Office of the Assistant Secretary for Planning and 

Evaluation, will produce a Primer on Trauma-Informed Human 

Services. The Primer is designed to introduce human services program leaders and their staff at the state, tribal, territorial, and 

local level to recent advances in trauma, toxic stress, and executive 

functioning, and inform program leaders and their staff about the 

implications of this research for program design, policy, evaluation, 

and service delivery. The Primer stresses historical trauma, a form 

of complex trauma that manifests throughout the life span and is 

passed down through generations. This psychological suffering endured by a group is particularly relevant to AI/AN communities, 

and the Primer provides a road-map to resources from ACF, 

SAMHSA, IHS, and others on addressing trauma through human 

services programs in AI/AN communities. 

Discussions with tribal leaders on SAMHSA’s Tribal Technical 

Advisory Committee (TTAC) led to the conceptualization of the National Tribal Behavioral Health Agenda. The voices of TTAC were 

joined by tribal leaders on the HHS STAC and other engaged leaders who sought a comprehensive behavioral health effort grounded 

in tribal and federal collaboration. Their intent was to address the 

root causes of behavioral health problems in tribal communities 

and not just the contributing factors. Some of these problems result 

from adverse childhood experiences and traumatic events that have 

been experienced historically and intergenerationally. The root 

causes and resulting behavioral health issues impact other areas 

9 

that contribute to well-being such as overall health, education, employment, child welfare, and engagement with the justice system in 

response to these concerns, SAMHSA and IHS worked with other 

Federal agencies and the National Indian Health Board to identify 

foundational elements, priorities, and strategies for the TBHA. The 

TBHA was drafted based on the voices and recommendations of 

tribal leaders and representatives acknowledges the importance of 

tribal wisdom and cultural practices in meeting the needs of tribal 

communities; provides a clear, national statement about 

prioritizing behavioral health as an essential component to improving overall health and wellness; facilitates tribal/Federal collaboration on common behavioral health priorities; and supports opportunities for improving behavioral health-related policies and programs geared to the specific needs of tribal communities. 

I would be happy to share with your staff a more complete listing 

of the programs and activities HHS is engaged in which focus on 

addressing trauma and behavioral health and wellness. 

Thank you for your work on this important issue and the opportunity to speak with you today. I am happy to answer any questions you may have. 

[The prepared statement of Ms. Robinson follows:] 

PREPARED STATEMENT OF HON. LILLIAN SPARKS ROBINSON, COMMISSIONER, 

ADMINISTRATION OF NATIVE AMERICANS—ADMINISTRATION FOR CHILDREN AND

FAMILIES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Senator Heitkamp and members of the Senate Committee on Indian Affairs, it is 

my honor to testify before this Committee on behalf of the Department of Health 

and Human Services (HHS) on the important topic of ‘‘Addressing Trauma and 

Mental Health Challenges in Indian Country’’. I am a member of the Rosebud Sioux 

Tribe, which is located in South Dakota. I serve as the Commissioner for the Administration for Native Americans, which is part of the Administration for Children and 

Families (ACF), as well as the Chair of the Intradepartmental Council on Native 

American Affairs (ICNAA). 

Development of HHS-Wide Policy to Address Trauma 

In my role as chair of the ICNAA, I have led meetings involving leadership from 

ACF, the Indian Health Service (IHS), and the Substance Abuse and Mental Health 

Services Administration (SAMHSA) to discuss how we may better lead collaborative 

efforts on an intra-departmental level to support improved outcomes in the health 

and emotional well-being of American Indians and Alaska Natives (AI/AN) and others in tribal communities. ACF, SAMHSA, and IHS were highlighted in the Committee’s December 17 letter requesting HHS develop and implement an integrated 

and coordinated Federal approach to addressing complex trauma, including historical trauma in Indian communities and are the primary agencies bringing a traumainformed lens to this work. We have examined the causes and effects of trauma, including historical and childhood trauma, with an intentional view toward better understanding and highlighting steps tribes themselves are taking to prevent and address the effects of trauma. We believe developing a comprehensive, integrated, and 

trauma-informed HHS-wide policy that is sustainable over the long-term requires 

collaboration not only across the health and the human services components of 

HHS, but also, with other Federal agencies and our AI/AN partners. 

We are actively engaged in the development of an HHS-wide policy and are planning on releasing and implementing it within this calendar year. We are currently 

soliciting input from our tribal partners as well as incorporating substantive material from HHS Operating Divisions contributing to the Department’s comprehensive 

trauma-informed policy. The policy will focus on moving tribal health promotion forward as well as learning from and incorporating AI/AN models of prevention, care, 

and healing in partnership with tribal leaders, experts, and communities. 

Recently, I invited tribal leaders to a listening session held on August 9 to solicit 

input and recommendations to inform this important work. This listening session 

was held in Portland, Oregon in conjunction with the 2016 IHS American Indian/ 

10 

Alaska Native Behavioral Health Conference. We are tentatively planning additional listening sessions. 

In addition, guidance and recommendations of tribal leaders in the development 

of the National Tribal Behavioral Health Agenda (TBHA), led by SAMHSA, has 

greatly informed the on-going development of our HHS-wide policy addressing trauma. The process for development of the TBHA was the result of SAMHSA’s months 

of information gathering, discussion, analysis, validation, sharing, and revalidation 

of input received from Indian tribes and tribal leaders in coordination with the Indian Health Service’s Office of Clinical and Preventive Services (OCPS) and the National Indian Health Board (NIHB). Development of the TBHA has been a strong, 

collaborative effort among Indian tribes, national and regional tribal leaders, 

SAMHSA regional administrators and staff, and numerous Federal partners. 

As you know, tribal leaders have consistently asked for support in addressing behavioral health issues affecting their communities as part of broader discussions of 

health and wellness. To bring a targeted focus to such issues at the outset of our 

work to develop Department-wide policy, in March 2016, we solicited and tribal 

leadership provided, through the HHS’ Secretary’s Tribal Advisory Committee 

(STAC), their recommendations on how we could approach the development of a 

comprehensive, integrated departmental policy to address complex trauma in AI/AN 

communities. Among the input we received were recommendations that we not only 

identify and understand the root causes of trauma, but that we make specific efforts 

to ensure that Federal partners are educated about models and approaches developed from tribal perspectives to more effectively prevent and address trauma in tribal communities including trauma affecting AI/AN children, youth, and families. 

Based on this and other feedback from tribes, we are encouraged to move beyond 

a deficits-based perspective and to reflect in our policy emphasis on protective factors and positive youth development strategies aimed at promoting resilience, 

which, we believe may have a larger impact on prevention than risk reduction strategies alone. Further, since the most effective trauma-informed activity is to prevent 

trauma from occurring, we are working to identify and promote interventions, such 

as home visiting, which address the intergenerational transmission of trauma and 

build on the strengths of young parents. 

With our tribal partners, we are moving forward to develop approaches that focus 

on cultivating, strengthening, and lifting up the Native assets and cultural resources found in AI/AN communities. One of the recommendations we heard 

through the STAC members was that our policy should acknowledge tribal elders 

as assets and resources. At a STAC meeting in June, we discussed the critical role 

of tribal elders in the development and implementation of policies addressing trauma, including strategies to foster resilience. Our colleagues in the Administration 

for Community Living (ACL), whose mission includes working with seniors and tribal elders, will be indispensable in our work to fully reflect tribal elders’ roles in addressing trauma. 

At the Departmental Fiscal Year (FY) 2018 Tribal Budget Consultation, Ms. 

Mirtha Beadle, the Director of the Office of Tribal Affairs and Policy at SAMHSA 

shared with tribal leaders that in HHS we take trauma and its effects very seriously 

and that it is something that informs our work every day as part of an all-HHS 

commitment to Native Americans. 

Beyond our work to develop a written HHS policy to effectively address trauma 

in AI/AN communities, others in the Department and I are working with Federal 

agency partners through the White House Council on Native Americans Affairs, an 

interagency body established to improve coordination of Federal programs, to develop a Federal Government-wide approach to improve our capacity, coordination, 

and collaboration in addressing the wellness of AI/AN communities. 

Ongoing Work to Address Trauma 

Since receipt of the Committee’s letter, my colleagues and I have worked hard to 

reach across agencies to identify trauma-informed work already being done in the 

Department and ways we, as champions for AI/AN children, youth, families, and 

communities, can coordinate this work better. We are focused on ways we can more 

effectively take advantage of the Department’s health and human services assets. 

I would like to share with the Committee and participants in this field hearing 

the three-pronged framework HHS is pursuing. 

Prong 1—Increase Awareness and Understanding. The initial step is to improve 

information available to key staff across HHS about the extent and impact of trauma in tribal communities and opportunities to more effectively improve well-being. 

This prong will be supported by increasing Federal staff access to webinars and informational materials and encouraging greater engagement with tribal leaders and 

representatives. Resources and discussions are intended to build staff knowledge 

11 

about cultural, practice, and evidence-based opportunities for creating and/or supporting systems that are trauma-informed. 

Among some examples of specific HHS activities to increase Federal staff awareness and understanding of trauma and its effects are: 

• The development of the ACF Principles for Working with Federally Recognized 

Indian Tribes; a set of principles designed and intended to foster AI/AN wellbeing by providing a framework for Federal leadership, partnership, and compassionate and effective human services delivery. These principles are intended 

to guide the internal management of ACF in its partnership with people in Federally-recognized tribes. 

• The launching of the ACF Trauma Network, which is a community of practice 

for ACF staff designed to share lessons learned and promising practices and to 

strengthen the agency’s ability to support trauma-informed programmatic work. 

The ACF Trauma Network will host an internal training on issues of trauma 

and resilience in AI/AN communities, currently scheduled for October 2016. 

This program will address research on protective factors and positive youth development strategies that may have a larger impact on prevention of negative 

health outcomes than risk reduction strategies. Representatives from the Center 

for American Indian Health of the Johns Hopkins School of Public Health will 

share with ACF leadership and staff strength-based interventions developed 

and evaluated with the White Mountain Apache and Navajo communities; interventions that have now been scaled to 75 tribal communities across 15 states, 

and two non-Native communities. 

• Each year, SAMHSA, through its Tribal Training and Technical Assistance 

Center, hosts a training program focused on improving the Agency’s work with 

AI/AN people. The training includes experiential exercises to assist SAMHSA 

staff gain greater awareness and understanding of intergenerational and historical trauma and their effects on tribal communities. The training is delivered 

in a format that allows SAMHSA staff at all levels to participate during the 

three-day program. Webinars are also offered throughout the year to improve 

knowledge about trauma-related issues in tribal communities and opportunities 

for addressing them. 

• Home visiting helps expectant families and those with young children provide 

stimulating learning environments and nurturing relationships. Beginning in 

2013, the IHS Community Health Representatives Program also partnered with 

the Center for American Indian Health of the Johns Hopkins School of Public 

Health to implement Family Spirit, an evidence-based, culturally tailored homevisiting program as a core strategy to support young families. Six pilot sites received intensive on-site training and technical assistance. Using lessons learned 

from the pilot project, IHS and Johns Hopkins will expand Family Spirit for implementation in other tribal communities beginning in 2016. Since 2010, ACF 

has been operating the Tribal Home Visiting Program, part of the Maternal, Infant, and Early Childhood Home Visiting Program. The Tribal Home Visiting 

Program is an unprecedented expansion of culturally responsive services for 

vulnerable AI/AN families and children. The program serves some of the most 

vulnerable families who experience multiple challenges often attributed to historical trauma. The program has served a total of 1,523 families and provided 

nearly 20,000 home visits through 25 funded grantees in 14 states. There are 

currently 15 rural grantees, three urban grantees, and seven grantees in a mix 

of rural and urban settings. 

• IHS provides comprehensive training options to build a workforce that is trauma-informed and responsive. Topics cover historical trauma, adverse childhood 

experiences, early screening and assessment of trauma, treating complex trauma, trauma informed care services and programming, and many others. Training is available online through the IHS TeleBehavioral Health Center of Excellence. 

• This year’s IHS AI/AN National Behavioral Health Conference was planned 

around the theme, ‘‘Creating Trauma Informed Systems in AI/AN Communities.’’ The conference was held in Portland, Oregon, from August 9–11, 2016, 

with 550 registrants over 35 breakout sessions, 90 presenters, and more than 

45 continuing education hours offered at no cost to participants. 

Prong 2—Improve Coordination and Collaboration. HHS is developing a comprehensive, integrated policy on actions that support healing from trauma and advance trauma-informed practices through programs that contribute to improving the 

health and well-being of tribal communities. As part of our work with the other 

agencies on these issues, we are developing a template for creating complementary 

12 

policies across Federal agencies that support trauma-informed practices. The intent 

is to: (1) strengthen support systems across health, behavioral health, education, 

child welfare, justice services, environmental, and other Federal programming; (2) 

improve actions to recognize and address the impacts of adverse childhood experiences among AI/AN populations; and (3) to the extent possible, better align programs to address trauma, prevent additional trauma, and support trauma-informed 

services that are continuous across systems. 

Examples of specific HHS activities to improve coordination and collaboration include: 

• ACF, in collaboration with the Centers for Disease Control and Prevention, 

Health Resources and Services Administration, IHS, and SAMHSA, is leading 

work to support improved social-emotional and behavioral health for children 

and families in tribal communities. The agencies hosted a one-day Tribal Experts Workgroup Meeting on February 25. The meeting included tribal leaders, 

community members, researchers, and advocates, as well as representatives 

from Federal agencies including HHS, the Department of Justice, and the Office 

of Management and Budget. The goal of the meeting was to learn from experts 

and discuss how we can better work together to: (1) raise awareness of challenges that pre-school children face in tribal populations with high rates of 

adult mental health and substance abuse issues; (2) provide tools and effective 

strategies for caregivers to support improved social-emotional and behavioral 

health outcomes for children and their families in tribal communities; and (3) 

develop policy recommendations to address funding and service delivery challenges. 

• Development of a comprehensive ACF Native American Child and Youth Policy 

Agenda to highlight the ongoing work of ACF program and staff offices to support thriving, resilient, safe, healthy, and economically secure children, families, 

and communities. The focus areas for this Policy Agenda are: (1) quality early 

childhood development and learning; (2) the role of self-determination and nation-building in strengthening families; (3) fostering child and youth well-being 

and resiliency in the face of trauma and adversity; (4) financial and economic 

security; and (5) building a new narrative with data. The ACF Policy Agenda 

is intended to both function as a structure for innovative policymaking to guide 

stronger and more effective programming and to lift up successful tribal models 

across the identified five focus areas. The Policy Agenda is very much an actionoriented roadmap we hope will provide AI/AN parents, caregivers, leadership, 

and children and youth, and federal staff with the tools they need to ensure improved child and youth outcomes. 

• IHS, in collaboration with SAMHSA, developed the FY 2016 funding opportunity for the Methamphetamine and Suicide Prevention Initiative Generation 

Indigenous. The funding opportunity is framed around addressing trauma by focusing on the following objectives: increasing positive youth development, building resiliency, and promoting family engagement. Newly awarded projects will 

have the opportunity to hire behavioral health providers to implement trauma 

informed services and programs, including the option to increase the number 

of paraprofessionals serving children, adolescents, and families. 

• SAMHSA established the Federal Partners Committee on Women and Trauma 

that is co-chaired by the Department of Labor. The Committee’s work has been 

guided by the recognition that the impact of violence and trauma on women is 

a public health problem with profound consequences for many different Federal 

departments and agencies. Initial efforts focused on identifying the impact of 

trauma on the mission and activities of each agency, raising awareness about 

trauma across government, and promoting evidence-based public health practices. The Committee includes more than 100 members from 40 divisions of 13 

Federal departments and agencies. An objective is to build a trauma-informed 

Nation through effective practices and cross-agency, systemic efforts at governmental levels. The Committee hosted a trauma event that reached an estimated 

2,000 individuals each day, over the course of two days. Given the impact of 

the Committee’s work and significance of trauma-informed approaches for AI/ 

AN women, discussions are underway on opportunities for leveraging these efforts as Federal partners work to support trauma-informed efforts for tribal 

youth, families, and communities. 

Prong 3—Build Federal and Tribal Capacity through On-Going and Coordinated 

Technical Assistance. HHS will continue to provide dynamic and collaborative technical assistance solutions that are evidence- and practice-informed, culturally relevant, and designed to help agencies and organizations build their capacity to imVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00016 Fmt 6633 Sfmt 6621 S:\DOCS\22689.TXT JACK
13 

prove and expand quality services to tribal communities. Examples of HHS work in 

this area include: 

• ACF, in partnership with other HHS agencies and offices, is currently developing toolkits to assist human services programs bring a trauma-informed lens 

to programs serving children, youth, and families, including focused resources 

tailored to the needs of programs serving AI/AN individuals and communities. 

To assist managers and administrators of HHS-supported human services programs, the HHS Behavioral Health Coordinating Committee’s Subcommittee on 

Trauma and Early Intervention, which is co-led by ACF and the Office of the 

Assistant Secretary for Planning and Evaluation, will produce a Primer on 

Trauma-Informed Human Services. The Primer is designed to introduce human 

services program leaders and their staff at the state, tribal, territorial, and local 

level to recent advances in trauma, toxic stress, and executive functioning, and 

inform program leaders and their staff about the implications of this research 

for program design, policy, evaluation, and service delivery. The Primer stresses 

historical trauma, a form of complex trauma that manifests throughout the life 

span and is passed down through generations. This psychological suffering endured by a group is particularly relevant to AI/AN communities, and the Primer 

provides a road-map to resources from ACF, SAMHSA, IHS, and others on addressing trauma through human services programs in AI/AN communities. 

• Discussions with tribal leaders on SAMHSA’s Tribal Technical Advisory Committee (TTAC) led to the conceptualization of the National Tribal Behavioral 

Health Agenda. The voices of TTAC were joined by tribal leaders on the HHS 

STAC and other engaged leaders who sought a comprehensive behavioral health 

effort grounded in tribal and federal collaboration. Their intent was to address 

the root causes of behavioral health problems in tribal communities and not just 

the contributing factors. Some of these problems result from adverse childhood 

experiences and traumatic events that have been experienced historically and 

intergenerationally. The root causes and resulting behavioral health issues impact other areas that contribute to well-being such as overall health, education, 

employment, child welfare, and engagement with the justice system. 

• In response to these concerns, SAMHSA and IHS worked with other Federal 

agencies and the National Indian Health Board to identify foundational elements, priorities, and strategies for the TBHA. The TBHA was drafted based 

on the voices and recommendations of tribal leaders and representatives—it acknowledges the importance of tribal wisdom and cultural practices in meeting 

the needs of tribal communities; provides a clear, national statement about 

prioritizing behavioral health as an essential component to improving overall 

health and wellness; facilitates tribal/Federal collaboration on common behavioral health priorities; and supports opportunities for improving behavioral 

health-related policies and programs geared to the specific needs of tribal communities. 

I would be happy to share with your staff a more complete listing of the programs 

and activities HHS is engaged in which focus on addressing trauma and behavioral 

health and wellness. 

Thank you for your work on this important issue and the opportunity to speak 

with you today. I am happy to answer any questions you may have. 

Senator HEITKAMP. Thank you. Next we will hear from Officer 

Darren Cruzan. He is the Director of the Office of Justice Services 

at the Bureau of Indian Affairs in the Department of the Interior. 

STATEMENT OF DARREN CRUZAN, DIRECTOR, OFFICE OF 

JUSTICE SERVICES, BUREAU OF INDIAN AFFAIRS, U.S. 

DEPARTMENT OF THE INTERIOR 

Mr. CRUZAN. My name is Darren Cruzan and I am the Director 

for the Office of Justice Services at the Bureau of Indian Affairs 

in the Department of the Interior. I am pleased to submit this 

statement for the Department on the topic of ‘‘Addressing Trauma 

and Mental Health Challenges in Indian Country.’’ 

As a result of repudiated past federal policies intended to disrupt 

American Indian and Alaska Native (AI/AN) families, today many 

14 

tribal citizens suffer from the effects of generational trauma. Trauma may be from emotional abuse, physical abuse, sexual abuse, 

emotional neglect, physical neglect, witnessing substance abuse or 

domestic violence in the home, or experiencing a parent’s divorce 

or incarceration. Symptoms can range from anxiety, impulsivity, to 

depression, and can manifest themselves as criminal behavior, poor 

school performance, chronic illness, and mental health issues. In 

November 2014, the Attorney General’s Taskforce on American Indian/Alaska Native Children Exposed to Violence documented a 

high rate of trauma in Indian Country and made policy recommendations to reduce it. 

As the Department responsible for providing law enforcement, 

child protection services and social workers, support for tribal 

courts, and education services, we know we are a key partner in 

addressing trauma in Indian Country. While we do not diagnose or 

treat individuals, we or tribes that administer our programs and 

services are the often the first responders to crisis in the home or 

at school and serve as a bridge for connecting families and individuals to the services they need. Officers, teachers, social worker and 

other professionals also witness firsthand the lack of resources 

available to treat the underlying conditions responsible for many of 

the troubling statistics. We appreciate the Committee’s efforts to 

raise awareness of this important issue and the opportunity to provide testimony today. 

BIA Trauma Informed Care Training Progress in addressing 

trauma in Indian Country cannot be made until more education on 

trauma and its effects occurs. To better equip our staff, earlier this 

year, the BIA provided training to all BIA regional social workers 

on trauma informed care. This training was presented by subject 

matter experts from the National Institute of Health and Johns 

Hopkins University. The regional social workers received information on historical trauma and additional training opportunities regarding this issue. 

In addition to this nationwide training, many of the regions are 

providing training directly to, or in partnership with, tribes in their 

service areas. Some examples are: Alaska Region—In partnership 

with the Southcentral Foundation Family Wellness Program, the 

Alaska Region provided trauma informed care training at the BIA 

Providers Conference this past year. The presentation was attended by approximately 400 tribal representatives, including 

ICWA workers, tribal administrators and tribal council members. 

Southern Plains Region, The Anadarko Agency, located in the 

Southern Plains Region, operates the Positive Indian Parenting 

Program, an effort to address the parenting challenges the Agency 

has identified in their clients. This program was developed by the 

Agency after years of seeing how historical trauma impacting parenting skills as a result of the parents, experience during the 

boarding school era. These problems have been passed down generation to generation, and impacts many child protective services 

referrals the Agency receives. The Positive Indian Parenting Program instructor is certified through the Active Parenting Program 

and has attended and uses the curriculum from the National Indian Child Welfare Association’s (NICWA) Positive Indian Parenting training. Through the combination of these parenting proVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00018 Fmt 6633 Sfmt 6601 S:\DOCS\22689.TXT JACK
15 

grams, the Agency has provided positive Indian parenting courses 

to Native parents. ,h Rocky Mountain Region—The Rocky Mountain Regional Office has forged a partnership with the Native Children’s Trauma Center—University of Montana for the last five 

years to develop Trauma Informed Child Protection Services. The 

Native Children’s Trauma Center has done training for social service staff and tribal court staff over that period, and has provided 

onsite technical assistance at case staffing and child protection 

meetings. The region provided several region-wide trainings, a 

webinar series and more recently in 2016, developed a two-week 

trauma informed training curriculum for Social Service staff. ,h 

Midwest Region—The BIA, Midwest Regional Office in partnership 

with the Native Wellness Institute (NWI) offered a series of trauma-informed training to the Tribes at the Midwest Region’s 2016 

Partners in Action Conference. The NWI recognizes the great impacts of historical trauma on Native people, and its impact on current day trauma in our families and communities. The NWI’s mission is to promote the well-being of individuals, families and communities; to create an awareness of where our negative behavior 

comes from and provide opportunities for community/family growth 

and healing. 

We are also empowering tribal communities to address trauma 

in their communities. As recommended by the Attorney General in 

3.1 of its report, Ending Violence so Children Can Thrive, we created a new initiative to allow tribes to braid federal funds together 

to address the distinct needs of their communities. 

Tiwahe, which means family in Lakota, is an initiative designed 

to demonstrate the effectiveness of wraparound services in tribal 

communities. It looks at funding streams from social services, child 

welfare, employment and training, recidivism and/or tribal courts 

and asks tribes to develop a plan to combine these funding streams 

to improve outcomes. The goal is to reduce the rate AI/NA children 

enter foster care, increase family reunification rates, reduce recidivism rates, and build capacity within tribal courts. 

In FY 2016, six tribes are participating in the demonstration 

project. These are: the Association of Village Council Presidents 

(AVCP); the Spirit Lake Tribe; Red Lake Band of Chippewa Indians; Ute Mountain Ute Tribe; Fort Belknap Indian Community; 

and the Pascua Yaqui Tribe. In addition, all tribes received an 

across-the-board increase to their base funding, referred to as Tribal Priority Allocation, for Indian Child Welfare Act and Social Services. We recently hired a National Tiwahe Coordinator who will 

start later this month to work with participating tribes. 

As we continue to build this program, our hope is to also improve 

how we collect data in partnership with tribes to fully understand 

how trauma and its effects impact Indian County. 

Current, relevant, and robust data is necessary to make informed 

policy decisions to craft effective trauma interventions. 

There is no more important issue than addressing the high suicide rate in Indian Country, particularly among youth, which is 

often the result of an individual’s exposure to trauma. Indian Affairs is directly involved in youth suicide prevention through the 

BIE, which provides technical assistance and monitoring to ensure 

schools are compliant with intervention strategies and reporting 

16 

protocols to further ensure student safety. In addition, under the 

BIE reorganization the School Health Policy Advisor position was 

created. This individual will support the BIE Associate Deputy Directors, staff in the Education Resource Centers and BIE schools 

with the development of additional mental health programs, initiatives and policies as well as suicide and substance abuse prevention. They will also coordinate with the BIA and support interagency work of the White House Council on Native American Affairs. 

BIE’s partnering with other federal agencies, including the Departments of Health and Human Services (Substance Abuse and 

Mental Health Services Administration and the Indian Health 

Service (IHS)) and Education, has enabled BIE to address the 

unique needs of students within these schools in the areas of mental and substance use disorders, including suicide. 

The BIE has developed a Suicide Prevention, Early Intervention 

and Postvention Policy to promote suicide prevention in BIE 

schools. The policy mandates specific actions in all schools, dormitories and the two post-secondary institutions; and encourages 

tribally-operated schools to develop similar policies. These actions 

create a safety net for students who are at risk of suicide and promotes proactive involvement of school personnel and communities 

in intervention, prevention and postvention activities. 

The BIA Office of Justice Services (OJS) partners with numerous 

health and social service programs to assist in educating and presenting at schools, seminars, workshops and community events to 

the youth and the community on suicide prevention. OJS gathers 

statistical data and identifies youth suicide trends within Indian 

Country, and will look for ways to expand suicide prevention training with other stakeholders in the future. 

The BIA’s Law Enforcement and Tribal Services programs, along 

with the BIE, continually seek ways to collaborate and to support 

activities directed at suicide prevention and services coordination. 

The BIE utilizes the Youth Risk Behavior Survey, Native American 

Student Information System (NASIS), local BIA Law Enforcement, 

and IHS data to develop interventions and track trends for program implementation and is committed to seeking out and enacting 

prevention strategies while ensuring a safe and secure environment for our students. 

Additionally, BIE schools and dormitories use NASIS to track 

and identify specific behavior trends to develop interventions to address school specific behavior issues. Training is provided on site 

by the School Safety Specialist at a number of locations throughout 

the school year during staff training sessions and all residential 

staff are required to receive suicide prevention training. 

It is important to note that Indian Country continues to suffer 

from a lack of comprehensive mental health treatment options. For 

example, OJS officers responding to a call for service involving a 

suicide threat are often left with no option but to arrest the individual. Without mental health facilities, jail is oftentimes the only 

place where the safety of the individual can be guaranteed. 

Indian Affairs has the advantage of working alongside tribes and 

understands firsthand the severity of the lack of resources in Indian Country and the impact it has on tribal communities. We look 

17 

forward to our continued partnership with Tribal governments, on 

a government-to-government basis, and with our federal partners 

to continue to address trauma related issues. 

Thank you. I will give the rest of my time to the others. 

[The prepared statement of Mr. Cruzan follows:] 

PREPARED STATEMENT OF DARREN CRUZAN, DIRECTOR, OFFICE OF JUSTICE SERVICES, BUREAU OF INDIAN AFFAIRS, U.S. DEPARTMENT OF THE INTERIOR

My name is Darren Cruzan and I am the Director for the Office of Justice Services at the Bureau of Indian Affairs in the Department of the Interior. I am pleased 

to submit this statement for the Department on the topic of ‘‘Addressing Trauma 

and Mental Health Challenges in Indian Country.’’ 

As a result of repudiated past federal policies intended to disrupt American Indian and Alaska Native (AI/AN) families, today many tribal citizens suffer from the 

effects of generational trauma. Trauma may be from emotional abuse, physical 

abuse, sexual abuse, emotional neglect, physical neglect, witnessing substance abuse 

or domestic violence in the home, or experiencing a parent’s divorce or incarceration. 

Symptoms can range from anxiety, impulsivity, to depression, and can manifest 

themselves as criminal behavior, poor school performance, chronic illness, and mental health issues. In November 2014, the Attorney General’s Taskforce on American 

Indian/Alaska Native Children Exposed to Violence documented a high rate of trauma in Indian Country and made policy recommendations to reduce it. 

As the Department responsible for providing law enforcement, child protection 

services and social workers, support for tribal courts, and education services, we 

know we are a key partner in addressing trauma in Indian Country. While we do 

not diagnose or treat individuals, we or tribes that administer our programs and 

services are the often the first responders to crisis in the home or at school and 

serve as a bridge for connecting families and individuals to the services they need. 

Officers, teachers, social worker and other professionals also witness firsthand the 

lack of resources available to treat the underlying conditions responsible for many 

of the troubling statistics. We appreciate the Committee’s efforts to raise awareness 

of this important issue and the opportunity to provide testimony today. 

BIA Trauma Informed Care Training 

Progress in addressing trauma in Indian Country cannot be made until more education on trauma and its effects occurs. To better equip our staff, earlier this year, 

the BIA provided training to all BIA regional social workers on trauma informed 

care. This training was presented by subject matter experts from the National Institute of Health and Johns Hopkins University. The regional social workers received 

information on historical trauma and additional training opportunities regarding 

this issue. 

In addition to this nationwide training, many of the regions are providing training 

directly to, or in partnership with, tribes in their service areas. Some examples are: 

• Alaska Region—In partnership with the Southcentral Foundation Family 

Wellness Program, the Alaska Region provided trauma informed care training 

at the BIA Providers Conference this past year. The presentation was attended 

by approximately 400 tribal representatives, including ICWA workers, tribal administrators and tribal council members. 

• Southern Plains Region—The Anadarko Agency, located in the Southern Plains 

Region, operates the Positive Indian Parenting Program, an effort to address 

the parenting challenges the Agency has identified in their clients. This program was developed by the Agency after years of seeing how historical trauma 

impacting parenting skills as a result of the parents’ experience during the 

boarding school era. These problems have been passed down generation to generation, and impacts many child protective services referrals the Agency receives. The Positive Indian Parenting Program instructor is certified through 

the Active Parenting Program and has attended and uses the curriculum from 

the National Indian Child Welfare Association’s (NICWA) Positive Indian Parenting training. Through the combination of these parenting programs, the 

Agency has provided positive Indian parenting courses to Native parents. 

• Rocky Mountain Region—The Rocky Mountain Regional Office has forged a 

partnership with the Native Children’s Trauma Center—University of Montana 

for the last five years to develop Trauma Informed Child Protection Services. 

The Native Children’s Trauma Center has done training for social service staff 

and tribal court staff over that period, and has provided onsite technical assistVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 S:\DOCS\22689.TXT JACK
18 

ance at case staffing and child protection meetings. The region provided several 

region-wide trainings, a webinar series and more recently in 2016, developed a 

two-week trauma informed training curriculum for Social Service staff. 

• Midwest Region—The BIA, Midwest Regional Office in partnership with the 

Native Wellness Institute (NWI) offered a series of trauma-informed training to 

the Tribes at the Midwest Region’s 2016 Partners in Action Conference. The 

NWI recognizes the great impacts of historical trauma on Native people, and 

its impact on current day trauma in our families and communities. The NWI’s 

mission is to promote the well-being of individuals, families and communities; 

to create an awareness of where our negative behavior comes from and provide 

opportunities for community/family growth and healing. 

Tiwahe Initiative 

We are also empowering tribal communities to address trauma in their communities. As recommended by the Attorney General in 3.1 of its report, ‘‘Ending Violence so Children Can Thrive,’’ we created a new initiative to allow tribes to braid 

federal funds together to address the distinct needs of their communities. 

Tiwahe, which means family in Lakota, is an initiative designed to demonstrate 

the effectiveness of wraparound services in tribal communities. It looks at funding 

streams from social services, child welfare, employment and training, recidivism 

and/or tribal courts and asks tribes to develop a plan to combine these funding 

streams to improve outcomes. The goal is to reduce the rate AI/NA children enter 

foster care, increase family reunification rates, reduce recidivism rates, and build 

capacity within tribal courts. 

In FY 2016, six tribes are participating in the demonstration project. These are: 

the Association of Village Council Presidents (AVCP); the Spirit Lake Tribe; Red 

Lake Band of Chippewa Indians; Ute Mountain Ute Tribe; Fort Belknap Indian 

Community; and the Pascua Yaqui Tribe. In addition, all tribes received an acrossthe-board increase to their base funding, referred to as Tribal Priority Allocation, 

for Indian Child Welfare Act and Social Services. We recently hired a National 

Tiwahe Coordinator who will start later this month to work with participating 

tribes. 

As we continue to build this program, our hope is to also improve how we collect 

data in partnership with tribes to fully understand how trauma and its effects impact Indian County. Current, relevant, and robust data is necessary to make informed policy decisions to craft effective trauma interventions. 

Suicide Prevention 

There is no more important issue than addressing the high suicide rate in Indian 

Country, particularly among youth, which is often the result of an individual’s exposure to trauma. Indian Affairs is directly involved in youth suicide prevention 

through the BIE, which provides technical assistance and monitoring to ensure 

schools are compliant with intervention strategies and reporting protocols to further 

ensure student safety. In addition, under the BIE reorganization the School Health 

Policy Advisor position was created. This individual will support the BIE Associate 

Deputy Directors, staff in the Education Resource Centers and BIE schools with the 

development of additional mental health programs, initiatives and policies as well 

as suicide and substance abuse prevention. They will also coordinate with the BIA 

and support interagency work of the White House Council on Native American Affairs. 

BIE’s partnering with other federal agencies, including the Departments of Health 

and Human Services (Substance Abuse and Mental Health Services Administration 

and the Indian Health Service (IHS)) and Education, has enabled BIE to address 

the unique needs of students within these schools in the areas of mental and substance use disorders, including suicide. 

The BIE has developed a Suicide Prevention, Early Intervention and Postvention 

Policy to promote suicide prevention in BIE schools. The policy mandates specific 

actions in all schools, dormitories and the two post-secondary institutions; and encourages tribally-operated schools to develop similar policies. These actions create 

a safety net for students who are at risk of suicide and promotes proactive involvement of school personnel and communities in intervention, prevention and 

postvention activities. 

The BIA Office of Justice Services (OJS) partners with numerous health and social service programs to assist in educating and presenting at schools, seminars, 

workshops and community events to the youth and the community on suicide prevention. OJS gathers statistical data and identifies youth suicide trends within Indian Country, and will look for ways to expand suicide prevention training with 

other stakeholders in the future. 

19 

The BIA’s Law Enforcement and Tribal Services programs, along with the BIE, 

continually seek ways to collaborate and to support activities directed at suicide prevention and services coordination. The BIE utilizes the Youth Risk Behavior Survey, 

Native American Student Information System (NASIS), local BIA Law Enforcement, 

and IHS data to develop interventions and track trends for program implementation 

and is committed to seeking out and enacting prevention strategies while ensuring 

a safe and secure environment for our students. 

Additionally, BIE schools and dormitories use NASIS to track and identify specific 

behavior trends to develop interventions to address school specific behavior issues. 

Training is provided on site by the School Safety Specialist at a number of locations 

throughout the school year during staff training sessions and all residential staff are 

required to receive suicide prevention training. 

It is important to note that Indian Country continues to suffer from a lack of comprehensive mental health treatment options. For example, OJS officers responding 

to a call for service involving a suicide threat are often left with no option but to 

arrest the individual. Without mental health facilities, jail is oftentimes the only 

place where the safety of the individual can be guaranteed. 

Conclusion 

Indian Affairs has the advantage of working alongside tribes and understands 

firsthand the severity of the lack of resources in Indian Country and the impact it 

has on tribal communities. We look forward to our continued partnership with Tribal governments, on a government-to-government basis, and with our federal partners to continue to address trauma related issues. 

Senator HEITKAMP. I have been preaching to the rest of the world 

about the great success that you had addressing trauma. So I want 

to congratulate you and the tribal leadership on taking this on. 

Your work has been recognized. You have a long history of working 

on behalf of your tribe and importantly on behalf of the children 

of your tribe. So I’m interested in hearing, and I know my colleagues and Senator Hoeven are interested in hearing about your 

success and what ideas we can share with the rest of the world. 

Thank you. 

STATEMENT OF HON. MYRNA WARRINGTON, CHAIRWOMAN, 

HEALTH AND FAMILY COMMITTEE, MENOMINEE INDIAN 

TRIBE OF WISCONSIN 

Ms. WARRINGTON. Thank you for inviting us here. It’s good to 

know that tribes have been recognized nationally for their effort to 

address the problems of our children and families. Senator 

Heitkamp, Senator Hoeven, and members of the Committee, my 

name is Myrna Warrington. This is my 8th year serving as on the 

Menominee Tribal Legislature and at this time I serve on the Menominee Indian Tribe’s Executive Team as the Secretary. Thank 

you for the opportunity to provide the Committee with the Menominee statement that addresses the trauma and mental health challenges experienced in Indian Country. 

The Menominee Indian Tribe is located in northeast Wisconsin, 

within our ancestral territory. Our Reservation is comprised of 

234,000 acres of land; bountiful in rivers, lakes, streams, wildlife, 

and forest land. Roughly 90 percent of the land held in trust for 

the Tribe is held in sustained yield for the Tribe’s long-standing 

practice in Sustainable Forest Management. The Tribal membership includes over 9,000 enrolled members. 

The Tribes history is mired in trauma due to the loss of Tribal 

status, identity, language and culture that was forced on our people 

by the Federal Government through overarching assimilation objectives, enactments of federal Indian policy, treaties, and judicial rulVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00023 Fmt 6633 Sfmt 6601 S:\DOCS\22689.TXT JACK
20 

ings. The negative remnants of trauma experienced from the treaty 

era, Boarding School Era, Menominee Termination Act of 1954, 

Federal Relocation Act of 1956, and finally the Restoration of the 

Menominee Indian Tribe to Federal Recognition in 1973, remain 

visible in the lives of our Tribal members. Throughout the last two 

centuries, the Menominee endured the large loss of ancestral territory, near extinction of Menominee language, and the loss of many 

critical cultural and religious beliefs, practices and communal values that guided the traditional Menominee society. Our oral history 

and the historical record remain to help guide the Tribe in the 

right direction to address the impacts from these experiences. 

In 2006, the Menominee Tribal Government, Menominee Indian 

School District, and Menominee Tribal Clinic, who, because of limited resources with narrow guidelines, broke down the silos to form 

the community collaboration. The Menominee Community Collaboration committed to creating data-driven solutions. The purpose 

was aimed at addressing the cumulative impacts that historical 

and intergenerational trauma were presenting upon the families of 

the Menominee Community. The initial identification process 

began with defining the negative behavioral, health, and educational problems that were manifesting in the lives of the Menominee youth. The community collaboration research led to the 

premise that the symptoms of poverty, low academic achievement, 

and poor health outcomes and factors were interconnected. 

Through this process, the Tribe was forced to confront the reality 

that the negative changes occurring within the youth population 

were a direct result of the changing family dynamic and community structure that were symptoms of a larger problem. These 

issues had not manifested overnight and were not isolated to just 

one event, but rather were symptoms resulting from trauma experienced throughout the course of the Tribes history. 

What is trauma informed care? Trauma Informed Care is defined 

as an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of 

all types of trauma. Trauma informed care also emphasizes physical, psychological and emotional safety for both consumers and 

providers, and helps survivors rebuild a sense of control and empowerment for the Menominee, the definitional scope of trauma 

was lacking any recognition of self-worth and cultural competency 

and had to be expanded to include the loss of Menominee language, 

values, and beliefs in order to accurately examine the collective impacts that historical and intergenerational trauma had on the community as a whole. By doing so, the Tribe was able to identify the 

symptoms of trauma which included suicide, poverty, substance 

abuse/addiction, identity loss, loss of societal/cultural norms, and 

many others and identify the impacts that these had on the individual, family unit, and community. 

To accurately assess the magnitude of traumatic experiences and 

the impact these had on Menominee youth and within the family 

dynamic, the Community Collaboration examined the statistics 

identifying child victimization rates in Menominee County which 

included neglect, abuse, suicide attempts, and alcohol and drug 

use/abuse. In 2013, 1,423 children resided on the Menominee Indian Reservation. According to the 2013 Wisconsin Department of 

21 

Children & Families Annual Report to the Governor and Legislature, approximately 10 children in 1,000 were victimized by either 

neglect, physical, sexual or emotional abuse. Equally alarming was 

the high incidence of youth hospitalizations for AODA and selfharm. For example, in 2015, there were 10 youth hospitalizations 

for emergency detention alone. From January through June 2016, 

there have already been a total of 14 emergency detention hospitalizations, 11 youth hospitalized, and 8 out of 11 youth hospitalized reported substance abuse and/or tested positive for alcohol or 

drugs at the time of admission. Statistics such as these are what 

initiated what is now known as the Menominee Fostering Futures 

Pilot Project that began in 2013. 

Based on the statistics identifying the high incidence of traumatic experiences for tribal children, the Community Collaboration 

identified that existing policies, procedures, and mandates were not 

working. Menominee children and families were continuing to suffer. The County/Tribe was continually ranked 72 out of 72 for 

health outcomes and factors by the University of Wisconsin Population Health Institute. Educational Attainment was at an all-time 

low among high school students. The Menominee Indian School 

District was in fact, coined a drop-out factor due to the extremely 

low percentage of students graduating. Finally, crime, victimization, and death rates remained high. 

The Community Collaborative Workgroup started by building a 

Menominee Model using the Bridges Out of Poverty framework 

which was a model for economic and social change, sustainability 

and stability. The simple premise of the Community Collaboration 

Workgroup identified that the causes of poverty, low academic 

achievement and poor health are inter-connected and formulated 

that the resources and responses the Community Collaboration 

would develop to combat them must also be inter-connected. This 

Community Collaborative workgroup vision of the Menominee 

Model evolved over time, which included the introduction and development of the Menominee Fostering Futures Initiative. 

The goal of Fostering Futures was designed to improve the lives 

of children and families by translating the knowledge gained from 

the Adverse Childhood Experience Study, neuroscientific information, and mental health literature on the long-term effects of chronic adversity and trauma in childhood. As a part of our Fostering 

Futures work, we had to pick 2 areas of concentration for our community. We chose the following: (1) Providing Adverse Childhood 

Experience Study and Trauma Informed Care education; and (2) 

Evaluating and modifying policies and procedures to be congruent 

with the Adverse Childhood Experience study and Trauma Informed Care. 

From the first goal, our Introduction to Trauma Informed Care 

training was developed. Initiatives of the Community Collaboration 

have included: Education Summits focused on Historical Trauma 

due to boarding schools and termination; the implementation of the 

Fostering Futures Program reservation wide promoting community 

awareness of Adverse Childhood Experiences (ACEs) and Trauma 

Informed Care (TIC). 

Trauma Informed Service Delivery is a key component and focus 

of the Community Engagement Workgroup. The Community EnVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00025 Fmt 6633 Sfmt 6601 S:\DOCS\22689.TXT JACK
22 

gagement meetings focus on the development, execution and completion of 90-day plans developed and reported quarterly on issues 

established by the workgroup that now involve all community service providers. The Tribe’s programs are implementing Trauma Informed Services by: reviewing internal policies and practices with 

an awareness of Trauma Informed Care; Continuing the Fostering 

Future Initiatives aimed at awareness of Trauma Informed Care, 

Adverse Childhood Experiences and sustainability; development of 

an AODA specific strategic plan to focus community efforts in areas 

of most critical need; using the Community Engagement Initiative 

to re-design the service delivery systems of government to ensure 

they are client focused and Trauma Informed; working to develop 

functions that: document processes being employed so that they can 

be cataloged and replicated; establishing a sustainable communitywide data collection and analysis function to measure results and 

guide decisionmaking; and requiring continuous collaboration 

among service providers when new grants or other initiatives are 

begun to eliminate duplication and stretch limited resources. 

Through diligence, outreach, community education and involvement of elected leaders from the various governmental entities, the 

workgroup now includes all 41 departments of the Menominee 

Tribal Government, Menominee County Human Services; the Menominee Indian School District and the College of Menominee Nation. 

The expansion of Trauma Informed Service Delivery across Menominee Community had led to extensive organizational and institutional changes that are showing growing success for our people. 

Some of these changes are evidenced by the following: 

1. Menominee Indian School District—The Menominee Indian 

School District has made many organizational changes aimed at increasing the student’s ability to self-identify and obtain assistance 

to regulate emotions in order to increase function and learning 

ability. Staff at all learning facilitates have been trained in Adverse Childhood Experiences, Trauma and Regulation. Beginning 

with the youngest learners, the District has removed the stigma of 

disciplinary action and created the morning mood check, the 

‘‘Sakom Room’’ and Calm down boxes that allow the student who 

is disregulated the opportunity to restore balance in a safe setting 

before returning to the learning environment. The District also provides for student physical and mental health at each facility and 

instituted the Screening, Brief Intervention, Referral Treatment 

(SBIRT) program for students with substance concerns. Finally, the 

District provides graduation coaches for all High School seniors. 

These interventions have led to a dramatic increase in high school 

graduation rates from 60 percent person in 2007 to nearly 99 percent percent in 2014. 

2. Menominee Tribal Head Start Program—At the Menominee 

Tribal Head Start all staff has completed the Head Start Trauma 

Smart Training and each facility has trained trauma coaches and 

family coaches. This aids in early recognition and intervention 

strategies benefiting our youngest learners and their families. In 

the coming academic year, families will have the opportunity to 

participate in the 10 module training. 

23 

3. Menominee Tribal Clinic—The integration of Trauma Informed Care and Adverse Childhood Experiences (ACES) survey 

has redesigned and changed operations in order to better assist patients, family and service providers by completely integrating services available. Noticing a problem of the high absenteeism, the 

Tribal Clinic redesigned the system by deviating from traditional 

appointment scheduling and offered same-day appointments, which 

was shown a dramatic decrease in absenteeism rates. By changing 

policies and procedures, the clinic has increased access to medical, 

dental, and mental health care to many individuals. The clinic has 

trained all staff on Trauma Informed Care; each patient is regularly screened for trauma in both the behavioral health and medical departments. The Tribal Clinic also has 4 full-time counselors 

trained in trauma interventions. These counselors rotate through 

the student health center at the Menominee Indian High School. 

The Tribal Clinic has also been accepted to start a Learning Collaborative in September 2016, to begin the accreditation process for 

pre and post PhD Psychology Interns. 

4. Menominee County Health and Human Services—The Menominee County Health & Human Services has trained all staff on 

Trauma Informed Care approaches. They have also started the Alternative Response, which focuses on providing less intimidating 

approaches to working with families. 

5. Community Education Initiative—The Community Education 

Initiative serves to provide the foundation for the Fostering Futures Initiative by providing awareness, information, and outreach 

to the Community and Service Providers on the principles of Trauma Informed Care and the relationship to historical trauma, brain 

development, Adverse Childhood Experiences, Secondary Trauma, 

and Resiliency. We have 2 Master Trainers working in the Community who have completed the Wisconsin Adverse Childhood Experience Training. Educational opportunities are offered to the community on a quarterly basis and to agencies upon request. This education is also offered to our families participating in the Temporary 

Assistance for Needy Families Program. 

What is Resilience? Resilience is the ability to adapt well over 

time to life-changing situations and stressful conditions. While 

many things contribute to resilience, studies show that caring and 

supportive relationships can help enhance resilience. Factors associated with resilience include, but are not limited to: (1) the ability 

to make and implement realistic plans; (2) A positive and confident 

outlook; (3) the ability to communicate and solve problems. 

We have recognized that while it is important to understand how 

and why traumatic experiences influence the person over their lifetime, we also know that it is equally important to understand and 

provide a foundation to overcome those traumatic experiences 

through education, awareness and support. The Community Collaboration has provided all agencies that work with children and 

families with consistent resiliency materials from the Children’s 

Resiliency Initiative or also known as Resilience Trumps ACES. 

In October 2015, the Menominee Indian Tribe, Menominee County, and Menominee Indian School District were recognized as 1 of 

8 communities to receive the Robert Wood Johnson Culture of 

Health Award for our innovative efforts to help our community 

24 

lead healthier lives. The Tribe has been featured in the SAMSHA 

Spotlight and we continue to receive requests from other Communities for our presentation delivery of Trauma Informed Care. 

Trauma Informed Care requires removal of silos created by limited resources with narrow guidelines and dated beliefs in service 

delivery to achieve outcomes based on mutual collaboration of resources for all community partners, providers, and individuals. To 

achieve that end, I am here today on behalf of the Menominee 

Community Collaboration to not only demonstrate the growing success of this concept, but to also ask the United States Senate Committee on Indian Affairs to assist and support Indian Country in 

this endeavor. We are asking that you recommend to Congress to 

appropriate funding for Native American need-specific interventions that include the ability for Tribes and organizations to pool 

goal-specific funding across federal agencies to progress our intervention goals. We are also asking that Tribes and partnering organizations have the ability to pool federal funds from any agency 

that were for the purpose of addressing some aspect of the problems facing that community. 

Fortunately, such provisions have already been created within 

the 2014 Consolidated Appropriations Act, titled the Performance 

Partnership for Disconnected Youth. This piece of legislation addresses siloing of Federal Programs by authorizing ten pilot 

projects under which states, cities, and tribes would be permitted 

to pool grant funds from any agency that were for the purpose of 

addressing some aspect of the problems facing disconnected youth. 

It directs OMB to designate a lead agency to manage the pooled 

grants. It also empowers each Secretary to waive any statute or 

regulations that will increase the efficiency of the program or increase access by the target population, so long as the waiver is consistent with the overall purposes of the program. 

[The prepared statement of Ms. Warrington follows:] 

PREPARED STATEMENT OF HON. MYRNA WARRINGTON, CHAIRWOMAN, HEALTH AND

FAMILY COMMITTEE, MENOMINEE INDIAN TRIBE OF WISCONSIN

I. Introduction 

Posoh (Hello in my Menominee Language) Senator Heitkamp, Senator Hoeven, 

and members of the Committee, my name is Myrna Warrington. This is my 8th year 

serving as on the Menominee Tribal Legislature and at this time I serve on the Menominee Indian Tribe’s Executive Team as the Secretary. Thank you for the opportunity to provide the Committee with the Menominee statement that addresses the 

trauma and mental health challenges experienced in Indian Country. 

The Menominee Indian Tribe is located in northeast Wisconsin, within our ancestral territory. Our Reservation is comprised of 234,000 acres of land; bountiful in 

rivers, lakes, streams, wildlife, and forest land. Roughly 90 percent of the land held 

in trust for the Tribe is held in sustained yield for the Tribe’s longstanding practice 

in Sustainable Forest Management. The Tribal membership includes over 9,000 enrolled members. 

The Tribes history is mired in trauma due to the loss of Tribal status, identity, 

language and culture that was forced on our people by the Federal Government 

through overarching assimilation objectives, enactments of federal Indian policy, 

treaties, and judicial rulings. The negative remnants of trauma experienced from 

the treaty era, Boarding School Era, Menominee Termination Act of 1954, Federal 

Relocation Act of 1956, and finally the Restoration of the Menominee Indian Tribe 

to Federal Recognition in 1973, remain visible in the lives of our Tribal members. 

Throughout the last two centuries, the Menominee endured the large loss of ancestral territory, near extinction of Menominee language, and the loss of many critical 

cultural and religious beliefs, practices and communal values that guided the tradiVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00028 Fmt 6633 Sfmt 6621 S:\DOCS\22689.TXT JACK
25 

tional Menominee society. Our oral history and the historical record remain to help 

guide the Tribe in the right direction to address the impacts from these experiences. 

In 2006, the Menominee Tribal Government, Menominee Indian School District, 

and Menominee Tribal Clinic, who, because of limited resources with narrow guidelines, broke down the silos to form the community collaboration. The Menominee 

Community Collaboration committed to creating data-driven solutions. The purpose 

was aimed at addressing the cumulative impacts that historical and 

intergenerational trauma were presenting upon the families of the Menominee Community. The initial identification process began with defining the negative behavioral, health, and educational problems that were manifesting in the lives of the Menominee youth. The community collaboration research led to the premise that the 

symptoms of poverty, low academic achievement, and poor health outcomes and factors were interconnected. Through this process, the Tribe was forced to confront the 

reality that the negative changes occurring within the youth population were a direct result of the changing family dynamic and community structure that were 

symptoms of a larger problem. These issues had not manifested overnight and were 

not isolated to just one event, but rather were symptoms resulting from trauma experienced throughout the course of the Tribes history. 

What is trauma informed care? Trauma Informed Care is defined as ‘‘an organizational structure and treatment framework that involves understanding, recognizing, 

and responding to the effects of all types of trauma. Trauma informed care also emphasizes physical, psychological and emotional safety for both consumers and providers, and helps survivors rebuild a sense of control and empowerment’’ (Trauma 

Informed Care Project, 2016). For the Menominee, the definitional scope of trauma 

was lacking any recognition of self-worth and cultural competency and had to be expanded to include the loss of Menominee language, values, and beliefs in order to 

accurately examine the collective impacts that historical and intergenerational trauma had on the community as a whole. By doing so, the Tribe was able to identify 

the symptoms of trauma which included suicide, poverty, substance abuse/addiction, 

identity loss, loss of societal/cultural norms, and many others and identify the impacts that these had on the individual, family unit, and community. 

II. Statistics 

To accurately assess the magnitude of traumatic experiences and the impact these 

had on Menominee youth and within the family dynamic, the Community Collaboration examined the statistics identifying child victimization rates in Menominee 

County which included neglect, abuse, suicide attempts, and alcohol and drug use/ 

abuse. In 2013, 1,423 children resided on the Menominee Indian Reservation. According to the 2013 Wisconsin Department of Children & Families Annual Report 

to the Governor and Legislature, approximately 10 children in 1,000 were victimized 

by either neglect, physical, sexual or emotional abuse (p. 71). Equally alarming was 

the high incidence of youth hospitalizations for AODA and self-harm. For example, 

in 2015, there were 10 youth hospitalizations for emergency detention alone. From 

January through June 2016, there have already been a total of 14 emergency detention hospitalizations, 11 youth hospitalized, and 8 out of 11 youth hospitalized reported substance abuse and/or tested positive for alcohol or drugs at the time of admission. Statistics such as these are what initiated what is now known as the Menominee Fostering Futures Pilot Project that began in 2013. 

III. Menominee Problem Identification & Solutions 

Based on the statistics identifying the high incidence of traumatic experiences for 

tribal children, the Community Collaboration identified that existing policies, procedures, and mandates were not working. Menominee children and families were continuing to suffer. The County/Tribe was continually ranked 72 out of 72 for health 

outcomes and factors by the University of Wisconsin Population Health Institute. 

Educational Attainment was at an all-time low among high school students. The 

Menominee Indian School District was in fact, coined a ‘‘drop-out factory’’ due to the 

extremely low percentage of students graduating. Finally, crime, victimization, and 

death rates remained high. 

IV. Menominee Model Making the Difference 

The Community Collaborative Workgroup started by building a Menominee Model 

using the ‘‘Bridges Out of Poverty’’ framework—which was a model for economic and 

social change, sustainability and stability. The simple premise of the Community 

Collaboration Workgroup identified that the causes of poverty, low academic 

achievement and poor health are inter-connected and formulated that the resources 

and responses the Community Collaboration would develop to combat them must 

also be inter-connected. This Community Collaborative workgroup vision of the MeVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00029 Fmt 6633 Sfmt 6621 S:\DOCS\22689.TXT JACK
26 

nominee Model evolved over time, which included the introduction and development 

of the Menominee Fostering Futures Initiative. 

The goal of Fostering Futures was designed to improve the lives of children and 

families by translating the knowledge gained from the Adverse Childhood Experience Study, neuroscientific information, and mental health literature on the longterm effects of chronic adversity and trauma in childhood. As a part of our Fostering 

Futures work, we had to pick 2 areas of concentration for our community. We chose 

the following: 

1. Providing Adverse Childhood Experience Study and Trauma Informed Care 

education; and 

2. Evaluating and modifying policies and procedures to be congruent with the 

Adverse Childhood Experience study and Trauma Informed Care. 

From the first goal, our Introduction to Trauma Informed Care training was developed. Initiatives of the Community Collaboration have included: 

• Education Summits focused on Historical Trauma due to boarding schools and 

termination; 

• The implementation of the Fostering Futures Program reservation wide promoting community awareness of Adverse Childhood Experiences (ACEs) and 

Trauma Informed Care (TIC). 

Trauma Informed Service Delivery is a key component and focus of the Community Engagement Workgroup. The Community Engagement meetings focus on the 

development, execution and completion of 90-day plans developed and reported 

quarterly on issues established by the workgroup that now involve all community 

service providers. The Tribe’s programs are implementing Trauma Informed Services by: 

• Reviewing internal policies and practices with an awareness of Trauma Informed Care; Continuing the Fostering Future Initiatives aimed at awareness 

of Trauma Informed Care, Adverse Childhood Experiences and sustainability; 

• Development of an AODA specific strategic plan to focus community efforts in 

areas of most critical need; 

• Using the Community Engagement Initiative to re-design the service delivery 

systems of government to ensure they are client focused and Trauma Informed; 

• Working to develop functions that: document processes being employed so that 

they can be cataloged and replicated; establishing a sustainable communitywide data collection and analysis function to measure results and guide decision-making; and 

• Requiring continuous collaboration among service providers when new grants or 

other initiatives are begun to eliminate duplication and stretch limited resources. 

Through diligence, outreach, community education and involvement of elected 

leaders from the various governmental entities, the workgroup now includes all 41 

departments of the Menominee Tribal Government, Menominee County Human 

Services; the Menominee Indian School District and the College of Menominee Nation. 

The expansion of Trauma Informed Service Delivery across Menominee Community had led to extensive organizational and institutional changes that are showing 

growing success for our people. Some of these changes are evidenced by the following: 

Menominee Indian School District 

The Menominee Indian School District has made many organizational changes 

aimed at increasing the student’s ability to self-identify and obtain assistance to regulate emotions in order to increase function and learning ability. Staff at all learning facilitates have been trained in Adverse Childhood Experiences, Trauma and 

Regulation. Beginning with the youngest learners, the District has removed the stigma of disciplinary action and created the morning mood check, the ‘‘Sakom Room’’ 

and Calm down boxes that allow the student who is dysregulated the opportunity 

to restore balance in a safe setting before returning to the learning environment. 

The District also provides for student physical and mental health at each facility 

and instituted the Screening, Brief Intervention, Referral Treatment (SBIRT) program for students with substance concerns. Finally, the District provides graduation 

coaches for all High School seniors. These interventions have led to a dramatic increase in high school graduation rates from 60 percent person in 2007 to nearly 99 

percent percent in 2014. 

27 

2. Menominee Tribal Head Start Program 

At the Menominee Tribal Head Start all staff has completed the Head Start Trauma Smart Training and each facility has trained trauma coaches and family coaches. This aids in early recognition and intervention strategies benefitting our youngest learners and their families. In the coming academic year, families will have the 

opportunity to participate in the 10 module training. 

3. Menominee Tribal Clinic 

The integration of Trauma Informed Care and Adverse Childhood Experiences 

(ACES) survey has redesigned and changed operations in order to better assist patients, family and service providers by completely integrating services available. Noticing a problem of the high absenteeism, the Tribal Clinic redesigned the system 

by deviating from traditional appointment scheduling and offered same-day appointments, which was shown a dramatic decrease in absenteeism rates. By changing 

policies and procedures, the clinic has increased access to medical, dental, and mental health care to many individuals. The clinic has trained all staff on Trauma Informed Care; each patient is regularly screened for trauma in both the behavioral 

health and medical departments. The Tribal Clinic also has 4 full-time counselors 

trained in trauma interventions. These counselors rotate through the student health 

center at the Menominee Indian High School. The Tribal Clinic has also been accepted to start a Learning Collaborative in September 2016, to begin the accreditation process for pre and post PhD Psychology Interns. 

4. Menominee County Health & Human Services 

The Menominee County Health & Human Services has trained all staff on Trauma Informed Care approaches. They have also started the Alternative Response, 

which focuses on providing less intimidating approaches to working with families. 

5. Community Education Initiative 

The Community Education Initiative serves to provide the foundation for the Fostering Futures Initiative by providing awareness, information, and outreach to the 

Community and Service Providers on the principles of Trauma Informed Care and 

the relationship to historical trauma, brain development, Adverse Childhood Experiences, Secondary Trauma, and Resiliency. We have 2 Master Trainers working in 

the Community who have completed the Wisconsin Adverse Childhood Experience 

Training. Educational opportunities are offered to the community on a quarterly 

basis and to agencies upon request. This education is also offered to our families 

participating in the Temporary Assistance for Needy Families Program. 

V. Resilience 

What is Resilience? Resilience is the ability to adapt well over time to life-changing situations and stressful conditions. While many things contribute to resilience, 

studies show that caring and supportive relationships can help enhance resilience. 

Factors associated with resilience include, but are not limited to: (1) the ability to 

make and implement realistic plans; (2) A positive and confident outlook; (3) the 

ability to communicate and solve problems. (DS Bigfoot, 2015). 

We have recognized that while it is important to understand how and why traumatic experiences influence the person over their lifetime, we also know that it is 

equally important to understand and provide a foundation to overcome those traumatic experiences through education, awareness and support. The Community Collaboration has provided all agencies that work with children and families with consistent resiliency materials from the Children’s Resiliency Initiative or also known 

as Resilience Trumps ACES. 

In October 2015, the Menominee Indian Tribe, Menominee County, and Menominee Indian School District were recognized as 1 of 8 communities to receive the 

Robert Wood Johnson ‘‘Culture of Health’’ Award for our innovative efforts to help 

our community lead healthier lives. The Tribe has been featured in the SAMSHA 

Spotlight and we continue to receive requests from other Communities for our presentation delivery of Trauma Informed Care. 

VI. Tribal Ask 

Trauma Informed Care requires removal of silos created by limited resources with 

narrow guidelines and dated beliefs in service delivery to achieve outcomes based 

on mutual collaboration of resources for all community partners, providers, and individuals. To achieve that end, I am here today on behalf of the Menominee Community Collaboration to not only demonstrate the growing success of this concept, but 

to also ask the United States Senate Committee on Indian Affairs to assist and support Indian Country in this endeavor. We are asking that you recommend to Congress to appropriate funding for Native American need-specific interventions that 

28 

include the ability for Tribes and organizations to pool goal-specific funding across 

federal agencies to progress our intervention goals. We are also asking that Tribes 

and partnering organizations have the ability to pool federal funds from any agency 

that were for the purpose of addressing some aspect of the problems facing that 

community. 

Fortunately, such provisions have already been created within the 2014 Consolidated Appropriations Act, titled the ‘‘Performance Partnership for Disconnected 

Youth.’’ This piece of legislation addresses siloing of Federal Programs by authorizing ten pilot projects under which states, cities, and tribes would be permitted to 

pool grant funds from any agency that were for the purpose of addressing some aspect of the problems facing disconnected youth. It directs OMB to designate a lead 

agency to manage the pooled grants. It also empowers each Secretary to waive any 

statute or regulations that will increase the efficiency of the program or increase 

access by the target population, so long as the waiver is consistent with the overall 

purposes of the program. 

Senator HEITKAMP. Thank you. And I know we’ll have an opportunity to expand on our testimony during our questions. Next we’re 

going to hear from Dr. Kathryn Eagle-Williams. Dr. Eagle-Williams, it’s good to see you again. Thank you for your committed effort holistically on what you do as a health care provider. 

STATEMENT OF KATHRYN R. EAGLE-WILLIAMS, M.D., CEO/ 

QUALITY CARE DIRECTOR, ELBOWOODS MEMORIAL HEALTH 

CENTER, MANDAN, HIDATSA AND ARIKARA NATION 

Dr. EAGLE-WILLIAMS. My name is Dr. Kathryn Eagle-Williams 

(Red Cedar Women) I am the Chief Executive Officer of Elbowoods 

Memorial Center of the Three Affiliated Tribes and an enrolled 

member of the Arikara. First of all, I would like to thank for your 

interest in addressing trauma and mental health challenges in Indian Country and in particular in North Dakota. I am going to 

start by informing the committee that I am a survivor of suicide. 

On September 7, 2011 I lost my daughter to depression. She died 

by way of hanging. As a result of her death we have an entire immediate family of approximately 50 plus individuals affected by her 

death, and an even large number of extended family and community members. She died in Tucson, Arizona where we made our 

home. Within 7 months of her death I moved home to North Dakota and this is where my healing process began. Although, we 

were in Arizona at the time the picture is still the same. In general, access to basic health services is limited as is funding and expertise in working with Native American populations in regard to 

mental health and trauma. Access to mental health services is 

more limited due to lack of mental health providers, programs, and 

funding. 

As health care providers in behavioral health we are aware of 

the fact that adverse child experiences contribute significantly to 

the health outcomes of any individual within a population, but 

must be mindful of the disparities within our Native American populations. 

Based on the latest statistics from 2009–2013 the suicide rate 

among AIAN was the highest in the United States, 34.3 deaths per 

100,000 for men and 9.9 deaths per 100,000 for women. AIAN 

males are twice as likely to complete suicide compared to other 

gender, racial and ethnic subgroups. Suicide is the 2nd leading 

cause of death for AIAN persons age 15–24 and 4x the national average. 

29 

Losing a child to depression is my story, but we all know there 

are many more stories of our men, women, and children who are 

suffering and have died from mental illness. We as Native people 

have heard the stories of our historical trauma and are still suffering from not only those traumas that affected our ancestors, but 

also the traumas that are a daily occurrence on our reservations 

and among our family and community members. We are still trying 

to overcome the Garrison Dam experience, we have a few elders 

still living who actually recall life before the dam and who remember a life that was much happier with few social and health issues 

and who recall the devastation of having to move from the bottom 

lands to higher ground. 

Through my personal journey with the help of friends, colleagues, 

and my tribe have been able to work on healing and for that I am 

grateful. Much my healing experience did not come from sitting in 

a counselors office, but from the support of my community and 

spiritual leaders. Our work in the area of health and wellness is 

has only begun, we need mental health first responders or behavioral health technicians to help with sudden unexpected deaths and 

trauma such as domestic violence and sexual assaults; we need 

grief counselors, and must destigmatize mental illness. 

In order to begin to heal a community we must first identify and 

recognized the trauma before we deal with it. Our people are living 

in crisis situations as I once was and are simply just trying to survive. At Elbowoods Memorial Health Center we are fully aware of 

the need for and protective factors associated with traditional medicine, but it seems as though the federal and state governments 

have not recognized the importance of spirituality and identity, 

which limits our ability to create programs that are meaningful 

and successful. We would like to see more of an investment into 

these modalities of therapy and health practices. We would like to 

offer these practices here with the possible consideration of medical 

reimbursement. 

Today I would like to share with some of what we experience on 

the Fort Berthold Reservation otherwise known as the Three Affiliated Tribes. 

The core of our challenges are as follows: (1) Limited access to 

services as a result of underfunding, criteria requirements, and licensure required for clinicians (locally), and lack of availability regionally. (2) Lack of access to hospital beds required for acute care 

and life threatening mental health conditions. (3) Lack of a plan to 

transport emergency life threatening mental health conditions requiring ambulance verse civil transports to the accepting hospitals. 

(4) Limited human resources and expertise: inability to staff our already under funded behavioral health programs. (5) Lack of funding, funding is often competitive and requires data that is often not 

available or scattered. (6) Lack of culturally sensitive trauma informed care models and training. (7) Limited resources in regard 

to prevention and intervention programs associated with suicide 

and mental and brain health. (8) Stigma associated with mental illness. (9) Social determinates of mental health. (10) Need of mental 

health first responders program to be established reservation wide. 

So, the question is how do we address these core challenges? 

First of all, it is through support of our leadership, tribal, state, 

30 

and federal that we can begin to impact the disparities. Secondly, 

we must educate and inform our policy maker and funding agencies the importance of working with Tribes and understanding the 

true demand may not always be established through data as we 

may not have access to meaningful data. Finally, the continuation 

of tribal consultation is a necessity initially and throughout the 

process of planning and development of programs. 

With that being said we are appreciative of the state’s respect 

and consideration to ask for tribal consultation and would like to 

be an integral part of a state wide plan to the development of realistic services and training that are not only on paper, but are being 

implemented throughout the great plains. Dr. Monica Taylor-Desir, 

Chief Medical Officer for Elbwoods Memorial Health Center, who 

we are very fortune to have, has reviewed the ND suicide prevention plan. Dr. Taylor Desir has identified the plan includes working 

with Native Americans but there is no evidence in the last 6 

months of the enactment of that plan in particular with our tribes. 

We need action not just words. We need support to educate and 

train our own people to help address the lack of human resources 

and access. 

We need help in addressing the social determinants of mental 

health which include the following: discrimination and social exclusion; adverse childhood experiences; poor education, unemployment, underemployment, job insecurity; income inequality, poverty 

and neighborhood deprivation; food insecurity; poor housing quality 

and housing instability; poor access to mental health care. 

It is our recommendation that when working with Native American people we must work from a strength based approach. It must 

be recognized that our cultural traditional ways of life and living 

are important protective factors in regard with mental, spiritual 

wellbeing of our people. We must destigmatize mental illness and 

focus on brain health and wellness. We must incorporating cultural 

practices into approved grants and other funding opportunities. We 

must promote commitment to cultural spirituality as well as promote strengthening of family ties and relationships. Incorporating, 

traditional spirituality and wellness must be recognized as a best 

practice. And in order to get at the heart of mental health we must 

incorporate trauma informed care while addressing addictions. We 

must not criminalize the addict or the broken spirit. 

As I conclude I would once again like to say thank you for your 

interest and consideration as we attempt to meet the health needs 

of our people. In writing this testimony I am honored and humbled 

to share my story which is an experience I unfortunately share 

with far too many of my people. 

[The prepared statement of Dr. Eagle-Williams follows:] 

PREPARED STATEMENT OF KATHRYN R. EAGLE-WILLIAMS, M.D., CEO/QUALITY CARE

DIRECTOR, ELBOWOODS MEMORIAL HEALTH CENTER, MANDAN, HIDATSA AND

ARIKARA NATION

My name is Dr. Kathryn Eagle-Williams (Red Cedar Women) I am the Chief Executive Officer of Elbowoods Memorial Center of the Three Affiliated Tribes and an 

enrolled member of the Arikara. First of all, I would like to thank for your interest 

in addressing trauma and mental health challenges in Indian Country and in particular in North Dakota. I am going to start by informing the committee that I am 

a survivor of suicide. On September 7, 2011 I lost my daughter to depression. She 

31 

died by way of hanging. As a result of her death we have an entire immediate family of approximately 50 plus individuals affect by her death, and an even large number of extended family and community members. She died in Tucson, Arizona where 

we made our home. Within 7 months of her death I moved home to North Dakota 

and this is where my healing process began. Although, we were in Arizona at the 

time the picture is still the same. In general, access to basic health services is limited as is funding and expertise in working with Native American populations in 

regard to mental health and trauma. Access to mental health services is more limited due to lack of mental health providers, programs, and funding. 

As health care providers in behavioral health we are aware of the fact that adverse child experiences contribute significantly to the health outcomes of any individual within a population, but must be mindful of the disparities within our Native 

American populations. 

Based on the latest statistics from 2009–2013 the suicide rate among AIAN was 

the highest in the United States. 

• 34.3 deaths per 100,000 for men 

• 9.9 deaths per 100,000 for women 

• AIAN males are twice as likely to complete suicide compared to other gender, 

racial and ethnic subgroups 

• Suicide is the 2nd leading cause of death for AIAN persons age 15–24 and 4x 

the national average 

Losing a child to depression is my story, but we all know there are many more 

stories of our men, women, and children who are suffering and have died from mental illness. We as Native have heard the stories of our historical trauma and are 

still suffering from not only those traumas that affected our ancestors, but also the 

traumas that are a daily occurrence on our reservations and among our family and 

community members. We are still trying to overcome the Garrison Dam experience, 

we have a few elders still living who actually recall life before the dam and who 

remember a life that was much happier with few social and health issues and who 

recall the devastation of having to move from the bottom lands to higher ground. 

Through my personal journey with the help of friends, collages, and my tribe have 

been able to work on healing and for that I am grateful. Much my healing experience did not come from sitting in a counselors office, but from the support of my 

community and spiritual leaders. Our work in the area of health and wellness work 

is has only begun, we need mental health first responders or behavioral health technicians to help with sudden unexpected deaths and trauma such as domestic violence and sexual assaults; we need grief counselors, and must destigmatize mental 

illness. 

In order to begin to heal a community we must first identify and recognized the 

trauma before we deal with it. Our people are living in crisis situations as I once 

was and are simply just trying to survive. At Elbowoods Memorial Health Center 

we are fully aware of the need for and protective factors associated with traditional 

medicine, but it seems as though the federal and state governments have not recognized the importance of spirituality and identity, which limits are ability to create 

programs that are meaningful and successful. We would like to see more of an investment into these modalities of therapy and health practices. We would like to 

offer these practices here with the possible consideration of medical reimbursement. 

Today I would like to share with some of what we experience on the Fort Berthold 

Reservation otherwise known as the Three Affiliated Tribes. 

The core of our challenges are as follows: 

1. Limited access to services as a result of underfunding, criteria requirements, 

and licensure required for clinicians (locally), and lack of availability regionally. 

2. Lack of access to hospital beds required for acute care and life threatening 

mental health conditions. 

3. Lack of a plan to transport emergency life threating mental health conditions 

requiring ambulance verse civil transports to the accepting hospitals. 

4. Limited human resources and expertise: inability to staff our already under 

funded behavioral health programs. 

5. Lack of funding, funding is often competitive and requires data that is often 

not available or scattered. 

6. Lack of culturally sensitive trauma informed care models and training. 

7. Limited resources in regard to prevention and intervention programs associated with suicide and mental ‘‘brain’’ health. 

32 

8. Stigma associated with mental illness 

9. Social determinates of mental health 

10. Need of mental health first responders program to be established reservation wide 

So, the question is how do we address these core challenges? First of all, it is 

through support of our leadership, tribal, state, and federal that we can begin to 

impact the disparities. Secondly, we must educate and inform our policy maker and 

funding agencies the importance of working with tribes and understanding the true 

demand may not always be established through data as we may not have access to 

meaningful data. Finally, the continuation of tribal consultation is a necessity initially and throughout the process of planning and development of programs. 

With that being said we are appreciative of the state’s respect and consideration 

to ask for tribal consultation and would like to be an integral part of a state wide 

plan to the development of realistic services and training that are not only on paper, 

but are being implemented throughout the great plains. Dr. Monica Taylor-Desir, 

Chief Medical Officer for Elbwoods Memorial Health Center, who we are very fortune to have, has reviewed the ND suicide prevention plan. Dr. Taylor-Desir has 

identified the plan includes working with Native Americans but there is no evidence 

in the last 6 months of the enactment of that plan in particular with our tribes. 

We need action not just words. We need support to educate and train our own people to help address the lack of human resources and access. 

We need help in addressing the social determinants of mental health which include the following: 

• Discrimination and social exclusion 

• Adverse childhood experiences 

• Poor education 

• Unemployment, underemployment, job insecurity 

• Income inequality, poverty and neighborhood deprivation 

• Food insecurity 

• Poor housing quality and housing instability 

• Poor access to mental health care 

It is our recommendation that when working with Native American people we 

must work from a strength based approach. It must be recognized that our cultural 

traditional ways of life and living are important protective factors in regard with 

mental, spiritual wellbeing of our people. We must destigmatize mental illness and 

focus on brain health and wellness. We must incorporating cultural practices into 

approved grants and other funding opportunities. We must promote commitment to 

cultural spirituality as well as promote strengthening of family ties and relationships. Incorporating, traditional spirituality and wellness must be recognized as a 

best practice. And in order to get at the heart of mental health we must incorporate 

trauma informed care while addressing addictions. We must not criminalize the addict or the broken spirit. 

As I conclude I would once again like to say thank you for your interest and consideration as we attempt to meet the health needs of our people. In writing this testimony I am honored and humbled to share my story which is an experience I unfortunately share with far too many of my people. 

Below you will find more information that has been gathered by our Behavioral 

Health Director, Dr. Lisa Keller-Schafer, a trained psychologist. 

Behavioral Health (BH) Obstacles for NA residing on and off Fort Berthold 

reservation 

1. Access to mental health services is severely limited for those living on and off 

the reservation due to: 

a. Lack of insurance 

i. 33 percent reported not having insurance compared to 11 percent of Whites; 

with 46 percent reported they could not afford the cost of healthcare 

ii. 57 percent rely on IHS for care 

b. Lack of tribal funding 

i. Due to changes in budgeting and outside payee sources many programs’ 

funding has been cut—some—including behavioral health, up to 50% 

c. Lack of transportation 

i. Of those who own a car, most cannot afford to fix minor repairs, pay for 

gas, or general upkeep. 

33 

ii. Others rely on relatives/friends to transport them, which often is money 

paid out of their pocket. An elderly lady reported having to pay $100 to her 

relative for each trip she took to a store 

d. Lack of providers 

i. currently Fort Berthold has one provider to cover the entire reservation 

ii. of those who apply for counseling positions, most are underqualified or not 

licensed 

iii. the only recruiting incentive is student loan repayment programs for those 

who are licensed 

iv. In regards to reasons tribal members do not seek BH services: 39 percent 

of tribal members reported a lack of providers and 48 percent reported limited 

clinic hours kept them from seeking mental health services; another 40 percent did not trust their information would not be kept confidential 

e. High poverty rates 

i. The percentage of the reservation population with income below the poverty 

level is at 23.1 percent. In comparison, this is more than double the average 

North Dakota poverty rate of 11.2 percent and is higher than the U.S. rate 

of 15.9 percent. In respect to children, the situation is worse, with 31.6 percent of the reservation population under the age of 18 living below the poverty line compared to 13.2 percent in North Dakota and 22.6 percent in the 

U.S. overall 

f. Emergency Service Barriers 

i. 78 percent of tribal members report there are no emergency services available in their area 

ii. ambulance drivers can refuse to transport individuals presenting with psychosis or a danger to others claiming they are at greater risk of harm because 

those individuals are violent—WHICH is a myth 

iii. there are no police transports for individuals presenting with severe mental illness—even those with homicidal and suicidal ideations due to boundary 

issues—basically TAT police are required to place criminal charges on individuals who they transport. This means for clients presenting with mental illness, they would have to be criminally charged before police can transport. 

AND even if police could transport they could only bring a client to the reservation line and then another police officer from the next county would need 

to take the client from there. AND the client would not be escorted to a hospital ED, but instead because criminal charges were placed on that client— 

the client would go to jail until his/her hearing. 

iv. There is no clean-cut civil commitment on the reservation. Family and 

friends who are attempting to get their loved ones help and the loved one is 

over 18 years must complete affidavits indicating why the loved one is a danger to the self or others. This goes to the judge who decides if the individual 

should be detained—but that is if the loved one can be easily found—given 

the PD are also understaffed. 

g. Lack of awareness about mental health issues and services AND Stigma 

i. Many elderly believe talking about mental health issues such as suicide will 

make things worse 

ii. Approximately 78 percent of all individuals presenting for mental health 

services have reported a dislike of psychotropic medications, but have used 

licit and illicit substances to relieve their symptoms 

iii. Many do not believe their information will remain confidential 

iv. misguided views that people with mental health problems may be more 

violent or unpredictable than people without such problems, or somehow just 

‘‘different’’, but none of these beliefs has any basis in fact; Psych ward—insane asylums—bloodthirsty killers in straightjackets - 

v. early beliefs about the causes of mental health problems, such as demonic 

or spirit possession, were ‘explanations’ that would almost certainly give rise 

to reactions of caution, fear and discrimination. 

vi. Even the medical model of mental health problems is itself an unwitting 

source of stigmatizing beliefs. First, the medical model implies that mental 

health problems are on a par with physical illnesses and may result from 

medical or physical dysfunction in some way (when many may not be simply 

reducible to biological or medical causes). This itself implies that people with 

mental health problems are in some way ‘different’ from ‘normally’ funcVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00037 Fmt 6633 Sfmt 6621 S:\DOCS\22689.TXT JACK
34 

tioning individuals. Secondly, the medical model implies diagnosis, and diagnosis implies a label that is applied to a ‘patient’. That label may well be associated with undesirable attributes (e.g. ‘mad’ people cannot function properly in society, or can sometimes be violent), and this again will perpetuate 

the view that people with mental health problems are different and should 

be treated with caution. 

vii. stigma directed at adolescents with mental health problems came from 

family members, peers, and teachers. 

viii. stigma perpetrated by teachers and school staff, who expressed fear, dislike, avoidance, and under-estimation of abilities 

ix. Mental health stigma is even widespread in the medical profession, at 

least in part because it is given a low priority during the training of physicians and GPs 

h. Limited services available on the reservation 

i. There is no speech or occupational services—46 percent have requested 

these services 

ii. There are no pain clinics—41 percent have requested these services—these 

services are essential for those using opiates to mask mental illness 

iii. No alternative care such as massage, acupuncture—35 percent have requested these services 

iv. There is no CT, MRI, Pet Scans 

v. There is no sleep study program, respiratory care, EEG 

Consequences 

1. Suicide: There are currently no statistics for the Fort Berthold Reservation in 

regards to the number of suicides. However, the Aberdeen IHS office has presented 

the following example from other reservations in its’ area. ‘‘It could be argued that 

the senseless stabbing death of a young teenage girl in January 2007 by two other 

young teenage girls being egged on by a circle of peers really set the tone for the 

2014 year: one of dread and despair that led to a continuous cycle of death. . . of 

16 other adolescents who took their own lives. In spite of efforts over the past 12 

months to reach-out to youth and families, to train all community members on prevention and intervention strategies, to partner with state and federal agencies for 

an increase in services, these lives lost are the best indicator that there are gaps, 

inadequacies, and barriers to current service structures. As shown above, in the 

number of agencies and organizations devoting resources to youth, there is dedication of purpose. These purposes and efforts, however, have not yet led to a transformed community where the choice for life far outreaches the choice for death.’’ 

2. Serious Emotional Behavioral Disorder (SEBD) reflects an individual (ages 8 

to 89 years) who: 

a. Is angry, bitter, hostile, and aggressive, prone to fighting and bulling, uses 

excessive profanity, who is constantly getting into trouble, prone to steal, 

arson and gang activity and who may act out sexually; 

b. Appears withdrawn, upset, frustrated, pouting and sulking, lazy and lethargic, confused, lacking attention, and who has poor hygiene, inadequate nutritional intake, sleep disturbance, and prone to lying, running away from 

home, self-mutilation; 

c. Shows a lack of respect, failure to thrive, has health problems and depression, 

is defiant, has low self-esteem, has attachment issues and prone to gang participation, has poor academic performance; and, 

d. Is prone to suicidal thoughts and ideations, social phobias and fear of certain 

people, has a false pride and demonstrates grandiosity or ‘big head’. 

3. Methamphetamine use is increasing. The Aberdeen Area Indian Health Service 

(IHS) reported that on average Behavioral Health Units (Alcohol Programs as well 

as IHS Mental Health Programs) are seeing an average of 48.5 cases of confirmed 

methamphetamine use per month per site. 

4. Liver diseases are ‘‘broken spirit’’ diseases for Indian people. HIV and Hepatitis 

(HBV and HCV) affects AI/AN in ways that are not always apparent because of 

small population sizes. Of all races/ethnicities, AI/AN had the highest percentages 

of diagnosed HIV and Hepatitis infections due to injection drug use. AI/AN face HIV 

and Hepatitis prevention challenges, including poverty, high rates of STIs, stigma, 

and lack of psychiatric care to treat predisposing mental illnesses. 

35 

5. A national study on Violence Against Women reported that American Indian 

women and experience the highest rate of Domestic Violence in the United States, 

and that three-fourths of Native American women and children have or will experience some type of sexual assault in their life time; with approximately 76 percent 

of women being raped by their significant other at least one time. Although recent 

reports of violence vary and specific numbers are not known, it is estimated that 

over the past 3 years Fort Berthold shows an increase in the number of violenceinduced injuries including 664 assaults, 60 stabbings, and 31 possible rapes. This 

report is a rough estimation of persons seeking medical or legal intervention on and 

off the reservation. 

6. The poverty of the area has a major impact on the health and wellness of the 

people. The Aberdeen Area Indian Health Service IHS which provides health care 

to Fort Berthold, and the tribes in South Dakota and Iowa, has some of the most 

startling health statistics of the twelve national IHS service areas (Indian Health 

Service, 2007): 

• The age-adjusted death rate (all causes) is more than double the U.S. All Races 

rate, and is the second highest Area rate in the Indian Health Service. 

• Other Data on Mortality rates: the 2nd highest Suicide Death Rate; the highest 

Alcoholism Death Rate; the second highest Diseases of the Heart Death Rate 

• The Diabetes Mellitus Death Rate is five times the U.S. All Races Rate. Diabetes is the fifth leading cause of death for Tribes in the Aberdeen Area (following 

heart disease, cancer, accidents, liver disease and cirrhosis). 

• The lowest Life Expectancy at Birth: 64.8 years compared to 75.8 years for the 

U.S. All Races and 71.1 years for the All IHS service populations. 

• The highest Years of Potential Life Lost Rate: 119.5 years/per 1,000 persons 

under the age of 65, which is 2.5 times the U.S. all races total. 

Senator HEITKAMP. Thank you very much, Dr. Eagle. Next we 

have Dr. DeCoteau shares some responsibility of talking about 

what more we could do to carry forward the idea and the knowledge about trauma. She is a leading expert throughout the country. 

STATEMENT OF TAMI DECOTEAU, PH.D., CLINICAL 

PSYCHOLOGIST, DECOTEAU TRAUMA—INFORMED CARE AND 

PRACTICE, PLLC 

Dr. DECOTEAU. Thank you, Senator Heitkamp. I am honored to 

be here. My name is Dr. Tami DeCoteau. I am an enrolled tribal 

member of the Mandan Hidatsa Arikara Nation and a proud descendant of the Turtle Mountain Chippewa. I have worked as a licensed clinical psychologist with an emphasis on the treatment of 

trauma disorders for more than a decade. In addition to maintaining a busy patient caseload, I own a Bismarck-based private practice that employs 6 mental health workers who are uniquely 

trained in the application of trauma-specific interventions for 

adults, children and families. Thank you for holding this hearing 

on trauma and mental health challenges in Indian country and inviting me to testify. 

Senator Heitkamp, I would like to thank you for your key role 

in advancing Native American priorities, your efforts to improve 

the lives of Native American people and for illuminating the important but tragically overlooked issue of historical trauma. I would 

also like to thank you for drafting and advocating for S. 246, ‘‘The 

Alyce Spotted Bear and Walter Soboleff Commission on Native 

Children.’’ S. 246 is essential to enhancing the lives of Native children. 

I have been asked by members of the Committee to focus my testimony on my professional experience and my clinical perspective 

on trauma. 

36 

I obtained a doctorate degree in Clinical Psychology in 2003 from 

the University of Nebraska-Lincoln with specialization in the cognitive-behavioral treatment of anxiety disorders, which at the time 

encompassed trauma disorders. My professional practice work has 

focused on providing services to trauma-survivors. I am certified in 

trauma-focused cognitive behavioral therapy. I have received training in the Neurosequential Model of Therapuetics (NMT), a developmentally sensitive, neurobiology-informed approach to working 

with at-risk children; Trust-Based Relational Intervention (TBRI), 

a therapeutic model that trains caregivers to provide effective support for at-risk children; and Eye Movement Desensitization and 

Reprocessing (EMDR), an intervention approach that helps reduce 

the long-lasting effects of traumatic memories. 

During my undergraduate and graduate training I received the 

honor of becoming a McNair Scholar and then an American Psychological Association (APA) Fellow. I also received the Indian Health 

Service 2009 Health Professional of the Year Award for outstanding service and the American Psychological Foundation 2010 

Early Career Award for providing culturally competent practice 

techniques for Native Americans and for developing training programs in rural, underserved areas. 

My career began with the Veteran’s Administration where I provided psychological services to traumatized Veterans. During my 

interim at the VA, Dr. Arthur McDonald (Ogala Lakota) and I 

joined forces to create psychology internship training and services 

for Native Americans. Our initial effort was funded by HRSA/BHP. 

During the 3-year grant phase we designed and implemented a 

model for training psychologists to provide culturally competent 

and relevant services in rural Native American communities. From 

this experience, evolved the stimulus for a much greater vision to 

develop reservation-based internship programs with unique missions to restore the individual and the collective sense of worth of 

Native American people by supporting the belief that the healing 

of Native Nations lies within the Nations themselves. 

The Standing Rock Psychology Internship and Post-doctoral Program became the flagship model of our vision. The Program evidenced success in recruiting and retaining psychology providers for 

rural Native American populations and substantially increased accessible mental health services. Doctorate-level trainees worked 

collaboratively with tribal health, schools, and judicial departments. In addition to the well over 3,000 hours of direct patient 

care, trainees provided community education, suicide prevention, 

and even equine assisted psychotherapy. One of the highlights of 

the Program was the mobile crisis response team that worked to 

prevent and reduce suicides on the reservation. The Program was 

a tribally-driven initiative that provided an excellent example of Indian self-determination. 

Unfortunately, it is difficult to sustain mental health services on 

the reservation. Mental health providers in Indian Country are at 

a particularly high risk for burnout. We work in an intense and crisis-oriented environment on a day-to-day basis. We face an unusual 

array of highly-stressful conditions including inadequate compensation, safety issues, lack of basic resources such as supplies and 

testing materials, professional isolation, lack of appropriate referral 

37 

and consultation resources, excessive time demands, and inadequate funding. In addition, we serve a patient population that has 

an unimaginable amount of emotional trauma and social problems. 

These conditions cause us to experience a constant state of physical 

and mental exhaustion and lead to feelings of depersonalization 

and dissatisfaction. It is no surprise that decreased worker effectiveness and burnout are common among mental health professional in rural Indian Country. 

While my heart still resides in working on Indian reservations, 

I have been drawn towards education and advocacy for trauma-survivors including training local teachers, educating congressional 

leaders, and serving as the president of Council for Native American Trauma-Informed Initiatives which is hosting this afternoon’s 

Roundtable on the Causes and Effects of Trauma In Native American Communities. 

Thus, in 2011, I step away from my clinical work on the reservation and began work as a private practice and consulting psychologist in Bismarck, ND. In a very short amount of time my clinic 

schedule was full of patients, primarily children in foster care with 

complex developmental trauma. Whether it be on, or off the reservation the need for trauma-based psychological services in North 

Dakota is immense. Over the course of my career I have become 

acutely aware of the ‘‘culture of trauma’’ that is overwhelming Indian communities and inhibiting the traditional ‘‘healing culture’’ 

practices. I will discuss the culture of trauma first. 

Historical trauma is the cumulative impact of historical losses 

caused by European settlers’ efforts to exterminate Native Americans and our culture and transmitted across generations. The assimilation policies of the federal government, particularly the one 

that involved sending young Indian children to boarding schools, 

continue to have a tremendous detrimental effect on Indian people. 

This history has led to a generational pattern of trauma that perpetuates itself in the form of abuse, neglect, substance addiction, 

violence, mental unwellness, physical illness, and unresolved grief. 

Trauma by definition is an unbearable and out of control sensation in the body. It leaves an imprint on the mind, body and brain 

and results in reorganization of the way the mind and brain manage perceptions. Trauma changes what we think, how we think, 

and our very capacity to think. Traumatized people have trouble 

deciphering what is going on around them. They superimpose their 

trauma on everything. Individuals who become conditioned to adversity come to believe they have no control over their lives so they 

give up trying—a response referred to as learned helplessness. 

Trauma affects those who are directly exposed to it as well as those 

around them. The current challenges in Indian country, including 

difficulties with social-environmental, physiological and psychological functioning, are evidence that the trauma that occurred long 

ago continues to impact Native Americans today. 

The therapists in my practice serve hundreds of traumatized individuals, many of whom are Native American children. The gutwrenching impact of trauma on these precious souls is evident in 

their persistent hyperarousal and hyperactivity. These children 

struggle to regulate their own emotions, attend to stimuli, and 

their capacity for learning is often greatly impaired. While they are 

38 

desperate for love and affection, their persisting fear-response 

causes them to perceive everything as threatening, and they are 

likely to lash out at even the most loving caregivers. Children who 

have such complex trauma cannot become functioning members of 

society without skillful trauma-focused intervention. 

Research shows that helping trauma survivors to describe their 

trauma is helpful, but is often not enough. Since trauma is encoded 

in the mind and body, for healing to occur, mind-body communication is needed. Scientists have discovered that individuals can restore their arousal system through practices such as mindfulness, 

movement, and rhythm—principles that have been used by Native 

American cultures for centuries. Although Native principles in 

healing have long been regarded as nonsense by modern day medicine, we now have scientific proof that the ability to heal ourselves 

and our communities lies within our traditional cultural practices. 

Recent scientific studies have developed some practical and effective interventions for trauma, and we now have a pretty good idea 

of what tribes can do to address the causes and effects of historical 

and childhood trauma. A comprehensive trauma-informed initiative 

that involves every institution on the reservation must be implemented. My recommendations are provided below. 

1. Implement Comprehensive Trauma Informed Initiatives. 

There is no one single intervention that every tribe must adopt. 

Rather, there are a number of different ones that have been shown 

to be effective for a specific area—the schools, the mental health 

program, the law enforcement system, and so on. Each tribe needs 

to select the approaches that are most appropriate for its values 

and culture. The keys are that the initiative must be comprehensive and the community must be fully educated about trauma and 

involved in the initiative. The problem is that right now there is 

no place a tribe can turn to in order to obtain technical assistance 

in setting up a comprehensive trauma-informed program. I urge 

Congress to appropriate funds to create an institute that would 

provide on-going assistance to tribes that are seeking to implement 

a comprehensive trauma-informed initiative. 

2. Provide funding for the use of interns. There is a desperate 

and immediate need for increased human service resources in order 

to address childhood and historical trauma. Although the Standing 

Rock Program is no longer in operation its model is universally applicable and has the ability to be reproduced in other underserved 

areas. By providing funding to enable tribes to implement psychology intern programs that bring pre- and post-doctoral psychologists to reservations we can expand the mental health workforce in 

our region. 

Senator Heitkamp and honorable members of the Committee, 

childhood and historical trauma are long-standing issues that have 

detrimental effects on our Federal and State budgets, health, and 

overall well-being. Indian Country needs maximum mental health 

power to deal with the trauma. Money must be allocated for tribal 

comprehensive trauma initiatives. I thank you for the time and opportunity to share my perspective on trauma and mental health 

challenges in Indian Country. 

[The prepared statement of Dr. DeCoteau follows:] 

39 

PREPARED STATEMENT OF TAMI DECOTEAU, PH.D., CLINICAL PSYCHOLOGIST, 

DECOTEAU TRAUMA—INFORMED CARE AND PRACTICE, PLLC 

Mr. Chairman and members of the Committee, my name is Dr. Tami De Coteau. 

I am an enrolled tribal member of the Mandan Hidatsa Arikara Nation and a proud 

descendant of the Turtle Mountain Chippewa. I have worked as a licensed clinical 

psychologist with an emphasis on the treatment of trauma disorders for more than 

a decade. In addition to maintaining a busy patient caseload, I own a Bismarckbased private practice that employs 6 mental health workers who are uniquely 

trained in the application of trauma-specific interventions for adults, children and 

families. Thank you for holding this hearing on trauma and mental health challenges in Indian country and inviting me to testify. 

Senator Heitkamp, I would like to thank you for your key role in advancing Native American priorities, your efforts to improve the lives of Native American people 

and for illuminating the important but tragically overlooked issue of historical trauma. I would also like to thank you for drafting and advocating for S. 246, ‘‘The Alyce 

Spotted Bear and Walter Soboleff Commission on Native Children.’’ S. 246 is essential to enhancing the lives of Native children. 

I have been asked by members of the Committee to focus my testimony on my 

professional experience and my clinical perspective on trauma. 

Professional Experience 

I obtained a doctorate degree in Clinical Psychology in 2003 from the University 

of Nebraska—Lincoln with specialization in the cognitive-behavioral treatment of 

anxiety disorders, which at the time encompassed trauma disorders. My professional 

practice work has focused on providing services to trauma-survivors. I am certified 

in trauma-focused cognitive behavioral therapy. I have received training in the 

Neurosequential Model of Therapuetics (NMT; Perry), a developmentally sensitive, 

neurobiology-informed approach to working with at-risk children; Trust-Based Relational Intervention (TBRI; Purvis), a therapeutic model that trains caregivers to 

provide effective support for at-risk children; and Eye Movement Desensitization 

and Reprocessing (EMDR; Shapiro), an intervention approach that helps reduce the 

long-lasting effects of traumatic memories. 

During my undergraduate and graduate training I received the honor of becoming 

a McNair Scholar and then an American Psychological Association (APA) Fellow. I 

also received the Indian Health Service 2009 Health Professional of the Year Award 

for outstanding service and the American Psychological Foundation 2010 Early Career Award for providing culturally competent practice techniques for Native Americans and for developing training programs in rural, underserved areas. 

My career began with the Veteran’s Administration where I provided psychological services to traumatized Veterans. During my interim at the VA, Dr. Arthur 

McDonald (Ogala Lakota) and I joined forces to create psychology internship training and services for Native Americans. Our initial effort was funded by HRSA/BHP. 

During the 3-year grant phase we designed and implemented a model for training 

psychologists to provide culturally competent and relevant services in rural Native 

American communities. From this experience, evolved the stimulus for a much 

greater vision to develop reservation-based internship programs with unique missions to restore the individual and the collective sense of worth of Native American 

people by supporting the belief that the healing of Native Nations lies within the 

Nations themselves. 

The Standing Rock Psychology Internship and Post-doctoral Program became the 

flagship model of our vision. The Program evidenced success in recruiting and retaining psychology providers for rural Native American populations and substantially increased accessible mental health services. Doctorate-level trainees worked 

collaboratively with tribal health, schools, and judicial departments. In addition to 

the well over 3,000 hours of direct patient care, trainees provided community education, suicide prevention, and even equine assisted psychotherapy. One of the highlights of the Program was the mobile crisis response team that worked to prevent 

and reduce suicides on the reservation. The Program was a tribally-driven initiative 

that provided an excellent example of Indian self-determination. 

Unfortunately, it is difficult to sustain mental health services on the reservation. 

Mental health providers in Indian Country are at a particularly high risk for burnout. We work in an intense and crisis-oriented environment on a day-to-day basis. 

We face an unusual array of highly-stressful conditions including inadequate compensation, safety issues, lack of basic resources such as supplies and testing materials, professional isolation, lack of appropriate referral and consultation resources, 

excessive time demands, and inadequate funding. In addition, we serve a patient 

population that has an unimaginable amount of emotional trauma and social probVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 S:\DOCS\22689.TXT JACK
40 

lems. These conditions cause us to experience a constant state of physical and mental exhaustion and lead to feelings of depersonalization and dissatisfaction. It is no 

surprise that decreased worker effectiveness and burnout are common among mental health professional in rural Indian Country. 

While my heart still resides in working on Indian reservations, I have been drawn 

towards education and advocacy for trauma-survivors including training local teachers, educating congressional leaders, and serving as the president of Council for Native American Trauma-Informed Initiatives which is hosting this afternoon’s Roundtable on the Causes and Effects of Trauma In Native American Communities. 

Thus, in 2011, I step away from my clinical work on the reservation and began 

work as a private practice and consulting psychologist in Bismarck, ND. In a very 

short amount of time my clinic schedule was full of patients, primarily children in 

foster care with complex developmental trauma. Whether it be on, or off the reservation the need for trauma-based psychological services in North Dakota is immense. Over the course of my career I have become acutely aware of the ‘‘culture 

of trauma’’ that is overwhelming Indian communities and inhibiting the traditional 

‘‘healing culture’’ practices. I will discuss the culture of trauma first. 

The Culture of Trauma 

Historical trauma is the cumulative impact of historical losses caused by European settlers’ efforts to exterminate Native Americans and our culture and transmitted across generations. The assimilation policies of the federal government, particularly the one that involved sending young Indian children to boarding schools, 

continue to have a tremendous detrimental effect on Indian people. This history has 

led to a generational pattern of trauma that perpetuates itself in the form of abuse, 

neglect, substance addiction, violence, mental unwellness, physical illness, and unresolved grief. 

Trauma by definition is an unbearable and out of control sensation in the body. 

It leaves an imprint on the mind, body and brain and results in reorganization of 

the way the mind and brain manage perceptions. Trauma changes what we think, 

how we think, and our very capacity to think. Traumatized people have trouble deciphering what is going on around them. They superimpose their trauma on everything. Individuals who become conditioned to adversity come to believe they have 

no control over their lives so they give up trying—a response referred to as learned 

helplessness. Trauma affects those who are directly exposed to it as well as those 

around them. The current challenges in Indian country, including difficulties with 

social-environmental, physiological and psychological functioning, are evidence that 

the trauma that occurred long ago continues to impact Native Americans today. 

The therapists in my practice serve hundreds of traumatized individuals, many 

of whom are Native American children. The gut-wrenching impact of trauma on 

these precious souls is evident in their persistent hyperarousal and hyperactivity. 

These children struggle to regulate their own emotions, attend to stimuli, and their 

capacity for learning is often greatly impaired. While they are desperate for love and 

affection, their persisting fear-response causes them to perceive everything as 

threating, and they are likely to lash out at even the most loving caregivers. Children who have such complex trauma cannot become functioning members of society 

without skillful trauma-focused intervention. 

The Healing Culture 

Research shows that helping trauma survivors to describe their trauma is helpful, 

but is often not enough. Since trauma is encoded in the mind and body, for healing 

to occur, mind-body communication is needed. Scientists have discovered that individuals can restore their arousal system through practices such as mindfulness, 

movement, and rhythm—principles that have been used by Native American cultures for centuries. Although Native principles in healing have long been regarded 

as nonsense by modern day medicine, we now have scientific proof that the ability 

to heal ourselves and our communities lies within our traditional cultural practices. 

Recommendations 

Recent scientific studies have developed some practical and effective interventions 

for trauma, and we now have a pretty good idea of what tribes can do to address 

the causes and effects of historical and childhood trauma. A comprehensive traumainformed initiative that involves every institution on the reservation must be implemented. My recommendations are provided below. 

1. Implement Comprehensive Trauma Informed Initiatives. There is no one single intervention that every tribe must adopt. Rather, there are a number of 

different ones that have been shown to be effective for a specific area—the 

schools, the mental health program, the law enforcement system, and so on. 

41 

Each tribe needs to select the approaches that are most appropriate for its 

values and culture. The keys are that the initiative must be comprehensive 

and the community must be fully educated about trauma and involved in the 

initiative. The problem is that right now there is no place a tribe can turn 

to in order to obtain technical assistance in setting up a comprehensive trauma-informed program. I urge Congress to appropriate funds to create an institute that would provide on-going assistance to tribes that are seeking to 

implement a comprehensive trauma-informed initiative. 

2. Provide funding for the use of interns. There is a desperate and immediate 

need for increased human service resources in order to address childhood and 

historical trauma. Although the Standing Rock Program is no longer in operation its model is universally applicable and has the ability to be reproduced 

in other underserved areas. By providing funding to enable tribes to implement psychology intern programs that bring pre- and post-doctoral psychologists to reservations we can expand the mental health workforce in our region. 

Conclusion 

Mr. Chairman and honorable members of the Committee, childhood and historical 

trauma are long-standing issues that have detrimental effects on our Federal and 

State budgets, health, and overall well-being. Indian Country needs maximum mental health power to deal with the trauma. Money must be allocated for tribal comprehensive trauma initiatives. I thank you for the time and opportunity to share my 

perspective on trauma and mental health challenges in Indian Country. 

Senator HEITKAMP. Thank you so much, Dr. DeCoteau. Thank 

you so much for your leadership and educating me on these issues. 

I don’t think that I would be nearly as informed without your assistance, without your persistence. And thank you to Don Schmitt 

for helping making this hearing a reality. I have known Don for 

many, many years. More years than probably either one of us want 

to recognize. There has been no greater advocate for children in 

foster care looking for advanced solutions, and we know so many 

heroes like this, and it’s important where we do have people who 

dedicate their life, that we recognize that. 

So I’m going to turn first turn to Senator Hoeven for a round of 

questions. I think we’re around five minutes, or as long as you 

want to go. 

Senator HOEVEN. Thank you to all of our witnesses. What I 

would start out with is the need for a comprehensive approach. I 

ask each witness to describe what that comprehensive approach 

looks like? Recently the State Department of Human Services had 

a workshop in Fargo on the opiods epidemic. We really talked 

about—and we had the people work on the prevention, people who 

work on treatment, and law enforcement. So the idea was we got 

people from the front lines and experts. We had them from all 

areas. So we can try to come at the problem in a comprehensive 

way. We talked about everything from drug court to making sure 

there’s education in schools and prevention, so people understand 

these drugs are not only addictive but they’re dangerous and 

they’re killing us. And then how law enforcement has to be able to 

not just incarcerate but to have treatment options. So same thing 

here, how each of you—What’s it take to get that comprehensive 

approach? And I would start with Miss Sparks. 

Ms. ROBINSON. Thank you. Thank you for that question. It’s a 

difficult question to answer, because it’s such a difficult issue for 

us to tackle and for us to wrap our minds around. As I mentioned, 

there are many pathways to be able to treat parts of the trauma 

and behavioral health. But what we first have to understand is 

42 

what actually are the causes. And I think that really varies impacting from community to community. We heard from Dr. Eagle Williams that the Garrison Dam is still something that’s impacting the 

elders and it’s transmitting down to the youth as well. And I think 

that each tribal community will have a similar story as to what is 

the root cause. But prevention, intervention, providing services, it’s 

complicated. Unfortunately I don’t have an answer for exactly what 

is the comprehensive approach, but I can tell you from Children 

and Families’ perspective would be that we want to start early 

childhood programs. We want to be able to provide trauma and foster care to the service providers in our head start and our childcare 

and our native language programs. We want to be able to reach the 

parents that might not only be suffering from some of the symptoms of trauma but are suffering from some of the more complex 

historicals or PTSD or other adverse childhood experiences and 

help them get the services they need. We want to be able to prevent the adverse childhood experiences before they happen. And if 

they have happened, how do we get to the kids where they are to 

prevent them from being further traumatized. But, you know, 

that’s just one way of approaching this particular topic. 

Mr. CRUZAN. Very interesting. And I realize now that it’s not just 

a drug and alcohol thing, which is what we see primarily. We have 

these activating events. There’s law enforcement and you’re dealing 

with really the symptoms and not the cause. One of the things 

we’re trying to do within the Office of Justice Services, you could 

sort of, which I’m not sure we’ll talk about, it’s a thing more than 

a thing. It’s a series of things, right? But one of the parts of that 

is a break in the system of services that are out there. I mean, I’m 

sure these people struggling with these issues can be referred separately, but for us there’s an activating event. We’re developing a 

graded system of services. It’s basically a poster that we’re trying 

to teach our law enforcement folks that you are a part of this healing process, for lack of better words, from the very beginning. So 

we’re trying to develop a system where a police officer gets called 

to an event where you have these individuals who are displaying 

the symptoms of a greater problem, where you can divert them, 

maybe have a court option, but you don’t immediately go to that 

judicial branch. You sort of have a diversion process where the officers who are dealing with these folks over and over again—I was 

just at Standing Rock yesterday and you look at the board of who 

is in the facility, and you can almost go back two years ago and 

it’s almost the same people. It’s the same names over and over 

again. So these officers who are dealing with these folks, if we have 

an option to divert them out of that judicial process into some sort 

of treatment, that would be our first option. Maybe that works. 

Maybe it doesn’t. If it doesn’t, you continue on this, continue here 

where now you go to work and Courts now have more options. 

Maybe it’s adjudication. Maybe it’s court ordered treatment. Maybe 

it’s through drug court. Maybe it’s a number of things. We’ve got 

a new system in place, and I think it’s fairly generic. It’s post-adjudication pre-sentencing that—So I’m arrested, I get brought in, I 

sit down, and I go through this with a court personnel. It’s an assessment that really begins to ask questions about my likelihood 

of reoffending and if it’s into where I should probably be. So maybe 

43 

court ordered treatment. It maybe jail as opposed to treatment. So 

you continue this through these services, hopefully these off ramps 

back in the community where they can live healthy lives. Again, I 

think we’re a part of the solution. I think it’s becoming more and 

more clear to me that we could be more active participants in this. 

But the issues that these folks that we’re dealing with are much 

deeper, and I’m not trying to tie this into these issues that—but 

foster homes, I can’t control. It’s in my head and and acting differently because of it. You know, you go and say, well, going down 

that path—You know, these folks that are struggling with these 

adverse childhood experiences are dealing with things that they 

can’t comprehend, they can’t control, and you can’t really reason 

yourself out of it. I’m not saying I completely can relate, but I can 

understand, and it makes a little bit more sense. They are acting 

out in these ways. It’s more than just alcohol and drug abuse. And 

we are working with that and I think for us it’s going to diving into 

the professionals with our analytical data and our statistics and 

our numbers. So I don’t know if I have a solution. 

Senator HEITKAMP. Thank you. Miss Warrington? 

Ms. WARRINGTON. Thank you. One of the things that we have 

been doing is getting from volume from all our governmental bodies. So they know what we are doing. We have quarterly meetings 

with them and we report to them on what we’re doing for trauma 

care. We have a casino and we involve all the players. The police 

department supports all the businesses. We involve them all so 

that they know that this is not going to wayside. It’s not a little 

thing we’re going to play right now. It’s continuing on, and they 

know this because we also ask them for money. We have to prove 

to them what we are doing, because they do contribute to the foster 

futures in the trauma group of people that we continue to work. 

We have regular meetings, but we have quarterly meetings as well. 

So I think it’s important to let them know who is being trained, 

what kind of training is going on, but also because—and I’ve been 

doing this for three years, and we are starting the evaluation process now, because it isn’t just, okay, here’s what trauma informed 

care is. It’s going back and saying, are you practicing it? How are 

you practicing it? Is it including your agencies? Is it improving 

your relationships? So that to us is very important to not to just 

be preaching to the choir, but also what are you doing? Are you actually feeling better about this, and do you have any ideas? What 

can we do to make it better? And I think that’s the number one 

thing, but also reporting out to those agencies so they can, if they 

are asked, they can say what it is that they’re doing. It’s a core 

group. We started with eight people, but we brought in several others involved in these regular meetings. We also said engagement 

meetings where we involve anybody from the community. So that 

is so important. We’re addressing the youth, bring them in. What 

are these kids saying? What do they need? What do they think is 

going to help us? So to talk about this we have to have the youth 

involved as well. 

Dr. EAGLE-WILLIAMS. Thank you so much. Some of what we’re 

seeing and what we’re doing is very similar. We’re very happy that 

we are working with our justice center as well as as our police force 

in educating them on basically what’s happening also in the homes 

44 

and the actual psychological effects of the parent and having the 

children witness these things, and also to help the police officers 

identify that. So we’ve been educating them on what we are seeing. 

And so that I think has been really helpful in working with the police force. And also coming from the aspect of, you know, not criminalizing our addicts. We have to change that mindset. Working in 

Indian country, I’ve worked primarily with women, I evaluated and 

did interviews, and when I did that there were 80 to 90 percent 

of the women that we treated on an outpatient treatment program, 

were molested, raped, had domestic violence in their homes. I realized that I had all of those risk factors as well, and I didn’t even 

know, and I’m a professional. So we are working on educating our 

communities. We’ve gone through the Ace study with some of our 

staff, and when we did that there wasn’t a dry eye in there of our 

women and our community members that hadn’t experienced those 

childhood experiences. So we are working on educating, and the 

powers in the community. The thing is, we don’t have enough staff. 

We have one counselor. You know, it’s just so difficult to find individuals that are able to address these situations. I have to say, that 

the other, finding ways to bringing that culture or peace that’s 

sometimes missing in these families is very important. And as 

we’re working with these individuals that are either getting incarcerated or children who are taken from their home, we have to develop a reentry program that are allowed to bring those families 

back together. Because you could be an alcoholic and still be extremely supportive of your family and or an addict could still have 

that love, but because of that addiction, we cannot criminalize 

those individuals because of any experiences that led them to 

where they are. The other things we have, or I’ve include in my 

testimony, includes addressing the mental health. Definitely we 

need prevention and intervention, the alternatives to abuses. I actually took my daughter to the ER two weeks before she died, and 

she said, ‘‘Mom, I am having chest pains.’’ You know, my heart was 

pounding. I was like, ‘‘Is she having an anxiety attack? What’s 

going on?’’ So I’m trying to do all these things and ask the right 

questions, and we’re working on collecting data from the State. It’s 

amazing how—I can’t remember the exact numbers, but we were 

identifying people at that point that were having anxiety or were 

suffering from depression but were released. That’s kind of where 

we’re at. So, again, thank you. Thank you for listening. 

Dr. DECOTEAU. So we know that trauma has horrible impact on 

a human being. There’s no one single approach that will work. We 

need comprehensive initiative from the community and it must include education of childhood trauma and historical trauma for all 

tribal systems and tribal leaders. There needs to be education on 

what the science says about intervention, and I think what tribal 

communities will find is that these interventions are very, they are 

very consistent with their tribal ways. What research is saying now 

is that safe, consistent relationships are a priority in restoring a 

traumatized individual, and things like rhythm and movement and 

mindfulness. And we’ve had these in our culture for generations. 

So we now understand that what use to be thought of as nonsense 

is scientifically proven as a successful intervention for traumatized 

individuals. A comprehensive initiative needs to have technical asVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00048 Fmt 6633 Sfmt 6601 S:\DOCS\22689.TXT JACK
45 

sistance that the tribes can reach out to for support, and identify 

consultants who are experts in their areas and who can assist the 

tribe in developing their own comprehensive initiatives in their 

communities. Tribal communities need a workforce, a workforce of 

mental health providers who are willing to leave the comfort of 

their office and do outreach to the furthest corners of the reservation. We’ve got to get to those folks because in my experience, those 

are the folks that are the highest risk for suicide. When I was 

working on the reservation, the one thing that was crystal clear to 

me was when there was a suicide, this was not somebody I knew. 

They were not a mental health patient. We’re not reaching the 

services that they need, and we need to do a better job in doing 

that. We need to develop internship programs. It’s hard to get folks 

to North Dakota. It’s hard to get folks to rural areas to work, but 

the Veteran’s Administration, other universities have established 

for decades that the best way to recruit professionals to our region 

is to develop internship training programs. We had that success 

and experience in the program at Standing Rock. We know that 

works. Thank you. 

Senator HOEVEN. Follow up questions for the next round. Thanks 

to each of you. 

Senator HEITKAMP. I think the great thing that’s here is we have 

the person who has been tasked with the challenge of taking a 

look, kind of breaking down those silos, and thinking about emanating programs. So many times we hear we started a project, we 

received great results and then the funding was up and it went 

away. So one of the concerns that I had about this issue involved 

consistency and longevity. So Dr. Robinson is here. She is tasked 

with that goal, and I want to just ask the three health care professionals here to offer some advice to her on what would be helpful 

in addressing trauma and making sure the trauma programs continue on and we continue to see the success that you’re seeing, but 

what more do you need from HHS to tackle this process. 

Ms. WARRINGTON. We’ve said it before, and that is like someone 

else said, the professional assistance. You know, having people 

there that can help, can counsel, and different programs, pediatric 

care, whether working with children. What better way to do that 

is to start with trauma affecting the lives and starting from when 

they are very young, but those experiences where they need care 

and they are few and far between. So having professionals that will 

go to where you want them to is very important to our treatment 

program for counseling services up there. I think that really that 

is one of the biggest things to me is having a professional availability and resources. 

Senator HEITKAMP. And you mean not in Washington DC, but actually on and in the trenches? 

Ms. WARRINGTON. Make that a point. 

Senator HEITKAMP. Next. 

Dr. EAGLE-WILLIAMS. We would like to see training programs 

that are accessible and efficient to train our local people as well as 

internships and funding that supports traditional health and 

wellness. Like Dr. DeCoteau said, why would a 17 year old girl who 

is extremely healthy, a leader in her school, and basketball player 

have to go to the hospital. We’re not seeing those individuals. We’re 

46 

not even seeing the individuals that are making attempts until we 

go through 911 calls, and at that time it’s three months later. So 

we’re developing the referral process, stuff like that, but we’d like 

to see more traditional health and wellness. We would also like to 

see incorporating the entire family, because obviously this is not 

just affecting that individual. It’s affecting the entire family and 

addressing the domestic violence within our homes. Just people in 

general are carrying, you know, historical trauma. We are carrying 

the trauma of our parents, our grandparents, and our children are 

doing the same. 

Dr. DECOTEAU. So the first thing that comes to mind is to provide the infrastructure for the mental health workers. I agree that 

we need a workforce, but coming from my own experience in reservation work, and many of you probably understand, when you’re 

doing mental health work on the reservation, you are the receptionist and the director and the clinician, and a number of other 

things. So the burnout is intense, and it’s very difficult to sustain 

that work even if that’s where your heart is. It’s exhausting. So we 

need to develop an infrastructure that supports the mental health 

workers and makes it possible for these individuals to function and 

stay in these jobs. Most of the people who do this, that’s where 

their hearts are, and if they leave, they leave for other reasons. So 

we need infrastructure. We need flexible use of funding. Sometimes 

when financing a grant for something I have to shave off the most 

innovative parts of my project to fit into what the grant is looking 

for. We need the ability to use the funding in flexible ways that 

make sense for the community and don’t just make sense for the 

granting agency. We also need a mandate for collaboration from 

emergency rooms both on and off the reservation. I cannot tell you 

how many times I have referred a high risk suicidal youth to the 

emergency room with burn marks on their neck because of an attempt, and they were turned away because they told the doctor 

they weren’t suicidal. It happens over and over and over, and we 

must collaborate better with our emergency rooms and doctors 

need to be educated, so we can help these individuals and save 

lives. We need to develop an ability to bill for services at the Federal rate, so that we can have sustainable funding sources for this 

type of project. We need to develop the ability for providers to private practice outside of the IHS system to have access to the same 

Federal rates when we’re doing reservation based work. 

Senator HEITKAMP. Miss Sparks-Robinson, if you could just kind 

of comment on what you’ve heard. And I’m particularly concerned, 

obviously we are at the end of the administration that has progressed greatly over the last eight years and their awareness and 

their willingness to commit, how do we perpetuate that? 

Ms. ROBINSON. So what I’ve heard from the listening session is 

that definitely the approaches have to be flexible, they have to be 

developed from tribal perspectives, they have to support the local 

solutions, and there’s a critical role of native language of education, 

and looking at the health. So that gives us some parameters on 

how we should collaborate. What I will tell you is that the staff is 

really helpful and is really dedicated to making sure trauma informed care is part of our normal practice. Especially for ACF and 

also at HHS. There is an HHS coordinating committee that will adVerDate Mar 15 2010 12:45 Nov 22, 2016 Jkt 022689 PO 00000 Frm 00050 Fmt 6633 Sfmt 6601 S:\DOCS\22689.TXT JACK
47 

dress trauma, not just in Indian communities, but across all of our 

programming. So this is an education piece that’s happening. 

There’s grants that we are providing specific to Indian Country 

that hopefully will provide some flexibility and it also is requiring 

that it’s done from the tribe perspective. We also have the methamphetamine/suicide initiative. We have tribal behavior health 

grants that we’re providing as well. So these are some of the activities and program funding that will continue to be available, you 

know, regardless of who is sitting here next year in this position. 

Last, we have to come up with proposals in the President’s budget 

that will allow for tribal training assistance center specific to native youth. That will look at small resources that are needed specific to trauma informed care. 

Senator HEITKAMP. Thank you. Just to make a comment, which 

is, we have seen with Indian health, and we’ve had some direct 

challenges with the Great Plains district; shutting down emergency 

rooms, failure to provid care, and we need to really examine Indian 

health in a way that I don’t think it’s been examined for awhile. 

But when we look at outcomes, and we know that Native Americans, their longevity is not what it is in the rest of the country. 

That tells us something. That tells us even though we’re working 

on beating chronic disease, whether it’s diabetes, whether it’s hypertension, we’re really only treating a symptom of something that 

we need to. Actually we’re finding this out all across the country 

that we no longer can afford to ignore mental health. We no longer 

can afford to ignore trauma and the things that lead to trauma. 

You know, one of the challenges that we have, and I hope you take 

back, is CMS needs to be responsive. We need to figure out how 

we pay to treat people in ways that actually achieve an outcome, 

not just, oh, you know, came and made sure that he had blood 

pressure checked, as opposed to why is this person experiencing hypertension? Why is this person experiencing high blood pressure? 

You know, we know that adverse childhood experiences have a very 

traumatic effect. Some reports would say 20 years off your life, we 

repeat treating the symptoms, and that’s expensive. If we don’t 

start looking at this differently, we not only will dig our hole deeper, but we’re going to continue to have the same outcomes. So we’re 

just really interested in how—and especially with Indian health. 

We need to have greater access to behavior and mental health services. We’ve got tribal chairmen in this room who would tell you 

that someone who is suffering from addiction, who is the first responder, the first responder the family calls is tribal court, BIA police. They didn’t commit a crime, but the emergency room isn’t a 

place where you’re going to go to get help. So the person looks for 

help in a church or a precinct. That is not an outcome that should 

happen. We’ve got to figure this out, and the challenge for me is 

to provide, you know, some sense that we can change outcomes. I 

think so many people have given up. So many people have given 

up and said, ‘‘It’s never going to change. We just have to continue 

to do what we’ve always done.’’ We can change it. We can change 

it if we take this great science that’s being done, great talents that 

are being developed in trauma informed and trauma based programs, and we start involving communities and we start involving 

what makes those communities unique. That’s the critical piece of 

48 

this, because we cannot fund our way out of this chronic disease 

without dealing with this issue as a potential to make change overall. So I’m committed to making sure that these programs continue 

to get attention. I’m going to turn it over to Senator Hoeven for 

some last questions. Thank you so much. 

Senator HOEVEN. And I just want to follow up. I appreciate that 

each of you had very good concepts and ideas to offer. I just want 

to follow up on a number of those with you. So I’m going to start 

with Miss Sparks-Robinson. You were talking about early childhood trauma, what is the key component to impacting outcomes? 

Ms. ROBINSON. Well there is a group who is incredibly dedicated 

to improving outcomes for Indian country. I spent some time with 

folks, including those that were practitioners in the community, to 

come up with what is the action that we need? What can we do 

to impact outcomes? And what we found is, so far, because the 

book is not done, is that there has to be screening tools. There has 

to be culturally specific screening that’s done in our health care 

center, in our childcare centers. They have to be developed in partnership with Indian Health Service to be able to identify what the 

needs are in that particular family. It has to be family based. We 

need that. When I have these conversations out in Indian country, 

both the kids and parents and leaders have all said, ‘‘I wish someone taught me how to be a better parent. I wish there was somewhere I could go to to be a better parent.’’ The youth are saying, 

‘‘I wish my mom would talk to me. I wish I knew how to talk to 

my dad. I wish my parents knew what I needed.’’ And tribal leaders are saying, ‘‘I wish there was a way to provide this service to 

our community members.’’ 

Senator HOEVEN. Does HHS or IHS have people come in and do 

some of the assessments? 

Ms. ROBINSON. So ACF through the tribal program, so ACH 

funds that program that’s funded through Versa. So we do have the 

ability, but you have to come in and apply but then there is somebody that actually comes out and does prenatal and early childhood 

activities. We have someone that teaches them, okay, this is what 

you need to be able to deliver a healthy baby. We need you to 

destress. We need you to make sure that you’re not being overwhelmed. This is what you need to be able to expect. Then comes 

in and does some screenings in the home, which we can’t always 

expect the patient or the person that’s in need to go to the place 

where the service is being provided. 

Senator HOEVEN. Thank you. Mr. Cruzan, you mentioned too, 

could you describe a little bit what you think is particularly effective in North Dakota about the program? 

Mr. CRUZAN. Absolutely. I think this one initiative in itself is 

really an effort, to the government watching in DC, we’re certainly 

not going to solve anybody’s problem by saying, ‘‘This is the way 

we’re going to do it.’’ So it is a break in services, if you will, and 

it’s an effort to give those services. The people closest to the issue, 

know the solution. People that have resources will ask. So I think 

that’s the effort that’s happening right now. Currently they are developing local plans driven by tribal leadership and the community 

and those service providers to tell, basically to say, ‘‘Here’s the direction we want to go.’’ There are—One size doesn’t fit all certainly 

49 

when it comes to that. So I think that’s what we’re doing is being 

very sensitive to the tribe’s developing a plan. And then being flexible with the funding and saying, ‘‘Well this isn’t normal but that 

sounds reasonable. So let’s do it.’’ 

Senator HOEVEN. Thank you. I agree and describing what they 

think would help. So I appreciate that. Dr. DeCoteau, you talked 

about a comprehensive approach, you talk about education of childhood trauma. So I wanted you to just describe what that is? You 

talked about safe and consistent relationships. You talked about 

technical assistance. I just don’t understand what you mean when 

you say ‘‘technical assistance.’’ Then you talk about outreach and 

internship programs as a way to resource, and I’m just wondering 

how you might structure or how you would come up with those outreach initiatives? 

Dr. DECOTEAU. So when I work with parents who are raising 

children with complex developmental trauma, one of the first 

things I do is I teach the parents how trauma impacts the brain 

and what that does to the child’s neurochemistry, so the parents 

can see that it isn’t a behavioral issue. It’s a brain development 

issue, and that’s what education about childhood trauma needs involve. Whether it be in the school systems or the parents or other 

agencies, people need to understand that the behaviors we see are 

the behaviors of traumatized children because they lack brain capacity to put forth the behaviors that are expected. Until parents 

and our systems learn to nurture the brains in the individuals, and 

have strategies that are directly targeted to rebuild the brain so we 

can rebuild the brain. And I always tell parents, it’s a brain development issue. I think if we had samples of the neurotransmitter 

panels of these children, we would see and understand that they 

are so disregulated. They cannot function. That helps us respond 

to these children in an empathetic way instead of an angry way. 

Safe relationships, that’s a simple term, but it really means a lot 

in terms of how do we help reduce the stress response in children 

that are always in a state of fear. We cannot rebuild a brain that 

has a constant fear signal, and they will always react to their environment in ways where they perceive fear. We don’t have a learning brain when there’s a fear response in the brain. So we need to 

interact with the child in a way that reduces that fear response, 

and we have a learning brain and now we can rebuild the brain. 

That comes first and foremost most with safe relationships. And 

what I’ve learned is that in our society loving, nurturing parents 

need help to know how to do this especially in traumatized children. So there needs to be strategies to teach parents how to be 

mindful with your child, how to provide healthy touches, how to 

provide nurturing, how to correct behaviors in ways that are not 

punitive, and build their self esteem, sense of self, which will, 

again, trigger their response. When I talk about technical assistance, I talked about, and I mean that rather broadly, I mean that 

in terms of having the kind of infrastructure support in a system 

where one person is not wearing all hats. Also, in terms of an ability to develop some research to provide timelines and to provide the 

data that we need to get the funding. When I was on the reservation a number of years ago, we had a project that was working to 

reduce the suicide rates, and we had a very unfortunate response 

50 

from the government. We were able to provide information about 

how this program is working and the government officials looked 

at myself and the tribal officials as we made our presentation and 

said, ‘‘I need to see timelines. This is just antidotal information, 

and it’s useless to us without data.’’ And I understand that data 

is required for funding, but the problem with that in reservation 

communities is you don’t have the infrastructure to develop a research base. Not that we couldn’t, but we need the assistance to 

be able to do that. We need the infrastructure to be able to do that. 

Outreach and internship, so there’s a difficulty in getting mental 

health workers and qualified mental health workers who want to 

do this work in Indian country. In my experience what I find is it’s 

harder to bring in providers who have been working. It’s harder to 

train those people because what’s required is an attitudal change 

in how you’re going to do your work. But interns and trainees are 

fresh, and they’re energetic and they want to make change and 

they’re idealistic and they want to follow your direction. They are 

usually younger, and they have a ton of energy. They come in with 

the mindset of changing the world. Of course we can’t change the 

world, but we can do what we can do. So using those internship 

models is a way to recruit people from outside the state, from inside the state, and keep them here. In fact, the internships that we 

had at Standing Rock, more than 30 percent of them came in from 

outside this state and stayed in this region. 

Senator HOEVEN. To me that makes a lot of sense. 

Dr. DECOTEAU. One important point I would like to make about 

that, Senator, is a handful of years ago I worked with this Committee on the Indian Health Care Reform Bill, and we made sure 

there was a specific provision written into that bill to allow for interns and trainees, not just in the field of mental health, but in all 

fields of health, to be billable providers at the Federal rate. So if 

we we could bill for those service and create stainable funding for 

our service. And these aren’t just, these are doctorate level trained 

folks. So they are quality individuals. I don’t know anybody that 

has used that yet, but it would have provide a system of funding. 

Senator HOEVEN. Thank you. Chairman Warrington, you mentioned having the counties more involved. Could you elaborate on 

that? 

Ms. WARRINGTON. Well a lot of times the counties are the only 

ones that are eligible for funding, so they can put— 

Senator HOEVEN. So you’re talking now about State dollars? 

Ms. WARRINGTON. Yes. And I know that a lot of tribes can’t get 

the county to the table to help share those resources to serve the 

people. We are a county, so most of them are part of the tribe. So 

we have a good relationship, but I know a lot of them don’t. And 

if we got in there, there’s ways that the government can make 

them do it. But I think that having that mandate, I think because 

they have to pay for some of these services to tribal members, because the tribe does not have the funds. 

Senator HOEVEN. How about some kind of cooperative agreement? Have you tried anything like that? 

Ms. WARRINGTON. I would think that would work, if the county 

was willing to do that. 

51 

Senator HOEVEN. When I was governor we had cooperative 

agreements, not necessarily in this area, just in general. Just asking if you think that might be possible? 

Ms. WARRINGTON. I don’t know if you would be able to do that 

with the county. 

Senator HOEVEN. And the idea of working together makes sense. 

Ms. WARRINGTON. It does to me, because pulling all those resources together makes it better. 

Senator HOEVEN. Right. Combine Federal and State resources? 

Ms. WARRINGTON. Yes. So we could apply for resources. 

Senator HOEVEN. Dr. Eagle-Williams, I am incredibly sorry for 

your loss. It takes incredible courage and strength to be here and 

talk about his. So I just want to commend you as far as making 

a difference for others. I want to bring up the Indians in the medicine programs and the Indians in the psychology programs. The 

reason is because of your testimony that you know there is obviously a lack with cultural and experienced trauma. So I think those 

are programs very good. Through our university system we’re trying to combine the training, you know, very sophisticated and comprehensive medical training, and some of these cultural understandings that we talked about. So I’m just going to ask what we 

think of those programs? Are they working? Should they be adjusted? Is there something more we should do, and how do we build 

off those kinds of programs? 

Dr. EAGLE-WILLIAMS. Actually those programs are very helpful, 

but we’re not necessarily seeing those individuals come back and 

return to our home. So it’s very difficult. The other thing is — 

Senator HOEVEN. Do you mean they don’t come back to the reservation? 

Dr. EAGLE-WILLIAMS. To Fort Berthold. Yes. But the other thing 

that we had experienced, we actually had a representative working 

very closely with the University of North Dakota and is actually an 

employee. Within the years that I had been there, we only had one 

graduate of that program. And actually, the success, it took six 

years to become a licensed clinical counselor, and that’s a challenge 

because the policy requirements in the State of North Dakota. And 

that’s what I’m saying, there’s a need for behavioral health specialists, you know, policy modifications to allow for sort of the 

layperson to receive adequate training to provide services that are 

universal. Because we’re not seeing a whole lot of people who are 

going into the field of medicine. I think we recently only had one 

graduate from the college of medicine who is a tribal member this 

last past year. I cannot say, we didn’t know, but I believe I was 

the last one to graduate from medical school in 2002 from the University of Arizona with little to no support as, I mean, I don’t practice medicine because of that. Getting through the boards and then 

dealing with all my own trauma, you know, just trauma being one 

in five in college of medicine, you know, that’s traumatizing, so. 

Senator HOEVEN. That’s what I was just going to wrap up with. 

Dr. DeCoteau, any thoughts on how we get people into those programs? 

Dr. DECOTEAU. Yes. So there’s three Indian programs in the psychology programs in the nation. There’s legislative law that will 

allow for up to five. They are great programs. Part of the difficulty 

52 

is that those individuals have an IHS pay back, and they have difficulty finding jobs in the IHS system. They are allowed to find jobs 

in other systems where they serve more than 50 percent native 

population, but there’s not a lot of available jobs, and some of those 

students are in default in their loans. The other issue is that the 

pipeline was never, it was never finished. So graduate school is not 

less, but you have to go to internship and you have to go on to postdoctoral residency. That’s where the recruitment is an issue. So if 

there’s not internship in post-doctoral programs in these rural communities, they go off to other metro areas. And then they usually 

start there careers in other metro areas. So we need to finish the 

pipeline. 

Senator HEITKAMP. I do want to comment that in our presence 

today is Dr. Don Warren, who runs the Ph.D. program for public 

health at NDSU and working very, very hard on building that capacity. Because a lot of what we’re talking about is integrating 

those public health models into the medicine, you know, just bringing it all together so that we’re not just focused on diabetes and 

hypertension and, you know, injuries, but that we’re actually looking at bringing a model to the system in Indian health that treats 

the whole person and treats the whole person culturally. So I 

couldn’t let it go by just talking about those two programs. I think 

Dr. Warren if you don’t mind just telling us what percentage of 

your graduate students now are Native? 

Dr. WARREN. In my program? 

Senator HEITKAMP. Yes. 

Dr. WARREN. Okay. We have the American Indian Public Health 

Program at NDSU is what you’re referring to, and our students 

start, actually tomorrow we have new student orientation, and 

we’ve now got 107 students and of that number 27 are American 

Indian. So it’s the most American Indians for any school in that 

timeframe. Sadly more than any school in our history. But we focus 

on health policy issues, cultural context issues, and recognizing the 

health disparities are really all the way back through historical 

trauma. But many of our students are planning to work in the tribal population and are wanting to work in public health, psychology. 

Essentially we need a public health focus which is dealing with 

prevention of a crisis. 

Senator HEITKAMP. What percentage of your folks that you graduated are working directly in Indian country? 

Dr. WARREN. We’ve had now of the 27 American Indian students, 

of that number there’s been about seven who have graduated, and 

I think we have one who is working for Sanford. The rest are working in Indian country. 

Senator HEITKAMP. That’s a huge resource for North Dakota. I 

would like to make that point. 

Senator HOEVEN. If I could ask, so kind of that follow up question that I’d asked for the panel members, how do you coordinate 

with the Deans of Medicine in those programs? 

Dr. WARREN. Yes. So public health is a different field, of course, 

than psychology and medicine, but they are integrated once we get 

out into the field. So we do have what’s called our coordinating 

counsel with UND. So we meet quarterly with the Medical School 

53 

Dean, their health care program direction, and other administrators to coordinate efforts. 

Senator HEITKAMP. I think we have a couple more comments and 

then we need to close it out. 

Dr. EAGLE-WILLIAMS. I would just like to say that the medicine 

program is actually a Federally funded program that may be a consideration of the State to implement into their budget for the next 

fiscal years. 

Dr. DECOTEAU. President McDonald has just reminded me that 

our Alaska Native relatives are in fact implementing an internship 

training program in their community and apparently they are 

using the billing to sustain the funding for their students. So we 

have a model with our Alaska relatives that we could look closely 

into. 

Senator HEITKAMP. We have a process that we need to follow. 

We’ve had a couple folks tell us that they would like to offer some 

comments. Comments, typically, because this is an official Senate 

hearing, we have to keep our usual schedule, what we planned on. 

So what I intend to do is offer an opportunity for anyone in this 

audience to submit written comments. Those written comments 

need to be sent to us in two weeks, and they will become part of 

the official record. So I’m going to close this hearing. 

[Whereupon, the hearing was concluded.] 

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A P P E N D I X 

PREPARED STATEMENT OF THE OCTETI SAKOWIN YOUTH


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PREPARED STATEMENT OF STEPHANIE YELLOW HAMMER, ENROLLED MEMBER, STANDING ROCK SIOUX TRIBE

I, Stephanie Yellow Hammer an enrolled member and lifelong resident of the 

Standing Rock Sioux Tribe and who has worked in the Early Childhood field here 

for 15 years, request to have my testimony entered into the official record for the 

Senate Indian Affairs Committee Trauma Field Hearing to be held on August 17, 

2016 in Bismarck North Dakota. 

Generation after generation our people have endured many historical traumatic 

events often one right after another. Each one of our generations has had to experience some type of traumatic event from the first contact of the European settlers 

to the present day event that is happening right now to the 7th generation with 

the placement of the Dakota Access Pipeline less than one mile north of our Standing Rock Reservation, which you people will refer to as an Adverse Childhood Experience (ACES) and once again breaking the treaties by placing this black snake that 

will carry crude oil from the northwestern part of North Dakota to Illinois. When 

this pipeline breaks it will contaminate not only our water source but all people who 

depend on the Missouri River for their water but we will be the first to feel this 

impact. In D/Lakota we say ‘‘Mni Wiconi’’ water is life; as without out water we cannot survive. 

Our people have never been able to heal and grieve as many of these traumatic 

events have been inflicted one right after another and somewhere in this process 


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we have lost our resiliency as we have had so much taken from us; Our Land, Our 

Culture, Our Language, Our Kids Forced into Boarding Schools, Denied the Right 

to Practice Our Sacred Ceremonies, Forced Relocations, we can go on and on about 

what was taken from us and what we have lost, but you all know what has happened to us. 

We need funding for housing as many of our families live in doubled or often tripled up homes, where some are exposed to alcohol, drug and sexual abuse. 

We need funding for Indian Health Services as many of our youth and children 

are in dire need of mental health services from the ‘‘effects’’ of the historical trauma 

and ACEs that they experience at an alarming rate. 

We need funding for cultural programs such as the Lakohol’iyapi Wahohpi and 

Wichakin Owayawa (Immersion) as we have lost our identity through all the trauma and grief. Our children need to be exposed to their culture and language so we 

can regain our identity that was stolen from us. 

We need more funding for prevention and educational programs so we can better 

educate our children and youth so we do not have to function in a reactive mode. 

We need a big push for the importance and need for Tribal Early Childhood Services so we can build strong children instead of repairing broken youth. 

We need funding for an inpatient treatment facility and addiction services so we 

can provide the much needed treatment services that our youth and adults need. 

You can educate people all you want on the Causes and Effects of Historical Trauma & Adverse Childhood Experiences in Native American Communities but until 

you can provide sufficient and adequate funding for our Tribal Nations you will continue to see the ‘‘Effects’’ of the trauma that the white man has inflicted on us. 

Hopefully this hearing will open the eyes of some of the elected officials and shed 

some much needed light on the issue. 

Wophila Thanka (Thank You) for your time. 

Æ