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97–503 PDF 2015

S. HRG. 114–112 

DEMANDING RESULTS TO END NATIVE YOUTH 

SUICIDES 

HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

JUNE 24, 2015 

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 

Hearing held on June 24, 2015 ............................................................................... 1 

Statement of Senator Barrasso ............................................................................... 1 

Statement of Senator Daines .................................................................................. 49 

Statement of Senator Franken ............................................................................... 36 

Statement of Senator Heitkamp ............................................................................. 4 

Statement of Senator Murkowski ........................................................................... 53 

Statement of Senator Tester ................................................................................... 2 

Statement of Senator Udall .................................................................................... 4 

WITNESSES

Clifford, Hon. Collins ‘‘C.J.’’, Tribal Council Member, Oglala Sioux Tribe ......... 13 

Prepared statement of Hon. John Yellow Bird Steele ................................... 15 

Lafromboise, Teresa D., Ph.D., Professor, Developmental and Psychological 

Sciences, Graduate School of Education, Stanford University ......................... 40 

Prepared statement .......................................................................................... 43 

Mcswain, Hon. Robert G., Acting Director, Indian Health Service, U.S. Department of Health and Human Services .......................................................... 5 

Prepared statement .......................................................................................... 7 

Seki Sr., Hon. Darrell G., Chairman, Red Lake Band of Chippewa Indians ...... 36 

Prepared statement .......................................................................................... 38 

(1) 

DEMANDING RESULTS TO END NATIVE 

YOUTH SUICIDES 

WEDNESDAY, JUNE 24, 2015 

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 2:30 p.m. in room 

628, Dirksen Senate Office Building, Hon. John Barrasso, 

Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. JOHN BARRASSO, 

U.S. SENATOR FROM WYOMING 

The CHAIRMAN. Good afternoon. I call this hearing to order. 

Today, the Committee will hold an oversight hearing entitled Demanding Results to End Native Youth Suicides. 

Over the past ten years, this Committee has held six formal 

hearings to address the issue of youth suicide. We return to this 

panel issue once again today because youth suicide continues to 

plague too many Indian communities. 

In 2011, the Substance Abuse and Mental Health Services Administration identified youth suicide as the second leading cause of 

death for Indian youth between 15 and 24 years of age. The U.S. 

Centers for Disease Control reported Native youth suicide to be two 

and a half times the national average in 2012. 

Some communities are dealing with daily suicide attempts and 

suicide clusters. Over the last six months, the Pine Ridge Indian 

Reservation in South Dakota has suffered at least 11 suicides and 

at least 379 suicide attempts have been reported. 

I was troubled to learn from the testimony submitted by President Steele that a youth pastor at the Pine Ridge Reservation received word that a group of children had planned a group suicide. 

The pastor sped to the place it was planned and found many ropes 

hanging from the trees. 

Thankfully, the pastor arrived before any of the children attempted to hang themselves. He was able to counsel them on the 

spot, undoubtedly saving their lives in the process. 

This is just one reservation. Many communities across Indian 

Country are facing similar tragedies or attempted tragedies. Our 

hearts go out to the families and communities for their great 

losses. 

I will not stand idly by, nor will this Committee. There must be 

a better way of supporting the young people, parents, teachers and 

community leaders that are fighting against suicide. We all share 

2 

the goal of ending youth suicides in Indian Country. Achieving this 

goal requires a comprehensive and evidence-based plan that is 

proactive instead of reactive. 

I am very concerned that the Administration’s plan and actions 

so far have been insufficient. The Department of Health and 

Human Services is responsible for the delivery of health services to 

American Indians and Alaska Natives. Its duty is to uphold the 

Federal obligation to promote healthy Indian communities and 

honor tribal governance, but it has failed to do so. 

I talked directly with Secretary Burwell last week. She shares 

our concern. Native youth suicide is too significant a threat for this 

Committee to accept anything less than measurable results. 

I am very troubled that Federal agencies with responsibilities to 

American Indians and Alaska Natives do not seem to be learning 

from the tribes like the White Mountain Apache Tribe and the Menominee Indian Tribe of Wisconsin which have actually reduced 

the number of suicides in their communities. 

We will not turn away from this issue until it is resolved. The 

time for finger pointing, lack of coordination and excuses is over. 

This Committee will do whatever it takes legislatively and in its 

oversight capacity to support results. 

Today, we will hear testimony from tribal leaders, a subject matter expert and the Administration. 

Speaking of the Administration, a lot of time and energy has 

been spent in preparing for this hearing today. It is unacceptable 

that the Committee only received the Administration’s testimony 

late yesterday afternoon. 

I want to welcome our panel and look forward to hearing their 

perspectives. 

Before we hear from the panel, I want to thank Vice Chairman 

Tester for his attention to the issue and invite him to make an 

opening statement. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman. Thank you for holding this hearing today. 

I would join you in your resolve to get this issue on youth suicide 

and suicide in Indian Country settled. I appreciate anything we can 

do to work together to truly make some inroads. 

This is a bad issue. My friend and former Chairman of this Committee, Senator Dorgan, who retired in 2011, put a good amount 

of time into solving this issue. It still is an epidemic among tribal 

nations across this country. 

As we have heard at our Committee hearings over and over 

again, children in Indian Country face some dreadful realities. Late 

last year, the Department of Justice releases a report called Ending 

Violence So Children Can Survive. Included in that report was a 

finding that Native children experience PTSD at the same rate as 

veterans from the wars in Iraq and Afghanistan. We have some 

problems. To say that this is troubling does not even begin to characterize the situation. 

Many of our Native children face hopelessness each and every 

day. They wake up to overcrowded homes with up to 10 or 15 peoVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 S:\DOCS\97503.TXT JACK
3 

ple living in a two or three bedroom house. Many lack access to 

fresh, healthy food or breakfast because they live in food deserts. 

These youths get on school buses sometimes traveling for an 

hour or more to get to schools that are often run down and lack 

available staff to teach and nurture them. We have had hearings 

on this also. 

These are just some of the challenges Native children face every 

day. This is all before lunch. 

There is no single, simple solution. We need to work together to 

improve everything from nutrition to housing to health care to public safety. I am grateful to see this Administration has formed a 

Council on Native American Affairs. This is a more holistic approach to addressing the needs of Native communities. It will help 

remove the bureaucratic red tape that has been in place for far too 

long. 

We cannot continue to air drop in resources erratically when suicides spike in Indian communities and turn around and abandon 

those communities when patchwork funding runs out. We need stability, consistency in mental health programs and a community effort to remove the stigma associated with mental health and mental health treatment. 

In my home State of Montana, sadly, this issue is not new. On 

the Fort Peck Indian Reservation, the tribe was faced with a wave 

of suicides in recent years and has since developed a suicide prevention plan. 

That plan includes significant steps to address risk factors, implement prevention efforts and develop a crisis response plan. Interestingly, many tribes are finding that increased access and exposure to culture and language resources promotes a positive self 

image and improves mental health for Native youth. Fort Peck’s 

plan also focuses on ways to increase community knowledge on how 

to assess risk in order to refer individuals for treatment and increased access to appropriate preventative care. 

Tribes know what they need. Many are in the position to implement programs to support these efforts. What they lack is a sustainable funding source. These efforts are at the heart of the trust 

responsibility our government holds with tribal nations. 

Now the Federal Government needs to step up and do what we 

need to do to support tribes in their efforts to stop this awful cycle. 

Unfortunately, this year it seems like we can provide more money 

for defense budgets but we cannot put more money into saving 

lives of Native youth. This is unacceptable by anybody’s standard. 

I look forward to the testimony of the witnesses today to hear 

what we can do to work together to help end this youth suicide epidemic. 

I want to thank the panelists for being here today. I know some 

of you have been through some very difficult times recently. You 

all know this issue inside and out. I look forward to your testimony. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Tester. 

Would any other members like to make a statement? Senator 

Heitkamp. 

4 

STATEMENT OF HON. HEIDI HEITKAMP, 

U.S. SENATOR FROM NORTH DAKOTA 

Senator HEITKAMP. Thank you, Mr. Chairman and Vice Chairman Tester. 

Once again, here we are, wringing our hands and telling deplorable and horrible stories of situations that should shock the Nation’s conscience but somehow do not ever seem to filter out of this 

hearing room. 

This is not a new issue. During my time serving as North Dakota’s Attorney General, we had a high rate of suicide in Indian 

Country but it has become almost epidemic. We cannot simply say 

‘‘we share your concern.’’ It is not enough any longer for the Federal Government to say we share the concerns of all the tribal entities and all the tribal families and all the tribal parents who are 

losing the next generation of their children. We must take action. 

The unfortunate thing is frequently that action we must take involves resources, involves community coming together, having 

enough resources, and having a great plan. 

Mr. Chairman, I welcome all of the wonderful witnesses we have 

today here to talk about an extraordinarily difficult subject, I am 

very interested in hearing what successful practices and models Dr. 

Teresa D. LaFromboise has to share, because we have to find a solution. We have to find best practices and then we have to fund 

those best practices. 

I want to personally thank Dr. LaFromboise for being here. She 

is of Miami tribal decent and is the proud mother of her daughter, 

Cecily, who is an enrolled member at the Turtle Mountain Band of 

Chippewa located in North Dakota. I think her expertise and her 

commitment will be revealed in her testimony. I am particularly 

anxious to hear what steps we need to take, when we need to take 

them and how we change this dynamic. What we have done in the 

past, taking a look at the rapid increases that we have seen, what 

we have done in the past clearly has not worked. 

Thank you, Mr. Chairman. You continue to have my participation and my commitment to work with you and with the Vice 

Chairman on a path forward. 

The CHAIRMAN. Thank you, Senator Heitkamp. 

Senator Udall? 

STATEMENT OF HON. TOM UDALL, 

U.S. SENATOR FROM NEW MEXICO 

Senator UDALL. Thank you very much, Chairman Barrasso and 

Vice Chairman Tester. I really appreciate your pulling this hearing 

together on this incredibly important subject. 

The loss of one child’s life is debilitating for families and I think 

for the entire community. In my home State of New Mexico, we 

have lost far too many young people in our Native communities. 

As Senator Heitkamp discussed, when I was Attorney General in 

New Mexico and then a Congressman before I came to the Senate, 

the numbers were way, way too high. Just to throw one at you, the 

New Mexico Department of Health estimates that at least 201 Native American youth have died of suicide between 1999 and 2013. 

There has been evidence of suicide clusters, a series of two or 

three suicides in the community over the course of the year or less 

5 

occurring on the Mescalero Apache Indian Reservation and also the 

Eastern Navajo Nation. It is likely that the statistics are significantly under-counting these tragedies. 

There are also high concentrations of risk factors in New Mexico’s Native communities. Last year, in a survey of 1,300 Native 

Americans from seven different tribal communities in the State, 

the University of New Mexico researchers found that 29 percent 

had been exposed to four or more traumatic experiences as children 

such as alcohol and drug abuse, physical violence at home, neglect, 

abuse, separated or divorced parents or a close family member in 

prison. 

It is critical that we listen to our Native youth and remove the 

stigma from talking about suicide and trauma. We must create and 

sustain opportunities for them to learn the value of their cultures 

and identities. 

We need to make sure they are connected to adequate mental 

health services. We must show them that their lives matter. 

I want to thank the witnesses for being here today and for all 

the hard work they have done in their communities and the crises 

that are occurring around the country. We must do better. 

Thank you very much, Mr. Chairman. 

The CHAIRMAN. Thank you. 

We will now hear from our witnesses. We have with us today the 

Honorable Robert G. McSwain, Acting Director, Indian Health 

Service, U.S. Department of Health and Human Services, Rockville, Maryland. We have the Honorable Collins ‘‘C.J.’’ Clifford, 

Tribal Council Member, Oglala Sioux Tribe of Pine Ridge, South 

Dakota. Councilman Clifford is filling in for President Steele. We 

also have the Honorable Darrell G. Seki, Sr., Chairman, Red Lake 

Band of Chippewa Indians, Red Lake, Minnesota, and Teresa D. 

LaFromboise, P.h.D, Professor, Developmental and Psychological 

Sciences, Graduate School of Education, Stanford University, Stanford, California. 

I thank you all for being here. I want to remind our witnesses 

that your full written testimony will be made a part of the official 

hearing record. Please keep your statements to five minutes so that 

we may have time for questions. I look forward to hearing your testimony, beginning with Mr. McSwain. 

STATEMENT OF HON. ROBERT G. MCSWAIN, ACTING 

DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Mr. MCSWAIN. Mr. Chairman, Vice Chairman and members of 

the Committee, good afternoon. 

I am Robert McSwain, current Acting Director of the Indian 

Health Service. I appreciate the opportunity to testify on demanding results to end Native youth suicide. 

I agree, number one, this is a very serious issue. I have been 

talking with Councilman Clifford as we prepared for the hearing 

about how things are going. I have not had a chance to talk with 

President Steele this week but I try to call him every week. 

I would just highlight some of the key programs, initiatives and 

investments that we are doing to end youth suicide. I look forward 

to continuing to work with the Committee, as you have offered. 

6 

As you know, Indian Health Service, of any group plays a rather 

unique role. We are providing health care and we are sitting on the 

reservation. I have some comments about how we can make that 

even better. 

The mission of the Indian Health Service is to raise the physical, 

mental, social and spiritual health of American Indians and Alaska 

Natives to the highest possible level. That is our mission and has 

been for the last 20 years. I just want to restate that. 

You mentioned some statistics and I am not going to go through 

all of those. You are probably well aware of it. I will say we have 

published a new Trends in Indian Health dated 2014. It is on our 

website. We have recited all of those particular notations you have 

made in the case of suicide which is the sixth leading cause of 

death overall for males residing in IHS service areas. I think that 

is a real issue. 

I want to say that when tribal leaders often request help from 

us in many different forms, either funding or during a cluster, we 

generally will respond immediately whether it is funding to help locally or if they have asked for deployments. We have done that. 

In fact, in the deployments to Pine Ridge, we were able to convene a deployment within a week to go to Pine Ridge. We had 

three cycles of folks up there. As you mentioned, Mr. Chairman, it 

was only temporary as we move ahead. We need to do something 

more substantial. 

The most important part I can say today is the fact that this 

year we will launch the Zero Suicide Initiative. The most important 

part of this concept is as patients go through our clinics, we have 

to have our folks trained to identify where the at-risk youth are 

coming to us, know when to see it and when to be able to have that 

conversation. We are a health system and they come to us for a lot 

of reasons. We ought to be able to monitor the youth better. 

I would just enumerate the other parts because you have it in 

my statement. We have a Meth Suicide Prevention Initiative. That 

has been going on for six years. We will get the results this year. 

That is community-based. 

There are 130 programs across the Nation. Domestic violence is 

another initiative that is community-based. These are important 

pieces we are putting in place. They had 65 projects and certainly 

the DVPI expands outreach. 

Prioritizing health care for youth is one I am very excited about. 

We are going to jump ahead. It is in the President’s budget for 

2016 but we are going to go ahead and open a Pathways program 

and begin to hire Native youth to work in our facilities and service 

units to get them doing something different and perhaps expose 

them to health care and forming youth steering committees so they 

can get together and begin to share. 

There was a comment about lack of integration. We are working 

closely with the Substance Abuse and Mental Health Administration. A good example of our response to Pine Ridge is that we are 

working on our health system to improve it and make it more responsive and SAMHSA is providing support to help the community 

work their piece of it. This is a two-part process. 

The other part is behavioral health. We have turned on Tele-Behavioral Health to Pine Ridge, for example, and to the outlying 

7 

clinics so that we can provide access to care locally in some of those 

health centers. 

I will also mention the biggest challenge we will have in rural 

America is recruit and retention of health care providers. We ran 

up against this at Pine Ridge and immediately we had a problem 

with housing. We did a little work-around. I won’t go into how we 

did the work-around, but we were able to provide temporary housing for staff that desperately needed to be on-site. 

We will do more in this area. I think there will be questions 

about health care professionals that we need in the area, certainly 

behavioral health folks. We are working on that very diligently. 

I think we have some pieces that we are putting together that 

will integrate all of the pieces. We have all these programs. We just 

want to have one place where they are all working together and 

not working in silos or separately. 

With that, I will close my oral remarks. 

[The prepared statement of Mr. McSwain follows:] 

PREPARED STATEMENT OF HON. ROBERT G. MCSWAIN, ACTING DIRECTOR, INDIAN

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

Chairman and Members of the Committee: 

Good afternoon, I am Robert G. McSwain, Acting Director of the Indian Health 

Service (IHS). Today, I appreciate the opportunity to testify on ‘‘Demanding Results 

to End Native Youth Suicide.’’ 

Thank you for the invitation to talk about this very serious issue of Native youth 

suicide. It is with a heavy heart that we discuss an issue that continues to plague 

American Indian and Alaska Native (AI/AN) communities. Most recently, the Oglala 

Sioux Tribe has faced the same tragedy of a suicide cluster that too many other AI/ 

AN communities have experienced. Our thoughts go out to the Oglala Sioux Tribe 

and the families and friends who are grieving the loss of their young people. Today, 

I will highlight our key programs, initiatives, and investments to end Native youth 

suicide and we look forward to continuing to work with the Committee to address 

this devastating problem. 

As you know, the Indian Health Service (IHS) plays a unique role in the Department of Health and Human Services because it is a health care system that was 

established to meet the federal trust responsibility to provide health care to American Indians and Alaska Natives. The IHS provides high-quality, comprehensive primary care and public health services through a system of IHS, Tribal, and Urban 

operated facilities and programs based on treaties, judicial determinations, and Acts 

of Congress. The IHS has the responsibility for the delivery of health services to an 

estimated 2.2 million American Indians and Alaska Natives who belong to 566 Federally-recognized Tribes. The mission of the agency is to raise the physical, mental, 

social, and spiritual health of American Indians and Alaska Natives to the highest 

level. The agency goal is to assure that comprehensive, culturally appropriate personal and public health services are available and accessible to the AI/AN population. Our duty is to uphold the Federal Government’s obligation to promote 

healthy AI/AN people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes. 

Two major pieces of legislation are at the core of the Federal Government’s responsibility for meeting the health needs of American Indians and Alaska Natives: 

The Snyder Act of 1921, 25 U.S.C § 13, and the Indian Health Care Improvement 

Act (IHCIA), 25 U.S.C. §§ 1601–1683. The Snyder Act authorized appropriations for 

‘‘the relief of distress and conservation of health’’ of American Indians and Alaska 

Natives. The IHCIA was enacted ‘‘to implement the Federal responsibility for the 

care and education of the Indian people by improving the services and facilities of 

Federal Indian health programs and encouraging maximum participation of Indians 

in such programs.’’ Like the Snyder Act, the IHCIA provides the authority for the 

provision of programs, services, functions, and activities to address the health needs 

of American Indians and Alaska Natives. The IHCIA also includes authorities for 

the recruitment and retention of health professionals serving Indian communities, 

health services for people, and the construction, replacement, and repair of 

healthcare facilities. 

8 

Introduction 

We share your deep concern about the tragedy of suicide among Native youth. 

Suicide is a complicated public health challenge with many contributing factors in 

AI/AN communities. Although suicide contagion is not unique to AI/AN populations, 

too frequently, AI/AN communities experience suicide that takes on a particularly 

worrying and seemingly contagious form, often referred to as suicide clusters. In 

these communities, the suicidal act becomes a regular and transmittable form of expression of the despair and hopelessness experienced by some Native youth. While 

most vividly and painfully expressed in close knit AI/AN communities, suicide and 

suicidal behavior and their consequences send shockwaves through the community. 

We at IHS—and at HHS more broadly—try to prevent these suicide clusters from 

beginning and to halt them once they begin occurring. 

However, all too many AI/AN communities are affected by high rates of suicide. 

The recently published IHS ‘‘Trends in Indian Health, 2014’’ reports: 

• The age adjusted suicide rate (18.5 per 100,000 population) for the three year 

period (2007–2009) in the IHS service areas was 1.6 times that of the U.S. all 

races rate (11.6) for 2008. 

• Suicide is the second leading cause of death (behind unintentional injuries) for 

Indian youth ages 15–24 residing in IHS service areas and the suicide death 

rate for this cohort is four times higher than the national average. 

• Suicide is the sixth leading cause of death overall for males residing in IHS 

service areas and ranks ahead of homicide. 

• AI/AN young people ages 15–34 make up 64 percent of all suicides in Indian 

country. 

Responding to Suicide Crises 

Tribal leaders will often request IHS to provide additional support and funding 

to help prevent any further suicides during a cluster. Since no two suicide clusters 

are the same, the IHS response is tailored to the needs of the community in crisis. 

In general, our Area Office typically takes the first steps to organize and implement 

a response to a suicide crisis. In particular, the IHS Area Office reaches out to tribal 

leadership to ensure IHS and key Federal partners, such as the Substance Abuse 

and Mental Health Services Administration (SAMHSA), are aware of the Tribe’s 

level of need and the specific requests for a response. We take steps to work handin-hand with the tribe, in organizing our response. IHS and SAMHSA coordinate 

to ensure Federal resources are readily available. 

SAMHSA’s resources may include existing grants awarded to the tribe under the 

new Tribal Behavioral Health Grant (TBHG) program that is focused on preventing 

suicidal behavior and substance abuse and promoting mental health in AI/AN youth 

or the Garrett Lee Smith State/Tribal Youth Suicide Prevention program that supports youth suicide prevention and early intervention strategies and collaborations 

among youth-serving institutions and systems (i.e., schools, juvenile justice, foster 

care, substance abuse, mental health, and other child and youth supporting organizations). Other SAMHSA resources include specialized technical assistance centers 

such as the Suicide Prevention Resource Center, National Native Children’s Trauma 

Center, and National AI/AN Addiction Technology Transfer Center. 

If the Tribe requests a deployment of healthcare providers, IHS takes the lead 

with the Division of Commissioned Corps Personnel and Readiness (DCCPR) to assess and plan for the deployment. A deployment team can be on the ground in a 

matter of days. These short term deployment teams are intended to deal with the 

immediate crisis until mid- and long-term solutions can be set in place. 

Zero Suicide 

In 2015, IHS will launch the Zero Suicide Initiative, a key concept of the 2012 

National Strategy for Suicide Prevention. In our current system, suicide care has 

traditionally been provided by individual local champions and clinical providers. 

IHS is moving toward a more programmatic system-wide approach by implementing 

Zero Suicide. IHS’ commitment to create a leadership-driven, safety-oriented culture 

committed to reducing suicide among people under our care will drive the improved 

patient outcomes we need to see as a result of a collective Agency effort. Moving 

forward, IHS is making the commitment to set big goals and improve our approach 

to inform system changes to provide better care for AI/AN individuals at risk for 

suicide. 

Zero Suicide represents a bold goal for IHS. It is the foundational belief that suicide deaths for individuals under our care within our health and behavioral health 

systems are preventable. IHS is committed to creating a leadership-driven, safetyoriented culture focused on reducing suicide. The approach represents a commitVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00012 Fmt 6633 Sfmt 6621 S:\DOCS\97503.TXT JACK
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ment from IHS to set in place an organizational structure where suicidal individuals 

and individuals at-risk will receive coordinated care from a competent workforce. 

The fundamentals of Zero Suicide implementation include: leadership’s commitment 

to reduce suicide deaths; training a competent, confident, caring workforce; identifying and assessing patients for suicide risk; engaging patients at risk for suicide 

in a care plan; treating suicidal thoughts and behaviors directly; following patients 

through every transition in care; and applying data-driven quality improvement. To 

accomplish our commitment, IHS has begun a virtual training series through the 

Tele-Behavioral Health Center of Excellence (TBHCE). IHS is also partnering with 

SAMHSA and the Suicide Prevention Resource Center to bring a tailored Zero Suicide Training Academy for IHS and Tribal healthcare facilities in 2015. In addition, 

as discussed below, the Fiscal Year (FY) 2016 Budget requests an additional $25 

million to hire additional behavioral health providers through the Methamphetamine and Suicide Prevention Initiative (MSPI). 

Methamphetamine and Suicide Prevention Initiative 

The MSPI is an IHS nationally-coordinated demonstration project, focusing on 

providing much-needed methamphetamine and suicide prevention and intervention 

resources for AI/AN communities. It is a key resource for IHS as we work to prevent 

youth suicides. It promotes the use and development of evidence-based and practicebased models that represent culturally-appropriate prevention and treatment approaches from a community-driven context. 

The MSPI supports 130 programs across the country. The goals of the MSPI are 

to: 

• Prevent, reduce, or delay the use and/or spread of methamphetamine use; 

• Build on the foundation of prior methamphetamine and suicide prevention and 

treatment efforts, in order to support the IHS, Tribes, and Urban Indian health 

organizations in developing and implementing culturally appropriate methamphetamine and suicide prevention and early intervention strategies; 

• Increase access to methamphetamine and suicide prevention services; 

• Improve services for behavioral health issues associated with methamphetamine use and suicide prevention; 

• Promote the development of new and promising services that are culturally and 

community relevant; and 

• Demonstrate efficacy and impact. 

MSPI projects provide multiple services related to suicide and methamphetamine 

use. The most common focus of funded projects is suicide prevention (94 percent), 

methamphetamine prevention (69 percent), and suicide treatment and intervention 

(55 percent). The MSPI projects are in the sixth and final year of the demonstration 

program. From 2009–2014, the MSPI resulted in over 9,400 individuals entering 

treatment for methamphetamine use; more than 12,000 encounters via tele-health 

for substance abuse and mental health disorders; over 13,150 professionals and community members trained in suicide crisis response; and more than 528,000 encounters with youth provided as part of evidence-based and practice-based prevention activities. 

MSPI projects offer a multitude of evidence-based practices and treatments. The 

most common types of evidence-based practices utilized among MSPI programs to 

prevent suicide are Question, Persuade, Refer (QPR); Applied Suicide Intervention 

Skills Training (ASIST); Safe Tell, Ask, Listen, Keepsafe (safeTALK); Mental Health 

First Aid; and Gathering of Native Americans. Evidence-based treatments to prevent suicide re-attempts utilized among MSPI programs include Motivational Interviewing, Cognitive Behavior Therapy (CBT), and Dialectical Behavior Therapy, to 

name a few. For instance, the White Earth MSPI project, called Native Alive, stations mental health professionals at reservations schools and maintains a support 

hotline staffed by health professionals trained in ASIST. 

MSPI projects often incorporate cultural elements into their programs and activities such as by teaching traditional beliefs, smudging, ceremonies, or sweat lodges 

in collaboration with traditional healers. The Absentee Shawnee MSPI project, Following in Our Footsteps, utilizes cultural activities such as Native American storytelling, arts and crafts, dancing, sweat lodge ceremonies, and positive youth activities to promote healthy life choices and positive decision-making skills. 

Building on the associations between social connections and lower suicide risk, 

MSPI projects enlist partners to build community-based suicide prevention. Partnerships with local schools are key in the MSPI for school-based interventions to develop skills to protect against suicidal thoughts and behaviors, raise awareness, encourage help-seeking, and teach positive life and coping skills. Examples of such acVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 S:\DOCS\97503.TXT JACK
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1See: http://www.iom.edu/Reports/2002/Reducing-Suicide-A-National-Imperative.aspx 

tivities at work in MSPI communities include American Indian Life Skills, Native 

Hope, and Project Venture. Youth may not want or may not always be able to ask 

appropriate adults for help and may reach out to their peers for assistance. MSPI 

projects offer training to youth to build their intervention skills for such situations. 

The MSPI funds allow projects to expand community-based mental health care into 

youth-based settings, increasing access to care for mental health and substance use 

disorders for our Native youth. The funding for MSPI funding is not enough to go 

to every Tribe. Therefore, IHS awards the funds on a competitive basis. In FY 2015, 

IHS will open a new funding announcement for a project period to run from September 30, 2015 to September 29, 2020, contingent on appropriations. 

Domestic Violence Prevention Initiative 

Since the Institutes of Medicine (2002) report 1 on suicide research, there has been 

much learned about the role of child abuse in later suicide risk. According to the 

Center on the Developing Child at Harvard University, a toxic stress response can 

occur when a child experiences strong, frequent, and/or prolonged adversity, such 

as physical or emotional abuse, chronic neglect, caregiver substance use and mental 

health disorders, exposure to violence, and/or the accumulated burdens of family 

economic hardship. These adverse childhood experiences can disrupt the development of brain architecture and other organ systems, and increase the risk for stressrelated disease and cognitive impairment, well into the adult years. 

IHS’ primary response to children exposed to violence is through the Domestic Violence Prevention Initiative (DVPI). The IHS began the DVPI in 2010 with the purpose of better addressing domestic violence (DV) and sexual assault (SA), including 

the pediatric and adolescent population, within AI/AN communities. The program 

has awarded funding to a total of 65 projects that include IHS/Tribal/Urban operated programs. This initiative promotes the development of evidence-based and 

practice-based models that represent culturally appropriate prevention and treatment approaches to DV and SA from a community-driven context. Types of evidence-based treatment practices provided by DVPI projects include CBT, Trauma 

Focused CBT, Beyond Trauma: Traumatic Incident Reduction, and Strengthening 

Families, a program to improve parenting and family relationships. Practice-based 

practices utilized by DVPI projects include elders teaching traditions, talking circles, 

or smudging ceremonies. For instance, Santa Clara Pueblo provides more community education activities; in-school services for young witnesses of family violence; 

violence prevention education in schools; and counseling for young victims of DV. 

The DVPI expands outreach and increases awareness by funding projects that 

provide victim advocacy, intervention, case coordination, policy development, community response teams, and community and school education programs. The funding is also used for the purchase of forensic equipment, medical personnel training, 

and the coordination of Sexual Assault Examiner (SAE) and Sexual Assault Response Team activities. From 2010–2014, the DVPI resulted in over 50,500 direct 

service encounters including crisis intervention, victim advocacy, case management, 

and counseling services. More than 38,000 referrals were made for domestic violence 

services, culturally-based services, and clinical behavioral health services. In addition, a total of 600 forensic evidence collection kits from eight SAE programs were 

submitted to Federal, state, and tribal law enforcement. In the last year, DVPI 

projects referred over 2,000 children and youth to behavioral health, cultural services, DV or SA services, shelter services, specialized medical care, or to victim advocates. 

Prioritizing Behavioral Health Services for Native Youth 

The Administration’s 2016 Budget proposes key investments to launch Generation 

Indigenous (Gen-I), an initiative addressing barriers to success for Native American 

youth. This integrative, comprehensive, and culturally appropriate approach across 

the Federal Government will help improve lives and opportunities for Native American youth. The HHS Budget Request includes a new Tribal Behavioral Health Initiative for Native Youth with a total of $50 million in funding for IHS and the 

SAMHSA. Within IHS, the request includes $25 million to expand the successful 

MSPI to increase the number of child and adolescent behavioral health professionals 

who will provide direct services and implement youth-based programming at IHS, 

tribal, and urban Indian health programs, school-based health centers, or youthbased programs. SAMHSA will expand the Tribal Behavioral Health Grant program 

to support mental health promotion and substance use prevention activities for 

high-risk Native youth and their families, enhance early detection of mental and 

substance use disorders among Native youth, and increase referral to treatment. 

11 

These activities will both fill gaps in services and fulfill requests from tribal leaders 

to support Native youth. 

IHS’ Gen-I activities include youth engagement through the development of youth 

steering committees at the local level to inform IHS on planning, implementation, 

and evaluation of its youth health programs and services. The information from the 

local youth steering committees will feed into regional and national recommendations to operationalize the input received from Native youth. Secondly, IHS will provide opportunities through its Pathways Internship Program. Pathways is a streamlined program designed to attract students enrolled in a wide variety of educational 

institutions (high school, home-school programs, vocational and technical, undergraduate and graduate) with paid opportunities to work in agencies and explore 

Federal careers while still in school. This program exposes students to jobs in the 

Federal civil service by providing meaningful ‘‘developmental work’’ at the beginning 

of their career, before their ‘‘career paths’’ are fully established. The flexible nature 

of the program is to accommodate the need to hire students to complete temporary 

work or projects, perform labor intensive tasks not requiring subject matter expertise, or to work traditional ‘‘summer jobs.’’ The program provides agencies with the 

opportunity to hire interns who successfully complete the program and academic requirements into any competitive service position for which the Intern is qualified. 

The IHS Gen-I Pathways Internship Program offers Native youth an opportunity to 

apply for paid summer positions at IHS Service Units in their local community. The 

initiative kicked off in May 2015, and we have posted job advertisements at all the 

IHS Areas and have over 80 summer internship positions allocated IHS-wide. 

IHS will also provide more funding opportunities geared toward Native youth for 

early intervention and positive youth development through its three largest initiatives. In the Special Diabetes Program for Indians, grantees will have the option 

to elect to use FY 2016 funding to implement the Family Spirit Program, an early 

intervention home visiting program. Family Spirit is an evidence-based and culturally tailored in-home parent training and support program. Parents gain knowledge and skills to achieve optimum development for their preschool aged children 

across the domains of physical, cognitive, social-emotional, language learning, and 

self-help. The program is currently the largest, most rigorous, and only evidencebased home visiting program ever designed specifically for American Indian families. Family Spirit now has randomized controlled trial evidence demonstrating that 

it reduces risk factors associated with a number of adverse outcomes, including obesity and substance use. 

The MSPI program will also provide FY 2015 funding for local programs to support their Gen-I activities through evidence-based and practice-based programming. 

Examples of such activities include implementation of American Indian Life Skills, 

Model Adolescent Suicide Prevention Program, Project Venture, Native HOPE 

(Helping Our People Endure), ASIST (Applied Suicide Intervention Skills Training), 

and cultural activities like Native American storytelling, traditional teachings, ceremonies, and other local relevant practices. 

Behavioral Health Integration with Primary Care 

The current system of services for treating mental health problems of American 

Indians and Alaska Natives is a complex and often fragmented system of tribal, 

Federal, state, local, and community-based services. The availability and adequacy 

of mental health programs for American Indians and Alaska Natives varies considerably across communities. The future of AI/AN health depends largely upon how 

effectively behavioral health is addressed by individuals, families, and communities 

and how well it is integrated into community health systems. We know that successful and sustained behavioral change will require cultural reconnection, community 

participation, increased resources, leadership capacity, and the ability of systems to 

be responsive to emerging issues and changing needs. In 2014, IHS began a small 

pilot project of six sites, the Behavioral Health Integration Initiative (BH2I). The 

goal of the funding was for sites to develop rapid cycle improvements of behavioral 

health integration with primary care using the Improving Patient Care (IPC) model. 

BH2I will continue into FY 2016. IHS will host a National Behavioral Health Integration with Primary Care Conference in Phoenix, Arizona to disseminate integration best practices and lessons learned from BH2I. 

The IPC Program is an outpatient primary care quality improvement program designed to assist IHS/Tribal/Urban Indian clinics with improving their care delivery 

and achieving Patient Centered Medical Home (PCMH) recognition. The PCMH is 

a model of care that aims to transform the delivery of comprehensive primary care 

to children, adolescents, and adults. The PCMH is best described as a model that 

is patient-centered, comprehensive, team-based, coordinated, accessible, and focused 

on quality and safety. The medical home is focused on the needs of patients, and 

12 

2See: Health Resources and Services Administration Shortage Designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations. Available at: 

www.hrsa.gov/shortage/find 

when appropriate, their families and caregivers. A significant element of the PCMH 

is integration of behavioral health services into primary care patient visits. This can 

include screening for behavioral health conditions, addressing beliefs about diseases 

and treatments, identifying disorders and initiating treatment, and collaboration 

with behavioral health professionals as part of the integrated primary care team. 

Training and Tele-Behavioral Health Services 

IHS recognizes the need to support access to services and to create a broader 

range of services linked into a larger network of support and care. IHS piloted the 

use of tele-behavioral health to increase access to specialty behavioral health services in the MSPI demonstration pilot phase. MSPI projects provided over 6,000 telebehavioral health encounters in the fifth year alone. 

The TBHCE was developed in 2009 to promote and develop tele-behavioral health 

services. Working in partnership with the University of New Mexico, the TBHCE 

provides services in a number of settings including school clinics, youth residential 

treatment centers, and health centers. The TBHCE has leveraged their ability to 

use federal service providers and provides technical and program support nationally 

for programs attempting to implement tele-health services. IHS programs are increasingly adopting and using these technologies with more than 8,000 encounters 

provided via tele-behavioral health in FY 2014. 

IHS benefits from the use of telemedicine for the prevention and treatment of 

youth suicide by connecting widely separated and often isolated programs of varying 

sizes together into a network of support. For example, small clinics would need to 

develop separate contracts for services such as child and adult psychiatric support, 

but the TBHCE is able to provide more cost-effective specialty care conveniently located within the clinic patients utilize for services. Such a system could provide 24/ 

7 access to emergency and routine behavioral health service in any setting with adequate telecommunications service and appropriately trained staff. 

The TBHCE also provides opportunities for mutual provider support. For example, currently when psychiatric providers are on leave or are attending a training 

conference there are often no direct services available during that time period. Sufficient services could be provided via tele-health connections to improve continuity of 

care with providers who are familiar with treating AI/AN patients. IHS also encourages families to participate in care through tele-health in circumstances when their 

youth may be transitioning from a treatment facility or residential program. 

Providers with particular specialty interests can also share their skills and knowledge across a broad area even if they themselves are located in an isolated location 

by videoconferencing, providing clinical supervision and working with multidisciplinary teams. Universities providing distance-based learning opportunities have 

demonstrated for years that educational activities can be facilitated by this technology and reduce burn out due to professional isolation. Recruitment also becomes 

less problematic because providers can readily live and practice out of larger urban 

or suburban areas and are thus more likely to continue providing service over time. 

The TBHCE also provides virtual training to primary care providers, nurses, and 

behavioral health providers on current and pressing behavioral health topics in an 

effort to increase the Indian health system’s capacity to provide integrated behavioral health care with primary care. In FY 2014, over 8,000 providers received training. 

Recruitment and Retention 

The rural and remote geographical locations of AI/AN communities present challenges with recruitment and retention of qualified behavioral health providers. 

Many of the facilities that serve AI/AN populations are in what the Health Resources and Services Administration (HRSA) has designated as health professional 

shortage areas. 2 The IHS offers financial incentive programs to recruit and retain 

behavioral health providers. The IHS Loan Repayment Program offers financial support in exchange for a service obligation in IHS-designated facilities upon completion of training and licensure. The IHS Indian Health Professions Scholarship Program is designed for AI/AN recipients entering the healthcare field. The recipients 

receive full or partial tuition support and a monthly stipend in exchange for a service obligation upon completion of training and appropriate licensure for placement 

within IHS-designated facilities located in designated shortage areas. The Indians 

into Psychology grant provides funding to colleges and universities for the purpose 

of developing and maintaining American Indian psychology career recruitment proVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00016 Fmt 6633 Sfmt 6621 S:\DOCS\97503.TXT JACK
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grams to encourage AI/AN students to enter the behavioral or mental health field. 

Recipients of the program receive tuition, fees, and a monthly stipend. Upon graduation with a Ph.D., these professionals are placed within IHS-designated facilities. 

The National Health Service Corps (NHSC), administered by HRSA, has both a 

scholarship program and a loan repayment program. The NHSC adds another 

source of service-obligated providers to IHS, Tribal, and Urban Indian health programs, including behavioral health professionals. IHS and HRSA collaborated to increase the numbers of IHS, Tribal, and Urban Indian health program sites that are 

eligible for assignment of NHSC personnel. The NHSC Loan Repayment Program 

is another opportunity for behavioral health providers to serve in communities with 

limited access to care and have their student loans repaid. 

Conclusion 

Suicide prevention needs to be addressed in the comprehensive, coordinated way 

outlined in the National Strategy for Suicide Prevention. No one agency or one approach will solve the tragedy of suicide in AI/AN communities. Suicide is complex 

and thus has many factors that must be considered. Reducing the number of suicides requires the engagement and commitment of people in many sectors in and 

outside government. IHS is committed to being a partner in the response to end Native youth suicides. As a central provider of health care for American Indians and 

Alaska Natives, we must do better in reaching youth with behavioral health and 

other help they need. We want to work with you to get us closer to the Zero Suicide 

goal. We all recognize that the challenges faced by Native youth run deep—we must 

all work together in offering them hope for a better future. 

The CHAIRMAN. Thank you so much, Mr. McSwain. 

Next we have C.J. Clifford, Council Member from Pine Ridge, 

South Dakota. I note that President Steele is not with us because 

he fell ill. Please give him our very best. 

Councilman Clifford. 

STATEMENT OF HON. COLLINS ‘‘C.J.’’ CLIFFORD, TRIBAL 

COUNCIL MEMBER, OGLALA SIOUX TRIBE 

Mr. CLIFFORD. I would like to say top of the afternoon to you, 

Chairman Barrasso and members of the Committee. Thank you for 

having me here today. 

My name is C.J. Clifford, Council Member for the Oglala Sioux 

Tribe. I am here in place of our tribal president, John Yellow Bird 

Steele, who fell ill. President Steele was very disappointed that he 

could not attend this important hearing. 

Between the week before Christmas and today, the Oglala Sioux 

Tribe has lost 14, to update you with numbers, young people to suicide. According to the Indian Health Service, 176 of our youth attempted suicide in that same period. The IHS treated 229 more 

who had suicidal ideas with plans and intent to carry it out. 

Though there is some overlap with IHS, our Tribe’s Sweetgrass 

Suicide Prevention Project served 276 young people exhibiting suicidal behavior. These are our children and we cannot bear to lose 

any more. When we lose one child, it hurts the spirit and soul of 

every one of our people. I hope the hearing today results in action 

from Congress to assist in saving the lives of our youth. 

President Steele issued a proclamation in February 2015 declaring a state of emergency on the Pine Ridge Reservation due to high 

incidence of suicide of our youth. I would like to submit this for the 

record. This is the second declaration since 2010. We are struggling 

and need to get resources to get in front of this problem. 

Our biggest challenge is to combat the hopelessness of our youth. 

We also need to combat the growing normalcy of suicide. Some chilVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00017 Fmt 6633 Sfmt 6601 S:\DOCS\97503.TXT JACK
14 

dren speak openly about suicide or discuss methods or stories at 

the school or on social media. 

To reiterate the story you mentioned earlier, this year one of the 

youth pastors on our reservation received a tip there would be a 

group suicide that day. He went to the site and found ropes hanging from the trees. Thankfully, no one had hanged themselves but 

the youth had begun to gather. This intervention saved them at 

this time. 

Feelings of hopelessness are compounded by the reality of living 

on Pine Ridge. Our poverty rate is more than 50 percent, our unemployment is above 70 percent and 60 percent of our students do 

not graduate high school. Life expectancy is around 50 years of age 

compared to the U.S. average of 79 years. 

The suicide rate is twice the national average. The latest cluster 

of suicides is almost unprecedented. Our children have the outlook 

that things may not get better for them, that they are destined to 

suffer the same history and injustice as our ancestors. 

Black Elk said the nation’s circle was broken by Wounded Knee; 

125 years later, we are still trying to heal. Just for your information, I am a direct descendent of Black Elk, the holy man. 

We have asked IHS to deploy behavioral health professionals. We 

have asked them to provide debriefing, education and individual 

assessments and to work with our schools. We have also asked 

them to begin home visits for youth treated for suicidal ideation, 

mental health problems or attempted suicide. 

IHS has begun to help us but there is so much work that needs 

to be done. We realize that IHS is struggling to provide adequate 

services nationwide due to insufficient funding but we are faced 

with urgent problems in need of immediate attention and assistance. 

Congress can help us in concrete ways. Immediate steps include: 

one, to encourage the Secretary to come out to Pine Ridge for a 

youth suicide prevention summit and create a task force devoted to 

accessing Federal resources for suicide prevention and intervention; 

two, to establish a school-based community so students can have 

access to counselors at their schools; three, to provide $240,000 

through SAMSHA, HRSA or elsewhere to install Tele-Health in our 

schools; four, establish and fund a Department of Labor youth opportunity program on the Pine Ridge Reservation and make opportunities to provide children with safe havens; five, to immediately 

provide surplus Federal housing to address our severely overcrowded housing situation which places significant stress on our 

children. 

There are also fundamental overarching steps Congress can take 

to help us. These are detailed in our written testimony. 

I will be glad to answer any questions. 

[The prepared statement of Mr. Yellow Bird Steele follows:] 

15 

PREPARED STATEMENT OF HON. JOHN YELLOW BIRD STEELE, PRESIDENT, OGLALA

SIOUX TRIBE


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The CHAIRMAN. Thank you so much for your testimony. It is compelling. We are grateful you could be with us today, Mr. Clifford. 

Senator Franken, if I could ask you to introduce our next witness. 


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36 

STATEMENT OF HON. AL FRANKEN, 

U.S. SENATOR FROM MINNESOTA 

Senator FRANKEN. Thank you, Mr. Chairman. 

It is my honor to introduce Chairman Darrell Seki of the Red 

Lake Band of Chippewa. Chairman Seki has served Red Lake in 

various roles over the past 40 years. He has served over a decade 

as treasurer of the Red Lake Tribal Council and last year, he was 

elected tribal chairman. 

The Red Lake Band is far too familiar with tragedy. Just since 

March when Chairman Seki testified before a House committee on 

this very issue, Red Lake has lost two children to suicide. 

Chairman Seki can speak not only to the challenge of addressing 

this immediate crisis but also to the struggle to fund services for 

Indian youth over the long term. 

I am pleased to welcome you, Mr. Chairman, to the Indian Affairs Committee. I look forward to hearing your valuable perspective on how we can make a sustained effort to prevent suicide and 

how we can create a better future for our young people in Indian 

Country. 

Thank you for being here. 

STATEMENT OF HON. DARRELL G. SEKI, SR., CHAIRMAN, RED 

LAKE BAND OF CHIPPEWA INDIANS 

Mr. SEKI. Thank you to Senator Franken for introducing me. 

[Prayer in Native language.] 

Mr. SEKI. Good afternoon, Chairman Barrasso, Vice Chairman 

Tester and members of the Committee. 

Thank you for the opportunity to testify today about ending Native youth suicides. I will focus my testimony on youth suicide but 

I would also point out that Red Lake suffers from high suicide 

rates in people over 18 as well. Like our brothers and sisters at the 

Pine Ridge Reservation, the Red Lake Nation is experiencing high 

numbers of youth suicide, attempted suicide, suicide ideations and 

counseling referrals. 

We are happy to hear Pine Ridge received a Department of Education SERV grant. Red Lake received a SERV grant and a 

SAMHSA grant 10 years ago after the Red Lake School shooting. 

Operating these grant programs, we learned two big lessons. 

First, was that school counselors can make a huge difference, second, we learned programs like this only work if they can be financially sustained over many years. It is long, hard, slow work. 

Just three months ago, we marked the 10-year anniversary of 

the Red Lake School shooting. Ten people lost their lives that day. 

Five were wounded and many other lives were changed forever. Although President George W. Bush promised we would not be forgotten, that promise has not endured. 

Last year, Red Lake suffered four youth suicides, two girls and 

two boys. This year, we already have lost two more kids to suicide 

including a 9 year old boy just a few weeks ago. 

Over the last year of school at Red Lake, there were more than 

75 cases of suicide ideation. School wellness counselor intervention 

resulted in more than 40 students being placed under protective 

watch and sent to appropriate medical facilities for care. 

37 

The counselors initiated dozens of safety plans which drove us to 

get assistance when needed. This proves our counselors are doing 

their job. Counselors can and do save lives. 

Because of staffing reductions and other sequestration, we are 

unable to reach all who need help. Anyone who thinks sequestration is not bad is dead wrong. Sequestration is a nightmare for 

tribes at Red Lake who must rely on Federal funding. 

The current youth suicide intervention process usually ends 

without any continuing care. After the crisis is over, there are no 

financial resources for follow up treatment. That is like funding an 

emergency room with only hospital services for performing surgery 

without any post-op rehab services. 

Students do not get needed after-care because of the Indian 

Health Service’s staffing shortage. Often these shortages lead to 

wait times of several weeks for follow up care. This frustrates some 

families and they give up. 

Last fall, my office conducted community meetings across our 

reservation focusing on suicide, drugs and bullying. In those meetings, we identified several obstacles to solving our suicide problem. 

Some of those obstacles include loss of our traditions in everyday 

life, lack of nearby facilities, needed after care services on reservations, more training in how to have difficult family conversations, 

and perhaps most important, parental drug use which includes alcohol. Our community members felt that solving drug abuse is critical in bringing an end to suicide. 

The solutions we came up with can easily be summed up. We 

simply must restore our sense of community. We have a plan to 

end suicide on our reservation. Components of our plan include 

strengthening our wellness counselor program by doubling the 

number of counselors and social workers; improving the process for 

follow-up care; rebuilding hope by rebuilding our infrastructure; 

getting tough on drug offenders and precluding them from our land 

while building rehabilitative services for our members. 

A key in building our rehabilitative services is the Tiwahe Initiative. We are very fortunate to have just been selected as one of the 

four tribes to participate in the pilot component of BIA’s Tiwahe 

Initiative. The purpose of the Initiative is to address the underlying causes of poverty, domestic violence, substance abuse and suicide. Tiwahe utilizes integrated approaches to service delivery and 

redesign of the services offered by bringing all of our programs together. 

We are going to break down the silos. We are going to find ways 

to implement what works. In building our infrastructure, we believe that hope is often fostered by prosperity. We have a plan to 

build our economy at Red Lake. We are focusing on our infrastructure like communications, roads, diversifying our tribal enterprises 

and improving local training programs in order to build our workforce. 

Congress can help by ending sequestration for tribes. We will 

have more recurring dollars to support our efforts to end youth suicides. By supporting the Tiwahe Initiative, we can strengthen our 

social service and rehabilitation programs. 

Congress needs to remove the obstacles imposed on tribes 

through a process of short term grants. Summed up, our big mesVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00041 Fmt 6633 Sfmt 6601 S:\DOCS\97503.TXT JACK
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sage is that only sustained funding of affected programs will end 

youth suicides in Indian Country. Red Lake has a plan to do that 

but we need sustained funding to do so. 

I want to thank the Committee for giving me this opportunity to 

speak on behalf of Red Lake Nation. 

[The prepared statement of Mr. Seki follows:] 

PREPARED STATEMENT OF HON. DARRELL G. SEKI SR., CHAIRMAN, RED LAKE BAND

OF CHIPPEWA INDIANS

Mr. Chairman, I thank you and the other distinguished members of the Committee for this opportunity to provide testimony on behalf of the Red Lake Band of 

Chippewa Indians, and for your attention on the problem of native youth suicides. 

For statistical purposes I will focus my testimony on youth under 18, but I would 

also point out Red Lake suffers from high suicide rates in over 18 years as well. 

On behalf of the Red Lake Nation, I want to extend my sympathies to my brother 

Mr. Yellow Bird Steele, and the people of Pine Ridge. The Red Lake Nation is also 

experiencing high numbers of youth suicides, attempted suicides, suicide ideations, 

and counselling referrals. We are happy you received a Department of Education 

SERV grant. Red Lake received a SERV grant and a SAMHSA grant 10 years ago 

after the Red Lake School Shooting. Two lessons we learned are that school counsellors can make a huge difference and programs like this only work if they can be 

financially sustained over time. 

About Red Lake Band of Chippewa Indians 

Red Lake is a fairly large tribe with 12,000 members. Our 840,000 acre reservation is held in trust for the tribe by the United States. While it has been diminished 

in size, our reservation has never been broken apart or allotted to individuals. Nor 

has it been subjected to the criminal or civil jurisdiction of the State of Minnesota. 

Thus, we have a large land area over which we exercise full governmental authority 

and control, in conjunction with the United States. At the same time, due in part 

to our remote location, we have few jobs available on our reservation. While the unemployment rate in Minnesota is 3.7 percent, ours remains at an outrageously high 

level of about 50 percent. The lack of infrastructure such as good roads, communications, technology and other necessary infrastructure continues to hold back economic 

development and job opportunities. 

Red Lake Suicide Rates and Intervention Process 

Health information laws constrain our ability to consolidate suicide data. The 

School district, law enforcement and our health services all collect data in different 

ways, which makes analysis of suicide-related data difficult. Focusing on just health 

services, the data shows that last year we had four youth suicides-two girls and two 

boys-and there were 63 cases of suicide ideation. Due to Wellness Counselor interventions, 34 students were placed under protective watch and sent to appropriate 

medical facilities for care. The counselors initiated dozens of Safety Plans with students to get assistance when needed. This proves the counselors are doing their job, 

and they can and do save lives. But because of staffing reductions under sequestration, we are unable to reach all who need help. Anyone who thinks sequestration 

is not so bad is dead wrong. Sequestration is a nightmare for tribes who must rely 

on federal funding. 

The current youth suicide intervention process ultimately ends with no lasting 

service. For example, when a student is having a problem in our school, the teacher 

will contact of a wellness counselor. The wellness counselor will first talk with the 

child and then take the child to the school social worker. If the child meets all the 

signs of suicidal behavior the child is taken to the hospital emergency room. After 

a doctor evaluates the child the hospital mental health staff will further evaluate 

to determine whether the child should go to a special facility for further treatment 

and observation. In this example, the child visited four separately funded programs, 

the independent school district, Red Lake Comprehensive Health Services, Indian 

Health Services—Emergency and Indian Health Services—Behavioral Health and if 

they are forwarded to another facility, it represents yet another funding source. At 

Red Lake, because of staffing shortages, it is well documented that Indian Health 

Service follow up care is always backed up by several weeks and children must wait 

weeks in order to be seen for follow up. 

39 

The History of Our Suicide Problem 

Last fall, my office conducted community meetings focusing on suicide, drugs and 

bullying. We visited all four of our tribal communities and had great attendance and 

participation from our members. From our community meetings our members identified several long-standing obstacles to solving our social ills including youth suicide. Some of those obstacles include: loss of our traditions in everyday life; lack of 

facilities nearby; no aftercare in our land; inability to have ‘‘difficult’’ conversations; 

and perhaps most importantly, parental drug use-which includes alcohol. Our community members felt that solving drug abuse and bullying are critical needs in 

bringing about an end to suicide. The solutions our community came up with can 

easily be summed up; restore our sense of community. 

The trail to suicide isn’t far from lack of job opportunities. A lack of employment 

opportunities results in poverty and disparity. Poverty and disparity can lead to 

drugs and addiction. Drug addiction leads to the tear down of our families, which 

often precipitates high suicide rates. 

But drugs are not the only source of our high suicide rate. Just three months ago, 

we marked the 10th anniversary of the Red Lake School shooting. 10 people lost 

their lives that day, 5 were wounded, and many other lives were changed forever. 

Today, a lot of those people are still suffering from the horror they faced that day. 

The story gets even more tragic when we consider that President George W. Bush 

told Red Lake the Government would come to our aid, and we would not be forgotten. But that promise did not endure. 

I talked about Red Lake’s youth suicide problem at the House Interior Appropriations Committee last March. Since that time two more kids committed suicide, including a nine year old boy just three weeks ago. I pointed out during the March 

hearing that for three years now, sequestration took about $1.5 million each year 

from Red Lake’s BIA and IHS base programs, and additional amounts from formulabased programs. This has made it very difficult for us to provide any sustained assistance to combat youth suicide. Grants are very difficult to apply for and to manage, and they don’t last. Sustained funding is our only hope to make a difference. 

How Red Lake Can End Suicide on Our Reservation 

a. Expanding our Wellness Counselor Program 

Our Tribal Health program funds the Red Lake Schools’ Wellness Program, which 

provides counselors to help students when they have problems and are thinking of 

harming themselves. It began after the School shooting, with help from a SAMHSA 

grant. The grant ended two years later, so the Tribe has had to pick up the tab 

ever since. Because of sequestration we had to cut the number of wellness counselors from 8 to 5, which is not nearly enough to assist hundreds of students in four 

schools. Additionally, we have only two school social workers, they are the specialists who usually make the first diagnosis of a problem. The wellness counselors and 

social workers in our schools are the critical front-line components of our suicide 

prevention plan. We need to at least double their numbers this year: from 5 to 10 

wellness counselors; and from 2 to 4 social workers. 

b. Attacking Our Drug Problem 

Drugs are a major factor in our suicide rates and we have taken a hard line 

against offenders. Within the last few weeks federal agents and our tribal police 

force arrested 41 people involved in trafficking drugs. The traffickers moved drugs 

such as heroin, methamphetamine and prescription pills in to Red Lake. We continue to work with our law enforcement partners and the United States Attorney’s 

Office to expand on the number of drug busts. And that isn’t all, the Red Lake Band 

of Chippewa Indians has also permanently removed many non-member drug Dealers from our lands. 

c. Large Concentrated Multi-Prong Push 

The Band will take a multi-program rehabilitative approach to address suicide 

and the underlying causes we see in Red Lake. We are very fortunate to have just 

been selected as one of four tribes to participate in the BIA’s Tiwahe Initiative. The 

purpose of the Tiwahe Initiative is to address the underlying causes of poverty, domestic violence, substance abuse, and suicide, by utilizing an integrated approach 

to service delivery, and redesign of the services offered. We are bringing all of our 

programs together, we are going to break down the silos, and we are going to find 

out what works and does not work, and we’re going to find a way to implement 

what works. We recently formed a suicide prevention task force to better coordinate 

mental health and suicide prevention services. 

40 

d. Building Infrastructure 

Hope is often fostered by prosperity. Providing adequate funding for governmental 

functions allows us to spend what little of our own money we have on economic development. We have a plan to build our economy in Red Lake. We are focusing on 

things that never leave the reservation; our infrastructure like communications and 

roads, and improving local training programs in order to build our workforce. 

How Congress Can Help Red Lake to Accomplish Our Plan 

Congress can help tribes reduce suicide by ending sequestration and by finding 

a way to provide additional and sustained funding. Red Lake, like many government 

agencies, suffers from compartmentalization of many services, including for mental 

health and suicide prevention. This makes it difficult to coordinate an effective approach to combatting the problem. And it makes it difficult for community members 

to know what services are available and where to go for help. Compartmentalization 

is partly the result of the fact that most funding to address mental health comes 

in the form of grants. Silos are created because granting agencies have their own 

unique funding requirements, and they award funds to different types of grantees 

(e.g. Department of Education to schools; HHS to health centers; DOJ and SAMHSA 

to tribal governments). 

I have already alluded to it, but one thing we know about Indian Country is that 

grants often do not work. Grants are short term and often non-strategic. Further, 

federal application and reporting requirements are cumbersome and require significant resources to complete. Our SAMHSA grant was helpful but it only lasted two 

years. 

The problem with grants is an issue that national scholars have noted. Miriam 

Jorgensen, the editor of ‘‘Rebuilding Native Nations’’ noted that often, Indian Tribes 

are unable to set their own development agenda—they must pattern it to obtain 

grants. Further Ms. Jorgensen pointed out, ‘‘few dollars come to Native Nations via 

block grants, a mechanism that would place more decisionmaking power in Indians 

hands.’’ 

Compounding the problems associated with grants, the only recurring funding we 

could count on, from BIA and IHS, has been hammered by sequestration and at 

least 14 different across the board rescissions. Congress could aid in reducing our 

suicide rate by ending sequestration in Indian Country, and returning our sequestered funds to us. 

In summary, in order to end suicide in Red Lake we need to better understand 

what we are doing right, and what we are doing wrong. We are optimistic that Red 

Lake’s participation in the Tiwahe Initiative will serve as the springboard to make 

changes that will work. Poverty brings about hopelessness and despair. Drugs that 

follow poverty have destroyed our understanding of family. The horrors of the school 

shooting still linger, and there is also generational trauma. Our community members feel we need to restore our sense of community. Sequestration has limited our 

ability to address our problems. Grants are not the answer-they set programs up 

for failure. Only sustained funding of effective programs will end youth suicides in 

Indian Country. Red Lake has a plan to do that, but we need sustained funding to 

do so. 

Thank you for allowing me to provide testimony today on the important topic of 

ending Native Youth Suicides. 

The CHAIRMAN. Thank you very much, Chairman Seki. 

Dr. LaFromboise. 

STATEMENT OF TERESA D. LAFROMBOISE, PH.D., PROFESSOR, 

DEVELOPMENTAL AND PSYCHOLOGICAL SCIENCES, 

GRADUATE SCHOOL OF EDUCATION, STANFORD 

UNIVERSITY 

Dr. LAFROMBOISE. Good afternoon, Mr. Chairman and members 

of the Committee. I am grateful for the opportunity to present testimony on a topic of urgent importance in Indian Country. 

I have been working in the field over American Indian suicide 

prevention since 1989. I began at the invitation of Mr. Hayes 

Lewis, the Superintendent of the Zuni Public School District. He 

made a request to me at Stanford to bring a team of educators and 

health promotion specialists from Stanford University to the PuebVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00044 Fmt 6633 Sfmt 6601 S:\DOCS\97503.TXT JACK
41 

lo of Zuni to help community experts develop a culturally grounded 

youth suicide prevention intervention. 

Over the course of three years, our team worked in Zuni to develop a life skills curriculum, to consult with the Zuni Board of 

Education and the Zuni Tribal Council, and conduct an outcome 

study of the curriculum we developed. We compared students in 

the curriculum with those who were not. We found those in the 

curriculum, the Zuni Life Skills Curriculum, displayed less suicidal 

ideation, suicide attempts, less hopelessness, greater self-efficacy to 

manage anger, and greater effectiveness in helping a suicidal 

friend solve problems and to go to someone for help. 

Today, I would like to talk a little bit about the derivative of the 

Zuni Life Skills which is the American Indian Life Skills. I would 

also like to talk about four other evidence-based interventions used 

in Indian communities and found to be effective in reducing suicide. The evaluations were not with Native communities but with 

communities across mainstream society. I think that might provide 

some help. 

When Mr. Lewis invited us to develop this curriculum, we were 

invited only to do work with the Zuni high school. We did not have 

a lot of experience, although I did teach junior high and high 

school, so I learned a lot about school-based suicide prevention. 

The rationale for suicide prevention in schools hinges on the recognition that a significant amount of suicidal behavior occurs 

among ostensibly well-functioning students. The idea is to do a 

population-based strategy of exposing all students to suicide awareness and skills about suicide so that it can reach the greatest number of students who will then help the smaller number of students 

who are at risk. 

These programs primarily target an individual student’s thinking 

and behavior. The ultimate goal is to help at-risk students receive 

psychological treatment before they become acutely suicidal. The 

type of approaches then in schools for suicide prevention consists 

of awareness and education curricula, peer leadership training, 

skills training, gatekeeper training and screening. 

The Zuni Life Skills was expanded to have examples from a 

number of different tribes so that we could reach a more diverse 

group of people. The emphasis is social skills training and intervention that emphasizes the fact that suicide is an action and a behavior rather than focusing on it as a mental illness. 

This curriculum has seven major themes: building self-esteem; 

identifying emotions and stress; increasing communication and 

problem-solving skills; recognizing self-destructive behavior and 

finding ways to eliminate it; learning information about suicide; 

helping a suicidal friend go for help; and planning ahead for a 

great future. 

You may say, what is cultural about that? There are a number 

of opportunities for cultural considerations in this curriculum but 

more of the scenarios in it emphasize realistic situations that occur 

in Native communities. We talk about culturally appropriate ways 

to express emotions and grief. 

Tribal community members are encouraged to be the ones that 

deliver the intervention. Tribal community members are invited 

into a number of the sessions to share cultural teachings and to 

42 

model cultural coping perspectives. It is cultural. This has been offered in a number of schools but it is also offered in cultural camps, 

local recreation and sports programs, Boys and Girls Clubs, Upward Bound, treatment centers, tribal colleges and tribal youth employment. 

It has been adapted in recent years for urban and suburban settings and in some tribal communities, a few, such as the Spirit 

Lake Dakota Tribe which has adapted it for their local community 

values and norms. 

I have had the opportunity of training community members from 

over 100 reservations that have participated in these trainings. 

Now we are working on internet applications in order to provide 

technical assistance after these trainings. 

I want to talk about four other programs. Basically, the reason 

I selected these four is that they have a history of implementation 

in Indian communities and also have yielded outcomes in randomized controlled trials. 

The first one is Sources of Strength. This was a program developed out of the United Tribes in Bismarck and later adapted for 

mainstream society. Basically, the emphasis of this program is a lot 

of positive messaging, suicidal awareness and training of peer leaders, the idea being that once the students identify who are the 

adults in the school who are really supportive of them as mentors 

and the peer leaders, those at risk might go to these peer leaders 

to get help. At three month follow-up, participants in Sources of 

Strength reported reduced suicide attempts and increased knowledge about suicide. 

Another program is called Reconnecting Youth. I learned about 

that because I was looking for a comparative treatment to evaluate 

the American Indian Life Skills. This was already being used at a 

number of reservations. 

The emphasis on this one is to work with at-risk students to help 

them be able to monitor their own substance use and monitor their 

attendance in school. This is like the last stop before getting kicked 

out of school. In this program, basically they learn rather than be 

kicked out for being out of control, or poor attendance or coming 

to school loaded, they learn how to manage this. 

I have to say we used this with middle school students. Over 

only 10 months, we saw reduced hopelessness at post-test and reduced suicidal ideation. Then at one year follow-up, we saw even 

greater gains. 

Another one is a shorter version of this called CAST, made by 

the same developers. Basically, it is a shortened version of Reconnecting Youth. 

Finally, I want to talk about the Good Behavior Game. I found 

out about these when I served on the National Academy of Sciences 

and Institutes of Medicine’s task force which developed a book, all 

this is outlined in there, to prevent behavioral, emotional and mental disorders in young children. 

The Good Behavior Game has been touted as the most effective 

behavioral vaccine. This is actually not a program; it is a strategy 

where in working with elementary children, they learn self-regulation. The teacher basically divides the class into teams. Teams are 

reinforced for staying on task, doing the appropriate thing, not 

43 

talking out of turn, and focusing on what they are doing for a 

while. 

I know it sounds manipulative. What they are learning is selfregulation. I have to say this has been used with First Nations elementary children and Metis Children in Canada. 

The important results of this is that following these elementary 

school children into adolescence, they were just exposed to it in elementary, and by adolescence they had less impulsive, disruptive 

behavior, less substance use, drug addiction, lower rates of suicidal 

ideation and suicidal attempts. That is quite a nice long term effect. 

The CHAIRMAN. Doctor, if you have any last summation you want 

to make, because I know there are a number of questions. 

Dr. LAFROMBOISE. I am so sorry. 

Basically, I think I would concur in what people have indicated 

as solutions to this. Unfortunately, what we have here is a situation where we do not have enough psychologists or behavioral 

health specialists to meet the need. 

In schools, it is very difficult to implement because administrators are very concerned about making grade in terms of AYP and 

high stakes testing. It is very difficult. 

I am suggesting that we really turn to looking at Masters level 

people. We have more jobs for Masters level people that will supplement the already existing counseling staff in schools and help 

with this kind of work because you can see the results. They can 

work. We just need the staff in order to deliver it. 

Thank you. 

[The prepared statement of Ms. LaFromboise follows:] 

PREPARED STATEMENT OF TERESA D. LAFROMBOISE, PH.D., PROFESSOR, DEVELOPMENTAL AND PSYCHOLOGICAL SCIENCES, GRADUATE SCHOOL OF

EDUCATION, STANFORD UNIVERSITY

Good afternoon Mr. Chairman and members of the committee. I am grateful for 

the opportunity to present testimony on a topic of urgent importance in Indian 

Country, that is, the need for effective interventions to reduce the exceedingly high 

rates of Native American youth suicide. 

My name is Teresa LaFromboise. I am a Professor of Psychological and Developmental Sciences at the Graduate School of Education at Stanford University. I have 

been working in the field of American Indian/Alaska Native (AI/AN) youth suicide 

prevention since 1989. 

The work began in response to a request from Mr. Hayes Lewis, the Superintendent of the Zuni Public School District, that I bring a team of educators and 

health promotion specialists from Stanford University to the Pueblo of Zuni to help 

community experts develop a culturally-grounded youth suicide prevention intervention. 

Over the course of three years we worked in Zuni to develop life skills pedagogy 

and curriculum lessons, consult with the Zuni Board of Education and the Zuni 

Tribal Council, and conduct an outcome study to assess the psychological impact of 

the curriculum (LaFromboise & Lewis, 2008) . This outcome evaluation demonstrated the following effects: less suicidal ideation and suicide attempts, less hopelessness, greater self-efficacy to manage anger, and greater effectiveness in helping 

a suicidal friend solve problems and go for help among participants in the Zuni Life 

Skills treatment group as compared to those in the no-treatment comparison group 

(LaFromboise & Howard-Pitney, 1995). 

Today, I want to provide a brief overview of ongoing work associated with American Indian Life Skills (AILS) and introduce four other evidence-based interventions 

delivered in school settings that have produced favorable outcomes in youth suicide 

prevention. I will discuss some of the limitations of interventions that focus solely 

on psychological rather than social, cultural and spiritual issues that may be more 

relevant in Native American youth suicide prevention. Finally, I will offer some recVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00047 Fmt 6633 Sfmt 6621 S:\DOCS\97503.TXT JACK
44 

ommendations concerning how we might more effectively reverse the rates of youth 

suicide within tribal communities. 

Promising Practices in School Based Suicide Prevention 

When we were invited to develop an intervention in Zuni we were only allowed 

access to the Zuni High School. Thus we learned a lot about suicide prevention in 

schools. The rationale for schools adopting suicide prevention programs hinges upon 

recognition that a significant amount of suicidal behavior occurs among ostensibly, 

well-functioning students. School suicide prevention programs try to reach the 

greatest number of students through population-based strategies to identify and assist the smaller number of students who are at risk. They primarily target an individual student’s thinking and behavior. The ultimate goal is to help at-risk students 

receive psychological treatment before they become acutely suicidal. 

Presently, there are five main types of suicide prevention interventions in schools: 

(a) awareness/education curricula, (b) peer leadership training, (c) skills training, (d) 

gatekeeper training and (e) screening. Awareness/education curricula focuses on increasing accurate knowledge about suicide, and encourages self-disclosure among 

peers to develop positive attitudes toward seeking help. Peer leadership training assists student leaders in learning to respond to suicidal peers and then to refer them 

to a ‘‘trusted adult’’ for further referral to treatment. Skills training fosters the 

growth of skills to support protective factors in the prevention of suicide (e.g., problem solving, self-regulation). Emphasis is also placed on the reduction of risk factors 

to prevent the development of suicidal behavior (e.g., depression, substance abuse, 

anger regulation). Gatekeeper training teaches school staff, students and their parents about symptoms of suicide, and additionally provides information regarding 

risk and protective factors in order to improve identification and referral of at-risk 

students to available resources. Lastly, screening programs assess suicidal ideation, 

depression symptoms, and other clinical mental health disorders (including multiple 

problems such as depression along with disturbed eating or binge drinking) in order 

to refer students displaying disorder to psychological services. 

American Indian Life Skills 

The success of the Zuni Life Skills Development Curriculum bolstered a more Native American generic version entitled the American Indian Life Skills Development 

Curriculum (AILS) which is available to any tribe or community that is searching 

for adolescent suicide prevention and life empowerment programs (LaFromboise, 

1996). 

AILS is a universal, community-driven suicide prevention intervention emphasizing social cognitive skills training to reduce suicidal behaviors . AILS strongly 

emphasizes suicide as an action and behavior rather than the result of mental illness. It emphasizes an array of psychosocial skills necessary for effectively dealing 

with everyday life such as: emotional regulation, mindfulness, problem solving, and 

anger regulation. It focuses on 7 main themes: (1) building self-esteem; (2) identifying emotions and stress; (3) increasing communication and problem-solving skills; 

(4) recognizing self-destructive behavior and finding ways to eliminate it; (5) learning information about suicide; (6) helping a suicidal friend go for help, and (7) planning ahead for a great future. 

A number of cultural considerations were considered in the design of this intervention. The curriculum is full of realistic situations that occur in AI/AN communities and homes. Lessons in AILS encourages culturally appropriate ways that students can express emotions like grief or anger. The preferred interventionist of AILS 

is a professionally trained community member. Additional community members are 

invited into AILS sessions at relevant times to share cultural teachings and model 

cultural coping perspectives. 

Ideally, AILS is offered in a required course such and social studies or language 

arts. However, AILS has been taught in culture camps, local recreation and sports 

camps, tribal youth employment and training programs, Upward Bound, treatment 

centers, and tribal colleges. It has been adapted for AI/AN adolescents in urban and 

suburban settings. In addition, tribal communities such as the Spirit Lake Dakota 

tribe have adapted AILS to their local community values and norms. 

Community members, teachers and behavioral health specialists from over 100 

reservations have participated in AILS trainings. Currently, we are working on 

Internet applications for providing on-going technical assistance to those who are 

implementing AILS following an initial 3-day Key Leader Orientation training. 

Schools as Sites for Suicide Prevention 

From my experience in this field and from systematic review of research on 

school-based suicide prevention programs, I have found a growing number of potentially effective mainstream programs that could be of help in reducing Native AmerVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00048 Fmt 6633 Sfmt 6621 S:\DOCS\97503.TXT JACK
45 

ican youth suicide. I selected the following evidence-based programs to highlight 

today because they each have some history of implementation in AI/AN communities 

and they have been found to yield outcomes associated with the prevention of adolescent suicide with diverse populations (LaFromboise & Hussain, in press). 

Sources of Strength (SOS). SOS is a universal program (meaning that it is offered 

to all students in a school) that emphasizes awareness/education and peer leadership to reduce suicidal behaviors (LoMurray, 2005). Its curriculum includes suicide 

awareness, positive messaging, empowering activities and screening strategies. Peer 

leaders are trained in responding to students who display risk factors for suicide, 

directing them to a trusted adult for further support. Originally designed for youth 

living in rural areas near United Tribes in Bismarck, North Dakota to tackle issues 

related to suicide, such as violence and substance use, SOS was later modified for 

widespread use with students from diverse backgrounds across the United States. 

At a 3-month follow up, participants in SOS reported reduced suicide attempts and 

increased knowledge about suicide (Aseltine, James, Schilling, & Glanovsky, 2007). 

Reconnecting Youth (RY). RY is a selected intervention utilizing a life-skills training approach which targets high school students who demonstrate poor academic 

achievement, are at risk for dropping out of school and exhibit maladaptive symptoms like aggressive behavior (Eggert & Nicholas, 2004). RY emphasizes the prevention of substance use and emotional distress while fostering resilience. Opportunity 

for social bonding is also achieved through intervention activities which form connections within the school and encourage parent involvement. Native American RY 

participants have reported reduced hopelessness and suicidal ideation immediately 

following the intervention and at 1-year follow up (LaFromboise & Malik, 2012). 

Coping and Support Training (CAST). CAST is a selected prevention program 

adapted from RY that uses a skills-training approach with high school students following their referral to the program based upon initial screening. CAST consists of 

12 sessions given over 6 weeks administered by service providers (e.g., teachers, 

nurses). CAST focuses on mood management and school performance and emphasizes decreased involvement with illicit substances. Participants of CAST have demonstrated increased problem solving skills, perceived family support and self-control, 

and decreased symptoms of depression and hopelessness (Thompson, Eggert, 

Randell & Pike, 2001). 

Good Behavior Game (GBG). GBG is a behavior management approach that has 

evolved into a universal, primary prevention program for elementary school students to teach self-regulation skills (Barrish, Saunders, & Wolf, 1969). The GBG socializes children into displaying cooperative rather than disruptive or aggressive behavior, both of which are risk factors for substance abuse and suicide. To play the 

GBG a teacher splits the classroom into two or more teams which are rewarded for 

being adaptive to academic social expectations (e.g., being on task for brief periods 

of time, not talking out of turn). Eventually they are expected to be cooperative for 

longer periods of time. The winner of the GBG is the team with the least amount 

of infractions. 

GBG has demonstrated long-term effects (following elementary school-age participants on into adolescence) on decreased impulsive/disruptive behavior, substance 

use, drug addictions, and lower rates of suicidal ideation and suicide attempts 

(Kellam et al., 2008). By incorporating the program into the classroom at an early 

age, there is a high cost-effectiveness ratio. 

Lessons Learned 

From having either carefully reviewed, implemented or tested each these programs, I found that it is very difficult to influence schools to engage in primary prevention. ‘‘School administrators and teachers working in public schools serving Indian populations are so bent upon meeting the high stakes demands of testing and 

Adequate Yearly Progress (AYP) that they have no time to do more than the minimum expected when it comes to responding to the emotional and cultural needs of 

Native American students’’ (Testimony of Hayes A. Lewis, Youth Suicide in Indian 

Country, February 26, 2009, p.4). It takes advocacy from community champions 

(e.g., tribal council members, members of prevention committees and parents) to influence school administrators to adopt programs sensitive to the social emotional 

needs of youth. 

Most of these interventions rely on the referral of at-risk students to psychological 

treatment before they become acutely suicidal. However, many rural AI/AN communities have limited school counseling services or behavioral health services. When 

formal mental health services are staffed by AI/AN behavioral health specialists 

those services are in high demand. When they are staffed by service providers from 

outside the community they may be underutilized due to the stigma of seeking help 

from those who seemingly represent the group that marginalizes and oppresses 

46 

them. The ultimate effectiveness of the prevention program, to save lives, relies on 

youth initiating or completing care. 

I also found that most individually focused ‘‘off the shelf interventions’’ do not address key perceived contributions to AI/AN suicide such as historical oppression, 

intergenerational trauma, prejudice and discrimination and other forms of collective 

disempowerment. Thus the protocols upon which these interventions were tested are 

either short lived or, in the best case scenario, modified to address more relevant 

social justice issues in Indian Country. 

Finally, those AI/AN communities, who actually implement programs such as the 

ones I have just reviewed and who find them intuitively ‘‘helpful,’’ are often reluctant to engage in further assessment of their effectiveness within their own community. I believe that this type of assessment would be helpful in guiding decisions 

about modifications to the intervention to better meet local community needs and 

norms or concerning whether or not to continue efforts toward sustaining the intervention overtime. 

Recommendations 

I respectfully offer the following recommendations to strengthen tribal capacity to 

improve service delivery to prevent Native youth suicide based upon my observations, research, and training experiences. 

Expand the number of empirically-validated suicide prevention interventions and 

evaluate their adaptation and implementation in diverse AI/AN contexts. 

School-based suicide prevention programs began in 1984 in reaction to a significant escalating trend in suicidal behavior among adolescents in many Western industrialized countries. Considering the relatively new introduction of prevention 

intervention to this complicated problem, issues with customized delivery that target specific variables such as ethnic/racial group background, cultural involvement, 

and tribal diversity still need significant innovation and evaluation. 

Make a commitment to continue to support the dissemination of valued community-driven approaches to suicide prevention across Indian Country. 

There is a sense of urgency among tribal leaders to preserve cultural ways of 

knowing before the knowledge keepers are gone. Research indicates that communities with higher levels of political and cultural engagement have lower suicide 

rates. Certain individual protective factors for Native youth suicide prevention include cultural identity and engagement in cultural activities as well as school completion. This presents a window of opportunity for collaboration between community 

leaders and prevention scientists to develop services that reflect community priorities and practices and to mobilize available support systems to prevent suicide. 

Encourage and support research on the interaction of community-level processes, 

family systems, and individual psychology that affect the well-being and resilience 

of Native youth. 

Historically suicide prevention has focused on the treatment of the individual and 

that type of intervention should continue but not at the cost of ignoring the gestalt 

of the disorder. Specific efforts have evolved for the last decades or two on economically viable, rapidly deployed and clinically efficacious efforts to target not only the 

individual but the larger system- from social media to society and everything in between. Let us continue that momentum. 

Tribal communities have practiced ‘‘integrated care’’ among individuals and families for generations but usually without adequate resources. Let us support continuation of those cultural practices and healing traditions. 

Thank you for providing this opportunity. 

References 

Barrish, H.H., Saunders, M., & Wolf, M.M. (1969). Good Behavior Game: Effects of 

individual contingencies for group consequences on disruptive behavior in a 

classroom. Journal of Applied Behavior Analysis, 2, 119–124. Retrieved from 

http://search.proquest.com/docview/615628148?accountid=14026 

Eggert, L.L., & Nicholas, L. J. (2004). Reconnecting youth. Bloomington, IN: National Educational Service. 

Kellam, S.G., Brown, H.C., Poduska, J.M., Ialongo, N.S., Wang, W., Toyinbo, P., & 

Wilcox, H.C. (2008). Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes. Drug and Alcohol Dependence, 95, S5–S28. doi: 10.1016/ 

j.drugalcdep.2008.01.004 

LaFromboise, T.D. (1996). American Indian Life Skills Development Curriculum. 

Madison, WI: University of Wisconsin Press. 

47 

LaFromboise, T.D., & Howard-Pitney, B. (1995). The Zuni Life Skills Development 

Curriculum: Description and evaluation of a suicide prevention program. Journal of Counseling Psychology, 42, 479–486. doi: 10.1037/0022–0167.42.4.47 

LaFromboise, T.D., & Hussain, S. (in press). School-based adolescent suicide prevention. In L. Bosworth (Eds.). Prevention Science in School Settings: Complex Relationships and Processes. New York: Springer. 

LaFromboise, T.D., & Lewis, H.A. (2008). The Zuni Life Skills Development Program: A school/community-based suicide prevention intervention. Suicide and 

Life-Threatening Behavior, 38, 343–353. doi: 10.1521/suli.2008.38.3.343 

LaFromboise, T.D., & Malik, S.S. (2012, May). Development of the American Indian 

Life Skills Curriculum: Middle School Version. Poster presentation, Second Biennial Conference of the Society for the Psychological Study of Ethnic Minority 

Issues. Ann Arbor, MI. 

LoMurray, M. (2005). Sources of Strength facilitators guide: Suicide prevention peer 

gatekeeper training. Bismarck, ND: The North Dakota Suicide Prevention 

Project. 

Thompson, E. A., Eggert, L. L., Randell, B. P., & Pike, K. C. (2001). Evaluation of 

indicated suicide risk prevention approaches for potential high school dropouts. 

American Journal of Public Health, 91, 742–752. doi: 0.2105/AJPH.91.5.742 

Wexler, L., Chandler, M., Gone, J., Cwik, M., Kirmayer, L., LaFromboise, T., 

Brockie, T., O’Keefe, V., Walkup, J., & Allen, J. (2015). Advancing suicide prevention research with rural American Indian and Alaska Native populations. 

American Journal of Public Health. 

The CHAIRMAN. Thank you so very much. 

I want to thank all of our witnesses for their testimony. 

I will now turn to questions from the Committee, starting with 

Senator Tester. 

Senator TESTER. Thank you, Mr. Chairman. 

I want to go back to you, Teresa. Your Ph.D is in what? 

Dr. LAFROMBOISE. Counseling Psychology. 

Senator TESTER. I would ask you to be as concise as you possibly 

can. 

Senator Udall went down the litany of things faced in Indian 

Country in his opening statement: alcohol, drug abuse, physical 

abuse, poor nutrition, poor schools, domestic violence, poverty, and 

overcrowded housing. You know the statistics probably better than 

anyone up here. The rate at which Native Americans commit suicide is the highest of any minority in the Country. In 15 to 34 year 

olds, the rate is twice that of anybody else. 

What do we do about this? If there is alcohol abuse, drug abuse 

by parents or the potential person who is going to commit suicide, 

combine that with poor nutrition and poor schools, where do you 

start? 

Dr. LAFROMBOISE. First, I understand what you are alluding to. 

You are alluding to all these intense social determinants of behavior. Probably you are thinking I am naive to focus on the individual. 

Senator TESTER. No, no. I want to do to solve the problem. 

Dr. LAFROMBOISE. Here is what I would suggest. All these problems need to be solved. One thing we do know about the resilience 

literature is that the children who are resilient, meaning they are 

able to thrive in spite of all this adversity, are children who are 

able to manage their emotions and are able to stay detached from 

situations and are able to have a strong identity. 

All these things these kinds of program do. They emphasize the 

protective factors. 

Senator TESTER. The resilience is taught where, in school? 

48 

Dr. LAFROMBOISE. Resilience begins as a child. 

Senator TESTER. I know, but when you have dysfunction, alcoholism, and housing problems, where the hell are they going to 

learn resilience? 

Dr. LAFROMBOISE. They can begin to learn it in school. Obviously 

I am an educator, so I think of school. The schools are sanctuaries. 

For some children, this is the only place they get a meal. For some, 

this is the only place they feel safe. 

That is why I am thinking of this arena as the place where we 

can really marshal some forces to try to help them. There are some 

wonderful programs. I remember Duane Mackey had a program a 

number of years ago called The Heart Room. This heart room was 

in schools. 

Children went into the heart room on Friday for prayer and 

meditation and to prepare for what they were going to have to go 

through over the weekend. They came back into that heart room 

on Monday in order to decompress and be ready to focus in school. 

Obviously, we need so much more. It would be nice if we could 

do this kind of work in families. Unfortunately, we really did not 

have access to families. 

Senator TESTER. Thank you. 

A month or two months ago, we had a hearing here on schools 

about being subpar, cold, lack of academic materials, and the lack 

of good teachers. We have a lot of problems. 

I want to go over to Mr. McSwain. It is a fact and folks have testified here today about recruitment and retention of dedicated, high 

quality health care providers as critical for your work at IHS. You 

indicated four different scholarship and loan repayment programs 

to recruit health care professionals in the IHS service areas. 

It is known, it is not a secret, that there is a shortage of IHS 

mental health providers. Why has IHS never employed the Indian 

Health Service Mental Health Prevention and Treatment Loan Repayment Program? 

Mr. MCSWAIN. Senator, that is a good question. 

I know we have been working on our own loan repayment, our 

own scholarship program and we have been using the National 

Health Service Corps Loan Repayment Program and using their 

scholars but we have not gone beyond that. 

Senator TESTER. To me, it sounds like the perfect program to try 

to get folks into Indian Country who can help. The professor talked 

about more professionals in Indian Country can help. Are there any 

plans to enact it? Do you have the dough to do it? What is the problem? 

Mr. MCSWAIN. A good point, because we just recently were identifying some vacancies but it was a matter of getting the people 

there in these remote locations. That is a challenge. I think Councilman Clifford mentioned that one of the biggest barriers to getting people out there is housing. 

Senator TESTER. Yes, but you also have to enact that program. 

I was going to ask you the same question I asked the Professor. 

What are some of the programs that work for youth? I cannot because I have run out of time. 

I want to say thank you guys very much for your testimony. We 

have to deal with this issue. If we do not deal with this issue, it 

49 

is not going to go away; it is not going to get better. It is going to 

be here and it is going to get worse. 

Whether it is working with the Administration or with individual 

tribes in Indian Country, we have to deal with this. 

I appreciate you guys making the trek to Washington, D.C. Once 

again, this is the start of another conversation that I hope ends up 

in something that will functionally fix the problem. 

The CHAIRMAN. Thank you, Senator Tester. 

Senator Daines? 

STATEMENT OF HON. STEVE DAINES, 

U.S. SENATOR FROM MONTANA 

Senator DAINES. Thank you, Senator Tester, for that. 

We both represent the State of Montana. I was meeting with four 

Montanans who came to my office yesterday. Montana has the 

highest per capita suicide rates in the Nation. We are number one. 

It is a combination of a lot of factors. Certainly we have a high 

Native population. We talked about that here today. We have a 

high per capita veteran population. There is a crisis in our home 

State. 

Mr. Chairman, thank you for holding this hearing. It is a tough 

topic to talk about but one we cannot ignore. 

Dr. LaFromboise, you mentioned the need for the culturallybased suicide prevention programs. I was struck with your academic biography as a professor at Stanford and working in American Indian and Alaska Native youth suicide prevention since 1989, 

for more than 25 years, so we are glad to have your expertise. 

I want to thank all of you for your testimonies today. I wish 

there was more time. 

One of my constituents, Dustin Monroe, is the head of a group 

called Native Generational Change in Montana. He is an Assiniboine Black Feet tribal member, an Iraq veteran of the 25th Infantry Division. He is working on preventing youth suicide among Natives in rural communities. 

One of the problems he has brought up is the lack of programs 

that adequately address the cultural differences that might exist 

between Indians and non-Indians with regard to suicide prevention 

and counseling. For example, Dustin mentions talking about the 

deceased might be therapeutic to some, but it could be very troubling to a Native population. 

How well do you believe our suicide prevention or counseling programs take these cultural differences into account? 

Dr. LAFROMBOISE. Certainly, the American Indian Life Skills 

has, because at the very beginning, the emphasis is saying that 

people who are doing this know best their own cultural teachings 

and that they should be respected. Therefore, they would be the 

ones to filter the information. 

We do not encourage people to think about the deceased. We do 

have one lesson on grief because we feel that people need to think 

about stages of grief. 

You are absolutely right. We do know from our research that 

people who have a strong cultural identity and strong involvement 

in cultural practices are certainly less likely to be involved in suicide. We also know that communities that have strong political enVerDate Mar 15 2010 10:38 Nov 10, 2015 Jkt 097503 PO 00000 Frm 00053 Fmt 6633 Sfmt 6601 S:\DOCS\97503.TXT JACK
50 

gagement are in charge of most of what is going on in their community and strong practices. 

I am not saying these things should be replaced. One of my recommendations would be that we should also increase the resources 

to help support community-driven interventions much like the individual you are talking about. I do not think one should replace the 

other. That is why I think it kind of helps to keep one in school 

and the other in the community because we are not interfering 

with each other. 

Senator DAINES. Thank you. 

You mentioned expanding the number of empirically-driven suicide interventions for school-based programs. I was struck by your 

comments to Senator Tester about how the school, for some young 

people, is the safe place they can go during the day and the week. 

Given the limited dollars we have for all these programs. Where 

you look at empirically-based, outcome-based metrics, what programs are working, what programs are not working? In the zero 

sum game we face often here in Washington, D.C., what programs 

should we stop and double down on other programs that are working? What is not working and what is working? 

Dr. LAFROMBOISE. I think it is very important to have gatekeeper training but I think the research would say that it does not 

really impact people as much as we think it does but it does help 

individuals who have already gone through the process of asking 

someone if they are suicidal and helps strengthen their skills. 

For individuals that have never asked the question, they can go 

through gatekeeper training and come out and still never ask the 

question. That is one a lot of money is appropriated for but I am 

not really sure how well that works. 

Senator DAINES. Before I run out of time, I want to ask Councilman Clifford from Pine Ridge a question. 

Yesterday’s conversation revolved around having a job, how that 

was a place to go, to work and when you are in poverty, the statistics you shared from Pine Ridge are staggering. What role does 

having a job and having employment play in trying to reduce suicide? 

Mr. CLIFFORD. It gives a person something to do and also to look 

forward to a paycheck and paying their bills and being able to assist. I like your conversation about the cultural elements and the 

academic part. I think that has a lot to do with it and ties into 

being a working person. The cultural relevance of it is being able 

to share with what we grew up with and actually knowing. 

The comparison and the so-called scientifically proven evidence, 

the cultural relevancy you cannot scientifically put a number on it. 

We know it works and it is there. It has always worked for many 

years. 

I am reminded of the coffee shop story of a young lady in school 

and having a job. Not long ago, this young lady was feeling bad, 

suicidal tendencies and the ideations that came with it. One of the 

special ed programs took her under their wing did some testing 

and found she was qualified for special ed. During that special ed 

time, she was withdrawn and not really functioning right, but as 

they worked with her, she was capable of learning to be responsible 

51 

for part of the coffee shop. It broke her shell and she was able to 

get up and talk about it. 

The other day during our meeting, they brought this young lady 

in and she actually got up and talked. She stuttered at the first 

but then all of a sudden, it just came out. That is what jobs and 

working can do. It is not always about the academic part, especially 

in Indian Country. 

If I could use this arm a little better, I would be able to explain 

because I too am like that, to express myself, to be able to show 

the point the importance of losing our child and what is happening 

today and the help we need. It needs to be equal on how it is 

shared and brought to us. Most important is the responsibility of 

growing up and being able to work and able to know that I have 

someplace to go. 

Senator DAINES. Thank you for the great story, Councilman 

Clifford. 

I am out of time. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Daines. 

Senator Heitkamp? 

Senator HEITKAMP. Thank you, Mr. Chairman. 

I do not think anyone here thinks that suicide is anything other 

than a symptom of what are clearly conditions that many children 

on the reservation and in Indian Country exist in, creating stress. 

In the last Congress, we held a hearing on trauma-based interventions and had some amazing testimony relative to altered brain 

chemistry as a result of stress. I want to address some of this with 

you, Doctor. 

At Johns Hopkins, an institution really close to Washington, the 

researchers think they have discovered a chemical alteration in a 

single human gene linked to stress reaction that if confirmed in 

larger studies could give doctors a blood test that may tell them 

who is at risk and who is not. They believe that this genetic mutation caused as a result of exposure to stress and trauma is a gene 

known as SKA–2. By looking at brain samples from people who 

had poor mental health and healthy people, the researchers found 

in that sample from people who had died by suicide, levels of SKA– 

2 that were significantly reduced. 

You can go back to the work being done in Montana on stress 

and trauma relative to brain chemistry. I think a lot of what we 

always talk about is treating symptoms. We are going to do intervention, we are going to build resiliency, when this problem is a 

systemic-based problem driven by trauma and stress. I am not a 

doctor but I think when you look at these issues, I think you have 

to come to a clear understanding of what we are dealing with. 

How can we integrate some of the new brain chemistry research 

that we are seeing now into the programs you are talking about? 

How can we do a better job modernizing the way we look at this? 

As the Senator from Utah and I know, because we both served 

as Attorneys General, we were talking about this problem in the 

1990s, we talked about this problem the last decade and we still 

are talking about this problem and guess what? It has not gotten 

any better. It has gotten worse. 

52 

What about a new idea and taking a new look at brain research 

and what we can do to fashion or model better intervention programs? 

Dr. LAFROMBOISE. That is a heavy one. 

Basically, here are a few things I would think about. You are 

talking about basically determining whether a person has experienced this trauma. It is also the case with screening which people 

are very resistant to but by early screening, you would be able to 

know a lot about a person to begin with. 

Having had a child who experienced language learning disabilities, when I was learning about that, I can remember one of the 

people doing the assessments saying after a certain point, it does 

not matter how it happened or the fact it is there, it is now what 

are you going to do. Yes, we do need to improve assessment and 

to be able to determine this, to know whether it is there or not. 

Senator HEITKAMP. I can tell you stories of children who have 

been involved in anti-suicide programs who have been model children who later committed suicide. Sometimes interventions are not 

adequate. 

Dr. LAFROMBOISE. Part of the intervention is also turning that 

around. In terms of even changing brain chemistry, the coping aspect of it, because what will you do once you get everyone diagnosed? There are still people who are functioning every day, carrying on with their lives, that need to keep going. 

Some of my colleagues said actually the article, the last one cited 

on my testimony by Wexler, probably the best researchers that I 

know of in Native American suicide, are there and we struggle 

with this all the time. 

Some people will say they think I am na?ve in terms of focusing 

on these interventions. They say we have to change the 

marginalization, the oppression and all these things. Yes, we do 

and we need to treat the people in the meantime. 

It may take three generations, even if we change all these things. 

What do we do with all the people in the meantime that do need 

help and are even mildly exposed to trauma and can benefit from 

these activities? 

Senator HEITKAMP. I have just a little bit of time. 

If we keep doing what we are doing right now and do everything 

the way we have done it and we are all here in ten years, do you 

think we have a better result? 

Dr. LAFROMBOISE. We are not doing enough right now. I am just 

highlighting the potential if we were using effective programs. We 

are not doing that now. 

Senator HEITKAMP. I think we need to modernize effective programs. I think there have been a number of examples, if I can take 

a minute, as we look at this and as we look at some of the tribalbased strategies treating trauma, identifying historic trauma, identifying some of the neurological issues that we have and being able 

to transition some of that new thinking into interventions, and 

when we look at this being done in places like the Menominee who 

have been able to double graduation rates. I just want to bring a 

broader kind of new development and new research into the discussion. 

Thank you, Mr. Chairman. 

53 

The CHAIRMAN. Thank you very much, Senator Heitkamp. 

Senator Murkowski? 

STATEMENT OF HON. LISA MURKOWSKI, 

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

It is always interesting listening to my colleague from North Dakota because of the issues you raise. The Chairman and I were just 

talking about how many hearings on suicide in Indian Country we 

have had before this Committee. Again, we are not seeing the statistics get much better. 

The one thing I have noted is that we are just kind of changing 

the deckchairs here. It used to be that Alaska was number one, 

now it is Montana and Wyoming tied for number one, New Mexico 

tied for number three and Alaska has dropped to number four. 

We have not really solved the problems. We are still continuing 

the discussions. In the meantime, we are losing our children. 

In addition, to follow up on your line of inquiry about the mental 

trauma and some of the research we are seeing, look at our increasing levels of suicide amongst our military, amongst our veterans, those who have experienced some level of trauma. 

Again, I am with you. I am not the doctor here but it does lead 

you to conclude that maybe we need to be looking at some other 

areas. I would certainly be interested in working with my friend on 

this. 

I look at where we seem to be having some limited success in my 

State. About four years ago now, we had a town hall on suicide in 

Bethel and brought out as many people who were willing to talk 

about suicide right after a horrible rash of suicide in some of the 

villages up north. 

In fairness, it was much of the same conversation that we hear 

around here until we came to the very end where some of the children, the students I had invited from some of the villages that had 

been impacted, rose to speak. 

It was painful listening to them because they stood in the center 

in front of all these grownups and elders and could not speak. They 

were so brave that they would not let themselves sit down. They 

stood for a minute in silence gathering the courage to speak about 

what had happened in their village. One young woman made the 

comment that yes, suicide was kind of a normal teenage thing. It 

ripped at your heart. 

I think it was from that roundtable that we have seen within the 

White Cage Sea, they identified four different villages, Hooper Bay, 

Chevak, Scammon and Alakanuk who have had exceptionally high 

rates of suicide. They began to focus specifically on these communities. 

In their message to me, since they have been doing that, they 

have experienced no suicides to this point in time. What are they 

doing? It is the culturally-based programs. It is gatherings, pot luck 

lunches, arts and crafts activities, making fish traps, and the talking circles. 

Some of the other things that we look to, there is a gentleman 

from Tanana, Vernon Stickman, Sr., who lost a daughter to suicide 

54 

in 2010. He walks the Yukon River during the wintertime, 140 

miles from community to community to raise awareness. 

Is that helping? I do not know. Is he as one person who does not 

have a program, who does not have a budget, just saying I am willing to do whatever it takes to get some attention to this, to shine 

some kind of a spotlight on it, to deal with my own personal grief, 

I think, as a dad. 

I look to where we can be making a difference. I just met with 

some of our leaders in suicide education and prevention yesterday. 

I said, James, what is the one thing we could do that would make 

a difference. It is the mental health professionals. 

It seems to me so much that particularly with youth suicide, it 

has to be the kids that are there for one another, saying I am there 

for you. As we talk about these programs, I hope that we are not 

just talking as adults in a room, talking about funding, budgets 

and what the MSPI program is doing to make progress. 

I really hope that it is designed to involve the young people for 

their ideas. I think it was not until those young people spoke up 

in Bethel that we really started to talk about it. It was not until 

the young people at AFN two years up ago spoke up from Tanana 

and called out the parents, the adults, the elders and said, we are 

tired of being the victims of neglect, sexual assault, violence, and 

suicide. Wake up, grownups. What are you going to do about it? 

Anything that we can be doing that is bringing in our young people 

for the solutions, I think has to be key. 

Mr. McSwain, I want to ask you one quick question regarding 

the MSPI program. We think it is making some progress. We are 

hearing from some of the groups in our State that it is. I have been 

a supporter of it. I think it is culturally relevant. I think it is getting us going in the right place. 

I have been told on a few occasions that the overall structure and 

the management currently inhibit the program from being used to 

its full potential. I was told by a group in Alaska that some questions they have submitted to the program virtually went unanswered. I do not know much more beyond that. 

I am wondering whether it is a lack of resources that is complicating effectively running this program or if you are aware of any 

other obstacles that we have faced with regard to the MSPI? 

Mr. MCSWAIN. Senator, I believe that the MSPI program is doing 

some great things. I think it is one of those where it is at the community level and the community is directing it. In all of our programs, whether it is STPI or MSPI, when the community has its 

own design on what they want to do with the resources, they know 

how to move forward. That is what is making the progress in that 

program. 

It has been six years since we have had it in place. We will be 

doing a full review of the six years to see what the successes are 

and what improvements ought to happen. We are doing that this 

year. 

I liked your other comment about the kids. That struck a tone 

with me. The one area we have not done a real good job about and 

we are going to do that, is simply having kids get together, having 

our service units. I recommend to the tribes that they do it as well. 

The tribes are really interested. 

55 

We start talking about the pathways, hiring students as a GS– 

1, GS–2 or GS–3 and having them provide support to us. I think 

a comment was made by Dr. LaFromboise about the schools and 

the security they feel. 

You can imagine what I felt when I was worried about suicides 

and the schools were letting out in the Northern Plains. What is 

going to happen to all those kids? Do they have any structure? 

That is a part of it and certainly a conversation we are having 

with all of the MSPI recipients as to what they can do for kids. 

This expansion we have proposed for 2016 in Generation Indigenous is about kids. It is building on the MSPI. 

If you are having questions, if there are concerns from folks from 

Alaska, ask us and we will look into it. 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Murkowski. 

Senator Udall. 

Senator UDALL. Thank you, Mr. Chairman. 

Mr. McSwain, Senator Heitkamp asked about brain research in 

this area, new brain research and the discussion with Dr. 

LaFromboise. Do you have any thoughts on that from the Indian 

Health Service perspective or your work with SAMHSA? Is this a 

fruitful area? Is this something we should be looking into, some of 

those latest things being discovered? 

Mr. MCSWAIN. I do not think we can leave any rock unturned, 

the brain being one of them. I think our health care delivery system will be looking to other folks, the professionals, if you will, certainly the NIH folks and others that do this kind of work for anything that can help. 

It is not going to be as easily magical as that. In my view, it is 

going to be a partnership that happens between the Administration 

and the tribes. That is the partnership that will be able to give 

them the tools. 

Making an observation, some of our communities are just paralyzed because of the suicides. We have to do more to help them feel 

they can do something. That is part of our administrative responsibility. 

In terms of science, I will leave that to scientists. 

Senator UDALL. Thank you. Thank you for your work in this 

area. 

Teresa, thank you for your work with the Zuni Pueblo. Longtime 

Pueblo in New Mexico really care about their young people. When 

they learn what is the right thing to do, they really invest in it. 

It is good to see that you were out there. 

I am wondering, were they able to incorporate these things into 

the schools and other areas in order to make a real impact? 

Dr. LAFROMBOISE. It has made a significant difference. I think 

Mr. Lewis testified here in 2008 that they had basically reversed 

the suicide rate and it is seldom happening now. It is a required 

course in the high school. 

I was there a few years ago and actually the families were having meetings in the evening because they were doing more cultural 

adaptation of it. 

Senator UDALL. What should a community do if they have one 

of these clusters? I have been to several in my tribal communities 

56 

when in a period of weeks they lose two or three of their young 

people. They may not have had this happen before. 

How do you view the steps that should be taken to tackle it if 

they run into that kind of situation? 

Dr. LAFROMBOISE. First of all, I have to defer to people who are 

clinical interventionists on the ground. I have focused in recent 

years more on prevention. 

In essence, I think having a rapid response and bringing in people who have dealt with trauma and also communities is critical. 

I am sure that Chairman Seki knows more about that from their 

experience with the trauma that happened years ago at Red Lake. 

Basically, there is work in place but there are better people to 

respond to that question. 

Senator UDALL. Chairman Seki, would you like to respond? 

Mr. SEKI. Are you talking about the trauma? 

Dr. LAFROMBOISE. The suicide clusters. 

Senator UDALL. Yes, the suicide clusters. 

Mr. SEKI. We suffered high suicide incidents and suicide ideation 

by our children for many years. The major factors underlying the 

suicide rates are long standing substance abuse, poverty and generation trauma. This is not a cluster but a sustained rise in suicide 

rates. 

Having more counselors and meeting with the students individually is crucial. Right now the ratio is one counselor per 290 students. It does not work. We have to have more counselors and more 

social workers to address these issues we have in our school system 

and our reservations. 

It is not easy to fix just like that. It takes time because people 

suffer a long, long time. When it happened in Red Lake, people are 

still suffering at this time. The suicides are happening on our reservation. 

Some counselors I talk with say it happens. One happened in one 

area and then there are others, these are friends, saying they want 

to do it, more or less seven or more people doing it at the same 

time. It is work that needs to be corrected by adding more counselors and social workers working together. 

Everything starts at home with parental involvement. Poverty 

and no jobs, create more jobs for the families so they can address 

these issues with their children because everything leads to drug 

and alcohol abuse when all this is not in place. 

It is very hard for our people back in Red Lake, what we face, 

to continue trying to address these issues with our Native youth 

because it is a problem all over, not just at Red Lake. I heard Pine 

Ridge and this lady talking about different ideas and Mr. McSwain. 

These are the things that you, as elected officials, have to come 

up with ways for us, tribal nations, to invest in tribes so they can 

fix their infrastructure, come up with ideas to improve the system 

and what is happening with our youth on our reservations. 

We need help. It is not just us but everyone. Everyone has to be 

involved all the way from the parents. You have to listen, as Senator Murkowski said, to the children’s ideas. You have to listen to 

the youth, what their ideas are. Pick that up and use that as working together to resolve these issues. 

57 

It is not going to happen if we keep cutting funds to the reservations because of sequestration. Those are the dollars they lose for 

creating more jobs, for bringing in more counselors and social service workers. 

If sequestration is reversed, it could be fixed in six months or 

less if it goes back to 2013. That is not enough, there is more to 

it, to create these programs. We need more culturally based programs for our people to understand the culture and teach our youth 

what it is to be a Shanabe person because it is not easy. It is hard. 

I am just now chairman for a year and I am very sensitive talking about our youth because I know they have problems. I like visiting with them, talking to them and finding ways to resolve their 

issues. 

Also bullying is a concern but it leads right back to the parents. 

Parenting needs to be focused because it all starts at the home. 

Senator UDALL. Mr. Chairman, you are absolutely right. I think 

you are right about the underlying causes. We have to tackle those. 

We have to invest the resources. We should not be cutting in terms 

of the kinds of resources that are there. 

I thank this panel very much and yield back. 

The CHAIRMAN. Thank you, Senator Udall. 

Senator Franken. 

Senator FRANKEN. Mr. Chairman, thank you, for what you just 

said. 

When we are faced with the realities, you sort of wonder where 

to begin because whether you begin with unemployment, that is a 

big place to start. I have been to Pine Ridge which is I think 75 

percent unemployment. What is the unemployment rate at Red 

Lake? 

Mr. SEKI. About 50 percent. 

Senator FRANKEN. We talk about trauma. I read a book called 

How Children Succeed, and it talked about adverse childhood experiences which lead to trauma. The author talks about extreme poverty, alcohol and drug abuse at home, abuse, whether it is neglect, 

physical abuse or sexual abuse, of you witnessing domestic abuse 

when you are a child, and living in a dangerous neighborhood 

where you see violence. 

American Indians, on top of that, have seen cultural trauma for 

generations, so where do you begin? You witness the other families’ 

domestic violence when you have poor housing and you see drug 

abuse too, even if your own parents are not using. 

I went to a rehab facility in Bemidji, Oshki Manidoo, a White 

Earth facility. I visited the kids there. Every child I talked to had 

started using with their parents. We have very systemic problems 

here. Where do you start? 

Mr. Chairman, I think you are right. You start with jobs but you 

also start with the funding that we do for programs. You are right. 

It was Buck Jourdain at the time, Buck I know longer than you 

and I apologize that during my introduction, I think I said Seki instead of Seki. 

President Bush said, we won’t forget you. During the last sequestration, there were less funds coming in for school counselors and 

during that time there were suicides. The very first thing we can 

do is fund these professionals. 

58 

Yes, these professionals engage the kids. These professionals 

should be professionals about engaging with children. We cannot 

depend on children to solve this themselves. We are the adults. We 

are supposed to be the adults. We are the grownups here. We are 

the Indian Affairs Committee. 

We are supposed to fight for funding for you because which other 

of our colleagues will do that if not us. My challenge is to my colleagues on this Committee. We have these hearings in which we 

hear this testimony and our other colleagues in the Senate do not 

even hear this. 

Our job on this Committee is to fight for you, to fight for your 

kids. We are supposed to be the grownups. We cannot put this off 

on the kids. Yes, a good counselor knows how to engage kids. A 

good counselor knows much better than we do how to get kids talking to other kids and kids involved in activities talking to other 

kids. 

We have adult responsibilities here. One of our adult responsibilities is not to take away school counselors during sequestration and 

not sit here when the Director of the Bureau of Indian Affairs has 

to defend the budget and the numbers are woefully lacking and 

embarrassing. 

I had questions about lots of things but it is our responsibility 

to be funding the things we know work and to fight for economic 

development in your communities, to fight for Indian energy, to 

fight for jobs but to also fight for the services that you need. 

I apologize. I can only apologize for myself, that we have not 

been doing enough for your kids and for you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Franken. 

Director McSwain, in briefings with the Committee staff and during a visit last week to Pine Ridge by one of our staff, it became 

clear that the agencies within the Department of Health and 

Human Services do not actually sufficiently coordinate with each 

other. 

Regardless of the level of support available, there does not seem 

to be sufficient coordination with each other or with agencies and 

other departments like the Bureau of Indian Affairs, the Bureau of 

Indian Education, to the effect that there are devastating consequences. 

What is your plan to fix this coordination and communication 

gap we heard about in last week’s visit to Pine Ridge? 

Mr. MCSWAIN. I am not so certain I know what you heard from 

Pine Ridge. Certainly from all the calls I have been on leading up 

to it, the coordination has increased. In fact, the Office of Secretary 

has taken a lead role and given us all assignments. We are all reporting on those assignments as we move forward. 

I think for the first time, as a department, we are all together. 

I know the department is reaching out to other people who have 

the ability to help like Education, DOI and so forth. 

I have seen a marked increase on coordination, particularly the 

ones with whom we work closely like HRSA, SAMHSA and such. 

That coordination has really increased. We just have to make sure 

that it is always there for the next crisis. 

59 

The CHAIRMAN. I think it makes a point that it needs to always 

be there. In my discussions with Secretary Burwell last week, I got 

the impression from her that now the focus was there but you wish 

it had been for a long period of time. We want to make sure that 

focus continues, not just in one location, but throughout the communities. I am going to call on you to please continue that level 

of focus that is there right now but had not been and we cannot 

let it fall apart. 

Mr. MCSWAIN. Yes, and I would say Secretary Burwell took a 

very personal interest in this. She said, we have to fix this. She 

told us all to step up and step up together. She put the Deputy Secretary in charge of making sure we did that. 

The CHAIRMAN. She mentioned that too. 

Native suicide is not a new issue. We were dealing with this on 

the Wind River Reservation back on the 1980s. It is still not clear 

to me that the Administration is operating under an evidencebased plan to prevent suicide across Indian Country. That is not 

just this Administration. I think we have seen this now for decades. 

Is there a plan in effect? If there is a plan in effect, it is obviously not working and needs to be reevaluated. As the head of the 

HIS, you are leading the effort. Your goal should be, of course, to 

bring the suicide rate for Native youth to zero. Task force meetings 

and planning sessions are not accomplishing that. When can we expect to see real results? 

Mr. MCSWAIN. We have something in the statement that talks 

about Zero Suicide which is really going to enable us to engage the 

system and be able to track certainly a lot better than the data we 

have had so far. 

We actually have relied on our health IT system to tell us a lot, 

but we have to reach out beyond that to be able to know what is 

happening in the community as opposed to just what is happening 

in our clinics. 

As you know, we have always said we are a health care provider, 

we do not get out in the community but we have to engage the 

community and be able to report that as well so we can have a 

complete data picture of what we are doing so we can have a baseline and be able to come back to you and say, these are the results. 

We have done that with the trends analysis but we need to do 

more. 

The CHAIRMAN. Chairman Seki, in your testimony you outlined 

how Red Lake could end suicide at your reservation. Specifically, 

you highlighted expanding your wellness counselor program. The 

wellness counselors are social workers located in the schools and 

are critical frontline components of your suicide prevention plan. 

Can you explain the advantages of having the counselors in the 

schools and how they have actually helped reduce suicides at Red 

Lake? 

Mr. SEKI. As I stated before, counselors meet with students individually. They have times set aside to talk with the students that 

have problems, talking about suicides or domestic issues at home. 

They address these with them individually, giving them a plan on 

how to resolve this and continue working with them. 

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Having only two counselors at each school is not enough. They 

need more counselors so the counselors have fewer students to 

speak to regarding the issues happening with our youth. 

It is very important that the agencies funding our youth counselors plus our social service people, that they continue to invest 

in them because we need more people, more of those counselors, 

more social workers to address these issues so that our students 

can go to someone when they have problems. 

The wellness counselors and social workers address these and 

help them, help our youth. 

The CHAIRMAN. Thank you. 

Councilman Clifford, last week during the visit I mentioned one 

of our staff members made to Pine Ridge, they heard a lot about 

problems with the Rapid City Regional West and Indian Health 

Service facility. 

Perhaps the most concerning was the impression among some 

community leaders that going to that facility did not really make 

a difference for Native youth. We heard that young people who are 

sent to the Regional West for being suicidal or attempting suicide 

often actually committed suicide later. 

I wanted to get kind of a follow-up from you. Some have suggested that sexual abuse is a major driving factor of Native youth 

suicide. There was a long editorial and story in the New York 

Times about that specific part of it. 

Based on your experience, could you talk a little bit about that, 

particularly as an educator who is at the front lines and helping 

young people every day? What role do you think sexual abuse and 

domestic abuse play with regard to the youth suicide question? 

Mr. CLIFFORD. First of all, whenever you combat whatever issue 

it is, we have to be stirred up and bring the issue forward. What 

happens on the Pine Ridge Reservation locally has a lot to do with 

alcohol and drugs, overwhelmed with them. 

Sexual abuse is amongst some of the crimes committed that are 

not dealt with. It is like getting a cut and it being able to fester 

and you are not taking care of it. Eventually, it is going to infect 

your whole body. 

The same is true of a physical attack on your mind emotionally, 

that festers to the point of where there is hopelessness and it is 

there. The reality of it is that it is there. I am here to tell you that 

the hopelessness is there. 

The lack of funding of different programs, I specifically worked 

in education for a great number of years and I am really glad you 

brought up funding disparities that go on. When we talk about 

counselors, guidance counselors versus a psychological counselor, 

there is a big difference there. 

What use do I have for one of them counselors or both of them 

counselors? I have use for both of them. I have mentioned that in 

dealing with some of these things in our life and education, we 

seem to put an individual education plan forward to children identified with special needs. 

In reality, I feel studying all these years, each and every young 

person from K to forever how long they go to school, having individual education plans set forth not just for the special needs children. 

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As we go through our life and place judgment on these children, 

I want to say judgment because that is how we use the data that 

is provided, they are gains, they are individual growth gains, not 

a standard that says all third graders are like that, not all seventh 

graders are like that but an individual education plan that would 

monitor that child and young person’s self, not rated amongst each 

other. 

The sexual abuse that does go on does happen on the Pine Ridge 

Indian Reservation and it relates to the poverty. 

I would like to quickly mention the disparity on some funding. 

We are underfunded in all schools nationwide, Indian education, 

operation and maintenance, and transportation. We take the ISEP 

dollars designed for children to learn and the title dollars and we 

use them to fix our schools. We are using them to pay our light bill 

and to pay for propane to keep them warm. 

I can go on forever on that. In the case of that, there needs to 

be money there. All of this work is critical. 

I would like to ask that the Committee support our efforts to 

save the lives of our children. We need long term solutions, not a 

quick band-aid today. 

Thank you. 

The CHAIRMAN. Thank you very much, Councilman Clifford. 

Do any of you have a short closing comment on the things you 

have heard said today? We are in the middle of roll call votes. I 

think we have a number of them now and the roll call vote has already been called so we have to summarize. 

Director McSwain, any last thoughts? 

Mr. MCSWAIN. I think this will require us, as the Administration, 

to work very, very closely with the communities and engage the 

communities where they are engaged on the issues. They need the 

tools and we need to provide the tools to be able to address this 

particular issue. 

Right now we are finding that many of our communities are, as 

I mentioned earlier, rather paralyzed. There is something they 

want to do. In fact, my weekly calls with President Steele to be 

able to see how he is doing and how the tribe is doing, as an Administration, we have to do more of that. 

The CHAIRMAN. Mr. Clifford? 

Mr. CLIFFORD. I would recommend the following: providing emergency funding for substance abuse and suicide prevention and mental health care; commit to economic development and infrastructure on the Pine Ridge. I ask respectfully to remove the jurisdictional restrictions and fund tribal police and courts and focus on 

education for our youth suicide epidemic. It would probably be best 

fought in the schools. 

Lastly, acknowledge the government’s treaty obligation to fully 

fund all these programs. 

Thank you. 

The CHAIRMAN. Mr. Seki? 

Mr. SEKI. Thank you for giving us this opportunity. I want to 

thank the panel here that spoke regarding the suicides. 

The thing I will keep addressing is the sequestration, to stop it, 

to put back the funds for the tribes so they can address these suicides happening on our reservations. Pine Ridge alluded to grants. 

62 

That is not the solution. Long term funding like SAMHSA and 

DOG is the solution. Put them through the 638 agreements, not 

short term because short term does not work. They only last as 

long as the grant and then it is over. Then we are back to square 

one again. 

I ask you as the Committee to invest in tribal nations for infrastructure, for economic development, for tribes to create jobs for 

our safety and for our generations to come, our youth. 

Thank you. 

The CHAIRMAN. Thank you, Mr. Seki. 

Dr. LaFromboise? 

Dr. LAFROMBOISE. In addition to all that has been said, I think 

we need to remember it is very important to strengthen the workforce of American Native and Alaska Natives in the fields of mental health. We need to look at funding beyond psychiatry and psychology with the Indian Health Service to include social work and 

Masters level people. They can work in collaboration with the 

schools to deliver some of these programs. There are programs 

proven to be effective. They just need the staffing with which to do 

that. 

I also realize that I pushed the issue of evidence-based but do 

agree with what has been said today, that there are many practices 

the community knows work. Unfortunately, because they have not 

been proven through scientific methods, they often are looked upon 

as less than and they are not. They are equal to, if not more powerful. We just do not have the resources for those to continue as 

much as they should in full force. 

I want to be on record as having said, there is really a balance 

between traditional practices and then some of these other more 

western-based practices that we have proven that do work with 

Native kids. 

The CHAIRMAN. Thank you. 

I appreciate your comments. There may be some written questions by other members of the Committee who were unable to be 

here with us today. The hearing record will be open for two weeks. 

I am going to remind the Administration that our work is not 

complete. I look forward to continued dialogue, including Committee briefings, listening sessions, and hearings in the weeks to 

come. 

I want to thank all the witnesses for your time and testimony. 

The hearing is adjourned. 

[Whereupon, at 4:12 p.m., the Committee was adjourned.] 

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