```

[Senate Hearing 114-446]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 114-446

    ADDRESSING TRAUMA AND MENTAL HEALTH CHALLENGES IN INDIAN COUNTRY

=======================================================================

                               FIELD HEARING

                                BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            AUGUST 17, 2016

                               __________

         Printed for the use of the Committee on Indian Affairs
         
                           
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                      COMMITTEE ON INDIAN AFFAIRS

                    JOHN BARRASSO, Wyoming, Chairman
                   JON TESTER, Montana, Vice Chairman
JOHN McCAIN, Arizona                 MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska               TOM UDALL, New Mexico
JOHN HOEVEN, North Dakota            AL FRANKEN, Minnesota
JAMES LANKFORD, Oklahoma             BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana                HEIDI HEITKAMP, North Dakota
MIKE CRAPO, Idaho
JERRY MORAN, Kansas
     T. Michael Andrews, Majority Staff Director and Chief Counsel
       Anthony Walters, Minority Staff Director and Chief Counsel
                            
                            
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Field hearing held on August 17, 2016............................     1
Statement of Senator Heitkamp....................................     1
Statement of Senator Hoeven......................................     2

                               Witnesses

Cruzan, Darren, Director, Office of Justice Services, Bureau of 
  Indian Affairs, U.S. Department of the Interior................    13
    Prepared statement...........................................    17
DeCoteau, Tami, Ph.D., Clinical Psychologist, DeCoteau Trauma--
  Informed Care and Practice, PLLC...............................    35
    Prepared statement...........................................    39
Eagle-Williams, Kathryn R., M.D., CEO/Quality Care Director, 
  Elbowoods Memorial Health Center, Mandan, Hidatsa and Arikara 
  Nation.........................................................    28
    Prepared statement...........................................    30
Robinson, Hon. Lillian Sparks, Commissioner, Administration of 
  Native Americans--Administration for Children and Families, 
  U.S. Department of Health and Human Services...................     3
    Prepared statement...........................................     9
Warrington, Hon. Myrna, Chairwoman, Health and Family Committee, 
  Menominee Indian Tribe of Wisconsin............................    19
    Prepared statement...........................................    24

                                Appendix

Octeti Sakowin youth, prepared statement.........................    55
Yellow Hammer, Stephanie, Standing Rock Sioux Tribe Member, 
  prepared statement.............................................    58

 
    ADDRESSING TRAUMA AND MENTAL HEALTH CHALLENGES IN INDIAN COUNTRY

                              ----------                              

                       WEDNESDAY, AUGUST 17, 2016

                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                      Bismarck, ND.
    The Committee met, pursuant to notice, at 9:30 a.m. at the 
Lewis Goodhouse Wellness Center, United Tribes Technical 
College, Hon. Heidi Heitkamp, U.S. Senator from North Dakota, 
presiding.

           OPENING STATEMENT OF HON. HEIDI HEITKAMP, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Heitkamp. Good morning. We're calling this hearing 
to order. I want to first thank all the tribal leaders, 
activists, providers, and community members for joining us 
today to discuss this critical issue. I want to thank the UTTC 
for hosting. I also want to recognize the staff of the Senate 
committee on Indian Affairs who have worked so closely with my 
office to make this field hearing happen. Today the Committee 
will examine, ``Addressing Trauma and Mental Health Challenges 
in Indian Country''. I am so honored to be hosting the field 
hearing in North Dakota to discuss how we can work together to 
address trauma in American Indian and Alaska Native 
communities. The U.S. and National Library of Medicine found 
implications of trauma on health, academics, and economic 
outcomes are significant. The average lifetime cost for a child 
exposed to non-fatal child maltreatment is over $200,000. This 
creates a significant cost and a need for services when 22 
percent of Native American children suffer from post-traumatic 
stress. The costs are not only financial but impact Native 
American communities as a whole. Adults experience trauma in 
racism, poverty, poor nutrition, alcoholism, and suicide. In 
2005 to 2008 data, the suicide rate for American Indians and 
Alaska Natives was 14.68, higher than the overall U.S. rate of 
11.15. To mitigate the effects of trauma, the Department of 
Health and Human Services designated 4,000 mental health 
professionals to professional shortage areas across the 
country, many of which include Native American and Alaska 
Native communities. This shows that primary care providers 
generally have limited training in recognizing and diagnosing 
mental health disorders. Of the 53 counties in North Dakota, 
only six are identified as not having a mental health 
professional shortage. Of the 53 counties in North Dakota, only 
six have enough mental health providers. I hope that today we 
find some attainable proposals that will achieve Native 
American and Alaska Native Communities that will benefit them 
across the nation, as well as focus on intervention models from 
the traumatic experience. I'm pleased and actually thrilled 
that I'm on this Committee, which I think speaks volumes to the 
history that we have in the Senate of Senators from North 
Dakota believing that this is an important issue. Senator John 
Hoeven has joined me here today to listen to this important 
testimony, provide questions, and take the message along with 
me back to Washington D.C. I turn now to Senator Hoeven for 
remarks.

                STATEMENT OF HON. JOHN HOEVEN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Hoeven. Thank you, Senator Heitkamp. I'm pleased to 
be here with you. Thanks to all of you for attending. Thanks to 
our witnesses and UTTC for hosting this event on a very, very 
important subject. The purpose of the hearing is to discuss how 
Federal agencies can coordinate to provide services to Native 
American children who suffer from trauma and mental health 
issues. Trauma is defined as a series of events that cause 
physical and psychological stress reactions. Native American 
children experience abuse and neglect at higher rates than non-
native children. As a result, they are more likely to 
experience trauma due to depression, substance abuse, 
homelessness, and poverty. Native Americans suffer from PTSD, 
post-traumatic stress disorder, at twice the rate of the 
general population in North Dakota. Between the years of 2006 
and 2010 the suicide rate among Native American people was 
twice that of non-natives. As we all know, the devastating 
effects of trauma are all too common to Native American 
communities, specifically among the children. I'm committed to 
doing all I can to work with my colleagues and Senator Heitkamp 
to address this very serious concern. I believe the most 
effective way to address trauma in Native American communities 
is to prevent it from happening in the first place, especially 
for children. So we're working on trying to prevent trauma, and 
one example is the Native American Children Safety Act that 
ensures that foster children on the reservation are placed in 
safe homes. We need to take this step and other steps in a 
comprehensive way. Let's hear from our witnesses as to how we 
can address the very important issue and comprehensive approach 
working together. Thank you to Senator Heitkamp for organizing 
this very important discussion. Thank you.
    Senator Heitkamp. Thank you so much, Senator Hoeven. I want 
to now turn to our witnesses, some of whom we've seen many 
times in front of our committee in Washington D.C, I dare say 
this, maybe a little more friendly than what you've seen in the 
past. But I also want to thank those of you who have traveled 
from so far to provide this testimony at this field hearing and 
to open up this discussion that we did a couple years ago on 
trauma and realize that this is not a one off. This isn't 
something that we talk about today and not realize we need to 
continue that dialogue well into the future. Our first witness 
is Lillian Sparks Robinson. She is Commissioner of the 
Administration of Native Americans--Administration for Children 
and Families within the U.S. Department of Health and Human 
Services. I am pleased that she is here with us today. I remind 
you your testimony is five minutes. I will introduce each of 
you before you speak.

   STATEMENT OF HON. LILLIAN SPARKS ROBINSON, COMMISSIONER, 
              ADMINISTRATION OF NATIVE AMERICANS--
        ADMINISTRATION FOR CHILDREN AND FAMILIES, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Ms. Robinson. Senator Heitkamp and members of the Senate 
Committee on Indian Affairs, it is my honor to testify before 
this Committee on behalf of the Department of Health and Human 
Services (HHS) on the important topic of Addressing Trauma and 
Mental Health Challenges in Indian Country.
    I am a member of the Rosebud Sioux Tribe, which is located 
in South Dakota. I serve as the Commissioner for the 
Administration for Native Americans, which is part of the 
Administration for Children and Families (ACF), as well as the 
Chair of the Intradepartmental Council on Native American 
Affairs (ICNAA).
    Development of HHS-Wide Policy to Address Trauma. In my 
role as chair of the ICNAA, I have led meetings involving 
leadership from ACF, the Indian Health Service (IHS), and the 
Substance Abuse and Mental Health Services Administration 
(SAMHSA) to discuss how we may better lead collaborative 
efforts on an intra-departmental level to support improved 
outcomes in the health and emotional well-being of American 
Indians and Alaska Natives (AI/AN) and others in tribal 
communities. ACF, SAMHSA, and IHS were highlighted in the 
Committee's December 17 letter requesting HHS develop and 
implement an integrated and coordinated Federal approach to 
addressing complex trauma, including historical trauma in 
Indian communities and are the primary agencies bringing a 
trauma-informed lens to this work. We have examined the causes 
and effects of trauma, including historical and childhood 
trauma, with an intentional view toward better understanding 
and highlighting steps tribes themselves are taking to prevent 
and address the effects of trauma. We believe developing a 
comprehensive, integrated, and trauma-informed HHS-wide policy 
that is sustainable over the long-term requires collaboration 
not only across the health and the human services components of 
HHS, but also, with other Federal agencies and our AI/AN 
partners.
    We are actively engaged in the development of an HHS-wide 
policy and are planning on releasing and implementing it within 
this calendar year. We are currently soliciting input from our 
tribal partners as well as incorporating substantive material 
from HHS Operating Divisions contributing to the Department's 
comprehensive trauma-informed policy. The policy will focus on 
moving tribal health promotion forward as well as learning from 
and incorporating AI/AN models of prevention, care, and healing 
in partnership with tribal leaders, experts, and communities.
    Recently, I invited tribal leaders to a listening session 
held on August 9 to solicit input and recommendations to inform 
this important work. This listening session was held in 
Portland, Oregon in conjunction with the 2016 IHS American 
Indian/Alaska Native Behavioral Health Conference. We are 
tentatively planning additional listening sessions.
    In addition, guidance and recommendations of tribal leaders 
in the development of the National Tribal Behavioral Health 
Agenda (TBHA), led by SAMHSA, has greatly informed the on-going 
development of our HHS-wide policy addressing trauma. The 
process for development of the TBHA was the result of SAMHSA's 
months of information gathering, discussion, analysis, 
validation, sharing, and revalidation of input received from 
Indian tribes and tribal leaders in coordination with the 
Indian Health Service's Office of Clinical and Preventive 
Services (OCPS) and the National Indian Health Board (NIHB). 
Development of the TBHA has been a strong collaborative effort 
among Indian tribes, national and regional tribal leaders, 
SAMHSA regional administrators and staff, and numerous Federal 
partners.
    As you know, tribal leaders have consistently asked for 
support in addressing behavioral health issues affecting their 
communities as part of broader discussions of health and 
wellness. To bring a targeted focus to such issues at the 
outset of our work to develop Department-wide policy, in March 
2016, we solicited and tribal leadership provided, through the 
HHS's Secretary's Tribal Advisory Committee (STAC), their 
recommendations on how we could approach the development of a 
comprehensive, integrated departmental policy to address 
complex trauma in AI/AN communities. Among the input we 
received were recommendations that we not only identify and 
understand the root causes of trauma, but that we make specific 
efforts to ensure that Federal partners are educated about 
models and approaches developed from tribal perspectives to 
more effectively prevent and address trauma in tribal 
communities including trauma affecting AI/AN children, youth, 
and families. Based on this and other feedback from tribes, we 
are encouraged to move beyond a deficits-based perspective and 
to reflect in our policy emphasis on protective factors and 
positive youth development strategies aimed at promoting 
resilience, which, we believe may have a larger impact on 
prevention than risk reduction strategies alone. Further, since 
the most effective trauma-informed activity is to prevent 
trauma from occurring, we are working to identify and promote 
interventions, such as home visiting, which address the 
intergenerational transmission of trauma and build on the 
strengths of young parents.
    With our tribal partners, we are moving forward to develop 
approaches that focus on cultivating, strengthening, and 
lifting up the Native assets and cultural resources found in 
AI/AN Communities. One of the recommendations we heard through 
the STAC members was that our policy should acknowledge tribal 
elders as assets and resources. At a STAC meeting in June, we 
discussed the critical role of tribal elders in the development 
and implementation of policies addressing trauma, including 
strategies to foster resilience. Our colleagues in the 
Administration for Community Living (ACL), whose mission 
includes working with seniors and tribal elders, will be 
indispensable in our work to fully reflect tribal elders' roles 
in addressing trauma.
    At the Departmental Fiscal Year (FY) 2018 Tribal Budget 
Consultation, Ms. Mirtha Beadle, the Director of the Office of 
Tribal Affairs and Policy at SAMHSA shared with tribal leaders 
that in HHS we take trauma and its effects very seriously and 
that it is something that informs our work every day as part of 
an all-HHS commitment to Native Americans.
    Beyond our work to develop a written HHS policy to 
effectively address trauma in AI/AN communities, others in the 
Department and I are working with Federal agency partners 
through the White House Council on Native Americans Affairs, an 
interagency body established to improve coordination of Federal 
programs, to develop a Federal Government-wide approach to 
improve our capacity, coordination, and collaboration in 
addressing the wellness of AI/AN communities.
    Ongoing Work to Address Trauma--Since receipt of the 
Committee's letter, my colleagues and I have worked hard to 
reach across agencies to identify trauma-informed work already 
being done in the Department and ways we as champions for AI/AN 
children, youth, families, and communities, can coordinate this 
work better. We are focused on ways we can more effectively 
take advantage of the Department's health and human services 
assets.
    I would like to share with the Committee and participants 
in this field hearing the three-pronged framework HHS is 
pursuing.
    Increase Awareness and Understanding. The initial step is 
to improve information available to key staff across HHS about 
the extent and impact of trauma in tribal communities and 
opportunities to more effectively improve well-being. This 
prong will be supported by increasing Federal staff access to 
webinars and informational materials and encouraging greater 
engagement with tribal leaders and representatives. Resources 
and discussions are intended to build staff knowledge about 
cultural, practice, and evidence-based opportunities for 
creating and/or supporting systems that are trauma-informed.
    Among some examples of specific HHS activities to increase 
Federal staff awareness and understanding of trauma and its 
effects are:
    The development of the ACF Principles for Working with 
Federally Recognized Indian Tribes; a set of principles 
designed and intended to foster AI/AN well-being by providing a 
framework for Federal leadership, partnership, and 
compassionate and effective human services delivery. These 
principles are intended to guide the internal management of ACF 
in its partnership with people in Federally-recognized tribes.
    The launching of the ACF Trauma Network, which is a 
community of practice for ACF staff designed to share lessons 
learned and promising practices and to strengthen the agency's 
ability to support trauma-informed programmatic work. The ACF 
Trauma Network will host an internal training on issues of 
trauma and resilience in AI/AN communities, currently scheduled 
for October 2016. This program will address research on 
protective factors and positive youth development strategies 
that may have a larger impact on prevention of negative health 
outcomes than risk reduction strategies. Representatives from 
the Center for American Indian Health of the Johns Hopkins 
School of Public Health will share with ACF leadership and 
staff strength-based interventions developed and evaluated with 
the White Mountain Apache and Navajo communities; interventions 
that have now been scaled to 75 tribal communities across 15 
states, and two non-Native communities.
    Each year, SAMHSA, through its Tribal Training and 
Technical Assistance Center, hosts a training program focused 
on improving the Agency's work with AI/AN people. The training 
includes experiential exercises to assist SAMHSA staff gain 
greater awareness and understanding of intergenerational and 
historical trauma and their effects on tribal communities. The 
training is delivered in a format that allows SAMHSA staff at 
all levels to participate during the three-day program. 
Webinars are also offered throughout the year to improve 
knowledge about trauma-related issues in tribal communities and 
opportunities for addressing them.
    Home visiting helps expectant families and those with young 
children provide stimulating learning environments and 
nurturing relationships. Beginning in 2013, the IHS Community 
Health Representatives Program also partnered with the Center 
for American Indian Health of the Johns Hopkins School of 
Public Health to implement Family Spirit, an evidence-based, 
culturally tailored home-visiting program as a core strategy to 
support young families. Six pilot sites received intensive on-
site training and technical assistance. Using lessons learned 
from the pilot project, IHS and Johns Hopkins will expand 
Family Spirit for implementation in other tribal communities 
beginning in 2016. Since 2010, ACF has been operating the 
Tribal Home Visiting Program, part of the Maternal, Infant, and 
Early Childhood Home Visiting Program. The Tribal Home Visiting 
Program is an unprecedented expansion of culturally responsive 
services for vulnerable AI/AN families and children. The 
program serves some of the most vulnerable families who 
experience multiple challenges often attributed to historical 
trauma. The program has served a total of 1,523 families and 
provided nearly 20,000 home visits through 25 funded grantees 
in 14 states. There are currently 15 rural grantees, three 
urban grantees, and seven grantees in a mix of rural and urban 
settings.
    IHS provides comprehensive training options to build a 
workforce that is trauma-informed and responsive. Topics cover 
historical trauma, adverse childhood experiences, early 
screening and assessment of trauma, treating complex trauma, 
trauma informed care services and programming, and many others. 
Training is available online through the IHS TeleBehavioral 
Health Center of Excellence.
    This year's IHS AI/AN National Behavioral Health Conference 
was planned around the theme, Creating Trauma Informed Systems 
in AI/AN Communities. The conference was held in Portland, 
Oregon, from August 9-11, 2016, with 550 registrants over 35 
breakout sessions, 90 presenters, and more than 45 continuing 
education hours offered at no cost to participants.
    Improve Coordination and Collaboration. HHS is developing a 
comprehensive, integrated policy on actions that support 
healing from trauma and advance trauma-informed practices 
through programs that contribute to improving the health and 
well-being of tribal communities. As part of our work with the 
other agencies on these issues, we are developing a template 
for creating complementary policies across Federal agencies 
that support trauma-informed practices. The intent is to: (1) 
strengthen support systems across health, behavioral health, 
education, child welfare, justice services, environmental, and 
other Federal programming; (2) improve actions to recognize and 
address the impacts of adverse childhood experiences among AI/
AN populations; and (3) to the extent possible, better align 
programs to address trauma, prevent additional trauma, and 
support trauma-informed services that are continuous across 
systems.
    Examples of specific HHS activities to improve coordination 
and collaboration include: ACF, in collaboration with the 
Centers for Disease Control and Prevention, Health Resources 
and Services Administration, IHS, and SAMHSA, is leading work 
to support improved social-emotional and behavioral health for 
children and families in tribal communities. The agencies 
hosted a one-day Tribal Experts Workgroup Meeting on February 
25. The meeting included tribal leaders, community members, 
researchers, and advocates, as well as representatives from 
Federal agencies including HHS, the Department of Justice, and 
the Office of Management and Budget. The goal of the meeting 
was to learn from experts and discuss how we can better work 
together to: (1) raise awareness of challenges that pre-school 
children face in tribal populations with high rates of adult 
mental health and substance abuse issues; (2) provide tools and 
effective strategies for caregivers to support improved social-
emotional and behavioral health outcomes for children and their 
families in tribal communities; and (3) develop policy 
recommendations to address funding and service delivery 
challenges. Development of a comprehensive ACF Native American 
Child and Youth Policy Agenda to highlight the ongoing work of 
ACF program and staff offices to support thriving, resilient, 
safe, healthy, and economically secure children, families, and 
communities. The focus areas for this Policy Agenda are: (1) 
quality early childhood development and learning; (2) the role 
of self-determination and nation-building in strengthening 
families; (3) fostering child and youth well-being and 
resiliency in the face of trauma and adversity; (4) financial 
and economic security; and (5) building a new narrative with 
data. The ACF Policy Agenda is intended to both function as a 
structure for innovative policymaking to guide stronger and 
more effective programming and to lift up successful tribal 
models across the identified five focus areas. The Policy 
Agenda is very much an action-oriented roadmap we hope will 
provide AI/AN parents, caregivers, leadership, and children and 
youth, and federal staff with the tools they need to ensure 
improved child and youth outcomes.
    IHS, in collaboration with SAMHSA, developed the FY 2016 
funding opportunity for the Methamphetamine and Suicide 
Prevention Initiative Generation Indigenous. The funding 
opportunity is framed around addressing trauma by focusing on 
the following objectives: increasing positive youth 
development, building resiliency, and promoting family 
engagement. Newly awarded projects will have the opportunity to 
hire behavioral health providers to implement trauma informed 
services and programs, including the option to increase the 
number of paraprofessionals serving children, adolescents, and 
families.
    SAMHSA established the Federal Partners Committee on Women 
and Trauma that is co-chaired by the Department of Labor. The 
Committee's work has been guided by the recognition that the 
impact of violence and trauma on women is a public health 
problem with profound consequences for many different Federal 
departments and agencies. Initial efforts focused on 
identifying the impact of trauma on the mission and activities 
of each agency, raising awareness about trauma across 
government, and promoting evidence-based public health 
practices. The Committee includes more than 100 members from 40 
divisions of 13 Federal departments and agencies. An objective 
is to build a trauma-informed Nation through effective 
practices and cross-agency, systemic efforts at governmental 
levels. The Committee hosted a trauma event that reached an 
estimated 2,000 individuals each day, over the course of two 
days. Given the impact of the Committee's work and significance 
of trauma-informed approaches for AI/AN women.
    Discussions are underway on opportunities for leveraging 
these efforts as Federal partners work to support trauma-
informed efforts for tribal youth, families, and communities 
build Federal and Tribal Capacity through On-Going and 
Coordinated Technical Assistance. HHS will continue to provide 
dynamic and collaborative technical assistance solutions that 
are evidence- and practice-informed, culturally relevant, and 
designed to help agencies and organizations build their 
capacity to improve and expand quality services to tribal 
communities. Examples of HHS work in this area include: ACF, in 
partnership with other HHS agencies and offices, is currently 
developing toolkits to assist human services programs bring a 
trauma-informed lens to programs serving children, youth, and 
families, including focused resources tailored to the needs of 
programs serving AI/AN individuals and communities. To assist 
managers and administrators of HHS-supported human services 
programs, the HHS Behavioral Health Coordinating Committee's 
Subcommittee on Trauma and Early Intervention, which is co-led 
by ACF and the Office of the Assistant Secretary for Planning 
and Evaluation, will produce a Primer on Trauma-Informed Human 
Services. The Primer is designed to introduce human services 
program leaders and their staff at the state, tribal, 
territorial, and local level to recent advances in trauma, 
toxic stress, and executive functioning, and inform program 
leaders and their staff about the implications of this research 
for program design, policy, evaluation, and service delivery. 
The Primer stresses historical trauma, a form of complex trauma 
that manifests throughout the life span and is passed down 
through generations. This psychological suffering endured by a 
group is particularly relevant to AI/AN communities, and the 
Primer provides a road-map to resources from ACF, SAMHSA, IHS, 
and others on addressing trauma through human services programs 
in AI/AN communities.
    Discussions with tribal leaders on SAMHSA's Tribal 
Technical Advisory Committee (TTAC) led to the 
conceptualization of the National Tribal Behavioral Health 
Agenda. The voices of TTAC were joined by tribal leaders on the 
HHS STAC and other engaged leaders who sought a comprehensive 
behavioral health effort grounded in tribal and federal 
collaboration. Their intent was to address the root causes of 
behavioral health problems in tribal communities and not just 
the contributing factors. Some of these problems result from 
adverse childhood experiences and traumatic events that have 
been experienced historically and intergenerationally. The root 
causes and resulting behavioral health issues impact other 
areas that contribute to well-being such as overall health, 
education, employment, child welfare, and engagement with the 
justice system in response to these concerns, SAMHSA and IHS 
worked with other Federal agencies and the National Indian 
Health Board to identify foundational elements, priorities, and 
strategies for the TBHA. The TBHA was drafted based on the 
voices and recommendations of tribal leaders and 
representatives acknowledges the importance of tribal wisdom 
and cultural practices in meeting the needs of tribal 
communities; provides a clear, national statement about 
prioritizing behavioral health as an essential component to 
improving overall health and wellness; facilitates tribal/
Federal collaboration on common behavioral health priorities; 
and supports opportunities for improving behavioral health-
related policies and programs geared to the specific needs of 
tribal communities.
    I would be happy to share with your staff a more complete 
listing of the programs and activities HHS is engaged in which 
focus on addressing trauma and behavioral health and wellness.
    Thank you for your work on this important issue and the 
opportunity to speak with you today. I am happy to answer any 
questions you may have.
    [The prepared statement of Ms. Robinson follows:]

   Prepared Statement of Hon. Lillian Sparks Robinson, Commissioner, 
  Administration of Native Americans--Administration for Children and 
         Families, U.S. Department of Health and Human Services
    Senator Heitkamp and members of the Senate Committee on Indian 
Affairs, it is my honor to testify before this Committee on behalf of 
the Department of Health and Human Services (HHS) on the important 
topic of ``Addressing Trauma and Mental Health Challenges in Indian 
Country''. I am a member of the Rosebud Sioux Tribe, which is located 
in South Dakota. I serve as the Commissioner for the Administration for 
Native Americans, which is part of the Administration for Children and 
Families (ACF), as well as the Chair of the Intradepartmental Council 
on Native American Affairs (ICNAA).
Development of HHS-Wide Policy to Address Trauma
    In my role as chair of the ICNAA, I have led meetings involving 
leadership from ACF, the Indian Health Service (IHS), and the Substance 
Abuse and Mental Health Services Administration (SAMHSA) to discuss how 
we may better lead collaborative efforts on an intra-departmental level 
to support improved outcomes in the health and emotional well-being of 
American Indians and Alaska Natives (AI/AN) and others in tribal 
communities. ACF, SAMHSA, and IHS were highlighted in the Committee's 
December 17 letter requesting HHS develop and implement an integrated 
and coordinated Federal approach to addressing complex trauma, 
including historical trauma in Indian communities and are the primary 
agencies bringing a trauma-informed lens to this work. We have examined 
the causes and effects of trauma, including historical and childhood 
trauma, with an intentional view toward better understanding and 
highlighting steps tribes themselves are taking to prevent and address 
the effects of trauma. We believe developing a comprehensive, 
integrated, and trauma-informed HHS-wide policy that is sustainable 
over the long-term requires collaboration not only across the health 
and the human services components of HHS, but also, with other Federal 
agencies and our AI/AN partners.
    We are actively engaged in the development of an HHS-wide policy 
and are planning on releasing and implementing it within this calendar 
year. We are currently soliciting input from our tribal partners as 
well as incorporating substantive material from HHS Operating Divisions 
contributing to the Department's comprehensive trauma-informed policy. 
The policy will focus on moving tribal health promotion forward as well 
as learning from and incorporating AI/AN models of prevention, care, 
and healing in partnership with tribal leaders, experts, and 
communities.
    Recently, I invited tribal leaders to a listening session held on 
August 9 to solicit input and recommendations to inform this important 
work. This listening session was held in Portland, Oregon in 
conjunction with the 2016 IHS American Indian/Alaska Native Behavioral 
Health Conference. We are tentatively planning additional listening 
sessions.
    In addition, guidance and recommendations of tribal leaders in the 
development of the National Tribal Behavioral Health Agenda (TBHA), led 
by SAMHSA, has greatly informed the on-going development of our HHS-
wide policy addressing trauma. The process for development of the TBHA 
was the result of SAMHSA's months of information gathering, discussion, 
analysis, validation, sharing, and revalidation of input received from 
Indian tribes and tribal leaders in coordination with the Indian Health 
Service's Office of Clinical and Preventive Services (OCPS) and the 
National Indian Health Board (NIHB). Development of the TBHA has been a 
strong, collaborative effort among Indian tribes, national and regional 
tribal leaders, SAMHSA regional administrators and staff, and numerous 
Federal partners.
    As you know, tribal leaders have consistently asked for support in 
addressing behavioral health issues affecting their communities as part 
of broader discussions of health and wellness. To bring a targeted 
focus to such issues at the outset of our work to develop Department-
wide policy, in March 2016, we solicited and tribal leadership 
provided, through the HHS' Secretary's Tribal Advisory Committee 
(STAC), their recommendations on how we could approach the development 
of a comprehensive, integrated departmental policy to address complex 
trauma in AI/AN communities. Among the input we received were 
recommendations that we not only identify and understand the root 
causes of trauma, but that we make specific efforts to ensure that 
Federal partners are educated about models and approaches developed 
from tribal perspectives to more effectively prevent and address trauma 
in tribal communities including trauma affecting AI/AN children, youth, 
and families. Based on this and other feedback from tribes, we are 
encouraged to move beyond a deficits-based perspective and to reflect 
in our policy emphasis on protective factors and positive youth 
development strategies aimed at promoting resilience, which, we believe 
may have a larger impact on prevention than risk reduction strategies 
alone. Further, since the most effective trauma-informed activity is to 
prevent trauma from occurring, we are working to identify and promote 
interventions, such as home visiting, which address the 
intergenerational transmission of trauma and build on the strengths of 
young parents.
    With our tribal partners, we are moving forward to develop 
approaches that focus on cultivating, strengthening, and lifting up the 
Native assets and cultural resources found in AI/AN communities. One of 
the recommendations we heard through the STAC members was that our 
policy should acknowledge tribal elders as assets and resources. At a 
STAC meeting in June, we discussed the critical role of tribal elders 
in the development and implementation of policies addressing trauma, 
including strategies to foster resilience. Our colleagues in the 
Administration for Community Living (ACL), whose mission includes 
working with seniors and tribal elders, will be indispensable in our 
work to fully reflect tribal elders' roles in addressing trauma.
    At the Departmental Fiscal Year (FY) 2018 Tribal Budget 
Consultation, Ms. Mirtha Beadle, the Director of the Office of Tribal 
Affairs and Policy at SAMHSA shared with tribal leaders that in HHS we 
take trauma and its effects very seriously and that it is something 
that informs our work every day as part of an all-HHS commitment to 
Native Americans.
    Beyond our work to develop a written HHS policy to effectively 
address trauma in AI/AN communities, others in the Department and I are 
working with Federal agency partners through the White House Council on 
Native Americans Affairs, an interagency body established to improve 
coordination of Federal programs, to develop a Federal Government-wide 
approach to improve our capacity, coordination, and collaboration in 
addressing the wellness of AI/AN communities.
Ongoing Work to Address Trauma
    Since receipt of the Committee's letter, my colleagues and I have 
worked hard to reach across agencies to identify trauma-informed work 
already being done in the Department and ways we, as champions for AI/
AN children, youth, families, and communities, can coordinate this work 
better. We are focused on ways we can more effectively take advantage 
of the Department's health and human services assets.
    I would like to share with the Committee and participants in this 
field hearing the three-pronged framework HHS is pursuing.
    Prong 1--Increase Awareness and Understanding. The initial step is 
to improve information available to key staff across HHS about the 
extent and impact of trauma in tribal communities and opportunities to 
more effectively improve well-being. This prong will be supported by 
increasing Federal staff access to webinars and informational materials 
and encouraging greater engagement with tribal leaders and 
representatives. Resources and discussions are intended to build staff 
knowledge about cultural, practice, and evidence-based opportunities 
for creating and/or supporting systems that are trauma-informed.
    Among some examples of specific HHS activities to increase Federal 
staff awareness and understanding of trauma and its effects are:

   The development of the ACF Principles for Working with 
        Federally Recognized Indian Tribes; a set of principles 
        designed and intended to foster AI/AN well-being by providing a 
        framework for Federal leadership, partnership, and 
        compassionate and effective human services delivery. These 
        principles are intended to guide the internal management of ACF 
        in its partnership with people in Federally-recognized tribes.

   The launching of the ACF Trauma Network, which is a 
        community of practice for ACF staff designed to share lessons 
        learned and promising practices and to strengthen the agency's 
        ability to support trauma-informed programmatic work. The ACF 
        Trauma Network will host an internal training on issues of 
        trauma and resilience in AI/AN communities, currently scheduled 
        for October 2016. This program will address research on 
        protective factors and positive youth development strategies 
        that may have a larger impact on prevention of negative health 
        outcomes than risk reduction strategies. Representatives from 
        the Center for American Indian Health of the Johns Hopkins 
        School of Public Health will share with ACF leadership and 
        staff strength-based interventions developed and evaluated with 
        the White Mountain Apache and Navajo communities; interventions 
        that have now been scaled to 75 tribal communities across 15 
        states, and two non-Native communities.

   Each year, SAMHSA, through its Tribal Training and Technical 
        Assistance Center, hosts a training program focused on 
        improving the Agency's work with AI/AN people. The training 
        includes experiential exercises to assist SAMHSA staff gain 
        greater awareness and understanding of intergenerational and 
        historical trauma and their effects on tribal communities. The 
        training is delivered in a format that allows SAMHSA staff at 
        all levels to participate during the three-day program. 
        Webinars are also offered throughout the year to improve 
        knowledge about trauma-related issues in tribal communities and 
        opportunities for addressing them.

   Home visiting helps expectant families and those with young 
        children provide stimulating learning environments and 
        nurturing relationships. Beginning in 2013, the IHS Community 
        Health Representatives Program also partnered with the Center 
        for American Indian Health of the Johns Hopkins School of 
        Public Health to implement Family Spirit, an evidence-based, 
        culturally tailored home-visiting program as a core strategy to 
        support young families. Six pilot sites received intensive on-
        site training and technical assistance. Using lessons learned 
        from the pilot project, IHS and Johns Hopkins will expand 
        Family Spirit for implementation in other tribal communities 
        beginning in 2016. Since 2010, ACF has been operating the 
        Tribal Home Visiting Program, part of the Maternal, Infant, and 
        Early Childhood Home Visiting Program. The Tribal Home Visiting 
        Program is an unprecedented expansion of culturally responsive 
        services for vulnerable AI/AN families and children. The 
        program serves some of the most vulnerable families who 
        experience multiple challenges often attributed to historical 
        trauma. The program has served a total of 1,523 families and 
        provided nearly 20,000 home visits through 25 funded grantees 
        in 14 states. There are currently 15 rural grantees, three 
        urban grantees, and seven grantees in a mix of rural and urban 
        settings.

   IHS provides comprehensive training options to build a 
        workforce that is trauma-informed and responsive. Topics cover 
        historical trauma, adverse childhood experiences, early 
        screening and assessment of trauma, treating complex trauma, 
        trauma informed care services and programming, and many others. 
        Training is available online through the IHS TeleBehavioral 
        Health Center of Excellence.

   This year's IHS AI/AN National Behavioral Health Conference 
        was planned around the theme, ``Creating Trauma Informed 
        Systems in AI/AN Communities.'' The conference was held in 
        Portland, Oregon, from August 9-11, 2016, with 550 registrants 
        over 35 breakout sessions, 90 presenters, and more than 45 
        continuing education hours offered at no cost to participants.

    Prong 2--Improve Coordination and Collaboration. HHS is developing 
a comprehensive, integrated policy on actions that support healing from 
trauma and advance trauma-informed practices through programs that 
contribute to improving the health and well-being of tribal 
communities. As part of our work with the other agencies on these 
issues, we are developing a template for creating complementary 
policies across Federal agencies that support trauma-informed 
practices. The intent is to: (1) strengthen support systems across 
health, behavioral health, education, child welfare, justice services, 
environmental, and other Federal programming; (2) improve actions to 
recognize and address the impacts of adverse childhood experiences 
among AI/AN populations; and (3) to the extent possible, better align 
programs to address trauma, prevent additional trauma, and support 
trauma-informed services that are continuous across systems.
    Examples of specific HHS activities to improve coordination and 
collaboration include:

   ACF, in collaboration with the Centers for Disease Control 
        and Prevention, Health Resources and Services Administration, 
        IHS, and SAMHSA, is leading work to support improved social-
        emotional and behavioral health for children and families in 
        tribal communities. The agencies hosted a one-day Tribal 
        Experts Workgroup Meeting on February 25. The meeting included 
        tribal leaders, community members, researchers, and advocates, 
        as well as representatives from Federal agencies including HHS, 
        the Department of Justice, and the Office of Management and 
        Budget. The goal of the meeting was to learn from experts and 
        discuss how we can better work together to: (1) raise awareness 
        of challenges that pre-school children face in tribal 
        populations with high rates of adult mental health and 
        substance abuse issues; (2) provide tools and effective 
        strategies for caregivers to support improved social-emotional 
        and behavioral health outcomes for children and their families 
        in tribal communities; and (3) develop policy recommendations 
        to address funding and service delivery challenges.

   Development of a comprehensive ACF Native American Child and 
        Youth Policy Agenda to highlight the ongoing work of ACF 
        program and staff offices to support thriving, resilient, safe, 
        healthy, and economically secure children, families, and 
        communities. The focus areas for this Policy Agenda are: (1) 
        quality early childhood development and learning; (2) the role 
        of self-determination and nation-building in strengthening 
        families; (3) fostering child and youth well-being and 
        resiliency in the face of trauma and adversity; (4) financial 
        and economic security; and (5) building a new narrative with 
        data. The ACF Policy Agenda is intended to both function as a 
        structure for innovative policymaking to guide stronger and 
        more effective programming and to lift up successful tribal 
        models across the identified five focus areas. The Policy 
        Agenda is very much an action-oriented roadmap we hope will 
        provide AI/AN parents, caregivers, leadership, and children and 
        youth, and federal staff with the tools they need to ensure 
        improved child and youth outcomes.

   IHS, in collaboration with SAMHSA, developed the FY 2016 
        funding opportunity for the Methamphetamine and Suicide 
        Prevention Initiative Generation Indigenous. The funding 
        opportunity is framed around addressing trauma by focusing on 
        the following objectives: increasing positive youth 
        development, building resiliency, and promoting family 
        engagement. Newly awarded projects will have the opportunity to 
        hire behavioral health providers to implement trauma informed 
        services and programs, including the option to increase the 
        number of paraprofessionals serving children, adolescents, and 
        families.

   SAMHSA established the Federal Partners Committee on Women 
        and Trauma that is co-chaired by the Department of Labor. The 
        Committee's work has been guided by the recognition that the 
        impact of violence and trauma on women is a public health 
        problem with profound consequences for many different Federal 
        departments and agencies. Initial efforts focused on 
        identifying the impact of trauma on the mission and activities 
        of each agency, raising awareness about trauma across 
        government, and promoting evidence-based public health 
        practices. The Committee includes more than 100 members from 40 
        divisions of 13 Federal departments and agencies. An objective 
        is to build a trauma-informed Nation through effective 
        practices and cross-agency, systemic efforts at governmental 
        levels. The Committee hosted a trauma event that reached an 
        estimated 2,000 individuals each day, over the course of two 
        days. Given the impact of the Committee's work and significance 
        of trauma-informed approaches for AI/AN women, discussions are 
        underway on opportunities for leveraging these efforts as 
        Federal partners work to support trauma-informed efforts for 
        tribal youth, families, and communities.

    Prong 3--Build Federal and Tribal Capacity through On-Going and 
Coordinated Technical Assistance. HHS will continue to provide dynamic 
and collaborative technical assistance solutions that are evidence- and 
practice-informed, culturally relevant, and designed to help agencies 
and organizations build their capacity to improve and expand quality 
services to tribal communities. Examples of HHS work in this area 
include:

   ACF, in partnership with other HHS agencies and offices, is 
        currently developing toolkits to assist human services programs 
        bring a trauma-informed lens to programs serving children, 
        youth, and families, including focused resources tailored to 
        the needs of programs serving AI/AN individuals and 
        communities. To assist managers and administrators of HHS-
        supported human services programs, the HHS Behavioral Health 
        Coordinating Committee's Subcommittee on Trauma and Early 
        Intervention, which is co-led by ACF and the Office of the 
        Assistant Secretary for Planning and Evaluation, will produce a 
        Primer on Trauma-Informed Human Services. The Primer is 
        designed to introduce human services program leaders and their 
        staff at the state, tribal, territorial, and local level to 
        recent advances in trauma, toxic stress, and executive 
        functioning, and inform program leaders and their staff about 
        the implications of this research for program design, policy, 
        evaluation, and service delivery. The Primer stresses 
        historical trauma, a form of complex trauma that manifests 
        throughout the life span and is passed down through 
        generations. This psychological suffering endured by a group is 
        particularly relevant to AI/AN communities, and the Primer 
        provides a road-map to resources from ACF, SAMHSA, IHS, and 
        others on addressing trauma through human services programs in 
        AI/AN communities.

   Discussions with tribal leaders on SAMHSA's Tribal Technical 
        Advisory Committee (TTAC) led to the conceptualization of the 
        National Tribal Behavioral Health Agenda. The voices of TTAC 
        were joined by tribal leaders on the HHS STAC and other engaged 
        leaders who sought a comprehensive behavioral health effort 
        grounded in tribal and federal collaboration. Their intent was 
        to address the root causes of behavioral health problems in 
        tribal communities and not just the contributing factors. Some 
        of these problems result from adverse childhood experiences and 
        traumatic events that have been experienced historically and 
        intergenerationally. The root causes and resulting behavioral 
        health issues impact other areas that contribute to well-being 
        such as overall health, education, employment, child welfare, 
        and engagement with the justice system.

   In response to these concerns, SAMHSA and IHS worked with 
        other Federal agencies and the National Indian Health Board to 
        identify foundational elements, priorities, and strategies for 
        the TBHA. The TBHA was drafted based on the voices and 
        recommendations of tribal leaders and representatives--it 
        acknowledges the importance of tribal wisdom and cultural 
        practices in meeting the needs of tribal communities; provides 
        a clear, national statement about prioritizing behavioral 
        health as an essential component to improving overall health 
        and wellness; facilitates tribal/Federal collaboration on 
        common behavioral health priorities; and supports opportunities 
        for improving behavioral health-related policies and programs 
        geared to the specific needs of tribal communities.

    I would be happy to share with your staff a more complete listing 
of the programs and activities HHS is engaged in which focus on 
addressing trauma and behavioral health and wellness.
    Thank you for your work on this important issue and the opportunity 
to speak with you today. I am happy to answer any questions you may 
have.

    Senator Heitkamp. Thank you. Next we will hear from Officer 
Darren Cruzan. He is the Director of the Office of Justice 
Services at the Bureau of Indian Affairs in the Department of 
the Interior.

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

    Mr. Cruzan. My name is Darren Cruzan and I am the Director 
for the Office of Justice Services at the Bureau of Indian 
Affairs in the Department of the Interior. I am pleased to 
submit this statement for the Department on the topic of 
``Addressing Trauma and Mental Health Challenges in Indian 
Country.''
    As a result of repudiated past federal policies intended to 
disrupt American Indian and Alaska Native (AI/AN) families, 
today many tribal citizens suffer from the effects of 
generational trauma. Trauma may be from emotional abuse, 
physical abuse, sexual abuse, emotional neglect, physical 
neglect, witnessing substance abuse or domestic violence in the 
home, or experiencing a parent's divorce or incarceration. 
Symptoms can range from anxiety, impulsivity, to depression, 
and can manifest themselves as criminal behavior, poor school 
performance, chronic illness, and mental health issues. In 
November 2014, the Attorney General's Taskforce on American 
Indian/Alaska Native Children Exposed to Violence documented a 
high rate of trauma in Indian Country and made policy 
recommendations to reduce it.
    As the Department responsible for providing law 
enforcement, child protection services and social workers, 
support for tribal courts, and education services, we know we 
are a key partner in addressing trauma in Indian Country. While 
we do not diagnose or treat individuals, we or tribes that 
administer our programs and services are the often the first 
responders to crisis in the home or at school and serve as a 
bridge for connecting families and individuals to the services 
they need. Officers, teachers, social worker and other 
professionals also witness firsthand the lack of resources 
available to treat the underlying conditions responsible for 
many of the troubling statistics. We appreciate the Committee's 
efforts to raise awareness of this important issue and the 
opportunity to provide testimony today.
    BIA Trauma Informed Care Training Progress in addressing 
trauma in Indian Country cannot be made until more education on 
trauma and its effects occurs. To better equip our staff, 
earlier this year, the BIA provided training to all BIA 
regional social workers on trauma informed care. This training 
was presented by subject matter experts from the National 
Institute of Health and Johns Hopkins University. The regional 
social workers received information on historical trauma and 
additional training opportunities regarding this issue.
    In addition to this nationwide training, many of the 
regions are providing training directly to, or in partnership 
with, tribes in their service areas. Some examples are: Alaska 
Region--In partnership with the Southcentral Foundation Family 
Wellness Program, the Alaska Region provided trauma informed 
care training at the BIA Providers Conference this past year. 
The presentation was attended by approximately 400 tribal 
representatives, including ICWA workers, tribal administrators 
and tribal council members. Southern Plains Region, The 
Anadarko Agency, located in the Southern Plains Region, 
operates the Positive Indian Parenting Program, an effort to 
address the parenting challenges the Agency has identified in 
their clients. This program was developed by the Agency after 
years of seeing how historical trauma impacting parenting 
skills as a result of the parents, experience during the 
boarding school era. These problems have been passed down 
generation to generation, and impacts many child protective 
services referrals the Agency receives. The Positive Indian 
Parenting Program instructor is certified through the Active 
Parenting Program and has attended and uses the curriculum from 
the National Indian Child Welfare Association's (NICWA) 
Positive Indian Parenting training. Through the combination of 
these parenting programs, the Agency has provided positive 
Indian parenting courses to Native parents. ,h Rocky Mountain 
Region--The Rocky Mountain Regional Office has forged a 
partnership with the Native Children's Trauma Center--
University of Montana for the last five years to develop Trauma 
Informed Child Protection Services. The Native Children's 
Trauma Center has done training for social service staff and 
tribal court staff over that period, and has provided onsite 
technical assistance at case staffing and child protection 
meetings. The region provided several region-wide trainings, a 
webinar series and more recently in 2016, developed a two-week 
trauma informed training curriculum for Social Service staff. 
,h Midwest Region--The BIA, Midwest Regional Office in 
partnership with the Native Wellness Institute (NWI) offered a 
series of trauma-informed training to the Tribes at the Midwest 
Region's 2016 Partners in Action Conference. The NWI recognizes 
the great impacts of historical trauma on Native people, and 
its impact on current day trauma in our families and 
communities. The NWI's mission is to promote the well-being of 
individuals, families and communities; to create an awareness 
of where our negative behavior comes from and provide 
opportunities for community/family growth and healing.
    We are also empowering tribal communities to address trauma 
in their communities. As recommended by the Attorney General in 
3.1 of its report, Ending Violence so Children Can Thrive, we 
created a new initiative to allow tribes to braid federal funds 
together to address the distinct needs of their communities.
    Tiwahe, which means family in Lakota, is an initiative 
designed to demonstrate the effectiveness of wraparound 
services in tribal communities. It looks at funding streams 
from social services, child welfare, employment and training, 
recidivism and/or tribal courts and asks tribes to develop a 
plan to combine these funding streams to improve outcomes. The 
goal is to reduce the rate AI/NA children enter foster care, 
increase family reunification rates, reduce recidivism rates, 
and build capacity within tribal courts.
    In FY 2016, six tribes are participating in the 
demonstration project. These are: the Association of Village 
Council Presidents (AVCP); the Spirit Lake Tribe; Red Lake Band 
of Chippewa Indians; Ute Mountain Ute Tribe; Fort Belknap 
Indian Community; and the Pascua Yaqui Tribe. In addition, all 
tribes received an across-the-board increase to their base 
funding, referred to as Tribal Priority Allocation, for Indian 
Child Welfare Act and Social Services. We recently hired a 
National Tiwahe Coordinator who will start later this month to 
work with participating tribes.
    As we continue to build this program, our hope is to also 
improve how we collect data in partnership with tribes to fully 
understand how trauma and its effects impact Indian County.
    Current, relevant, and robust data is necessary to make 
informed policy decisions to craft effective trauma 
interventions.
    There is no more important issue than addressing the high 
suicide rate in Indian Country, particularly among youth, which 
is often the result of an individual's exposure to trauma. 
Indian Affairs is directly involved in youth suicide prevention 
through the BIE, which provides technical assistance and 
monitoring to ensure schools are compliant with intervention 
strategies and reporting protocols to further ensure student 
safety. In addition, under the BIE reorganization the School 
Health Policy Advisor position was created. This individual 
will support the BIE Associate Deputy Directors, staff in the 
Education Resource Centers and BIE schools with the development 
of additional mental health programs, initiatives and policies 
as well as suicide and substance abuse prevention. They will 
also coordinate with the BIA and support interagency work of 
the White House Council on Native American Affairs.
    BIE's partnering with other federal agencies, including the 
Departments of Health and Human Services (Substance Abuse and 
Mental Health Services Administration and the Indian Health 
Service (IHS)) and Education, has enabled BIE to address the 
unique needs of students within these schools in the areas of 
mental and substance use disorders, including suicide.
    The BIE has developed a Suicide Prevention, Early 
Intervention and Postvention Policy to promote suicide 
prevention in BIE schools. The policy mandates specific actions 
in all schools, dormitories and the two post-secondary 
institutions; and encourages tribally-operated schools to 
develop similar policies. These actions create a safety net for 
students who are at risk of suicide and promotes proactive 
involvement of school personnel and communities in 
intervention, prevention and postvention activities.
    The BIA Office of Justice Services (OJS) partners with 
numerous health and social service programs to assist in 
educating and presenting at schools, seminars, workshops and 
community events to the youth and the community on suicide 
prevention. OJS gathers statistical data and identifies youth 
suicide trends within Indian Country, and will look for ways to 
expand suicide prevention training with other stakeholders in 
the future.
    The BIA's Law Enforcement and Tribal Services programs, 
along with the BIE, continually seek ways to collaborate and to 
support activities directed at suicide prevention and services 
coordination. The BIE utilizes the Youth Risk Behavior Survey, 
Native American Student Information System (NASIS), local BIA 
Law Enforcement, and IHS data to develop interventions and 
track trends for program implementation and is committed to 
seeking out and enacting prevention strategies while ensuring a 
safe and secure environment for our students.
    Additionally, BIE schools and dormitories use NASIS to 
track and identify specific behavior trends to develop 
interventions to address school specific behavior issues. 
Training is provided on site by the School Safety Specialist at 
a number of locations throughout the school year during staff 
training sessions and all residential staff are required to 
receive suicide prevention training.
    It is important to note that Indian Country continues to 
suffer from a lack of comprehensive mental health treatment 
options. For example, OJS officers responding to a call for 
service involving a suicide threat are often left with no 
option but to arrest the individual. Without mental health 
facilities, jail is oftentimes the only place where the safety 
of the individual can be guaranteed.
    Indian Affairs has the advantage of working alongside 
tribes and understands firsthand the severity of the lack of 
resources in Indian Country and the impact it has on tribal 
communities. We look forward to our continued partnership with 
Tribal governments, on a government-to-government basis, and 
with our federal partners to continue to address trauma related 
issues.
    Thank you. I will give the rest of my time to the others.
    [The prepared statement of Mr. Cruzan follows:]

   Prepared Statement of Darren Cruzan, Director, Office of Justice 
  Services, Bureau of Indian Affairs, U.S. Department of the Interior
    My name is Darren Cruzan and I am the Director for the Office of 
Justice Services at the Bureau of Indian Affairs in the Department of 
the Interior. I am pleased to submit this statement for the Department 
on the topic of ``Addressing Trauma and Mental Health Challenges in 
Indian Country.''
    As a result of repudiated past federal policies intended to disrupt 
American Indian and Alaska Native (AI/AN) families, today many tribal 
citizens suffer from the effects of generational trauma. Trauma may be 
from emotional abuse, physical abuse, sexual abuse, emotional neglect, 
physical neglect, witnessing substance abuse or domestic violence in 
the home, or experiencing a parent's divorce or incarceration. Symptoms 
can range from anxiety, impulsivity, to depression, and can manifest 
themselves as criminal behavior, poor school performance, chronic 
illness, and mental health issues. In November 2014, the Attorney 
General's Taskforce on American Indian/Alaska Native Children Exposed 
to Violence documented a high rate of trauma in Indian Country and made 
policy recommendations to reduce it.
    As the Department responsible for providing law enforcement, child 
protection services and social workers, support for tribal courts, and 
education services, we know we are a key partner in addressing trauma 
in Indian Country. While we do not diagnose or treat individuals, we or 
tribes that administer our programs and services are the often the 
first responders to crisis in the home or at school and serve as a 
bridge for connecting families and individuals to the services they 
need. Officers, teachers, social worker and other professionals also 
witness firsthand the lack of resources available to treat the 
underlying conditions responsible for many of the troubling statistics. 
We appreciate the Committee's efforts to raise awareness of this 
important issue and the opportunity to provide testimony today.
BIA Trauma Informed Care Training
    Progress in addressing trauma in Indian Country cannot be made 
until more education on trauma and its effects occurs. To better equip 
our staff, earlier this year, the BIA provided training to all BIA 
regional social workers on trauma informed care. This training was 
presented by subject matter experts from the National Institute of 
Health and Johns Hopkins University. The regional social workers 
received information on historical trauma and additional training 
opportunities regarding this issue.
    In addition to this nationwide training, many of the regions are 
providing training directly to, or in partnership with, tribes in their 
service areas. Some examples are:

   Alaska Region--In partnership with the Southcentral 
        Foundation Family Wellness Program, the Alaska Region provided 
        trauma informed care training at the BIA Providers Conference 
        this past year. The presentation was attended by approximately 
        400 tribal representatives, including ICWA workers, tribal 
        administrators and tribal council members.

   Southern Plains Region--The Anadarko Agency, located in the 
        Southern Plains Region, operates the Positive Indian Parenting 
        Program, an effort to address the parenting challenges the 
        Agency has identified in their clients. This program was 
        developed by the Agency after years of seeing how historical 
        trauma impacting parenting skills as a result of the parents' 
        experience during the boarding school era. These problems have 
        been passed down generation to generation, and impacts many 
        child protective services referrals the Agency receives. The 
        Positive Indian Parenting Program instructor is certified 
        through the Active Parenting Program and has attended and uses 
        the curriculum from the National Indian Child Welfare 
        Association's (NICWA) Positive Indian Parenting training. 
        Through the combination of these parenting programs, the Agency 
        has provided positive Indian parenting courses to Native 
        parents.

   Rocky Mountain Region--The Rocky Mountain Regional Office 
        has forged a partnership with the Native Children's Trauma 
        Center--University of Montana for the last five years to 
        develop Trauma Informed Child Protection Services. The Native 
        Children's Trauma Center has done training for social service 
        staff and tribal court staff over that period, and has provided 
        onsite technical assistance at case staffing and child 
        protection meetings. The region provided several region-wide 
        trainings, a webinar series and more recently in 2016, 
        developed a two-week trauma informed training curriculum for 
        Social Service staff.

   Midwest Region--The BIA, Midwest Regional Office in 
        partnership with the Native Wellness Institute (NWI) offered a 
        series of trauma-informed training to the Tribes at the Midwest 
        Region's 2016 Partners in Action Conference. The NWI recognizes 
        the great impacts of historical trauma on Native people, and 
        its impact on current day trauma in our families and 
        communities. The NWI's mission is to promote the well-being of 
        individuals, families and communities; to create an awareness 
        of where our negative behavior comes from and provide 
        opportunities for community/family growth and healing.

Tiwahe Initiative
    We are also empowering tribal communities to address trauma in 
their communities. As recommended by the Attorney General in 3.1 of its 
report, ``Ending Violence so Children Can Thrive,'' we created a new 
initiative to allow tribes to braid federal funds together to address 
the distinct needs of their communities.
    Tiwahe, which means family in Lakota, is an initiative designed to 
demonstrate the effectiveness of wraparound services in tribal 
communities. It looks at funding streams from social services, child 
welfare, employment and training, recidivism and/or tribal courts and 
asks tribes to develop a plan to combine these funding streams to 
improve outcomes. The goal is to reduce the rate AI/NA children enter 
foster care, increase family reunification rates, reduce recidivism 
rates, and build capacity within tribal courts.
    In FY 2016, six tribes are participating in the demonstration 
project. These are: the Association of Village Council Presidents 
(AVCP); the Spirit Lake Tribe; Red Lake Band of Chippewa Indians; Ute 
Mountain Ute Tribe; Fort Belknap Indian Community; and the Pascua Yaqui 
Tribe. In addition, all tribes received an across-the-board increase to 
their base funding, referred to as Tribal Priority Allocation, for 
Indian Child Welfare Act and Social Services. We recently hired a 
National Tiwahe Coordinator who will start later this month to work 
with participating tribes.
    As we continue to build this program, our hope is to also improve 
how we collect data in partnership with tribes to fully understand how 
trauma and its effects impact Indian County. Current, relevant, and 
robust data is necessary to make informed policy decisions to craft 
effective trauma interventions.
Suicide Prevention
    There is no more important issue than addressing the high suicide 
rate in Indian Country, particularly among youth, which is often the 
result of an individual's exposure to trauma. Indian Affairs is 
directly involved in youth suicide prevention through the BIE, which 
provides technical assistance and monitoring to ensure schools are 
compliant with intervention strategies and reporting protocols to 
further ensure student safety. In addition, under the BIE 
reorganization the School Health Policy Advisor position was created. 
This individual will support the BIE Associate Deputy Directors, staff 
in the Education Resource Centers and BIE schools with the development 
of additional mental health programs, initiatives and policies as well 
as suicide and substance abuse prevention. They will also coordinate 
with the BIA and support interagency work of the White House Council on 
Native American Affairs.
    BIE's partnering with other federal agencies, including the 
Departments of Health and Human Services (Substance Abuse and Mental 
Health Services Administration and the Indian Health Service (IHS)) and 
Education, has enabled BIE to address the unique needs of students 
within these schools in the areas of mental and substance use 
disorders, including suicide.
    The BIE has developed a Suicide Prevention, Early Intervention and 
Postvention Policy to promote suicide prevention in BIE schools. The 
policy mandates specific actions in all schools, dormitories and the 
two post-secondary institutions; and encourages tribally-operated 
schools to develop similar policies. These actions create a safety net 
for students who are at risk of suicide and promotes proactive 
involvement of school personnel and communities in intervention, 
prevention and postvention activities.
    The BIA Office of Justice Services (OJS) partners with numerous 
health and social service programs to assist in educating and 
presenting at schools, seminars, workshops and community events to the 
youth and the community on suicide prevention. OJS gathers statistical 
data and identifies youth suicide trends within Indian Country, and 
will look for ways to expand suicide prevention training with other 
stakeholders in the future.
    The BIA's Law Enforcement and Tribal Services programs, along with 
the BIE, continually seek ways to collaborate and to support activities 
directed at suicide prevention and services coordination. The BIE 
utilizes the Youth Risk Behavior Survey, Native American Student 
Information System (NASIS), local BIA Law Enforcement, and IHS data to 
develop interventions and track trends for program implementation and 
is committed to seeking out and enacting prevention strategies while 
ensuring a safe and secure environment for our students.
    Additionally, BIE schools and dormitories use NASIS to track and 
identify specific behavior trends to develop interventions to address 
school specific behavior issues. Training is provided on site by the 
School Safety Specialist at a number of locations throughout the school 
year during staff training sessions and all residential staff are 
required to receive suicide prevention training.
    It is important to note that Indian Country continues to suffer 
from a lack of comprehensive mental health treatment options. For 
example, OJS officers responding to a call for service involving a 
suicide threat are often left with no option but to arrest the 
individual. Without mental health facilities, jail is oftentimes the 
only place where the safety of the individual can be guaranteed.
Conclusion
    Indian Affairs has the advantage of working alongside tribes and 
understands firsthand the severity of the lack of resources in Indian 
Country and the impact it has on tribal communities. We look forward to 
our continued partnership with Tribal governments, on a government-to-
government basis, and with our federal partners to continue to address 
trauma related issues.

    Senator Heitkamp. I have been preaching to the rest of the 
world about the great success that you had addressing trauma. 
So I want to congratulate you and the tribal leadership on 
taking this on. Your work has been recognized. You have a long 
history of working on behalf of your tribe and importantly on 
behalf of the children of your tribe. So I'm interested in 
hearing, and I know my colleagues and Senator Hoeven are 
interested in hearing about your success and what ideas we can 
share with the rest of the world. Thank you.

  STATEMENT OF HON. MYRNA WARRINGTON, CHAIRWOMAN, HEALTH AND 
     FAMILY COMMITTEE, MENOMINEE INDIAN TRIBE OF WISCONSIN

    Ms. Warrington. Thank you for inviting us here. It's good 
to know that tribes have been recognized nationally for their 
effort to address the problems of our children and families. 
Senator Heitkamp, Senator Hoeven, and members of the Committee, 
my name is Myrna Warrington. This is my 8th year serving as on 
the Menominee Tribal Legislature and at this time I serve on 
the Menominee Indian Tribe's Executive Team as the Secretary. 
Thank you for the opportunity to provide the Committee with the 
Menominee statement that addresses the trauma and mental health 
challenges experienced in Indian Country.
    The Menominee Indian Tribe is located in northeast 
Wisconsin, within our ancestral territory. Our Reservation is 
comprised of 234,000 acres of land; bountiful in rivers, lakes, 
streams, wildlife, and forest land. Roughly 90 percent of the 
land held in trust for the Tribe is held in sustained yield for 
the Tribe's long-standing practice in Sustainable Forest 
Management. The Tribal membership includes over 9,000 enrolled 
members.
    The Tribes history is mired in trauma due to the loss of 
Tribal status, identity, language and culture that was forced 
on our people by the Federal Government through overarching 
assimilation objectives, enactments of federal Indian policy, 
treaties, and judicial rulings. The negative remnants of trauma 
experienced from the treaty era, Boarding School Era, Menominee 
Termination Act of 1954, Federal Relocation Act of 1956, and 
finally the Restoration of the Menominee Indian Tribe to 
Federal Recognition in 1973, remain visible in the lives of our 
Tribal members. Throughout the last two centuries, the 
Menominee endured the large loss of ancestral territory, near 
extinction of Menominee language, and the loss of many critical 
cultural and religious beliefs, practices and communal values 
that guided the traditional Menominee society. Our oral history 
and the historical record remain to help guide the Tribe in the 
right direction to address the impacts from these experiences.
    In 2006, the Menominee Tribal Government, Menominee Indian 
School District, and Menominee Tribal Clinic, who, because of 
limited resources with narrow guidelines, broke down the silos 
to form the community collaboration. The Menominee Community 
Collaboration committed to creating data-driven solutions. The 
purpose was aimed at addressing the cumulative impacts that 
historical and intergenerational trauma were presenting upon 
the families of the Menominee Community. The initial 
identification process began with defining the negative 
behavioral, health, and educational problems that were 
manifesting in the lives of the Menominee youth. The community 
collaboration research led to the premise that the symptoms of 
poverty, low academic achievement, and poor health outcomes and 
factors were interconnected. Through this process, the Tribe 
was forced to confront the reality that the negative changes 
occurring within the youth population were a direct result of 
the changing family dynamic and community structure that were 
symptoms of a larger problem. These issues had not manifested 
overnight and were not isolated to just one event, but rather 
were symptoms resulting from trauma experienced throughout the 
course of the Tribes history.
    What is trauma informed care? Trauma Informed Care is 
defined as an organizational structure and treatment framework 
that involves understanding, recognizing, and responding to the 
effects of all types of trauma. Trauma informed care also 
emphasizes physical, psychological and emotional safety for 
both consumers and providers, and helps survivors rebuild a 
sense of control and empowerment for the Menominee, the 
definitional scope of trauma was lacking any recognition of 
self-worth and cultural competency and had to be expanded to 
include the loss of Menominee language, values, and beliefs in 
order to accurately examine the collective impacts that 
historical and intergenerational trauma had on the community as 
a whole. By doing so, the Tribe was able to identify the 
symptoms of trauma which included suicide, poverty, substance 
abuse/addiction, identity loss, loss of societal/cultural 
norms, and many others and identify the impacts that these had 
on the individual, family unit, and community.
    To accurately assess the magnitude of traumatic experiences 
and the impact these had on Menominee youth and within the 
family dynamic, the Community Collaboration examined the 
statistics identifying child victimization rates in Menominee 
County which included neglect, abuse, suicide attempts, and 
alcohol and drug use/abuse. In 2013, 1,423 children resided on 
the Menominee Indian Reservation. According to the 2013 
Wisconsin Department of Children & Families Annual Report to 
the Governor and Legislature, approximately 10 children in 
1,000 were victimized by either neglect, physical, sexual or 
emotional abuse. Equally alarming was the high incidence of 
youth hospitalizations for AODA and self-harm. For example, in 
2015, there were 10 youth hospitalizations for emergency 
detention alone. From January through June 2016, there have 
already been a total of 14 emergency detention 
hospitalizations, 11 youth hospitalized, and 8 out of 11 youth 
hospitalized reported substance abuse and/or tested positive 
for alcohol or drugs at the time of admission. Statistics such 
as these are what initiated what is now known as the Menominee 
Fostering Futures Pilot Project that began in 2013.
    Based on the statistics identifying the high incidence of 
traumatic experiences for tribal children, the Community 
Collaboration identified that existing policies, procedures, 
and mandates were not working. Menominee children and families 
were continuing to suffer. The County/Tribe was continually 
ranked 72 out of 72 for health outcomes and factors by the 
University of Wisconsin Population Health Institute. 
Educational Attainment was at an all-time low among high school 
students. The Menominee Indian School District was in fact, 
coined a drop-out factor due to the extremely low percentage of 
students graduating. Finally, crime, victimization, and death 
rates remained high.
    The Community Collaborative Workgroup started by building a 
Menominee Model using the Bridges Out of Poverty framework 
which was a model for economic and social change, 
sustainability and stability. The simple premise of the 
Community Collaboration Workgroup identified that the causes of 
poverty, low academic achievement and poor health are inter-
connected and formulated that the resources and responses the 
Community Collaboration would develop to combat them must also 
be inter-connected. This Community Collaborative workgroup 
vision of the Menominee Model evolved over time, which included 
the introduction and development of the Menominee Fostering 
Futures Initiative.
    The goal of Fostering Futures was designed to improve the 
lives of children and families by translating the knowledge 
gained from the Adverse Childhood Experience Study, 
neuroscientific information, and mental health literature on 
the long-term effects of chronic adversity and trauma in 
childhood. As a part of our Fostering Futures work, we had to 
pick 2 areas of concentration for our community. We chose the 
following: (1) Providing Adverse Childhood Experience Study and 
Trauma Informed Care education; and (2) Evaluating and 
modifying policies and procedures to be congruent with the 
Adverse Childhood Experience study and Trauma Informed Care.
    From the first goal, our Introduction to Trauma Informed 
Care training was developed. Initiatives of the Community 
Collaboration have included: Education Summits focused on 
Historical Trauma due to boarding schools and termination; the 
implementation of the Fostering Futures Program reservation 
wide promoting community awareness of Adverse Childhood 
Experiences (ACEs) and Trauma Informed Care (TIC).
    Trauma Informed Service Delivery is a key component and 
focus of the Community Engagement Workgroup. The Community 
Engagement meetings focus on the development, execution and 
completion of 90-day plans developed and reported quarterly on 
issues established by the workgroup that now involve all 
community service providers. The Tribe's programs are 
implementing Trauma Informed Services by: reviewing internal 
policies and practices with an awareness of Trauma Informed 
Care; Continuing the Fostering Future Initiatives aimed at 
awareness of Trauma Informed Care, Adverse Childhood 
Experiences and sustainability; development of an AODA specific 
strategic plan to focus community efforts in areas of most 
critical need; using the Community Engagement Initiative to re-
design the service delivery systems of government to ensure 
they are client focused and Trauma Informed; working to develop 
functions that: document processes being employed so that they 
can be cataloged and replicated; establishing a sustainable 
community-wide data collection and analysis function to measure 
results and guide decisionmaking; and requiring continuous 
collaboration among service providers when new grants or other 
initiatives are begun to eliminate duplication and stretch 
limited resources.
    Through diligence, outreach, community education and 
involvement of elected leaders from the various governmental 
entities, the workgroup now includes all 41 departments of the 
Menominee Tribal Government, Menominee County Human Services; 
the Menominee Indian School District and the College of 
Menominee Nation.
    The expansion of Trauma Informed Service Delivery across 
Menominee Community had led to extensive organizational and 
institutional changes that are showing growing success for our 
people. Some of these changes are evidenced by the following:
    1. Menominee Indian School District--The Menominee Indian 
School District has made many organizational changes aimed at 
increasing the student's ability to self-identify and obtain 
assistance to regulate emotions in order to increase function 
and learning ability. Staff at all learning facilitates have 
been trained in Adverse Childhood Experiences, Trauma and 
Regulation. Beginning with the youngest learners, the District 
has removed the stigma of disciplinary action and created the 
morning mood check, the ``Sakom Room'' and Calm down boxes that 
allow the student who is disregulated the opportunity to 
restore balance in a safe setting before returning to the 
learning environment. The District also provides for student 
physical and mental health at each facility and instituted the 
Screening, Brief Intervention, Referral Treatment (SBIRT) 
program for students with substance concerns. Finally, the 
District provides graduation coaches for all High School 
seniors. These interventions have led to a dramatic increase in 
high school graduation rates from 60 percent person in 2007 to 
nearly 99 percent percent in 2014.
    2. Menominee Tribal Head Start Program--At the Menominee 
Tribal Head Start all staff has completed the Head Start Trauma 
Smart Training and each facility has trained trauma coaches and 
family coaches. This aids in early recognition and intervention 
strategies benefiting our youngest learners and their families. 
In the coming academic year, families will have the opportunity 
to participate in the 10 module training.
    3. Menominee Tribal Clinic--The integration of Trauma 
Informed Care and Adverse Childhood Experiences (ACES) survey 
has redesigned and changed operations in order to better assist 
patients, family and service providers by completely 
integrating services available. Noticing a problem of the high 
absenteeism, the Tribal Clinic redesigned the system by 
deviating from traditional appointment scheduling and offered 
same-day appointments, which was shown a dramatic decrease in 
absenteeism rates. By changing policies and procedures, the 
clinic has increased access to medical, dental, and mental 
health care to many individuals. The clinic has trained all 
staff on Trauma Informed Care; each patient is regularly 
screened for trauma in both the behavioral health and medical 
departments. The Tribal Clinic also has 4 full-time counselors 
trained in trauma interventions. These counselors rotate 
through the student health center at the Menominee Indian High 
School. The Tribal Clinic has also been accepted to start a 
Learning Collaborative in September 2016, to begin the 
accreditation process for pre and post PhD Psychology Interns.
    4. Menominee County Health and Human Services--The 
Menominee County Health & Human Services has trained all staff 
on Trauma Informed Care approaches. They have also started the 
Alternative Response, which focuses on providing less 
intimidating approaches to working with families.
    5. Community Education Initiative--The Community Education 
Initiative serves to provide the foundation for the Fostering 
Futures Initiative by providing awareness, information, and 
outreach to the Community and Service Providers on the 
principles of Trauma Informed Care and the relationship to 
historical trauma, brain development, Adverse Childhood 
Experiences, Secondary Trauma, and Resiliency. We have 2 Master 
Trainers working in the Community who have completed the 
Wisconsin Adverse Childhood Experience Training. Educational 
opportunities are offered to the community on a quarterly basis 
and to agencies upon request. This education is also offered to 
our families participating in the Temporary Assistance for 
Needy Families Program.
    What is Resilience? Resilience is the ability to adapt well 
over time to life-changing situations and stressful conditions. 
While many things contribute to resilience, studies show that 
caring and supportive relationships can help enhance 
resilience. Factors associated with resilience include, but are 
not limited to: (1) the ability to make and implement realistic 
plans; (2) A positive and confident outlook; (3) the ability to 
communicate and solve problems.
    We have recognized that while it is important to understand 
how and why traumatic experiences influence the person over 
their lifetime, we also know that it is equally important to 
understand and provide a foundation to overcome those traumatic 
experiences through education, awareness and support. The 
Community Collaboration has provided all agencies that work 
with children and families with consistent resiliency materials 
from the Children's Resiliency Initiative or also known as 
Resilience Trumps ACES.
    In October 2015, the Menominee Indian Tribe, Menominee 
County, and Menominee Indian School District were recognized as 
1 of 8 communities to receive the Robert Wood Johnson Culture 
of Health Award for our innovative efforts to help our 
community lead healthier lives. The Tribe has been featured in 
the SAMSHA Spotlight and we continue to receive requests from 
other Communities for our presentation delivery of Trauma 
Informed Care.
    Trauma Informed Care requires removal of silos created by 
limited resources with narrow guidelines and dated beliefs in 
service delivery to achieve outcomes based on mutual 
collaboration of resources for all community partners, 
providers, and individuals. To achieve that end, I am here 
today on behalf of the Menominee Community Collaboration to not 
only demonstrate the growing success of this concept, but to 
also ask the United States Senate Committee on Indian Affairs 
to assist and support Indian Country in this endeavor. We are 
asking that you recommend to Congress to appropriate funding 
for Native American need-specific interventions that include 
the ability for Tribes and organizations to pool goal-specific 
funding across federal agencies to progress our intervention 
goals. We are also asking that Tribes and partnering 
organizations have the ability to pool federal funds from any 
agency that were for the purpose of addressing some aspect of 
the problems facing that community.
    Fortunately, such provisions have already been created 
within the 2014 Consolidated Appropriations Act, titled the 
Performance Partnership for Disconnected Youth. This piece of 
legislation addresses siloing of Federal Programs by 
authorizing ten pilot projects under which states, cities, and 
tribes would be permitted to pool grant funds from any agency 
that were for the purpose of addressing some aspect of the 
problems facing disconnected youth. It directs OMB to designate 
a lead agency to manage the pooled grants. It also empowers 
each Secretary to waive any statute or regulations that will 
increase the efficiency of the program or increase access by 
the target population, so long as the waiver is consistent with 
the overall purposes of the program.
    [The prepared statement of Ms. Warrington follows:]

  Prepared Statement of Hon. Myrna Warrington, Chairwoman, Health and 
         Family Committee, Menominee Indian Tribe of Wisconsin
I. Introduction
    Posoh (Hello in my Menominee Language) Senator Heitkamp, Senator 
Hoeven, and members of the Committee, my name is Myrna Warrington. This 
is my 8th year serving as on the Menominee Tribal Legislature and at 
this time I serve on the Menominee Indian Tribe's Executive Team as the 
Secretary. Thank you for the opportunity to provide the Committee with 
the Menominee statement that addresses the trauma and mental health 
challenges experienced in Indian Country.
    The Menominee Indian Tribe is located in northeast Wisconsin, 
within our ancestral territory. Our Reservation is comprised of 234,000 
acres of land; bountiful in rivers, lakes, streams, wildlife, and 
forest land. Roughly 90 percent of the land held in trust for the Tribe 
is held in sustained yield for the Tribe's longstanding practice in 
Sustainable Forest Management. The Tribal membership includes over 
9,000 enrolled members.
    The Tribes history is mired in trauma due to the loss of Tribal 
status, identity, language and culture that was forced on our people by 
the Federal Government through overarching assimilation objectives, 
enactments of federal Indian policy, treaties, and judicial rulings. 
The negative remnants of trauma experienced from the treaty era, 
Boarding School Era, Menominee Termination Act of 1954, Federal 
Relocation Act of 1956, and finally the Restoration of the Menominee 
Indian Tribe to Federal Recognition in 1973, remain visible in the 
lives of our Tribal members. Throughout the last two centuries, the 
Menominee endured the large loss of ancestral territory, near 
extinction of Menominee language, and the loss of many critical 
cultural and religious beliefs, practices and communal values that 
guided the traditional Menominee society. Our oral history and the 
historical record remain to help guide the Tribe in the right direction 
to address the impacts from these experiences.
    In 2006, the Menominee Tribal Government, Menominee Indian School 
District, and Menominee Tribal Clinic, who, because of limited 
resources with narrow guidelines, broke down the silos to form the 
community collaboration. The Menominee Community Collaboration 
committed to creating data-driven solutions. The purpose was aimed at 
addressing the cumulative impacts that historical and intergenerational 
trauma were presenting upon the families of the Menominee Community. 
The initial identification process began with defining the negative 
behavioral, health, and educational problems that were manifesting in 
the lives of the Menominee youth. The community collaboration research 
led to the premise that the symptoms of poverty, low academic 
achievement, and poor health outcomes and factors were interconnected. 
Through this process, the Tribe was forced to confront the reality that 
the negative changes occurring within the youth population were a 
direct result of the changing family dynamic and community structure 
that were symptoms of a larger problem. These issues had not manifested 
overnight and were not isolated to just one event, but rather were 
symptoms resulting from trauma experienced throughout the course of the 
Tribes history.
    What is trauma informed care? Trauma Informed Care is defined as 
``an organizational structure and treatment framework that involves 
understanding, recognizing, and responding to the effects of all types 
of trauma. Trauma informed care also emphasizes physical, psychological 
and emotional safety for both consumers and providers, and helps 
survivors rebuild a sense of control and empowerment'' (Trauma Informed 
Care Project, 2016). For the Menominee, the definitional scope of 
trauma was lacking any recognition of self-worth and cultural 
competency and had to be expanded to include the loss of Menominee 
language, values, and beliefs in order to accurately examine the 
collective impacts that historical and intergenerational trauma had on 
the community as a whole. By doing so, the Tribe was able to identify 
the symptoms of trauma which included suicide, poverty, substance 
abuse/addiction, identity loss, loss of societal/cultural norms, and 
many others and identify the impacts that these had on the individual, 
family unit, and community.
II. Statistics
    To accurately assess the magnitude of traumatic experiences and the 
impact these had on Menominee youth and within the family dynamic, the 
Community Collaboration examined the statistics identifying child 
victimization rates in Menominee County which included neglect, abuse, 
suicide attempts, and alcohol and drug use/abuse. In 2013, 1,423 
children resided on the Menominee Indian Reservation. According to the 
2013 Wisconsin Department of Children & Families Annual Report to the 
Governor and Legislature, approximately 10 children in 1,000 were 
victimized by either neglect, physical, sexual or emotional abuse (p. 
71). Equally alarming was the high incidence of youth hospitalizations 
for AODA and self-harm. For example, in 2015, there were 10 youth 
hospitalizations for emergency detention alone. From January through 
June 2016, there have already been a total of 14 emergency detention 
hospitalizations, 11 youth hospitalized, and 8 out of 11 youth 
hospitalized reported substance abuse and/or tested positive for 
alcohol or drugs at the time of admission. Statistics such as these are 
what initiated what is now known as the Menominee Fostering Futures 
Pilot Project that began in 2013.
III. Menominee Problem Identification & Solutions
    Based on the statistics identifying the high incidence of traumatic 
experiences for tribal children, the Community Collaboration identified 
that existing policies, procedures, and mandates were not working. 
Menominee children and families were continuing to suffer. The County/
Tribe was continually ranked 72 out of 72 for health outcomes and 
factors by the University of Wisconsin Population Health Institute. 
Educational Attainment was at an all-time low among high school 
students. The Menominee Indian School District was in fact, coined a 
``drop-out factory'' due to the extremely low percentage of students 
graduating. Finally, crime, victimization, and death rates remained 
high.
IV. Menominee Model Making the Difference
    The Community Collaborative Workgroup started by building a 
Menominee Model using the ``Bridges Out of Poverty'' framework--which 
was a model for economic and social change, sustainability and 
stability. The simple premise of the Community Collaboration Workgroup 
identified that the causes of poverty, low academic achievement and 
poor health are inter-connected and formulated that the resources and 
responses the Community Collaboration would develop to combat them must 
also be inter-connected. This Community Collaborative workgroup vision 
of the Menominee Model evolved over time, which included the 
introduction and development of the Menominee Fostering Futures 
Initiative.
    The goal of Fostering Futures was designed to improve the lives of 
children and families by translating the knowledge gained from the 
Adverse Childhood Experience Study, neuroscientific information, and 
mental health literature on the long-term effects of chronic adversity 
and trauma in childhood. As a part of our Fostering Futures work, we 
had to pick 2 areas of concentration for our community. We chose the 
following:

        1.  Providing Adverse Childhood Experience Study and Trauma 
        Informed Care education; and

        2.  Evaluating and modifying policies and procedures to be 
        congruent with the Adverse Childhood Experience study and 
        Trauma Informed Care.

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

   Education Summits focused on Historical Trauma due to 
        boarding schools and termination;

   The implementation of the Fostering Futures Program 
        reservation wide promoting community awareness of Adverse 
        Childhood Experiences (ACEs) and Trauma Informed Care (TIC).

    Trauma Informed Service Delivery is a key component and focus of 
the Community Engagement Workgroup. The Community Engagement meetings 
focus on the development, execution and completion of 90-day plans 
developed and reported quarterly on issues established by the workgroup 
that now involve all community service providers. The Tribe's programs 
are implementing Trauma Informed Services by:

   Reviewing internal policies and practices with an awareness 
        of Trauma Informed Care; Continuing the Fostering Future 
        Initiatives aimed at awareness of Trauma Informed Care, Adverse 
        Childhood Experiences and sustainability;

   Development of an AODA specific strategic plan to focus 
        community efforts in areas of most critical need;

   Using the Community Engagement Initiative to re-design the 
        service delivery systems of government to ensure they are 
        client focused and Trauma Informed;

   Working to develop functions that: document processes being 
        employed so that they can be cataloged and replicated; 
        establishing a sustainable community-wide data collection and 
        analysis function to measure results and guide decision-making; 
        and

   Requiring continuous collaboration among service providers 
        when new grants or other initiatives are begun to eliminate 
        duplication and stretch limited resources.

    Through diligence, outreach, community education and involvement of 
elected leaders from the various governmental entities, the workgroup 
now includes all 41 departments of the Menominee Tribal Government, 
Menominee County Human Services; the Menominee Indian School District 
and the College of Menominee Nation.
    The expansion of Trauma Informed Service Delivery across Menominee 
Community had led to extensive organizational and institutional changes 
that are showing growing success for our people. Some of these changes 
are evidenced by the following:
Menominee Indian School District
    The Menominee Indian School District has made many organizational 
changes aimed at increasing the student's ability to self-identify and 
obtain assistance to regulate emotions in order to increase function 
and learning ability. Staff at all learning facilitates have been 
trained in Adverse Childhood Experiences, Trauma and Regulation. 
Beginning with the youngest learners, the District has removed the 
stigma of disciplinary action and created the morning mood check, the 
``Sakom Room'' and Calm down boxes that allow the student who is 
dysregulated the opportunity to restore balance in a safe setting 
before returning to the learning environment. The District also 
provides for student physical and mental health at each facility and 
instituted the Screening, Brief Intervention, Referral Treatment 
(SBIRT) program for students with substance concerns. Finally, the 
District provides graduation coaches for all High School seniors. These 
interventions have led to a dramatic increase in high school graduation 
rates from 60 percent person in 2007 to nearly 99 percent percent in 
2014.
2. Menominee Tribal Head Start Program
    At the Menominee Tribal Head Start all staff has completed the Head 
Start Trauma Smart Training and each facility has trained trauma 
coaches and family coaches. This aids in early recognition and 
intervention strategies benefitting our youngest learners and their 
families. In the coming academic year, families will have the 
opportunity to participate in the 10 module training.
3. Menominee Tribal Clinic
    The integration of Trauma Informed Care and Adverse Childhood 
Experiences (ACES) survey has redesigned and changed operations in 
order to better assist patients, family and service providers by 
completely integrating services available. Noticing a problem of the 
high absenteeism, the Tribal Clinic redesigned the system by deviating 
from traditional appointment scheduling and offered same-day 
appointments, which was shown a dramatic decrease in absenteeism rates. 
By changing policies and procedures, the clinic has increased access to 
medical, dental, and mental health care to many individuals. The clinic 
has trained all staff on Trauma Informed Care; each patient is 
regularly screened for trauma in both the behavioral health and medical 
departments. The Tribal Clinic also has 4 full-time counselors trained 
in trauma interventions. These counselors rotate through the student 
health center at the Menominee Indian High School. The Tribal Clinic 
has also been accepted to start a Learning Collaborative in September 
2016, to begin the accreditation process for pre and post PhD 
Psychology Interns.
4. Menominee County Health & Human Services
    The Menominee County Health & Human Services has trained all staff 
on Trauma Informed Care approaches. They have also started the 
Alternative Response, which focuses on providing less intimidating 
approaches to working with families.
5. Community Education Initiative
    The Community Education Initiative serves to provide the foundation 
for the Fostering Futures Initiative by providing awareness, 
information, and outreach to the Community and Service Providers on the 
principles of Trauma Informed Care and the relationship to historical 
trauma, brain development, Adverse Childhood Experiences, Secondary 
Trauma, and Resiliency. We have 2 Master Trainers working in the 
Community who have completed the Wisconsin Adverse Childhood Experience 
Training. Educational opportunities are offered to the community on a 
quarterly basis and to agencies upon request. This education is also 
offered to our families participating in the Temporary Assistance for 
Needy Families Program.
V. Resilience
    What is Resilience? Resilience is the ability to adapt well over 
time to life-changing situations and stressful conditions. While many 
things contribute to resilience, studies show that caring and 
supportive relationships can help enhance resilience. Factors 
associated with resilience include, but are not limited to: (1) the 
ability to make and implement realistic plans; (2) A positive and 
confident outlook; (3) the ability to communicate and solve problems. 
(DS Bigfoot, 2015).
    We have recognized that while it is important to understand how and 
why traumatic experiences influence the person over their lifetime, we 
also know that it is equally important to understand and provide a 
foundation to overcome those traumatic experiences through education, 
awareness and support. The Community Collaboration has provided all 
agencies that work with children and families with consistent 
resiliency materials from the Children's Resiliency Initiative or also 
known as Resilience Trumps ACES.
    In October 2015, the Menominee Indian Tribe, Menominee County, and 
Menominee Indian School District were recognized as 1 of 8 communities 
to receive the Robert Wood Johnson ``Culture of Health'' Award for our 
innovative efforts to help our community lead healthier lives. The 
Tribe has been featured in the SAMSHA Spotlight and we continue to 
receive requests from other Communities for our presentation delivery 
of Trauma Informed Care.
VI. Tribal Ask
    Trauma Informed Care requires removal of silos created by limited 
resources with narrow guidelines and dated beliefs in service delivery 
to achieve outcomes based on mutual collaboration of resources for all 
community partners, providers, and individuals. To achieve that end, I 
am here today on behalf of the Menominee Community Collaboration to not 
only demonstrate the growing success of this concept, but to also ask 
the United States Senate Committee on Indian Affairs to assist and 
support Indian Country in this endeavor. We are asking that you 
recommend to Congress to appropriate funding for Native American need-
specific interventions that include the ability for Tribes and 
organizations to pool goal-specific funding across federal agencies to 
progress our intervention goals. We are also asking that Tribes and 
partnering organizations have the ability to pool federal funds from 
any agency that were for the purpose of addressing some aspect of the 
problems facing that community.
    Fortunately, such provisions have already been created within the 
2014 Consolidated Appropriations Act, titled the ``Performance 
Partnership for Disconnected Youth.'' This piece of legislation 
addresses siloing of Federal Programs by authorizing ten pilot projects 
under which states, cities, and tribes would be permitted to pool grant 
funds from any agency that were for the purpose of addressing some 
aspect of the problems facing disconnected youth. It directs OMB to 
designate a lead agency to manage the pooled grants. It also empowers 
each Secretary to waive any statute or regulations that will increase 
the efficiency of the program or increase access by the target 
population, so long as the waiver is consistent with the overall 
purposes of the program.

    Senator Heitkamp. Thank you. And I know we'll have an 
opportunity to expand on our testimony during our questions. 
Next we're going to hear from Dr. Kathryn Eagle-Williams. Dr. 
Eagle-Williams, it's good to see you again. Thank you for your 
committed effort holistically on what you do as a health care 
provider.

STATEMENT OF KATHRYN R. EAGLE-WILLIAMS, M.D., CEO/QUALITY CARE 
DIRECTOR, ELBOWOODS MEMORIAL HEALTH CENTER, MANDAN, HIDATSA AND 
                         ARIKARA NATION

    Dr. Eagle-Williams. My name is Dr. Kathryn Eagle-Williams 
(Red Cedar Women) I am the Chief Executive Officer of Elbowoods 
Memorial Center of the Three Affiliated Tribes and an enrolled 
member of the Arikara. First of all, I would like to thank for 
your interest in addressing trauma and mental health challenges 
in Indian Country and in particular in North Dakota. I am going 
to start by informing the committee that I am a survivor of 
suicide. On September 7, 2011 I lost my daughter to depression. 
She died by way of hanging. As a result of her death we have an 
entire immediate family of approximately 50 plus individuals 
affected by her death, and an even large number of extended 
family and community members. She died in Tucson, Arizona where 
we made our home. Within 7 months of her death I moved home to 
North Dakota and this is where my healing process began. 
Although, we were in Arizona at the time the picture is still 
the same. In general, access to basic health services is 
limited as is funding and expertise in working with Native 
American populations in regard to mental health and trauma. 
Access to mental health services is more limited due to lack of 
mental health providers, programs, and funding.
    As health care providers in behavioral health we are aware 
of the fact that adverse child experiences contribute 
significantly to the health outcomes of any individual within a 
population, but must be mindful of the disparities within our 
Native American populations.
    Based on the latest statistics from 2009-2013 the suicide 
rate among AIAN was the highest in the United States, 34.3 
deaths per 100,000 for men and 9.9 deaths per 100,000 for 
women. AIAN males are twice as likely to complete suicide 
compared to other gender, racial and ethnic subgroups. Suicide 
is the 2nd leading cause of death for AIAN persons age 15-24 
and 4x the national average.
    Losing a child to depression is my story, but we all know 
there are many more stories of our men, women, and children who 
are suffering and have died from mental illness. We as Native 
people have heard the stories of our historical trauma and are 
still suffering from not only those traumas that affected our 
ancestors, but also the traumas that are a daily occurrence on 
our reservations and among our family and community members. We 
are still trying to overcome the Garrison Dam experience, we 
have a few elders still living who actually recall life before 
the dam and who remember a life that was much happier with few 
social and health issues and who recall the devastation of 
having to move from the bottom lands to higher ground.
    Through my personal journey with the help of friends, 
colleagues, and my tribe have been able to work on healing and 
for that I am grateful. Much my healing experience did not come 
from sitting in a counselors office, but from the support of my 
community and spiritual leaders. Our work in the area of health 
and wellness is has only begun, we need mental health first 
responders or behavioral health technicians to help with sudden 
unexpected deaths and trauma such as domestic violence and 
sexual assaults; we need grief counselors, and must 
destigmatize mental illness.
    In order to begin to heal a community we must first 
identify and recognized the trauma before we deal with it. Our 
people are living in crisis situations as I once was and are 
simply just trying to survive. At Elbowoods Memorial Health 
Center we are fully aware of the need for and protective 
factors associated with traditional medicine, but it seems as 
though the federal and state governments have not recognized 
the importance of spirituality and identity, which limits our 
ability to create programs that are meaningful and successful. 
We would like to see more of an investment into these 
modalities of therapy and health practices. We would like to 
offer these practices here with the possible consideration of 
medical reimbursement.
    Today I would like to share with some of what we experience 
on the Fort Berthold Reservation otherwise known as the Three 
Affiliated Tribes.
    The core of our challenges are as follows: (1) Limited 
access to services as a result of underfunding, criteria 
requirements, and licensure required for clinicians (locally), 
and lack of availability regionally. (2) Lack of access to 
hospital beds required for acute care and life threatening 
mental health conditions. (3) Lack of a plan to transport 
emergency life threatening mental health conditions requiring 
ambulance verse civil transports to the accepting hospitals. 
(4) Limited human resources and expertise: inability to staff 
our already under funded behavioral health programs. (5) Lack 
of funding, funding is often competitive and requires data that 
is often not available or scattered. (6) Lack of culturally 
sensitive trauma informed care models and training. (7) Limited 
resources in regard to prevention and intervention programs 
associated with suicide and mental and brain health. (8) Stigma 
associated with mental illness. (9) Social determinates of 
mental health. (10) Need of mental health first responders 
program to be established reservation wide.
    So, the question is how do we address these core 
challenges? First of all, it is through support of our 
leadership, tribal, state, and federal that we can begin to 
impact the disparities. Secondly, we must educate and inform 
our policy maker and funding agencies the importance of working 
with Tribes and understanding the true demand may not always be 
established through data as we may not have access to 
meaningful data. Finally, the continuation of tribal 
consultation is a necessity initially and throughout the 
process of planning and development of programs.
    With that being said we are appreciative of the state's 
respect and consideration to ask for tribal consultation and 
would like to be an integral part of a state wide plan to the 
development of realistic services and training that are not 
only on paper, but are being implemented throughout the great 
plains. Dr. Monica Taylor-Desir, Chief Medical Officer for 
Elbwoods Memorial Health Center, who we are very fortune to 
have, has reviewed the ND suicide prevention plan. Dr. Taylor 
Desir has identified the plan includes working with Native 
Americans but there is no evidence in the last 6 months of the 
enactment of that plan in particular with our tribes. We need 
action not just words. We need support to educate and train our 
own people to help address the lack of human resources and 
access.
    We need help in addressing the social determinants of 
mental health which include the following: discrimination and 
social exclusion; adverse childhood experiences; poor 
education, unemployment, underemployment, job insecurity; 
income inequality, poverty and neighborhood deprivation; food 
insecurity; poor housing quality and housing instability; poor 
access to mental health care.
    It is our recommendation that when working with Native 
American people we must work from a strength based approach. It 
must be recognized that our cultural traditional ways of life 
and living are important protective factors in regard with 
mental, spiritual wellbeing of our people. We must destigmatize 
mental illness and focus on brain health and wellness. We must 
incorporating cultural practices into approved grants and other 
funding opportunities. We must promote commitment to cultural 
spirituality as well as promote strengthening of family ties 
and relationships. Incorporating, traditional spirituality and 
wellness must be recognized as a best practice. And in order to 
get at the heart of mental health we must incorporate trauma 
informed care while addressing addictions. We must not 
criminalize the addict or the broken spirit.
    As I conclude I would once again like to say thank you for 
your interest and consideration as we attempt to meet the 
health needs of our people. In writing this testimony I am 
honored and humbled to share my story which is an experience I 
unfortunately share with far too many of my people.
    [The prepared statement of Dr. Eagle-Williams follows:]

Prepared Statement of Kathryn R. Eagle-Williams, M.D., CEO/Quality Care 
Director, Elbowoods Memorial Health Center, Mandan, Hidatsa and Arikara 
                                 Nation
    My name is Dr. Kathryn Eagle-Williams (Red Cedar Women) I am the 
Chief Executive Officer of Elbowoods Memorial Center of the Three 
Affiliated Tribes and an enrolled member of the Arikara. First of all, 
I would like to thank for your interest in addressing trauma and mental 
health challenges in Indian Country and in particular in North Dakota. 
I am going to start by informing the committee that I am a survivor of 
suicide. On September 7, 2011 I lost my daughter to depression. She 
died by way of hanging. As a result of her death we have an entire 
immediate family of approximately 50 plus individuals affect by her 
death, and an even large number of extended family and community 
members. She died in Tucson, Arizona where we made our home. Within 7 
months of her death I moved home to North Dakota and this is where my 
healing process began. Although, we were in Arizona at the time the 
picture is still the same. In general, access to basic health services 
is limited as is funding and expertise in working with Native American 
populations in regard to mental health and trauma. Access to mental 
health services is more limited due to lack of mental health providers, 
programs, and funding.
    As health care providers in behavioral health we are aware of the 
fact that adverse child experiences contribute significantly to the 
health outcomes of any individual within a population, but must be 
mindful of the disparities within our Native American populations.
    Based on the latest statistics from 2009-2013 the suicide rate 
among AIAN was the highest in the United States.

   34.3 deaths per 100,000 for men

   9.9 deaths per 100,000 for women

   AIAN males are twice as likely to complete suicide compared 
        to other gender, racial and ethnic subgroups

   Suicide is the 2nd leading cause of death for AIAN persons 
        age 15-24 and 4x the national average

    Losing a child to depression is my story, but we all know there are 
many more stories of our men, women, and children who are suffering and 
have died from mental illness. We as Native have heard the stories of 
our historical trauma and are still suffering from not only those 
traumas that affected our ancestors, but also the traumas that are a 
daily occurrence on our reservations and among our family and community 
members. We are still trying to overcome the Garrison Dam experience, 
we have a few elders still living who actually recall life before the 
dam and who remember a life that was much happier with few social and 
health issues and who recall the devastation of having to move from the 
bottom lands to higher ground.
    Through my personal journey with the help of friends, collages, and 
my tribe have been able to work on healing and for that I am grateful. 
Much my healing experience did not come from sitting in a counselors 
office, but from the support of my community and spiritual leaders. Our 
work in the area of health and wellness work is has only begun, we need 
mental health first responders or behavioral health technicians to help 
with sudden unexpected deaths and trauma such as domestic violence and 
sexual assaults; we need grief counselors, and must destigmatize mental 
illness.
    In order to begin to heal a community we must first identify and 
recognized the trauma before we deal with it. Our people are living in 
crisis situations as I once was and are simply just trying to survive. 
At Elbowoods Memorial Health Center we are fully aware of the need for 
and protective factors associated with traditional medicine, but it 
seems as though the federal and state governments have not recognized 
the importance of spirituality and identity, which limits are ability 
to create programs that are meaningful and successful. We would like to 
see more of an investment into these modalities of therapy and health 
practices. We would like to offer these practices here with the 
possible consideration of medical reimbursement.
    Today I would like to share with some of what we experience on the 
Fort Berthold Reservation otherwise known as the Three Affiliated 
Tribes.
    The core of our challenges are as follows:

        1.  Limited access to services as a result of underfunding, 
        criteria requirements, and licensure required for clinicians 
        (locally), and lack of availability regionally.

        2.  Lack of access to hospital beds required for acute care and 
        life threatening mental health conditions.

        3.  Lack of a plan to transport emergency life threating mental 
        health conditions requiring ambulance verse civil transports to 
        the accepting hospitals.

        4.  Limited human resources and expertise: inability to staff 
        our already under funded behavioral health programs.

        5.  Lack of funding, funding is often competitive and requires 
        data that is often not available or scattered.

        6.  Lack of culturally sensitive trauma informed care models 
        and training.

        7.  Limited resources in regard to prevention and intervention 
        programs associated with suicide and mental ``brain'' health.

        8.  Stigma associated with mental illness

        9.  Social determinates of mental health

        10.  Need of mental health first responders program to be 
        established reservation wide

    So, the question is how do we address these core challenges? First 
of all, it is through support of our leadership, tribal, state, and 
federal that we can begin to impact the disparities. Secondly, we must 
educate and inform our policy maker and funding agencies the importance 
of working with tribes and understanding the true demand may not always 
be established through data as we may not have access to meaningful 
data. Finally, the continuation of tribal consultation is a necessity 
initially and throughout the process of planning and development of 
programs.
    With that being said we are appreciative of the state's respect and 
consideration to ask for tribal consultation and would like to be an 
integral part of a state wide plan to the development of realistic 
services and training that are not only on paper, but are being 
implemented throughout the great plains. Dr. Monica Taylor-Desir, Chief 
Medical Officer for Elbwoods Memorial Health Center, who we are very 
fortune to have, has reviewed the ND suicide prevention plan. Dr. 
Taylor-Desir has identified the plan includes working with Native 
Americans but there is no evidence in the last 6 months of the 
enactment of that plan in particular with our tribes. We need action 
not just words. We need support to educate and train our own people to 
help address the lack of human resources and access.
    We need help in addressing the social determinants of mental health 
which include the following:

   Discrimination and social exclusion
   Adverse childhood experiences
   Poor education
   Unemployment, underemployment, job insecurity
   Income inequality, poverty and neighborhood deprivation
   Food insecurity
   Poor housing quality and housing instability
   Poor access to mental health care

    It is our recommendation that when working with Native American 
people we must work from a strength based approach. It must be 
recognized that our cultural traditional ways of life and living are 
important protective factors in regard with mental, spiritual wellbeing 
of our people. We must destigmatize mental illness and focus on brain 
health and wellness. We must incorporating cultural practices into 
approved grants and other funding opportunities. We must promote 
commitment to cultural spirituality as well as promote strengthening of 
family ties and relationships. Incorporating, traditional spirituality 
and wellness must be recognized as a best practice. And in order to get 
at the heart of mental health we must incorporate trauma informed care 
while addressing addictions. We must not criminalize the addict or the 
broken spirit.
    As I conclude I would once again like to say thank you for your 
interest and consideration as we attempt to meet the health needs of 
our people. In writing this testimony I am honored and humbled to share 
my story which is an experience I unfortunately share with far too many 
of my people.
    Below you will find more information that has been gathered by our 
Behavioral Health Director, Dr. Lisa Keller-Schafer, a trained 
psychologist.
Behavioral Health (BH) Obstacles for NA residing on and off Fort 
        Berthold reservation
    1. Access to mental health services is severely limited for those 
living on and off the reservation due to:

           a. Lack of insurance

           i. 33 percent reported not having insurance compared to 11 
        percent of Whites; with 46 percent reported they could not 
        afford the cost of healthcare

           ii. 57 percent rely on IHS for care

        b. Lack of tribal funding

           i. Due to changes in budgeting and outside payee sources 
        many programs' funding has been cut--some--including behavioral 
        health, up to 50%

        c. Lack of transportation

           i. Of those who own a car, most cannot afford to fix minor 
        repairs, pay for gas, or general upkeep.

           ii. Others rely on relatives/friends to transport them, 
        which often is money paid out of their pocket. An elderly lady 
        reported having to pay $100 to her relative for each trip she 
        took to a store

        d. Lack of providers

           i. currently Fort Berthold has one provider to cover the 
        entire reservation

           ii. of those who apply for counseling positions, most are 
        underqualified or not licensed

           iii. the only recruiting incentive is student loan repayment 
        programs for those who are licensed

           iv. In regards to reasons tribal members do not seek BH 
        services: 39 percent of tribal members reported a lack of 
        providers and 48 percent reported limited clinic hours kept 
        them from seeking mental health services; another 40 percent 
        did not trust their information would not be kept confidential

        e. High poverty rates

           i. The percentage of the reservation population with income 
        below the poverty level is at 23.1 percent. In comparison, this 
        is more than double the average North Dakota poverty rate of 
        11.2 percent and is higher than the U.S. rate of 15.9 percent. 
        In respect to children, the situation is worse, with 31.6 
        percent of the reservation population under the age of 18 
        living below the poverty line compared to 13.2 percent in North 
        Dakota and 22.6 percent in the U.S. overall

        f. Emergency Service Barriers

           i. 78 percent of tribal members report there are no 
        emergency services available in their area

           ii. ambulance drivers can refuse to transport individuals 
        presenting with psychosis or a danger to others claiming they 
        are at greater risk of harm because those individuals are 
        violent--WHICH is a myth

           iii. there are no police transports for individuals 
        presenting with severe mental illness--even those with 
        homicidal and suicidal ideations due to boundary issues--
        basically TAT police are required to place criminal charges on 
        individuals who they transport. This means for clients 
        presenting with mental illness, they would have to be 
        criminally charged before police can transport. AND even if 
        police could transport they could only bring a client to the 
        reservation line and then another police officer from the next 
        county would need to take the client from there. AND the client 
        would not be escorted to a hospital ED, but instead because 
        criminal charges were placed on that client--the client would 
        go to jail until his/her hearing.

           iv. There is no clean-cut civil commitment on the 
        reservation. Family and friends who are attempting to get their 
        loved ones help and the loved one is over 18 years must 
        complete affidavits indicating why the loved one is a danger to 
        the self or others. This goes to the judge who decides if the 
        individual should be detained--but that is if the loved one can 
        be easily found--given the PD are also understaffed.

        g. Lack of awareness about mental health issues and services 
        AND Stigma

           i. Many elderly believe talking about mental health issues 
        such as suicide will make things worse

           ii. Approximately 78 percent of all individuals presenting 
        for mental health services have reported a dislike of 
        psychotropic medications, but have used licit and illicit 
        substances to relieve their symptoms

           iii. Many do not believe their information will remain 
        confidential

           iv. misguided views that people with mental health problems 
        may be more violent or unpredictable than people without such 
        problems, or somehow just ``different'', but none of these 
        beliefs has any basis in fact; Psych ward--insane asylums--
        bloodthirsty killers in straightjackets -

           v. early beliefs about the causes of mental health problems, 
        such as demonic or spirit possession, were `explanations' that 
        would almost certainly give rise to reactions of caution, fear 
        and discrimination.

           vi. Even the medical model of mental health problems is 
        itself an unwitting source of stigmatizing beliefs. First, the 
        medical model implies that mental health problems are on a par 
        with physical illnesses and may result from medical or physical 
        dysfunction in some way (when many may not be simply reducible 
        to biological or medical causes). This itself implies that 
        people with mental health problems are in some way `different' 
        from `normally' functioning individuals. Secondly, the medical 
        model implies diagnosis, and diagnosis implies a label that is 
        applied to a `patient'. That label may well be associated with 
        undesirable attributes (e.g. `mad' people cannot function 
        properly in society, or can sometimes be violent), and this 
        again will perpetuate the view that people with mental health 
        problems are different and should be treated with caution.

           vii. stigma directed at adolescents with mental health 
        problems came from family members, peers, and teachers.

           viii. stigma perpetrated by teachers and school staff, who 
        expressed fear, dislike, avoidance, and under-estimation of 
        abilities

           ix. Mental health stigma is even widespread in the medical 
        profession, at least in part because it is given a low priority 
        during the training of physicians and GPs

        h. Limited services available on the reservation

           i. There is no speech or occupational services--46 percent 
        have requested these services

           ii. There are no pain clinics--41 percent have requested 
        these services--these services are essential for those using 
        opiates to mask mental illness

           iii. No alternative care such as massage, acupuncture--35 
        percent have requested these services

           iv. There is no CT, MRI, Pet Scans

           v. There is no sleep study program, respiratory care, EEG

Consequences
    1. Suicide: There are currently no statistics for the Fort Berthold 
Reservation in regards to the number of suicides. However, the Aberdeen 
IHS office has presented the following example from other reservations 
in its' area. ``It could be argued that the senseless stabbing death of 
a young teenage girl in January 2007 by two other young teenage girls 
being egged on by a circle of peers really set the tone for the 2014 
year: one of dread and despair that led to a continuous cycle of death. 
. . of 16 other adolescents who took their own lives. In spite of 
efforts over the past 12 months to reach-out to youth and families, to 
train all community members on prevention and intervention strategies, 
to partner with state and federal agencies for an increase in services, 
these lives lost are the best indicator that there are gaps, 
inadequacies, and barriers to current service structures. As shown 
above, in the number of agencies and organizations devoting resources 
to youth, there is dedication of purpose. These purposes and efforts, 
however, have not yet led to a transformed community where the choice 
for life far outreaches the choice for death.''

    2. Serious Emotional Behavioral Disorder (SEBD) reflects an 
individual (ages 8 to 89 years) who:

        a.  Is angry, bitter, hostile, and aggressive, prone to 
        fighting and bulling, uses excessive profanity, who is 
        constantly getting into trouble, prone to steal, arson and gang 
        activity and who may act out sexually;

        b.  Appears withdrawn, upset, frustrated, pouting and sulking, 
        lazy and lethargic, confused, lacking attention, and who has 
        poor hygiene, inadequate nutritional intake, sleep disturbance, 
        and prone to lying, running away from home, self-mutilation;

        c.  Shows a lack of respect, failure to thrive, has health 
        problems and depression, is defiant, has low self-esteem, has 
        attachment issues and prone to gang participation, has poor 
        academic performance; and,

        d.  Is prone to suicidal thoughts and ideations, social phobias 
        and fear of certain people, has a false pride and demonstrates 
        grandiosity or `big head'.

    3. Methamphetamine use is increasing. The Aberdeen Area Indian 
Health Service (IHS) reported that on average Behavioral Health Units 
(Alcohol Programs as well as IHS Mental Health Programs) are seeing an 
average of 48.5 cases of confirmed methamphetamine use per month per 
site.

    4. Liver diseases are ``broken spirit'' diseases for Indian people. 
HIV and Hepatitis (HBV and HCV) affects AI/AN in ways that are not 
always apparent because of small population sizes. Of all races/
ethnicities, AI/AN had the highest percentages of diagnosed HIV and 
Hepatitis infections due to injection drug use. AI/AN face HIV and 
Hepatitis prevention challenges, including poverty, high rates of STIs, 
stigma, and lack of psychiatric care to treat predisposing mental 
illnesses.

    5. A national study on Violence Against Women reported that 
American Indian women and experience the highest rate of Domestic 
Violence in the United States, and that three-fourths of Native 
American women and children have or will experience some type of sexual 
assault in their life time; with approximately 76 percent of women 
being raped by their significant other at least one time. Although 
recent reports of violence vary and specific numbers are not known, it 
is estimated that over the past 3 years Fort Berthold shows an increase 
in the number of violence-induced injuries including 664 assaults, 60 
stabbings, and 31 possible rapes. This report is a rough estimation of 
persons seeking medical or legal intervention on and off the 
reservation.

    6. The poverty of the area has a major impact on the health and 
wellness of the people. The Aberdeen Area Indian Health Service IHS 
which provides health care to Fort Berthold, and the tribes in South 
Dakota and Iowa, has some of the most startling health statistics of 
the twelve national IHS service areas (Indian Health Service, 2007):

   The age-adjusted death rate (all causes) is more than double 
        the U.S. All Races rate, and is the second highest Area rate in 
        the Indian Health Service.

   Other Data on Mortality rates: the 2nd highest Suicide Death 
        Rate; the highest Alcoholism Death Rate; the second highest 
        Diseases of the Heart Death Rate

   The Diabetes Mellitus Death Rate is five times the U.S. All 
        Races Rate. Diabetes is the fifth leading cause of death for 
        Tribes in the Aberdeen Area (following heart disease, cancer, 
        accidents, liver disease and cirrhosis).

   The lowest Life Expectancy at Birth: 64.8 years compared to 
        75.8 years for the U.S. All Races and 71.1 years for the All 
        IHS service populations.

   The highest Years of Potential Life Lost Rate: 119.5 years/
        per 1,000 persons under the age of 65, which is 2.5 times the 
        U.S. all races total.

    Senator Heitkamp. Thank you very much, Dr. Eagle. Next we 
have Dr. DeCoteau shares some responsibility of talking about 
what more we could do to carry forward the idea and the 
knowledge about trauma. She is a leading expert throughout the 
country.

          STATEMENT OF TAMI DeCOTEAU, Ph.D., CLINICAL 
PSYCHOLOGIST, DeCOTEAU TRAUMA--INFORMED CARE AND PRACTICE, PLLC

    Dr. DeCoteau. Thank you, Senator Heitkamp. I am honored to 
be here. My name is Dr. Tami DeCoteau. I am an enrolled tribal 
member of the Mandan Hidatsa Arikara Nation and a proud 
descendant of the Turtle Mountain Chippewa. I have worked as a 
licensed clinical psychologist with an emphasis on the 
treatment of trauma disorders for more than a decade. In 
addition to maintaining a busy patient caseload, I own a 
Bismarck-based private practice that employs 6 mental health 
workers who are uniquely trained in the application of trauma-
specific interventions for adults, children and families. Thank 
you for holding this hearing on trauma and mental health 
challenges in Indian country and inviting me to testify.
    Senator Heitkamp, I would like to thank you for your key 
role in advancing Native American priorities, your efforts to 
improve the lives of Native American people and for 
illuminating the important but tragically overlooked issue of 
historical trauma. I would also like to thank you for drafting 
and advocating for S. 246, ``The Alyce Spotted Bear and Walter 
Soboleff Commission on Native Children.'' S. 246 is essential 
to enhancing the lives of Native children.
    I have been asked by members of the Committee to focus my 
testimony on my professional experience and my clinical 
perspective on trauma.
    I obtained a doctorate degree in Clinical Psychology in 
2003 from the University of Nebraska-Lincoln with 
specialization in the cognitive-behavioral treatment of anxiety 
disorders, which at the time encompassed trauma disorders. My 
professional practice work has focused on providing services to 
trauma-survivors. I am certified in trauma-focused cognitive 
behavioral therapy. I have received training in the 
Neurosequential Model of Therapuetics (NMT), a developmentally 
sensitive, neurobiology-informed approach to working with at-
risk children; Trust-Based Relational Intervention (TBRI), a 
therapeutic model that trains caregivers to provide effective 
support for at-risk children; and Eye Movement Desensitization 
and Reprocessing (EMDR), an intervention approach that helps 
reduce the long-lasting effects of traumatic memories.
    During my undergraduate and graduate training I received 
the honor of becoming a McNair Scholar and then an American 
Psychological Association (APA) Fellow. I also received the 
Indian Health Service 2009 Health Professional of the Year 
Award for outstanding service and the American Psychological 
Foundation 2010 Early Career Award for providing culturally 
competent practice techniques for Native Americans and for 
developing training programs in rural, underserved areas.
    My career began with the Veteran's Administration where I 
provided psychological services to traumatized Veterans. During 
my interim at the VA, Dr. Arthur McDonald (Ogala Lakota) and I 
joined forces to create psychology internship training and 
services for Native Americans. Our initial effort was funded by 
HRSA/BHP. During the 3-year grant phase we designed and 
implemented a model for training psychologists to provide 
culturally competent and relevant services in rural Native 
American communities. From this experience, evolved the 
stimulus for a much greater vision to develop reservation-based 
internship programs with unique missions to restore the 
individual and the collective sense of worth of Native American 
people by supporting the belief that the healing of Native 
Nations lies within the Nations themselves.
    The Standing Rock Psychology Internship and Post-doctoral 
Program became the flagship model of our vision. The Program 
evidenced success in recruiting and retaining psychology 
providers for rural Native American populations and 
substantially increased accessible mental health services. 
Doctorate-level trainees worked collaboratively with tribal 
health, schools, and judicial departments. In addition to the 
well over 3,000 hours of direct patient care, trainees provided 
community education, suicide prevention, and even equine 
assisted psychotherapy. One of the highlights of the Program 
was the mobile crisis response team that worked to prevent and 
reduce suicides on the reservation. The Program was a tribally-
driven initiative that provided an excellent example of Indian 
self-determination.
    Unfortunately, it is difficult to sustain mental health 
services on the reservation. Mental health providers in Indian 
Country are at a particularly high risk for burnout. We work in 
an intense and crisis-oriented environment on a day-to-day 
basis. We face an unusual array of highly-stressful conditions 
including inadequate compensation, safety issues, lack of basic 
resources such as supplies and testing materials, professional 
isolation, lack of appropriate referral and consultation 
resources, excessive time demands, and inadequate funding. In 
addition, we serve a patient population that has an 
unimaginable amount of emotional trauma and social problems. 
These conditions cause us to experience a constant state of 
physical and mental exhaustion and lead to feelings of 
depersonalization and dissatisfaction. It is no surprise that 
decreased worker effectiveness and burnout are common among 
mental health professional in rural Indian Country.
    While my heart still resides in working on Indian 
reservations, I have been drawn towards education and advocacy 
for trauma-survivors including training local teachers, 
educating congressional leaders, and serving as the president 
of Council for Native American Trauma-Informed Initiatives 
which is hosting this afternoon's Roundtable on the Causes and 
Effects of Trauma In Native American Communities.
    Thus, in 2011, I step away from my clinical work on the 
reservation and began work as a private practice and consulting 
psychologist in Bismarck, ND. In a very short amount of time my 
clinic schedule was full of patients, primarily children in 
foster care with complex developmental trauma. Whether it be 
on, or off the reservation the need for trauma-based 
psychological services in North Dakota is immense. Over the 
course of my career I have become acutely aware of the 
``culture of trauma'' that is overwhelming Indian communities 
and inhibiting the traditional ``healing culture'' practices. I 
will discuss the culture of trauma first.
    Historical trauma is the cumulative impact of historical 
losses caused by European settlers' efforts to exterminate 
Native Americans and our culture and transmitted across 
generations. The assimilation policies of the federal 
government, particularly the one that involved sending young 
Indian children to boarding schools, continue to have a 
tremendous detrimental effect on Indian people. This history 
has led to a generational pattern of trauma that perpetuates 
itself in the form of abuse, neglect, substance addiction, 
violence, mental unwellness, physical illness, and unresolved 
grief.
    Trauma by definition is an unbearable and out of control 
sensation in the body. It leaves an imprint on the mind, body 
and brain and results in reorganization of the way the mind and 
brain manage perceptions. Trauma changes what we think, how we 
think, and our very capacity to think. Traumatized people have 
trouble deciphering what is going on around them. They 
superimpose their trauma on everything. Individuals who become 
conditioned to adversity come to believe they have no control 
over their lives so they give up trying--a response referred to 
as learned helplessness. Trauma affects those who are directly 
exposed to it as well as those around them. The current 
challenges in Indian country, including difficulties with 
social-environmental, physiological and psychological 
functioning, are evidence that the trauma that occurred long 
ago continues to impact Native Americans today.
    The therapists in my practice serve hundreds of traumatized 
individuals, many of whom are Native American children. The 
gut-wrenching impact of trauma on these precious souls is 
evident in their persistent hyperarousal and hyperactivity. 
These children struggle to regulate their own emotions, attend 
to stimuli, and their capacity for learning is often greatly 
impaired. While they are desperate for love and affection, 
their persisting fear-response causes them to perceive 
everything as threatening, and they are likely to lash out at 
even the most loving caregivers. Children who have such complex 
trauma cannot become functioning members of society without 
skillful trauma-focused intervention.
    Research shows that helping trauma survivors to describe 
their trauma is helpful, but is often not enough. Since trauma 
is encoded in the mind and body, for healing to occur, mind-
body communication is needed. Scientists have discovered that 
individuals can restore their arousal system through practices 
such as mindfulness, movement, and rhythm--principles that have 
been used by Native American cultures for centuries. Although 
Native principles in healing have long been regarded as 
nonsense by modern day medicine, we now have scientific proof 
that the ability to heal ourselves and our communities lies 
within our traditional cultural practices.
    Recent scientific studies have developed some practical and 
effective interventions for trauma, and we now have a pretty 
good idea of what tribes can do to address the causes and 
effects of historical and childhood trauma. A comprehensive 
trauma-informed initiative that involves every institution on 
the reservation must be implemented. My recommendations are 
provided below.
    1. Implement Comprehensive Trauma Informed Initiatives. 
There is no one single intervention that every tribe must 
adopt. Rather, there are a number of different ones that have 
been shown to be effective for a specific area--the schools, 
the mental health program, the law enforcement system, and so 
on. Each tribe needs to select the approaches that are most 
appropriate for its values and culture. The keys are that the 
initiative must be comprehensive and the community must be 
fully educated about trauma and involved in the initiative. The 
problem is that right now there is no place a tribe can turn to 
in order to obtain technical assistance in setting up a 
comprehensive trauma-informed program. I urge Congress to 
appropriate funds to create an institute that would provide on-
going assistance to tribes that are seeking to implement a 
comprehensive trauma-informed initiative.
    2. Provide funding for the use of interns. There is a 
desperate and immediate need for increased human service 
resources in order to address childhood and historical trauma. 
Although the Standing Rock Program is no longer in operation 
its model is universally applicable and has the ability to be 
reproduced in other underserved areas. By providing funding to 
enable tribes to implement psychology intern programs that 
bring pre- and post-doctoral psychologists to reservations we 
can expand the mental health workforce in our region.
    Senator Heitkamp and honorable members of the Committee, 
childhood and historical trauma are long-standing issues that 
have detrimental effects on our Federal and State budgets, 
health, and overall well-being. Indian Country needs maximum 
mental health power to deal with the trauma. Money must be 
allocated for tribal comprehensive trauma initiatives. I thank 
you for the time and opportunity to share my perspective on 
trauma and mental health challenges in Indian Country.
    [The prepared statement of Dr. DeCoteau follows:]

  Prepared Statement of Tami DeCoteau, Ph.D., Clinical Psychologist, 
           DeCoteau Trauma--Informed Care and Practice, PLLC
    Mr. Chairman and members of the Committee, my name is Dr. Tami De 
Coteau. I am an enrolled tribal member of the Mandan Hidatsa Arikara 
Nation and a proud descendant of the Turtle Mountain Chippewa. I have 
worked as a licensed clinical psychologist with an emphasis on the 
treatment of trauma disorders for more than a decade. In addition to 
maintaining a busy patient caseload, I own a Bismarck-based private 
practice that employs 6 mental health workers who are uniquely trained 
in the application of trauma-specific interventions for adults, 
children and families. Thank you for holding this hearing on trauma and 
mental health challenges in Indian country and inviting me to testify.
    Senator Heitkamp, I would like to thank you for your key role in 
advancing Native American priorities, your efforts to improve the lives 
of Native American people and for illuminating the important but 
tragically overlooked issue of historical trauma. I would also like to 
thank you for drafting and advocating for S. 246, ``The Alyce Spotted 
Bear and Walter Soboleff Commission on Native Children.'' S. 246 is 
essential to enhancing the lives of Native children.
    I have been asked by members of the Committee to focus my testimony 
on my professional experience and my clinical perspective on trauma.
Professional Experience
    I obtained a doctorate degree in Clinical Psychology in 2003 from 
the University of Nebraska--Lincoln with specialization in the 
cognitive-behavioral treatment of anxiety disorders, which at the time 
encompassed trauma disorders. My professional practice work has focused 
on providing services to trauma-survivors. I am certified in trauma-
focused cognitive behavioral therapy. I have received training in the 
Neurosequential Model of Therapuetics (NMT; Perry), a developmentally 
sensitive, neurobiology-informed approach to working with at-risk 
children; Trust-Based Relational Intervention (TBRI; Purvis), a 
therapeutic model that trains caregivers to provide effective support 
for at-risk children; and Eye Movement Desensitization and Reprocessing 
(EMDR; Shapiro), an intervention approach that helps reduce the long-
lasting effects of traumatic memories.
    During my undergraduate and graduate training I received the honor 
of becoming a McNair Scholar and then an American Psychological 
Association (APA) Fellow. I also received the Indian Health Service 
2009 Health Professional of the Year Award for outstanding service and 
the American Psychological Foundation 2010 Early Career Award for 
providing culturally competent practice techniques for Native Americans 
and for developing training programs in rural, underserved areas.
    My career began with the Veteran's Administration where I provided 
psychological services to traumatized Veterans. During my interim at 
the VA, Dr. Arthur McDonald (Ogala Lakota) and I joined forces to 
create psychology internship training and services for Native 
Americans. Our initial effort was funded by HRSA/BHP. During the 3-year 
grant phase we designed and implemented a model for training 
psychologists to provide culturally competent and relevant services in 
rural Native American communities. From this experience, evolved the 
stimulus for a much greater vision to develop reservation-based 
internship programs with unique missions to restore the individual and 
the collective sense of worth of Native American people by supporting 
the belief that the healing of Native Nations lies within the Nations 
themselves.
    The Standing Rock Psychology Internship and Post-doctoral Program 
became the flagship model of our vision. The Program evidenced success 
in recruiting and retaining psychology providers for rural Native 
American populations and substantially increased accessible mental 
health services. Doctorate-level trainees worked collaboratively with 
tribal health, schools, and judicial departments. In addition to the 
well over 3,000 hours of direct patient care, trainees provided 
community education, suicide prevention, and even equine assisted 
psychotherapy. One of the highlights of the Program was the mobile 
crisis response team that worked to prevent and reduce suicides on the 
reservation. The Program was a tribally-driven initiative that provided 
an excellent example of Indian self-determination.
    Unfortunately, it is difficult to sustain mental health services on 
the reservation. Mental health providers in Indian Country are at a 
particularly high risk for burnout. We work in an intense and crisis-
oriented environment on a day-to-day basis. We face an unusual array of 
highly-stressful conditions including inadequate compensation, safety 
issues, lack of basic resources such as supplies and testing materials, 
professional isolation, lack of appropriate referral and consultation 
resources, excessive time demands, and inadequate funding. In addition, 
we serve a patient population that has an unimaginable amount of 
emotional trauma and social problems. These conditions cause us to 
experience a constant state of physical and mental exhaustion and lead 
to feelings of depersonalization and dissatisfaction. It is no surprise 
that decreased worker effectiveness and burnout are common among mental 
health professional in rural Indian Country.
    While my heart still resides in working on Indian reservations, I 
have been drawn towards education and advocacy for trauma-survivors 
including training local teachers, educating congressional leaders, and 
serving as the president of Council for Native American Trauma-Informed 
Initiatives which is hosting this afternoon's Roundtable on the Causes 
and Effects of Trauma In Native American Communities.
    Thus, in 2011, I step away from my clinical work on the reservation 
and began work as a private practice and consulting psychologist in 
Bismarck, ND. In a very short amount of time my clinic schedule was 
full of patients, primarily children in foster care with complex 
developmental trauma. Whether it be on, or off the reservation the need 
for trauma-based psychological services in North Dakota is immense. 
Over the course of my career I have become acutely aware of the 
``culture of trauma'' that is overwhelming Indian communities and 
inhibiting the traditional ``healing culture'' practices. I will 
discuss the culture of trauma first.
The Culture of Trauma
    Historical trauma is the cumulative impact of historical losses 
caused by European settlers' efforts to exterminate Native Americans 
and our culture and transmitted across generations. The assimilation 
policies of the federal government, particularly the one that involved 
sending young Indian children to boarding schools, continue to have a 
tremendous detrimental effect on Indian people. This history has led to 
a generational pattern of trauma that perpetuates itself in the form of 
abuse, neglect, substance addiction, violence, mental unwellness, 
physical illness, and unresolved grief.
    Trauma by definition is an unbearable and out of control sensation 
in the body. It leaves an imprint on the mind, body and brain and 
results in reorganization of the way the mind and brain manage 
perceptions. Trauma changes what we think, how we think, and our very 
capacity to think. Traumatized people have trouble deciphering what is 
going on around them. They superimpose their trauma on everything. 
Individuals who become conditioned to adversity come to believe they 
have no control over their lives so they give up trying--a response 
referred to as learned helplessness. Trauma affects those who are 
directly exposed to it as well as those around them. The current 
challenges in Indian country, including difficulties with social-
environmental, physiological and psychological functioning, are 
evidence that the trauma that occurred long ago continues to impact 
Native Americans today.
    The therapists in my practice serve hundreds of traumatized 
individuals, many of whom are Native American children. The gut-
wrenching impact of trauma on these precious souls is evident in their 
persistent hyperarousal and hyperactivity. These children struggle to 
regulate their own emotions, attend to stimuli, and their capacity for 
learning is often greatly impaired. While they are desperate for love 
and affection, their persisting fear-response causes them to perceive 
everything as threating, and they are likely to lash out at even the 
most loving caregivers. Children who have such complex trauma cannot 
become functioning members of society without skillful trauma-focused 
intervention.
The Healing Culture
    Research shows that helping trauma survivors to describe their 
trauma is helpful, but is often not enough. Since trauma is encoded in 
the mind and body, for healing to occur, mind-body communication is 
needed. Scientists have discovered that individuals can restore their 
arousal system through practices such as mindfulness, movement, and 
rhythm--principles that have been used by Native American cultures for 
centuries. Although Native principles in healing have long been 
regarded as nonsense by modern day medicine, we now have scientific 
proof that the ability to heal ourselves and our communities lies 
within our traditional cultural practices.
Recommendations
    Recent scientific studies have developed some practical and 
effective interventions for trauma, and we now have a pretty good idea 
of what tribes can do to address the causes and effects of historical 
and childhood trauma. A comprehensive trauma-informed initiative that 
involves every institution on the reservation must be implemented. My 
recommendations are provided below.

        1.  Implement Comprehensive Trauma Informed Initiatives. There 
        is no one single intervention that every tribe must adopt. 
        Rather, there are a number of different ones that have been 
        shown to be effective for a specific area--the schools, the 
        mental health program, the law enforcement system, and so on. 
        Each tribe needs to select the approaches that are most 
        appropriate for its values and culture. The keys are that the 
        initiative must be comprehensive and the community must be 
        fully educated about trauma and involved in the initiative. The 
        problem is that right now there is no place a tribe can turn to 
        in order to obtain technical assistance in setting up a 
        comprehensive trauma-informed program. I urge Congress to 
        appropriate funds to create an institute that would provide on-
        going assistance to tribes that are seeking to implement a 
        comprehensive trauma-informed initiative.

        2.  Provide funding for the use of interns. There is a 
        desperate and immediate need for increased human service 
        resources in order to address childhood and historical trauma. 
        Although the Standing Rock Program is no longer in operation 
        its model is universally applicable and has the ability to be 
        reproduced in other underserved areas. By providing funding to 
        enable tribes to implement psychology intern programs that 
        bring pre- and post-doctoral psychologists to reservations we 
        can expand the mental health workforce in our region.

Conclusion
    Mr. Chairman and honorable members of the Committee, childhood and 
historical trauma are long-standing issues that have detrimental 
effects on our Federal and State budgets, health, and overall well-
being. Indian Country needs maximum mental health power to deal with 
the trauma. Money must be allocated for tribal comprehensive trauma 
initiatives. I thank you for the time and opportunity to share my 
perspective on trauma and mental health challenges in Indian Country.

    Senator Heitkamp. Thank you so much, Dr. DeCoteau. Thank 
you so much for your leadership and educating me on these 
issues. I don't think that I would be nearly as informed 
without your assistance, without your persistence. And thank 
you to Don Schmitt for helping making this hearing a reality. I 
have known Don for many, many years. More years than probably 
either one of us want to recognize. There has been no greater 
advocate for children in foster care looking for advanced 
solutions, and we know so many heroes like this, and it's 
important where we do have people who dedicate their life, that 
we recognize that.
    So I'm going to turn first turn to Senator Hoeven for a 
round of questions. I think we're around five minutes, or as 
long as you want to go.
    Senator Hoeven. Thank you to all of our witnesses. What I 
would start out with is the need for a comprehensive approach. 
I ask each witness to describe what that comprehensive approach 
looks like? Recently the State Department of Human Services had 
a workshop in Fargo on the opiods epidemic. We really talked 
about--and we had the people work on the prevention, people who 
work on treatment, and law enforcement. So the idea was we got 
people from the front lines and experts. We had them from all 
areas. So we can try to come at the problem in a comprehensive 
way. We talked about everything from drug court to making sure 
there's education in schools and prevention, so people 
understand these drugs are not only addictive but they're 
dangerous and they're killing us. And then how law enforcement 
has to be able to not just incarcerate but to have treatment 
options. So same thing here, how each of you--What's it take to 
get that comprehensive approach? And I would start with Miss 
Sparks.
    Ms. Robinson. Thank you. Thank you for that question. It's 
a difficult question to answer, because it's such a difficult 
issue for us to tackle and for us to wrap our minds around. As 
I mentioned, there are many pathways to be able to treat parts 
of the trauma and behavioral health. But what we first have to 
understand is what actually are the causes. And I think that 
really varies impacting from community to community. We heard 
from Dr. Eagle Williams that the Garrison Dam is still 
something that's impacting the elders and it's transmitting 
down to the youth as well. And I think that each tribal 
community will have a similar story as to what is the root 
cause. But prevention, intervention, providing services, it's 
complicated. Unfortunately I don't have an answer for exactly 
what is the comprehensive approach, but I can tell you from 
Children and Families' perspective would be that we want to 
start early childhood programs. We want to be able to provide 
trauma and foster care to the service providers in our head 
start and our childcare and our native language programs. We 
want to be able to reach the parents that might not only be 
suffering from some of the symptoms of trauma but are suffering 
from some of the more complex historicals or PTSD or other 
adverse childhood experiences and help them get the services 
they need. We want to be able to prevent the adverse childhood 
experiences before they happen. And if they have happened, how 
do we get to the kids where they are to prevent them from being 
further traumatized. But, you know, that's just one way of 
approaching this particular topic.
    Mr. Cruzan. Very interesting. And I realize now that it's 
not just a drug and alcohol thing, which is what we see 
primarily. We have these activating events. There's law 
enforcement and you're dealing with really the symptoms and not 
the cause. One of the things we're trying to do within the 
Office of Justice Services, you could sort of, which I'm not 
sure we'll talk about, it's a thing more than a thing. It's a 
series of things, right? But one of the parts of that is a 
break in the system of services that are out there. I mean, I'm 
sure these people struggling with these issues can be referred 
separately, but for us there's an activating event. We're 
developing a graded system of services. It's basically a poster 
that we're trying to teach our law enforcement folks that you 
are a part of this healing process, for lack of better words, 
from the very beginning. So we're trying to develop a system 
where a police officer gets called to an event where you have 
these individuals who are displaying the symptoms of a greater 
problem, where you can divert them, maybe have a court option, 
but you don't immediately go to that judicial branch. You sort 
of have a diversion process where the officers who are dealing 
with these folks over and over again--I was just at Standing 
Rock yesterday and you look at the board of who is in the 
facility, and you can almost go back two years ago and it's 
almost the same people. It's the same names over and over 
again. So these officers who are dealing with these folks, if 
we have an option to divert them out of that judicial process 
into some sort of treatment, that would be our first option. 
Maybe that works. Maybe it doesn't. If it doesn't, you continue 
on this, continue here where now you go to work and Courts now 
have more options. Maybe it's adjudication. Maybe it's court 
ordered treatment. Maybe it's through drug court. Maybe it's a 
number of things. We've got a new system in place, and I think 
it's fairly generic. It's post-adjudication pre-sentencing 
that--So I'm arrested, I get brought in, I sit down, and I go 
through this with a court personnel. It's an assessment that 
really begins to ask questions about my likelihood of 
reoffending and if it's into where I should probably be. So 
maybe court ordered treatment. It maybe jail as opposed to 
treatment. So you continue this through these services, 
hopefully these off ramps back in the community where they can 
live healthy lives. Again, I think we're a part of the 
solution. I think it's becoming more and more clear to me that 
we could be more active participants in this. But the issues 
that these folks that we're dealing with are much deeper, and 
I'm not trying to tie this into these issues that--but foster 
homes, I can't control. It's in my head and and acting 
differently because of it. You know, you go and say, well, 
going down that path--You know, these folks that are struggling 
with these adverse childhood experiences are dealing with 
things that they can't comprehend, they can't control, and you 
can't really reason yourself out of it. I'm not saying I 
completely can relate, but I can understand, and it makes a 
little bit more sense. They are acting out in these ways. It's 
more than just alcohol and drug abuse. And we are working with 
that and I think for us it's going to diving into the 
professionals with our analytical data and our statistics and 
our numbers. So I don't know if I have a solution.
    Senator Heitkamp. Thank you. Miss Warrington?
    Ms. Warrington. Thank you. One of the things that we have 
been doing is getting from volume from all our governmental 
bodies. So they know what we are doing. We have quarterly 
meetings with them and we report to them on what we're doing 
for trauma care. We have a casino and we involve all the 
players. The police department supports all the businesses. We 
involve them all so that they know that this is not going to 
wayside. It's not a little thing we're going to play right now. 
It's continuing on, and they know this because we also ask them 
for money. We have to prove to them what we are doing, because 
they do contribute to the foster futures in the trauma group of 
people that we continue to work. We have regular meetings, but 
we have quarterly meetings as well. So I think it's important 
to let them know who is being trained, what kind of training is 
going on, but also because--and I've been doing this for three 
years, and we are starting the evaluation process now, because 
it isn't just, okay, here's what trauma informed care is. It's 
going back and saying, are you practicing it? How are you 
practicing it? Is it including your agencies? Is it improving 
your relationships? So that to us is very important to not to 
just be preaching to the choir, but also what are you doing? 
Are you actually feeling better about this, and do you have any 
ideas? What can we do to make it better? And I think that's the 
number one thing, but also reporting out to those agencies so 
they can, if they are asked, they can say what it is that 
they're doing. It's a core group. We started with eight people, 
but we brought in several others involved in these regular 
meetings. We also said engagement meetings where we involve 
anybody from the community. So that is so important. We're 
addressing the youth, bring them in. What are these kids 
saying? What do they need? What do they think is going to help 
us? So to talk about this we have to have the youth involved as 
well.
    Dr. Eagle-Williams. Thank you so much. Some of what we're 
seeing and what we're doing is very similar. We're very happy 
that we are working with our justice center as well as as our 
police force in educating them on basically what's happening 
also in the homes and the actual psychological effects of the 
parent and having the children witness these things, and also 
to help the police officers identify that. So we've been 
educating them on what we are seeing. And so that I think has 
been really helpful in working with the police force. And also 
coming from the aspect of, you know, not criminalizing our 
addicts. We have to change that mindset. Working in Indian 
country, I've worked primarily with women, I evaluated and did 
interviews, and when I did that there were 80 to 90 percent of 
the women that we treated on an outpatient treatment program, 
were molested, raped, had domestic violence in their homes. I 
realized that I had all of those risk factors as well, and I 
didn't even know, and I'm a professional. So we are working on 
educating our communities. We've gone through the Ace study 
with some of our staff, and when we did that there wasn't a dry 
eye in there of our women and our community members that hadn't 
experienced those childhood experiences. So we are working on 
educating, and the powers in the community. The thing is, we 
don't have enough staff. We have one counselor. You know, it's 
just so difficult to find individuals that are able to address 
these situations. I have to say, that the other, finding ways 
to bringing that culture or peace that's sometimes missing in 
these families is very important. And as we're working with 
these individuals that are either getting incarcerated or 
children who are taken from their home, we have to develop a 
reentry program that are allowed to bring those families back 
together. Because you could be an alcoholic and still be 
extremely supportive of your family and or an addict could 
still have that love, but because of that addiction, we cannot 
criminalize those individuals because of any experiences that 
led them to where they are. The other things we have, or I've 
include in my testimony, includes addressing the mental health. 
Definitely we need prevention and intervention, the 
alternatives to abuses. I actually took my daughter to the ER 
two weeks before she died, and she said, ``Mom, I am having 
chest pains.'' You know, my heart was pounding. I was like, 
``Is she having an anxiety attack? What's going on?'' So I'm 
trying to do all these things and ask the right questions, and 
we're working on collecting data from the State. It's amazing 
how--I can't remember the exact numbers, but we were 
identifying people at that point that were having anxiety or 
were suffering from depression but were released. That's kind 
of where we're at. So, again, thank you. Thank you for 
listening.
    Dr. DeCoteau. So we know that trauma has horrible impact on 
a human being. There's no one single approach that will work. 
We need comprehensive initiative from the community and it must 
include education of childhood trauma and historical trauma for 
all tribal systems and tribal leaders. There needs to be 
education on what the science says about intervention, and I 
think what tribal communities will find is that these 
interventions are very, they are very consistent with their 
tribal ways. What research is saying now is that safe, 
consistent relationships are a priority in restoring a 
traumatized individual, and things like rhythm and movement and 
mindfulness. And we've had these in our culture for 
generations. So we now understand that what use to be thought 
of as nonsense is scientifically proven as a successful 
intervention for traumatized individuals. A comprehensive 
initiative needs to have technical assistance that the tribes 
can reach out to for support, and identify consultants who are 
experts in their areas and who can assist the tribe in 
developing their own comprehensive initiatives in their 
communities. Tribal communities need a workforce, a workforce 
of mental health providers who are willing to leave the comfort 
of their office and do outreach to the furthest corners of the 
reservation. We've got to get to those folks because in my 
experience, those are the folks that are the highest risk for 
suicide. When I was working on the reservation, the one thing 
that was crystal clear to me was when there was a suicide, this 
was not somebody I knew. They were not a mental health patient. 
We're not reaching the services that they need, and we need to 
do a better job in doing that. We need to develop internship 
programs. It's hard to get folks to North Dakota. It's hard to 
get folks to rural areas to work, but the Veteran's 
Administration, other universities have established for decades 
that the best way to recruit professionals to our region is to 
develop internship training programs. We had that success and 
experience in the program at Standing Rock. We know that works. 
Thank you.
    Senator Hoeven. Follow up questions for the next round. 
Thanks to each of you.
    Senator Heitkamp. I think the great thing that's here is we 
have the person who has been tasked with the challenge of 
taking a look, kind of breaking down those silos, and thinking 
about emanating programs. So many times we hear we started a 
project, we received great results and then the funding was up 
and it went away. So one of the concerns that I had about this 
issue involved consistency and longevity. So Dr. Robinson is 
here. She is tasked with that goal, and I want to just ask the 
three health care professionals here to offer some advice to 
her on what would be helpful in addressing trauma and making 
sure the trauma programs continue on and we continue to see the 
success that you're seeing, but what more do you need from HHS 
to tackle this process.
    Ms. Warrington. We've said it before, and that is like 
someone else said, the professional assistance. You know, 
having people there that can help, can counsel, and different 
programs, pediatric care, whether working with children. What 
better way to do that is to start with trauma affecting the 
lives and starting from when they are very young, but those 
experiences where they need care and they are few and far 
between. So having professionals that will go to where you want 
them to is very important to our treatment program for 
counseling services up there. I think that really that is one 
of the biggest things to me is having a professional 
availability and resources.
    Senator Heitkamp. And you mean not in Washington DC, but 
actually on and in the trenches?
    Ms. Warrington. Make that a point.
    Senator Heitkamp. Next.
    Dr. Eagle-Williams. We would like to see training programs 
that are accessible and efficient to train our local people as 
well as internships and funding that supports traditional 
health and wellness. Like Dr. DeCoteau said, why would a 17 
year old girl who is extremely healthy, a leader in her school, 
and basketball player have to go to the hospital. We're not 
seeing those individuals. We're not even seeing the individuals 
that are making attempts until we go through 911 calls, and at 
that time it's three months later. So we're developing the 
referral process, stuff like that, but we'd like to see more 
traditional health and wellness. We would also like to see 
incorporating the entire family, because obviously this is not 
just affecting that individual. It's affecting the entire 
family and addressing the domestic violence within our homes. 
Just people in general are carrying, you know, historical 
trauma. We are carrying the trauma of our parents, our 
grandparents, and our children are doing the same.
    Dr. DeCoteau. So the first thing that comes to mind is to 
provide the infrastructure for the mental health workers. I 
agree that we need a workforce, but coming from my own 
experience in reservation work, and many of you probably 
understand, when you're doing mental health work on the 
reservation, you are the receptionist and the director and the 
clinician, and a number of other things. So the burnout is 
intense, and it's very difficult to sustain that work even if 
that's where your heart is. It's exhausting. So we need to 
develop an infrastructure that supports the mental health 
workers and makes it possible for these individuals to function 
and stay in these jobs. Most of the people who do this, that's 
where their hearts are, and if they leave, they leave for other 
reasons. So we need infrastructure. We need flexible use of 
funding. Sometimes when financing a grant for something I have 
to shave off the most innovative parts of my project to fit 
into what the grant is looking for. We need the ability to use 
the funding in flexible ways that make sense for the community 
and don't just make sense for the granting agency. We also need 
a mandate for collaboration from emergency rooms both on and 
off the reservation. I cannot tell you how many times I have 
referred a high risk suicidal youth to the emergency room with 
burn marks on their neck because of an attempt, and they were 
turned away because they told the doctor they weren't suicidal. 
It happens over and over and over, and we must collaborate 
better with our emergency rooms and doctors need to be 
educated, so we can help these individuals and save lives. We 
need to develop an ability to bill for services at the Federal 
rate, so that we can have sustainable funding sources for this 
type of project. We need to develop the ability for providers 
to private practice outside of the IHS system to have access to 
the same Federal rates when we're doing reservation based work.
    Senator Heitkamp. Miss Sparks-Robinson, if you could just 
kind of comment on what you've heard. And I'm particularly 
concerned, obviously we are at the end of the administration 
that has progressed greatly over the last eight years and their 
awareness and their willingness to commit, how do we perpetuate 
that?
    Ms. Robinson. So what I've heard from the listening session 
is that definitely the approaches have to be flexible, they 
have to be developed from tribal perspectives, they have to 
support the local solutions, and there's a critical role of 
native language of education, and looking at the health. So 
that gives us some parameters on how we should collaborate. 
What I will tell you is that the staff is really helpful and is 
really dedicated to making sure trauma informed care is part of 
our normal practice. Especially for ACF and also at HHS. There 
is an HHS coordinating committee that will address trauma, not 
just in Indian communities, but across all of our programming. 
So this is an education piece that's happening. There's grants 
that we are providing specific to Indian Country that hopefully 
will provide some flexibility and it also is requiring that 
it's done from the tribe perspective. We also have the 
methamphetamine/suicide initiative. We have tribal behavior 
health grants that we're providing as well. So these are some 
of the activities and program funding that will continue to be 
available, you know, regardless of who is sitting here next 
year in this position. Last, we have to come up with proposals 
in the President's budget that will allow for tribal training 
assistance center specific to native youth. That will look at 
small resources that are needed specific to trauma informed 
care.
    Senator Heitkamp. Thank you. Just to make a comment, which 
is, we have seen with Indian health, and we've had some direct 
challenges with the Great Plains district; shutting down 
emergency rooms, failure to provid care, and we need to really 
examine Indian health in a way that I don't think it's been 
examined for awhile. But when we look at outcomes, and we know 
that Native Americans, their longevity is not what it is in the 
rest of the country. That tells us something. That tells us 
even though we're working on beating chronic disease, whether 
it's diabetes, whether it's hypertension, we're really only 
treating a symptom of something that we need to. Actually we're 
finding this out all across the country that we no longer can 
afford to ignore mental health. We no longer can afford to 
ignore trauma and the things that lead to trauma. You know, one 
of the challenges that we have, and I hope you take back, is 
CMS needs to be responsive. We need to figure out how we pay to 
treat people in ways that actually achieve an outcome, not 
just, oh, you know, came and made sure that he had blood 
pressure checked, as opposed to why is this person experiencing 
hypertension? Why is this person experiencing high blood 
pressure? You know, we know that adverse childhood experiences 
have a very traumatic effect. Some reports would say 20 years 
off your life, we repeat treating the symptoms, and that's 
expensive. If we don't start looking at this differently, we 
not only will dig our hole deeper, but we're going to continue 
to have the same outcomes. So we're just really interested in 
how--and especially with Indian health. We need to have greater 
access to behavior and mental health services. We've got tribal 
chairmen in this room who would tell you that someone who is 
suffering from addiction, who is the first responder, the first 
responder the family calls is tribal court, BIA police. They 
didn't commit a crime, but the emergency room isn't a place 
where you're going to go to get help. So the person looks for 
help in a church or a precinct. That is not an outcome that 
should happen. We've got to figure this out, and the challenge 
for me is to provide, you know, some sense that we can change 
outcomes. I think so many people have given up. So many people 
have given up and said, ``It's never going to change. We just 
have to continue to do what we've always done.'' We can change 
it. We can change it if we take this great science that's being 
done, great talents that are being developed in trauma informed 
and trauma based programs, and we start involving communities 
and we start involving what makes those communities unique. 
That's the critical piece of this, because we cannot fund our 
way out of this chronic disease without dealing with this issue 
as a potential to make change overall. So I'm committed to 
making sure that these programs continue to get attention. I'm 
going to turn it over to Senator Hoeven for some last 
questions. Thank you so much.
    Senator Hoeven. And I just want to follow up. I appreciate 
that each of you had very good concepts and ideas to offer. I 
just want to follow up on a number of those with you. So I'm 
going to start with Miss Sparks-Robinson. You were talking 
about early childhood trauma, what is the key component to 
impacting outcomes?
    Ms. Robinson. Well there is a group who is incredibly 
dedicated to improving outcomes for Indian country. I spent 
some time with folks, including those that were practitioners 
in the community, to come up with what is the action that we 
need? What can we do to impact outcomes? And what we found is, 
so far, because the book is not done, is that there has to be 
screening tools. There has to be culturally specific screening 
that's done in our health care center, in our childcare 
centers. They have to be developed in partnership with Indian 
Health Service to be able to identify what the needs are in 
that particular family. It has to be family based. We need 
that. When I have these conversations out in Indian country, 
both the kids and parents and leaders have all said, ``I wish 
someone taught me how to be a better parent. I wish there was 
somewhere I could go to to be a better parent.'' The youth are 
saying, ``I wish my mom would talk to me. I wish I knew how to 
talk to my dad. I wish my parents knew what I needed.'' And 
tribal leaders are saying, ``I wish there was a way to provide 
this service to our community members.''
    Senator Hoeven. Does HHS or IHS have people come in and do 
some of the assessments?
    Ms. Robinson. So ACF through the tribal program, so ACH 
funds that program that's funded through Versa. So we do have 
the ability, but you have to come in and apply but then there 
is somebody that actually comes out and does prenatal and early 
childhood activities. We have someone that teaches them, okay, 
this is what you need to be able to deliver a healthy baby. We 
need you to destress. We need you to make sure that you're not 
being overwhelmed. This is what you need to be able to expect. 
Then comes in and does some screenings in the home, which we 
can't always expect the patient or the person that's in need to 
go to the place where the service is being provided.
    Senator Hoeven. Thank you. Mr. Cruzan, you mentioned too, 
could you describe a little bit what you think is particularly 
effective in North Dakota about the program?
    Mr. Cruzan. Absolutely. I think this one initiative in 
itself is really an effort, to the government watching in DC, 
we're certainly not going to solve anybody's problem by saying, 
``This is the way we're going to do it.'' So it is a break in 
services, if you will, and it's an effort to give those 
services. The people closest to the issue, know the solution. 
People that have resources will ask. So I think that's the 
effort that's happening right now. Currently they are 
developing local plans driven by tribal leadership and the 
community and those service providers to tell, basically to 
say, ``Here's the direction we want to go.'' There are--One 
size doesn't fit all certainly when it comes to that. So I 
think that's what we're doing is being very sensitive to the 
tribe's developing a plan. And then being flexible with the 
funding and saying, ``Well this isn't normal but that sounds 
reasonable. So let's do it.''
    Senator Hoeven. Thank you. I agree and describing what they 
think would help. So I appreciate that. Dr. DeCoteau, you 
talked about a comprehensive approach, you talk about education 
of childhood trauma. So I wanted you to just describe what that 
is? You talked about safe and consistent relationships. You 
talked about technical assistance. I just don't understand what 
you mean when you say ``technical assistance.'' Then you talk 
about outreach and internship programs as a way to resource, 
and I'm just wondering how you might structure or how you would 
come up with those outreach initiatives?
    Dr. DeCoteau. So when I work with parents who are raising 
children with complex developmental trauma, one of the first 
things I do is I teach the parents how trauma impacts the brain 
and what that does to the child's neurochemistry, so the 
parents can see that it isn't a behavioral issue. It's a brain 
development issue, and that's what education about childhood 
trauma needs involve. Whether it be in the school systems or 
the parents or other agencies, people need to understand that 
the behaviors we see are the behaviors of traumatized children 
because they lack brain capacity to put forth the behaviors 
that are expected. Until parents and our systems learn to 
nurture the brains in the individuals, and have strategies that 
are directly targeted to rebuild the brain so we can rebuild 
the brain. And I always tell parents, it's a brain development 
issue. I think if we had samples of the neurotransmitter panels 
of these children, we would see and understand that they are so 
disregulated. They cannot function. That helps us respond to 
these children in an empathetic way instead of an angry way. 
Safe relationships, that's a simple term, but it really means a 
lot in terms of how do we help reduce the stress response in 
children that are always in a state of fear. We cannot rebuild 
a brain that has a constant fear signal, and they will always 
react to their environment in ways where they perceive fear. We 
don't have a learning brain when there's a fear response in the 
brain. So we need to interact with the child in a way that 
reduces that fear response, and we have a learning brain and 
now we can rebuild the brain. That comes first and foremost 
most with safe relationships. And what I've learned is that in 
our society loving, nurturing parents need help to know how to 
do this especially in traumatized children. So there needs to 
be strategies to teach parents how to be mindful with your 
child, how to provide healthy touches, how to provide 
nurturing, how to correct behaviors in ways that are not 
punitive, and build their self esteem, sense of self, which 
will, again, trigger their response. When I talk about 
technical assistance, I talked about, and I mean that rather 
broadly, I mean that in terms of having the kind of 
infrastructure support in a system where one person is not 
wearing all hats. Also, in terms of an ability to develop some 
research to provide timelines and to provide the data that we 
need to get the funding. When I was on the reservation a number 
of years ago, we had a project that was working to reduce the 
suicide rates, and we had a very unfortunate response from the 
government. We were able to provide information about how this 
program is working and the government officials looked at 
myself and the tribal officials as we made our presentation and 
said, ``I need to see timelines. This is just antidotal 
information, and it's useless to us without data.'' And I 
understand that data is required for funding, but the problem 
with that in reservation communities is you don't have the 
infrastructure to develop a research base. Not that we 
couldn't, but we need the assistance to be able to do that. We 
need the infrastructure to be able to do that. Outreach and 
internship, so there's a difficulty in getting mental health 
workers and qualified mental health workers who want to do this 
work in Indian country. In my experience what I find is it's 
harder to bring in providers who have been working. It's harder 
to train those people because what's required is an attitudal 
change in how you're going to do your work. But interns and 
trainees are fresh, and they're energetic and they want to make 
change and they're idealistic and they want to follow your 
direction. They are usually younger, and they have a ton of 
energy. They come in with the mindset of changing the world. Of 
course we can't change the world, but we can do what we can do. 
So using those internship models is a way to recruit people 
from outside the state, from inside the state, and keep them 
here. In fact, the internships that we had at Standing Rock, 
more than 30 percent of them came in from outside this state 
and stayed in this region.
    Senator Hoeven. To me that makes a lot of sense.
    Dr. DeCoteau. One important point I would like to make 
about that, Senator, is a handful of years ago I worked with 
this Committee on the Indian Health Care Reform Bill, and we 
made sure there was a specific provision written into that bill 
to allow for interns and trainees, not just in the field of 
mental health, but in all fields of health, to be billable 
providers at the Federal rate. So if we we could bill for those 
service and create stainable funding for our service. And these 
aren't just, these are doctorate level trained folks. So they 
are quality individuals. I don't know anybody that has used 
that yet, but it would have provide a system of funding.
    Senator Hoeven. Thank you. Chairman Warrington, you 
mentioned having the counties more involved. Could you 
elaborate on that?
    Ms. Warrington. Well a lot of times the counties are the 
only ones that are eligible for funding, so they can put--
    Senator Hoeven. So you're talking now about State dollars?
    Ms. Warrington. Yes. And I know that a lot of tribes can't 
get the county to the table to help share those resources to 
serve the people. We are a county, so most of them are part of 
the tribe. So we have a good relationship, but I know a lot of 
them don't. And if we got in there, there's ways that the 
government can make them do it. But I think that having that 
mandate, I think because they have to pay for some of these 
services to tribal members, because the tribe does not have the 
funds.
    Senator Hoeven. How about some kind of cooperative 
agreement? Have you tried anything like that?
    Ms. Warrington. I would think that would work, if the 
county was willing to do that.
    Senator Hoeven. When I was governor we had cooperative 
agreements, not necessarily in this area, just in general. Just 
asking if you think that might be possible?
    Ms. Warrington. I don't know if you would be able to do 
that with the county.
    Senator Hoeven. And the idea of working together makes 
sense.
    Ms. Warrington. It does to me, because pulling all those 
resources together makes it better.
    Senator Hoeven. Right. Combine Federal and State resources?
    Ms. Warrington. Yes. So we could apply for resources.
    Senator Hoeven. Dr. Eagle-Williams, I am incredibly sorry 
for your loss. It takes incredible courage and strength to be 
here and talk about his. So I just want to commend you as far 
as making a difference for others. I want to bring up the 
Indians in the medicine programs and the Indians in the 
psychology programs. The reason is because of your testimony 
that you know there is obviously a lack with cultural and 
experienced trauma. So I think those are programs very good. 
Through our university system we're trying to combine the 
training, you know, very sophisticated and comprehensive 
medical training, and some of these cultural understandings 
that we talked about. So I'm just going to ask what we think of 
those programs? Are they working? Should they be adjusted? Is 
there something more we should do, and how do we build off 
those kinds of programs?
    Dr. Eagle-Williams. Actually those programs are very 
helpful, but we're not necessarily seeing those individuals 
come back and return to our home. So it's very difficult. The 
other thing is --
    Senator Hoeven. Do you mean they don't come back to the 
reservation?
    Dr. Eagle-Williams. To Fort Berthold. Yes. But the other 
thing that we had experienced, we actually had a representative 
working very closely with the University of North Dakota and is 
actually an employee. Within the years that I had been there, 
we only had one graduate of that program. And actually, the 
success, it took six years to become a licensed clinical 
counselor, and that's a challenge because the policy 
requirements in the State of North Dakota. And that's what I'm 
saying, there's a need for behavioral health specialists, you 
know, policy modifications to allow for sort of the layperson 
to receive adequate training to provide services that are 
universal. Because we're not seeing a whole lot of people who 
are going into the field of medicine. I think we recently only 
had one graduate from the college of medicine who is a tribal 
member this last past year. I cannot say, we didn't know, but I 
believe I was the last one to graduate from medical school in 
2002 from the University of Arizona with little to no support 
as, I mean, I don't practice medicine because of that. Getting 
through the boards and then dealing with all my own trauma, you 
know, just trauma being one in five in college of medicine, you 
know, that's traumatizing, so.
    Senator Hoeven. That's what I was just going to wrap up 
with. Dr. DeCoteau, any thoughts on how we get people into 
those programs?
    Dr. DeCoteau. Yes. So there's three Indian programs in the 
psychology programs in the nation. There's legislative law that 
will allow for up to five. They are great programs. Part of the 
difficulty is that those individuals have an IHS pay back, and 
they have difficulty finding jobs in the IHS system. They are 
allowed to find jobs in other systems where they serve more 
than 50 percent native population, but there's not a lot of 
available jobs, and some of those students are in default in 
their loans. The other issue is that the pipeline was never, it 
was never finished. So graduate school is not less, but you 
have to go to internship and you have to go on to post-doctoral 
residency. That's where the recruitment is an issue. So if 
there's not internship in post-doctoral programs in these rural 
communities, they go off to other metro areas. And then they 
usually start there careers in other metro areas. So we need to 
finish the pipeline.
    Senator Heitkamp. I do want to comment that in our presence 
today is Dr. Don Warren, who runs the Ph.D. program for public 
health at NDSU and working very, very hard on building that 
capacity. Because a lot of what we're talking about is 
integrating those public health models into the medicine, you 
know, just bringing it all together so that we're not just 
focused on diabetes and hypertension and, you know, injuries, 
but that we're actually looking at bringing a model to the 
system in Indian health that treats the whole person and treats 
the whole person culturally. So I couldn't let it go by just 
talking about those two programs. I think Dr. Warren if you 
don't mind just telling us what percentage of your graduate 
students now are Native?
    Dr. Warren. In my program?
    Senator Heitkamp. Yes.
    Dr. Warren. Okay. We have the American Indian Public Health 
Program at NDSU is what you're referring to, and our students 
start, actually tomorrow we have new student orientation, and 
we've now got 107 students and of that number 27 are American 
Indian. So it's the most American Indians for any school in 
that timeframe. Sadly more than any school in our history. But 
we focus on health policy issues, cultural context issues, and 
recognizing the health disparities are really all the way back 
through historical trauma. But many of our students are 
planning to work in the tribal population and are wanting to 
work in public health, psychology. Essentially we need a public 
health focus which is dealing with prevention of a crisis.
    Senator Heitkamp. What percentage of your folks that you 
graduated are working directly in Indian country?
    Dr. Warren. We've had now of the 27 American Indian 
students, of that number there's been about seven who have 
graduated, and I think we have one who is working for Sanford. 
The rest are working in Indian country.
    Senator Heitkamp. That's a huge resource for North Dakota. 
I would like to make that point.
    Senator Hoeven. If I could ask, so kind of that follow up 
question that I'd asked for the panel members, how do you 
coordinate with the Deans of Medicine in those programs?
    Dr. Warren. Yes. So public health is a different field, of 
course, than psychology and medicine, but they are integrated 
once we get out into the field. So we do have what's called our 
coordinating counsel with UND. So we meet quarterly with the 
Medical School Dean, their health care program direction, and 
other administrators to coordinate efforts.
    Senator Heitkamp. I think we have a couple more comments 
and then we need to close it out.
    Dr. Eagle-Williams. I would just like to say that the 
medicine program is actually a Federally funded program that 
may be a consideration of the State to implement into their 
budget for the next fiscal years.
    Dr. DeCoteau. President McDonald has just reminded me that 
our Alaska Native relatives are in fact implementing an 
internship training program in their community and apparently 
they are using the billing to sustain the funding for their 
students. So we have a model with our Alaska relatives that we 
could look closely into.
    Senator Heitkamp. We have a process that we need to follow. 
We've had a couple folks tell us that they would like to offer 
some comments. Comments, typically, because this is an official 
Senate hearing, we have to keep our usual schedule, what we 
planned on. So what I intend to do is offer an opportunity for 
anyone in this audience to submit written comments. Those 
written comments need to be sent to us in two weeks, and they 
will become part of the official record. So I'm going to close 
this hearing.
    [Whereupon, the hearing was concluded.]

                            A P P E N D I X

             Prepared Statement of the Octeti Sakowin youth
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                ______
                                 
    Prepared Statement of Stephanie Yellow Hammer, Enrolled Member, 
                       Standing Rock Sioux Tribe
    I, Stephanie Yellow Hammer an enrolled member and lifelong resident 
of the Standing Rock Sioux Tribe and who has worked in the Early 
Childhood field here for 15 years, request to have my testimony entered 
into the official record for the Senate Indian Affairs Committee Trauma 
Field Hearing to be held on August 17, 2016 in Bismarck North Dakota.
    Generation after generation our people have endured many historical 
traumatic events often one right after another. Each one of our 
generations has had to experience some type of traumatic event from the 
first contact of the European settlers to the present day event that is 
happening right now to the 7th generation with the placement of the 
Dakota Access Pipeline less than one mile north of our Standing Rock 
Reservation, which you people will refer to as an Adverse Childhood 
Experience (ACES) and once again breaking the treaties by placing this 
black snake that will carry crude oil from the northwestern part of 
North Dakota to Illinois. When this pipeline breaks it will contaminate 
not only our water source but all people who depend on the Missouri 
River for their water but we will be the first to feel this impact. In 
D/Lakota we say ``Mni Wiconi'' water is life; as without out water we 
cannot survive.
    Our people have never been able to heal and grieve as many of these 
traumatic events have been inflicted one right after another and 
somewhere in this process we have lost our resiliency as we have had so 
much taken from us; Our Land, Our Culture, Our Language, Our Kids 
Forced into Boarding Schools, Denied the Right to Practice Our Sacred 
Ceremonies, Forced Relocations, we can go on and on about what was 
taken from us and what we have lost, but you all know what has happened 
to us.
    We need funding for housing as many of our families live in doubled 
or often tripled up homes, where some are exposed to alcohol, drug and 
sexual abuse.
    We need funding for Indian Health Services as many of our youth and 
children are in dire need of mental health services from the 
``effects'' of the historical trauma and ACEs that they experience at 
an alarming rate.
    We need funding for cultural programs such as the Lakohol'iyapi 
Wahohpi and Wichakin Owayawa (Immersion) as we have lost our identity 
through all the trauma and grief. Our children need to be exposed to 
their culture and language so we can regain our identity that was 
stolen from us.
    We need more funding for prevention and educational programs so we 
can better educate our children and youth so we do not have to function 
in a reactive mode.
    We need a big push for the importance and need for Tribal Early 
Childhood Services so we can build strong children instead of repairing 
broken youth.
    We need funding for an inpatient treatment facility and addiction 
services so we can provide the much needed treatment services that our 
youth and adults need.
    You can educate people all you want on the Causes and Effects of 
Historical Trauma & Adverse Childhood Experiences in Native American 
Communities but until you can provide sufficient and adequate funding 
for our Tribal Nations you will continue to see the ``Effects'' of the 
trauma that the white man has inflicted on us. Hopefully this hearing 
will open the eyes of some of the elected officials and shed some much 
needed light on the issue.
        Wophila Thanka (Thank You) for your time.

                                  [all]
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