Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
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Transcript of Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
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The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services
An Approach to Evidence Based Practice: the Partnership of Traditional and
Contemporary Medicine in Healing
Wisconsin TeleconferenceJanuary 25, 2007
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
Bentson McFarland, MD, PhD, Michelle Singer 0HSU – Portland, Oregon
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One Sky Center
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Program Goals• Promote and nurture effective and
culturally appropriate prevention and treatment
• Identify and disseminate evidence-based prevention and treatment practices
• Provide training and technical assistance
• Help to expand capacity
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One Sky Center Outreach
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Six Missions Impossible?How do we:
• Define ourselves?
• Define health care?
• Ask for help?
• Get Federal and State agencies to work together and with us?
• Build our communities?
• Restore what is lost?
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Overview
• An Environmental Scan
• Behavioral Health Care Issues
• Fragmentation and Integration
• Best Practice = Evidence-Based + Indigenous Knowledge
• You do both
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Scientifically Based Approaches to Drug Addiction Treatment
• Relapse Prevention • Matrix Model • Supportive-Expressive Psychotherapy • Individualized Drug Counseling • Motivational Enhancement Therapy • Behavioral Therapy for Adolescents • Multidimensional Family Therapy (MDFT) for Adolescents • Multisystemic Therapy (MST) • Combined Behavioral and Nicotine Replacement Therapy for
Nicotine Addiction • Community Reinforcement Approach (CRA) Plus Vouchers • Voucher-Based Reinforcement Therapy in Methadone
Maintenance Treatment • Day Treatment with Abstinence Contingencies and Vouchers
http://www.nida.nih.gov/PODAT/PODATindex.html
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10 Leading Causes of Disability in the World
(WHO, 1997)• Unipolar Depression• Iron-deficiency Anemia• Falls• Alcohol Use• COPD• Bipolar disorder• Congenital anomalies• Osteoarthritis• Schizophrenia• Obsessive-compulsive
disorder
• 10.7%• 4.7• 4.6• 3.3• 3.1• 3.0• 2.9• 2.8• 2.6• 2.2
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Health Problems
1. Alcoholism 6X
2. Tuberculosis 6X
3. Diabetes 3.5 X
4. Accidents 3X
5. Physicians 72/100,000 (US 242)
6. 60% Over 65 live in poverty (US 27%)
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American Indians
• Have same disorders as general population
• Greater prevalence• Greater severity• Much less access to Tx• Cultural relevance more challenging• Social context disintegrated
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Agencies Involved in B.H. Delivery
1. Indian Health Service (IHS)A. Mental HealthB. Primary HealthC. Alcoholism / Substance Abuse
2. Bureau of Indian Affairs (BIA)A. EducationB. VocationalC. Social ServicesD. Police
3. Tribal Health4. Urban Indian Health5. State and Local Agencies6. Federal Agencies: SAMHSA, VAMC
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Disconnect Between Addictions / Mental
Health
• Professionals are undertrained in one of two domains
• Patients are underdiagnosed
• Patients are undertreated
• Neither integrates well with medical and social service
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Difficulties of Program Integration
• Separate funding streams and coverage gaps
• Agency turf issues
• Different treatment philosophies
• Different training philosophies
• Lack of resources
• Poor cross training
• Consumer and family barriers
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How are we functioning?(Carl Bell, 7/03)
One size fits allOne size fits all
Different goals Different goals Resource silosResource silos
Activity-drivenActivity-driven
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We need Synergy and an Integrated System (Carl Bell, 7/03)
Culturally Specific
Culturally Specific
Best Practice
Best Practice
IntegratingResources
IntegratingResources
Outcome Driven
Outcome Driven
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Indigenous Knowledge
• Is local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, which is used as a basis for decision-making for all of life’s needs.
Definitions:
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Traditional Medicine
• The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health.
WHO 2002
Definitions:
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Evidence-based Practices
• Interventions that show consistent scientific evidence of improving a person’s outcome of treatment and/or prevention in controlled settings.
SAMHSA 2003
Definitions:
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Best Practices
• Examples and cases that illustrate the use of community knowledge and science in developing cost effective and sustainable survival strategies to overcome a chronic illness.
WHO 2002
Definitions:
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World Conference on Science
• Recommended that scientific and indigenous knowledge be integrated in interdisciplinary projects dealing with culture, environment and chronic illness.
1999
A partnership begins!
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ID Best Practice
Best Practice
Clinical/servicesResearch
TraditionalMedicine
MainstreamPractice
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Circle of Care
Best Practices
Child & Adolescent Programs
Prevention Programs
Primary Care
EmergencyRooms
TraditionalHealers
A&D Programs
Colleges & Universities
Boarding Schools
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Traditional and complementary medicine is widely and increasingly
used in all regions of the world
Populations using traditional medicine for primary health care
60%
60%
70%
70%
70%
90%Ethiopia
Benin
India
Rwanda
Tanzania
Uganda
Populations in developed countries who have used complementary and alternative medicine at least once 31%
42%
49%
48%
70%Canada
Australia
France
USA
Belgium
Sources: Eisenberg DM et al. 1998; Fisher P & Ward A, 1994; Health Canada, 2001;World Health Organization, 1998; and government reports submitted to WHO.
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Cultural Approach
• Original Holistic Approach• Psychopharmacology Approach• The unconscious has always been
there• Group Therapy• Network Therapy• Recreational / Outdoors• Traditional Interventions• Indian is...
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Selected Treatment/Prevention Activities
• The Talking Circle• Smudging• Story telling• Traditional healers• Medicine Person• Herbal remedies• Traditional ceremonies• Sweat Lodge• Traditional Experiences Preservation
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Basic Science
What Is Integrative Medicine?
CAMliteracy
Evidence Based
Medicine
Wellness
Power Of the Mind
Cultural Sensitivity
PatientCentered
Care
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Principles of Integrative Medicine
1. It is better to prevent than to treat later.
2. Recognition of the interaction between body, mind, spirit, and environment.
3. Integrate the best of conventional and traditional medicine.
4. Belief that bodies respond uniquely, so treatment must be customized.
5. Belief in innate healing powers of the body.
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The Intervention Spectrum for Behavioral Disorders
CaseIdentification Standard
Treatmentfor KnownDisorders
Compliancewith Long-TermTreatment(Goal: Reduction inRelapse and Recurrence)
Aftercare(Including
Rehabilitation)
Prev
entio
n
TreatmentM
aintenance
Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.
Indicated—Diagnosed Youth
Selective—Health RiskGroups
Universal—General Population
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Ecological Model
IndividualPeer/FamilySociety Community/Tribe
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IndividualGenetics
Personality
Attitudesbeliefs
Interpersonal
Community
Parents Peers
Schools Local legal
Personal situations
Portrayal in media
Culturalbeliefs
Stigma
National attitudes
Individual
Environmental Interpersonal societal
Tribalattitudes
Stateattitudes
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Treatment Settings - Social Support
• Tribal
• Community
• Family
• Sibs
• Peers
• Individual
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Evidence-Based Practices for Alcohol Treatment
• Brief intervention• Social skills training• Motivational enhancement• Community reinforcement• Behavioral contracting
Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd ed., pp 12 – 44). Boston: Allyn & Bacon.
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Evidence-Based Approaches to Addiction Treatment• Cognitive–behavioral interventions
• Community reinforcement
• Motivational enhancement therapy
• 12-step facilitation
• Contingency management
• Pharmacological therapies
• Systems treatment1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse.
2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse
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Unified Services PlanCase management should
address:
• Mental health• Education/vocation• Leisure/social• Parenting/family• Housing• Financial• Daily living skills• Physical health
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Partnered Collaboration
Research-Education-Treatment
Grassroots Groups
Community-BasedOrganizations
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Contact us at503-494-3703E-mail Dale Walker, [email protected] visit our website:www.oneskycenter.org