A Community-Based Intervention for American Indian/Alaska Native Mental Health
By Teresa LaFromboise, Ph.D., Stanford University
Suicide is the third leading cause of death among American Indian/Alaska Native children and adolescents in the 10 to 14-year-old age group and the second leading cause of death in the 15 to 24-year-old age group (National Center for Health Statistics, 2002). Completed suicide is 72% more common among Native American people than among the general U.S. population (Indian Health Service, 2002).
Ecological factors such as historical trauma, the stress to acculturate within mainstream U.S. society and pervasive poverty; social factors such as family dysfunction and violence in the community; interpersonal problems such as poor coping abilities and individual factors such as depression, anxiety, substance abuse and psychiatric disorders act as moderators of suicidal ideation and behavior. When depressed adolescents pervasively employ avoidant coping strategies in the face of stressors, have negative thoughts and feelings of hopelessness and have difficultly identifying solutions to problems, suicide is more likely to be selected as a viable option.
The American Indian Life Skills (AILS) curriculum is an intensive, multi-component intervention consisting of psycho-education, coping skills enhancement, and lifestyle changing activities (LaFromboise, 1995). It was designed to focus upon key classes of stressful episodes including risk-taking behaviors associated with substance abuse, sexual activity, bullying, and suicide attempts. This intervention incorporates experiences relevant to Native American adolescent life into seven major units that focus upon life skills as follows: (1) building self-esteem; (2) identifying emotions and stress; (3) increasing communication and problem-solving skills; (4) recognizing and eliminating self-destructive behavior; (5) advancing knowledge about the variability in rates of suicide across tribes and risk factors for Native adolescent suicidal behavior; (6) practicing how to ask for help for themselves or for their friends when suicide becomes an issue; and (7) engaging in individual and collectivistic goal-setting. The AILS emphasizes approach coping and strives to enhance youth awareness of their personal power to make a difference in other’s lives.
The AILS intervention employs a social skills training approach whereby interventionists follow the format of information giving, modeling, behavior rehearsal, and feedback for skills development. The AILS training manual contains 56 lessons which can be delivered over a 30-week period of time. The AILS is most often delivered by classroom teachers. However, community members who work in behavioral health and positive youth development programs (e.g., Indian Boys and Girls Clubs, church camps, tribal juvenile services) have also delivered the intervention.
AILS is an evidence-based suicide prevention intervention that is tailored for cultural sensitivity in Native communities. An effectiveness study following a quasi-experimental design found that the AILS reduced Native youths’ hopelessness, increased their confidence to manage anger, and increased their problem-solving and suicide-intervention ability (LaFromboise & Howard-Pitney, 1995). A longitudinal study of the mental health status of students attending boarding schools conducted by the National Center for American Indian Alaska Native Health Research (Manson, Beals, Dick, & Duclos, 1989; Manson, 1987-1992) verified the reduction of a 20-year suicide rate among students at Sequoyah High School in Tahlequah, Oklahoma, with no deaths by suicide noted since implementation of the AILS in the early 1990s (see Goldsmith, Pellmar, Kleinman, & Bunney, 2002).
Since suicidal behavior can start very early in life, an early adolescent version of the AILS, consisting of 30, 30-minute lessons, is being refined and evaluated. The aim of the middle school version (AILS-M) is to prevent the onset of self-destructive and suicide-related behavior, reduce negative thoughts about the future or hopelessness, and impart life skills at an early age.
Increasingly, American Indian/Alaska Native communities are becoming more willing to participate in comprehensive interventions that modify target behaviors (May, Serna, Hurt, & DeBruyn, 2005) and to offer information about essential cultural elements that should be considered in the content and delivery of these interventions (BigFoot & Schmidt, 2006). The main outcome of this integrative work is for parents and other adult family members, community leaders, school staff, and Native youth to work together to create a community of support for Native resilient adaptation.