Lillian Sparks Robinson
Administration for Children and Families
U.S. Department of Health and Human Services
Senate Committee on Indian Affairs
August 17, 2016
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 Intra-Departmental 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.