Evolution of San Francisco Bay Area Urban Trails.
Article Type: Report
Subject: Psychiatric services (Access control)
Mental health law (Evaluation)
Indigenous peoples (Psychological aspects)
Indigenous peoples (Care and treatment)
Cultural competence (Methods)
Author: Desmond, Bree
Pub Date: 10/01/2011
Publication: Name: Journal of Psychoactive Drugs Publisher: Taylor & Francis Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Taylor & Francis Ltd. ISSN: 0279-1072
Issue: Date: Oct-Dec, 2011 Source Volume: 43 Source Issue: 4
Product: Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 278880921
Full Text: Abstract--The Family and Child Guidance Clinic of the Native American Health Center (NAHC) has developed strong working relationships with San Francisco Bay Area system partners in order to serve the mental health needs of American Indian/Alaska Native children and families. NAHC worked relentlessly with stakeholders to pave the Urban Trails that urban Indigenous community members utilize to access culturally competent care. These Urban Trails have been grounded in a community-based system of care model and cultural framework that links substance abuse and mental health through a holistic approach congruent with Indigenous values and traditions. This article describes how NAHC has partnered with community members and organizational stakeholders to develop and sustain an effective holistic system for serving urban Indigenous people.

Keywords--American Indian/Alaska Native, Child Mental Health Initiative, outcome evaluation, sustainability, urban Indigenous, Urban Trails

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The long history of oppression of American Indian/Alaska Natives (AI/ANs) has had a disturbing effect on the health of Native people. Colonization, forced relocation, and outlawing AI/AN languages and spiritual practices have led to wariness of government programs and health institutions (NIH 2006). During the 1950s, Indians from various tribes began migrating in significant numbers from reservations to the San Francisco (SF) Bay Area under the Bureau of Indian Affairs (BIA) Relocation Program. Ultimately, the BIA did not deliver on its promises of transitional assistance and relocation and only succeeded in creating a further chronically disenfranchised urban Indian population with extremely diverse identities and acculturation experiences.

Relocation contributed to increases in intertribal and interracial marriages and offspring, isolation from tribal-specific practices and social support, the invisibility of Indians to non-Indians, and historical trauma. Most mainstream providers do not understand that historical trauma needs to be addressed to promote AI/AN healing and recovery. Many urban Indigenous community members do not utilize mainstream health services unless there are urgent needs that cannot be addressed alternatively and often prefer to receive services through Native organizations which specialize in serving Indigenous populations. Access to resources within Native agencies often leads to improved health and positive community outcomes that are not often achieved without accessible Native-specific resources.

DEMOGRAPHICS

California is home to the largest AI/AN population in the country, with over 720,904 identifying as AI/AN. Seventy percent live in urban areas. The SF Bay Area urban Indigenous population is diverse, with more than 500 different tribal affiliations represented. "Violence is more likely to be reported among AI/AN families, both as an element of abuse and/or neglect and in general" (Earle & Cross 2001). As a result of lower socioeconomic status, American Indians and Alaska Natives are also more likely to be exposed to trauma than members of more economically advantaged groups (USDHHS 2001).

Substance use is the most common factor in child welfare cases. National data show the serious impact of substance use and its consequences among AI/ANs, with higher rates of use, greater frequency and intensity of use, earlier first use, and much higher alcohol-related mortality than other racial groups (CDC 2010; SAMHSA 2007, 2006; Szlemko, Wood & Thurman 2006; USCCR 2004). In California, AI/AN adults, youth and pregnant women show more intense and frequent alcohol use than non-AI/ANs and, among those admitted to alcohol and drug treatment programs, 45% of AI/ANs reported first use of alcohol or drugs before age 14 as compared with 31% of non-AI/ANs (Wright, Nebelkopf & Jim 2007).

Substance use affects the entire family and evidence of this can be seen in data on drug use among Native youth. Data from the school-based California Healthy Kids Survey shows that from 1997 to 2006 rates of use for nearly all substances surveyed were consistently higher among Native youth in all age groups (seventh, ninth, and eleventh grades) (Wright, Nebelkopf & Jim 2007) with 42% of AI/AN eleventh graders reporting drinking alcohol within the past 30 days, 28% binge drinking, and 45.9% ever using marijuana.

The combined issues of violence, substance abuse, and mental health play out in school and juvenile court. Estimates imply that as many as 30% of American Indian children have been removed from their families (Cross, Earle & Simmons 2000). A recent analysis of 17,000 AI/AN and White neglect cases from NCANDS revealed that AI/AN cases were more likely to be associated with foster care placement, juvenile court petition, alcohol abuse of child or caretaker, violence in the family, and family receipt of family assistance (Fox 2004). Also, AI/AN children are placed in foster care far more often than White children and there are insufficient AI/AN foster homes available.

LAYING THE FOUNDATION

When SF Bay Area Native community members asserted a need for behavioral health services for children in the 1990s, the Family and Child Guidance Clinic (FCGC) began the process of seeking resources to address this identified need. FCGC began by obtaining a three-year Center for Mental Health Services (CMHS) American Indian Circle of Care planning grant in 1998. In partnership with the Indian Health Service (IHS), National Institute for Mental Health (NIMH), and the Department of Justice, CMHS provided funding and technical assistance to federally recognized tribes and urban AI/AN communities to plan, design, and assess the feasibility of a culturally respectful system of care. The National Indian Child Welfare Association and University of Colorado National Center for American Indian and Alaska Native Mental Health Research provided technical assistance to grantees. NAHC was the only urban AI/AN program funded in this first Circle of Care funding cycle.

In the Circle of Care Needs Assessment, it became clear that children were being labeled as substance abusers, delinquents, emotionally disturbed, or having learning disorders depending upon the institution that identified the child as "having a problem." Staff of FCGC realized that these were the same children struggling with imbalance, effects of historical trauma, and family dysfunction. Given this reality, community members chose to define these children as "the most needy and vulnerable children."

This Circle of Care promoted a unifying and enduring sense of urban Indian community identity, pride and cohesion based on common traditional Native values and beliefs; built leadership skills and capacity among Indian families and community-based organizations that serve the Indian community; produced a strategic plan for implementing a system of care that links prevention with treatment and substance abuse with mental illness; and secured resources to implement a community-based system of care.

INCEPTION OF URBAN TRAILS

The strategic plan that resulted from the Circle of Care was implemented in 2003 through a six-year CMHS-funded Child Mental Health Initiative project called Urban Trails. The city of Oakland was the lead agency in this unique partnership with NAHC, which paved the way for urban tribal organizations to implement systems of care for AI/AN youth and their families. As an urban tribal organization, NAHC was eligible to participate in Circle of Care. However, for statutory reasons, urban tribal organizations were not eligible for Child Mental Health Initiative grants. To overcome this barrier the application was submitted by a government entity, the city of Oakland, and a subcontract was developed with NAHC to provide program services.

The goal of Urban Trails was to implement a holistic system of care for Native American children diagnosed with a serious emotional disturbance (SED) and their families. A commitment from families, youth, community members, community-based organizations, and public agencies was made to implement a continuum of care that ranged from early intervention to treatment, and links mental health, substance abuse, medical, and social services.

The Urban Trails system of care was integrated into the Alameda County strategic plan through memoranda of understanding (MOUs) and subcontracts with the Alameda County Health Care Services Agency, Alameda County Social Services Agency, Alameda County Children & Families Commission, and Oakland Department of Human Services.

Staff formalized interagency collaboration and provided treatment and support through a wraparound approach to meeting client needs that included a comprehensive array of services, case management, individualized service planning, interagency coordination, family involvement, and linkages with early identification and prevention services. NAHC had a six-year subcontract with Friendship House Association of American Indians to expand capacity to serve Native American children diagnosed with SEDs and their families, with a particular locus on women and their children residing at the Friendship House American Indian Lodge in Oakland. The Urban Trails project has provided the opportunity for both NAHC and Friendship House to hire additional therapists and support staff to provide services for children with SEDs and their families.

The Child Mental Health Initiative (CMHI), which funded the development of Urban Trails, mandates that its grantees implement a longitudinal study as a part of their national evaluation including the administration of subsets of required copyrighted and noncopyrighted instruments that measure progress toward targeted outcomes of the CMHI. With input from community stakeholders, the Urban Trails evaluation team narrowed the locus of the national evaluation and conducted a local evaluation through analysis of progress within domains of most interest to the community.

METHODS

One caregiver and one youth (age 11 and older) in each family served through Urban Trails were eligible and offered the opportunity to participate in national evaluation interviews. Those interested in participating provided informed consent to participate in the national evaluation. Trained interviewers within the Urban Trails evaluation team administered mandated instruments through evaluation interviews at baseline and subsequent follow-up data collection points every six months for up to three years. The Urban Trails local evaluation featured a comparison of mean scores among data collected from youth and families at baseline and follow-up 24 months later. Instruments included the Child Behavioral Checklist, Columbia Impairment Scale, Caregiver Strain Questionnaire, and Behavioral and Emotional Rating Scale (King et al. 2009).

RESULTS

The Child Behavior Checklist for Ages 6-18 (Achenbach & Rescorla 2001) was administered with the 27 caregivers of youth (age six to 18) who were retained as participants throughout the timeframe of analysis to measure behavioral and emotional problems in children/youth. Analysis shows significant improvement in symptoms and functioning of the overall population served. There were statistically significant (p < .05) decreases in internalizing, externalizing, and total problems scales. Decreases in internalization of problems were indicated by decreases in somatic complaints and anxious or depressive feelings. Results also showed a reduction in externalization of behavior problems, such as: rule breaking, aggressive behavior, and overall problems.

According to the Columbia Impairment Scale (Bird et al. 1993) all 40 youth in the sample showed improvements, including those with: relationship problems, behavioral problems in all environments, and emotion management problems. These improvements amounted to a statistically significant reduction in global impairment (p < .05).

The Caregiver Strain Questionnaire (CGSQ) (Brannan, Heflinger, & Bickman, 1998) was administered with 45 caregivers and measures the extent to which caregivers are affected by the unique problems associated with caring for a child with emotional or behavioral problems such as: fatigue, feelings of resentment toward the child, worry, disruption of life, and guilt. Caregivers reported significantly less strain according to the global strain scale (p < .001).

Results of the Behavioral and Emotional Rating Scale (BERS-2C) (Epstein 2004) indicated statistically significant increases in overall behavioral and emotional strengths as measured by the total strength index (p < .05), and increases in interpersonal strength (p < .001) measurable by the youth's ability to control his/her emotions or behaviors in social situations.

These figures demonstrate the efficacy of the Urban Trails program in Oakland, and are evidence of this program's ability to provide culturally appropriate support and services, that improve the lives of both the participants and their communities.

COLLABORATION AND SUSTAINABILITY

In an effort to support sustainability of culturally competent services, NAHC joined a collaboration of public agencies and AI/AN programs in the San Francisco Bay Area through the Bay Area Indian Child Welfare Improvement Initiative. This collaborative was initially facilitated by the Annie B. Casey Foundation with the goal of strengthening and supporting San Francisco Bay Area AI/AN children and families. Organizations involved included NAHC, Friendship House Association of American Indians, Indigenous Nations Child and Family Agency, Inter-tribal Friendship House, Native American AIDS Project, United Indian Nations, Tribal Temporary Assistance for Native Families (TANF), American Indian Child Resource Center (AICRC), San Francisco Human Services Agency, Judicial Council of California, Alameda County Social Services Agency, and the Casey Family Programs Bay Area Office. Services offered by these groups include foster care referral and support, crisis intervention, school court advocacy, teen pregnancy prevention, substance abuse counseling, mental health counseling, care coordination, Indian Child Welfare advocacy, cultural activities and traditional Native American healing. This collaborative has continued its work and is now called the Bay Area Collaborative of American Indian Resources (BACAIR).

One of the most valuable things accomplished by Urban Trails was the involvement of community members in policymaking bodies within San Francisco Bay Area counties. The value of consumer and community member advocacy has assisted NAHC in leveraging additional funding to provide mental health services for AI/AN youth and families.

NAHC also developed Prevention and Early Intervention (PEI) services for AI/ANs in Alameda County through the creation of the Native American Prevention Center, which provides outreach and education, mental health consultation, and early intervention. This program brings together consumers, families, community members, natural helpers, and mental health professionals to build a community that reflects the values of Indian people in Alameda County.

The Urban Native Center for Life Empowerment (UNCLE), funded by CMHS in 2009 for three years, focuses on the development of a Community Treatment and Services Center for AI/AN youth, age three to 18, in Oakland. Culturally competent, evidence-based, trauma-informed services have been implemented in community settings and institutions that serve urban AI/AN children, adolescents, and families. Project services support the continuation and improvement of services provided for children and families who participated in Urban Trails.

URBAN TRAILS SAN FRANCISCO

Many AI/AN community members who reside in San Francisco were unable to access culturally competent mental health and substance abuse prevention services through Urban Trails in Oakland due to county boundary restrictions. These families and children had no intention of utilizing mainstream system services in SF despite great need. In order to respond to this reality, NAHC forged on and built more pathways to services for the urban Indigenous community upon the foundation that was built through implementation of the Urban Trails grant in Oakland and the work of BACAIR.

Like NAHC, the city and county of SF had already administered a CMHI grant, which developed their capacity to serve children and youth with serious mental health needs. Through the duration of SF's SAMHSA-funded CMHI project, 550 youth and their families were enrolled in services. Of the 5,172 youth in the SFSOC database in 2007-08, only 47 were identified as AI/AN (alone or in combination with one other race) and only one was formally enrolled in the SF CMHI project. Though this is likely an underrepresentation, data indicated that AI/AN youth were falling through the cracks in SF and did not have easy access to services within the SFSOC (Ronmey et al. 2008).

It became clear that the disparities in mental health programs for AI/AN children in SF could be addressed by creating a linkage between the existing SFSOC--Human Services Agency, Juvenile Probation Department and San Francisco Unified School District--and Native American nonprofit organizations. With documented positive outcomes and sustainability of both Urban Trails in Oakland and the SFSOC, additional federal CMHS Child Mental Health Initiative funds were leveraged for further expansion of an urban indigenous system of care in the SF Bay Area. In 2009, through a partnership with the San Francisco Department of Public Health, the NAHC began Urban Trails San Francisco, a replication of our successful Oakland project. The city and county of SF and NAHC have collaboratively begun implementation of a system of care for AI/AN children with SEDs and their families. With the SF Department of Public Health (SFDPH) as the lead agency, this project integrates primary health care with mental health and social services. The NAHC Family and Child Guidance Clinic works closely with the SFDPH Children and Family Services division as well as the SFDPH Cultural Competence and Relations section in order to increase AI/AN access to effective care.

Though not enough data has been collected yet to document outcomes of this effort, after one year of planning and eight months of service implementation, NAHC has enrolled 27 children and families in services and the Urban Trails San Francisco (UT-SF) project has already make great strides towards system transformation.

The population which has begun being served through UT-SF includes those who self-identify as North, South and Central American Indigenous community members in a groundbreaking effort to forge an alliance among Indigenous people north and south of the border. This effort aims to increase both AI/AN and Mayan community member access to culturally competent wraparound services. A contract was developed with Instituto Familiar de la Raza (IFR), a community-based agency in SF that serves Indigenous people from Latin America. A Mayan community member has been employed to serve as an UT-SF case manager for Mayan UT-SF clients who reside in San Francisco.

Additionally, since the SF AI/AN/Indigenous population includes many lesbian, gay, bisexual, transgender, queer, and/or two spirit (LGBTQ2-S) youth, NAHC is fortunate to have staff members who self-identify as LGBTQ2-S and have personal experiences which may assist them with engagement and retention of LGBTQ2-S youth.

Even though the SF Bay Area has one of the largest urban AI/AN populations in North America, there is still some degree of invisibility of this population. Accurate identification of and access to AI/ANs through county service data is an ongoing challenge. NAHC provides training to SF system partners focused on more accurate identification of AI/AN/Indigenous youth within the SF system of care. In addition, NAHC provides training to agencies in cultural competency and trauma-informed services.

NAHC also participates in the SFDPH Prevention and Early Intervention (PEI) initiative as part of the State of California Mental Health Services Act (MHSA) through a project called Living in Balance. PEI services have been implemented in the same location where UT-SF services are provided with seamless linkages between UT-SF services and the talking circles, community events and other cultural activities provided through the Living in Balance project.

Early accomplishments within the UT-SF project include the youth-driven development of an AI/AN Youth Taskforce called the Native REACH (Re-inventing Education And Community Health) Council and an AI/AN Family Involvement Team called the Blanket Weavers. Evidenced based and promising practices being integrated in UT-SF service provision include Trauma Focused Cognitive Behavioral Therapy, high fidelity wraparound services, and the Gathering of Native Americans curriculum, which allows the NAHC to reach out to our community members in a culturally appropriate manner and build trust through an emphasis on the importance of balancing the belonging, mastery, interdependence, and generosity within AI/AN individuals and communities.

NAHC also brings in Traditional consultants with various tribal affiliations to provide culturally competent support to individuals, families, and groups. Finally, the fact that UT-SF staff members are trained to understand the vast impacts of historical trauma on Indigenous populations allows our team to integrate that knowledge into work with children and families which alone leads to increased cultural competence within service provision.

URBAN TRAILS RICHMOND

Though NAHC efforts have contributed to increased access to mental health services for highly underserved AI/ANs in both Oakland and San Francisco, there are still AI/ANs in Contra Costa County who desperately need culturally competent behavioral health services. Contra Costa County's largest city is Richmond, which has high rates of substance abuse, gang- and gun-related violence.

In 2010, NAHC was funded by Contra Costa County to develop a Native Wellness Center in Richmond and provide prevention and early intervention services through California's Mental Health Services Act (MHSA). Through ongoing productive relationships with Contra Costa County's Native community members, NAHC heard yet another call for the expansion of services for children and families in Richmond. NAHC is planning to increase access to culturally competent medical, dental, and behavioral health services in Contra Costa County and potentially decrease the disparities that exist there. NAHC is collaborating with the city of Richmond Mayor's Office and Contra Costa County Behavioral Health to develop a system of care for Native children and their families in conjunction with preventing violence in Richmond. Urban Trails Richmond would provide wraparound services to meet the needs of vulnerable and underserved AI/AN children and their families in Richmond and Contra Costa County.

CONCLUSION

Plans for sustainability of San Francisco Bay Area Urban Trails are grounded in its Federally Qualified Health Center (FQHC) status and capitalization of available Medicaid funding through this billing mechanism. Ongoing advocacy efforts support sustainability of culturally competent care for AI/AN children and families in the San Francisco Bay Area. The California Department of Alcohol and Drugs and Department of Mental Health have provided NAHC funding for statewide planning and technical assistance efforts to promote cultural competence for those programs working with AI/AN people.

Since 1998, NAHC has provided children and family services through CMHS-funded projects. NAHC continues its efforts to build pathways that lead to better outcomes for Native children and families. We are a community serving our people and will never stop overcoming barriers and finding ways to support one another towards balanced health and wellness.

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Bree Desmond, M.S.W. (a)

This work was supported by the Substance Abuse and Mental Health Services Administration Center for Mental Health Services project Urban Trails San Francisco (SM 59036). The contents of this article are solely the responsibility of the author.

(a) Evaluator, Family & Child Guidance Clinic, Native American Health Centre, Oakland, CA.

Please address correspondence to Bree Desmond, M.S.W., 160 Capp Street, San Francisco, CA 94110: phone: 415-621-4371; email: allisouD@nativehealth.org.

DOI: 10.1080/02791072.2011.629151
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