Located in the beautiful and rugged inland mountain region of California, the Toiyabe Indian Health Project serves a consortium of seven federally recognized Tribes and two American Indian Communities. Toiyabe works to address a range of health-related hardships endured by the communities they serve, using medical services as well as public health and wellness programing.  As part of their health promotion work, they have focused on increasing the resiliency and coping skills of the youngest members of their communities.

As part of their Methamphetamine and Suicide Prevention Initiative (MSPI), Toiyabe adapted the evidence-based American Indian Life Skills Curriculum to create the Numa Life Skills Program for Tribal youth attending one of the local Elementary schools.  While the American Indian Life Skills Program seeks to increase resiliency in high school aged youth, the curriculum Toiyabe created looks to build coping skills in younger children.  Sheila Turner, Toiyabe Behavioral Health Director, explained the strategy this way: "Our communities face the same problems as communities everywhere.  We see substance abuse, depression, and people at- risk.  We thought a good way to address these issues was to make sure people have the resilience and coping skills they need to face life's problems, starting at a young age."

Building Resilience

Resilience - the quality that allows people to withstand adversity and still thrive - develops over time, and touches upon many different aspects of a person's life. Resilience comes from supportive relationships with family and friends, and the support that culture and traditions provide. Resilience also requires a set of personal life skills; these skills allow a person to navigate difficult situations by managing their thoughts, emotions and behaviors in constructive ways. Resilience can be developed across the life span by cultivating supportive relationships, by engaging with culture and traditions, and by learning life skills.  A number of evidence-based curricula focus on building resiliency, including the program Toiyabe used as a model - American Indian Life Skills.

American Indian Life Skills (AILS) (formally the Zuni Life Skills) Development program is a school-based program that aims to build protective factors in youth and prevent suicide ideation. The AILS curriculum includes anywhere from 28 - 56 lesson plans covering topics such as: building self-esteem, identifying emotions and stress, recognizing and eliminating self-destructive behavior, and increasing communication and problem-solving skills. The design of the lessons allows for them to be easily adapted to incorporate situations and experiences relevant to the youth community served. Importantly, the curriculum has been rigorously tested and shown to be effective.

Getting Buy-In & Creating the Program

The success of the AILS program helped when it came time to propose the idea to Bishop elementary school.  The project also required building relationships with the school administration, carefully explaining the vision of the project, and getting feedback from parents, teachers and the community. Natalie Vega, Behavioral Health Therapist Intern at the Toiyabe Indian Health Project and the core developer Numa Life Skills explained the process: "Initially, we worked with the Native American liaison as the school.  She was really helpful in the process and she knew about the needs of the Native students, especially those at risk. After working with her, we had meetings with the school principle and vice principle, we conducted surveys with the teachers, and we shared information with parents. After this groundwork, the program was accepted into the school."

Ms. Vega has put many hours into the adaptation of the AILS program to make it more kid-friendly and culturally relevant. For example, some components in the AILS curriculum, like directly speaking to students about suicide, are hard to translate to 5 - 10 year olds. The Numa Life Skills curriculum adapts this material. In the example of talking about suicide, death is discussed in more general terms to level with the younger population while teaching coping skills to deal with the tragedy of death in the family.

Vega and Turner have also worked to incorporated many cultural practices and traditions to teach children about their heritage. The curriculum works various Paiute words into their activities to familiarize the children with a Native language. Turner and Vega also reach out to community members to share legends and traditional stories to teach lessons, as well as songs and dances that help children learn how to express themselves and understand how to deal with difficult situations. Numa Life Skill has even incorporated sign language into their curriculum. "Different languages can give kids the skill sets and tools to communicate in new ways and to express the things they don't know how to before," offered Turner.

The Program in Action; Seeing Significant Results

"The initial planning is the most difficult, but once you put the work in and get the program, going, it speaks for itself," Vega reported.  She explained that the kids enjoy these activities so much that they don't realize they are learning at the same time. Positive feedback from children, parents and teachers has led to overwhelming participation in the program. Now in its fourth year, the program began with 30 kindergarteners and has grown to 70 participants. The course is offered for a length of 5 months over the spring semester, and convenes twice a week so that students have the opportunity to attend at least one session a week.

The children are split up into groups roughly according to age, with some grade levels mixed. Vega and Turner have seen this structure benefit students in ways they never expected: "With the mix of older and younger and previous and new students in the program, we are seeing kids becoming leaders and taking on the role of peace builders. The older students who have been through the program are learning how to help new and younger kids who are struggling." 

While the program is open to all students within this non-Native school, the curriculum is culturally geared toward American Indians and 98% of the students are Native. Enrollment is on a first come, first serve basis, but referrals from the Native American Liaison are taken into consideration. The Native American Liaison plays a special role in the success of this program, and has the advantage of observing the students' behavior and well-being on a day-to-day basis. She not only helps to reach out to the students who need the most help, but she also reports on the many significant changes and tangible positive effects the program has within the school.

Building Sustainability through Partnerships

Toiyabe Indian Health Project's partnership with the Bishop Elementary School makes a large impact on the program. Through outreach to administration and teachers, the project secured an outlet to reach the youth, staff to assist with the program, and a location to hold the sessions. While there were some hesitations from staff that the program was too focused on one group of students, the need presented was very great in the eyes of most teachers and administrators, who overwhelmingly have supported the Numa Life Skills Development program. By keeping in touch with staff and faculty through surveys and on-going discussions, the program has allowed for continuous quality improvement in order to find ways to best serve students and kept up their positive relationship with the school.

Beyond the school, the Numa Life Skills Development program also has reached out to parents throughout the process. Seeking parents' opinions while building the program, engaging them through meetings during the first couple years, and sending home newsletters to update parents on program activities has built valuable partnerships with the community as well. Through this collaboration, the program has been able to call on parents as volunteers for much of their programing. Involving parents and the community has also expanded the outreach of behavioral health staff in general. These meetings and other interactions acquaint families and community members with the behavioral health staff and build relationships that encourage more individuals to seek the clinical care they need.

Numa Life Skills also has engaged in important partnerships with other community programs like Temporary Assistance for Needy Families (TANF). Twice a week, during the lunch hour lessons, TANF provides all the food for the students, saving the program time and money. Additionally, much of the staff for the program are already staff of the school, the Toiyabe Indian Health Project, or volunteers, which make the costs of the program extremely manageable.

Bringing it all Together

Understanding the need, choosing a successful approach, and building essential partnerships has allowed Toiyabe to make impressive strides in their goal of promoting resiliency in their youth. The success of Toiyabe's MSPI project and the Numa Life Skills Development program rely upon the collaborative relationships that staff have cultivated - all reinforcing each other and hold the promise of long-term sustainability, and the long term positive impacts on the communities they serve.

To learn more about Numa Life Skills, please contact:

Natalie Vega, M.S.

Behavioral Health Therapist

52 TuSu Lane, Bishop, CA 93514

760-873-6394

The National Indian Health Board staff extends appreciation to Dr. Teresa LaFromboise, developer of AILS, for agreeing to be interviewed for this article. 

Tribal programs looking for an evidence-based prevention curriculum have a number of promising options they can choose.  While almost all of these curricula demonstrate effectiveness with general populations - only a small handful have been designed for and shown effective with American Indian/Alaska Native (AI/AN) youth.  American Indian Life Skills (AILS) Development program stands out as one of those exemplary AI/AN programs.

"In 1989, in light of recent tragedies in the community, I was invited to the Pueblo of Zuni and asked to build a suicide prevention program for their high school students," Teresa LaFromboise shared when asked what sparked the development of this program. Dr. LaFromboise brought down her education graduate students with her from Stanford and was welcomed into the community. Working closely with school administration and invited into the homes of community members, Dr. LaFromboise and her team developed what was originally known as the Zuni Life Skills Development program.  "We spent one year developing the program, one year piloting it, and one year to do a final evaluation."

Much work and promising outcomes have been accomplished since then and have led to what is now American Indian Life Skills.  The curriculum has been implemented in schools across the country. After great success in Zuni Pueblo, Dr. LaFromboise was invited to implement this program with Cherokee youth at Sequoyah High School. "This was a unique situation in which we were working to serve students from 20 different Tribes at the time in this boarding school." Dr. LaFromboise explained that they started by identifying Zuni specific references, practices or images in the curriculum. These portions of the curriculum were altered, but many Tribal specific examples were interspersed throughout the curriculum to accommodate diverse Tribes.

"Suicide is an end stage behavior - when problem solving skills are lacking, an individual does not have the tools needed to cope with traumatic events. Many prevention activities like suicide awareness day, talks, and trainings are sporadic and seldom internalized by youth.  They don't instill a fundamental change." Dr. LaFromboise explained that prevention focusing upon fundamental coping and social skills building can empower youth with adaptive resilience.   

To accomplish this, AILS Development program is based in 7 core topics:

1. Building Self-Esteem
2. Identifying Emotions and Stress
3. Increasing Communication and Problem-Solving Skills
4. Recognizing and Eliminating Self-Destructive Behavior
5. Learning about Suicide
6. Role-Playing around Suicide Prevention (learning how to help a friend who is suicidal)
7. Setting Personal  and Community Goals

These topics have been developed into sets of lessons that are designed to be administered to youth in anywhere from 28 to 56 lessons. This high school-based curriculum is typically delivered over 30 weeks, with students participating in lessons 3 times a week. "It is most beneficial to recruit a credible interventionist to teach these lessons; someone in consulting, public health, social work or human resources. And in order for this program to truly work well, there must be support from the Tribe, school administration and community." Guest speakers are often part of the curriculum, and Dr. LaFromboise recommends reaching out to members of the community that would really connect with the students to heighten the effectiveness of the program.

After various trials and evaluations, American Indian Life Skills was granted the status of an evidence-based practice and is listed on SAMHSA's National Registry of Evidence-based Programs and Practices. Various studies have shown that AILS programing consistently lowers hopelessness and suicide ideation and raises a collective self-esteem, self-efficacy and self-awareness. At least one study has shown that after implementing AILS there were no deaths from suicide among students over a 12 year period of time.

Many American Indian/Alaska Native (AI/AN) communities suffering from high rates of substance abuse are concerned about ex-offenders with histories of abuse reentering the community. The DOJ's report revealed that more than half of all inmates in prison reported drug use within the month of their offense, with one third of all inmates reporting drug use at the time of the offense.  This report also noted that while overall drug use among prisoners has not changed since 1997, methamphetamine use has increased.[2] Methamphetamine abusers that are released from detention run a particularly high risk of relapse and recidivism and generally pose a greater challenge due to the uniquely difficult nature of meth addiction and the intensive treatment required.

Considerations when Designing a Reentry Program

Compounded Personal Issues

Effects of Incarceration

In addition to poor access to treatment, some argue that the fundamental structure of prison and jails can also negatively affect an inmate. A study by Craig Haney examined the psychological changes that many inmates undergo when experiencing the highly structured and isolated nature of institutionalization.[8] He identified major transformations, including: increased dependence on institutional structure, emotional over-control, social withdrawal, incorporation of exploitative norms of prison culture (i.e. frowning on signs of weakness and vulnerability), diminished sense of self-worth, and post-traumatic stress reactions to prison experiences. Not all people experience these outcomes of the correctional setting, and those that do exhibit these transformations experience them at varying levels.  This further complicates the de-institutionalization process with people presenting with wide-ranging needs and greater readjustments.

For AI/ANs incarceration brings additional challenges. Incarceration removes AI/ANs not just from the community, but also from cultural centers and spiritual practices - further compounding feelings of isolation. Some individuals are placed into an environment where they may be the only Native American, and facilities are not equipped, prepared, or permitted to facilitate participation in traditional practices (such as smudging, sweat lodges, or the use of traditional medicines) or communicate with spiritual advisors. AI/AN people may also be relocated to sites far from their Tribal communities, making it difficult for families and relatives to visit consistently and frequently. Losing these close connections with relatives and personal identity removes significant protective factors and heightens the psychological impacts and feelings of isolation that make reentry more complicated.

Overcoming Barriers of Readjusting

Difficulty adjusting is very common among people recently released from jail or prison reentering the community within the first year after release, and many experience heightened anxiety, discouragement and high risk of recidivism. Once people leave the highly structured settings of jails and prisons and enter communities, it is increasingly important that services are equipped to meet their complex behavioral health and treatment needs.  Building a program that is structured and requires responsibility and accountability, yet is welcoming and not off-putting is especially important in assisting ex-offenders with substance abuse histories to reenter the community. Programs should be tailored to individual needs, and be ready to address any transformations made during incarceration, generalized anxiety about returning to a community after such an absence, reuniting with families, navigating past relationships and social networks that might have contributed to past criminal or substance using behavior, and how all of these may trigger mental health lapses or substance use. 

Incorporating Principles of Drug Abuse Treatment

Well-Rounded Programming

These research-based principles also align with the understanding that effective reentry programs start in prison, are present during actual reentry (in the pre-release, half-way houses or parole environments), and have a continuous presence within the daily lives of individuals reentering the community. A consistent presence and supportive program appears to be components of effective programming.  Various programming has also incorporated the participation of family and friends to build or reinstall a stronger support system.

Reentry programs should also not try to recreate services that may already exist in the community.  Peer groups, local or Tribal health departments, community and social services may be vital resources for persons recently released, and those managing a reentry program should reach out to these services to ensure that staff members are knowledgeable and prepared to meet the needs of those recently released from jail or prison. Additionally, implementing cultural practices within reentry programs or facilitating participation in cultural and spiritual practices can not only encourage persistent involvement, but are important in ensuring true healing.

Closing

There is no 'one size fits all' formula for constructing and implementing an effective reentry program for American Indian and Alaska Native people released from jail or prison.  Unique experiences, criminal histories, stress of incarceration, and the stress of re-integration into a community all paint a distinctive and individualized portrait of need.  Reentry programs should focus on each participant and tailor their participation to meet varied, individualized needs.  It the purpose of these programs to support the vision of a healthier future by identifying and brokering resources, working closely with existing programs, communicating with the ex-offender to identify and prioritize his/her needs and design a corresponding wellness plan in order to effectively assist an individual reenter a community.  The wellness plan may include, but is not limited to: substance use treatment, behavioral health counseling, mentoring, peer to peer support, cultural activities, job training, or educational activities.  All of these activities support change, growth, and health.  After all, the correctional system focuses on what happened in the past, while reentry programs focus on supporting peoples' futures.