Case Study of "The Team"- Chapter 16

As a member of a team of Native American mental health professionals and traditional spiritual leaders (hereafter called "the Team"), I have had the opportunity to respond to community crises in Native communities. Often these responses have come after communities have experienced clusters of youth suicides. The following is a description of one of those responses. The health director of a remote tribal community of approximately 2,500 contacted and met with the Team leaders (one of the community's traditional spiritual/cultural leaders and me, a clinical psychologist).

She described the occurrence of 17 youth suicides in the community, all by hanging, over a 2-month period. Most members of the community had been affected directly in some way, and some families had lost more than one child. Service providers and first responders in the community were overwhelmed and exhausted as suicide attempts were continuing almost every day. Community leaders had sent the health director to request that the Team respond as soon as possible to help stop the suicide attempts and help the community begin a healing process. Team Activities The Team prepared itself through spiritual ceremony and then traveled to the community within 3 days. The following are some of the activities of the Team over the next several weeks.

Meeting with first-line service providers (FLSPs). The Team spent the first day meeting with a group of service providers and first responders from the community, providing training on the effects of traumatic stress and using talking circles to give the FLSPs a chance to talk about the ways they had been affected by the suicides. The FLSPs became the lead group for all the following work and worked closely with the Team for the remainder of the visit. Community meeting. The Team conducted an open community meeting to hear the perceptions and ideas of community members about what had been happening. Meeting with tribal government.

The Team met with the tribal government to ensure that community members recognized that the Team had been authorized to be in the community, and to present a report and recommendations to tribal leaders at the end of the visit. The Team maintained contact with tribal leaders as recommendations were implemented over the next several years. Meeting with spiritual leaders. Traditional Native spiritual leaders and church leaders had never met together before but were able to come together to provide united spiritual support to community members. Working with schools.

All of the schools serving the reservation children (public, church-based, tribal) were visited. This was facilitated by school counselors who were part of the FLSP group. Team members working with members of the FLSP group held talking circles with children in every grade, all teachers, and all administrators to educate (in grade-appropriate formats) about the effects of traumatic stress and to identify high-risk children. Meeting with affected families and relatives. Team members traveled to families' homes or met them in places they felt comfortable.

In some cases, families had not yet reentered the homes where their children had died. Spiritual leader members of the Team conducted the appropriate ceremonies that would allow them to go into their homes or enter their children's rooms. Mental health members of the Team worked with the children, adults, and families to help them express their grief, honor their loved ones, and support one another. Meeting with representatives of the judicial system.

Some children whose siblings had died were afraid to return to school because they were afraid someone else in their families would die. The schools had started to press charges against the parents for truancy. Team members met with representatives of the judicial system and were able to work out solutions that included in-home schooling for affected children. Building a context.

Meetings with the tribal health director over a 2-week period revealed a broader context that included 4 years of massive flooding on the reservation, basements that held 3-4 feet of standing water, increases in respiratory illnesses, deaths of elders, occurrence of hantavirus, and washed-out roads requiring school buses to detour 70 miles (resulting in children going to school in the dark and not returning until dark). Many families had moved to the central district of the reservation, where services and schools were centered, but a severe housing shortage required them to live with friends or relatives. Families were separated, with members scattered among multiple households and their possessions somewhere else.

Federal funding cuts meant that service providers were overwhelmed. Overcrowded living conditions led to increases in substance abuse, domestic violence, and gambling. Preexisting racial tensions between the reservation residents and people living in the nearby town were exacerbated. There was a single half-time mental health professional for the reservation, and when the suicide attempts started, young people who attempted to harm themselves were sent off the reservation to hospitals more than 100 miles away for evaluation.

Often, their families did not have access to transportation and could not go with them. When the young people returned, their families were not informed about diagnoses, medications, or warning signs, and there was no aftercare in the community. This was the case for many of the young people who had died.

People started to believe that when their children were "sent away," they were put on medicine that contributed to them killing themselves, so now there were many more suicide attempts that went unreported. The young people who had died were actually seen as the youth leaders in the community.

Sharing the context. The Team worked with the health director and tribal governance to build the context for the current crisis situation. The tribal chairperson called a mandatory meeting of all community members so that the Team could share the context with community members. People in the community had not connected the long-term stress brought on by the flooding to the suicides.

The tribe did not think of the flooding as a "disaster" because it was a part of the natural world (there actually is no word for disaster in the tribal language). Team members had also been working with the young people, developing a new set of youth leaders. These youth shared their grief, feelings of loss, and need for adult guidance at the community meeting. Sharing this context allowed community members to get a "big-picture" view of what had been happening and allowed them to come together and mobilize community resources to support each other and begin a healing process.

Developing a community crisis team. The Team worked with the FLSP group to develop a community crisis team with an emergency plan and connection to needed resources. The Team had discovered a pattern of suicide attempts, and planning was done for the community crisis team to use time periods when no suicide attempts were happening to do community education and outreach. Engaging in advocacy.

The Team was able to advocate with FEMA to get needed resources to the community. Acknowledging the relationship. The Team maintained contact with the community and its leaders. Follow-up visits focused on further development of the crisis team, the youth leadership, community education, and advocacy for resources.

It was important for the Team to acknowledge that its relationship with the community did not end at the end of the crisis. Engaging in self-care. The Team met at the end of every day so that members could debrief and check in with each other. Even when the Team worked late into the night, this meeting was important to make sure that everyone remained healthy. In a situation where children have died and everyone in the community has been affected, it is difficult for helpers not to be overwhelmed as well.

Throughout this intervention and the several years that followed, the Team maintained a supportive presence, stayed in the background, and empowered community leaders and service providers to shape and implement their plans. Community members who had felt helpless in the beginning became active leaders for change in their own community. The suicide attempts stopped, the youth leadership asked for representation in tribal governance, and needed resources (including mental health professionals) were received in the community.

1. What are some of the reactions to traumatic stress seen in the community described above? Would you describe the community above as resilient? Why or why not?

2. How did culture play a role in the crisis that occurred in this community?

3. How do the IASC guidelines apply in this setting? How do they serve to protect a community during a crisis response?