In this premiere episode of Breaking the Silence: Addressing Youth Suicide, part of the APA’s Moore Equity in Mental Health podcast series, host Dr. Helen Blaisdell Brennan speaks with Dr. Dale Walker, a Cherokee psychiatrist and Director of the One Sky Center. Together, they explore the deeply rooted factors contributing to elevated suicide rates among American Indian, Alaska Native, and Native Hawaiian youth—including historical trauma, limited access to care, and systemic inequities. Dr. Walker emphasizes the importance of cultural continuity, community connection, and empowering Indigenous youth by drawing on their traditions, languages, and ancestral strength. The conversation highlights promising prevention strategies, including school and family-based programs, and calls on psychiatrists to step beyond the clinic and work in partnership with tribal communities. With cultural humility, advocacy, and a commitment to holistic care, mental health professionals can help shape a future where Indigenous youth thrive.

Transcript for Audio

[00:02] Dr. Dale Walker: We need to unity, empowerment, security, control, and dignity as a part of our model of care to help individuals. They need to have that empowerment to be able to move along the spectrum of the past tense, the present tense, and the future.

[00:24] Fatima Reynolds: Hello and welcome to the American Psychiatric Association's More Equity in Mental Health podcast series titled Breaking the Silence, Addressing Youth Suicide. In the first episode of this series, our host is Dr. Helen Blaisdell Brennan interviewing Dr. Dale Walker. Dr. Blaisdell Brennan is a psychiatrist, professor, and passionate advocate for equity in Indigenous healthcare. The first Native Hawaiian woman to graduate from Harvard, she brings deep cultural and clinical expertise shaped by a powerful lineage of healers, including her father, Dr. Kekuni Blaisdell, a founding figure in Native Hawaiian medicine and policy. She currently serves as Assistant Clinical Professor of Psychiatry at the University of Hawaii and is the president of the American Psychiatric Association's caucus of American Indian, Alaska Native, and Native Hawaiian psychiatrists. Whether she's mentoring future doctors or shaping national policy, her work continues to uplift communities and carry forward a legacy of healing. So now let's break the silence with Dr. Blaisdell Brennan and Dr. Dale Walker.

[01:31] Dr. Helen Blaisdell Brennan: I'm Helen Blaisdell Brennan here with Dr. Dale Walker. Dr. Walker is Emeritus Professor of Psychiatry at Oregon Health and Science University and a Director of the One Sky Center, a national resource hub for American Indian Health, Education and Research. A Cherokee from rural Oklahoma, Dr. Walker has dedicated his career to improving mental health and substance use services for Native communities through research, leadership and mentorship. A former president of the Association of American Indian Physicians, Dr. Walker has held numerous national leadership roles and received multiple honors for his service. His work spans over 50 research grants and 100 publications focusing on culturally informed care and treatment. Welcome Dr. Walker.

[02:25] Dr. Dale Walker: Thank you very much, Dr. Blasey. It's very good to be here with you and good to see you again.

[02:34] Dr. Helen Blaisdell Brennan: Yes, well, we're here to discuss the important issue of breaking the silence on American Indian, Alaska Native, and Native Hawaiian adolescent suicide. So we'll dive right in, if you don't mind. Given the significantly higher suicide rates among American Indian and Alaska Native youth compared to other groups, what unique challenges do psychiatrists face in addressing this crisis?

[03:02] Dr. Dale Walker: Well, that's a good question to begin. The first thing that we need to do is to look at the population. Where do Indians live? How many are there? What's it all about out there in Indian country? There are 9.7 million American Indians who live in the United States in the 2020 census. Currently, there are 574 federally recognized tribes and there are 63 recognized tribes by states in 11 states actually throughout the country. There are 400 tribes that are neither federally or state recognized that are seeking recognition. What that means is they get federal funding and support for health care and other benefits within their community. There are 326 reservations, so they're scattered across the country, and it's really interesting. We don't share that history very often with the world. And so it's fascinating to see that we have this scattered out system of care. The Indian Health Service supports the care 42 % of the time. The other funding is not available. And so we struggle with an issue that has reduced access to care.

The geographic isolation is a real problem and there are no resources or available staff in many communities. And so the care is hodgepodge and a little bit difficult in some places. Not to fault the Indian Health Service who's doing a great job with the resources they're given. But the fact is the access to care is a real problem and I think that's the outstanding issue. Now, by the way, 75 % of Indian people do not live on reservation. They live in either rural areas or urban areas or in city areas. And those people receive healthcare funding through Obamacare and Medicaid. Both of those issues are on the chopping block, as you well know. And so we have great concern about what's going to happen in the immediate future with mental health care for Native people.

[05:27] Dr. Helen Blaisdell Brennan: The suicide rate among American Indian and Alaska Native adolescents increased roughly 26 % from 2018 to 2021. What factors might be contributing to this alarming trend and how can psychiatrists better monitor and respond to emerging risk factors?

[05:46] Dr. Dale Walker: That's an interesting question because a lot of events happened between those two particular days. The first thing is COVID and the COVID pandemic. That created incredible release of organizational structure throughout the United States. School systems were closed and dealt with by telehealth as best as possible, but we've seen a resulting decline in performance because of the closure of schools over that time period. In addition to that, the economic problems that were created, you many jobs were lost during the COVID phase. Opportunities for health care were reduced because the staff were leaving, were not available. It's significant to note that the death rate from COVID and American Indian, Alaska Native communities and probably Native Hawaiian data are all higher than the general population. And so the problem hit severely. It was dealt with with very small support services and it was a difficult time. And I think that accounts for the rapid increase in suicide problems.

[07:13] Dr. Helen Blaisdell Brennan: With suicide as the second leading cause of death for Indigenous youth aged 10 to 24, what early intervention strategies could psychiatrists implement to reach children before adolescence?

[07:29] Dr. Dale Walker: Well, I think there are two targets that initially have to be addressed. One is reaching to the family and the other is to the school system. Most of the prevention intervention models start with those two pieces for adolescents. But we need to also have an understanding of how school enrichment can be developed throughout Indian country and Native Hawaiian country. We need to look at better jobs, housing and available food for these areas. There are two programs I'd recommend that we mention, and that is the National Indian Youth Leadership Program, which provides kind of a challenge course for community agencies and children to work through their problems and work competitively to solve problems and enrich their culture remind themselves sometimes of their culture. The other is the American Indian Life Skills Program, which is a cognitive behavioral training program to get children to talk about the changes in their lives, how they deal with frustrations, and talk about suicide as a risk within a community. Both of those programs have promise for prevention intervention projects.

[08:56] Dr. Helen Blaisdell Brennan: You know, when I, I don't know about you, but when I read the statistics, suicide at the age of 10 just struck me as unfathomable. What factors do you think are at play leading our Native children to even consider death at such a young age?

[09:13] Dr. Dale Walker: Well, I agree with you. And sadly, it can be even younger. As I've thought more and more about prevention intervention and age groups, one of the things that strikes out is something called cultural continuity. And cultural continuity relates to how a person looks from generation to generation and their background about those valuable pieces that are a part of their culture and how they grew up. It's a part of their history, it's a part of their tradition, and it's an issue of their history. And bringing that continuity together in a way is what an individual works for in the present tense. So we take history and look in the present tense as we form our identity. And the interesting thing for many native communities or indigenous communities is that without the history and if you look at the present when the system is disorganized, when there's not enough funding for housing, when there's problems with employment, problems with food availability, and problems with the school system, it's hard to make decisions about your present and hard to make decisions about your future. So what happens is there's a great deal of frustration. There's a feeling of hopelessness. There's a feeling of frustration that you're unable to move forward in that situation. And that happens to 10-year-olds, though identity is more a 12-year-old issue. 10-year-old people are struggling with what this background is all about. And so what you have is increased addictions. You have domestic and community violence. You have suicide ideation, and ultimately suicide. And so we need to look at this prevention intervention model to cover past tense, present tense, and future.

[11:26] Dr. Helen Blaisdell Brennan: You know, what you're speaking of reminds me of when recently when we've gotten into the Hawaiian community, one of the things we do for adults and children is to model how Native Hawaiians would recite our language is mostly oral, our genealogy. So for instance, we would say so and so and so and so gave birth to so and so, so on and so forth until it comes to the actual individual.

And we find that when children do this and adolescents do this, they immediately become aware that it's, as you were saying, it's not just today that matters, but they're, on how far you go back in genealogy, there's a long line of proud and strong and resilient native Hawaiians, in our case on many times on many different islands, who set the stage for this very special individual to be here today.

And we end that chant with a connection to my mountain, my mauna is the Kaolau's, my water is Kapaki Pika, the Pacific Ocean, and my rain is in every island in Anahu and every valley actually has a different rain. So we name our rain and that tends to ground and center the children and indeed the adults to a sense that we're not only connected to our ancestors who came before us, but to the aina, the land, the mountains, the ocean, and the rains that make us who we are. What do you think about that?

[13:06] Dr. Dale Walker: I think that you've hit the target. When you look at cultural continuity, which is what you're doing, taking that information of the history in the community for the psychiatrist to work with that in developing a prevention intervention project, they have to know it. So psychiatrists have to learn from the community what's the history and what are the present day problems and then you can build a way of dealing with that. Now, one of the things that I wanted to talk about was looking at the social determinants of health. Michael Marmot developed this in the 1990s, and he's looked at many indigenous groups across the world. And, you know, it's an interesting process, first of all, to remember that when you look at social determinants of health, what you're saying is that people who have wealth and influence and are doing well, they have a better morbidity and mortality. The ones who aren't doing so well have higher morbidity and mortality. That's the populations you and I work with every day. And in able to do that, what Marmot has described is that we need to develop unity, empowerment, security, control and dignity as a part of our model of care to help individuals. They need to have that empowerment to be able to move along the spectrum of the past tense, the present tense, and the future. And to do that in our systems, what that means is we have to look at housing, education, employment, social services. All of these things have a role to play in helping a person get through the present so they can plan for the future. That's the perfect model for a prevention intervention approach.

[15:17] Dr. Helen Blaisdell Brennan: Absolutely. know at Wyni Comprehensive Health Center where I worked for more than 15 years, we really did tackle Maslow's hierarchy of needs. In many respects, psychiatrists were social workers. We connected them with housing resources and food resources and so forth with the understanding that our patients can't effectively work with their mental health issues if they don't have food, clothing, shelter, a safe place to sleep and so on. So I see there's a lot in common between your indigenous communities and ours. Considering the strong cultural stigma around discussing suicide in some indigenous communities, how can we psychiatrists sensitively encourage more open conversations about suicidal thoughts and behaviors?

[15:52] Dr. Dale Walker: It's well said.

Well, you know, that's an interesting question because stigma is a confusing term. We say on the one hand that suicide is more common in indigenous people. So they do talk about it. It is real, but they deal with the reaction to suicide and the sadness and the grief that they have in the process. And sometimes that is so overwhelming that it makes it difficult to stop doing intervention, try to work with the problem, understand what happened. When I work with a community, I have to go in and untangle and find out exactly what happened in each suicide over the last year so that I can actually understand the process and how it happened and what was the follow-up.

And out of that, I tried to learn how we might build a model to take care of the community and take care of the family. I think that's the difference now. It's a much more active role for psychiatrists to play in this work.

[17:22] Dr. Helen Blaisdell Brennan: Good. Programs that center Indigenous traditions, language, and elder involvement have shown promise. How can we psychiatrists collaborate more effectively with Indigenous community leaders to implement culturally grounded prevention strategies?

[17:40] Dr. Dale Walker: Again, I think that you need to study the tribe, study the community, study the individuals, the groups that you're talking about. It breaks out in funny ways and you don't control that. You just need to know it. once you kind of have that information and you get out of your office, you know the community well and you'll be able to help them, I think, a lot more easily. So I think mental health providers can do that. I think that they can collaborate much more effectively when they're aware of the system instead of waiting in their office for a problem to come in.

[18:21] Dr. Helen Blaisdell Brennan: I've been recently impressed by the number of articles on cultural competence and cultural humility. And I think those are very effective, not only for we psychiatrists, but for all mental health professionals. I can speak specifically to the Island of Maui after the Lahaina fires. There was some issue because there was a shortage of local psychiatrists and mental health providers. But when providers were brought in from the outside, some who hadn't been, didn't have your experience, for instance, in cultural competence and cultural humility, would be saying things to the wildfire survivors, some of whom were suicidal, like, you know, what's a good place to eat and what's a nice beach and where would you recommend? And so they were actually unaware that they were, you know, they were re-traumatizing the individuals because instead of focusing on the care for the wildfire survivors, they were also kind of inserting their needs into it. You know, I'm looking for a place to stay. Do you know anyone? Can you tell me where the good beaches are? I know a lot of the restaurants have burned down. Is there another one that you would recommend? And so I think in addition to getting out into the community, there's that kernel of cultural humility and competence that I think APA is doing a great job of spreading that message. And I just took my ABPN recertification and their articles on cultural humility too. So I think that's an excellent way also to not only bridge ourselves with the community, but to avoid pitfalls that may either not build a therapeutic alliance or actually traumatize a therapeutic alliance.

[20:14] Dr. Dale Walker: Well, I agree with you and I think that that's what makes psychiatry fun. That, you know, it isn't our book learning, it's what we do with the book learning and how we reach into a community and help them grow and prosper as opposed to us going through the textbook or the cookbook of medicine and saying, this is the way it's going to work, this is the way you will get better or, you know, it's not going to happen and then you blame the patient. We have a lot of work to do and I know that we'll talk about that in the next few moments.

[20:56] Dr. Helen Blaisdell Brennan: Given the complex socioeconomic disparities affecting indigenous communities, what holistic approaches should psychiatrists consider to support youth beyond traditional therapy settings?

[21:11] Dr. Dale Walker: In some ways, a timely question because of what's happening in our country right now. You know, over the past 50 years, medicine has expanded from simply providing reactive treatment to a problem to now including public health and prevention intervention, which I would call proactive treatment. We're now trying to avoid or reduce the risk of having a problem instead of just treating it.

That's a very progressive, sometimes provocative change in how we approach patient care in this country. It requires us to do all of the things we've been talking about, to work with the community, to work with systems, to find systems that have problems and help them resolve their problems, or people in their community will be having health problems. And so we have to really reach far beyond what we've learned in treatment now to look at prevention and intervention and public health. That's not easy. And I tell you what's happening in our country right now, know, Medicaid, which covers a lot of what we're talking about with children is under fire. And we need to worry about what's going to happen if we lose the support to do these things? Are we going to be pushed back into another form of treatment where, we don't care about the systems, that's their problem. That's not the way I want to see psychiatry go.

[22:53] Dr. Helen Blaisdell Brennan: I would agree and I'm hoping that we will support our public health colleagues who are leading the charge explaining that prevention is actually not only better for cultures, including indigenous tribes and all people, but also saves money and being proactive and providing ways of preventing mental health issues as well as other health issues will really win in the end as it'll save morbidity and mortality and also lower costs. So I'm hoping that we all psychiatrists and all mental health professionals can really get behind our public health colleagues and support continuation of national efforts to improve preventive medicine.

[23:48] Dr. Dale Walker: Well, let's not let them take the fun out of what we do.

[23:54] Dr. Helen Blaisdell Brennan: All right, how important is it for mental health professionals to be trained specifically in culturally competent care? We were just going over that. And what gaps currently exist in professional education regarding indigenous mental health?

[24:08] Dr. Dale Walker: Well, we have kind of gone over this. It's obviously critical. We need to take the time to learn everything about a patient and the community. We need to look at the history. We need to look at the cultural continuity and analyze it as we try to develop a prevention intervention plan that reinforces and helps the child make decisions about their life and about their future. I think that that's important. We need to work with the patient and the family.

But we also need to open the doors to other community members who want to help, but they have difficulty in finding their own life.

[24:50] Dr. Helen Blaisdell Brennan: Community and family connectedness are significant protective factors. How can psychiatrists support strengthening these connections in communities affected by historical disruption and systemic oppression?

[25:04] Dr. Dale Walker: Again, my experience in this area is to bring the community in to assist in solving the problem. And by the way, that's an unusual approach. When I'm asked to see a community and deal with problems like this, I usually meet with the tribal council first to find out what they really want because they decide things and it's important to work with them get their trust and okay to kind of do this work. But after we do that, then I interview members of the community who might be decision makers about making things happen to improve the tribe. And that would include medicine people. It would include elders, youth. always, we always forget, might be nice to talk to the kids about suicide and get their advice on what's needed. We sometimes skip that issue. But if we bring the teachers and the religious people and other people, one of my favorites is people who are the academic, I'm sorry, the recreation coordinators. Those people know the kids and they know how to set goals and work with kids in a way that a lot of the other systems don't know how. It's important to bring them in and create a task force of all of those people and let them have input into what prevention intervention means.

[26:48] Dr. Helen Blaisdell Brennan: How can mental health professionals effectively measure and communicate the impact of culturally specific interventions to policymakers and funding agencies to secure sustained support for tribal mental health initiatives?

[27:03] Dr. Dale Walker: You've asked me a very good question and one that I work on a lot. In today's government, that's really the $64,000 question. All politics are real and they're all personal. Whenever I try to work with a problem and bring it to the government for advocacy, I always try to personalize it to the problems in their congressional district or in their state.

You can get much better response if you give examples that they need to decide upon. And if you present it to them, visibly they have to react to it. They have to have a reaction to do it. Now, if the problem's broader than one state, you bring in other people, other senators or other congresspeople or congressional staff to help you with developing a broader based approach to working.

But advocacy should be training in psychiatry. We need to know how to advocate for our people because a lot of people don't have an interest in this area, especially healthcare. We don't stand up for the needs of our patients. And I would take my hat off to psychiatry. Psychiatry was the first medical association to testify to the Senate Committee on Indian Affairs about the needs of Indian people.

[28:35] Dr. Helen Blaisdell Brennan: I didn't know that. Fantastic. All right, we've reached our five minute warning. Finally, Dr. Walker, considering the interconnected nature of suicide, substance abuse, violence, exposure, and poverty, how can we psychiatrists advocate for integrated community services to holistically address the needs of Indigenous youth?

[28:58] Dr. Dale Walker: We need to be a part of the solution. We need to be a builder and help provide access. In many ways, it's a consultation role as opposed to a therapist role. If we can identify the problem by looking at the system and if we know that we'd have to have better housing, know, many of the people, there might be a three-bedroom house, but there might be 20 people living in it.

And you can just imagine for an adolescent what that's like and the chaos surrounding where the food comes from, all of the energy inside a place like that. It's really an important issue for us to be concerned about, but we have to be active as bringing the pieces together to find solutions. When we do that, we then let them be the task force and we're the consultants to the task force to help find solutions to reality test to see if we can bring a bit of a contest of who can do this the fastest. know, those are the things that you can do to have a little fun getting the community to work with the problem and help people and always have a feedback loop so that you know that you're making a difference and that you're able to kind of find a solution to the problem.

[30:27] Dr. Helen Blaisdell Brennan: Thank you so much, Dr. Walker. In 2019, suicide was actually the leading cause of death for Native Hawaiian and Pacific Islanders between the ages of 15 and 24. And HPI students were more likely to have made a plan for suicide and yet three times less likely to receive mental health services or treatment medications. So we in Hawaii have a long way to go, but thank you for sharing your mana'o, your thoughts on these and special thanks to APA for bringing this important topic to the public and to the American Psychiatric Association.

[31:04] Dr. Dale Walker: It's a pleasure to work with you and I'm sure we're gonna have a lot of fun with this in the future.

[31:10] Dr. Helen Blaisdell Brennan: Looking forward to working with you, sir.

[31:12] Dr. Dale Walker: Thank you very much.

[31:14] Fatima Reynolds: Thank you for joining us on Breaking the Silence, Addressing Youth Suicide. Please visit the Medical Mind Podcast homepage at psychiatry.org for more information and a resource document related to this episode. We also invite you to visit psychiatry.org slash more equity, M-O-O-R-E-E-Q-U-I-T-Y for more information on the APA More Equity in Mental Health Initiative. Take care.

[31:43] Dr. Helen Blaisdell Brennan: The views and opinions expressed in this podcast are those of the individual speakers only and do not necessarily represent the views of the American Psychiatric Association. The content of this podcast is provided for general information purposes only and does not offer medical or any other type of professional advice. If you are having a medical emergency, please contact your local emergency response number.