Tribally-Run Health Care Center: One of the Best

“They say that when something breaks down, there are other pieces that also break with you, so you always address every area. If you’re drinking, there’s got to be some sort of mental thing that’s happening, spirituality is broken down. In order for someone to be totally well, you have to make sure every aspect of their life is well also, or gets well.”

These are the words of Mary Casoose. She is native to the San Carlos Apache Nation, and she is also the prevention manager at the San Carlos Apache Wellness Center. For Apaches, this is the way it has always been, she says.

This same guiding principle is also applied at the Wellness Center, an internationally-recognized mental health and substance abuse clinic located on the reservation, where each patient’s health is considered on all four levels.

Spiritual, Physical, Emotion

The center is tribally-run, as opposed to being federally-run by Indian Health Services. Before there was the Wellness Center, there was the behavioral health department and the substance abuse department, two separate entities run by IHS, employing one half-time and one full-time position to serve the needs of the entire reservation.

In 1996, the tribe elected to ‘638’, or self-govern, its behavioral health and substance abuse programs, transferring oversight of the programs from the IHS directly to the tribe.

In 2003, behavioral health and substance abuse were brought under one roof, along with the teen substance abuse department, to create what is now the Wellness Center. It was considered a pioneer program at the time, one of the first to take an integrated approach on a reservation. Since then the center has gained nationwide attention for its success, becoming a model for tribes across the nation.

The center now occupies two buildings with a current staff of 86 employees, including what are considered some of the best psychologists in the nation. Eighty five percent of its employees are members of the tribe, and both postdoctoral residents are Native American (there are only approximately 237 Native American psychologists in the U.S. and Canada).

In 2007 the Wellness Center was one of first tribally-run programs to get international accreditation.

A year later it received a Behavioral Health Program of the Year award through the Substance Abuse and Mental Health Services Administration.

The design of the center itself reflects Apache tradition and encourages tribal members to feel at home. There are skylights throughout the building. The colors in the rooms stand for the different directions. The first thing you will notice when you enter the Wellness Center is the Wickiup room, which is round.

“The Wickiup was where people lived, that’s your house. And the roundness is the continuation of life, the circle,” Casoose explains.

Group meetings are also conducted in circles. This goes back to the tradition of a talking circle, where people relay ideas and emotions in a clockwise manner.

All tribal members have access to this facility. Anyone can walk in and be treated, free of charge, regardless of income or age.

And they do.

As of 2011, almost half the tribe (45 percent) was using at least one of the Wellness Center’s services.

The center has developed a trusting relationship with many in the tribe because of its emphasis on confidentiality.

The tribe has seen some trying times, and this program developed out a need. Drug and alcohol abuse, as well as suicides, have been high on the reservation. A lot of this has to do with high poverty and unemployment rates, as well as historical trauma, Casoose says.

Keep in mind, the Apaches were not considered U.S. citizens until the 1940s, and could not self-govern until the 1950s.

“We never really got out of it,” she says. “Our spirituality, our way, our culture was pushed back and we were told that’s something that’s not acceptable, it’s wrong, even our language.”

“I think it just carried over, and pretty soon the adults in our lives were all depressed about how their lives were, and the teachings were gone,” she continues. “And now that’s what we’re looking at bringing back, is teaching in the right way.”

Since the Wellness Center came into being, suicide rates have dropped. The center created a suicide prevention task force in 2008, a cooperative team involving the tribe, the county, the state, IHS and the Bureau of Indian Affairs. The task force was exceedingly successful, and it is now recognized as the best in the nation.

As the center continues to grow, the number one priority has been to expand services offered to the tribe, including educational programs, counseling, telepsychiatry, psycho-social rehabilitation and group therapy.

When you are sitting and beading moccasins, you are accessing different parts of the brain. Stranding beads together is a meditative process, it allows the mind to wander other places at the same time. When you are joined by others doing the same thing, it becomes an ideal setting for discussion, whether it’s about concerns, fears or experiences.

It makes sense, then, that the Wellness Center offers more than 30 therapy groups centered around these kinds of activities. The tribe has found that group therapy is overall more effective in addressing issues like substance abuse, anger management and healthy relationships. Other groups include an 18-week domestic violence group, a sweat lodge group and a drumming group.

Studies in California are showing that drumming has a calming effect on moods. Since October, postdoctoral resident William Shunkamolah runs a small drumming group once a week at the clinic using his personal family drum. Coming from a Native background mixed with Osage, Kiowa, Navajo and Tohono O’odham, this is something he grew up with.

Shunkamolah guides the drum beats with song, some of which are more than 100 years old.

He will sing inter-tribal and social songs, in addition to songs he was taught as a kid. Many of them reflect lessons about relationships, responsibility and humility.

“I have people come in and they’re really tired from work, and maybe they’re not in the greatest mood,” he says. “But by the end of the session they’ve focused on the drumbeat, and I do see changes in their mood, they seem a little more relaxed a little more open.”

Despite the fact that the songs and the drum are not Apache, the drumming group creates some level of comfort and familiarity, patients tell Shunkamolah, and they are more trusting of him.

Since the Wellness Center brings in court-ordered patients, this is especially significant to how they view the center.

“It’s not just some institutional place they have to come to that doesn’t represent them,” Shunkamolah explains.

Clinical director Dr. Thea Wilshire attributes the center’s success to its need-based approach. For instance, the center identified which groups were most at risk, and developed clinical intervention based on those numbers.

Suicide rates were high among children in unsupervised homes, so the center created a seven-week free summer camp for kids. Treatment money could be used for these programs because they were preventative. The center created the Young Warriors program, a before and after school program, as well as Extreme Warriors, a weekend program where licensed recreation technicians take kids as far as California and Colorado to ski, surf, rock climb and hike.

“These kids went to camp and didn’t have anything,” says Wilshire. “We gave them a sleeping bag, a Camelbak, warm clothes, meals and transportation.”

As a result of these programs, behavioral incidents in schools decreased.

Another focus at the center is providing new social structures to tribal members who are now sober, whose lifestyles no longer revolve around alcohol or substance abuse.

“We understand that a lot of our clients get the jitterbug to go drinking, that urge starts to come alive,” says Louie Lorenzo, the Bylas prevention coordinator.

In response, Lorenzo is developing a new program where families can spend two weekends a month at Point of Pines, complete with meals, wellness and health education, activities like fishing, canoeing, talking circles and AA meetings.

Casoose is a well-known face throughout San Carlos. Like Lorenzo, she is constantly organizing preventative activities, like mens’ and womens’ retreats up in the mountains that incorporate activities like hiking and tai chi with presentations on relationships, jobs and education. All of these tie back to addressing and supporting different parts of the participants’ life, whether it’s spiritual, physical, social or mental.

“I fight like crazy for the finances to cover this, and I’ll write it up and I’ll justify why we do this,” she says. “It really does lift them up when they see there are different things they can do for themselves.”

Funding of IHS has been chronically low. In 2005, it was the least funded health care program of any in the federal budget, at $2130 per capita. After 1996, however, the Wellness Center gained other sources of federal funding through Medicaid and grants.

Activities like the retreats have helped people turn sober.

Casoose also organizes community events, many of which draw up to 1500 people. One of her biggest success stories is the fall festival, which has been going strong for the last six years.

“We started doing that at the beginning it was because we realized that a lot of the people that we deal with, the kids that we deal with, have been through so much crisis in their lives,” she explains.

Initially, parents were dropping their kids off. But within the last two years, that is changing. Dad’s are sobering up to take their kids to events.

“We know it’s had an impact, because the fathers are there,” she says.