Alaska Native communities’ suicide prevention focuses on strengths : NPR

Alaska’s Yukon-Kuskokwim Delta is one of the nation’s most remote regions, stretching across 75,000 square miles of mountains, tundra and coastal wetlands along the Bering Sea. The U.S. Census counts the population at roughly 27,000 – the majority of whom are Alaska Natives of Yup’ik and Athabascan descent – placing the region among the most sparsely populated areas in the United States. There are no roads connecting the Delta’s 50 villages to the national system. It’s also home to the nation’s highest rates of suicide.

Since the 1950s, mental health experts say that suicide prevention models have largely been designed to identify and mitigate risk through an individualized approach, treating symptoms like anxiety or suicidal ideation through therapy or counseling. But as suicide rates have steadily risen over the past few decades, a group of Indigenous researchers at the Center for Alaska Native Health Research (CANHR) have been developing a new approach across the villages of the Y-K Delta.

Over several decades, CANHR has designed programs that aim to build up a community’s endemic strengths, rather than solely treating the risks facing individuals within that community. By providing support and resources that enable access to Alaska Native cultural activities, they hope to strengthen social bonds that build resilience. Their approach has shown such promise that it’s now being piloted in Alaska’s military population – another demographic highly impacted by suicide – with hopes that the model could scale both nationally and abroad.

‘A People in Peril’

For decades, it’s been common to see headlines that highlight the wide spectrum of challenges confronting the Y-K Delta: the lingering psychological impacts of residential boarding schools; high rates of substance use and sexual violence stemming from generational trauma; dwindling salmon runs that limit food and livelihood; and a changing climate that is threatening low-lying village communities along the coast with flooding and erosion.

But the researchers at CANHR, who work out of the University of Alaska Fairbanks, believe that all this focus on risks might actually be part of the problem. They say that as a result, these communities are often viewed solely through the prism of their challenges, while funders and research groups across the field of suicide prevention have dedicated too little attention and resources towards approaches that emphasize their inherent strengths. “We’ve been trying risk reduction approaches for nearly half a century,” says Stacy Rasmus, the director at CANHR. “And we are not moving the needle with those approaches.”

The origins of CANHR’s innovative prevention efforts can be traced, in part, to the conversations that emerged in response to intense media coverage of the problems confronting the communities of the Y-K Delta. In the 1980s, the Anchorage Daily News published a Pulitzer Prize-winning series called “A People in Peril,” which described a burgeoning crisis of suicide and substance use in Alaska’s Bush villages. “The Alaska Federation of Natives came out after that and said, ‘yes, that’s a reality, but that’s not who we are,’” says Rasmus.

Rasmus – who is Indigenous – says those articles failed to capture the positives that also exist in village communities. “We need our young people to know that they’re not vanishing, they’re not all drowning in ‘a river of booze’. That was literally a title of one of the ‘People in Peril’ articles,” says Rasmus. “Actually, the large majority of Alaska Native people are living their ancestral ways of life. Indigenous people are here, and have these strengths.”

Subsequently, a group of leaders from Alakanuk – one of the villages named in the article – approached CANHR to collaborate on an action plan that would focus on building up the community strengths that already existed in the local Yup’ik culture, rather than treating the individual risks identified by the series – like substance use and depression.

Implementing a community-based program required a break from decades of common practice in suicide prevention, which has historically tended towards an individualized, medical approach, often in a clinical setting. As a former village clinician in the Y-K Delta, Rasmus had seen firsthand the need for a different strategy. “I went and lived out in Emmonak for three years before realizing that a clinician’s toolkit wasn’t gonna help.”

During her tenure in the village, as an unlicensed clinician fresh out of graduate school, Rasmus was immediately confronted by eight consecutive youth suicides. Rasmus found herself facing a lot of difficult questions from the community: “What’s going on with our young people? What can we do? You’re a mental health clinician – fix it.”

But Rasmus struggled to get her young patients to open up. She remembers one young man who “walked in, took his hoodie strings, put his head down, and tightened it up. And that was it. This young man was never going say one word to me.”

In search of a more effective approach, CANHR embarked on a research project that would come to span decades, traveling to seven different villages across the Y-K Delta to meet and collaborate with Elders and local leadership. Through interviews and conversations, they identified positive qualities within communities that are protective against suicide, such as the cultural traditions surrounding Alaska Native food, hunting, music and storytelling. These ‘protective factors’ would prove foundational to more than a dozen studies that followed, funded by the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Service Administration’s (SAMHSA) Native Connections Program.

The culmination of these efforts was a flagship program called Qungasvik, a Yup’ik word meaning ‘toolkit,’ which aims to reduce suicide risk by providing youth with culturally grounded activities and learning.

Rasmus has been helping oversee Qungasvik for the last fifteen years. “In a Yup’ik worldview, suicide is not a mental health disorder, and it’s not an individual affliction, it’s a disruption of the collective,” she says. “And so the solution to suicide needs to be at the community level.”

‘Tools for Life’

Every week in the coastal village of Hooper Bay, a local dance group gets together for practice in the tribal council building. In this village of roughly 1,300 people in Alaska’s Y-K Delta, public spaces are scarce, so the room gets used for council meetings during the day and events at night. Tables and bingo machines have been swept to the side, and rows of folding chairs are laid out facing a small stage where a group of about 20 locals are gathered. A row of drummers plays in the front, while Elders teach the youth to dance. People of all ages shuffle in and out of the door in heavy winter clothes.

Gideon Green is one of the regulars. “Doing our Eskimo dances and drumming, it takes your stress away,” says Green. “It takes my depression away when I’m hitting the drum. It just takes out all the anger.”

Back in 2015, a string of youth suicides rocked Hooper Bay. Many of those who died were among Green’s peers. “We had three suicides in less than a week,” he reflects. Young Alaska Native men are among the nation’s most disproportionately impacted demographics for suicide risk.

Many village residents, including Green, pointed to a lack of healthy options for how young people could spend their time outside of school. “We have to start doing our cultural activities,” he recalls telling friends. So when he saw CANHR volunteers recruiting for Qungasvik, it felt like a natural fit. “They got us some stuff so we could start with the youth group Eskimo dance practice,” he says. That’s the dance practice that’s still going on today in the tribal council building. It’s one of many activities – like beadwork or seal hunting – that have been supported by the program.

The thought behind these activities is threefold: first, it helps to address a lack of options for how young people spend their idle time outside of school. Next, it provides a context for trained community volunteers to help instill healthy behaviors, while fostering social connection, and a sense of shared purpose that research has shown protects against suicidal behavior. Finally, it provides a bridge for youth to reconnect with aspects of their cultural traditions that were eroded during the forced assimilation of residential schools during their parents’ generations.

In the eyes of Yup’ik leaders, subsistence living provides valuable life skills for survival, connection and self-worth. During interviews and conversations, village Elders repeatedly told researchers from CANHR that facilitating opportunities for young people to spend time on the land was essential to supporting mental health. “Our Elders tell us that nature is our medicine,” says Simeon John, one of CANHR’s local program coordinators. “We’re spiritually connected to everything – the land, air, water, the plants. When you’re out berry picking or hunting, you can let go of what’s bothering you.” Youth are required to give away their first kill to Elders and vulnerable members of the community, which John says provides young hunters with a direct and tangible sense of purpose.

For Jerome Nukusuk, a high school student in Hooper Bay, spending time on the land serves as a reprieve from the challenges of the village. “I feel at peace, just hearing birds and enjoying nature,” he says. At seventeen, Nukusuk has already lost four friends to suicide. “When my closest friend passed in 2020, I didn’t eat for three days, and I didn’t go to school for two weeks.” Nukusuk was only thirteen at the time, but when he saw CANHR staff recruiting for Qungasvik at school, he signed up. “It really opened my eyes to a lot of opportunities,” he recalls. The program gave Nukusuk the opportunity to learn new skills, like making harpoons or fishing nets that he could use while out on the water. “That really helped me through a lot of my suicide problems, just keeping my hands busy.”

Promising results, uncertain funding

Since the outset of the program, CANHR has been able to successfully identify and prescribe a robust series of activities. For some – like beading, or dancing – it’s been easier to get the necessary funding and approvals. But when it comes to activities like hunting that many communities identified as being essential, CANHR has faced greater challenges. And complicated funding mechanisms have also made it hard to consistently implement a broad array of programs.

Over the years, subsistence activities have become increasingly reliant on the cost of key supplies like fuel and ammunition. This can present obstacles for many remote communities, where the added expense of air deliveries mean that common goods can cost more than five times the national average. For a region living on a median household income of roughly $42,000 per year these costs can be prohibitive.

CANHR has tried to address that barrier by providing villages with access to vehicles and supplies. But the University of Alaska Fairbanks wouldn’t let the program fund activities involving minors, firearms and boating in the Arctic due to liability concerns. “People from the western world try to come in and imply what works for them, and demand that this is a model that you’re going to use. But a lot of the time it doesn’t apply to us, because we do things differently out here,” says Simeon John.

Sustainability is also a big challenge. Qungasvik receives federal grants that are typically funded on 3-5 year cycles. This can be a problem for programs that seek to address complex, longstanding issues like suicide. Holly Wilcox, a national suicide prevention researcher and professor at Johns Hopkins University, says that this is a recurring issue for prevention programs across the country. “It could be that you’re just finally making momentum and able to do things at high quality, and then the grant ends.”

CANHR has assisted regional tribal entities in applying for their own grants to continue funding the program locally, but this piecemeal approach has, at times, yielded uneven results. Such was the case in Hooper Bay, whose Qungasvik program was temporarily halted despite widespread popularity after their Native Connections grant expired in September of last year. CANHR was able to assist the village in securing a new grant through the NIH in March, effectively resuming the program after a six month pause in services.

These short funding cycles, along with working among small populations, make it hard to measure whether the program has caused a drop in suicide deaths. But in two outcome papers, published in 2017 and 2022, respectively, CANHR was able to show that the program did help improve factors that reduced suicide risk over two-year study periods.

Additionally, other Native groups across the country like the White Mountain Apache tribe, who have run similar community prevention programs, have been able to demonstrate a reduction in suicide rates as much as 38.3% over six years.

These promising results have left Rasmus and her colleagues feeling optimistic that their community-centric approach could be applied in other contexts.

Purpose, identity and grit

Through their work in the villages of the Y-K Delta, CANHR felt they had developed a process for identifying community strengths that could be used as a model elsewhere. Through interviews and collaboration with local leaders to identify cultural strengths, researchers felt they could design new programs and activities that help to reinforce a strong sense of purpose. And in 2021, CANHR had their first opportunity to demonstrate their approach in a totally different group: the U.S. military.

“The universality of the Yup’ik approach, it’s really a protective factors approach,” says Rasmus. “Every community and culture has protective factors.”

In the late 2010’s, deep within the Alaskan interior, military service members were killing themselves at astonishingly high rates. Suicide rates for military servicemembers are roughly double that of their civilian peers, and among military populations over the last five years, Alaska’s suicide rate was more than triple the national average. Despite persistent attention and investment, the problem wasn’t getting better.

“I think about it every day, every time my phone rings,” says Command Sgt. Maj. Joe Gaskin of the U.S. Army’s 11th Airborne Division. “We’re devastated every time these things happen.”

In 2022, Alaska Sens Lisa Murkowski and Dan Sullivan successfully lobbied for additional funding to allocate toward military suicide prevention. Congress also directed the Department of Defense to investigate the high occurrence of suicides on remote, rural military installations like those in Alaska. These actions laid the groundwork for CANHR to receive their first grant in 2022 to start working with the 11th Airborne Division, and begin to adapt the model they’d developed through Qungasvik within the military.

The 11th Airborne Division’s 1st Brigade is housed at Ft. Wainwright in Fairbanks, just down the road from CANHR’s offices at the University of Alaska. Sticking with their philosophy of working in partnership with communities, CANHR staffed their internal team with military officers and worked closely with their Army counterparts to develop an approach.

They started by identifying the challenges the group was facing. Military leaders said the unit suffered from a lack of identity. “When I first got here, it was like mass triage,” says Maj. General Brian Eifler, the unit’s top commander. “The worst thing you can have are people that don’t know their purpose.” He said years of fighting in desert wars left recruits wondering why they were going to such extreme lengths to train in Arctic combat. Soldiers felt isolated from their families in the lower 48 and were struggling to connect with their mission.

What was needed – the military leaders felt – was a rebranding of sorts. Concurrent to CANHR’s partnership, the Army unified its Alaska forces under the banner of the 11th Airborne Division and invested in building their identity as Arctic warfare specialists.

CANHR worked with their military counterparts to design a new program. They started by interviewing Division leadership to define the cultural strengths within the organization, and quickly honed in on three themes; purpose, identity and grit. Gaskin, who helps to oversee the program, explains, “if you fill soldiers’ lives with purpose and identity, those corrosive behaviors like suicide and alcohol abuse start to delete themselves naturally.”

Next, they developed a series of training programs designed to empower junior leaders with the skills to help their soldiers connect with those core principles. The implementation of that training started to roll out this spring, allowing those trainees to start applying their newly developed skills within their units.

Finally, they participated in community-building activities, like lessons in preparing wild salmon, and polar plunges, that provide a context in which those skills could be applied. Those activities also helped leaders connect soldiers with their peers, and to build a sense of shared purpose.

During a recent such community outing at a folk school in Fairbanks, soldiers learned to smoke salmon while volunteer leaders encouraged the privates to get to know one another. An officer asked the assembled group, “why did y’all join the army?” Part of the thinking behind these activities is to create opportunities for conversations around topics like identity, or the deeper meaning of serving in the Armed Forces. “Mostly because of family, and to expand my reach as well,” one of the soldiers replied. “To become a stronger person, mentally,” said another.

As the program continues, CANHR will gather data from participants and leaders that will help to further refine their approach and measure its effectiveness. They received their second grant in February to expand their research to include the Alaska National Guard and U.S. Coast Guard. As they continue to collect and analyze the data from the study’s initial phases, their aim is to present a model to the Department of Defense by the end of 2025 that could be used across the military.

Gaskin says he thinks it’s all making a difference. “I lose sleep every night thinking about these kids that we’ve lost along the way. I think about their parents, their families…” he pauses for a moment. “We’ve got to protect what’s left.”

A new paradigm

In the latest iteration of the National Suicide Prevention Strategy published by the U.S. Department of Health and Human Services in April, community-based suicide prevention was designated as the top strategic priority. Last year, U.S. Surgeon General Vivek Murthy released an advisory warning about “our epidemic of loneliness and isolation,” both of which are considered key risk factors for suicide. Within the 82-page treatise, Dr. Murthy praised “the healing effects of social connection and community,” as a potential antidote.

To Holly Wilcox and her professional peers, the federal government’s emphasis on community prevention feels like a signal of a new paradigm. “I actually think it’s been long overdue,” she says. “We really need to be focusing more on upstream, community-based, public health approaches to this major and leading cause of death.”

In addition to its other strengths, Wilcox feels that programs like Qungasvik, which leverage peers and paraprofessionals from within local communities, may offer a potential blueprint to address the shortfalls in the mental healthcare workforce that have been a persistent problem nationwide. “Many of us are thinking, can we engage people with lived experience that we can train?” she asks. “They’re from the same neighborhoods. They know the lay of the land in terms of the resources and the supports that are most engaging and effective in their own community. And they can develop rapport with folks because they’ve walked in their shoes.”

As the president of the International Academy of Suicide Research, Wilcox sees the greater potential for this emergent model. Outside the U.S., CANHR has collaborated with Indigenous groups from Canada, Greenland, Norway and Siberia – the circumpolar nations that represent some of the world’s highest rates of suicide.

But according to Wilcox, a number of barriers still stand in the way of widespread implementation of this new approach. She says that research organizations and the government agencies that fund prevention programs often operate in silos. So while research might support a certain model, it might not be prioritized by funders or decision makers. Wilcox also feels that sustainable funding streams for community-based prevention programs will be necessary to establish momentum and longevity for local efforts. “Funding streams that are not reliant on grants and contracts, but are more part of the background infrastructure, are ideal,” she says.

Wilcox wants to see more groups around the country seize the opportunity to deliver programs that follow this approach. With the increased attention from the federal government, she’s feeling more hopeful that they might.