Tribal Mental Health Gets New Focus, But Equity Barriers Remain

Drug overdose deaths among American Indians and Alaska Natives grew 43% between 2019 and 2020—the highest rate of deaths in 2020 and 30% higher than for White individuals.

Suicides were the second leading cause of death for that group in 2019, with a rate around 20% higher than that of non-Hispanic Whites.

But now, the federal government is trying to direct more money toward policies meant to help the unique population that has long suffered from mental health challenges, advocates say.

“You’ve got to notice when these very high-consequence drug issues are coming into our tribal nations,” such as skyrocketing opioid and methamphetamine use, said Melissa Walls, a researcher at John Hopkins University who comes from an indigenous background.

“Health inequities are already persistent. Layer on top of it Covid-19 and the fact that Covid is creating more issues with mental health and substance use,” she said. “It’s very heavy and very hard.”

‘Culturally Incongruent’

Now, Congress and the Biden administration are trying to offer more money to treat substance use and mental health issues for long-underserved American Indian communities.

“There is a sea change coming, and that’s exciting,” said Brenna Greenfield, a University of Minnesota Medical School professor working in indigenous health equity.

Native American mental health was previously “overlooked or addressed in culturally incongruent ways,” but it’s now “being discussed nationally and better funded from state to national levels,” she said.

Historically, mental health treatment has come in a one-size-fits-all approach that aligned more with Western European than indigenous values. Decades of prejudice and poor policy have left many from tribal backgrounds lacking in professional and other opportunities, making the problem worse.

While researchers welcome more funding and a greater focus on health equity as a needed boost, there’s a long road ahead for greater health equity.

“There are 574 very unique and different tribal nations, and tribal nations also struggle with the issue of stigma. That can be impactful for folks coming for treatment,” said Karen Hearod, director of the Substance Abuse and Mental Health Services Administration’s Office of Tribal Affairs and Policy.

Overcoming Stigma

Research has shown that in years past, stigma around mental health in Native communities was second only to HIV, said Spero Manson, director of the Centers for American Indian & Alaska Native Health at the Colorado School of Public Health.

That’s a “significantly greater” level of stigma in relation to other populations, he said.

“I don’t think it’s changed much today,” said Manson, who is also of a Native American background.

Manson recalls talking to a member of a tribal group who said he’d “rather be thought a drunk than crazy” in his community, where mental health services were provided in a double-wide trailer adjacent to a hospital, up a sidewalk littered with weeds.

When someone walks to that trailer, everyone knows where he or she is going, Manson said. “There’s no privacy or confidentiality.”

Prioritizing the Problem

Mental health parity and treatment access were touched on in a suite of bills the House Energy & Commerce Committee considered in April. American Indians were among the groups considered in these efforts, with H.R. 4251 creating a behavioral health program for indigenous individuals and H.R. 7235 launching an HHS office to coordinate mental health work with tribes.

“We have a difficult and terrible physician and provider shortage in these underserved communities and reservations. We have a lack of prioritization of equity in Indian country. And we lack not just the providers, but the workforce to help administer and do the outreach,” said Rep. Raul Ruiz (D-Calif.), a co-sponsor of H.R. 4251.

Researchers largely agree the government is on the right track in improving tribal services. Yet getting services up to snuff for a group long-neglected and often harmed by federal efforts is a major challenge.

Take H.R. 7235. The legislation is part of the government’s 9-8-8 suicide hotline set to launch in July. But for tribal Americans who might need the service, “there’s generational trauma we’re dealing with and potentially language barriers,” said Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness, or NAMI.

“Many American Indians have grown up speaking a different language at home. So when they call 988 in a crisis, who’s answering? And are there going to be any translation issues that are going to keep them from connecting and getting the help they need?” she said.

On the Biden administration side, SAMHSA researches indigenous health needs and awards grant money to tribes. Among those grants are the Tribal Opioid Response Grants, which provide $50,000,000 for tribes.

But “providing these dollars through grants is a challenge, especially for Tribes that may be smaller,” Hearod said. “We’re working on some proposals to possibly be able to streamline how grants are applied for and also to provide more technical assistance.”

Some question why they should have to rely on grants rather than improving funding for the government’s Indian Health Service, said Joseph P. Gone, a tribal member and Harvard social scientist working on indigenous mental health. “The thing about a grant is it’s temporary. But it also puts the burden on tribes—they have to apply and compete.”

Needs More Money

The tribal health system is “severely underfunded,” coming in at around $6 billion while “full funding” would be around $48 billion, according to the National Indian Health Board, a nonprofit advocating for tribes. In its recommendation for the government’s fiscal 2022 Indian Health Service budget, the board said the president’s budget should secure nearly $13 billion for IHS, with about $309 million for mental health and $255 million for alcohol and substance use—the second and third most expensive priorities in a list of 21.

“Every year, Congress votes to underfund the Indian Health Service,” Greenfield said.

IHS comes last in receiving government dollars for its health-care programs, according to a policy briefing by George Mason University’s Mercatus Center. The Veterans Health Administration and Medicare get two to three times more funding on a per-person basis, the research noted.

“That is a reason why you have the health disparities and the inequities in access to care as evident in the higher health illnesses disparity in Native Americans and on Tribal Lands,” Ruiz said.

The White House wants to make IHS’ funding mandatory rather than discretionary. That would include over $9 billion in funding in fiscal 2023, a nearly $3 billion increase above the 2021 amount. Congress would have to approve the increase.

Mental Health ‘Mismatch’

In 2019, nearly 20% of America’s Native American or Alaskan Natives—well over 800,000 people—claimed to have suffered a mental illness, according to Mental Health America, and accessing mental health services has been anything but easy.

“Tribes are massively diverse, just like all communities,” Walls said. And how services “roll out” depends on whether a tribe falls under IHS oversight or has a so-called “638 contract,” under which an indigenous group “took control of their own health care system and receives and directs the use of funds.”

“That makes it difficult to figure out best practices,” Walls said.

According to NAMI, things like living quarters far from urban centers, lower health insurance coverage, and skepticism of the federal government erect hefty barriers to treatment specific to Indigenous communities.

Another big ticket item is cultural competency, or operating with cultural differences in mind. It’s something that mental health experts say is particularly difficult to come by for tribal communities.

“There’s generational trauma we’re dealing with, and potentially language barriers,” and tribes are “much further behind in having many services implemented,” Wesolowski said.

For American Indians, community elders and traditional healers may play a more critical role in recovery than doctors and others in the spectrum of Western medicine.

Yet in many instances, Native community members are seeing mental health specialists through clinics “just like anyone else” due to billing requirements and access, Walls said. That’s because there’s “a mismatch between what people in the community want and what they can get.”

“Where policy could really, really help is listening to practice-based evidence. Because the empirical evidence for culture-based treatment isn’t as strong as for any Western forms of treatment because the funding hasn’t gone there,” Walls said.

Yet as mental health access and addiction services get increasing attention from the Biden administration and Congress, so do culturally specific services.

“We’re getting better in modern times,” Walls said. “I see a lot of promise.”