Priorities for Working Collaboratively through the Tribal Behavioral Health Agenda

At the core of this priority area is the importance of ensuring that families who have also been affected by traumatic events receive appropriate support. The intent is that all members of a family receive the support required for individuals and the collective to heal. Without support mechanisms for all family members, strategies to assist individual family members may fail. Incorporation of supports for the family will require program flexibility, collaboration, and commitment. It is important that tribes be informed of the resources available to them and, even more importantly, that tribes are comfortable with the competency and scope of the resources. Recommended strategies include:

• HIT1.1: Actively inform communities about the forms of trauma and their manifestations as a means for enhancing the potential for family engagement in services.
• HIT1.2: Incorporate into Federal, Tribal, and other programs opportunities for engaging family members who live with trauma as part of funded activities to ensure that they have access to support mechanisms.
• HIT1.3: Allow tribes, within existing programs and new funding streams, the flexibility to develop, tailor, and/ or implement support mechanisms that best address their local and specific manifestations of trauma.
• HIT1.4: Incorporate opportunities to address unresolved grief as a root cause of behavioral health challenges and a core component in positive healing within programs that focus on Tribal communities.
• HIT1.5: Strengthen support systems across health, behavioral health, education, child welfare, and justice services programming to ensure continuity and availability of support for family members who connect through different systems.

The literature shows that an individual’s sense of his or her own belonging, and connection to the communities he or she lives in, is a strong protective factor against many behavioral health issues, including suicide, depression, and substance use. Fostering connectedness with their communities includes expanding inherent strengths within a person and a community, strengths such as pride, self-esteem, community values, tradition, culture, and local resources. Recommended strategies include:

• HIT2.1: Expand opportunities for tribes to incorporate Native language learning and development as a means for strengthening pride, self-esteem, identity, and other contributions to community connectedness.
• HIT2.2: Provide support for creating new or maximizing existing healthy social structures and social supports through schools and other local settings that permit community members to engage and be validated as valuable members of the community.
• HIT2.3: Support Gathering of Native Americans (GONA) events to support community healing from historical trauma and enhance local prevention capacity through meaningful activities that incorporate healthy traditions; focus on a holistic approach to wellness; empower community members; and provide a safe place to share, heal, and plan for action.

One of the most insidious aspects of historical trauma is its heritability. It is passed down through families and communities – most often unknowingly – exposing future generations to centuries-old sorrow and trauma. Opportunities to intervene in this process are often overlooked or not identified, and so the cycle continues. An important way to actively promote healing is to break this cycle and interrupt the passing down of messages that contribute to trauma. Trauma should be proactively addressed in informed ways by the appropriate tribal (e.g., family members, teachers, leaders, traditional practitioners, behavioral health professionals) and non-tribal parties. Recommended strategies include:

• HIT3.1: Align Tribal, Federal, and other programs that support actions to address trauma and prevent retraumatization as a means for supporting trauma-informed services that are continuous across systems.
• HIT3.2: Integrate authentic cultural interventions and culturally tailored evidence-based practices into existing Tribal programs as a means for reestablishing Tribal spiritual conditions of physical, mental, and spiritual health.
• HIT3.3: Review and modify Tribal, Federal, state, and other programs to recognize and address the impacts of adverse childhood experiences among American Indian and Alaska Native populations.
• HIT3.4: Widely diffuse strategies, in concert with established support mechanisms, across Tribal communities to encourage families to talk in safe ways about their own identities and experiences with trauma to begin the process of healing.
• HIT3.5: Develop a research agenda on current, historical and intergenerational trauma to aid building knowledge in areas that require further investigation.
• HIT3.6: Use existing workforce development/learning centers to intensify education for health, behavioral health, and other professionals about historical and intergenerational trauma and support efforts to more effectively address trauma in clinical and professional settings.

One commonality tribes share is a strong connection to nature and the environment; nature is highly revered and treated with respect. The connection is not only spiritual but also a way of life that includes nature as a source of traditional foods and medicine. Tribes have experienced devastation that has endangered nature and hope to protect and preserve their environment. Protecting the environment and tribal lands is directly related to tribes’ sovereign interest in protecting natural resources and treaty rights. Recommendations include:

• SCE1.1: Proactively advance collaborations among Tribal, Federal, and state programs to protect environmental resources as a vital part of the spiritual connection and traditional lifestyle.
• SCE1.2: Incorporate actions across Tribal, Federal, and state programs that improve access to safe and healthy traditional foods.

Tribes and Tribal communities face many challenges when it comes to infrastructure. Unemployment rates throughout Indian Country are high, and housing shortages affect Tribal members. The lack of adequate housing not only poses obvious challenges for Tribal members but also impacts the ability to attract and support a critically needed health services workforce. Recommended strategies include:

• SCE2.1: Strengthen educational capacity of schools and access to education resources.
• SCE2.2: Collaborate with state and Federal agencies on creative opportunities for addressing the determinants of health, including opportunities to increase housing stock, facilitate transportation needs, and improve job readiness.
• SCE2.3: Improve collaboration during the planning of new tribal housing to ensure water and waste infrastructure needs are considered.
• SCE2.4: Strengthen tribal capacity to effectively manage water programs.

Similar to community connectedness, family structures within Indian Country are vital sources of strength. However, family structures are becoming more fragmented, with many youth lacking strong parental figures in their lives. Strong family structures are important in helping youth grow into healthy and resilient adults. Elders are the gatekeepers of knowledge and tradition within Tribal communities, and tribes have suggested engaging elders in a more meaningful way by strengthening their connection with youth. Recommended strategies include:

• SCE3.1: Support broader efforts to strengthen families as integral prevention and invention mechanisms and develop family-driven strategies for reinforcement.
• SCE3.2: Collaborate across local, Tribal, state, Federal, and private and non-profit organizations to leverage opportunities to create safe and nurturing environments for youth.
• SCE3.3: Expand collaboration across education, health, and human service systems that engage, support, and protect elders.

All prevention and treatment programs are not designed to meet the diverse needs of differing communities, nor are they designed to readily incorporate traditional American Indian and Alaska Native worldviews that promote health and healing. Tribal communities must have the flexibility, support, and resources to implement prevention, treatment, and recovery programming that meet the needs of their populations.

• PR1.1: Create and support culturally and spiritually based programming and healing that aligns with the diversity and needs of the local Tribal population and engages communities in the development of diversion and reentry programs.
• PR1.2: Support and coordinate reentry programming across service sectors and programming for incarcerated persons and their families, especially their children.
• PR1.3: Prioritize and collaborate on behavioral health-related prevention efforts as a primary strategy across education, health, behavioral health, child welfare, law enforcement, and other systems.
• PR1.4: Treat mental and substance use disorders as chronic conditions that require support and services across the spectrum – from prevention for individuals at all levels of risk through recovery.
• PR1.5: Advocate for and support comprehensive suicide prevention efforts that incorporate protocols for at-risk youth and adults, required infrastructure for supporting suicide prevention, active community outreach following discharge from the hospital or the emergency department, trained community workers, and coordinated crisis response and intervention systems.
• PR1.6: Support, establish, or improve data collection systems to support the collection of information on suicide prevention activities that is managed locally or in collaboration with a Tribal Epidemiology Center.
• PR1.7: Support suicide prevention efforts that include youth, families, and communities.
• PR1.8: Build and sustain supportive environments in schools.
• PR1.9: Support and promote Tribal Healing to Wellness Courts, Veterans Courts (or the VA Diversion Courts Peer-to-Peer Support Program), and other courts that support recovery.

Behavioral health is a community health issue that requires a communitywide response. Given the importance of addressing behavioral health problems in many communities, Tribal leaders should take ownership of these issues and work with their tribal community, tribal councils, Federal agencies, state agencies, regional and local partners, and other interested parties to develop an appropriate local response. Communities may need guidance from their leaders to understand their choices for response including seeking approval for technical assistance from organizations or agencies.

• PR2.1: Formulate and implement long-term, communitywide engagement and mobilization strategies that emphasize community ownership of their issues and solutions.
• PR2.2: Support and train community members to serve as peer counselors.
• PR2.3: Actively address and support the behavioral health related programming needs of urban- and reservation-based American Indian and Alaska Native populations.

Tribes face staffing shortages at nearly all levels. Sometimes these shortages can mean that an individual in crisis is not able to receive immediate, adequate care. Furthermore, many tribes believe that behavioral health professionals would benefit from cultural competency training. In the face of high levels of unemployment and staffing shortages, improving the skills and practice of existing providers and addressing development of the behavioral health workforce using a “grow your own” model are highly favored.

• BH1.1: Support and develop collaboration among tribes, Tribal organizations, Tribal Colleges and Universities, (TCUs) and Federal agencies to establish local “grow your own” behavioral health education programs and provide basic training for local Tribal behavioral health aides (community workers). For areas with limited access to TCUs other forms of collaboration for supporting training should be explored.
• BH1.2: Establish collaborations between tribes and Addiction Technology Transfer Centers to support education, training for certification exams, and clinical supervision opportunities for behavioral health professionals working in Tribal facilities to obtain and maintain certification.
• BH1.3: Support the incorporation of traditional practitioners within service delivery systems and provide training on cultural and organizational competency for all employees.
• BH1.4: Actively pursue collaborations with the HRSA National Health Service Corps Program to recruit psychiatrists, behavioral health professionals, and other practitioners to work in Tribal facilities.

Tribal behavioral health programs frequently struggle as a result of insufficient funding. Programs are frequently underfunded or funded only for a finite period. Furthermore, the requirements of some programs do not always align with other Tribal priorities, values, or traditional practices. Tribes have advocated for greater access to particular funding streams and for direct funding from Federal programs rather than through states.

• BH2.1: Assess state engagement with tribes and promote meaningful state/Tribal consultations.
• BH2.2: Monitor state behavioral health spending and support equitable resources and support to tribes and other entities providing services for Tribal members.
• BH2.3: Increase flexibility in funding requirements to tribes to support culturally based programming that meets the programmatic needs of Tribal communities.
• BH2.4: Develop flexibilities that allow tribes with multiple Federal grants to lower administrative costs, increase integration of funded programs, and enhance collaborative reporting.
• BH2.5: Prioritize behavioral health and related programs in all budgeting processes.
• BH2.6: Assess opportunities for funding traditional services including staffing and supplies.

Tribes know best the needs of their communities. However, funders may not regularly consult with tribes about their programs and may thus develop program requirements, design evaluations, and require reporting using solely a Western lens.

• BH3.1: Consult with tribes on programs that tribes are eligible for prior to developing program announcements.
• BH3.2: Support tribal efforts to incorporate cultural interventions into program activities that allow tribes to more effectively meet program expectations.
• BH3.3: Support tribally driven assessments and implementation of strengths-based, Tribal best practices.
• BH3.4: Increase coordination and collaboration among Federal, state, Tribal, and/or urban programs by aligning resources, decreasing competition, and improving strategic planning.
• BH3.5: Engage tribes about their technical assistance and other support needs prior to developing technical assistance requirements.

Youth hold an important position within Tribal communities – they are the literal future for tribes. Youth-specific programs in Tribal communities require additional support given the limited resources and services that may be available locally. Learning about culture is a strong protective factor, and providing education on behavioral health issues may help reduce concerns surrounding treatment.

• BH4.1: Allow tribes the flexibility to engage youth in developing and implementing programming that targets American Indian and Alaska Native youth.
• BH4.2: Support targeted education for youth that incorporates learning their Native language, respective culture(s), and role that culture plays in supporting behavioral health.

In response to service-related challenges, including, funding, staffing, facility shortages, and quality services, many tribes do not receive or are unable to provide a full continuum of services for their members. This often means that Tribal members must leave the community to receive care or not receive the services they need. Tribes have sought expansion in the scope of programming to ensure that Tribal members are able to receive vital care within their communities. Strategies include:

• BH5.1: Identify new models of care delivery that ensure more accessible intensive inpatient and long-term care.
• BH5.2: Support implementation of Tribal, Federal, and/ or state collaborations that bolster wraparound services.
• BH5.3: Support and immediately implement a collaboration that supports early intervention services for behavioral health.
• BH5.4: Support expansion of telebehavioral services to additional Tribal communities or clinics.

American Indians and Alaska Natives with mental and/ or substance use disorders often end up in the criminal justice system rather than receiving services. Incarceration frequently compounds already challenging preexisting conditions, and tribes are seeking greater collaboration between the behavioral health and criminal justice systems in a way that does not further victimize Native youth and adults, supports growth, and promotes healthy living.

• BH6.1: Strengthen collaborations among health, behavioral health, and justice system programs of the U.S. Department of Health and Human Services, U.S. Department of Justice, and U.S. Department of the Interior to strengthen programs for Native youth in collaboration with tribal courts to create alternatives to incarceration that incorporate tribal values, culture, and tradition in programming that addresses behavioral health issues.
• BH6.2: Support expansion of Tribal healing to wellness court programs of the U.S. Department of Health and Human Services, U.S. Department of Justice, and U.S. Department of the Interior to support diversion of Tribal members with a mental and/or substance use disorder from the criminal justice system to local behavioral health care.

Tribes have the ability to decide what information to share and what not to share, what warrants national attention and what does not, and what steps will benefit versus further damage their communities. Should Tribal leaders choose to address behavioral health issues locally or nationally, they will require data, support, and capacity development on ways to best communicate challenges and successes in their communities. Strategies include:

• NA1.1: Support and engage in capacity-building efforts to raise the collective capacity of tribes to speak about the effectiveness of culture in prevention and care and their own best practices.
• NA1.2: Support and raise the capacity of tribes to discuss the impact of historical and intergenerational trauma within their own communities and with external partners, if they choose.
• NA1.3: Actively educate Tribal communities about behavioral health in an effort to normalize topics of behavioral and emotional health.
• NA1.4: Support and raise the capacity of tribes to create and implement media and public relations plans.

In order to communicate effectively with media outlets, external and internal communities, and governmental collaborators, tribes need support on how best to exchange information and communicate in a timely and effective manner. These plans and strategies must be developed and managed in collaboration with tribes.

• NA2.1: Establish a national behavioral health communications campaign, in collaboration with tribes, to educate individuals about behavioral health issues affecting Tribal communities. The campaign would focus on specific mental and substance use disorders and/or co-occurring disorders that could be shared through multiple platforms and also tailored by tribes for local use. Broad national dissemination would ensure that urban Indian populations receive similar messages and support.
• NA2.2: Develop messages for American Indians and Alaska Natives that contain positive, Native-focused, media images and incorporate the voices of survivors and Tribal strengths to discuss issues and lived experiences.
• NA2.3: Package existing communications messages developed by Federal agencies and ensure that multiple entities leverage the messages to improve diffusion to communities requiring support and stakeholders who can assist.
• NA2.4: Create web-based tools and resources that Tribal leaders and officials can utilize to craft media communication and public relations strategies, especially during times of crisis or increased need.

There are many entities that engage with tribes on health-related matters, including Federal, state, and other governments; nonprofit and community-based organizations; health and service providers; insurers; emergency response systems; and the media. These entities require continuous capacity building when working with Tribal communities to effectively engage and support change. Strategies include:

• NA3.1: Support establishment of targeted training and technical assistance across Federal agencies about American Indian and Alaska Native populations, sovereignty, the nature of the government-to-government relationship, and issues that contribute to well-being.
• NA3.2: Engage in meaningful Tribal consultation and communication.
• NA3.3: Support establishment of measures to increase the capacity of collaborators and stakeholders to understand the scope of the diversity and behavioral health challenges within Indian Country and how to treat this information in accordance with Tribal direction.

American Indian and Alaska Native culture places importance on honoring youth and building strong foundations for future generations. Native youth hold an important role in the future of tribes; however, they are significantly and negatively affected by poverty, substance use disorder, depression, and suicide and are at high risk for other behavioral health challenges. Healthy youth lead to healthy adults and healthy communities. Across foundational elements, youth were identified as an important part of the solution for issues they face as well as those faced by their peers, families, and communities. Behavioral health planning should incorporate the voices of youth and engage them in developing and implementing activities.

American Indians and Alaska Natives connect their political identity with varying aspects of cultural, geographic, Tribal, familial, and social frameworks – creating a unique identity framework that is unique not only to American Indian and Alaska Native groups but also to American Indian and Alaska Native individuals. Understanding the sources of identity, honoring them, and embracing them can be a significant source of communal and individual strength that can be harnessed to combat behavioral health challenges. Behavioral health professionals who are actively working with American Indians and Alaska Natives can incorporate identity exploration into their treatment plans; community action plans can celebrate communal identities; education can take place to ensure that external collaborators, entities, and funders understand the nature of American Indian and Alaska Native identity; and, traditional practitioners can work with clinicians on how best to honor the identities of the people they serve.

Culture is the root of American Indian and Alaska Native identities – culture incorporates aspects of living, interpersonal and communal relationships, communication, worldviews, traditional customs, and spirituality. The uniqueness of Tribal cultures as well as their commonalities is a source of strength. Although each American Indian and Alaska Native tribe is unique, there are commonalities that tribes share, including valuing traditional practices, honoring elders, respecting nature, and emphasizing clan/community importance. American Indian and Alaska Native communities also have a Native language that serves to connect them to their culture and Tribal identities as well as create a strong cultural bond with other Indigenous communities. These commonalities affect the manner in which tribes conduct themselves, including in health care delivery and behavioral health program design and implementation. Revitalization of American Indian and Alaska Native languages is essential to continuing culture and strengthening self-determination. Research has shown that use of languages builds identity and assists communities in moving toward social cohesion and self-sufficiency. Language and culture foster higher educational outcomes by Native youth as a result of lower levels of depression, increased academic achievement, and strengthened problem-solving skills.¹ Furthermore, American Indian and Alaska Native values and traditions are embedded in language, and there is growing evidence that language and culture act as protective factors against suicide and suicidal ideation, substance use disorders, and other risky behaviors. Languages are among the most critical and meaningful culturally and linguistically based tools to not just survive, but to thrive.

Tribes and Tribal members are autonomous – they have the capacity to act independently on their own behalf. While tribes know best what works and does not work for their communities, Tribal members also have the ability to make individual decisions. At the individual level, self-sufficiency encompasses the full development of individuals – spiritually, mentally, physically, educationally, and economically among other ways – in a manner that contributes to their success in life. The intent is for one to have the capacity and initiative to take care of self and ultimately contribute to the well-being of their families and communities. The value is in being able to take care of self in order to effectively contribute to the lives of others. Individual self-sufficiency contributes to Tribal self-sufficiency and the responsibilities of sovereign nations to their people. Tribal representatives who contributed to building the TBHA believe that opportunities should exist across foundational elements that contribute to the ability of Tribal members and tribes to be self-sufficient. This could include availability, accessibility, and/or oversight of education and training opportunities; access to Native foods; access to prevention and treatment resources to address unique behavioral health challenges that exist in communities; referral networks across systems that support well-being; and law enforcement agreements, among others.

The problems of accuracy and access to viable data have long impacted American Indian and Alaska Native communities. Small sample sizes make it difficult to capture accurate data, and the same small sample sizes make sharing data even more tenuous for fear of violating confidentiality. Frequently data available to tribes is significantly outdated, requiring them to use data sets that may not reflect the reality within their community. And, all too often, American Indians and Alaska Natives are not a distinct group captured within larger data sets. Without access to timely and accurate data, communities are unable to capture their true needs, thereby inhibiting effective community-based planning and improvement of outcomes. As a cross-cutting consideration, improving data accuracy, availability, and access offers real opportunities to improve definitions for data collection; strengthen Tribal data collection systems; provide capacity building for tribes and partners on how to collect and manage data that is tribally owned; interpret and use data to improve systems and programs; and create systems that allow partners to benefit from available data. Methodologies used in national and other non-tribal data collection systems should be assessed in order to more accurately include American Indian and Alaska Native populations in urban areas, counties, and states. These opportunities should be leveraged within strategies that support foundational elements and their accompanying priority areas and strategies.

Tribal leaders care deeply for their communities and hold significant responsibility for the welfare of their people. Their leadership is critical in helping empower communities and support readiness to change. They also have the authority and communal support to take action and can serve as drivers of meaningful community change. To be most effective on behavioral health matters, Tribal leaders must be informed about problems in their communities; lead community-based dialogs to hear from their people about behavioral health and factors that influence wellness; work with their Tribal councils and with a range of Federal departments and agencies to address prevention as well as systems, facilities, and service needs; and seek, identify, and/or champion funding and programs that most effectively support behavioral health needs. Throughout the input received for developing the TBHA, Tribal leaders and tribal representatives conveyed that Tribal leaders need to “own” the behavioral health challenges facing their communities in order to assume true leadership on the issue. Tribal leaders viewed as being the most effective on behavioral health were identified as champions who were informed and took a visible role in driving solutions.

Improving the behavioral health of culturally, geographically, and socioeconomically diverse populations is a complex undertaking that requires a multipronged approach. There is no single strategy that will accomplish this task; there are interwoven factors and systems that may each require intense examination, deconstruction, and retooling. Individual behavioral health risk unfolds within the social settings of families, peer networks, schools, communities, and service systems and within the cultural and historical contexts of the tribe.² Health care systems are needed that provide new perspectives on integrating treatment for mental and substance use disorders with holistic well-being, including family, community, socioeconomic, and social supports.³ Strategies need to be developed to effect system and policy-level changes that reduce barriers to high-quality care and promote the well-being of American Indian and Alaska Native youth, families, and communities.⁴