Two years after the COVID-19 pandemic changed the world, healthcare workers are beginning to – cautiously, tentatively – resume normal operations. Variants are still a concern. Public health researchers are studying long COVID. But most clinicians now spend their time on the conditions and injuries that used to dominate hospitals and exam rooms. Yet even as COVID’s oppressive shadow seems to shrink, a quieter shadow that’s floated alongside it is growing bigger: the mental health pandemic.
Maybe you read the letter the Government Accountability Office sent to Congress a few months ago. It said, “The pandemic is potentially driving another national crisis, with people experiencing new or exacerbated behavioral health symptoms or conditions.” Their report noted a rise in wait times for care, along with more demand for treatment. They also identified 6 populations at high risk of pandemic-related mental health issues. The first: Native Americans, who were hospitalized 3.5 times as often as white people during the pandemic. Other populations include (to no one’s surprise) healthcare workers and people with preexisting mental health issues.
The rising demand for mental health support runs smack into behavioral health shortages – and both ends of the equation are heightened for Indigenous communities.
A Disastrous Collision
Tribal nations have struggled with behavioral care shortages, high rates of substance abuse, and mental health struggles for a long time. Indigenous Americans have one of the highest rates of deaths from alcohol poisoning in the U.S.; the suicide rate for Native American women has risen 139% since 1999.
The last two years have only worsened that. During lockdowns, many Americans turned to social media and digital communities for solace and support. That wasn’t an option for Indigenous communities without Internet access or electricity. Another struggle: the pandemic has ridden side by side with a rise in discoveries of the remains of Indigenous children at abusive boarding schools in Canada and the United States. The recent spotlight on the mass graves has sparked an increase in despair, anxiety, and depression.
While the media has run stories on the record COVID levels and mortality rates in Tribal nations, there’s been little ink or airtime devoted to the ways the worst pandemic impact has collided with high levels of untreated mental illness and substance abuse. Sending more resources to Tribal nations to support Indigenous mental health is a start – but only dismantling systemic barriers can unlock lasting change.
4 Barriers to Behavioral Care in Indigenous Communities
- Staffing shortages are worse in Tribal nations. Yes, the entire industry is feeling the pinch of the behavioral health staff shortage. But these shortages are more pronounced in Indian Health Service and Tribal facilities. 61% of areas with mental healthcare provider shortages are rural or partially rural. Asking patients to drive three hours for a one-hour appointment with the nearest psychiatrist or addiction counselor, then drive three hours home, isn’t realistic. Mental health treatment plans typically require frequent appointments and multiple levels of care, from medication management to talk therapy to family counseling. Local resources are critical.
- Lack of culturally informed care. Native patients in non-Native treatment centers or psych units are likely to be thrust into programs that ignore their cultural background and beliefs. Their therapists and psychiatrists may not understand historical trauma or their community challenges – and so the resulting treatment plans may not be effective for an Indigenous patient’s needs and struggles. The upcoming national 988 rollout is a fantastic breakthrough in suicide prevention, but will Indigenous callers be connected to someone who understands historical trauma?
- Distrust and lack of engagement. Many patients are worried about the stigma of behavioral health; some may be in denial about needing substance misuse treatment. But Native patients often feel another level of reluctance to engage with behavioral healthcare. Many have experienced racism in past clinical experiences; Indigenous communities also have a long history of disturbing violations at the hands of the American medical establishment. Indigenous patients may be understandably reluctant to trust the few behavioral health channels open to them.
- Lack of follow-up support. Native patients who complete an inpatient stay for a mental health crisis or substance abuse treatment are often discharged to find themselves on their own, without community resources to help them stay clean, repair financial and social damage, or maintain healthy habits. Without reintegration programs or a support network, many fall back into familiar but toxic habits and social circles.
The State of Indigenous Mental Health
Without resources, Indigenous communities are forced to deploy desperate strategies. Some hospitals resort to psych boarding, where behavioral health patients are kept in emergency departments for days or weeks; some communities have criminalized suicide attempts, incarcerating patients until a treatment bed is available. All of these measures are designed to keep patients safe, but they have unintended consequences. When a behavioral patient occupies an ED bed, care may be delayed for another patient. Hearing about another person’s arrest after a suicide attempt may make someone reluctant to call 911 for a friend in crisis.
The good news is that we know the right steps and resources to support Indigenous mental health – they’re just not easy to implement. A few include:
- Increased clinician diversity
- Advanced clinical frameworks in Indian Health Service and Tribally operated facilities
- Provider training in Tribal identity and historical trauma
- Greater awareness and education regarding trafficking, partner violence, and Missing and Murdered Indigenous People (MMIP) risk factors
- Integration of primary, emergency, and behavioral care
- Provision of wraparound services and reintegration programs
- Telepsych models and digital health resources
Throughout this year, as we launch Tribal Behavioral Health, we’ll be taking a closer look at behavioral health solutions for Indigenous patients. We’ll talk about MMIP, suicide prevention, substance abuse, clinical protocols, capacity management, and much more. We’ll also offer more training in specific areas, such as training front-line staff to understand historical trauma or recognize signs of sex trafficking.
Anyone working in healthcare knows that transforming substance abuse rates and mental health outcomes isn’t easy. The aforementioned barriers can feel like brick walls. But creating new behavioral health ecosystems for Indigenous people can manifest real and long-lasting change. This has to be a collaborative and culturally intelligent effort – but by working together, we can create new and affective pathways to mental health in Tribal nations.