National Tribal Behavioral Health Agenda

Overview

Tribal leaders have consistently called for coordination and collaboration among federal agencies whose efforts contribute to the health and well-being of American Indian and Alaska Native (AI/AN) communities. A view is that the multitude of programs and initiatives intended to improve the spiritual, physical, and emotional health of AI/AN populations largely operate in isolation and would be more effective if they worked together. Underpinning this view is that:

• American Indians and Alaska Natives continue to face significant behavioral health problems—the issues that impact behavioral health include many factors.
• Behavioral health issues are not isolated—there are important correlations with physical health and other social and economic conditions in communities that require a more collective approach.
• The high rates of behavioral health problems among AI/AN people, creates an urgency for tribes, federal agencies, and other stakeholders to partner in a manner that meaningfully improves the well-being of tribal communities.
• Federal agencies beyond the Indian Health Service (IHS), Bureau of Indian Affairs (BIA), and Bureau of Indian Education (BIE) have a trust responsibility for improving the health and well-being of AI/AN people.
• There is no one single national document that elevates the importance of behavioral health for AI/AN people, identifies the collective priorities of tribal communities related to behavioral health, and guides the development and/or incorporation of behavioral health-related actions intended to improve the well-being of Native youth, families, and communities.

An innumerable number of individual strategic plans and documents exist that address behavioral health or have a bearing on factors that influence the behavioral health of tribal communities. The National Tribal Behavioral Health Agenda (TBHA) is not a strategic plan. That is, it is not intended to replace existing strategic plans or prescribe a set of actions that tribal, federal, state, and local governments or other stakeholders must take to address behavioral health for AI/AN people. Rather, the TBHA is a blueprint that:

• Provides a clear, national statement about the extent of behavioral health-related problems and their impact on the well-being of tribal communities.
• Identifies foundational elements, such as healing from historical and intergenerational trauma and prevention and recovery support that should be considered across programs designed to contribute to improved emotional well-being of tribal communities.
• Provides actions that tribal, federal, state, and local governments and the private sector should consider based on evidence- and practice based strategies.
• Elevates priorities for action that could or are likely to contribute to meaningful progress in tackling persistent behavioral health problems for Native youth, families, and communities.
• Guides the development of strategies that over time more cohesively addresses factors that contribute to improved emotional health.

Background: Genesis for the National Tribal Behavioral Health Agenda

The Substance Abuse and Mental Health Services Administration (SAMHSA) has had discussions with tribal leaders during SAMHSA Tribal Technical Advisory Committee meetings, Secretary’s Tribal Advisory Committee meetings, the Department of Health and Human Services Annual Tribal Budget Consultation Session, and other meetings about the need for a behavioral health agenda. Discussions have addressed the:

• Lack of national visibility/awareness of tribal community tragedies in a manner that is comparable to non-Native communities and the related national and high-level federal responses.
• Recognition that no one tribe or federal agency can address the significant behavioral health problems faced by AI/AN communities alone.
• Need to improve collaborative work across federal agencies in a manner that best facilitates behavioral health-related needs in AI/AN communities.
• View that any approach to addressing issues in AI/AN communities must target the root cause(s) of behavioral health problems (i.e., historical trauma) and not simply the symptoms (i.e., alcohol and substance abuse).

A significant number of strategic plans exist that address, or have a bearing on, behavioral health in tribal communities. Each is important to the well-being of AI/AN people and has a designed purpose. The TBHA is intended to improve the impact of these plans/documents by targeting opportunities that can be leveraged. Examples of a few strategic plans and documents that play an important role in improving well-being in tribal communities include:

• SAMHSA’s Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018.
  This strategic plan includes six strategic initiatives focused on leading change to better meet the behavioral health care needs of individuals, communities, and service providers. Through the prevention of substance abuse and mental illness, health care and health systems integration, trauma and justice, recovery support, health information technology, and workforce development strategic initiatives, SAMHSA is working to: (1) increase awareness and understanding of mental and substance use disorders; (2) promote emotional health and wellness; (3) address the prevention of substance abuse and mental illness; (4) increase access to effective treatment; and, (5) support recovery.
• SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.
  The purpose of this paper was to develop a working concept of trauma and a trauma-informed approach; develop a shared understanding of these concepts across an array of service systems and stakeholder groups; and, provide a framework for the behavioral health specialty sectors that can be adapted by other sectors. The desired goal was to build a framework that helps systems “talk” to each other, understand better the connections between trauma and behavioral health issues, and guide systems to become trauma-informed.
• IHS American Indian/Alaska Native National Behavioral Health Strategic Plan 2011-2015.
  This Plan was prepared by the IHS National Tribal Advisory Committee on Behavioral Health, IHS Behavioral Health Work Group, and IHS and includes three strategic directions: (1) develop and promote Tribal, Urban, and IHS behavioral health programs in a cooperative, connected, and mutually supportive Indian Behavioral Health System; (2) realize cultural renewal and wellness through an emphasis on sobriety, community, elders, and positive youth development; and (3) build a strong foundation for effective behavioral health services.
• IHS AI/AN National Suicide Prevention Strategic Plan.
  This plan was intended as a first step in describing and promoting the accumulated practice-based wisdom in AI/AN communities. The plan mirrors, in many aspects, the National Strategy for Suicide Prevention—a national initiative to reduce the impact of suicide and suicide-related behaviors.
• Bureau of Indian Education Strategic Plan 2014-2018.
  This plan identifies four major priority areas to begin transforming the face of American Indian Education at BIE‐Funded schools. The priority areas promote: (1) increased educational outcomes and opportunities; (2) self‐determination in American Indian Education; (3) sustainability of Native culture, history, and language; and (4) excellence through support of BIE and tribal school employees.
• Blueprint for Reforming BIE Schools:
  This document provides findings and recommendations by the BIE Study Group for the Secretaries of Interior and Education. The Study Group referred to BIE as the legacy of the Indian boarding schools that were part of the federal government’s assimilation policy to eradicate Native cultures and languages. Although the assimilation policy ended several decades ago, BIE schools have produced generations of American Indians who are poorly educated and unable to compete for jobs which contribute to extreme poverty on many reservations. The recommendations focus on five areas for reform: (1) highly effective teachers and principals; (2) agile organizational environment; (3) educational self-determination for tribal nations; (4) comprehensive supports through partnerships; and, (5) budget that supports a capacity-building mission.
• Report of the Attorney General's Task Force on American Indian/Alaska Native Children Exposed to Violence.
  This report is a blueprint for preventing children's exposure to violence and for reducing the negative effects experienced by children exposed to violence.

Other strategic plans and documents will be identified and considered in developing the TBHA.

Framework

The response to tribal leader requests to collaboratively address behavioral health is the development of a National Tribal Behavioral Health Agenda (TBHA)—a collaborative blueprint for tribal, federal, state, and local governments and other stakeholders. To frame the TBHA, tribal leaders requested that it include four cross-cutting issues (youth, culture, identity, and individual self-sufficiency) as well as five foundational elements:

• Historical and Intergenerational Trauma.
  Historical trauma is the impact of chronic stress and trauma that negatively affects health. These impacts are magnified when entire communities experience and re-experience past and present trauma. The intent of this element is not to further assess historical trauma but rather support development of priorities and evidence- and practice-based actions to support healing.
• National Awareness and Visibility.
  There is general awareness that AI/ANs experience higher rates of alcohol and substance use, however, the scope of behavioral health problems is not fully understood. The intent of this element is to support development of priorities and actions by improving understanding of AI/AN behavioral health disparities as well as their consequent impacts on physical health and well-being.
• Social-Ecological Approach.
  There are a number of factors, and interplay among those factors at multiple levels, that influence health outcomes. For AI/AN people, these factors include historical trauma (and other contexts) and a range of social, policy, and economic conditions (i.e., poverty, under employment, lack of access to health care, lower educational attainment, housing problems, violence, etc.). The intent of this element is to support development of priorities and actions that capture the larger context within which AI/AN behavioral health issues are rooted and interventions to more effectively address them. Actions should address diverse priorities that tribal, federal, state, and local governments and the private sector can take that collectively contribute to positive outcomes.
• Prevention and Recovery Support.
  Traditionally, AI/AN people have understood that the mind, body, and spirit are inseparable. Despite traditional practices and beliefs, attitudinal barriers exist for people with behavioral health disorders. The intent of this element is to support development of priorities and actions to address issues that inhibit opportunities to intervene early and that are required to sustain positive emotional health.
• Behavioral Health Services and Systems Improvement.
  AI/AN communities face service delivery issues that are complicated by personnel shortages, limited health care resources, and distances to obtain services. There also are other issues that inhibit access to appropriate behavioral health services including referrals from school, detention, court, housing, primary care, child welfare, and other systems. The intent of this element is to support development of priorities and actions to improve coordination, linkages, and access to behavioral health-related services.