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Improving Native Health, Holistically

A new initiative supported by the Indian Health Service aims to address Native health problems in a more comprehensive manner.
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Indian country is plagued by significantly higher rates of depression, substance abuse, interpersonal violence and suicide than the general U.S. population. A new initiative supported by the Indian Health Service (IHS) aims to address those problems in a more comprehensive manner than has been previously attempted by federal health policy.

In early December, the agency, in coordination with the Substance Abuse and Mental Health Services Administration (SAMSHA), released what it is calling a Tribal Behavioral Health Agenda (TBHA) as a first step in formulating policy tailored to address tribe-specific issues.

The TBHA is based on the assumption that social injustice "...endured over the course of multiple generations...." by tribal communities has produced a consistent array of symptoms across Indian country.

To correct the problem, the TBHA establishes loose guidance for behavioral health policy for tribes and the federal and state departments, agencies and associations that support them. It provides a more holistic, identity-driven and culturally and spiritually-based approach to treatment of these problems in Indian country.

The TBHA also calls for more collaboration amongst tribes.


“The only way we will transform our communities is through partnership. We must be innovative,” said IHS Principal Deputy Director Mary L. Smith. “Using the Tribal Behavioral Health Agenda as a guide will allow us to find solutions that will require sustained collaboration between Indian health programs and policymaking bodies.”

SAMHSA Principal Deputy Administrator Kana Enomoto added that the initiative “ gives American Indian and Alaska Native tribes a greater role in determining how to address their behavioral health needs with urgency and respect.”

Robert Foley, Chief Program Officer of the National Indian Health Board (NIHB), said the initiative comprises a "...groundbreaking opportunity with a groundswell of tribal and federal support to build a bridge between tribes, as well as state and federal governments to address overwhelming behavioral health issues in Indian country."

The practical direction for the TBHA:

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  1. Focusing on healing from historical and intergenerational trauma;
  2. Using a socio-cultural-ecological approach to improving behavioral health;
  3. Ensuring support for both prevention and recovery;
  4. Strengthening behavioral health systems and related services and supports; and
  5. Improving national awareness and visibility of behavioral health issues faced by tribal communities.

According to Aaron Payment, Chairman of the Sault Ste. Marie Tribe of Chippewa Indians and Co-Chair of the Health Research Advisory Council (HRAC) and Chair of the National Institutes of Health Tribal Consultation Advisory Committee, trauma theory is well-accepted. Nevertheless, it took a deeper dive into general social theory to convince HRAC.

Briefly, social trauma theory, the associative ecological approach, critical race theory, tribal race theory and cultural environment theory recognize the validity of historical trauma. Per theory, resulting learned helplessness from historical trauma devolves into a cycle of poverty. This cycle holds tribal members back socio-culturally, economically, educationally and politically. It also has a multi-generational effect unless the cycle is broken. Self-determination is the antidote, Payment said, adding that it tells us where we need to go in order to course correct.

"The signatories of the tribal leaders can be taken as validation of the notion," added Foley.

In terms of federal advocacy of the TBHA, SAMHSA believes in overarching point that historical trauma is the underlying cause, said Beadle.

"Not only does SAMHSA believe that trauma is a problem writ large, but it is especially so for tribes that have had events that have caused them more and different trauma," Beadle added. "The TBHA specifically addresses how historical passing on of trauma requires helping each community in its own way heal from its trauma.”

Carolyn Hornbuckle, Director of Public Health Policy and Programs at NIHB, characterized the value of the agenda. "The TBHA was intended to be a practical tool...that we are hoping tribal communities engage with,” she said. “It has multiple components that will be useful for multiple communities. You can break it down into pieces that are useful to all partners in Indian behavioral health.”

The TBHA is, so far, a good news story for Indian country. As summed up by Beadle, "I've been working with HHS on tribal issues for a very long time. I've seen the relationship between tribal leaders and the federal government grow tremendously over the past 19 years. The TBHA is a reflection of this growth."

Even facing an upcoming change in the administration, the TBHA was written to transcend politics – and administrations.

“Using the Tribal Behavioral Health Agenda as a guide will allow us to find solutions that will require sustained collaboration between Indian health programs and policymaking bodies, as well as a willingness to thoughtfully engage deep issues such as historical trauma and cultural renewal, and a readiness to include entire communities in healing work,” Smith said.