When it comes to her job, Clara Bushyhead does not pull any punches. The coordinator for the Cheyenne and Arapaho Tribes’ Tradition not Addiction program, Bushyhead acknowledges that in order to address some of the problems facing her tribes’ youth, like substance abuse and mental health, she sometimes has to cast a wider net.

“You have to go after the whole community,” she said. “You can’t just target the kids. Where are those kids getting alcohol? The number one response they gave us was ‘at home.’ Sometimes you have to be real with folks.”

Bushyhead was among the presenters who converged on the Hard Rock Hotel and Casino in Catoosa, Oklahoma in mid-August for a behavioral health summit. Hosted by the National Indian Health Board, the three-day affair gave attendees a chance to review and dissect some of the more successful initiatives underway in Indian country to address substance abuse rates, suicide prevention, and workforce development. Although there is little concrete data on depression rates in Indian country, what information is available implies a higher frequency of mental health issues among American Indian and Alaska Natives than their non-Native peers, especially among youth.

Higher rates of poverty, substance abuse and exposure to trauma—historical or otherwise—are among the multiple risk factors for mental illness seen more commonly in indigenous communities compared to society as a whole.

That data bears out the nine counties within the Cheyenne and Arapaho Tribes’ jurisdictional area. Prior to its launch, Cheyenne and Arapaho youth were nearly twice as likely to be arrested for an alcohol-related offense than a non-Native teen in three of the nine counties.

Despite initial hesitation from students, parents and school administrators, the SAMHSA-funded program has become more popular, thanks to a steady stream of activities, including beading classes, a Color Run and a community buffalo butchering session.

Since the program’s implementation in 2014, the rates of alcohol, tobacco and marijuana use have dropped among Cheyenne and Arapaho youth. The alcohol use rate alone has decreased almost 20 percent in less than three years from 45.3 percent in 2014 to 27.1 percent in 2016, a decline Bushyhead partially credits to the increased access for to cultural activities.

“We are the ones who know our people,” Bushyhead said. “We shouldn’t wait on someone else to step up.”

Other presenters and attendees expressed a similar sentiment with respect to preventative mental health care.

“What good are we doing trying to help someone with diabetes if we don’t know where they are mentally?” Johnna James said.

A citizen of the Chickasaw Nation, James is the tribal liaison for the Oklahoma Department of Mental Health and Substance Abuse. Along with trying to coordinate policy decisions between the state and Oklahoma’s 38 federally recognized tribes via consultation, part of James’ position is to try to minimize the access to care disparities that exist within the state, as well as the impact that it can have on physical health.

That also sometimes means explaining why some practices and questions that routinely show up in mental health screenings are culturally inappropriate when working with indigenous clients.

“One of the mental health questionnaires we received in our office had this question early on: ‘Do you think the American government is out to get you?’” James said, drawing chuckles and head nods from summit attendees.

Awkward questions aside, further compounding the problem for many in Indian country is a provider shortage of mental health professionals.

According to the National Rural Health Association, among rural counties nationwide with a population of 20,000 or less, 75 percent do not have at least one practicing psychiatrist.

Among the estimated 605,000 Native Americans and Alaska Natives eligible to utilize one of Indian Health Services’ 41 urban health centers nationwide, only one in five reported being able to access those programs in 2000.

“We have to know what we’re working with,” James said. “There’s strength in your DNA.”