Understanding and supporting the mental health needs of American Indian and Alaska Native (AI/AN) people

American Indian and Alaska Native (AI/AN) refers to all the people who lived in the U.S. prior to European colonization. According to the 2021 U.S. Census Bureau, 2.9% of the U.S. population — 9.7 million people — identify as AI/AN, with a rich history, culture, and customs that predate colonization.¹

While AI/AN people have mental healthcare needs like other groups, they have specific spiritual, historical, and social factors that affect prevalence, experience, and care-seeking behaviors.

“When working with Indigenous Americans, culture matters,” explains Dr. James Polo, Vice President and Chief Medical Officer, Carelon Behavioral Health. “Well intentioned providers often approach Indigenous communities with everything they think they know, wanting to rush in and help. However, many Indigenous practices are different than what providers are accustomed to, and providers need to recognize that.”

“Tribal leaders want to address the safety and welfare of their members, usually based on Tribal laws and cultural traditions, as Tribes are very community focused. It is important to learn about Tribal sovereignty and how a Tribal government is run as each Tribe has a different level of priorities,” says Tiffany Villines, MPA, Director, Carelon Behavioral Health.

Providers should also understand that they first need to earn Indigenous populations’ trust. “Indigenous peoples have a historical distrust of government systems, a history of being let down, and having everything taken away. Hospitals and systemized clinics are government entities in Indigenous peoples’ eyes, for which they feel extreme distrust,” says Dr. Polo.

AI/AN people frequently experience barriers when seeking access to mental healthcare, preventing them from getting the services they need. The challenges are both quantitative and qualitative. “Not only is it difficult for AI/AN individuals to access care; when they access care, the care itself may not be culturally affirming,” says Dr. Hossam Mahmoud, Regional Chief Medical Officer – Northeast/Southeast, Carelon Behavioral Health.

Roadblocks that prevent many people from receiving help include chronic underfunding for services, living in rural or frontier communities, implicit bias within government systems, lack of available and accessible information regarding mental health resources, language barriers, and poverty.²

Villines cites additional unique challenges. “Tribes sometimes have ideas as to how they want to improve access, but don’t know how to implement them. Some reservations don’t follow the same licensing criteria as the states. In certain Tribes, Elders are grandfathered in as therapists since they are the Tribe’s storytellers and medicine people.”

When working to establish relationships with AI/AN people, healthcare providers can start by learning about and respecting Native traditions and history. Even though AI/AN people represent nearly 3% of the U.S. population, only 0.2% of U.S. medical school faculty in psychiatry identify as Native American and Alaskan Native, resulting in a provider knowledge gap.³

Dr. Polo emphasizes a proactive approach. “Health equity improves with access, so providers need to have an intentional approach to reach communities. For example, if providers are opening a clinic in Anchorage, they should work with the local Tribes. Talk to the medicine man in the community, find out what Tribal members need or want. Learn the annual ceremonies and celebrations and be aware of potential conflicts. Prioritize these important days as much as the December holidays. And create that structure from the beginning.”

Many AI/AN traditional belief systems focus on connectedness with the past and present, strong family bonds, and oneness with nature. AI/AN people are also more likely to seek help for mental health conditions and substance use disorders from a provider who understands AI/AN culture or from spiritual and traditional healers.⁴

AI/AN people living on reservations, particularly Elders, typically find traditional healing more accessible. Traditional healing, also known as Indigenous ways of knowing, includes oral narratives, symbolic methods of communicating, planting and harvesting techniques, hunting and gathering skills, specialized ways of understanding the greater ecosystem, and the manufacturing of specialized tools and technologies.⁵

However, providers also need to recognize that many Tribes exist, and they are all different from one another. Understanding the differences is critical to improving health outcomes. “There are multiple Alaskan Tribes, all different,” says Dr. Polo. “There are big differences between Tribes that hunt seal and those living in the southern part of Alaska, living off of the land.”

AI/AN youth serve many roles in their families and communities, not unlike many other young people. However, AI/AN youth also experience mental health concerns at a higher rate than their peers. They are the fastest growing segment of the AI/AN community and often live within multiple cultures. They balance their traditional family structure with the broader integrated youth world, including school, pop culture, and social media.¹

“Young Indigenous individuals have a lot in common with their non-indigenous peers,” says Dr. Polo. “However, that doesn’t mean they have forsaken their own cultural roots. Providers need to assess where young Indigenous people are, individually, to earn their trust.”

When providers take the time to recognize AI/AN culture, they take an important first step in building trust. Dr. Mahmoud shares his experience. He says, “When I worked at a First Nations reservation in Canada, I first had to be invited into the community. My invitation came from a social worker who had been working with the community for a decade, who had established trust within the community and with the Tribal leaders.

“Rather than starting to deliver care right away, I was invited to meet the community members. I spent a day listening to the history of the people on the reservation, the culture, and the challenges they face. I learned what was important to them and their vision of how treatment should be delivered. I also shared with the community my background, culture, and experience — not just my credentials.”

Villines describes the process of building trust when she worked with Tribes in Washington. She says, “It was challenging earning trust in the beginning. But I kept going to meetings in person, becoming part of the Tribal community. Through the process of moccasin telegraph, I developed a good reputation, which spread to other Tribes.⁶ They knew me and knew I worked for the state."

“One day a Tribe reached out to me for help, wanting to build a nursing home complex, as they didn’t know where to start. My team and I reached out to the National Congress of American Indians and to SAMSHA, to send staff out to help the Tribe execute the project for their Elders. We worked on planning, development, and licensing for a few years to help make it happen.”

Dr. Polo shares how Alaskan Indigenous communities have a very different survival culture than those in other U.S. regions. He says, “When I was in Alaska, a local Tribe I worked with would hold a ceremony at the beginning of winter. Elders who were not going to survive were sent out on the water as an end-of-life ritual since the Tribe knew exactly what it took for their members to survive and knew that these Elders were not going to make it through the winter due to poor health or age."

“The Elders whom the Tribe sent had already lived a full life. They looked at this ritual as an honor, as having the opportunity to help contribute to the Tribe’s survival. The survival of the Tribe was more important than any one individual. Sacrificing oneself, going back to the earth, and becoming part of the spirit of the world, was meaningful to that Tribe.”

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines cultural humility as a provider’s ability to maintain an interpersonal stance while being open to various aspects of a patient’s cultural identity, especially those aspects that are most important to the patient.⁷

“When providers exhibit cultural humility towards their patients, they make a significant first step in building a provider-patient relationship,” says Dr. Mahmoud.

Cultural humility also means a provider showing respect and a lack of superiority towards a patient's culture. The provider does not assume competence in terms of working with a particular patient based on prior experience or from working with other patients from similar backgrounds.⁷

“Providers should be culturally sensitive, understanding the context, while avoiding generalizing. Providers should articulate what they think they know about a Tribe’s culture but be open. Tribal members may correct them,” says Dr. Polo.