Indigenous

The term Indigenous refers to all groups who lived in the U.S. prior to colonization by European settlers, and currently make up about 1.5% of the U.S. population.

This population is a very complex society that lived and thrived here for centuries before Europeans — a reality that often gets left out when talking about Indigenous people.

Referring to Indigenous people as “American Indians” is somewhat misleading, as the name “America” was not used until after colonization. The same can be said about the term “Indian” — it was a name applied by colonizers who mistakenly thought they had arrived in India. Many Native people prefer using their original nation names they have been known by for thousands of years. It is not unusual for many to consider that identity separate from their identities as “Americans.”

Indigenous groups believe that they have lived here since “time immemorial,” or since man first inhabited the earth, but there is no clear or precise time frame. There were approximately 100 million Indigenous people and thousands of tribes in what is now called the United States prior to the arrival of the first colonists.

Today, there are over 574 federally recognized native nations (variously called tribes, nations, bands, pueblos, communities and native villages) in this country. These nations include over 200 Indigenous languages (and many dialects within those languages), and countless diverse cultures, traditions and histories within those nations.

Important Factors of Indigenous Mental Health

Although there is a huge amount of diversity among Indigenous communities in the U.S., they share some common cultural threads. For example: having a close attachment to land and nature, sharing connectedness with the past and with others in the community, nurturing strong family bonds, following the wisdom of Elders and fostering meaningful traditions are strong factors commonly shared as part of one’s Indigenous identity.

Many of these shared cultural experiences are protective factors for mental health, but members of Indigenous communities also share many burdens, including economic and political marginalization, education disparities, discrimination and mental health challenges rooted in a long history of trauma.

Much of traditional Indigenous life is organized around a deep respect for the land, and the resources provided by “Mother Earth” to feed, clothe and shelter us. Villages or communities were spread out in different areas to prevent overuse of resources, and sustainability was a priority while harvesting plants and catching animals and fish.

This attachment to the land is a large reason why colonization was so devastating – Indigenous communities faced mass violence, displacement and forced removal as colonizers imposed borders, cut down trees and blocked waterways. The trail of tears, refers to the 5,043 miles spanning nine states (Alabama, Arkansas, Georgia, Illinois, Kentucky, Missouri, North Carolina, Oklahoma and Tennessee) that over 125,000 individuals in the south east were forced to march to reach a designated “Indian Territory” away from ancestral and desirable land. This land held little value and access to resources causing food shortages and, in some cases, starvation. While this deadly journey occurred in the early 1830’s, the effects of historical trauma and economic impact is still felt today.

Mental health and emotional well-being among Native people are often closely tied to cultural traditions of prayer and ceremony. In recent generations, these supportive cultural traditions have been endangered by forced assimilation. The process of forced assimilation included children being forcefully separated from their communities to be educated in boarding schools, where their Native culture and languages were discouraged through extreme discipline, violence and death.

Due to this history and continued discrimination and lack of opportunity, there are thousands of Native people suffering from multi-generational trauma. The result of this trauma includes mental illness, substance use disorders and suicide. Nearly a quarter (22%) of Native adults experienced mental illness in the last year. Some studies have shown alcohol and other drug use at younger ages, and at higher rates than for other ethnic groups. And suicide rates for Native youth are exceedingly high, over double the rate of white youth.

Barriers to Mental Health Care

Despite the need mental health care, very few who need treatment access it. The following represent some of the key barriers to adequate mental health care for Indigenous communities.

Rural and Isolated Locations
While not all indigenous people live in rural and isolated areas, many still do, and they don’t have appropriate mental health services to meet their needs. While most of the clinics and hospitals of the Indian Health Service are located on reservations, the majority of Indigenous people live outside of tribal areas.

Mistrust of Government Services
About 43% of indigenous people in the U.S. rely on Medicaid or public coverage. However, as a result of the government’s treatment of this population — including broken treaties, forced removal from their land and the effort to eradicate native culture — many in the Indigenous community do not trust services provided by the federal government, often from health care providers with no connection or experience with Native life.

Less Health Insurance Coverage
Of the Indigenous population, 14.9% don’t have health insurance, which is over three times more than the white population (5.9%).

Lack of Cultural Competence
Cultural competency is incredibly important when it comes to serving the mental health needs of Indigenous populations. Many members of this community hold a fundamentally different understanding of mental health than their “Western” counterparts, and therefore may not see value in the treatments offered.

There are very few mental and behavioral health programs that can provide treatment in a culturally, spiritually and traditionally appropriate manner. Part of the issue is due to the lack of clear, consistent and measurable definitions — meaning that programs modified for Indigenous communities often do not meet criteria to be designated as “best practices.” Additionally, those who have intent to be culturally competent must have extensive training in spirituality and traditional values taught to them by a qualified Elder, which can be a long process. And lastly, charging money for providing services is contrary to traditional practices who provide services for free.

Language Barriers
Approximately 372,000 Native people speak a language other than English at home. Language traditions are especially strong in the American Southwest and in Alaska; nearly 200,000 individuals speak Navajo or Yup’ik. There are many areas where differences in language are an important consideration for treatment. For example, words such as "depressed" and "anxious" are absent from some Native languages.

Even if the person does speak English, it can be challenging to convey the same meaning in English. Many speakers quit communicating when they can’t get the true meaning of what a provider is trying to say.

Poverty and Unemployment
The removal of indigenous people from their lands has resulted in the high rates of poverty that characterize this population. In the U.S., 10.5% of the total population lives in poverty. This may seem like a high percentage, but for the indigenous population, it is over double that with 26.6% of people living in poverty. Of those in poverty, many live in tents without running water, electricity or food. Additionally, indigenous people are almost twice as likely to be unemployed.

How to Seek Culturally Competent Care

When meeting with a provider, it is important to ask questions to get a sense of their level of cultural sensitivity. Providers expect and welcome questions from their patients since this helps them better understand what is important in their treatment. Here are some questions to ask:

  • Have you treated other Indigenous people?
  • Have you received training in spirituality or traditional practices?
  • How do you see our cultural backgrounds influencing our communication and my treatment?
  • Do you have training in trauma-informed care?

Whether seeking help from a primary care doctor or a mental health professional, you should leave the appointment feeling heard and respected. The amount of respect shown by the provider is the most important basis for an effective treatment relationship. It is essential see an effort on the part of the provider to: overcome any barriers, understand the past and present experiences of Indigenous peoples and have respect and empathy towards alternative practices and worldviews.

You may want to ask yourself:

  • Did my provider communicate effectively with me?
  • Is my provider willing to integrate my beliefs, practices, identity and cultural background into my treatment plan?
  • Did I feel like I was treated with respect and dignity?
  • Do I feel like my provider understands and relates well with me?

The relationship and communication between a person and their mental health provider is a key aspect of treatment. It’s very important for a person to feel that their identity is understood by their provider in order to receive the best possible support and care.

Resources

Circles of Care: Creating Models of Care for American Indian and Alaska Native Youth
Describes the Substance Abuse and Mental Health Services Administration's grant program, Circles of Care, which develops culturally appropriate interventions to serve youth with serious behavioral health challenges.

Indian Health Service
A Federal program for American Indians and Alaska Natives. Website includes FAQ for patients and section on Behavior Health services in the AI/AN health care services.

Indian Country Child Trauma Center (ICCTC) (405-271-8858)
A SAMHSA-funded program established to develop training, technical assistance, program development and resources on trauma-informed care to tribal communities. Oklahoma City-based center specializes in treatment of Native American children that live with trauma and sexual abuse.

One Sky Center (503-970-7895)
Provides resources and a “Find a Therapist” locator for treating mental health and substance use disorder within Native American communities.

StrongHearts Native HelpLine (844-762-8483)
StrongHearts Native Helpline is a domestic violence and dating violence helpline for American Indians and Alaska Natives, offering culturally appropriate support daily from 7 a.m. to 10 p.m. CT via phone and online chat. StrongHearts Native Helpline's one-on-one chat sessions with advocates can be accessed by clicking on the “Chat Now” icon at strongheartshelpline.org.