The National Tribal 

Behavioral Health Agenda

December 2016

The development of a 

TRIBAL BEHAVIORAL HEALTH AGENDA

is long overdue. And the development of 

this particular document and its contents 

was the result of months of discussing, 

analyzing, validating, sharing, and 

revalidating. The Tribal Behavioral Health 

Agenda was a collaborative effort between 

many Tribes, leaders, organizations, and 

federal agencies. 

The authors would like to acknowledge 

that the idea for this document originated 

from direct discussions with Tribal leaders 

around the challenges Tribes are facing with 

behavioral health. 

It was their passion

 vision and dedication

that led to the development of this Agenda. 

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 1
TRIBAL BEHAVIORAL HEALTH AGENDA

Federal 

Leadership Letter

DEAR TRIBAL LEADERS, FEDERAL PARTNERS, 

AND OTHER COLLABORATORS:

There has never been a more important time 

to work together to improve the behavioral 

health – mental and substance use disorders – 

of American Indians and Alaska Natives. 

Mental and substance use disorders are 

impacting tribal communities and, in many 

cases, rates for specific disorders are higher 

when compared to other communities in the 

United States. The relationship between behavioral health, overall health, and well-being is 

unequivocal. Behavioral health is influenced by 

factors that also influence overall health, and 

people with mental and substance use disorders may have higher rates of physical health 

problems. 

The Substance Abuse and Mental Health 

Services Administration (SAMHSA) and the 

Indian Health Service (IHS) are committed 

to collaborating with tribal nations, urban 

Indian health programs, other federal departments and agencies, and other entities to 

improve the well-being of American Indians 

and Alaska Natives. SAMHSA, as the lead 

federal agency for advancing the behavioral 

health of the nation, is working to reduce the 

impact of mental and substance use disorders 

on America’s communities, including tribal 

communities. 

IHS, in partnership with tribal health and 

urban Indian health programs, is working to 

raise the physical, mental, social, and spiritual 

health of American Indians and Alaska Natives 

to the highest level. Through complementary missions, federal, tribal, urban Indian 

health, and other entities can work together to 

improve behavioral health and overall wellness.

The concept for the National Tribal Behavioral 

Health Agenda (TBHA) was born from the 

voices of tribal leaders who spoke compellingly about the extent to which mental and 

substance use disorders are impacting tribal 

communities. Beyond the issues, they also 

spoke about the need for collaboration and 

working differently together in order to make a 

difference in the lives of American Indians and 

Alaska Natives. SAMHSA and IHS accepted the 

advice and worked with the National Indian 

Health Board to gather input on what would 

ultimately become the TBHA.

Through discussions, five elements which form 

the foundation for the TBHA were developed 

and affirmed by tribal leaders and tribal representatives. Through many more discussions, 

content of what would become the priorities 

and strategies for the TBHA emerged and were 

affirmed. Thus, the TBHA includes foundational elements, priorities, and strategies that 

chart a course for more meaningful collaborations and opportunities for strengthening 

policies, programs, and activities.

2
The content and order of the information in 

the TBHA hold significance. Globally, there 

are three significant components to this 

document. These components include the 

American Indian and Alaska Native Cultural 

Wisdom Declaration (CWD); sections which 

provide background and form Part One of the 

document; and, sections which comprise the 

substance of the TBHA and are included in 

Part Two of the document. 

The CWD was developed by tribal leaders 

and representatives who sought to elevate 

the importance of tribal identities, culture, 

spiritual beliefs, and practices for improving 

well-being. The intent of the CWD is to ensure 

that cultural wisdom and traditional practices 

are taken into account and supported as fundamental elements of programs, policies, and 

activities that are designed, or contribute, to 

improvements in behavioral health. 

Part One of the document provides background on the historical and current contexts 

of tribal communities, data on targeted behavioral health issues faced by American Indians 

and Alaska Natives, and health care service system issues and considerations. The TBHA is a 

collaborative tool – it can be used by any entity 

that has the ability to contribute positively to 

tribal communities. As such, the information 

aims to achieve common understanding of the 

issues requiring collaboration.

Part Two of the document includes the foundational elements, priorities, and strategies of 

the TBHA that were derived through tribal 

input. The components of the TBHA are not 

all-inclusive but rather, collectively they reflect 

areas of agreement across many conversations 

that have been elevated for collaboration. Part 

Two also includes examples of current federal 

programs that are synergistic with the foundational elements, priorities, and strategies. 

The federal examples underscore that critical 

programs exist and can be effectively leveraged 

to improve behavioral health.

SAMHSA and IHS commit to working with 

you to advance the TBHA, improve behavioral 

health, and contribute to the well-being of 

American Indians and Alaska Native people.

Kana Enomoto

Principal Deputy 

Administrator

SAMHSA

Mary Smith 

Principal Deputy 

Director

IHS

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 3
american Indian AND 

Alaska Native Cultural 

Wisdom Declaration

This statement is an attempt to motivate and set in motion, culturally 

derived efforts that will address the present state of health for American Indian 

and Alaska Native people. American Indian and Alaska Native tribes are diverse 

and unique in culture and traditions but share a common history in our relationship with 

the Federal government and common goals for improving the lives of our people. 

We hope this statement will be accepted and supported by American Indian and Alaska 

Native tribes as a statement of intent that will move us forward in preserving and 

promoting our identities and cultural and spiritual beliefs and practices while 

practicing our respective traditional wisdom in health protection that 

has been passed from generation to generation. 

As indigenous people, we possess the culturally 

relevant knowledge and expertise to address 

and enhance the overall health and well-being of all American Indian and Alaska Native 

people across the country. We also expect this 

statement will be honored and implemented 

by U.S. Federal Agencies, state agencies, and 

private and non-profit organizations charged 

with improving the health status of American 

Indian and Alaska Native people. 

BACKGROUND

Native Americans are experiencing vast health 

inequities as evidenced by high rates of cancer, 

diabetes, trauma, mental and substance use 

disorders (including suicide), and unintentional injury. Present efforts to address the 

health status of American Indian and Alaska 

Native- people remain marginally effective 

in alleviating these health disparities. While 

research and programs consistently recommend that prevention and health care programs also implement traditional practices 

and philosophies, barriers exist that prevent 

the successful implementation of culturally tailored health promotion and healing 

interventions. 

The intent of this declaration is to address the 

existing barriers and move towards successful 

implementation of culturally driven health 

promotion models of care and healing. This 

declaration promotes the voice of American 

Indians and Alaska Natives to ensure success in 

embedding culturally relevant health promotion and healing interventions into health and 

human service initiatives supported by Tribes, 

Federal agencies, and other entities. 

WE BELIEVE... 

We honor the ancestral cultural knowledge, 

wisdom, ceremony, and practices of American 

Indian and Alaska Native tribes. Our respective cultural knowledge is sacred and has 

been practiced for centuries as evident in our 

shared inter-tribal survival and resilience. 

This traditional cultural wisdom predates the 

U.S. Constitution. We are experts of our own 

cultural wisdom. Our wisdom has been passed 

down orally from generation to generation, 

and the depths of our wisdom remains within 

the hearts and minds of our people. Our 

cultural wisdom exists solely for us. It is tribe 

specific and this sacred knowledge exists to 

benefit our health, our well-being, and the 

health and well-being of future generations. 

Our cultural wisdom is guarded and protected 

4
because of the history of broken promises and 

broken trust we have experienced over and 

over again. Our cultural wisdom will remain 

protected. Our cultural wisdom will continue 

to be transferred orally, as it has been in the 

past. Our worldview on health and healing is 

holistic, encompassing the body, mind, spirit, 

nature and our environment.

WE WILL....

We will preserve and implement our cultural 

wisdom as a means to promote health and 

well-being in our communities through stories, 

songs, prayers, rituals, and ceremonies and 

other traditional practices. Our respective 

traditional wisdom, ceremonies, language, and 

customs will be implemented in our communities to benefit our present and future 

generations while we honor the ancestral and 

sacred elements of this knowledge and control 

its use and dissemination. All details of cultural 

wisdom will remain authentic to traditional 

ways of being, knowing, and doing. We will 

integrate authentic cultural interventions 

alongside existing healthcare promotion efforts 

to ensure a culturally tailored and culturally 

relevant approach to health promotion and 

healthcare delivery for American Indian and 

Alaska Native people.

WE KNOW....

We know that Native American wisdom exists 

within our stories, language, ceremonies, songs, 

and teachings. We know our Native ways are 

effective. We know that these ways are different 

from the Western worldview. We know we are 

experts in practicing and implementing our 

traditional ways to enhance the health of our 

people. We know our ways are unique and specific to Tribal groups. The authenticity of our 

Native American cultural wisdom is acknowledged and validated by our families, our clans, 

our communities. This knowledge has been 

validated for centuries by our ancestors. This 

knowledge exists within American Indian 

and Alaska Native communities, it is known 

by our people, and we will protect this sacred 

knowledge.

We expect the following from those agencies that have power, authority and funding 

relevant to American Indian and Alaska Native 

health including Tribal, State, Federal, private 

and non-profit organizations:

▶ TRUST

▶ RESPECT

▶ ACCEPTANCE

▶ COMMITMENT

▶ SUPPORT

▶ FINANCIAL RESOURCES

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 5
And to ensure the success of this declaration we recommend the following:

ʠ Respect our intent to keep sacred knowledge private and allow 

details of this cultural knowledge and wisdom to remain 

with the knowledge keepers (elders, traditional healers, 

storytellers, and American Indian and Alaska Native people).

ʠ Support our unique ideas and models of health 

and healing interventions that may not fit 

typical or standard western approaches.

ʠ Modify your requirements to fit the relevant traditional tribal 

paradigm or allow room for flexibility when evaluating proposals 

submitted by American Indian and Alaska Native tribal nations.

ʠ Provide adequate time and financial resources required to 

work in rural and remote areas, with hard to reach populations 

and within the legal frameworks of sovereign nations.

ʠ Trust the Nations to deliver their culturally derived interventions.

ʠ Accept our distinct American Indian and Alaska Native 

cultural ways of being, knowing and doing.

ʠ Support our authority to practice American Indian 

and Alaska Native culture as practiced for generations, 

without modification, without restriction.

ʠ Support the cost of structuring innovative and culturally 

tailored models of health promotion through advocating 

for additional funding in the form of budget increases 

and specific grant funding that targets unique American 

Indian and Alaska Native health promotion efforts.

The following individuals, Tribes/Nations and Other 

American Indian and Alaska Native community agencies 

and organizations support this statement.

SIGNATORIES

Lincoln Bean – Chairman, Alaska Native Health Board

Vernon Miller – Chairman, Omaha Tribe of Nebraska

Aaron Payment – Chairman, Sault Ste. Marie Tribe of 

Chippewa Indians

Andy Joseph, Jr. – Tribal Council Member, Confederated 

Tribes of the Colville Reservation

Tina Richards – Tribal Business Council Member, Susanville 

Indian Rancheria 

Wilfrid Cleveland – President, Ho-Chunk Nation

Rita Jefferson – Tribal Business Council Member, Lummi 

Nation

6
Tom Johnson, Jr. – Chairman, Sun’aq Tribe of Kodiak 

Marilyn M. Scott – Tribal Council Member, Upper Skagit 

Indian Tribe

Patsy M. Bain – Tribal Council Member, Makah Tribe 

Lester Secatero – Chairman, Albuquerque Area Indian Health 

Board

Patrick Marcellais – Tribal Council Representative, Turtle 

Mountain Band of Chippewa Indians

Vinton Hawley – Chairman, Pyramid Lake Paiute Tribe

Lisa Elgin – Tribal Administrator, Manchester-Point Area 

Band of Pomo Indians

Chester Antone – Tribal Legislative Council Member, Tohono 

O’odham Nation

Marty Wafford – Chairperson, Southern Plains Tribal Health 

Board

Thomas Beauty – Chairman, Yavapai-Apache Nation

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 7
ACKNOWLEDGMENTS

The development of the first National Tribal Behavioral Health 

Agenda (TBHA) is long overdue. The concept for the TBHA came from 

the Substance Abuse and Mental Health Services Administration’s 

(SAMHSA) Tribal Technical Advisory Committee (TTAC) and was 

driven forward by the HHS Secretary’s Tribal Advisory Committee. 

SAMHSA owes a debt of gratitude to Joe 

Garcia (Ohkay Owingeh Pueblo) whose 

vision initiated the TTAC discussion and 

who passionately spoke about the importance of Tribal leaders’ voices in framing a 

behavioral health agenda for Tribal nations. 

SAMHSA also appreciates the leadership 

and guidance from other Tribal leaders on 

the TTAC whose collective voices helped 

shape and guide completion of the TBHA: 

Timothy Ballew II (Lummi Indian Nation), 

Brooks Big John (Lac du Flambeau Tribe), 

Amber Crotty (Navajo Nation), Anthony J. 

Francisco, Jr. (Tohono O’odham Nation), Andy 

Joseph, Jr. (Confederated Tribes of the Colville 

Reservation), Juana Majel-Dixon (Pauma Band 

of Luiseno Mission Indians), Keith Massaway 

(Sault Ste. Marie Tribe of Chippewa Indians), 

and Vernon Miller (Omaha Tribe of Nebraska).

The insight and guidance provided by the U.S. 

Department of Health and Human Services 

Secretary’s Tribal Advisory Committee (STAC)

during many discussions about behavioral 

health and in particular, suicide in Indian 

Country, were invaluable in shaping the TBHA. 

In addition, the input and support from Tribal 

leaders on the Board of Directors for the 

National Indian Health Board were significant 

and appreciated.

Special appreciation is extended to Cathy 

Abramson (Sault Ste. Marie Tribe of Chippewa 

Indians) and Chester Antone (Tohono 

O’odham Nation) whose dedication to uplifting the behavioral health of American Indians 

and Alaska Natives and their engagement on 

the TBHA throughout its development have 

proven them to be champions for Native 

people.

The process for developing the TBHA was the 

result of months of information-gathering 

and discussing, analyzing, validating, sharing, 

and revalidating the input received. SAMHSA’s 

Office of Tribal Affairs and Policy (OTAP) 

worked with the Indian Health Service’s (IHS) 

Office of Clinical and Preventive Services 

(OCPS) and the National Indian Health Board 

(NIHB) to engage Tribal leaders, Tribal administrators, and Tribal members to obtain input 

and ensure that Tribal voices were honored in 

developing the TBHA. The following individuals are recognized for their leadership in 

bringing Tribal leaders’ vision for the TBHA to 

fruition:

ʠ MIRTHA BEADLE, OTAP, SAMHSA

ʠ STACY BOHLEN (Sault Ste. Marie Tribe 

of Chippewa Indians), NIHB

ʠ SHEILA COOPER (Seneca 

Nation), OTAP, SAMHSA 

ʠ BEVERLY COTTON (Mississippi Band 

of Choctaw Indians), Division of 

Behavioral Health (DBH), OCPS, IHS

8
ʠ JACQUELYNN ENGEBRETSON

(Ahtna Athabascan), NIHB

ʠ ROBERT FOLEY, NIHB

ʠ HANKIE ORTIZ, Bureau of Indian Affairs

ʠ MARCELLA RONYAK (Confederated Tribes of 

the Colville Reservation), DBH, OCPS, IHS

ʠ DEBORAH SCOTT (Cherokee 

Nation), Sage Associates, Inc.

ʠ ALEC THUNDERCLOUD (Ho-Chunk 

Nation), OCPS, IHS

An essential component of the TBHA is the 

American Indian and Alaska Native Cultural 

Wisdom Declaration which promotes inclusion 

of culturally relevant health promotion and 

healing interventions in all health and human 

services. The authors of the Declaration are 

recognized for their invaluable contribution 

toward reducing barriers to culturally driven 

care and healing:

ʠ CHESTER ANTONE (Tohono 

O’odham), STAC Chair

ʠ MIGUEL FLORES (Tohono O’odham/

Pascua Yaqui), IHS Phoenix Area

ʠ MICHELLE KAHN-JOHN (Navajo), College 

of Nursing, University of Arizona 

ʠ TESHIA ARAMBULA SOLOMON (Choctaw/

Mexican/American), Native American Research 

and Training Center, University of Arizona

Appreciation is extended to the following 

individuals for providing technical expertise 

and support for the TBHA: Tom Anderson 

(Cherokee Nation), Oklahoma Area Tribal 

Epidemiology Center; Frank Bajowski, 

Cabezon Group, Inc.; Carla Britton, Alaska 

Native Epidemiology Center; Dawn Coley 

(Penobscot Nation), NIHB; Devin Delrow 

(Navajo Nation), NIHB; Kristin Hill, Great 

Lakes Inter-Tribal Epidemiology Center; 

Michael Koscinski, OIASA, OTAP, SAMHSA; 

Byron Larson (Northern Cheyenne Tribe), 

Urban Indian Health Institute; Caitrin Shuy, 

NIHB; Donna Cay Tharpe, Cabezon Group, 

Inc.; and the Tribal Law and Order Act Indian 

Alcohol and Substance Abuse Coordinating 

Committee’s Data Workgroup.

The TBHA was a collaborative effort among 

tribes, Tribal leaders, national and regional 

Tribal organizations, SAMHSA Regional 

Administrators, SAMHSA staff members, and 

Federal partners. Three specific Tribal organizations – National Indian Health Board, 

National Council of Urban Indian Health, 

and National Congress of American Indians – 

were instrumental in supporting, advancing, 

and disseminating the TBHA. Although it is 

difficult to identify all supporters by name, the 

TBHA would not have been possible without 

all of you.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 9
TRIBAL BEHAVIORAL HEALTH AGENDA

CONTENTS

12 EXECUTIVE SUMMARY

Part One

16 SECTION I. INTRODUCTION

17 PURPOSE OF THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

18 DEVELOPMENT OF THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

20 SECTION II. THE HISTORICAL AND CURRENT CONTEXTS

21 STORY OF SURVIVAL

 21 Federally Recognized Tribal Governments

 23 Historical and Intergenerational Trauma

26 SECTION III. BEHAVIORAL HEALTH: STATE OF URGENCY

27 TRAUMA

 27 Interpersonal Violence

 29 Adolescents and Violence

 29 Children of Incarcerated Parents

 29 Veterans

29 DEPRESSIVE SYMPTOMS

 29 Depression

 30 Grief and Loss

30 SUBSTANCE USE

31 SUICIDE

34 SECTION IV. HEALTH CARE AND SUPPORTIVE SERVICE CONSIDERATIONS

35 INDIGENOUS HEALING PRACTICES

 35 Integration of Traditional and Western Practices

 35 Components of Integrated Interventions

 35 Components of Integrated Systems

36 HEALTH CARE AND SERVICE SYSTEMS

37 WORKFORCE DEVELOPMENT

37 INDIAN HEALTH CARE SYSTEM FUNDING

38 OTHER IMPORTANT FEDERAL SOURCES OF FUNDING

38 ACCESS TO SERVICES

38 AVAILABILITY AND QUALITY OF SERVICES

39 ATTITUDES TOWARD BEHAVIORAL HEALTH AND SERVICES

40 SUPPORTIVE SERVICES

40 PUBLIC HEALTH AND RESEARCH INFRASTRUCTURE

10
Part Two

42 SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

44 CONSIDERATIONS FOR COLLABORATION

 44 Tribal, Federal, and State Government Relationships

 44 Alignment of Local and National Efforts

 44 Creation and Support of New Efforts

45 CROSS-CUTTING CONSIDERATIONS

 45 Youth

 45 Identity

 45 Culture

 46 Individual Self-Sufficiency

 46 Data

 46 Tribal Leadership

47 FOUNDATIONAL ELEMENTS, PRIORITY AREAS, AND STRATEGIES

 50 Foundational Element 1: Historical and Intergenerational Trauma (HIT)

 54 Foundational Element 2: Socio-cultural-ecological (SCE) Approach

 57 Foundational Element 3: Prevention and Recovery (PR) Support

 62 Foundational Element 4: Behavioral Health (BH) Systems and Support

 68 Foundational Element 5: National Awareness (NA) and Visibility

70 SECTION VI. MOVING FORWARD

72 REFERENCES

78 APPENDIXES

78 APPENDIX 1 

 Highlights of the Key National Tribal Behavioral Health Agenda Information-Gathering Sessions

80 APPENDIX 2 

 Selected List of Federal Strategic Plans and Documents: Correlations with the National Tribal 

Behavioral Health Agenda

89 APPENDIX 3 

 Tribal Resolutions Supporting the National Tribal Behavioral Health Agenda

 89 National Indian Health Board

 90 National Congress of American Indians

 91 Tohono O’odham Nation

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 11
TRIBAL BEHAVIORAL HEALTH AGENDA

EXECUTIVE SUMMARY

THE VOICES

Suicide pacts among American 

Indian youth in small and 

tight-knit communities

Long waiting 

lists to see a 

health provider

Providers who have little 

understanding of historical 

and traditional practices

These comments are but a few of the concerns voiced by hundreds of 

Tribal members when asked about behavioral health issues in their communities. 

The story of American Indians and Alaska Natives is one of resiliency and 

survival. However, threats such as social injustices, perpetuated over multiple 

generations, continue to have enduring consequences for Tribal communities and 

contribute to the behavioral health problems being experienced today.

The problems – which result from adverse 

childhood experiences and traumatic events 

experienced historically and intergenerationally – are reflected in high rates of interpersonal violence, depressive symptoms 

(depression and unresolved grief and loss), 

substance use (drug misuse use as well as 

illicit drug use), and suicide. The root causes 

and resulting behavioral health issues impact 

other areas that contribute to well-being such 

as overall health, education, employment, 

child welfare, and engagement with the justice 

system that create an urgent need for Tribes, 

Federal agencies, and other interested parties to 

work together differently and more effectively.

The idea for a comprehensive document 

focused on the behavioral health of Tribal 

communities was brought forward by concerned and engaged Tribal leaders. There is no 

one single national program or document that 

brings together and elevates the importance of 

behavioral health for Native people, identifies 

priorities developed by Tribal communities, 

and guides incorporation of strategies to 

improve the well-being of youth, families, and 

communities. Many individuals and organizations play a role in addressing behavioral 

health and their related problems and are at 

times loosely connected through a broad landscape of Tribal and Federal projects, programs, 

12
initiatives, and funding streams that require 

better coordination to improve well-being.

To bring the TBHA idea to fruition, the 

Substance Abuse and Mental Health Services 

Administration, Indian Health Service, and the 

National Indian Health Board shared information and facilitated discussions and meetings with hundreds of Tribal leaders, Tribal 

administrators, Tribal members, advocates for 

American Indian and Alaska Native health, 

Native youth, and Federal agency representatives. From the many meetings and discussions 

emerged a series of overlapping opportunities 

and priorities that serve as the framework for 

the National Tribal Behavioral Health Agenda 

(TBHA). The TBHA is not a strategic plan; 

rather it is a guiding blueprint that will assist in 

strengthening policies and programs, aligning 

disparate resources, and facilitating collaboration. It identifies existing strategic plans and 

efforts that can serve as initial pathways for 

action and a single, unifying tool around which 

engaged parties can gather, utilizing common language and priorities. All parties have 

a responsibility and role to play in creating 

solutions that are viable and sustainable, and 

the TBHA provides the needed framework and 

priorities for doing so.

The TBHA framework is organized around five 

foundational elements that provide both content and direction. The foundational elements 

were dominant themes from early formative 

work with Tribal leaders and capture the 

opportunities and issues presented. Underlying 

each of the five foundational elements are 

priority areas that reflect the recurring issues 

raised by Tribal leaders, Tribal members, and 

stakeholders as outlined on the following page.

Within the priority areas are strategies that 

can be framed to address unique community 

circumstances. The strategies are not prescriptive and range from engaging key stakeholders 

in policy and systems changes to examining 

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 13
staffing patterns to create a healthier and more 

responsive workforce. Some strategies are 

appropriate for Tribal governments, whereas 

others are more appropriate for Federal partners or even individual community members, 

reflecting opportunities where interested 

parties can engage.

Tribal leaders, Tribal council members, Tribal 

administrators, American Indian and Alaska 

Native health advocates, and Federal agency 

representatives have consistently called for 

coordination and collaboration among the 

distinct jurisdictions and entities whose efforts 

contribute to the health and well-being of 

American Indian and Alaska Native communities. The TBHA offers the opportunity 

for these parties to find common ground for 

developing interrelated and integrated actions 

for addressing the behavioral health needs of 

American Indians and Alaska Natives. This 

includes a commitment to incorporate the 

long-held wisdom and cultural practices of 

Tribal communities and Western approaches 

and systems in identifying solutions, garnering appropriate attention and resources 

for addressing outstanding challenges, and 

mobilizing collaborators to act together to 

combat localized behavioral health and related 

issues. The TBHA creates a platform that will 

allow Tribal and Federal collaborators to chart 

priorities for funding, programs, and policy 

decisions. Collaboration is the power of the 

TBHA.

THE TRIBAL BEHAVIORAL HEALTH AGENDA FOUNDATIONAL ELEMENTS

1 2 3 4 5

HISTORICAL AND 

INTERGENERATIONAL 

TRAUMA

NATIONAL

AWARENESS

AND VISIBILITY

PREVENTION AND

RECOVERY SUPPORT

BEHAVIORAL HEALTH

SYSTEMS AND

SUPPORT

SOCIO-CULTURALECOLOGICAL

APPROACH

1. HISTORICAL AND 

INTERGENERATIONAL 

TRAUMA

SUPPORT SYSTEMS

COMMUNITY 

CONNECTEDNESS

BREAKING THE CYCLE

2. SOCIO-CULTURALECOLOGICAL

APPROACH

SUSTAINING 

ENVIRONMENTAL 

RESOURCES

RELIABLE INFRASTRUCTURE

HEALTHY FAMILIES 

AND KINSHIP

3. PREVENTION AND 

RECOVERY SUPPORT

PROGRAMMING 

THAT MEETS 

COMMMUNITY NEEDS

COMMUNITY 

MOBILIZATION AND 

ENGAGEMENT

4. BEHAVIORAL 

HEALTH SYSTEMS 

AND SUPPORT

WORKFORCE 

DEVELOPMENT

FUNDING 

MECHANISMS

TRIBALLY DIRECTED 

PROGRAMS

YOUTH-BASED 

PROGRAMMING

SCOPE OF 

PROGRAMMING

LAW ENFORCEMENT 

AND JUSTICE 

PROGRAMS

5. NATIONAL 

AWARENESS 

AND VISIBILITY

TRIBAL CAPACITY 

BUILDING

TRIBALLY DIRECTED 

COMMUNICATION 

STRATEGIES

COLLABORATOR 

CAPACITY BUILDING

EXECUTIVE SUMMARY

14
NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 15
1

TRIBAL BEHAVIORAL HEALTH AGENDA SECTION I

INTRODUCTION

16
The significant health issues confronting American Indian and Alaska Native communities 

on a national scale are well known and well documented. What is not as well documented 

are the stories of success and survival that often accompany daunting health and behavioral 

health concerns. The term “behavioral health” refers to the promotion of mental health, 

resilience, and well-being; the prevention and treatment of mental and substance use 

disorders; and the support of those who are in recovery from these conditions, along with 

their families and communities.1 Strength and resiliency are ingrained traits of American 

Indian and Alaska Native communities. Adaptability has become an equally important 

attribute as contemporary times and challenges have forced these communities to examine 

their health and wellness through the predominantly Western lenses of clinical care, 

programmatic effectiveness, sustainability, and impact.

Tribal leaders have voiced concerns about the state of 

behavioral health in Indian Country. Tragic stories have 

been shared of continuing suicides among youth in 

small, tight-knit communities. Stories have been shared 

of long waiting lists to see a behavioral health provider 

who is only in the community a limited number of days 

a month. Other stories have been shared of providers 

who are not knowledgeable enough of local traditions to 

work with their clients in a manner that honors historical and traditional practices. These stories paved the 

path to where we are today. Now is the time to inventory 

the collective knowledge, resources, and commitment 

for addressing behavioral health issues and converting 

opportunities to action.

The National Tribal Behavioral Health Agenda (TBHA) 

honors the history and trust relationship that the U.S. 

Government has with American Indian and Alaska 

Native tribes by acknowledging barriers, identifying 

common priorities, and proposing strategies that can be 

addressed by Tribes, Federal agencies, and other entities 

working together. All parties have the goal of improving 

the well-being of American Indians and Alaska Natives, 

and the TBHA was created as a blueprint for informing 

programs, policies, and activities that can assist in reaching that goal.

PURPOSE OF THE NATIONAL TRIBAL 

BEHAVIORAL HEALTH AGENDA

Tribal leaders, Tribal administrators, American Indian and 

Alaska Native health advocates, and Federal agency representatives have consistently called for coordination and collaboration among the distinct jurisdictions and entities whose 

efforts contribute to the health and well-being of American 

Indian and Alaska Native communities. One view is that the 

many programs and initiatives intended to improve the spiritual, physical, and emotional health of American Indians 

and Alaska Natives operate in isolation and would be more 

effective if they worked more closely together. Underpinning 

this view are the following tenets:

ʠ American Indians and Alaska Natives continue to face 

significant behavioral health problems, and the factors that 

serve as determinants of these health challenges vary greatly.

ʠ Behavioral health issues are not isolated. Behavioral health shares 

important correlations with physical health as well as with social 

and economic conditions in Tribal communities that require a 

more collective and collaborative approach. These correlations 

require a broader view of the components of a comprehensive 

prevention and treatment approach to behavioral health issues.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 17
ʠ The high rates of behavioral health problems among American 

Indians and Alaska Natives create urgency for Tribes, Federal 

agencies, and other entities to work together in a manner that 

meaningfully improves the well-being of Tribal communities.

ʠ The Federal Government has a trust responsibility 

for improving the health and well-being of 

American Indians and Alaska Natives.

ʠ There is no single national program or document that 

elevates the importance of behavioral health for American 

Indians and Alaska Natives, identifies the collective priorities 

of Tribal communities related to behavioral health, and 

guides the development and/or incorporation of behavioral 

health-related actions to improve the well-being of American 

Indian and Alaska Native youth, families, and communities.

The TBHA is not a strategic plan. 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 should take to address the behavioral health of 

American Indians and Alaska Natives. Rather, the TBHA is 

a blueprint that:

ʠ Provides a clear national statement about the extent and need to 

prioritize behavioral health and related problems, their impact 

on the well-being of Tribal communities, and a set of strategies 

based on direct input from Tribal leaders and representatives.

ʠ Identifies foundational elements that should be 

considered and integrated into both existing and 

potential programmatic and policy efforts.

ʠ 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.

ʠ Creates a platform to allow Tribal and Federal collaborators 

to routinely examine funding, program, and policy priorities 

that best support opportunities to improve communication, 

align efforts, and make real and measurable improvements in 

behavioral health for American Indians and Alaska Natives.

DEVELOPMENT OF THE NATIONAL TRIBAL 

BEHAVIORAL HEALTH AGENDA

The idea and necessity for a blueprint such as the TBHA 

were brought forward by the Tribal Technical Advisory 

Committee of the Substance Abuse and Mental Health 

Services Administration (SAMHSA), which comprises 

elected Tribal leaders. The concept was advanced by other 

equally concerned and engaged Tribal leaders who also 

witnessed inequities in resources available to non-Native 

communities, compared with Native communities experiencing significant challenges, such as multiple suicides. In 

response, SAMHSA and the Indian Health Service (IHS) 

worked to lay the foundation for what would become the 

TBHA. To bring this idea to fruition, SAMHSA, IHS, and 

the National Indian Health Board (NIHB) engaged in discussions with Tribal leaders and members, Tribal administrators, Tribal advocates for American Indian and Alaska 

Native health, and Federal agency representatives over an 

18-month period through the end of 2015.

18
SECTION I. INTRODUCTION

Input was received through facilitated sessions held 

independently or that took place during other scheduled 

Tribal and Federal gatherings and meetings (see Appendix 

1. Highlights of Key National Tribal Behavioral Health 

Agenda Information-Gathering Sessions). Dedicated 

conference calls with elected Tribal leaders also took place 

concerning efforts to develop the TBHA. Because it was 

important to garner Federal input in the process, the 

U.S. Department of Health and Human Services (HHS) 

hosted a Federal interagency forum in December 2015 to 

discuss current Federal programming that might align 

with the TBHA. Federal interagency forum discussions 

demonstrated a synergy between Tribal and Federal representatives that substantial opportunity exists for greater 

collaboration. Participants at the forum included representatives from the following agencies:

ʠ Administration for Children and Families (ACF), HHS

ʠ Administration for Community Living (ACL), HHS

ʠ Bureau of Indian Affairs (BIA), U.S. Department of the Interior

ʠ Centers for Disease Control and Prevention (CDC), HHS

ʠ Centers for Medicare & Medicaid Services (CMS), HHS

ʠ Health Resources and Services Administration (HRSA), HHS

ʠ IHS, HHS

ʠ National Institutes of Health (NIH), HHS

ʠ Office of Juvenile Justice and Delinquency 

Prevention, U.S. Department of Justice (DOJ)

ʠ SAMHSA, HHS

ʠ Social Security Administration (SSA)

ʠ U.S. Department of Veterans Affairs (VA) 

Collectively, the input sessions allowed participants to share 

information on behavioral health and related priorities, 

the nature of behavioral health service delivery, significant 

successes and challenges, and considerations for advancing behavioral health among American Indian and Alaska 

Native people and communities. A qualitative strategy for 

analyzing the input received, in a manner that honored all 

of the feedback and input, was adopted. The development 

process was inherently iterative, with prior meetings and 

discussions shaping subsequent conversations to validate 

and supplement previous information and conclusions. 

Discussions were transcribed and then analyzed manually 

in teams of two or three people to examine similarities and 

identify broader themes. At the end of the process, data 

were categorized and collapsed into foundational elements 

and recommendations across all conversations. Across 

discussions, Tribal leaders and representatives agreed to 

the importance of a TBHA, the foundational elements, and 

considerations for the development of the TBHA.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 19
2 TRIBAL BEHAVIORAL HEALTH AGENDA SECTION II

HISTORICAL AND 

CURRENT CONTEXTS

20
Story of Survival

Each Tribal nation across the United States has a unique history, culture, 

language, and story, contradicting the generic and ethnic sameness that might 

be implied by the terms “American Indians” and “Alaska Natives.”

FEDERALLY RECOGNIZED TRIBAL 

GOVERNMENTS

The United States has a unique government-to-government 

relationship with Indian tribes that is grounded in the U.S. 

Constitution, numerous treaties, statutes, Federal case law, 

regulations, and executive orders that establish and define a 

trust relationship with Indian tribes.

GEOGRAPHY

Within the boundaries of the United States, there are 

currently 567 federally recognized and dependent sovereign American Indian and Alaska Native nations, tribes, 

rancherias, villages, and pueblos and 65 state-recognized 

tribes.2 Federally recognized tribes with reservation lands 

are on one of 326 federally recognized American Indian 

reservations.3 Through allotment policies established in the 

19th century, many tribes lost communally held lands, with 

ownership passing out of Tribal jurisdiction. Tribal members continued to congregate in established communities, 

and today they account for tribes with no federally recognized reservations, such as the 39 tribes in Oklahoma.4

Through other policies focused on relocating or “terminating” tribes in the 1950s, American Indian and Alaska 

Natives from many tribes were moved to 12 urban areas to 

better access employment and to encourage assimilation.5

Today, these urban areas are home to the larger urban 

American Indian and Alaska Native groups, with most 

living in small, scattered pockets across vast cityscapes.

POPULATION

American Indians and Alaska Natives total more than 6.6 

million persons or 2% of the total U.S. population, with 

48% identifying as solely one race and 52% identifying 

as American Indian and Alaska Native and at least one 

other race.6 The majority of American Indians and Alaska 

Natives, about 71%, live in rural, urban, or suburban areas 

rather than on reservations.7,8

There are 21 states with 100,000 or more American Indian 

or Alaska Native residents – California, Oklahoma, Arizona, 

Texas, New York, New Mexico, Washington, North Carolina, 

Florida, Michigan, Alaska, Oregon, Colorado, Pennsylvania, 

and Minnesota.9 The following 10 cities are home to the 

largest number of urban American Indian and Alaska 

Natives: New York City, Los Angeles, Phoenix, Oklahoma 

City, Anchorage, Tulsa, Albuquerque, Chicago, Houston, 

and San Antonio.10

AGE AND EDUCATION 

American Indian and Alaska Native populations are overall 

younger than the general U.S. population. In 2014 the 

mean age of American Indians and Alaska Natives was 31.4 

years compared with 37.7 years for the U.S. population at 

large.11 American Indians and Alaska Natives also tend to 

be less well educated. The dropout rate for Native students 

is twice the national average, the highest of any U.S. ethnic 

or racial group. About 3 out of every 10 American Indian 

and Alaska Native students drop out before graduating 

from high school, both on reservations and in cities.12

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 21
UNEMPLOYMENT

Accurate estimates of unemployment rates for American 

Indians and Alaska Natives are not available;13 however, 

rates are known to be high in many Native communities where economies are depressed and the number of 

available jobs is low. Common reasons for unemployment 

are lack of education, absence of jobs, and high rates 

of disabilities. Even when American Indians and Alaska 

Natives are similar to Whites in terms of factors such as age, 

sex, education, marital status, and place of residence, their 

odds of being employed are 31% lower than Whites.14 This 

suggests the presence of factors that go beyond known conditions and include racial discrimination and geography. 

For example, American Indian and Alaska Native unemployment rates are lower in states with no reservations and 

higher in reservation states.

SANITATION FACILITY INFRASTRUCTURE. 

Adequate sanitation facilities (running water and/or 

waste water disposal) is lacking in approximately 145,000 

American Indian and Alaska Native homes which represent 

36 percent of the universe of tribal homes tracked by the 

Indian Health Service.15 In addition, many tribes with adequate sanitation facilities are struggling to properly operate 

and maintain the infrastructure and safely deliver services. 

Research in American Indian and Alaska Native communities has linked lack of adequate sanitation services with 

serious health conditions.16 

POVERTY

Compared with all other races, American Indians and 

Alaska Natives are most likely to live in poverty (26.6% 

compared with 14.7% for the U.S. general population).17

Furthermore, in studies of both urban and rural communities, American Indians and Alaska Natives are approximately twice as likely as the general population in those 

same areas to be poor, unemployed, and without a college 

degree.18,19 In addition to the complexity of poverty and 

unemployment is the problem of underemployment. In 

environments where there is competition for employment (including both on reservations and in urban-based 

settings), American Indians and Alaska Natives may be 

economically forced to accept part-time or poorly paid 

work in lieu of no employment.20

MORBIDITY/MORTALITY

American Indians and Alaska Natives born today have a 

life expectancy that is 4.2 years less than all other races in 

the United States and continue to die at higher rates than 

others due to liver disease, diabetes mellitus, unintentional 

injuries, assault/homicide, and intentional self-harm/suicide.21 Alcohol is considered to be the largest contributing 

factor to increased mortality,22 and American Indians and 

Alaska Natives are approximately twice as likely to die of 

alcohol-related causes than the general American public.23

However, there is significant variability for alcohol-specific 

deaths across American Indian and Alaska Native populations – from 17.0 per 100,000 in the Nashville Area to 83.4 

per 100,000 in the Aberdeen Area.24

22
SECTION II. THE HISTORICAL AND CURRENT CONTEXTS

Historical and Intergenerational Trauma

Historical trauma is recognized as the root cause of much of 

the behavioral health disparities currently experienced by 

American Indians and Alaska Natives.25

Social injustices, perpetuated over multiple generations, 

have had enduring consequences for many American 

Indian and Alaska Native individuals, families and communities. Research documents massacres, genocidal policies, 

pandemics from the effects of introduced diseases, forced 

relocations, forced removal of children through boarding 

school policies, and prohibition of spiritual and cultural 

practices (including the prohibition of the use of Native 

languages).26,27 Native youth who were removed from their 

homes were prohibited from communicating in the only 

language they knew – their Native language. 

Maria Yellow Horse Brave Heart defines historical trauma 

as the collective complex trauma inflicted on a group 

of people who share a specific group identity or affiliation.28,29,30,31 The symptoms and long-term effects of 

historical trauma include psychological distress, poor 

overall physical and mental health, and unmet medical and 

psychological needs,32 evidenced by increased exposure to 

trauma, depressive symptoms,33 substance misuse,34 and 

suicidal thoughts and attempts.35Trauma affects individuals differently. In some cases exposure to traumatic events 

will not have lasting negative effects. However, in other 

cases people may experience traumatic stress reactions. If 

trauma is left unaddressed, the risk of mental and substance use disorders and chronic physical disease significantly increases.36

The intergenerational effects of historical trauma on 

long-term health have been documented among American 

Indian and Alaska Native populations through adverse 

childhood event (ACE) studies. These studies assess the 

prevalence of personal experiences – physical abuse, verbal 

abuse, sexual abuse, physical neglect, emotional neglect, 

and family experiences – for example, a parent with alcohol 

problems, a mother who has been a victim of domestic 

violence, a family member in jail, a family member with 

a mental disorder, or the loss of a parent through divorce, 

death, or abandonment. Higher scores are correlated with 

poorer long-term outcomes. In the report “A Framework to 

Examine the Role of Epigenetics among Native Americans,” 

Brockie, Heinzelmann, and Gil37 report that “Native 

Americans disproportionately experience ACEs and health 

disparities, significantly impacting long-term physical and 

psychological health.”

Traumatic events experienced by American Indians and 

Alaska Natives are not confined to a single catastrophic 

period in the past, nor are they confined to a single event 

but from many sources; they are ongoing and present in 

modern times.38,39 A history of unethical research authorized by the U.S. Government created distrust and reluctance on the part of tribes to engage in large-scale studies 

that could provide information specific to American 

Indians and Alaska Natives about problems such as alcohol 

use disorder, suicide, and depression.40 Blood quantum 

requirements (also known as blood quantum laws), which 

originated in the Indian Reorganization Act of 1934 and 

were incorporated into many Tribal constitutions, create 

threats for future generations. Children of intertribal 

unions may not meet Tribal blood quantum requirements, 

thus eliminating their eligibility for Tribal membership and 

access to services.41

American Indians and Alaska Natives who are prosecuted 

in Federal courts face lengthier confinements than non-Natives prosecuted for the same crime in state courts42 and 

are incarcerated at a rate higher than the national average.43

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 23
Native children are disproportionately represented in the 

foster care system and may be placed with non-Native 

families. For example, in South Dakota American Indian 

and Alaska Native children make up less than 15% of the 

child population, yet they represent more than half of the 

children in foster care.44

Although the symptoms and effects of historical trauma 

are well known, Native youth are neither likely to recognize 

that their present-life experiences, or modern-day traumas, 

are triggered by past events nor to make the connection to 

the root cause. This is despite the fact that American Indian 

and Alaska Native adolescents exhibit the effects of historical trauma through high suicide rates,45 alcohol and other 

drug misuse as well as alcohol and other drug disorders,46

and sexual risk-taking.47

Researchers studying the effects of historical trauma across 

generations of American Indians and Alaska Natives found 

that perceptions of historical trauma differed by age and 

generation. For example, in a study of Diné youth, parents, and grandparents, elders were much more aware 

of the long-term consequences of historical trauma and 

easily connected it to loss of cultural knowledge, high rates 

of disease, alcohol and other drug misuse, unhappiness, 

violence, premature death, and overall lack of health.48

Although only one generation removed, the majority of 

elders’ adult children did not think that the root cause of 

their adverse life conditions resulted from historical trauma 

and were more likely to view events such as community 

violence as temporally rather than historically linked. Two 

generations removed, the grandchildren of elders did not 

believe that historically traumatic events had any negative 

effects on their community or their own lives. Individuals 

in the study did not see themselves, their families, or their 

communities as subject to continued oppression through 

control by outsiders.49 The perpetuation of self-destructive 

behaviors cannot be addressed or interrupted without a 

deeper understanding of how trauma impacted past generations and that it continues to impact present generations 

and is constantly triggered by the events, policies, and 

practices of modern times.

Despite historical and other traumas, American Indian and 

Alaska Native communities have managed to survive and 

some communities are thriving. During the 20th century 

American Indians and Alaska Natives rebuilt their nations, 

adapted to cultural and economic pressures, overcame 

adverse and destructive policies, and retained their place in 

the U.S. landscape.50

Time, history, and adversity have fostered inherent traits 

and beliefs that have engendered strong and resilient Native 

communities. An important value, and one that differs 

24
widely from the dominant society, is the importance of 

the group, be it tribe, community, or family. Tribal leaders 

and decisionmakers deliberate on the welfare and needs 

of the group rather than focus solely on individuals. There 

is consideration and mindfulness of the ramifications 

of present-day decisions on children and grandchildren, 

across generations. Extended kinship networks often provide strength, protection, and support, particularly during 

times of hardship. The resources of the group, such as food, 

shelter, transportation, and money, are shared to provide 

for the well-being and safety of all.51

Tribal language and stories ensure that the tribe’s worldview is passed on to the next generation. There are words, 

definitions, and understandings distinct to a tribe’s language that help Native youth understand their place in the 

tribe and in the world. Creation stories and teaching stories 

preserve identity while instilling resilience factors and 

cultural and social norms. Shared beliefs about the importance of balance – spiritual, physical, mental, and emotional – provide a framework for protecting and preserving 

the Tribal community and helping ensure the long-term 

viability of the tribe. All of these characteristics combine to 

create a powerful and resilient practice of culture and serve 

as strong protective factors against adversity.

SECTION II. THE HISTORICAL AND CURRENT CONTEXTS

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 25
3TRIBAL BEHAVIORAL HEALTH AGENDA SECTION III

BEHAVIORAL HEALTH: 

STATE OF URGENCY

26
The information presented in this document paints a difficult picture and 

underscores the urgency to address behavioral health among Native people. 

When armed with facts, Tribal leaders are better able to have open discussions 

about strategies within their community contexts, which hold potential for 

overcoming behavioral health challenges. These challenges are evident through 

comparisons of Tribal communities with nontribal communities; however, this 

often fails to highlight the exceptionality of these challenges as they exist with 

the cultural, community, geographic, economic, and psychosocial realities of 

American Indian and Alaska Native communities.52

An Indigenous definition of health is “. . . not just the 

physical well-being of an individual, but refers to the social, 

emotional, and cultural well-being of the whole community in which each individual is able to achieve their full 

potential as a human being thereby bringing about the total 

well-being of their community.”53 American Indian and 

Alaska Native communities are aware of the physical health 

challenges of their people, but there are also behavioral 

health challenges that are often more difficult to discuss 

and that also impact overall health and well-being. These 

behavioral health challenges are associated with increased 

exposure to trauma, depressive symptoms,54 substance 

misuse,55 and suicidal thoughts.56

The list of exposures and outcomes assessed in this section 

is not necessarily exhaustive; rather, the information provided represent key factors for which plausibly representative data are available. There are many other factors that 

are potentially relevant here, but that are not adequately 

assessed via currently available data sources.

The following discussion of trauma identifies critical areas 

for targeted, renewed, or enhanced Tribal and Federal collaboration across programs, policies, and activities.

TRAUMA

INTERPERSONAL VIOLENCE (IPV)

Current rates of violent victimization for both American 

Indian and Alaska Native males and females in every age 

group are higher than for all other races. American Indian 

and Alaska Native females are at an elevated risk of intimate partner violence.57, 58 Specifically, American Indian 

and Alaska Native women report higher rates of victimization on all measures of violence than their non-Hispanic 

White (NHW) counterparts, including rape, other sexual 

violence, stalking, and partner physical violence and psychological aggression. American Indian and Alaska Native 

men report higher rates of victimization than White/NonHispanic individuals in other sexual violence and partner 

physical violence and psychological aggression (TABLE 1). 

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 27
TABLE 1: 

LIFETIME PREVALENCE OF SEXUAL VIOLENCE, STALKING VICTIMIZATION, 

AND INTIMATE PARTNER VIOLENCE

AI/AN VS. NON-HISPANIC WHITE ADULTS AGE 18+ – NISVS, 2011A,B

WOMEN MEN

% 95% CI Estimated N % 95% CI Estimated N

WHITE NON-HISPANIC

Rape 20.5 18.8-22.3 16,475,000 1.6 1.2-2.2 1,232,000

Other Sexual Violence 46.9 44.9-48.9 37,661,000 22.2 20.5-24.1 16,846,000

Stalking 15.9 14.4-17.5 12,749,000 4.7 3.9-5.8 3,581,000

IPV: Rape 9.6 8.4-10.9 7,730,000 -- -- --

IPV: Other Sexual Violence 17.1 15.6-18.7 13,710,000 7.6 6.5-8.9 5,777,000

IPV: Physical Violence 30.5 28.6-32.4 24,469,000 26.6 24.8-28.6 20,190,000

IPV: Stalking 9.9 8.6-11.3 7,935,000 1.7 1.3-2.3 1,279,000

IPV: Psychological Aggression 47.2 45.2-49.2 37,888,000 44.8 42.7-46.9 33,959,000

AMERICAN INDIAN/ALASKA NATIVE

Rape 27.5 16.1-42.7 -- -- -- --

Other Sexual Violence 55.0 41.5-67.9 452,000 24.5 13.5-40.3 --

Stalking 24.5 14.2-38.8 -- -- -- --

IPV: Rape -- -- -- -- -- --

IPV: Other Sexual Violence -- -- -- -- -- --

IPV: Physical Violence 51.7 38.1-65.0 424,000 43.0 27.4-60.1 335,000

IPV: Stalking -- -- -- -- -- --

IPV: Psychological Aggression 63.8 50.4-75.3 523,000 47.2 31.1-64.0 368,000

a Estimates from Breiding, M. J. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization – 

National Intimate Partner and Sexual Violence Survey, United States, 2011. 

b This data collection does not allow estimates for all measures due to low sample sizes, and these comparisons have not been subjected to inferential 

testing.

28
American Indians and Alaska Natives fall victim to violent crime at more than double the rate of all other U.S. 

citizens,59 and at least 70% of violent victimization experienced by American Indians and Alaska Natives is committed by non-Natives and usually while they are drinking. 

Nearly one-third of all American Indian and Alaska Native 

victims of violence are between the ages of 18 and 24 years, 

and about one violent crime occurs for every four persons 

of this age.60 The combination of interpersonal violence 

layered over historical trauma creates compound negative 

effects for American Indians and Alaska Natives.

ADOLESCENTS AND VIOLENCE 

Teen exposure to violence is associated with multiple 

adverse health outcomes, including depression, anxiety, 

suicidal ideation, substance use, posttraumatic stress 

disorder (PTSD), risky sexual behavior, and eating disorders.61,62,63,64,65,66,67,68 To add to the limited information 

about American Indian and Alaska Native adolescents and 

violence, Morsette and colleagues studied exposure to violence and trauma among 302 American Indian and Alaska 

Native middle-school students and found that 77.5% had 

clinically significant levels of psychometrically assessed 

violence exposure and 52% had clinically significant levels 

of PTSD.69 Unwittingly, Native teens are experiencing the 

effects of historical trauma and in turn are reporting emotional and behavioral problems.

CHILDREN OF INCARCERATED PARENTS

Research regarding American Indian and Alaska Native 

children of incarcerated parents is derived from larger studies with no specific data for American Indian and Alaska 

Native children despite high rates of American Indian and 

Alaska Native adult incarcerations.70,71,72,73,74 In an unpublished review of risks among 1,184 American Indian and 

Alaska Native students attending BIA residential boarding 

schools, 25% reported having a parent who had been 

incarcerated.75

Having an incarcerated parent can impact a child’s mental 

health, social behavior, and educational prospects. Children 

may experience emotional trauma, a disrupted family life, 

and discrimination as a result of having a parent in prison 

or jail.76 Financial hardship follows the loss of that parent’s 

income,77 and if parental rights are terminated, children 

may lose not only the parent but also the connection to 

their entire family if they are placed in foster care.78

Children of incarcerated parents may experience trauma 

related to their parent’s arrest or events leading up to it79

and are more likely to have faced other ACEs, including 

witnessing violence in their communities or directly in 

their household or exposure to alcohol and other drug 

misuse.80 Due to the long-term negative effects of historical 

trauma across generations that have resulted in high rates 

of incarceration for American Indian and Alaska Native 

people, children are now experiencing historical trauma in 

new and current forms.

VETERANS 

American Indian and Alaska Native males who serve in the 

U.S. Military do so in greater proportion than all eligible 

males in general – 3% of all American Indian and Alaska 

Native males, ages 20 to 44 years, compared with 2% of 

all U.S. males (all races) in the same age group. The U.S. 

Department of Defense reported that more than 24,000 

active duty military personnel (out of the 1.4 million total 

personnel) were American Indians and Alaska Natives, 

including 3,900 women. There are more American Indian 

and Alaska Native women veterans (11.5%) than veteran 

women of other races (8.0%).81 It is estimated that 22% of 

Native Americans age 18 years and older are current veterans,82 and the population of older American Indian and 

Alaska Native veterans will likely increase 60% by 2020.83

In a study of Vietnam veterans and the long-term effects 

of exposure to war zone stress and other military dangers, researchers found that veterans are at risk for PTSD 

decades after exposure. They also found that PTSD rates for 

Native American Vietnam veterans are higher than for their 

White counterparts.84,85 High rates of alcohol use disorder 

among veterans may be the result of the use of alcohol 

to self-soothe psychiatric distress related to PTSD symptoms.86,87 Survey data from the American Indian and Alaska 

Native Veterans: 2013 American Community Survey showed 

that American Indian and Alaska Native veterans were 

more likely to lack health insurance and to have a disability, service-connected or otherwise, than military veterans 

of other races.88 The likelihood of American Indian and 

Alaska Native veterans being more likely to lack health 

insurance may be related their dual status – their potential 

eligibility to receive health care at an Indian Health Service 

or Tribal Health Program facility as well as a U.S. Veterans 

Administration health care facility.

DEPRESSIVE SYMPTOMS

DEPRESSION 

In general, American Indians and Alaska Natives have comparatively poorer behavioral health. Although there are no 

large-scale studies to determine the prevalence of depression and other common mental health concerns among 

American Indian and Alaska Natives, available data indicate 

that problems exist at disproportionately high rates for 

both urban and reservation American Indians and Alaska 

Natives89 and that approximately 30% of Alaska Natives in 

particular will suffer from depression at some point in their 

lifetimes.90 Data from the 2015 National Survey on Drug 

Use and Health indicate that American Indian and Alaska 

SECTION III. BEHAVIOR HEALTH: STATE OF URGENCY 

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 29
Native adults aged 18 and older experienced higher rates of 

past year mental illness compared with the general population (21.2% versus 17.9%).

Among U.S. adolescents ages 12 to 20, American Indians 

and Alaska Natives had the highest lifetime major depressive episode prevalence and the highest major depressive 

episode prevalence in the past year.91 Among 9,464 children 

participating in a depression study, American Indian and 

Alaska Native children had the highest self-reported depression rates, and depression increased with age, peaking 

between 16 and 17 years of age. In the same study, race was 

analyzed as an independent risk factor, and results showed 

that simply being American Indian or Alaska Native, apart 

from any other factor, increased the rate of depression 

2.6-fold.92

Despite the need, service utilization rates for American 

Indians and Alaska Natives are low,93 which is likely due 

to a combination of factors, including stigmatization, 

lack of culturally trained providers, lack of services, and 

discrimination.94 Low utilization rates may also be due to a 

misalignment between the world views of American Indian 

and Alaska Native peoples and that of the behavioral health 

field. Anecdotal evidence suggests that when services are 

culturally based (e.g., a tribal system of care), utilization 

increases.

GRIEF AND LOSS 

The quality and intensity of interpersonal attachments 

within most American Indian and Alaska Native communities differ from the broader society, due in part to an 

extensive, complicated, and close-linked kinship network in 

Native communities. Higher morbidity and mortality rates, 

lower life expectancy, and higher rates of suicide and accidental death among American Indians and Alaska Natives 

often result in the loss of one or more family members 

annually.95 As an example, among American Indian and 

Alaska Native youth attending a residential boarding school, 

58% reported the loss of one or more close family members 

within the preceding 12 months.96

Unresolved grief may lead to depression or PTSD. 

Researchers have found that individuals who are grieving 

are also at increased risk of death due to accidents, violence, 

and alcohol-related causes and are more likely to attempt 

suicide (fatal and nonfatal).97

SUBSTANCE MISUSE

Determining universal rates and risks of substance misuse 

for American Indians and Alaska Natives is difficult due 

to the diversity and geographical dispersion of American 

Indian and Alaska Native populations.98,99 Overall, the rate 

of alcohol consumption among American Indians and 

Alaska Natives is significantly lower than the national average (43.9% vs. 55.2%, respectively).100 However, there are 

differences by region and tribe. Some American Indian and 

Alaska Native communities have low rates, and others have 

distinctly higher rates.101,102,103 American Indians and Alaska 

Natives who reside in urban or suburban areas, on average, 

drink more frequently than reservation-based American 

Indians and Alaska Natives and more heavily than the 

national sample and may be at particularly high risk for 

alcohol-related disorders.104 Diversity in rates and patterns 

of use across American Indian and Alaska Native groups 

is often due to substance availability, finances, presence of 

substance-misusing peers, and attitudes toward substance 

misuse.105

Although rates and risks vary across tribes, there is a body 

of knowledge that informs on patterns of use by American 

Indian and Alaska Native youth. In particular, youth on 

reservations are at the highest risk of developing alcohol-related disorders.106 The 2013 Youth Risk Behavior 

Survey (TABLE 2) shows that American Indian and Alaska 

Native youth had higher rates of drinking alcohol before 

age 13 compared to national rates (28.2 compared to 18.6 

respectively). Data from the American Drug and Alcohol 

Survey administered to Native youth at 33 schools from 

2009-2012 was compared to data from the Monitoring the 

Future Survey. The comparison showed much higher prevalence of drug and alcohol use amongst 8th and 10th grade 

Native youth in comparison to national averages.107 Early 

substance use may result from stress events, and is a clear 

marker of risk for prolonged and problematic use,108,109,110

along with lower academic achievement, academic problems, drug use, and alcoholism later in life.111

30
SECTION III. BEHAVIOR HEALTH: STATE OF URGENCY 

TABLE 2: 

AI/AN VS. NATIONAL YOUTH ALCOHOL USE DATA, 

YOUTH RISK BEHAVIOR SURVEY 2013A

Alcohol Use National AI/AN

Ever had at least one drink of alcohol 66.2 (63.7–68.5)

13,104

70.0 (58.0–79.8)

113

Drank alcohol before age 13 years 18.6 (17.2–20.0)

13,308

28.2 (17.0–42.9)

114

Currently drank alcohol 34.9 (32.8–37.1)

12,288

33.4 (23.9–44.4)

101

Usually obtained the alcohol they drank by 

someone giving it to them

41.8 (39.4–44.1)

4,239

N/A 

33

Had five or more drinks of alcohol in a row 20.8 (19.1–22.7)

13,060

18.3 (11.7–27.5)

109

Reported that their largest number of drinks 

in a row was 10 or more

6.1 (5.2–7.1)

12,363

6.1 (2.5–14.2)

101

a

 Comparisons have not been subjected to inferential testing.

American Indians and Alaska Native crime victims report 

higher rates of offender alcohol/drug-involved violent victimizations than individuals who are not Native American 

(TABLE 3) 

Drug overdose deaths from opioid misuse are of significant 

concern to Tribal communities. The Northwest Portland 

Area Indian Health Board reported that from 2006 to 2012, 

a total of 10,565 deaths occurred among American Indian 

and Alaska Native residents in the states of Idaho, Oregon, 

and Washington. There were 584,070 deaths among 

non-Hispanic White (NHW) in the three-state region. 

Drug overdoses accounted for 4.3% (450) of all deaths 

among Northwest American Indians and Alaska Natives 

and 1.7% (9,868) of all deaths among NHWs. Of the drug 

overdose deaths, 65.3% (294) of American Indian and 

Alaska Native deaths and 69.3% (6,837) of NHW deaths 

were from prescription drugs. Furthermore, of the prescription drug overdose deaths, 77.2% (227) of American 

Indian and Alaska Native deaths and 75.4% (5,157) of 

NHW deaths were from opioid overdoses.112

A 2011 Great Lakes Inter-Tribal Council community 

assessment reflecting aggregated data from 10 Tribal 

nations, found that:113

ʠ 30.9% of youth, 27.7% of minor adults, and 24.9% of 

adults intentionally misused prescription medication.

ʠ 7.6% of youth think there is no risk in misusing prescription 

drugs; another 5.9% think there is only a slight risk.

ʠ 5.2% of survey responders indicated it is very likely 

they will misuse prescription drugs in the next 6 

months; another 6% indicate it is somewhat likely.

ʠ 15.6% of youth, 34% of minor adults, and 28.1% of adults 

indicate it would be very easy for them to obtain prescription 

drugs without a prescription if they wanted them.

According to SAMHSA’s Treatment Episode Data Set 

(TEDS), in 2012 there were about 1.7 million individuals 

admitted to substance use treatment facilities. Of these, 

43,576 (2.5%) were American Indians and Alaska Natives. 

Approximately 77% of American Indian and Alaska Native 

individuals admitted reported alcohol misuse. Twentythree percent of the American Indian and Alaska Native 

admissions were ages 15 to 24 years, and among this age 

group, 68.5% (6,885) reported alcohol misuse. Among 

American Indian and Alaska Native individuals who were 

admitted and misused alcohol only 80.5% (21,008) of them 

reported being first intoxicated at age 17 years or younger.

SUICIDE

Studies show that both American Indian and Alaska Native 

adults and adolescents suffer from high rates of suicide. In 

2011 the suicide rate for all American Indians and Alaska 

Natives was 14.68 per 100,000 compared with the overall 

U.S. rate of 11.15 per 100,000.114 American Indian youth 

experience the highest rates of youth suicide in the country, 

and suicide is the second leading cause of death.In 2012-

2013, the suicide rate for American Indian and Alaska 

Native young adult males was 34.3 per 100,000 compared 

to 24.8 for non-Hispanic White males in the same age 

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 31
TABLE 3: 

VIOLENT VICTIMIZATION RATE, BY VICTIM PERCEPTION OF OFFENDER’S ALCOHOL/DRUG INVOLVEMENT

NATIONAL CRIME VICTIMIZATION SURVEY (NCVS) 2004-2013A,B

Violent Victimization Rate* Offender Alcohol/Drug Involved

RACE OF VICTIM** TOTAL YES NO DON’T KNOW

All races 25.57 8.35 7.95 9.27

AI/AN 76.94 31.75 18.59 26.60

Non-AI/AN

      White – Non-Hispanic 25.14 8.71 7.96 8.48

      Hispanic 22.85 6.38 7.01 9.46

      Black – Non-Hispanic 31.23 7.85 9.62 13.76

      Asian/Pacific Islander – Non-Hispanic 11.70 3.62 3.43 4.65

      Two or more races – Non-Hispanic 166.31 29.82 83.60 52.89

Proportions Offender Alcohol/Drug Involved

RACE OF VICTIM TOTAL YES NO DON’T KNOW

All races 100% 33% 31% 36%

AI/AN 100% 41% 24% 35%

Non-AI/AN

      White – Non-Hispanic 100% 35% 32% 34%

      Hispanic 100% 28% 31% 41%

      Black – Non-Hispanic 100% 25% 31% 44%

      Asian/Pacific Islander – Non-Hispanic 100% 31% 29% 40%

      Two or more races – Non-Hispanic 100% 18% 50% 32%

a NCVS, Bureau of Justice Statistics (BJS), Department of Justice (DOJ) and the Uniform Crime Reporting (UCR), Federal Bureau of 

Investigation, DOJ.

b

 Comparisons have not been subjected to inferential testing.

* Violent victimizations include rape or sexual assault, robbery, aggravated assault and simple assault. The rate is defined as victimizations 

per 1,000 persons age 12 or older.

** The race/Hispanic origin categories used in this table are defined differently than those found in BJSreports. The AI/AN category includes 

persons who self-identified as being AI/AN, regardless of whether they also identified as being other races or Hispanic origin as well.

32
SECTION III. BEHAVIOR HEALTH: STATE OF URGENCY 

group. For American Indian and Alaska Native young 

adult females the rate was 9.9 per 100,000 compared to 

5.5 for non-Hispanic White females 18-24. A 2008 Centers 

for Disease Control and Prevention study estimated that 

overall deaths for American Indians and Alaska Natives was 

underreported by 30% thus the suicide rate for American 

Indian and Alaska Native young adults are expected to be 

under estimated.115 For Alaska Natives, suicide is the fourth 

leading cause of death, with a rate 3.6 times greater than 

the White population.116

Contributing factors to suicide risk for some American 

Indians and Alaska Natives may stem from persistent 

unemployment, poverty, poor educational outcomes, 

victimization, mental and substance use disorders, and/

or exposure to violence.117 In one study 77% of American 

Indian and Alaska Native males who had attempted suicide 

(fatal and nonfatal) had incomes of less than $10,000 per 

year, and 79% of them were unemployed.118,119Adults who 

attempt suicide (fatal and nonfatal) increase the suicide risk 

for their children by 20%.120 American Indian and Alaska 

Native youth report higher rates of having felt sad or hopeless, seriously considered attempting suicide, or made a 

plan about how they would attempt suicide (TABLE 4). Risks 

for American Indian and Alaska Native youth include exposure to multiple childhood traumas,121 sexual and physical 

violence,122 and family conflict.123

TABLE 4: 

YOUTH RISK BEHAVIOR SURVEY (YRBS) 2013a

Suicide-Related Behaviors National AI/AN

Felt sad or hopeless 29.9 (28.3–31.6)

13,495

38.8 (28.9–49.7)

120

Seriously considered attempting suicide 17.0 (15.8–18.2)

13,491

27.4 (19.5–36.9)

120

Made a plan about how they would attempt 

suicide

13.6 (12.3–15.0)

13,485

23.1 (15.5–33.0)

120

Attempted suicide 8.0 (7.2–8.9)

11,982

N/A 

98

Attempted suicide that resulted in an injury, 

poisoning, or overdose that had to be 

treated by a doctor or nurse

2.7 (2.3–3.1)

11,750

N/A 

90

a

 Comparisons have not been subjected to inferential testing.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 33
4

TRIBAL BEHAVIORAL HEALTH AGENDA SECTION IV

HEALTH CARE AND 

SUPPORTIVE SERVICe 

CONSIDERATIONS 

34
INDIGENOUS HEALING PRACTICES 

Researchers who have interviewed American Indians and Alaska Natives across time and place about behavioral 

health report that, despite cultural and geographical differences, participants consistently referred to historical 

trauma and healing in discussions about mental health.124 These terms focus on the group experience and 

describe an alternative perspective to illness and treatment when compared with typical Western practice, 

which tends to “reduce suffering to discrete illnesses with individually based causes and solutions.” Holistic 

healing of a person within the context of their family and community is typically the emphasis within many 

Indigenous cultures.125,126,127 Historical and anecdotal knowledge also tells of how tribes have been engaged 

in healing practices through the use of ceremony and traditional medicines for centuries that have been 

effective at promoting health, stemming illness, and reinforcing balance in the individual and community. 

These practices include prayer, the use of herbs and plants for medicinal purposes, and ceremonies that evoke 

spiritual support for individual and community health.

INTEGRATION OF TRADITIONAL 

AND WESTERN PRACTICES

Traditional healing practices and ceremonies are important sources of help to many American Indians and Alaska 

Natives; however, the integration of these approaches with 

Western biomedical services is often tenuous,128 with tension between traditional and Western providers.129 At the 

same time, researchers are increasingly aware of the need 

for integrated care130,131,132,133 and consideration of historical trauma.134,135,136,137,138,139,140,141 Historical and anecdotal 

knowledge should be integrated with science-based medicine and measurement-based care. Scientifically rigorous 

assessment of efficacy and effectiveness must always be 

respectful and culturally competent – reflecting each tribal 

communities’ and their individual members’ concepts of 

illness and treatment objectives – in order to extend to 

tribal communities the same entitlement to high-quality, 

evidence-based practices for which other parts of the US 

health system are increasingly held to account. Important 

support for integrated behavioral health is the currently accepted evidence-based practice of the American 

Psychological Association142 which calls for integration of 

cultural beliefs, values, and preferences into the treatment 

decisionmaking process.

The IHS issued a special memorandum in 1994 affirming 

its organizational commitment to protect and preserve the 

right of all American Indians and Alaska Natives to exercise 

their traditional practices and stating that IHS employees 

should also demonstrate respect for these practices.143 In 

addition, other Federal agencies recognize and support the 

inclusion of traditional healing practices through grant 

programs and initiatives. Some tribes have made strides 

and have been quite successful in formalizing the integration of traditional healing practices into their health 

facilities, services, and programs to improve the well-being 

of their communities. Through the American Indian and 

Alaska Native Cultural Wisdom Declaration that is part 

of this document tribal nations are seeking greater support for inclusion of traditional practices as fundamental 

to effectively implementing funded programs in their 

communities.

Recovery from substance use disorder is taking place with 

the assistance of culturally specific methods in American 

Indian and Alaska Native communities in North America. 

Many of these communities not only utilize recovery 

approaches that make up today’s best practices but also use 

their own cultural and ethnic strengths as an important 

part of their substance use discorder recovery.144 Some of 

the most promising suicide prevention approaches involve 

evidence-based, trauma-informed interventions integrated 

with practices that promote Tribal language, culture, and 

traditional healing.145 Tribal and youth regional treatment 

centers engage in varying degrees of integrated care to 

address substance use treatment and relapse prevention.

COMPONENTS OF INTEGRATED INTERVENTIONS

Interventions focused on individuals, families, and communities should occur early and be intergenerational. Content 

may include teachings on traditional narratives, beliefs, and 

practices: address historical events in culturally appropriate 

ways; and, relate them to current conditions and family 

dynamics. Activities should emphasize active skills-building; facilitate communication and interaction among 

elders, parents, and youth; and those at the community 

level should avoid addressing more than one issue at a time. 

Traditional knowledge and practices should be incorporated into care based on the preferences of the Tribe.146

COMPONENTS OF INTEGRATED SYSTEMS 

An integrated system links prevention and treatment 

systems and includes a flexible approach to provider-client 

and provider-patient relationships that allows for adaptive 

treatment approaches.147 Staff members should be educated 

and culturally competent, and the community should be 

involved in implementing structural changes to affect surrounding conditions.148,149

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 35
HEALTH CARE AND SERVICE SYSTEMS 

American Indians and Alaska Natives receive health 

care services through multiple sources, including the 

IHS, tribally operated facilities, urban Indian health care 

programs, the U.S. Veterans Administration (VA), private 

health care systems, and Federally Qualified Health Centers 

(FQHCs).150 The IHS is one of the primary Federal agencies responsible for fulfilling the Federal Government’s 

health care obligation to American Indian and Alaska 

Native tribes. Through treaty agreements with Tribes, the 

Federal Government has committed to provide health 

care to American Indians and Alaska Natives, primarily in 

exchange for ceded land. To fulfill this component of the 

Federal Government’s trust responsibility to tribes and 

Tribal members, a unique health care system has evolved 

that allows American Indians and Alaska Natives to receive 

physical and behavioral health services through a variety of 

mechanisms.

IHS, an HHS agency, is charged with providing primary 

care and behavioral health services to American Indians 

and Alaska Natives living on or near reservations. There 

are 12 regional service areas within the Indian Health 

Care System. Within IHS, the Division of Behavioral 

Health oversees programs that focus on alcohol and other 

substance use prevention, domestic violence prevention, 

forensic health care, mental health, methamphetamine use 

prevention, suicide prevention, telebehavioral health, and 

Youth Regional Treatment Centers (YRTCs).151

The IHS and tribes provide primary medical care and community health services mainly in small, rural communities 

in more than 660 locations across 36 states,including 45 

hospitals, 617 ambulatory facilities (343 health centers, 111 

health stations, 163 Alaska Native village clinics,152 and 34 

urban programs. These facilities can be grouped into three 

categories:

ʠ Facilities operated directly by IHS

ʠ Facilities operated by tribes through a Tribal Health 

Authority (THA) by contract or compact with IHS

ʠ Programs managed by urban Indian health 

programs to provide services to American Indians 

and Alaska Natives in certain urban areas

Tribes that receive health services from a facility operated 

directly by IHS are known as direct service tribes, and 

tribes that manage their own health systems are known 

as self-governance tribes. Many tribes are also served by 

community health (e.g., childhood immunizations, home 

visits) and environmental health (e.g., sanitation, injury 

prevention) programs, which may be administered by IHS 

or THA. Specialty services and types of medical care that 

are not available at a given facility are purchased from providers in the private health sector through a program that 

is now known as purchased and referred care (PRC).153

TABLE 5: 

FY 2014 IHS ANNUAL PATIENT SERVICES

Inpatient Admissions 44,677

Outpatient Visits 13,180,745

Alcohol and Substance Use Outpatient Visits 87,947

Mental Health Client Service Encounters 490,994

Alcohol and Substance Use Inpatient Days 8,238

YRTC Number of Youth Served (FY 2012) 915

Average age 15.8 years

36
SECTION IV. HEALTH CARE AND SUPPORTIVE SERVICE CONSIDERATIONS

The IHS and THAs apply stringent eligibility criteria to 

determine which patients qualify for PRC funding. The 

severely limited pool of PRC dollars also means that most 

PRC programs limit reimbursements for those diagnostic 

or therapeutic services needed to prevent immediate death 

or serious health consequences. Among other problems, 

this results in reduced access to screening services and 

contributes to increased mortality.

American Indians and Alaska Natives living in urban communities have been referred to as a “population in crisis” 

given their extreme poverty, poor health, and cultural isolation.154 Their status is compounded by a number of factors, 

including lack of access to health services that are located 

on or near reservations, transportation challenges, distrust 

of government services, and risk of receiving mediocre or 

poor-quality care. Currently, there are 34 Urban Indian 

Health Programs supported through IHS. These urban 

Indian programs are eligible for FQHC status, and approximately 45% receive Medicaid reimbursement.

WORKFORCE DEVELOPMENT

Lack of mental health services may in part be attributable to a shortage of behavioral health service providers. 

Barriers to recruitment include funding disparities across 

IHS regions, lack of opportunity to maintain skills, lack 

of opportunity for professional growth, lack of exposure 

to best practices and new developments, isolated work 

locations, highly stressful work environments, and a lack of 

support staff members. For example, across IHS there are 

TABLE 6:

IHS 2016 EMPLOYEES

Total 15,369 

Nurses 2,648

Physicians 725

Pharmacists 698

Engineers/Sanitarians 110

Physician Assistants 115

Dentists 272

Behavioral Health Providers Over 500

16 allocated psychiatric nursing positions located in Alaska 

and Navajo Areas.155 The vacancy rate for these positions 

averaged 38% over calendar year 2010, demonstrating the 

difficulty in filling these positions.156

Developing a clinically skilled and culturally competent 

behavioral health workforce for Tribal communities lies in 

improving the pathways for Native young people to seek 

educational and training options that are accessible to 

them, both community-based, onsite and online. Providing 

avenues to advanced training and college education as well 

as working to improve existing school systems will assist in 

moving toward a culturally competent skilled workforce 

with an understanding of the attitudes, issues, and concerns of Native populations.

INDIAN HEALTH CARE SYSTEM FUNDING

The Indian Health Care System is supported through 

annual congressional appropriations. The fiscal year (FY) 

2016 IHS funding was $6.2 billion and includes slight 

increases for mental health and alcohol treatment programs.Approximately 98% of the IHS budget for direct 

health services is focused primarily on serving American 

Indians and Alaska Natives who live on or near reservations. 

The IHS budget specifically focused on supporting urban 

Indian health clinics represents the remaining 2% of the 

budget for health services.Many programs are also dependent on grant funding, Tribal revenue, and collections from 

third-party payers (e.g., Medicaid) to remain financially 

viable.157 IHS estimates it receives 22% of the funding 

needed for the Urban Indian Health Program.

Historical estimates document per capita expenditures 

for health care for American Indians and Alaska Natives 

at less than half of those for Medicaid and lower than all 

other federally funded health systems, including prisons.158 Former North Dakota Senator Byron Dorgan, who 

chaired the U.S. Senate Committee on Indian Affairs for 18 

years, has expressed concerns that IHS, which serves the 

Nation’s 567 tribes, has persistent funding challenges. “We 

need more mental health services to save the lives of our 

youngest First Americans,” Senator Dorgan said. “Tribes 

and nonprofits may get two- or three-year grants to address 

an issue that cannot possibly be resolved in that amount of 

time.”159

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 37
OTHER IMPORTANT FEDERAL SOURCES 

OF FUNDING

Tribes that operate their own health systems also invest in 

their systems beyond funds received through 638 compacts, 

contracts, and reimbursements from Medicare, Medicaid, 

and private insurance. In addition, tribes are eligible for 

grants, contracts, and other support from Federal agencies 

across the Executive Branch. 

Federal departments and agencies such as SAMHSA, ACF, 

ACL, HRSA, DOJ, and others support programs that 

address one or more of the following health, safety, and/

or wellness areas: suicide prevention; alcohol and other 

drug use prevention; services for Tribal youth that promote 

prevention, treatment, and recovery from mental and 

substance use disorders; services for pregnant and postpartum women with substance use disorders; development of 

systems of mental health services for children with serious 

emotional disturbances; early childhood development; 

Native language preservation and maintenance; economic 

self-sufficiency; Tribal healing to wellness courts that 

provide substance use treatment; domestic violence prevention; workforce training, development, and certification; 

and many other programs. Descriptions of some Federal 

programs are provided in Part Two of this document. These 

and other funding opportunities support Tribal efforts 

to more comprehensively address factors that impact the 

behavioral health and wellness of Tribal communities.

ACCESS TO SERVICES

The Affordable Care Act (ACA) created a new portal to 

health care services for more than 500,000 American 

Indian and Alaska Native people. Those earning between 

100% and 400% of the Federal poverty level may be eligible 

for advance premium tax credits and could qualify for zero 

or limited cost sharing plans under the Health Insurance 

Marketplace. And, many American Indians and Alaska 

Natives with low to no income (up to 138% of Federal 

poverty level) are now eligible for Medicaid if they live in a 

state that has expanded coverage. The ACA’s amendments 

to the Indian Health Care Improvement Act expanded the 

types of services facilities can offer and included behavioral health services. With greater numbers of American 

Indians and Alaska Natives receiving some form of coverage, IHS will be better able to provide needed health care 

services.160,161 The ACA has altered the landscape of service 

delivery by increasing the opportunity for access to much 

needed services.

The IHS is designated as a “payer of last resort,” meaning 

that Medicare, Medicaid, and private insurance companies 

are billed before IHS is required to pay for medical costs. 

Medicare, Medicaid and private insurance payments help 

to cover IHS and Tribal health care expenses without a 

reduction in IHS appropriated funding.

AVAILABILITY AND QUALITY OF SERVICES

The availability of IHS services varies by location. Most 

IHS clinics are in rural areas, and thus access to those 

clinics is limited for the large urban American Indian and 

Alaska Native population. Services and the availability of 

services also vary from service unit to service unit, often 

creating an unreliable and unpredictable level of care 

for those in Tribal or urban communities. Services are 

performed by both licensed and unlicensed health care 

providers.162,163,164,165 All services, including public health, 

behavioral health care, and medical care, often are provided 

by an amalgam of IHS, Tribal, county, state, and nonprofit 

organizations.166,167 Distances to service providers, as well 

as insufficient resources for fuel and childcare, impact 

American Indian and Alaska Native use of services.168

38
SECTION IV. HEALTH CARE AND SUPPORTIVE SERVICE CONSIDERATIONS

In a study of 514 IHS and Tribal facilities, 82% reported 

providing some type of mental health service such as psychiatric services, behavioral health services, substance use 

treatment, or traditional healing practices, and to improve 

access, 17% (87) have implemented telemedicine for 

mental health services.169 However, none provide inpatient 

psychiatric services. Without access to care, persons in 

psychiatric distress often end up in the hospital emergency 

department.170

Concerns regarding the quality of care available to 

American Indians and Alaska Natives have been raised.171

Significant efforts are underway to ensure the quality of 

care throughout the Indian Health Care System. These 

efforts include improvement, enhancement, modernization, 

and increased security of the health information technology system used for patient data; establishment of the IHS 

Quality Consortium to coordinate quality improvement 

activities among hospitals and clinics; addressing workforce 

shortages; and improving infrastructure.172

In an effort to examine and prioritize behavioral health 

quality prevention, treatment, and recovery elements, 

SAMHSA developed the National Behavioral Health 

Quality Framework (NBHQF). The NBHQF is a document 

that guides the identification and implementation of key 

behavioral health quality measures that support funding 

decisions, monitoring of behavioral health, and delivery 

of behavioral health care. The framework is aligned with 

the National Quality Strategy and supports the three aims 

of better care – healthy people, healthy communities, and 

affordable care. The NBHQF also provides for dissemination of proven interventions and accessible care, which 

includes the affordability of care and the impact of health 

disparities.

ATTITUDES TOWARD BEHAVIORAL HEALTH 

AND SERVICES

Individual, systemic, and cultural barriers influence decisions about accessing behavioral health services. Within 

many American Indian and Alaska Native communities, 

there is a wide range of cultural beliefs surrounding mental 

health. For some American Indian and Alaska Native tribes, 

speaking about negative things such as depression, suicide, and other mental disorders invites these things into 

their world, so such discussions are forbidden, avoided, or 

discouraged.

Researchers have found that culture plays an important 

role in one’s attitudes toward psychotherapy,173,174 decisions 

about starting treatment,175 premature termination of treatment,176,177 and eventual treatment outcome.178,179 Across 

racial and ethnic groups, research indicates that attitude 

toward treatment is one of the best predictors of treatment 

use.180,181,182

SUPPORTIVE SERVICES

The Bureau of Indian Affairs’ social services program 

supports an array of social service activities that strengthen 

Indian families, promotes family stability, and ensures 

health and well-being. The social services program manages applications for financial assistance, delivers child 

and adult protective services, provides services to children 

and families affected by alcohol and substance use and 

domestic/family violence, provides technical assistance 

and training to tribal contractors on regulatory issues and 

best practices, and fulfills the BIA’s fiduciary responsibility 

of managing supervised Indian Individual Monies (IIM) 

accounts. 

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 39
BIA funding for tribal Indian Child Welfare Act (ICWA) 

programs support social workers that work with tribal 

courts, state courts, and Indian families in the areas of child 

protection. Children are reunified with their families when 

possible. When reunification is not possible, children are 

placed into Indian foster and adoptive homes. 

BIA maintains a comprehensive plan for addressing the 

needs of Indian communities with high rates of domestic 

and family violence, and high incidences of child abuse and 

neglect. The plan focuses on strategies to expand family 

services related to domestic and family violence; improve 

collaboration and coordination between law enforcement 

and social services to more rapidly address instances of 

domestic and family violence and improve coordination 

of services with other tribal, state, and federal partners on 

domestic and family violence initiatives/activities in Indian 

Country. The plan also includes a gap analysis and best 

practices model; developing and scheduling domestic violence training; visiting Tribal domestic and family violence 

programs to learn more about their work, and providing 

technical assistance to tribes operating domestic violence/

family violence prevention programs. 

The Tiwahe Initiative was recently launched by BIA as a 

means for more holistically delivering services. The Tiwahe 

Initiative is a five-year comprehensive plan to strengthen 

Indian families and promote family stability in order to 

fortify tribal communities. The Tiwahe Initiative is a 

demonstration project and seeks to show how integration 

in the delivery of services to children, youth, and families 

will help preserve the family unit and support healthy and 

productive families. Under the Tiwahe Initiative, each 

Tiwahe site will be required to develop and submit a plan 

for an integrated service delivery model that is centered 

on the needs of their tribal community and addresses the 

interrelated problems that are often a result of child abuse 

and neglect, poverty, family violence, substance misuse, 

unemployment, and incarceration in American Indian and 

Alaska Native communities. 

PUBLIC HEALTH AND RESEARCH 

INFRASTRUCTURE

There have been well-documented reports of breaches in 

research ethics,183 violations of participants’ rights,184 and 

lack of respect for cultural practices in research. This has 

led to an understandable wariness of Western research on 

the part of American Indians and Alaska Natives. In addition, the comparatively small number of American Indian 

and Alaska Native researchers has limited research-based 

knowledge development on matters of health in Indian 

Country. This realization has led to a revitalization of 

research in Indian Country but with more Tribal control.

Recent publications on research ethics in Indian Country 

have held that community-based participatory research 

(CBPR) is the gold standard for how studies should be 

conducted, which may not always result in evidence similar 

to a randomized controlled trial.185,186,187 CBPR is a partnership in which the community is treated as a full and equal 

partner in all stages of research including, study design, 

data collection, analysis, and dissemination/application 

of results. Because of the history of unethical research 

in Indian Country, CBPR is a helpful strategy to support 

communities in healing from historical trauma and past 

research abuses. CBPR itself can be healing for a community through the process of taking ownership of research 

and data collection, and then determining how to use that 

information in line with principles of tribal sovereignty. 

The Native American Research Centers for Health 

(NARCH) program is a collaboration between NIH and 

IHS. NARCH supports partnerships between American 

Indian and Alaska Native tribes or tribally based organizations and institutions that conduct academic biomedical 

and behavioral research. NARCH is a grant program that 

provides opportunities for conducting research, research 

training, and faculty development to meet the needs of 

American Indian and Alaska Native communities.

40
There are 12 Tribal Epidemiology Centers (TECs) that work 

to improve the health of American Indians and Alaska 

Natives by identifying and understanding health problems 

and disease risks, strengthening public health capacity, and 

developing solutions for disease prevention and control.188

These TECs have made progress in documenting the health 

problems facing American Indians and Alaska Natives 

and work regionally and nationally to design and evaluate 

culturally relevant health interventsions.189

More and more tribes are taking an active role in public 

health practice and research in their communities. As an 

exercise in Tribal sovereignty and an acknowledgment 

that respectful research is still needed to advance the state 

of tribe-specific knowledge, a growing number of tribes 

have initiated their own Tribal review processes to govern 

research efforts undertaken on Tribal lands and with Tribal 

members. Other tribes are undertaking grant-funded collaborations with academic researchers and Federal agencies 

and active collaborations with state and county health 

departments. Many of these collaborations are based on the 

fundamentals of CBPR, which provides a critical impetus 

for the development of interventions that build on cultural, 

community, and individual strengths to promote positive 

outcomes for American Indians and Alaska Natives.190

SECTION IV. HEALTH CARE AND SUPPORTIVE SERVICE CONSIDERATIONS

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 41
5

TRIBAL BEHAVIORAL HEALTH AGENDA SECTION V

THE NATIONAL TRIBAL 

BEHAVIORAL HEALTH 

AGENDA

42
The Historical and Current Contexts section of this document underscores 

the importance of developing the TBHA. That is, the contexts and factors 

that must be considered in an effort to improve the behavioral health of 

American Indians and Alaska Natives are complex and must be understood 

to create a blueprint for meaningful change. Ultimately, the intent is to help 

construct a more informed and productive path forward.

THIS PART OF THE DOCUMENT PROVIDES THE 

FRAMEWORK FOR THE TBHA BASED ON:

▶TRIBAL INPUT

▶ INFORMATION FROM SELECTED FEDERAL 

STRATEGIC PLANS AND DOCUMENTS THAT 

PRESENT EXISTING PATHWAYS ON WHICH TO 

BUILD MORE COLLABORATIVE ACTIVITIES

▶ EXAMPLES OF EXISTING FEDERAL PROGRAMS 

THAT SUPPORT THE WORK THAT TRIBAL 

LEADERS AND TRIBAL REPRESENTATIVES 

BELIEVE ARE CRITICAL FOR SUPPORTING THE 

WELL-BEING OF THEIR COMMUNITIES

The intent of including the information noted above is to 

demonstrate that positive and useful efforts exist and can 

be built upon, that there is fertile ground to improve the 

coordination and collaboration that Tribal leaders are seeking, and that opportunities exist that can enhance behavioral health-related efforts by working together.

The most important aspect of the TBHA is that it was 

identified through discussions with Tribal leaders, tribal 

administrators, and Tribal members. It is important to note 

that: 

ʠ The TBHA is not an exact map but an initial step toward 

driving action in the same direction and along a common path. 

It is organized around five elements that were deemed to be 

foundational for designing an agenda that holds significance 

for Tribal communities. The foundational elements organically 

coalesced from conversations with Tribal leaders around 

their concerns with the state of behavioral health in Indian 

Country. Through the various meetings, discussions, and input 

opportunities that contributed to building this blueprint, the 

five foundational elements were affirmed and reaffirmed.

ʠ The priorities that follow are a reflection of Tribal views 

and areas of importance through the Tribal perspective. It 

is significant to note that during conversations and input 

sessions many of the comments were not framed in terms of 

quantitative actions but rather in terms of the conditions that 

are necessary for positive emotional health and well-being to 

exist. As questions were posed, Tribal leaders and representatives 

used their cultural knowledge and experience as reference 

points for their comments. The framing and essence of Tribal 

input were consistent across discussions. The points of view 

shared were not optional but rather essential to a new state 

of collaboration among Tribal nations, Federal departments 

and agencies, and other interested parties – a state in which 

all parties commit to “working differently” together for the 

benefit of Tribal communities. This document honors and 

attempts to share input in the context in which they were given.

ʠ Following an examination of the historical and current 

contexts that frame the state of behavioral health for American 

Indians and Alaska Natives today, the breadth and essence 

of Tribal input, and discussions around existing Federal 

programs and strategic directions, priorities for working 

collaboratively on a range of opportunities were developed. 

The opportunities extend beyond Tribes and Federal agencies 

to state and local entities and other potential collaborators.

The foundational elements, priority areas, and strategies 

section begins on page 47.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 43
CONSIDERATIONS FOR COLLABORATION

TRIBAL, FEDERAL, AND STATE GOVERNMENT 

RELATIONSHIPS 

Very few of the challenges cited in this document can be 

successfully addressed without collaborative efforts on 

the part of tribes and other stakeholders – most notably 

Federal and state governments. Tribes are sovereign entities 

with distinct governing structures and authorities. However, 

Federal and state governments bring a wealth of resources 

from which tribes can and do benefit. Although there are 

actions that tribes undertake on their own, there are others 

where it is mutually beneficial to collaborate with other 

governments. The TBHA serves as a platform for engagement and a reference point for developing and improving governmental relationships and efforts that benefit 

American Indians and Alaska Natives.

ALIGNMENT OF LOCAL AND NATIONAL EFFORTS 

Through a process of stakeholder engagement, the priority 

areas within the TBHA were created to reflect the current 

reality of behavioral health in Indian Country. Tribes and 

Tribal organizations and Federal departments and agencies 

had opportunities to provide input. The priority areas were 

validated through extensive conversations and represent a 

unity of thought that supports the alignment of local and 

national efforts under common themes. Tribal, Federal, 

state, and local governments, as well as other stakeholders, can begin the process of examining their own efforts, 

identifying where those efforts connect and align to the 

priorities areas in the TBHA and determining how they 

might contribute to furthering them.

The process of alignment helps ensure that resources are 

allocated and spent most effectively, efforts target priority 

issues, communication is open, and collaboration is fruitful. 

These activities could lead to more informed development 

of programs that more effectively allow tribes to respond in 

a manner that meets the unique needs of their communities. The activities also could lead to expansion of opportunities within existing programs that allow tribes to work 

in new areas, the inclusion of tribes or urban Indian health 

programs in funding streams that did not previously reach 

them, and flexibility to ensure that the programs allow 

for the incorporation of traditional ways as described in 

the American Indian and Alaska Native Cultural Wisdom 

Declaration in this document. Finally, these opportunities 

allow for growth of thought that tribes not only use evidence-based practices along with traditional practices but 

also develop practices that have evidence and can inform 

the work of other communities. There are opportunities of 

mutual benefit, and those benefits are bidirectional.

CREATION AND SUPPORT OF NEW EFFORTS 

The priority areas contained in the TBHA can help a tribe, 

urban Indian health program, other governments, and 

other stakeholders design new program efforts or activities 

that carry out the recommendations through a new and 

innovative method. The priority areas can assist funders 

create or strengthen existing programs or initiatives, 

whereas tribes and urban Indian health programs can do 

the same at the local or area level. The priority areas and 

strategies lend themselves to incorporation into funding 

opportunity announcements, framing scopes of work, and/

or joint development of initiatives and programs.

44
SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

CROSS-CUTTING CONSIDERATIONS

Throughout the input-gathering sessions and TBHA 

development discussions, several considerations for 

improving behavioral health arose that cut across multiple 

foundational elements. These considerations related to 

actions that support recognition of youth, identity, culture, 

self-sufficiency, data, and Tribal leadership. To maximize 

collaborative work across the foundational elements, the 

cross-cutting topics are defined as follows.

YOUTH

American Indian and Alaska Native culture places importance on honoring youth and building strong foundations 

for future generations. Native youth hold an important 

role in the future of tribes; however, they are significantly 

and negatively affected by poverty, substance use disorder, depression, and suicide and are at high risk for other 

behavioral health challenges. Healthy youth lead to healthy 

adults and healthy communities. Across foundational 

elements, youth were identified as an important part of the 

solution for issues they face as well as those faced by their 

peers, families, and communities. Behavioral health planning should incorporate the voices of youth and engage 

them in developing and implementing activities.

IDENTITY 

American Indians and Alaska Natives connect their political 

identity with varying aspects of cultural, geographic, Tribal, 

familial, and social frameworks – creating a unique identity 

framework that is unique not only to American Indian 

and Alaska Native groups but also to American Indian and 

Alaska Native individuals. Understanding the sources of 

identity, honoring them, and embracing them can be a significant source of communal and individual strength that 

can be harnessed to combat behavioral health challenges. 

Behavioral health professionals who are actively working 

with American Indians and Alaska Natives can incorporate 

identity exploration into their treatment plans; community 

action plans can celebrate communal identities; education 

can take place to ensure that external collaborators, entities, 

and funders understand the nature of American Indian and 

Alaska Native identity; and, traditional practitioners can 

work with clinicians on how best to honor the identities of 

the people they serve.

CULTURE 

Culture is the root of American Indian and Alaska Native 

identities – culture incorporates aspects of living, interpersonal and communal relationships, communication, worldviews, traditional customs, and spirituality. The uniqueness 

of Tribal cultures as well as their commonalities is a source 

of strength. Although each American Indian and Alaska 

Native tribe is unique, there are commonalities that tribes 

share, including valuing traditional practices, honoring 

elders, respecting nature, and emphasizing clan/community 

importance. American Indian and Alaska Native communities also have a Native language that serves to connect 

them to their culture and Tribal identities as well as create 

a strong cultural bond with other Indigenous communities. 

These commonalities affect the manner in which tribes 

conduct themselves, including in health care delivery and 

behavioral health program design and implementation.

Revitalization of American Indian and Alaska Native languages is essential to continuing culture and strengthening 

self-determination. Research has shown that use of languages builds identity and assists communities in moving 

toward social cohesion and self-sufficiency. Language and 

culture foster higher educational outcomes by Native youth 

as a result of lower levels of depression, increased academic 

achievement, and strengthened problem-solving skills.191

Furthermore, American Indian and Alaska Native values 

and traditions are embedded in language, and there is 

growing evidence that language and culture act as protective factors against suicide and suicidal ideation, substance 

use disorders, and other risky behaviors. Languages are 

among the most critical and meaningful culturally and 

linguistically based tools to not just survive, but to thrive.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 45
In 2008, Canadian researchers could find only one article 

that examined the link between Indigenous language and 

health. The findings were significant: Bands with higher 

levels of language knowledge (as measured by a majority 

of its members having conversational-level abilities) had 

fewer suicides than those with lower levels. In fact, the 

rates of suicide in the bands with high language knowledge 

levels were “well below the provincial averages for both 

Aboriginal and non-Aboriginal youth.” When the language 

knowledge factor was added to six other measures, “the 

presence of the language factor made a drastic difference in 

suicide rates.” In all cases but one, the suicide rate dropped 

to zero when the language factor was added.192

Tribal consultation and listening sessions held by HHS 

indicate that investments in Native language programs 

are critical to Tribal communities. As educational institutions recognize that Native culture and language are 

inherent strengths, the self-worth and optimism of Native 

youth increase. It is by going back to traditional, ancestral, 

Indigenous ways of knowing based in culturally and linguistically specific values and norms that American Indian 

and Alaska Native communities will thrive on their own 

terms.

INDIVIDUAL SELF-SUFFICIENCY

Tribes and Tribal members are autonomous – they have the 

capacity to act independently on their own behalf. While 

tribes know best what works and does not work for their 

communities, Tribal members also have the ability to make 

individual decisions. At the individual level, self-sufficiency 

encompasses the full development of individuals – spiritually, mentally, physically, educationally, and economically 

among other ways – in a manner that contributes to their 

success in life. The intent is for one to have the capacity and 

initiative to take care of self and ultimately contribute to 

the well-being of their families and communities. The value 

is in being able to take care of self in order to effectively 

contribute to the lives of others. Individual self-sufficiency 

contributes to Tribal self-sufficiency and the responsibilities 

of sovereign nations to their people. Tribal representatives 

who contributed to building the TBHA believe that opportunities should exist across foundational elements that 

contribute to the ability of Tribal members and tribes to be 

self-sufficient. This could include availability, accessibility, 

and/or oversight of education and training opportunities; 

access to Native foods; access to prevention and treatment 

resources to address unique behavioral health challenges 

that exist in communities; referral networks across systems 

that support well-being; and law enforcement agreements, 

among others.

DATA 

The problems of accuracy and access to viable data have 

long impacted American Indian and Alaska Native communities. Small sample sizes make it difficult to capture accurate data, and the same small sample sizes make sharing 

data even more tenuous for fear of violating confidentiality. 

Frequently data available to tribes is significantly outdated, requiring them to use data sets that may not reflect 

the reality within their community. And, all too often, 

American Indians and Alaska Natives are not a distinct 

group captured within larger data sets. Without access to 

timely and accurate data, communities are unable to capture their true needs, thereby inhibiting effective community-based planning and improvement of outcomes.

As a cross-cutting consideration, improving data accuracy, 

availability, and access offers real opportunities to improve 

definitions for data collection; strengthen Tribal data 

collection systems; provide capacity building for tribes and 

partners on how to collect and manage data that is tribally 

owned; interpret and use data to improve systems and 

programs; and create systems that allow partners to benefit 

from available data. Methodologies used in national and 

other non-tribal data collection systems should be assessed 

in order to more accurately include American Indian and 

Alaska Native populations in urban areas, counties, and 

states. These opportunities should be leveraged within 

strategies that support foundational elements and their 

accompanying priority areas and strategies.

TRIBAL LEADERSHIP 

Tribal leaders care deeply for their communities and 

hold significant responsibility for the welfare of their 

people. Their leadership is critical in helping empower 

46
communities and support readiness to change. They also 

have the authority and communal support to take action 

and can serve as drivers of meaningful community change. 

To be most effective on behavioral health matters, Tribal 

leaders must be informed about problems in their communities; lead community-based dialogs to hear from their 

people about behavioral health and factors that influence 

wellness; work with their Tribal councils and with a range 

of Federal departments and agencies to address prevention 

as well as systems, facilities, and service needs; and seek, 

identify, and/or champion funding and programs that most 

effectively support behavioral health needs.

Throughout the input received for developing the TBHA, 

Tribal leaders and tribal representatives conveyed that 

Tribal leaders need to “own” the behavioral health challenges facing their communities in order to assume true 

leadership on the issue. Tribal leaders viewed as being 

the most effective on behavioral health were identified as 

champions who were informed and took a visible role in 

driving solutions.

“We continue to address the impacts of alcohol 

and drugs, youth suicides, domestic violence 

and the list continues. However, now is the 

time to address the source of these symptoms – 

historical and intergenerational trauma.”

– Tribal leader, White House Tribal Nations Conference, 2014

Improving the behavioral health of culturally, geographically, and socioeconomically diverse populations is a complex undertaking that requires a multipronged approach. 

There is no single strategy that will accomplish this task; 

there are interwoven factors and systems that may each 

require intense examination, deconstruction, and retooling. 

Individual behavioral health risk unfolds within the social 

settings of families, peer networks, schools, communities, 

and service systems and within the cultural and historical 

contexts of the tribe.193 Health care systems are needed 

that provide new perspectives on integrating treatment for 

mental and substance use disorders with holistic well-being, 

including family, community, socioeconomic, and social 

supports.194 Strategies need to be developed to effect systemand policy-level changes that reduce barriers to high-quality care and promote the well-being of American Indian 

and Alaska Native youth, families, and communities.195

FOUNDATIONAL ELEMENTS, PRIORITY 

AREAS, AND STRATEGIES

The foundational elements of the Tribal Behavioral Health 

Agenda were the first product of the many discussions 

held with Tribal leaders, Tribal administrators, and tribal 

representatives regarding the factors contributing to 

or exacerbating behavioral health challenges in Indian 

Country. Each foundational element includes priority areas 

that were gleaned from targeted conversations about the 

most pressing concerns. The priority areas contain strategies based on analysis of responses to questions related 

to desired outcomes, healthy communities, and stronger 

systems. What follows are the results of engagement and 

investigation into the state of behavioral health, prevalent 

attitudes regarding behavioral health, predominant barriers 

and challenges at the systems and community levels, and 

insights into potential solutions.

1 2 3 4 5

HISTORICAL AND 

INTERGENERATIONAL 

TRAUMA

NATIONAL

AWARENESS

AND VISIBILITY

PREVENTION AND

RECOVERY SUPPORT

BEHAVIORAL HEALTH

SYSTEMS AND

SUPPORT

SOCIO-CULTURALECOLOGICAL

APPROACH

SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 47
1 2 3 4 5

HISTORICAL AND 

INTERGENERATIONAL 

TRAUMA

NATIONAL

AWARENESS

AND VISIBILITY

PREVENTION AND

RECOVERY SUPPORT

BEHAVIORAL HEALTH

SYSTEMS AND

SUPPORT

SOCIO-CULTURALECOLOGICAL

APPROACH

FOUNDATIONAL ELEMENT 1: 

Historical and Intergenerational 

Trauma (HIT)

Dr. Maria Yellow Horse Brave Heart describes historical 

trauma as the “cumulative emotional and psychological 

wounding across generations, including the lifespan, which 

emanates from massive group trauma”196 and includes the 

impact of chronic stress and trauma that negatively affect 

health. These impacts are magnified when entire communities experience and reexperience past and present trauma.

It is important to understand historical and intergenerational trauma from a variety of perspectives. First, understanding the sources of the trauma is important in creating 

a common understanding of how the past can contribute 

to the present. Second, understanding and learning how to 

take that information and openly discuss it are important 

steps. American Indian and Alaska Native people may not 

seek to discuss traumatic events or how they manifest in 

their daily lives for fear of giving the trauma power. It is 

vital to lay out the issues in such a way that Tribal members, 

allies, and other stakeholders (including Federal and state 

governmental entities) can understand and thus meaningfully engage in a discussion of healing.

Discussions regarding trauma should not be limited to 

adult Tribal members. Youth also experience intergenerational trauma but may not have the skills or language to 

conceptualize or talk about it in the context of modern-day 

pressures and situations. The purpose of discovering, 

uncovering, and talking about historical and intergenerational trauma is to support healing. The intent of 

Foundational Element 1 is not necessarily to further assess 

historical trauma but rather to support the development 

of priorities and evidence- and practice-based actions to 

support healing for Tribal members.

Healing practices should acknowledge the root causes of 

intergenerational and other types of trauma (i.e., genocidal 

policies, forced relocations, etc.). Trauma that is directly 

experienced in the present compounds issues and reinforces the sense of hopelessness. Resources and community norms need to actively support the prevention of 

modern-day trauma and incorporate strategies to address 

historical and intergenerational trauma as a real and contributing factor to contemporary issues.

Federal Support for Addressing Trauma

A review of selected Federal strategic plans and documents 

identified a number of existing goals and recommendations focused on addressing trauma (see Appendix 3. 

Selected List of Federal Strategic Plans and Documents: 

Correlations With the National Tribal Behavioral Health 

Agenda). These plans and documents either cut across all 

populations or specifically focus on American Indians and 

Alaska Natives. For example, as part of its Strategic Plan 

“Leading Change 2.0: Advancing the Behavioral Health 

of the Nation,” SAMHSA established trauma and justice 

as one of its six priorities; these priorities are linked to 

SAMHSA’s policy, program, and financial planning. An 

objective within the Trauma and Justice Strategic Initiative 

focuses on integrating an understanding of trauma and 

strategies for implementing trauma-informed approaches 

across SAMHSA, interested Federal agencies, and other 

public service sectors. Similarly, a strategic initiative in 

ACF’s Strategic Plan promotes the use of evidence-based 

and trauma-informed practices that effectively address the 

needs of children and families and encourage achievement 

of timely permanency for children in the child welfare 

system.

Recommendations in the Attorney General’s Advisory 

Committee on American Indian/Alaska Native Children 

Exposed to Violence: Ending Violence so Children Can 

Thrive report197 promote Tribal-state collaborations to meet 

the needs of children who have been exposed to violence. 

The recommendations also support training for American 

Indian and Alaska Native communities on the needs of 

children exposed to violence and for Federal employees 

who are assigned to work on issues pertaining to American 

Indian and Alaska Native communities to obtain training 

within the first 60 days of their job assignment. Additional 

recommendations focus on collaborations with organizations that specialize in treatment and services for traumatized children, the establishment of safe places where 

children exposed to violence can obtain services, and the 

promotion of youth afterschool programs that are culturally based and trauma informed.

48
Federal efforts such as SAMHSA’s Tribal Behavioral Health 

Grant program focus not only on preventing and reducing 

suicidal behavior and substance use and promoting mental 

health but also on addressing the impact of trauma. Tribes 

and Tribal organizations can propose activities that are 

aligned with the particular needs of their communities, 

such as implementing community events to address historical and intergenerational trauma, beginning collective 

conversations about trauma, and building consensus on 

solutions. The IHS, through its Telebehavioral Health 

Center of Excellence, provides a range of behavioral health 

services, technical assistance, and training via electronic 

mechanisms on current and pressing behavioral health 

issues, including historical and intergenerational trauma. 

The NIH funded ongoing research study “Historical 

Trauma Informed Clinical Intervention Research and 

Practice,” which could further Tribal efforts to address historical and intergenerational trauma in Tribal communities.

These and other Federal and Tribal strategic efforts and 

programs provide existing pathways on which to build 

or expand strategies that more effectively address healing 

from trauma.

Priority Areas and Strategies

Priority areas emerged from tribal input that focus on creating viable and appropriate support mechanisms, promoting community connectedness, and breaking the cycle of 

trauma. The following three priority areas reflect the views 

from the conversations. Following each priority area below 

are recommended strategies for addressing them.

HIT1 – Support Systems

At the core of this priority area is the importance of ensuring that families who have also been affected by traumatic 

events receive appropriate support. The intent is that all 

members of a family receive the support required for individuals and the collective to heal. Without support mechanisms for all family members, strategies to assist individual 

family members may fail. Incorporation of supports for the 

family will require program flexibility, collaboration, and 

commitment. It is important that tribes be informed of the 

resources available to them and, even more importantly, 

that tribes are comfortable with the competency and scope 

of the resources. Recommended strategies include:

ʠ HIT1.1: Actively inform communities about the forms of 

trauma and their manifestations as a means for enhancing 

the potential for family engagement in services.

ʠ HIT1.2: Incorporate into Federal, Tribal, and other 

programs opportunities for engaging family members 

who live with trauma as part of funded activities to 

ensure that they have access to support mechanisms.

ʠ HIT1.3: Allow tribes, within existing programs and new 

funding streams, the flexibility to develop, tailor, and/

or implement support mechanisms that best address 

their local and specific manifestations of trauma.

ʠ HIT1.4: Incorporate opportunities to address unresolved 

grief as a root cause of behavioral health challenges 

and a core component in positive healing within 

programs that focus on Tribal communities.

ʠ HIT1.5: Strengthen support systems across health, behavioral 

health, education, child welfare, and justice services 

programming to ensure continuity and availability of support 

for family members who connect through different systems.

SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 49
HIT2 – Community Connectedness

The literature shows that an individual’s sense of his or her 

own belonging, and connection to the communities he 

or she lives in, is a strong protective factor against many 

behavioral health issues, including suicide, depression, and 

substance use. Fostering connectedness with their communities includes expanding inherent strengths within a person and a community, strengths such as pride, self-esteem, 

community values, tradition, culture, and local resources. 

Recommended strategies include:

ʠ HIT2.1: Expand opportunities for tribes to incorporate 

Native language learning and development as a means 

for strengthening pride, self-esteem, identity, and 

other contributions to community connectedness.

ʠ HIT2.2: Provide support for creating new or 

maximizing existing healthy social structures and social 

supports through schools and other local settings 

that permit community members to engage and be 

validated as valuable members of the community.

ʠ HIT2.3: Support Gathering of Native Americans (GONA) events 

to support community healing from historical trauma and 

enhance local prevention capacity through meaningful activities 

that incorporate healthy traditions; focus on a holistic approach 

to wellness; empower community members; and provide a safe 

place to share, heal, and plan for action.

PROJECT MAKING MEDICINE

This project is a culturally adapted, evidence-based training 

program for treating child physical and sexual abuse whose 

overarching goal is to improve clinician capability to provide 

early identification and a culturally appropriate response to 

victims of familial violence and abuse, particularly women and 

children, in American Indian and Alaska Native communities.

HIT3 – Breaking the Cycle

One of the most insidious aspects of historical trauma is its 

heritability. It is passed down through families and communities – most often unknowingly – exposing future generations to centuries-old sorrow and trauma. Opportunities 

to intervene in this process are often overlooked or not 

identified, and so the cycle continues. An important way to 

actively promote healing is to break this cycle and interrupt 

the passing down of messages that contribute to trauma. 

Trauma should be proactively addressed in informed ways 

by the appropriate tribal (e.g., family members, teachers, 

leaders, traditional practitioners, behavioral health professionals) and non-tribal parties. Recommended strategies 

include:

ʠ HIT3.1: Align Tribal, Federal, and other programs 

that support actions to address trauma and prevent 

retraumatization as a means for supporting traumainformed services that are continuous across systems.

ʠ HIT3.2: Integrate authentic cultural interventions and 

culturally tailored evidence-based practices into existing 

Tribal programs as a means for reestablishing Tribal spiritual 

conditions of physical, mental, and spiritual health.

ʠ HIT3.3: Review and modify Tribal, Federal, state, 

and other programs to recognize and address the 

impacts of adverse childhood experiences among 

American Indian and Alaska Native populations.

ʠ HIT3.4: Widely diffuse strategies, in concert with established 

support mechanisms, across Tribal communities to encourage 

families to talk in safe ways about their own identities and 

experiences with trauma to begin the process of healing.

ʠ HIT3.5: Develop a research agenda on current, historical 

and intergenerational trauma to aid building knowledge 

in areas that require further investigation.

ʠ HIT3.6: Use existing workforce development/learning centers 

to intensify education for health, behavioral health, and 

other professionals about historical and intergenerational 

trauma and support efforts to more effectively address 

trauma in clinical and professional settings.

1 2 3 4 5

HISTORICAL AND 

INTERGENERATIONAL 

TRAUMA

NATIONAL

AWARENESS

AND VISIBILITY

PREVENTION AND

RECOVERY SUPPORT

BEHAVIORAL HEALTH

SYSTEMS AND

SUPPORT

SOCIO-CULTURALECOLOGICAL

APPROACH

50
Who can help advance the historical and 

intergenerational trauma priorities?

CHART 1:

ADVANCING HISTORICAL AND 

INTERGENERATIONAL TRAUMA PRIORITIES

OPPORTUNITIES

 Individual Family Community Tribal  Government State  Government Federal  Government

HIT1.1: Actively inform communities about the forms of trauma and their manifestations as a 

means for enhancing the potential for family engagement in services. 3 3 3 3 3 3

HIT1.2: Incorporate into Federal, Tribal, and other programs opportunities for engaging family 

members who live with trauma as part of funded activities to ensure that they have access to 

support mechanisms.

3 3 3 3 3 3

HIT1.3: Allow tribes, within existing programs and new funding streams, the flexibility to 

develop, tailor, and/or implement support mechanisms that best address their local and specific 

manifestations of trauma.

3 3 3 3

HIT1.4: Incorporate opportunities to address unresolved grief as a root cause of behavioral 

health challenges and a core component in positive healing within programs that focus on Tribal 

communities.

3 3 3 3

HIT1.5: Strengthen support systems across health, behavioral health, education, child welfare, and 

justice services programming to ensure continuity and availability of support for family members 

who connect through different systems.

3 3 3

HIT2.1: Expand opportunities for tribes to incorporate Native language learning and development 

as a means for strengthening pride, self-esteem, identity, and other contributions to community 

connectedness. 

3 3 3

HIT2.2: Provide support for creating new or maximizing existing healthy social structures and 

social supports through schools and other local settings that permit community members to 

engage and be validated as valuable members of the community.

3 3 3 3 3 3

HIT2.3: Support Gathering of Native Americans (GONA) events to support community healing 

from historical trauma and enhance local prevention capacity through meaningful activities that 

incorporate healthy traditions; focus on a holistic approach to wellness; empower community 

members; and provide a safe place to share, heal, and plan for action.

3 3 3 3 3 3

HIT3.1: Align Tribal, Federal, and other programs that support actions to address trauma and 

prevent retraumatization as a means for supporting trauma-informed services that are continuous 

across systems.

3 3 3

HIT3.2: Integrate authentic cultural interventions and culturally tailored evidence-based practices 

into existing Tribal programs as a means for reestablishing Tribal spiritual conditions of physical, 

mental, and spiritual health.

3 3 3 3

HIT3.3: Review and modify Tribal, Federal, state, and other programs to recognize and address the 

impacts of adverse childhood experiences among American Indian and Alaska Native populations. 3 3 3

HIT3.4: Widely diffuse strategies, in concert with established support mechanisms, across Tribal 

communities to encourage families to talk in safe ways about their own identities and experiences 

with trauma to begin the process of healing.

3 3 3 3 3 3

HIT3.5: Develop a research agenda on historical and intergenerational trauma to aid building 

knowledge in areas that require further investigation. 3 3 3

HIT3.6: Use existing workforce development/learning centers to intensify education for health, 

behavioral health, and other professionals about historical and intergenerational trauma and 

support efforts to more effectively address trauma in clinical and professional settings.

3 3 3 3

SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 51
SECTION V. THE NATIONAL TRIBAL 

BEHAVIORAL HEALTH AGENDA

2 3 4 5

RICAL AND 

NERATIONAL 

RAUMA

NATIONAL

AWARENESS

AND VISIBILITY

PREVENTION AND

RECOVERY SUPPORT

BEHAVIORAL HEALTH

SYSTEMS AND

SUPPORT

SOCIO-CULTURALECOLOGICAL

APPROACH

FOUNDATIONAL ELEMENT 2: 

Socio-cultural-ecological (SCE) Approach

Behavioral health challenges evolve in a multivariate 

environment that extends well beyond the individual. A 

socio-cultural-ecological approach aims to understand and 

address the problems recognized and to work within the 

construct of the social determinants of health. An individual exists within intersecting spheres of influence that 

include peers and social networks, families, communities, 

governing structures, economic systems and circumstances, 

and the even broader and often intangible influences of 

culture and history. These influencing factors impact an 

individual’s attitudes about what is acceptable and how 

to behave and thus help shape the norms that create and 

solidify an individual’s worldview. A socio-cultural-ecological approach elevates cultural preservation and revitalization as a key element of mental health for communities.

Many factors shape how people conceptualize health, 

health services, and what is considered healthy. These 

factors are even more complicated in American Indian and 

Alaska Native communities where traditional spheres of 

influence are often in conflict with Western approaches. For 

example, a Western governance structure communicates a 

different style of leadership and engagement than a more 

traditional and historical Native approach. These powerful variables contribute to how a community responds to 

challenges and how resources are structured to address 

such challenges.

The intent of Foundational Element 2 is to both begin to 

understand the larger context and pressures within which 

American Indian and Alaska Native behavioral health issues 

are rooted and guide interventions and efforts to address 

root and base causes of these issues. Solutions to behavioral health challenges must target factors that contribute 

to the problem and cause it to proliferate. Approaches that 

are part of the socio-cultural-ecological model will bring 

in collaborators that have expertise or influence over a 

variety of factors that may support development of viable 

solutions – these factors include environment, justice, 

financial systems, education, health, housing, labor, and 

transportation. 

Whereas a socio-cultural-ecological approach could focus 

on a variety of factors, including those identified above, 

Tribal leaders, communities, and programs also can focus 

on factors contributing to sustaining environmental 

resources, reliable infrastructure, and healthy families and 

kinship.

Federal Support for Addressing Sociocultural-ecological Factors

Federal agencies are supporting wide-ranging efforts to 

improve physical health and behavioral health. For example, 

NIH is conducting the ongoing study “Ojibwe Pathways” 

through the high school years. The study will use prospective data to investigate culturally specific protective factors 

that exist within the Ojibwe culture that may prevent, delay, 

or reduce the consequences of early-onset substance misuse 

and transition to substance use disorder. It will also assess 

the risk factors associated with individual characteristics 

and the social contexts of Ojibwe children during their 

high school years.

The BIA, through its Housing Improvement Program, 

provides grants for cost-effective services to repair, renovate, or replace existing housing and provide new housing 

for eligible members of federally recognized Indian tribes. 

This program is carried out in collaboration with the U.S. 

Department of Housing and Urban Development and the 

U.S. Department of Agriculture.

The IHS’s Great Plains Area and DOI’s Bureau of Indian 

Education (BIE) established a formal partnership to deliver 

behavioral health services in BIE-operated schools. The 

IHS will evaluate this partnership as a potential national 

model of community- and school-based services. 

The SSA, through its Video Service Delivery (VSD), has 

also developed a process that provides immediate services 

to tribes whose SSA field offices may be located great distances from reservations. VSD is a great resource for tribes 

such as the Pine Ridge Indian reservation in South Dakota, 

who experienced a 300% increase in claims. Through 

VSD, the SSA is able to process numerous services that are 

important to obtaining or maintaining information about 

services such as applying for a replacement Social Security 

Number card or changing an address. 

52
The CDC, through its Good Health and Wellness in Indian 

Country program, uses a model to directly fund tribes to 

prevent heart disease, diabetes, stroke, and associated risk 

factors in American Indian tribes and Alaska Native villages 

through a holistic approach to population health and wellness. Funded tribes use effective community-chosen and 

culturally adapted public health interventions using a combination of policy and environmental approaches, community clinical linkages, and health system interventions. This 

model also promotes the leadership of Tribal organizations 

and use of culturally adapted evidence-based interventions. 

Examples of program priorities include improvement in 

nutrition and physical activity and an increase in health 

literacy.

Priority Areas and Strategies

Priorities areas emerged from tribal input that focus on 

sustaining environmental resources, ensuring reliable 

infrastructure, and supporting healthy families and kinship. 

Following each priority area below are recommended strategies for addressing them.

SCE1 – Sustaining Environmental Resources

One commonality tribes share is a strong connection to 

nature and the environment; nature is highly revered and 

treated with respect. The connection is not only spiritual 

but also a way of life that includes nature as a source of 

traditional foods and medicine. Tribes have experienced 

devastation that has endangered nature and hope to protect 

and preserve their environment. Protecting the environment and tribal lands is directly related to tribes’ sovereign 

interest in protecting natural resources and treaty rights.

Recommendations include:

ʠ SCE1.1: Proactively advance collaborations among Tribal, 

Federal, and state programs to protect environmental resources 

as a vital part of the spiritual connection and traditional lifestyle.

ʠ SCE1.2: Incorporate actions across Tribal, 

Federal, and state programs that improve access 

to safe and healthy traditional foods.

SCE2 – Reliable Infrastructure

Tribes and Tribal communities face many challenges 

when it comes to infrastructure. Unemployment rates 

throughout Indian Country are high, and housing shortages affect Tribal members. The lack of adequate housing 

not only poses obvious challenges for Tribal members but 

also impacts the ability to attract and support a critically 

needed health services workforce. Recommended strategies 

include:

ʠ SCE2.1: Strengthen educational capacity of 

schools and access to education resources.

ʠ SCE2.2: Collaborate with state and Federal agencies on 

creative opportunities for addressing the determinants of 

health, including opportunities to increase housing stock, 

facilitate transportation needs, and improve job readiness.

ʠ SCE2.3: Improve collaboration during the planning 

of new tribal housing to ensure water and waste 

infrastructure needs are considered.

ʠ SCE2.4: Strengthen tribal capacity to 

effectively manage water programs.

SCE3 – Healthy Families and Kinship

Similar to community connectedness, family structures 

within Indian Country are vital sources of strength. 

However, family structures are becoming more fragmented, 

with many youth lacking strong parental figures in their 

lives. Strong family structures are important in helping 

youth grow into healthy and resilient adults. Elders are 

the gatekeepers of knowledge and tradition within Tribal 

communities, and tribes have suggested engaging elders in 

a more meaningful way by strengthening their connection 

with youth. Recommended strategies include:

ʠ SCE3.1: Support broader efforts to strengthen families 

as integral prevention and invention mechanisms and 

develop family-driven strategies for reinforcement.

ʠ SCE3.2: Collaborate across local, Tribal, state, Federal, and 

private and non-profit organizations to leverage opportunities 

to create safe and nurturing environments for youth.

ʠ SCE3.3: Expand collaboration across education, health, and 

human service systems that engage, support, and protect elders.

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Who can help advance sociocultural-ecological priorities?

CHART 2:

ADVANCING SOCIO-CULTURAL-ECOLOGICAL PRIORITIES OPPORTUNITIES Individual Family Community Tribal Government

 State  Government Federal  Government

SCE1.1: Proactively advance collaborations among Tribal, Federal, and state programs 

to protect environmental resources as a vital part of the spiritual connection and 

traditional lifestyle.

3 3 3 3 3 3

SCE1.2: Incorporate actions across Tribal, Federal, and state programs that improve 

access to safe and healthy traditional foods. 3 3 3 3

SCE2.1: Strengthen educational capacity of schools and access to education resources. 3 3 3

SCE2.2: Collaborate with state and Federal agencies on creative opportunities for 

addressing the determinants of health, including opportunities to increase housing 

stock, facilitate transportation needs, and improve job readiness.

3 3 3 3

SCE2.3: Improve coordination during the planning of new tribal housing to ensure 

water and waste infrastructure needs are considered. 3 3 3

SCE2.4: Strengthen tribal capacity to effectively manage water programs. 3 3 3 3

SCE3.1: Support broader efforts to strengthen families as integral prevention and 

invention mechanisms and develop family-driven strategies for reinforcement. 3 3 3 3 3 3

SCE3.2: Collaborate across local, Tribal, state, Federal, and private entities to leverage 

opportunities to create safe and nurturing environments for youth. 3 3 3 3 3 3

SCE3.3: Expand collaboration across education, health, and human service systems 

that engage, support, and protect elders. 3 3 3 3 3 3

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FOUNDATIONAL ELEMENT 3: 

Prevention and Recovery 

(PR) Support

Strong public health delivery models emphasize early 

identification of community health issues to prevent the 

deterioration of health and wellness. Similarly, following 

an intervention, services should be available to provide 

ongoing, comprehensive support for recovery and prevention. Existing systems must be strengthened to assess 

for the availability of critical services, gaps in services, and 

opportunities for improvement to meet community needs.

Federal Support for Addressing Prevention 

and Recovery Support

A number of Federal strategic plans address prevention and 

recovery efforts. For example, IHS, through its American 

Indian/Alaska Native National Behavioral Health Strategic 

Plan, is working to launch a systemwide collaboration 

between those working in child abuse/neglect prevention 

and those working in behavioral health to coordinate 

services for the whole family. Additional IHS strategies 

support community-specific planning, readiness, and 

mobilization around the prevention of suicide, violence, 

and substance misuse.

SAMHSA, through “Leading Change 2.0: Advancing the 

Behavioral Health of the Nation,” is working to enhance 

cooperation and coordination among Federal and 

non-Federal organizations to prevent and reduce underage drinking and to promote recovery-oriented service 

systems that include coordinated clinical treatment and 

recovery support. Recommendations developed through 

the Attorney General’s Advisory Committee on American 

Indian/Alaska Native Children Exposed to Violence 

“Ending Violence so Children Can Thrive” report198 also 

support access to culturally appropriate behavioral health 

and substance use prevention and treatment.

The noted Federal strategic plans and report and others 

support critical programming. IHS’s Methamphetamine 

and Suicide Prevention Initiative (MSPI) expands community-level access to effective methamphetamine and/

or suicide prevention and treatment programs. MSPI also 

enhances evidence- and practice-based methamphetamine 

and suicide prevention and treatment programs and 

community mobilization programs. The IHS Domestic 

Violence Prevention Initiative (DVPI) promotes the 

development of evidence- and practice-based models that 

represent culturally appropriate prevention and treatment 

approaches to domestic violence and sexual assault from a 

community-driven context. The DVPI expands outreach 

and increases awareness by funding programs that provide 

outreach, victim advocacy, intervention, policy development, community response teams, and community and 

school education programs.

The BIA’s Domestic Violence Prevention Program focuses 

on developing strategies to expand family services related 

to domestic violence, improve teamwork between law 

enforcement and social services to more rapidly address 

instances of domestic and family violence, and improve 

the coordination of services with other domestic and 

family violence partners in Indian Country. This program 

addresses the unmet needs of Native communities with 

high rates of domestic and family violence and high incidences of child abuse and neglect. The BIA collaborates on 

this program with DOJ and HHS.

VA established the national Opioid Safety Initiative (OSI) 

to reduce unsafe opioid pain medicine prescribing. The 

purpose of the OSI is to prevent opioid overdose and 

opioid use disorder. This multipronged approach includes 

provider and patient education about the risks and benefits 

of opioid pain medicines for chronic non-cancer pain, 

increasing access to more effective and safe stepped care 

strategies for chronic pain management, co-prescribing 

of naloxone rescue kits for those at-risk of overdose, and, 

when indicated, providing medication assisted treatment 

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 55
for opioid use disorder using buprenorphine/naloxone, 

methadone administered through an opioid treatment 

program, or extended-release injectable naltrexone. DOJ 

launched its Coordinated Tribal Assistance Solicitation 

(CTAS) in FY 2010 in direct response to concerns raised 

by tribal leaders about the Department’s grant process that 

did not provide the flexibility tribes needed to address their 

criminal justice and public safety needs. DOJ designed this 

comprehensive approach to save time and resources and 

allow tribes and DOJ to gain a better understanding of the 

tribes’ overall public safety needs. 

Under CTAS, the Bureau of Justice Assistance offers justice 

systems and alcohol and substance misuse funding. Tribes 

are able to develop, enhance, and continue tribal justice 

systems, including law enforcement, pretrial services, risk 

and needs assessment development and implementation, 

diversion programming, tribal court services, detention 

programming, community corrections, re-entry planning 

and programming, justice system infrastructure enhancement, and justice system information sharing.

Tribes can also respond to and prevent alcohol- and substance use-related crimes, including alcohol and substance 

use prevention, healing to wellness courts, intervention, or 

treatment. They are also able to: (a) develop, implement, 

and enhance substance use prevention and treatment programs, including those that prevent and address the needs 

of drug-endangered children; (b) implement enhanced 

authorities and provisions under the Tribal Law and Order 

Act and the Violence Against Women Reauthorization Act 

of 2013; and (c) engage in comprehensive strategic planning to improve tribal justice and community safety as it 

relates to tribal courts and alcohol and substance use.

DOJ incorporated the Juvenile Healing to Wellness Courts 

program into the CTAS in FY 2015 to enhance the capacity 

of tribal courts to respond to the alcohol and substance 

use-related issues of youth under the age of 21.

Through the Garrett Lee Smith (GLS) State/Tribal Suicide 

Prevention Program, SAMHSA has funded 49 tribes, Tribal 

organizations, and urban Indian organizations to carry out 

youth suicide prevention projects. The purpose of the GLS 

Program is to support states and tribes in developing and 

implementing statewide or Tribal youth suicide prevention 

and early intervention strategies. The program strongly 

encourages collaboration among youth-serving institutions 

and agencies and includes schools, educational institutions, 

juvenile justice systems, foster care systems, substance 

use and mental health programs, and other child- and 

youth-supporting organizations.

SAMHSA’s GLS Program cross-site evaluation found that 

these grants have had a lifesaving impact. Counties that 

implemented GLS-funded youth suicide prevention activities had lower rates of youth deaths by suicide and nonfatal 

suicide attempts than matched counties that did not. This 

was estimated to amount to 487 suicide deaths averted and 

79,000 nonfatal suicide attempts averted. It is unknown 

whether the impact was equally distributed across states 

and tribes. However, the impact was stronger in rural counties. This powerful impact was present in the first year after 

the activities were implemented and faded in the second 

year, strongly suggesting the importance of embedding 

suicide prevention within a sustainable infrastructure in 

both states and tribes.199, 200 In addition to the findings from 

the cross-site evaluation, local evaluations of some Tribal 

suicide prevention efforts have also been encouraging.

WHITE MOUNTAIN APACHE TRIBE (WMAT)

The WMAT suicide prevention program, working with 

the Johns Hopkins Center for American Indian Health, 

includes the evaluation of two culturally adapted 

interventions. These interventions are linked to a 

unique tribally mandated suicide surveillance system 

that identifies youth who have exhibited suicidal 

behavior. Preliminary results suggest a reduction in 

suicidal ideation for the interventions. An important 

element of the WMAT system is that every suicidal youth 

reported to the system receives rapid follow up by the 

Apache community workers, typically in their homes.

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Lessons learned from a decade of SAMHSA-funded 

American Indian and Alaska Native suicide prevention 

efforts include:

ʠ Suicide prevention efforts must be organized in a 

comprehensive way to be successful and must include all 

youth-serving organizations and institutions. Buy-in by the 

community and Tribal leadership is essential and can be 

facilitated by a Tribal resolution. Building organizational 

infrastructure from the beginning is important.

ʠ Tribes need access to their own data to be able to plan 

meaningful and effective suicide prevention activities. 

Understanding that historical trauma affects resistance 

to evaluation is vital since, historically, evaluation meant 

that something would be taken away from a community 

or used without community consent. Data and evaluation 

should be used by the community for the community.

ʠ Tribes should have protocols in place to guide 

how to respond to at-risk youth encountering 

any part of Tribal youth-serving systems.

ʠ Youth with suicidal ideation or who have made a suicide attempt 

must receive active outreach in the community. Discharge 

from a hospital inpatient unit or emergency department 

cannot be considered sufficient to eliminate suicide risk; 

rather, connection with the youth needs to be maintained 

for a minimum of 90 days during this high-risk period.

ʠ Trained community workers can play a vital 

role in suicide prevention efforts.

ʠ Suicide clusters can have a profound, tragic, and potentially 

multigenerational impact on Tribal communities. Sharing 

learning and experiences in responding to a suicide cluster is 

of great significance in helping us learn how to prevent clusters 

from starting and how to interrupt them once they have begun.

ʠ Health and mental health programs serving tribes would benefit 

from utilization of a systematic suicide prevention effort such 

as that encapsulated in the Zero Suicide prevention model.

ʠ Coordinated crisis response and crisis 

intervention systems are critical.

ʠ There is a need for increased family participation in suicide 

prevention work. Much of the federally supported work 

has focused on the community and youth, but there is a 

need to work more intensively on family involvement.

Priority Areas and Strategies

Priority areas that emerged from tribal input focus on 

restructuring programming to meet community needs 

and advance community mobilization and engagement. 

Following each priority area below are recommended strategies for addressing them.

PR1 – Programming That Meets Community Needs

All prevention and treatment programs are not designed to 

meet the diverse needs of differing communities, nor are 

they designed to readily incorporate traditional American 

Indian and Alaska Native worldviews that promote health 

and healing. Tribal communities must have the flexibility, 

support, and resources to implement prevention, treatment, 

and recovery programming that meet the needs of their 

populations. Recommendations include:

ʠ PR1.1: Create and support culturally and spiritually based 

programming and healing that aligns with the diversity and 

needs of the local Tribal population and engages communities 

in the development of diversion and reentry programs.

ʠ PR1.2: Support and coordinate reentry programming 

across service sectors and programming for incarcerated 

persons and their families, especially their children.

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ʠ PR1.3: Prioritize and collaborate on behavioral 

health-related prevention efforts as a primary strategy 

across education, health, behavioral health, child 

welfare, law enforcement, and other systems.

ʠ PR1.4: Treat mental and substance use disorders 

as chronic conditions that require support and 

services across the spectrum – from prevention for 

individuals at all levels of risk through recovery.

ʠ PR1.5: Advocate for and support comprehensive 

suicide prevention efforts that incorporate protocols 

for at-risk youth and adults, required infrastructure 

for supporting suicide prevention, active community 

outreach following discharge from the hospital or the 

emergency department, trained community workers, and 

coordinated crisis response and intervention systems.

ʠ PR1.6: Support, establish, or improve data collection 

systems to support the collection of information on 

suicide prevention activities that is managed locally or 

in collaboration with a Tribal Epidemiology Center.

ʠ PR1.7: Support suicide prevention efforts that 

include youth, families, and communities.

ʠ PR1.8: Build and sustain supportive environments in schools.

ʠ PR1.9: Support and promote Tribal Healing to Wellness Courts, 

Veterans Courts (or the VA Diversion Courts Peer-to-Peer 

Support Program), and other courts that support recovery.

PR2 – Community Mobilization and Engagement

Behavioral health is a community health issue that requires 

a communitywide response. Given the importance of 

addressing behavioral health problems in many communities, Tribal leaders should take ownership of these issues 

and work with their tribal community, tribal councils, 

Federal agencies, state agencies, regional and local partners, 

and other interested parties to develop an appropriate local 

response. Communities may need guidance from their 

leaders to understand their choices for response including 

seeking approval for technical assistance from organizations or agencies. Strategies include:

ʠ PR2.1: Formulate and implement long-term, communitywide 

engagement and mobilization strategies that emphasize 

community ownership of their issues and solutions.

ʠ PR2.2: Support and train community 

members to serve as peer counselors.

ʠ PR2.3: Actively address and support the behavioral healthrelated programming needs of urban- and reservation-based 

American Indian and Alaska Native populations.

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SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

Who can help advance prevention and 

recovery priorities?

CHART 3:

ADVANCING PREVENTION AND RECOVERY PRIORITIES OPPORTUNITIES Individual Family Community Tribal Government

 State  Government Federal  Government

PR1.1: Create and support culturally and spiritually based programming and healing 

that aligns with the diversity and needs of the local Tribal population and engages 

communities in the development of diversions and reentry programs.

3 3 3 3 3 3

PR1.2: Support and coordinate reentry programming across service sectors and 

programming for incarcerated persons and their families, especially their children. 3 3 3 3 3 3

PR1.3: Prioritize and collaborate on behavioral health-related prevention efforts as 

a primary strategy across education, health, behavioral health, child welfare, law 

enforcement, and other systems.

3 3 3 3 3 3

PR1.4: Treat mental and substance use disorders as chronic conditions that require 

support and services across the spectrum – from prevention for individuals at all 

levels of risk through recovery.

3 3 3 3 3 3

PR1.5: Advocate for and support comprehensive suicide prevention efforts that 

incorporate protocols for at-risk youth and adults, required infrastructure to 

supporting suicide prevention, active community outreach following discharge 

from the hospital or the emergency department, trained community workers, and 

coordinated crisis response and intervention systems.

3 3 3 3 3 3

PR1.6: Support, establish, or improve data collection systems to support the collection of information on suicide prevention activities that is managed locally or in 

collaboration with a Tribal Epidemiology Center.

3 3 3

PR1.7: Support suicide prevention efforts that include youth, families, and 

communities. 3 3 3 3 3 3

PR1.8: Build and sustain supportive environments in schools. 3 3 3 3 3 3

PR1.9: Support and promote Tribal Healing to Wellness Courts, Veterans Courts 

(or the VA Diversion Courts Peer-to-Peer Support Program), and other courts that 

support recovery.

3 3 3 3 3 3

PR2.1: Formulate and implement long-term, communitywide engagement and 

mobilization strategies that emphasize community ownership of their issues and 

solutions. 

3 3 3 3 3 3

PR2.2: Support and train community members to serve as peer counselors. 3 3 3 3

PR2.3: Actively address and support the behavioral health-related programming needs of urban- and reservation-based American Indian and Alaska Native 

populations.

3 3 3 3 3 3

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FOUNDATIONAL ELEMENT 4: 

Behavioral Health (BH) 

Systems and Support

As with all systemic issues, arriving at options for improving behavioral health services is complex. An assessment 

of applicable systems and their interactions with the 

community and community members is critical to identifying challenges and realistic opportunities for identifying 

resources for needed services. The source of resources 

can vary – Tribal, Federal, state, or private – and require 

that tribes and other stakeholders work together to create 

coordinated and effective systems for American Indian and 

Alaska Native peoples.

Issues that impact access, quality, and availability of health, 

behavioral health, and related services have long been 

raised by Tribal leaders, community members, and other 

stakeholders. The literature describes concerns related to 

personnel shortages, limited health care resources, and 

lengthy travel distances to obtain services. Other issues 

also inhibit access to appropriate services, including lack of 

referrals from school, detention, court appearances, housing needs, primary care, child welfare, and other systems.

The intent of Foundational Element 4 is not only to 

identify challenges but also to address priorities and 

strategies that improve coordination, linkages, and access 

to high-quality behavioral health services. The strategies 

include examination of the available workforce, development of the existing workforce, ensuring cultural competency in the delivery of services, and potential options for 

improving meaningful access. In Tribal communities, geographic distances to obtain services and staffing concerns 

inhibit community members from seeking services, but low 

utilization numbers also may reflect a belief that services 

are not effective or in line with an individual’s path for 

healing or inclusive of the person’s worldview. The reflection of belief systems within services and as part of service 

delivery is also a real consideration for American Indian 

and Alaska Native people who live in urban areas and may 

receive referrals to providers who have no historical experience in working with Native peoples.

Additional service and service system considerations 

always include concerns related to funding – amounts, 

streams, allocations, and adequacy. Substantive system 

change cannot take place without adequate resources to 

create and support the desired change. In keeping with 

the purpose and approach of the TBHA, specific and 

detailed recommendations about funding have not been 

made. Discussions regarding the funding of programs and 

initiatives should be managed by the appropriate Tribal and 

Federal authorities.

Foundational Element 4, one of the most complex foundational elements in the TBHA, creates substantial opportunities for collaboration. Potential collaborations may 

involve prevention, treatment, and services, including 

sources of referrals, education and communication, patient 

navigation, advocacy services, and more. It engages the 

community and its leadership to positively influence attitudes, foster support for improvements, and drive actions 

that align with and benefit local needs.

Federal Support for Addressing Behavioral 

Health Services and Systems Improvement

Behavioral health issues are addressed in many existing 

Federal strategic plans. For example, SAMHSA and IHS, 

through their strategic plans, collectively have nearly 

20 objectives focused on suicide prevention and skilled 

follow up; implementing effective clinical and professional 

practices and standards for assessing and treating those at 

risk for suicide; raising awareness about prescription drug 

misuse; removing financial barriers and incentivizing effective care coordination and integrated treatment delivery; 

supporting culture-based approaches; and training and 

support for behavioral health providers.

The IHS’s Behavioral Health Program provides vital 

outpatient mental health counseling and access to dual 

diagnosis services, mental health crisis response and triage, 

case management services, community-based prevention 

programming, and outreach and health education activities. 

The IHS also operates the Alcohol and Substance Abuse 

Prevention Program to raise the behavioral health status 

of American Indian and Alaska Native communities to 

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the highest possible level through a comprehensive array 

of preventive, educational, and treatment services that are 

community driven and culturally competent. Tribal contracting has enabled both of these programs to transition 

from IHS to local community control.

The VA has established several telebehavioral clinics in 

IHS and Tribal health programs in Montana, Arizona, and 

Alaska to increase access to care closer to home. The intent 

is to increase access to behavioral health services for veterans in Tribal and rural communities through collaboration 

with local health care providers in the establishment of 

embedded VA telehealth clinics. The VA will explore opportunities to expand telebehavioral services to additional 

Tribal communities or clinics serving veterans.

SAMHSA also funds adult treatment drug courts and 

Tribal healing to wellness courts. Tribes funded through 

this program provide a coordinated, multisystem approach 

that combines the sanctioning power of treatment drug 

courts with effective substance use disorder treatment 

services to break the cycle of criminal behavior, alcohol and 

other drug misuse, and incarceration or other penalties. 

SAMHSA funds also are used to serve people diagnosed 

with a substance use disorder as their primary condition.

Workforce-related programs exist throughout the Federal 

Government. For example, HRSA, through its National 

Health Service Corps Program, seeks eligible clinicians 

(including mental and behavioral health professionals) to 

provide culturally competent, interdisciplinary primary 

health care services to underserved populations that reside 

in selected Health Professional Shortage Areas. HRSA’s 

Regional Administrators work in collaboration with 

SAMHSA Regional Administrators to assess the behavioral 

health needs of Tribal communities and addresses identified needs by providing training and technical assistance. 

In addition, BIA, through its Job Placement and Training 

Program, funds tribes to provide training and work experience to decrease unemployment.

The NIH funded a study on evidence-based practices and 

substance use treatment for Native Americans. The study 

explored evidence-based practices to describe the factors 

associated with the decision to implement them in these 

programs, identify methods for more effective dissemination of evidence-based practices to substance use treatment 

programs serving American Indian and Alaska Native 

communities, and identify characteristics of the workforce 

implementing American Indian and Alaska Native substance use treatment measures.

The SSA offers a variety of benefits for Tribal members, including retirement and disability programs, 

Supplemental Security Income, Medicare, online account 

access with mySocialSecurity, and special programs. SSA is 

working to improve access and understanding of available programs such as the Medicare Extra Help Program 

to assist qualified beneficiaries with their Medicare 

Prescription drug plan costs; and, the Wounded Warriors 

program which offers expedited case processing for disability benefits for military service members. 

The HHS Office of Minority Health’s National Workforce 

Diversity Pipeline Program supports projects that develop 

innovative strategies to identify promising students in their 

first year of high school and provide them with a foundation to pursue successful careers in the health professions. 

The program seeks to address health disparities among 

racial and ethnic minorities by supporting networks of 

institutions focused on, and with demonstrated commitment and capacity to establish, pipeline programs to 

increase minority and disadvantaged students’ awareness 

and pursuit of careers in health care, including behavioral 

health.

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Priority Areas and Strategies 

BH1 – Workforce Development

Tribes face staffing shortages at nearly all levels. Sometimes 

these shortages can mean that an individual in crisis is not 

able to receive immediate, adequate care. Furthermore, 

many tribes believe that behavioral health professionals 

would benefit from cultural competency training. In the 

face of high levels of unemployment and staffing shortages, 

improving the skills and practice of existing providers and 

addressing development of the behavioral health workforce using a “grow your own” model are highly favored. 

Strategies include:

ʠ BH1.1: Support and develop collaboration among tribes, 

Tribal organizations, Tribal Colleges and Universities, (TCUs) 

and Federal agencies to establish local “grow your own” 

behavioral health education programs and provide basic 

training for local Tribal behavioral health aides (community 

workers). For areas with limited access to TCUs other forms 

of collaboration for supporting training should be explored.

ʠ BH1.2: Establish collaborations between tribes and 

Addiction Technology Transfer Centers to support education, 

training for certification exams, and clinical supervision 

opportunities for behavioral health professionals working 

in Tribal facilities to obtain and maintain certification.

ʠ BH1.3: Support the incorporation of traditional practitioners 

within service delivery systems and provide training on 

cultural and organizational competency for all employees.

ʠ BH1.4: Actively pursue collaborations with the HRSA 

National Health Service Corps Program to recruit 

psychiatrists, behavioral health professionals, and 

other practitioners to work in Tribal facilities.

BH2 – Funding Mechanisms

Tribal behavioral health programs frequently struggle 

as a result of insufficient funding. Programs are frequently underfunded or funded only for a finite period. 

Furthermore, the requirements of some programs do not 

always align with other Tribal priorities, values, or traditional practices. Tribes have advocated for greater access 

to particular funding streams and for direct funding from 

Federal programs rather than through states. Strategies 

include:

ʠ BH2.1: Assess state engagement with tribes and 

promote meaningful state/Tribal consultations.

ʠ BH2.2: Monitor state behavioral health spending and 

support equitable resources and support to tribes and 

other entities providing services for Tribal members.

ʠ BH2.3: Increase flexibility in funding requirements to 

tribes to support culturally based programming that 

meets the programmatic needs of Tribal communities.

ʠ BH2.4: Develop flexibilities that allow tribes with multiple 

Federal grants to lower administrative costs, increase integration 

of funded programs, and enhance collaborative reporting.

ʠ BH2.5: Prioritize behavioral health and related 

programs in all budgeting processes.

ʠ BH2.6: Assess opportunities for funding traditional 

services including staffing and supplies.

BH3 – Tribally Directed Programs

Tribes know best the needs of their communities. However, 

funders may not regularly consult with tribes about their 

programs and may thus develop program requirements, 

design evaluations, and require reporting using solely a 

Western lens. Strategies include:

ʠ BH3.1: Consult with tribes on programs that tribes are 

eligible for prior to developing program announcements.

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ʠ BH3.2: Support tribal efforts to incorporate cultural 

interventions into program activities that allow tribes 

to more effectively meet program expectations.

ʠ BH3.3: Support tribally driven assessments and 

implementation of strengths-based, Tribal best practices.

ʠ BH3.4: Increase coordination and collaboration among Federal, 

state, Tribal, and/or urban programs by aligning resources, 

decreasing competition, and improving strategic planning.

ʠ BH3.5: Engage tribes about their technical 

assistance and other support needs prior to 

developing technical assistance requirements.

BH4 – Youth-Based Programming

Youth hold an important position within Tribal communities – they are the literal future for tribes. Youth-specific 

programs in Tribal communities require additional support 

given the limited resources and services that may be 

available locally. Learning about culture is a strong protective factor, and providing education on behavioral health 

issues may help reduce concerns surrounding treatment. 

Strategies include:

ʠ BH4.1: Allow tribes the flexibility to engage youth 

in developing and implementing programming that 

targets American Indian and Alaska Native youth.

ʠ BH4.2: Support targeted education for youth that incorporates 

learning their Native language, respective culture(s), and 

role that culture plays in supporting behavioral health.

BH5 – Scope of Programming

In response to service-related challenges, including, funding, staffing, facility shortages, and quality services, many 

tribes do not receive or are unable to provide a full continuum of services for their members. This often means that 

Tribal members must leave the community to receive care 

or not receive the services they need. Tribes have sought 

expansion in the scope of programming to ensure that 

Tribal members are able to receive vital care within their 

communities. Strategies include:

ʠ BH5.1: Identify new models of care delivery that ensure 

more accessible intensive inpatient and long-term care.

ʠ BH5.2: Support implementation of Tribal, Federal, and/

or state collaborations that bolster wraparound services.

ʠ BH5.3: Support and immediately implement a collaboration 

that supports early intervention services for behavioral health.

ʠ BH5.4: Support expansion of telebehavioral services 

to additional Tribal communities or clinics.

BH6 – Law Enforcement and Justice Programs

American Indians and Alaska Natives with mental and/

or substance use disorders often end up in the criminal 

justice system rather than receiving services. Incarceration 

frequently compounds already challenging preexisting 

conditions, and tribes are seeking greater collaboration 

between the behavioral health and criminal justice systems in a way that does not further victimize Native youth 

and adults, supports growth, and promotes healthy living. 

Strategies include:

ʠ BH6.1: Strengthen collaborations among health, behavioral 

health, and justice system programs of the U.S. Department of 

Health and Human Services, U.S. Department of Justice, and U.S. 

Department of the Interior to strengthen programs for Native 

youth in collaboration with tribal courts to create alternatives 

to incarceration that incorporate tribal values, culture, and 

tradition in programming that addresses behavioral health issues.

ʠ BH6.2: Support expansion of Tribal healing to wellness court 

programs of the U.S. Department of Health and Human 

Services, U.S. Department of Justice, and U.S. Department 

of the Interior to support diversion of Tribal members 

with a mental and/or substance use disorder from the 

criminal justice system to local behavioral health care.

SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 63
4 5

NATIONAL

AWARENESS

AND VISIBILITY

 AND

PPORT

BEHAVIORAL HEALTH

SYSTEMS AND

SUPPORT

Who can help advance 

behavioral health systems and 

support priorities?

CHART 4:

ADVANCING BEHAVIORAL HEALTH SYSTEMS AND SUPPORT OPPORTUNITIES Individual Family Community Tribal Government

 State  Government Federal  Government

BH1.1: Support and develop a collaboration among tribes, Tribal organizations, Tribal Colleges 

and Universities, and Federal agencies to establish local “grow your own” behavioral health 

education programs and provide basic training for local Tribal behavioral health aides 

(community workers).

3 3 3 3

BH1.2: Establish collaborations between tribes and Addiction Technology Transfer Centers 

to support education, training for certification exams, and clinical supervision opportunities 

for behavioral health professionals working in Tribal facilities to obtain and maintain 

certification.

3 3

BH1.3: Support the incorporation of traditional practitioners within service delivery systems 

and provide training on cultural and organizational competency for all employees. 3 3 3

BH1.4: Actively pursue collaborations with the HRSA National Health Service Corps Program 

to recruit psychiatrists, behavioral health professionals, and other practitioners to work in 

Tribal facilities.

3

BH2.1: Assess state engagement with tribes and promote meaningful state/Tribal 

consultations. 3 3 3

BH2.2: Monitor state behavioral health spending and support equitable resources and 

support to tribes and other entities providing services for Tribal members. 3 3 3

BH2.3: Increase flexibility in funding requirements to tribes to support culturally based 

programming that meets the programmatic needs of Tribal communities. 3 3

BH2.4: Develop flexibilities that allow tribes with multiple Federal grants to lower 

administrative costs, increase integration of funded programs, and enhance collaborative 

reporting.

3 3

BH2.5: Prioritize behavioral health and related programs in all budgeting processes. 3 3 3 3 3 3

BH2.6: Assess opportunities for funding traditional services including staffing and supplies. 3 3 3

BH3.1: Consult with tribes on programs that tribes are eligible for prior to developing 

program announcements. 3 3

BH3.2: Support tribal efforts to incorporate cultural interventions into program activities 

that allow tribes to more effectively meet program expectations. 3 3 3 3 3 3

BH3.3: Support tribally driven assessments and implementation of strengths-based, Tribal 

best practices. 3 3

64
OPPORTUNITIES

 Individual Family Community Tribal  Government State  Government Federal  Government

BH3.4: Increase coordination and collaboration among Federal, state, Tribal, and urban 

programs by sharing resources, decreasing competition, and improving strategic planning. 3 3 3

BH3.5: Engage tribes on their technical assistance and support needs prior to articulating 

technical assistance requirements. 3 3

BH4.1: Allow tribes the flexibility to engage youth in developing and implementing 

programming that target American Indian and Alaska Native youth. 3 3

BH4.2: Support targeted education for youth that incorporates learning their Native 

language, respective culture(s), and role that culture plays in supporting behavioral health. 3 3 3 3 3 3

BH5.1: Identify new models of care delivery that ensure more accessible intensive inpatient 

and long-term care. 3 3 3

BH5.2: Support implementation of Tribal, Federal, and/or state collaborations that bolster 

wraparound services. 3 3 3 3 3 3

BH5.3: Support and immediately implement a collaboration that supports early intervention 

services for behavioral health. 3 3 3

BH5.4: Support expansion of telebehavioral services to additional Tribal communities or 

clinics. 3 3 3 3 3 3

BH6.1: Strengthen collaborations among health, behavioral health, and justice system 

programs of the U.S. Department of Health and Human Services, U.S. Department of 

Justice, and U.S. Department of the Interior to strengthen programs for Native youth in 

collaboration with tribal courts to create alternatives to incarceration that incorporate tribal 

values, culture, and tradition in programming that addresses behavioral health issues..

3 3 3

BH6.2: Support the expansion of the Tribal healing to wellness court programs of the U.S. 

Department of Health and Human Services, U.S. Department of Justice, and U.S. Department 

of the Interior to support diversion of Tribal members with a mental and/or substance use 

disorder from the criminal justice system to local behavioral health care. 

3 3 3 3 3 3

SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 65
5

NATIONAL

AWARENESS

AND VISIBILITY

ORAL HEALTH

TEMS AND

UPPORT

FOUNDATIONAL ELEMENT 5: 

National Awareness 

(NA) and Visibility

Increasing the visibility of behavioral health issues is a key 

strategy for ensuring that stakeholders understand the 

unique challenges and potential solutions for American 

Indian and Alaska Native communities. These challenges 

can include geography, lack of access to basic resources, 

poverty, poor living conditions, and the impacts of traumatic events. Some tribes are concerned about extensive 

national visibility on issues that are better addressed locally, 

whereas other tribes believe that openly talking about and 

broadening engagement of appropriate authorities will lead 

to funding support and better solutions for their people. 

Increasing visibility while ensuring that Tribal governments 

have the ability to control messages shared can serve to 

strengthen a tribe’s public and behavioral health response 

and readiness.

Federal Support for Addressing National 

Awareness and Visibility Priorities

The IHS funded five campaigns to increase national awareness, including “I Strengthen My Nation” (substance use 

prevention campaign); “Stand Up, Stand Strong” (bullying 

prevention campaign); “Community Is the Healer That 

Breaks the Silence” (suicide prevention campaign); “What 

Is Done to One Is Felt by All (family violence prevention 

campaign); and “My Mind, Body and Spirit Are Sacred” 

(sexual assault prevention campaign). In addition, IHS 

frequently shares information and highlights behavioral 

health resources, prevention and treatment practices.

Other examples of engagement by Federal agencies include 

NIH journal articles and publications on American 

Indian and Alaska Native substance use issues. In addition, 

SAMHSA developed the “Talk. They Hear You.” underage 

drinking prevention campaign for Tribal communities 

and also recently published two reports on the prevention 

of suicide and suicide clusters in American Indian and 

Alaska Native Communities. The first report, “Preventing 

and Responding to Suicide Clusters in American Indian 

and Alaska Native Communities,” interviews community 

members to learn more about the events and responses to 

youth suicide clusters between 2009 and 2011 and offers 

recommendations for Tribal communities and for Federal, 

state, and local collaborators. The second report, “Suicide 

Prevention in Alaska,” informs Tribal communities, policymakers, and public health professionals about suicide 

prevention efforts in Native Alaska communities and 

recommends actions to advance future suicide prevention 

work within those communities.

Priority Areas and Strategies 

NA1 – Tribal Capacity Building

Tribes have the ability to decide what information to share 

and what not to share, what warrants national attention 

and what does not, and what steps will benefit versus 

further damage their communities. Should Tribal leaders choose to address behavioral health issues locally or 

nationally, they will require data, support, and capacity 

development on ways to best communicate challenges and 

successes in their communities. Strategies include:

ʠ NA1.1: Support and engage in capacity-building efforts to raise 

the collective capacity of tribes to speak about the effectiveness 

of culture in prevention and care and their own best practices.

ʠ NA1.2: Support and raise the capacity of tribes to discuss the 

impact of historical and intergenerational trauma within their 

own communities and with external partners, if they choose.

ʠ NA1.3: Actively educate Tribal communities 

about behavioral health in an effort to normalize 

topics of behavioral and emotional health.

ʠ NA1.4: Support and raise the capacity of tribes to create 

and implement media and public relations plans.

NA2 – Tribally Directed Communication Strategies

In order to communicate effectively with media outlets, 

external and internal communities, and governmental 

collaborators, tribes need support on how best to exchange 

information and communicate in a timely and effective 

manner. These plans and strategies must be developed and 

managed in collaboration with tribes.

66
ʠ NA2.1: Establish a national behavioral health communications 

campaign, in collaboration with tribes, to educate individuals 

about behavioral health issues affecting Tribal communities. The 

campaign would focus on specific mental and substance use 

disorders and/or co-occurring disorders that could be shared 

through multiple platforms and also tailored by tribes for local 

use. Broad national dissemination would ensure that urban 

Indian populations receive similar messages and support.

ʠ NA2.2: Develop messages for American Indians and Alaska 

Natives that contain positive, Native-focused, media 

images and incorporate the voices of survivors and Tribal 

strengths to discuss issues and lived experiences.

ʠ NA2.3: Package existing communications messages developed 

by Federal agencies and ensure that multiple entities 

leverage the messages to improve diffusion to communities 

requiring support and stakeholders who can assist.

ʠ NA2.4: Create web-based tools and resources that 

Tribal leaders and officials can utilize to craft media 

communication and public relations strategies, 

especially during times of crisis or increased need.

NA3 – Collaborator Capacity Building

There are many entities that engage with tribes on 

health-related matters, including Federal, state, and other 

governments; nonprofit and community-based organizations; health and service providers; insurers; emergency 

response systems; and the media. These entities require 

continuous capacity building when working with Tribal 

communities to effectively engage and support change. 

Strategies include:

ʠ NA3.1: Support establishment of targeted training 

and technical assistance across Federal agencies about 

American Indian and Alaska Native populations, 

sovereignty, the nature of the government-to-government 

relationship, and issues that contribute to well-being.

ʠ NA3.2: Engage in meaningful Tribal 

consultation and communication.

ʠ NA3.3: Support establishment of measures to increase 

the capacity of collaborators and stakeholders to 

understand the scope of the diversity and behavioral 

health challenges within Indian Country and how to treat 

this information in accordance with Tribal direction.

SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 67
Who can help advance national 

awareness and visibility priorities?

CHART 5:

ADVANCING NATIONAL AWARENESS 

AND VISIBILITY PRIORITIES

5

NATIONAL

AWARENESS

AND VISIBILITY

EALTH

ND

OPPORTUNITIES

 Individual Family Community Tribal Government State Government Federal  Government

NA1.1: Support and engage in capacity-building efforts to raise the collective capacity of 

tribes to speak about the effectiveness of culture in prevention and care and their own best 

practices.

3 3 3 3 3 3

NA1.2: Support and raise the capacity of tribes to discuss the impact of historical and 

intergenerational trauma within their own communities and with external partners, if they 

choose.

3 3 3 3 3 3

NA1.3: Actively educate Tribal communities about behavioral health in an effort to 

normalize topics of behavioral and emotional health. 3 3 3 3 3 3

NA1.4: Support and raise the capacity of tribes to create and implement media and public 

relations plans. 3 3 3 3 3 3

NA2.1: Establish a national behavioral health communications campaign, in collaboration 

with tribes, to educate individuals about behavioral health issues affecting Tribal 

communities. The campaign would target specific mental disorders, substance use, and/or 

co-occurring disorders that could be shared through multiple platforms and also tailored 

by tribes for local use. Broad national dissemination would ensure that urban Indian 

populations receive similar messages and support.

3 3 3

NA2.2: Develop messages for American Indians and Alaska Natives that contain positive, 

Native-focused, media images and incorporate the voices of survivors and Tribal strengths 

to discuss issues and lived experiences.

3 3 3 3 3 3

NA2.3: Package existing communications messages developed by Federal agencies and 

ensure that multiple entities leverage the messages to improve diffusion to communities 

requiring support and stakeholders who can assist. 

3 3 3 3 3

NA2.4: Create web-based tools and resources that Tribal leaders and officials can utilize to 

craft media communication and public relations strategies, especially during times of crisis 

or increased need.

3 3 3 3 3 3

NA3.1: Support establishment of targeted training and technical assistance across Federal 

agencies about American Indian and Alaska Native populations, sovereignty, the nature of 

the government-to-government relationship, and issues that contribute to well-being..

3 3 3 3 3

NA3.2: Engage in meaningful Tribal consultation and communication. 3 3 3

NA3.3: Institute measures to increase the capacity of collaborators and stakeholders 

to understand the scope of the diversity and behavioral health challenges within Indian 

Country and how to treat this information in accordance with Tribal direction.

3 3 3

SECTION V. THE NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA

68
NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 69
6TRIBAL BEHAVIORAL HEALTH AGENDA SECTION VI

Moving Forward

70
One of the messages that framed development of the TBHA remains one of the most 

important messages on which to frame the path forward: There is no single entity, 

program, or activity alone that will improve behavioral health outcomes for American 

Indians and Alaska Natives. Tribal leaders asked for tribes and Federal agencies to “work 

together differently” to improve the wellness of their communities. Through extensive 

conversations, Tribal leaders, Tribal administrators, and Tribal members from communities 

across Indian Country provided input on what they believed was best for healing their 

people from traumatic events compounded over time. And, despite the differences across 

tribes, geography, cultures, and language, they found areas of common benefit on which 

to frame priorities that allow for collaborative work across sectors and governments to 

target the factors contributing to behavioral health problems.

The National Tribal Behavioral Health Agenda is not an 

end but a continuing chapter in Tribal-Federal relations. It 

uses as a starting place the ideas and beliefs of Tribal communities to build a path forward. Within this document 

are examples of Federal strategic plan goals and recommendations that are being addressed and comport with 

the priorities and strategies of the TBHA. That is, the path 

for making progress on the TBHA is largely already paved. 

What proceeds from here are efforts to identify through 

existing, well-defined structures how to ensure uptake of 

the priorities, support meaningful collaboration, and assess 

progress on a continuing basis.

The framework, priorities, and strategies of the TBHA will 

be shared with Tribal leaders who are members of Federal 

Tribal advisory councils to determine areas they would like 

to advance that are within the scope of the agencies with 

whom they work. Updates from the work of these councils 

will be shared with the HHS Intradepartmental Council 

on Native American Affairs for guidance and coordination. 

Federal staff members who participated in the Federal 

Interagency Forum on developing the TBHA found the 

meeting a useful platform for addressing and coordinating 

work and requested future meetings. To that end, future 

meetings will be scheduled to assess progress and identify 

innovative ideas.

Information on collaborative actions with tribes 

will be documented in a “National Tribal Behavioral 

Health Agenda Report.” The Tribal Law and Order Act’s 

Interagency Alcohol and Substance Abuse Data Workgroup 

already has drafted an initial report specifically for the 

TBHA that includes data sets from multiple Federal departments and will serve as a data source for comparisons on 

the state of mental and substance use disorders in Indian 

Country.

Ultimately, this work requires examination and modification of some policies, programs, activities, and beliefs 

about developing programs that bear significance for 

American Indian and Alaska Native peoples. Tribal leaders 

have shared the power of cultural wisdom and traditional 

practices for their people. They have asked for all levels of 

government, including Tribal governments, to respect the 

authenticity of cultural wisdom; accept traditional ways 

of being, knowing, and doing; and commit to supporting 

their unique ideas of health and healing through multiple 

means. They have asked that all interested parties trust 

Tribal nations to do the best for their people. 

Information has been shared, priorities have been identified, and a path has been established. It is now up to Tribal, 

Federal, and other entities to embrace and advance meaningful collaborations.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 71
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NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 73
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10.3109/00952990.2012.694529.

168 U.S. Department of Health and Human 

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Facilities.

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169 Office of Inspector General. (2016). 

Indian Health Service Hospitals: Longstanding 

Challenges Warrant Focused Attention to 

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Washington, DC. Retrieved from https://oig.

hhs.gov/oei/reports/oei-06-14-00011.pdf. 

170 Urban Indian Health Institute. (2012). 

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WA: Urban Indian Health Institute.

171 Indian Health Service. (2011). Inpatient 

mental health assessment. Retrieved from http://

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IHCIA_InpatientMH_Assessment_Final.pdf.

172 Indian Health Service Quality Framework 

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display_objects/documents/IHS_2016-2017_

QualityFramework.PDF

173 Connor, K.O., Koeske, G., & Brown, 

C. (2009). Racial differences in attitudes 

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174 Gonzalez, J.M., Alegria, M., & Prihoda, T.J. 

(2005). How do attitudes toward mental health 

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race in young adults? Journal of Community 

Psychology 33, 611-629. doi: 10.1002/jcop.20071.

175 Poleshuck, E.L., Cerrito, B., Leshoure, N., 

Finocan-Kaag, G., & Kearney, M.H. (2013). 

Underserved women in a women’s health 

clinic describe their experiences of depressive 

symptoms and why the have low uptake of psychotherapy. Community Mental Health Journal 

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176 McCabe, K.M. (2002). Factors that predict 

premature termination among MexicanAmerican children in outpatient psychotherapy. 

Journal of Child and Family Studies 11, 347-359. 

doi: 10.1023/A:1016876224388.

177 O’Sullivan, M.J., Peterson, P.D., Cox, 

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Psychology 17, 17-30. doi: 10.1007/BF00931200.

178 Coyhis, D., & Simonelli, R. (2008). The 

Native American Healing Experience. Substance 

Use and Misuse 43(12-13), 1927-1949.

179 Gone, J.P., & Trimble, J.E. (2012). 

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annrev-climpsy-032511-143127.

180 Jimenez, D.E., Bartels, S.J., Cadenas, V., 

& Alegria, M. (2013). Stigmatizing attitudes 

toward mental illness among racial/ethnic older 

adults in primary care. International Journal of 

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gps.3928. Jimenez, D.E., Bartels, S.J., Cadenas, 

V., & Alegria, M. (2013). Stigmatizing attitudes 

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adults in primary care. International Journal 

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181 Vogel, D.L., Wade, N.G., & Hackler, A.H. 

(2007). Perceived social stigma and the willingness to seek counseling: The mediating roles 

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10.1037/0022-0167.54.1.40.

182 Zhang, N., & Dixon, D.N. (2003). 

Acculturation and attitudes of Asian international students toward seeking psychological 

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Development 31, 205-222. doi: 10.1002/j.2161-

191.2003.tb00544.x.

183 Drabiak-Syed, K. (2010). Lessons from 

Havasupai Tribe v. Arizona State University 

Board of Regents: Recognizing Group, Cultural, 

and Dignitary Harms as Legitimate Risks 

Warranting Integration into Research Practice. 

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175-225.

184 Advisory Committee on Human Radiation 

Experiments. Chapter 12: The Iodine 131 

Experiment in Alaska. Retrieved at: https://

bioethicsarchive.georgetown.edu/achre/final/

chap12_4.html

185 Ball, T.J. & Fisher, P.A. (2003). Tribal 

participatory research: mechanisms of a collaborative model. American Journal of Community 

Psychology 32(3-4), 207-216.

186 Laveaux, D., & Christopher, S. (2009). 

Contextualizing CBPR: key principles of 

CBPR meet the indigenous research context. 

Pimatisiwin 7(1), 1.

187 Sahota, P.C. (2010). Community-based 

participatory research in American Indian 

and Alaska Native communities. Retrieved 

from http://www.ncaipc.org/files/CBPR%20

Paper%20FINAL.pdf.

188 National Indian Health Board. (2015b). 

Tribal epidemiology centers. Retrieved from 

http://www.nihb.org/tribal_resources/tribal_

epidemiology.php.

189 Roberts, J., & Jones, J.D. (2004). Health 

disparities challenge public health among 

Native Americans. Northwest Public Health 

(Fall/Winter), 8-10.

190 Thomas, L.R., Donovan, D.M., Sigo, R.L., 

Austin, L., & Marlatt, G.A. (2009). The community pulling together: A tribal community-university partnership project to reduce substance 

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Substance Abuse 8(3), 283.

191 Pewewardy, C., & Hammer, P. C. (2003). 

Culturally Responsive Teaching for American 

Indian Students. ERIC Digest.

192 Hallett, D., Chandler, M.J., & Lalonde, 

C.E. (2007). Aboriginal language knowledge 

and youth suicide. Cognitive Development 22, 

392-399.

193 Whitesell, N.R., Beals, J., BigCrow, 

C., Mitchell, C.M., & Novis, D.K. (2012). 

Epidemiology and etiology of substance 

use among American Indian and Alaska 

Natives: Risk, protection, and implications 

for prevention. American Journal of Drug 

and Alcohol Abuse 38(5), 376-382. doi: 

10.3109/000952990.2012.694527.

194 Urban Indian Health Institute. (2012). 

Addressing Depression Among American Indians 

and Alaska Natives: A Literature Review. Seattle, 

WA: Urban Indian Health Institute.

195 Brown, B.G., Baldwin, J.A., & Walsh, M.L 

(2012). Putting tribal nations first: Historical 

trends, current needs, and future directions in 

substance use prevention for American Indian 

and Alaska youths. In C. Camp-Yeaky (Series 

Ed.) & S.R. Notaro (Vol. Ed.), Advances in 

Education in Diverse Communities: Research, 

Policy and Praxis. 9, pp. 3-47).

196 Brave Heart, M.Y.H. (1998). The return to 

the sacred path: Healing the historical trauma 

and historical unresolved grief response among 

the Lakota through a psychoeducational group 

intervention. Smith College Studies in Social 

Work 68(3), 288-305.

197 U.S. Department of Justice. Attorney 

General’s Advisory Committee on American 

Indian/Alaska Native Children Exposed to 

Violence: Ending Violence so Children Can 

Thrive, November 2014.

198 U.S. Department of Justice. Attorney 

General’s Advisory Committee on American 

Indian/Alaska Native Children Exposed to 

Violence: Ending Violence so Children Can 

Thrive, November 2014.

199 Walrath, C., Godoy Garraza, L., Reid, H., 

Goldston, D. B., McKeon, R., (2015). Impact of 

the Garrett Lee Smith Youth Suicide Prevention 

Program on Suicide Mortality. American 

Journal of Public Health. 105(5), pp. 986-993. 

200 Godoy Garraza, L., Walrath, C., Goldston, 

D. B., Reid, H., McKeon, R., (2015). Impact 

of the Garrett Lee Smith Memorial Suicide 

Prevention Program on Suicide Attempts 

Among Youths. JAMA Psychiatry. 72(11): pp. 

1143-9.

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 77
Appendixes

APPENDIX 1.

HIGHLIGHTS OF KEY NATIONAL TBHA INFORMATION GATHERING SESSIONS

EVENT DATE ACTIVITIES

APPROXIMATE 

PARTICIPATION

SAMHSA Tribal Technical 

Advisory Committee (TTAC) 2014 & 2015

Discussion on SAMHSA’s internal Tribal 

Behavioral Health Agenda led to discussion 

on a national TBHA

8 tribal leaders (each year)

HHS Secretary’s Tribal 

Advisory Committee 2014 & 2015

Discussion on accomplishments in health 

policy, services and resources and the need 

to continue momentum 

14 tribal leaders 

25 tribal representatives

(each year)

White House Tribal Nations 

Conference 2014 First session on mental health was held 20 tribal leaders20 audience members

HHS Regional Tribal 

Consultation – Nashville Area 2015

An overview of the concept and need for 

a Tribal Behavioral Health Agenda was 

presented

5 tribal leaders and 25 

audience members

Tribal Self-governance 

Conference Session 2015

An overview of the concept and need for 

a Tribal Behavioral Health Agenda was 

presented with input sought

35 tribal leaders and 

members

National Tribal Advisory 

Committee on Behavioral 

Health 

2015

An overview of the concept and need for 

a Tribal Behavioral Health Agenda was 

presented with input sought

7 Tribal representatives, 3 

IHS Behavioral Health staff 

and 8 audience members

Department of Health and 

Human Services Annual Tribal 

Budget Consultation Session

2015

An overview of the concept and need for 

a Tribal Behavioral Health Agenda was 

presented with input sought

35 Tribal Leaders and 30 

audience members

NIHB Board of Directors 

Meetings

March 4, 2015

An overview of the concept and need for 

a Tribal Behavioral Health Agenda was 

presented

10 Tribal leaders

15 audience members

Sept. 20, 2015

A discussion was held on the content of 

the THBA and a resolution was passed in 

unanimous support of the TBHA

11 Tribal leaders

10 audience members

Jan. 21, 2016

Board received an update on the 

development of the TBHA and a question 

and answer session was held on the content 

of the TBHA

10 Tribal leaders

20 audience members

NIHB National Tribal Public 

Health Summit April 7, 2015

A special three hour session was held where 

facilitated small groups brainstormed 

outstanding needs and potential solutions 

to behavioral health challenges in Indian 

Country

80 Tribal members, public 

health practitioners, or 

stakeholders 

78
EVENT DATE ACTIVITIES

APPROXIMATE 

PARTICIPATION

NIHB Annual Consumer 

Conference

Sept. 21, 2015

A special session was held where Tribal 

and federal leaders discussed the need for 

a TBHA, and written and verbal input was 

gathered from participants on the content 

and structure for the TBHA

120 Tribal members, Tribal 

leaders, health advocates, 

or stakeholders

Sept. 24, 2015

A world Café style input session was 

facilitated to elicit feedback on content for 

the TBHA

200 Tribal members, Tribal 

leaders, health advocates, 

or stakeholders

National Council of Urban 

Indian Health 2015 Annual 

Leadership Conference

May 21, 2015

An overview of the TBHA was provided 

and discussion held to obtain responses 

for the six topical questions related to the 

development of the TBHA. 

100 Tribal members, Urban 

Indian health leaders, 

health advocates, or 

stakeholders

SAMHSA Native American 

Youth Conference Nov. 17-19, 2014

Youth developed a positive identity for 

change in Native American communities 

and shared challenges, provided 

recommendations, and asked questions of 

federal officials

150 youth

100 adults

National Congress of 

American Indians Mid-Year 

Meeting

June 30,2015

Presented overview of the TBHA and 

facilitated a question and answer session 

during the Health Sub-committee Meeting

35 tribal leaders, tribal 

members and health 

stakeholders

National Congress of 

American Indians Annual 

Convention and Marketplace

Oct. 19, 2015

Presented overview of the TBHA and 

facilitated a question and answer session 

during the Health Sub-committee Meeting

35 Tribal leaders, Tribal 

members, health 

advocates, or stakeholders

Oct. 20, 2015

Sponsored a resolution for consideration 

and ultimately approval by Health Subcommittee and the Human Resources 

Committee

30 Tribal leaders, Tribal 

members, health 

advocates, or stakeholders

Oct. 21, 2015

Hosted a two-hour discussion group around 

behavioral health priorities and recommend 

actions

80 Tribal leaders, Tribal 

members, health 

advocates, or stakeholders

Online Comment Period Oct. 1 – Nov. 30, 

2015

An open submission portal was created 

where anybody could submit open-ended 

comments on the TBHA or any thoughts 

related to behavioral health in Indian 

Country

15 online submissions

Federal Interagency Forum Dec. 14, 2015

Federal agencies were invited to join in a 

discussion about what programs and efforts 

they currently operate that could align with 

TBHA priorities, and about how a TBHA 

could be utilized by their agencies

20 representatives from 

federal departments, 

agencies or offices

4 representatives from 

National Native American 

organizations

IHS Direct Service Tribes 

Quarterly Meeting June 2, 2016 Presented overview of the TBHA and a question and answer session

10 tribal representatives

6 audience members

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 79
APPENDIX 2. 

SELECTED LIST OF FEDERAL STRATEGIC PLANS AND DOCUMENTS — 

CORRELATIONS WITH THE NATIONAL TRIBAL BEHAVIOR HEALTH AGENDA

FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of 

Document Selected Goal(s), Objectives, and Actions Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

SAMHSA 2015-

2018

Leading 

Change 2.0: 

Advancing 

the 

Behavioral 

Health of 

the Nation

Goal 1.1: Promote Emotional Health and wellness, 

prevent or delay the onset of and complications from 

substance abuse and mental illness, and identify and 

respond to emerging behavioral health issues 

Objective 1.1.1: Prevent Substance abuse and promote 

emotional health and well-being in states, territories, 

tribes, and communities across the nation

• •

Goal 1.2: Prevent and reduce underage drinking and 

young adult problem drinking

Objective 1.2.3: Enhance cooperation and coordination 

among federal agencies and non-federal organizations 

to prevent and reduce underage drinking among youth 

and young adults

• • •

Goal 1.3: Prevent and reduce attempted suicides and 

deaths by suicide among populations at high risk • • • •

Objective 1.3.1: Promote suicide prevention as a 

core components of health care services, including 

integrated primary care services, consistent with Goal 

8 of the National Strategy for Suicide Prevention

• •

Objective1.3.2: Promote and implement effective 

clinical and professional practices and standards for 

assessing and treating those identified as high-risk 

for suicidal behaviors, especially among primary care, 

mental health, and substance abuse service providers

• •

Objective 1.3.3: Promote rapid, continued, and skilled 

follow up with individuals who have attempted suicide 

or experienced a suicidal crisis

• •

Objective 1.3.4: Increase public preparedness to 

address the warning signs for suicide and actions to 

take in response

• •

Goal 1.4: Prevent and reduce prescription drug and 

illicit opioid misuse and abuse

Objective 1.4.3: Raise awareness and bring prescription 

drug misuse and abuse prevention activities and 

education to schools, communities, parents, 

prescribers, health care professionals, and other 

patients

• • • •

1 Foundational elements: Historical and intergenerational trauma (HT); Socio-ecological Approach (SA); Prevention and Recovery (PR); Health Systems 

(HS); National awareness and visibility

2 Cross-cutting Considerations: Youth (Y); Culture (C); Identity (I); Individual self-sufficiency (S); Data (D); Tribal Leadership (L)

80
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of 

Document Selected Goal(s), Objectives, and Actions Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

Goal 2.1: Foster integration between behavioral health and 

health care, social support, and prevention systems

Objective 2.1.2: Remove financial barriers and incentivize 

effective care coordination and integrated treatment 

delivery for people with mental illness and substance abuse 

conditions (for example: Schizophrenia, bi-polar disorder, 

and substance use disorder) through ongoing collaboration 

with federal partners and other stakeholders

• •

Goal 3.1: Implement and study a trauma-informed approach

throughout health, behavioral health, and related systems

Objective 3.1.1: Integrate an understanding of trauma and 

strategies for implementing a trauma-informed approach 

across SAMHSA, interested federal agencies, and other 

public service sectors

• • •

Goal 4.1: Improve the physical and behavioral health of 

individuals with mental illness and/or substance use 

disorders and their families

Objective 4.1.2: Promote recovery-oriented service systems 

that include coordinated clinical treatment and recovery 

support services

• • •

Goal 6.1: Develop and disseminate workforce training 

and education tools and core competencies to address 

behavioral health issues

Objective 6.1.4: In collaboration with HRSA, support 

investments in training the future behavioral health 

workforce to practice in integrated care settings and 

improve care for underserved populations

•

Goal 6.4: Influence and support funding for the behavioral 

health workforce

Objective 6.4.1: Support the identification and analysis of 

pay incentives and barriers for behavioral health providers 

across settings

• • •

IHS 2011-

2015

American

Indian/

Alaska Native

National 

Behavioral

Health 

Strategic Plan

Strategic Direction I, Goal A. Mutual Tribal, Urban, and 

IHS planning and development of treatment services and 

programs.

Action I.A.4: Develop recommendations and identify 

strategies to increase behavioral health data, generate 

aggregate data, and address data ownership issues. Utilize 

national, regional, and local data resources

•

Action I.A.7: Provide ongoing specialized prevention, 

intervention, and administrative training to better address 

new, emerging challenges in behavioral health and 

substance abuse clinical and program issues

•

Strategic Direction I, Goal B: Promoting national sharing of 

prevention, treatment, and education information

Action I.B.4: Assess need for training and ongoing support 

of clinical supervisory positions in Tribal behavioral health 

programs and then collaborate with other Federal and 

Tribal resources, such as SAMHSA and research institutions, 

to promote train-the-trainer opportunities to enhance 

knowledge transfer and the application of agreed-upon

behavioral health standards.

• •

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 81
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of 

Document Selected Goal(s), Objectives, and Actions Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

Action I.B.5: Support local and regional efforts to utilize traditional AI/

AN practitioners or practices within the service delivery framework for 

behavioral health.

• •

Strategic Direction II, Goal A: Creating a common awareness of 

and supporting behavioral changes towards wellness, sobriety, and

community health

Action II.A.2: Create a website portal to identify and disseminate best

and promising practices in behavioral health

• •

Action II.A.3: Work with Tribal Technical Advisory Group to ensure 

that culture-based and tradition-based approaches are designated as

evidence-based practices for purposes of funding and reimbursement.

• • •

Action II.A.5: Support community-specific planning, readiness, and

mobilization around the prevention of suicide, violence, and substance

abuse by providing resources, collaborations, or connections to other

Federal partners.

• •

Strategic Direction II, Goal B: Increasing resiliency and protective factors

for AI/AN youth.

Action II.B.5: Involve AI/AN youth in the identification and planning of

strategies for the prevention of youth violence, substance abuse, and

suicide.

• •

Action II.B.7: Launch a system-wide collaboration between those

working in child abuse neglect prevention and those working in

behavioral health in order to coordinate services for the whole family.

• •

Strategic Direction III, Goal A: Encouraging the development and

promotion of behavioral health standards and credentials.

Action III.A.6: IHS, in consultation with Tribal and Urban leaders, will

examine the creation, development, and deployment of a nationally

funded crisis team to respond to behavioral health crises without

depleting local resources. The guidelines for declaring a state of

emergency and processes required to access emergency resources will

be made available to all communities on an ongoing basis.

• •

Strategic Direction III, Goal B: Integrating behavioral health within 

thestructure of health services.

Action III.B.4: Identify benchmarks and outcome measures to assess

whether behavioral health is being integrated into health delivery

systems. [Note: this action was shortened].

• •

Action III.B.8: In partnership with local community members and

persons served (including youth), conduct an education and awareness

campaign to inform providers, persons served, and community

members about behavioral health issues and resources.

• • •

Action III.B.9: Through local leadership, integrate behavioral health

within the larger aftercare and prevention framework of housing, law

enforcement, education, and social services.

• • •

82
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of 

Document Selected Goal(s), Objectives, and Actions Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

Strategic Direction III, Goal C: Developing a skilled and 

culturally competent workforce to meet the demand for 

services.

Action III.C.6: Seek additional funding for health career 

scholarships and web-based certification and licensure 

training specifically targeted at behavioral health 

professions, such as social work, psychology, counseling, etc. 

Change the priorities for health scholarships to emphasize 

behavioral health professionals training.

•

Action III.C.7: Implement a mentoring/internship/

preceptorship Initiative that provides recruitment of a new 

AI/AN workforce into behavioral health fields, by focusing 

resources and creating opportunities on a national and local 

level (e.g., National Behavioral Health Conference).

• •

Strategic Direction III, Goal D: Securing necessary 

reimbursement for behavioral health services.

Action III.D.6: Seek support from CMS, IHS, and SAMHSA to 

ensure that cultural, traditional, or faith-based interventions 

and practices utilized in AI/AN behavioral health programs 

are considered as evidence-based programs or practices 

for purposes of reimbursement and provide training and 

technical assistance to secure evidence-based designation.

• •

Strategic Direction III, Goal E: Sustaining interagency 

partnerships in order to support behavioral health.

Action III.E.2: Work with tribal leaders to pursue increased 

multi- agency behavioral health funding and the 

development of a multi- agency behavioral health allocation 

process, including but not limited to HHS, HUD, DOI, ED, BIA, 

BIE, and other agencies.

• •

Action III.E.4: Modify the IHS Epidemiology cooperative 

agreements to

• •

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 83
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of Document Selected Goal(s), Objectives, and Actions Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

facilitate an inter-agency approach to the collection and 

use of aggregate behavioral health data in Tribal/Urban, 

regional, and national profiles.

ACF 2015-

2016

Administration 

for Children and 

Families Strategic 

Plan

Goal One: Promote economic, health, and social wellbeing for individuals, families, and communities

1.2.1 We will support families through successful 

implementation of healthy marriage and responsible 

fatherhood programs that encourage responsible 

parenting, foster economic stability, promote 

stable relationships and healthy marriages, take into 

consideration trauma- informed care, and work to create 

positive child outcomes.

•

1.3.3 We will incentivize the development of asset-building 

programs in underserved states and territories and among 

special populations, such as Native Americans, refugees, 

and survivors of human trafficking

•

Goal Two: Promote Healthy Development and School 

Readiness for Children, Especially Those in Low-Income 

Families

2.1.5 We will promote better policies and practices 

with regard to the social-emotional and behavioral 

development of children, including reducing preschool 

expulsion, promoting universal developmental

screenings, strengthening family-program relationships, 

and implementing mental health consultations.

• •

2.3.2 We will implement and evaluate the Tribal Early 

Learning Initiative, targeted to support tribes’ efforts 

to effectively coordinate and leverage Child Care 

Development Fund, Early Head Start-Head Start, and 

Tribal Maternal, Infant, and Early Childhood Home Visiting

program funding.

•

2.4.1 We will partner with federal agencies that support 

community and economic development, environmental 

protection, and native languages in order to leverage 

existing resources and programs to maximize ACF’s 

investment in projects funded by the Administration for 

Native Americans. These partnerships will expand ANA’s 

reach into communities and make other federal resources 

more accessible to ANA grantees.

• • •

2.4.4 We will collaborate with federal partners to actively 

encourage states, tribes, and territories to promote 

interoperability, and improve access to integrated health 

care and human services.

• • • •

Goal Three: Promote Safety and Well-being of Children, 

Youth, and Families

•

84
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of 

Document Selected Goal(s), Objectives, and Actions Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

3.1.1 We will promote the use of evidence-based and 

trauma-informed practices that effectively address 

the needs of children and families and encourage 

achievement of timely permanency for children in 

the child welfare system.

3.2.1 We will support youth and young adults in 

foster care in their transition to adulthood through 

technical assistance to state and tribal agencies 

and courts, and through policies, and programs 

that effectively address varying cultural/linguistic 

and other special needs, and the development 

of independence/self-sufficiency, including an 

emphasis on building financial capability, education 

and vocational training, and permanent connections 

with responsible, caring adults.

• • • • •

3.3.4 We will establish common standards for 

ensuring that health and human service providers 

supported by ACF have the capacity to

recognize the impact of domestic violence on the 

populations they serve, consider varying cultural/

linguistic and other special needs, and respond 

effectively and safely link program participants to 

domestic violence services as appropriate.

• • •

Goal Four: Support Underserved and 

Underrepresented Populations

4.1.6 We will promote and facilitate improved tribal/

state relations and policy at the regional and state 

levels to foster improved outcomes for Native 

American children, families, and communities.

• •

Goal Five: Upgrade the Capacity of the 

Administration for Children and Families to Make a 

Difference for Families and Children

5.2.10 We will work with the Native American 

Affairs Advisory Council to develop a data 

framework through which to collect, use, and 

share data more efficiently to inform decision 

making, educate stakeholders, increase the 

impact of ACF communications, and facilitate 

stronger partnerships to effectively address the 

demonstrated needs of Native American children, 

families, and communities.

• •

OJJDP Nov 

2014

Attorney 

General’s 

Advisory 

Committee 

on American 

Indian/

Alaska Native 

Children 

Exposed to 

Violence: 

Ending 

Violence so 

Children can 

Thrive

1.6 The legislative and executive branches of the 

federal government should encourage tribal-state 

collaborations to meet the needs of

AI/AN children exposed to violence.

•

1.7 The federal government should provide training 

for AI/AN Nations and for the federal agencies 

serving AI/AN communities on the

needs of AI/AN children exposed to violence. Federal 

employees assigned to work on issues pertaining to 

AI/AN communities should be required to obtain 

training on tribal sovereignty, working with

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 85
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of Document Selected Goal(s), Objectives, and Actions 

Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

This report was

created as part of the

Defending Childhood

Initiative created by

Attorney General Eric

H. Holder, Jr. This

initiative strives to

harness resources

from across the

Department of Justice 

to:

• Prevent Children’s

exposure to violence

• Mitigate the

negative impact of

children’s exposure to 

violence when it does 

occur; and

• Develop knowledge 

and spread awareness

about children’s

exposure to violence

tribal governments, and the impact of historical 

trauma and colonization on tribal Nations within 

the first sixty days of their job assignment.

2.4 The Indian Health Service (IHS) in the 

Department of Health and Human Services 

(HHS), state public health services, and other 

state and federal agencies that provide pre- or 

postnatal services should provide culturally 

appropriate education and skills training for

parents, foster parents, and caregivers of AI/AN 

children. Agencies should work with tribes to 

culturally adapt proven therapeutic models for 

their unique tribal communities (e.g., adaptation 

of home visitation service to include local cultural 

beliefs and values).

•

2.6 The Secretary of Health and Human Services 

(HHS) should increase and support access to 

culturally appropriate behavioral health and

substance abuse prevention and treatment 

services in all AI/AN communities, especially the 

use of traditional healers and helpers identified by 

tribal communities.

• •

3.1.A The White House Native American Affairs 

Office, the U.S. Attorney General, the Secretaries 

of the Department of Interior (DOI) and Health 

and Human Services (HHS), and the heads of 

other agencies that provide funds that serve 

AI/AN children should annually consult with 

tribal governments to solicit recommendations 

on the mechanisms that would provide flexible 

funds for the assessment of local needs, and for 

the development and adaptation of promising 

practices that allow for the integration of the 

unique cultures and healing traditions of the local 

tribal community.

• •

3.1.B The White House Native American Affairs 

Office and the U.S. Attorney General should 

work with the organizations that specialize 

in treatment and services for traumatized 

children, for example, National Child Traumatic 

Stress Network, to ensure that services for AI/

AN children exposed to violence are traumainformed.

• •

3.1.C The White House Native American Affairs 

Office should coordinate the development and 

implementation of federal policy that mandates 

exposure to violence trauma screening and suicide

screening be a part of services offered to AI/AN 

children during medical, juvenile justice, and/or 

social service intakes.

• • •

3.3 The White House Native American Affairs 

Office and responsible

• • •

86
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of 

Document

Selected Goal(s), Objectives, and Actions 

Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

federal agencies should provide AI/AN youthserving organizations such as schools, Head 

Starts, daycares, foster care programs, and so

forth with the resources needed to create and 

sustain safe places where AI/AN children exposed 

to violence can obtain services. Every youthserving organization in tribal and urban Native 

communities should receive mandated traumainformed training and have trauma-informed staff 

and consultants providing school-based traumainformed treatment in bullying, suicide, and gang

prevention/intervention

3.5 The White House Native American Affairs 

Office should work with Congress and executive 

branch agencies in consultation with tribes

to develop, promote, and fund youth-based 

afterschool programs for AI/An youth. The 

programs must be culturally based and traumainformed, must partner with parents/caregivers, 

and when necessary, provide referrals to 

trauma-informed behavioral health providers. 

Where appropriate, local capacity should also be

expanded through partnerships with America’s 

volunteer organizations, for example, Americorps.

• • • •

3.6 The White House Native American Affairs 

Office and the Secretary of Health and Human 

Services (HHS) should develop and implement 

a plan to expand access to Indian Health Service 

(IHS), tribal, and urban Indian centers to provide 

behavioral health services to AI/AN children in 

schools This should include the deployment of 

behavioral health services providers to serve 

students in the school setting.

• •

NOTE: Chapter 3 following 3.6 goes on to explain 

that: “Federal agencies should work with public 

schools and Bureau of Indian Education (BIE)-

funded schools to ensure that services are offered, 

preferably in the schools, to students attending 

BIE-funded schools. School-based services

increase the availability and utilization of services 

and will increase safety in schools.”

BIE July

2014

Findings and

Recommendations

Prepared by the

Bureau of Indian

Education Study

Group Submitted 

to the Secretaries 

of the

Reform Area 4: Comprehensive Supports through 

Partnerships

In September 2013, Secretary of the Interior Sally 

Jewell and Secretary of Education Arne Duncan 

appointed the American Indian Education Study

Group to diagnose the causes of too common 

academic failure in BIE- funded schools. The 

Study Group, based largely on written comments

and feedback received during tribal consultations, 

recommends that the

• •

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 87
FEDERAL STRATEGIC PLANS/DOCUMENTS RELATIONSHIP OF STRATEGIC PLAN TO TBHA

Agency Time Name of Document Selected Goal(s), Objectives, and Actions Period

Foundational Elements1 Cross-Cutting 

Considerations2

HT SE PR HS NA Y C I S D L

Departments of the 

Interior and Education

The Study Group’s 

findings focus on five 

areas of reform:

• Highly Effective 

Teachers and Principals

• Agile

Organizational 

Environment

• Promote Educational 

Self- Determination for 

Tribal Nations

• Comprehensive 

Supports through 

Partnerships

• Budget that Supports 

Capacity- Building 

Mission

BIE focus on fostering five areas of reform.

Issues raised related to partnerships and that are 

pertinent to the TBHA include: traumas faced 

by students and families, impact of trauma on 

academic performance, depression, substance 

abuse, poor health outcomes, high unemployment, 

rampant crime, support so that students come to 

class ready to learn, leveraging local and national 

expertise, and innovative partnerships to address 

social problems. The Study Group recommended 

that BIE’s approach cut across all Federal agencies 

and their community-based programs that serve 

tribal communities to eliminate redundancy, 

disconnection, and waste of federal resources.

Select Partnership Recommendations:

• Coordinate with other Federal agencies so that 

community-based tribal grants help provide 

wraparound services to students attending BIEfunded schools.

•

• Work with Indian Health Service (IHS) to increase 

and institutionalize the practice of providing 

school-based services to ensure that students 

are ready to learn and can focus (e.g., provision 

of immunizations in time for start of school and 

counseling services)

•

88
APPENDIX 3:

TRIBAL RESOLUTIONS SUPPORTING THE NATIONAL TRIBAL 

BEHAVIORAL HEALTH AGENDA

National IndianHealth Board

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 89
National Congress of American Indians

90
Tohono O’odham Nation

NATIONAL TRIBAL BEHAVIORAL HEALTH AGENDA 91