Culturally Appropriate Mental Health Care to Address American Indian/Alaska Native (AI/AN) Mental Health Disparities

August 6, 2018

Sean A. Bear, BA, CADC
Co-Director, National American Indian and Alaska Native Addiction Technology Transfer Center

Originally posted  in the National Partnership for Action to End Health Disparities blog, In the Spotlight

Non-Hispanic American Indian and Native American (AI/AN) adults and children are at greater risk than all other racial groups of experiencing poor mental health outcomes and unmet medical and mental healthcare needs. For instance, suicide rates for AI/AN adults and youth are higher than the national average.

For native people, cultural differences play a crucial role in this gap as well as in the misdiagnosis. An accurate assessment is not possible without intimate knowledge of another culture; such knowledge cannot always be learned in the present educational systems, many of which do not share the same historical accounts or knowledge tribal systems have been teaching for thousands of years.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) states that understanding a culture means comprehending and applying that culture’s beliefs, ceremonial rituals, and customs. With the Native American culture, this would not be possible without the actual time and tutelage of an American Indian or First Nations Healer and Spiritual Person, who would be most qualified to provide the appropriate expertise. In order for native-serving providers to meet the standards set forth in the DSM-5, they must learn from outside of the Western medical education system.

Few mental health diagnostic tools, assessments, or treatments have been studied in AI/AN communities. For instance, few mental health treatment models apply spiritual phenomena—such as spirits, ghosts, or healing—but this is an area common within Native American tribes.

Native Americans also experience historical trauma that produces negative impacts on mental health and wellbeing and that can be passed down through generations both socially and genetically. Native Americans can experience historical loss symptoms (e.g., depression, anxiety, substance use disorders) as a result of the cross-generational transmission of trauma from historical losses (e.g., loss of land and population). Historical trauma must be taken into account in mental health assessments of native clients and patients. When considering historical trauma, we should be reminded that the Native American Religious Freedom Act was passed only in 1978, meaning that native people in the United States have only legally been able to practice our ceremonial ways for the past 40 years.

Historical trauma must be taken into account in mental health assessments of native clients and patients. When considering historical trauma, we should be reminded that the Native American Religious Freedom Act was passed only in 1978, meaning that native people in the United States have only legally been able to practice our ceremonial ways for the past 40 years. 
Discrimination also contributes to poor mental health outcomes and persists among AI/AN communities. One example is what goes on in many community stores: Native people regularly experience looks of distrust and are followed from aisle to aisle. People from other cultures treat them with disgust and contempt. This is done not only by non-natives but also by those within the tribal community who have become assimilated to the Euro-American philosophy that blood quantum and being enrolled in a tribe is a traditional practice.

Looking at mental health disparities, we must remember to consider cultural differences between patients and providers, diagnostic tools, discrimination, and historical and continued trauma. Although some of these topics are not heard by many, they are important in the holistic care that is needed for tribal communities and members throughout the country. If we all seek true peace in and among all peoples, we must look into the possible future of mankind and the planet but also into the depths of ourselves, which is where our healing begins.

For more information on culturally appropriate mental health and substance use disorder treatment for American Indian/Alaska Native populations, visit the National American Indian & Alaska Native ATTC website. 

Mark your calendars for these upcoming webinars from the National American and Alaska Native ATTC:
Clinical Evaluation: Treatment PlanningAugust 15, 2018
Presenter: Sean A. Bear I, BA, CADC, Meskwaki Tribal Nation
1:00-2:30 ET, 12:00-1:30 CT, 11:00-12:30 MT, 10:00-11:30am PT, 9:00-10:30am Alaska
Recovery MonthAugust 29, 2018
Presenter: Sean A. Bear I, BA, CADC, Meskwaki Tribal Nation
1:00-2:00 ET, 12:00-1:00 CT, 11:00-12:00 MT, 10:00-11:00am PT, 9:00-10:00am Alaska
For questions about the webinars or other programming, contact Kate Thrams:

Community Resilience: Recovering Together

July 30, 2018

Caroline Miller, MSW
Director, Wisconsin Voices for Recovery
Associate Researcher, UW-Madison Department of Family Medicine and Community Health

Rally for Recovery, State Capitol, Madison WI, September 2017

Wisconsin Voices for Recovery is actively building community resilience through its events and programming across the state. Two initiatives in particular, the ED2Recovery program and the Rally for Recovery in celebration of 2018 National Recovery Month, demonstrate the important ways that people in recovery, their friends and families, have come together to support recovering together in Wisconsin.


ED2Recovery is a program that pairs Recovery Coaches and Peer Support Specialists with individuals who have survived an opioid overdose or who have been admitted to the Emergency Department for other opioid-related issues. ED2Recovery is currently working with 22 hospitals in 17 counties to employ more than 104 certified Recovery Coaches.

The Level Up!: Coaches are the Game Changer Conference is going to be a place for the ED2Recovery Coaching network to boost their skills and enhance the support services they provide. This is a crucial element in harnessing the power and potential of recovery capital available in WI to save lives and build thriving communities.
This is a unique program nationally, as it creates a statewide network of medical providers and ED settings, peer support providers, and recovery community organizations, or RCOs.
  • As of May 2018, Recovery Coaches who are a part of the ED2Recovery network have made 526 contacts with those seeking recovery following an opioid overdose or other opioid-related admission in the Wisconsin Eds. 
  • People seeking support have spent 25,934 minutes with Recovery Coaches from the ED2Recovery program!*
*Wisconsin Voices for Recovery will  be conducting a rigorous evaluation of the program and effectiveness of peer support provided in community-based settings such as the ED. Stay tuned for more information in the coming months. 

Professional Growth of Peer Workforce 

The ED2Recovery program builds community resilience and also supports the professional growth of Wisconsin's peer workforce. This October, Helios Addiction Recovery Services is coordinating the first annual LEVEL UP Conference in Appleton, WI.  This conference will equip the Recovery Coaches and Certified Peer Support Specialists who are part of ED2Recovery with the skills they need to build a strong community of resilient peer support providers.

Rally for Recovery

Every year in September, hundreds of people gather at the State Capitol to celebrate National Recovery Month at the Wisconsin Voices for Recovery Rally for Recovery. This year, we're hosting our fifth annual event that celebrates the joys of recovery from addiction, honors those we have lost to addiction and their family members, and educates the public about the realities of addiction as a medical condition.
The 2018 Rally for Recovery is focused on encouraging social connectedness through partnerships and building a culture of resilience in order to build a stronger foundation against the opiate epidemic and the current public health crisis.  Jessica Geschke, Statewide Program Coordinator

Mark your calendars for Saturday, September 22, 11:00-2:00pm, State Capitol, Madison. Our featured speaker is spoken word artist Joseph Green.

This year's event theme is Community Resilience: Recovering Together, because we know that it is only when we join together and support each other as a community that change can happen. Change on the personal level, through hope and transformation, and change on the community level, making our families healthier, safer, and stronger.

Wisconsin Voices for Recovery is a peer-run recovery project supported by the Wisconsin Department of Health Services and the University of Wisconsin-Madison Department of Family Medicine and Community Health. For more information about ED2Recovery, Rally for Recovery, or how you can get involved, visit our website at:

Opioid Treatment and Recovery News Roundup

July 12, 2018

Maureen Fitzgerald
ATTC Network/NIATx 

Have you been taking a summer break from the news? Get caught up with five recent news and research headlines, plus a great new Road to Recovery TV episode from SAMHSA

1. Expanding primary care buprenorphine treatment could curb opioid overdose crisis
Science Daily
Research published by Drs. Sarah Wakeman and Michael Barnett describes barriers to wider use of buprenorphine treatment for opioid use disorder, and how to overcome them.

Among the most persistent barriers? Stigma.

Hear more from Dr. Wakeman and Dr. Martha Kane on Monday, July 23, during a free webinar sponsored by the Great Lakes, New England, Northwest and Pacific Southwest ATTCs in collaboration with the Western States Nodes of the Clinical Trials Network: The Massachusetts General Hospital Substance Use Disorders Initiative: A Health Systems Approach to Treating Addiction as a Chronic Disease

2. When an Iowa Family Doctor Takes On the Opioid Epidemic, New York Times 
After arriving in Marshalltown, Iowa, in July 2015, Dr. Gastala was "struck by the number of patients dependent on opioids they'd been prescribed over the years..."

3. Dental pain and Opioid Use: Latest Findings, Pew Charitable Trusts
Recent studies provide support for the American Dental Association's efforts to reduce opioid prescription rates. 

cites Recovery Oriented Systems of Care as key to addressing the opioid epidemic.

5. Jails and prisons: the unmanned front in the battle against the opioid epidemic
Stat News
"Most prisoners with opioid addictions who have their medication stopped don’t have any of it waiting at home for them after their release. Instead, they turn to the streets for illicit opioids to alleviate their cravings."

To learn more about treatment and recovery efforts for people in the criminal justice system:

Watch SAMHSA's July 2018 Road to Recovery Series TV episode: Justice Intervention: Bringing Services to Scale

And while your visiting the SAMHSA site, check out all of the great resources available  for National Recovery Month 2018!

What's Your Favorite News Source?

What news source do you turn to to stay up-to-date with the opioid crisis? Let us know in the comments section below!

Celebrate PRIDE Month: Visit the YMSM+LGBT CoE Website

June 21, 2018
Brandy Oeser, MPH
Project Director
YMSM + LGBT Center of Excellence

LGBT Pride Month is celebrated each year in the month of June to honor the 1969 Stonewall riots in Manhattan. As part of the ATTC’s recognition of LGBT Pride Month we would like to encourage you to visit the YMSM + LGBT CoE website, which features archived webinars where you can learn more about the LGBT community. Webinars are available on many topics, including Creating an LGBT Affirming Organization, Supporting Change for LGBTQ Young Adults, and Working with and for Two-Spirit Individuals. To learn more, please visit LGBT Webinar Recordings.

About the YMSM + LGBT CoE

Between September 30, 2014, and September 29, 2017, the Center of Excellence for Racial/ethnic Minority Young Men Who Have Sex with Men and other Lesbian, Gay, Bisexual, and Transgender populations (YMSM+LGBT COE) provided training and technical assistance to providers on culturally responsive prevention and treatment services to decrease rates of substance use and HIV infections among YMSM and LGBT communities. A collaborative team from the PS-ATTC, NeC-ATTC and National American Indian and Alaska Native ATTC led the COE, in partnership with the National Hispanic and Latino ATTC and Charles R. Drew University.

The YMSM+LGBT COE generated innovative curricula, developed 97 trainers and established a national training infrastructure. The YMSM+LGBT COE also hosted monthly webinars and created a website to serve as an information clearinghouse for research articles and best practices to serve YMSM and LGBT clients. The website also contains information and other resources for providers who serve YMSM and LGBT clients. 

Continuing our work   

Though funding for the COE has ended, the work has continued thanks to the dedicated and passionate trainers affiliated with the project. LGBT trainings have recently been conducted in Arizona, California, Colorado, North Carolina, New Hampshire, Pennsylvania, New York, Massachusetts, American Samoa and Bermuda! YMSM and LGBT related presentations are being conducted at conferences throughout the country. We are moving to quarterly webinars now thanks to the support of the PS-ATTC and UNR CASAT.

For more information or to request a training please email Brandy Oeser at

Is your organization observing PRIDE Month?  Tell us how in the comments section below.

How to Become a Best Place to Work for 10 Years in a Row

June 19, 2018

Maureen Fitzgerald
ATTC Network/NIATx

Horizon Health Services began in 1975 with a single location in Buffalo, NY.  Today, the agency has more than 600 employees providing a full continuum of services at more than 20 locations in three counties.

At Horizon, staff satisfaction and growth are at the heart of workforce development. 

Really—the agency trains all new staff on the Communicate with H.E.A.R.T. model, a communication model developed by the Cleveland Clinic.

"The H.E.A.R.T. (Hear, Empathize, Apologize, Respond, and Thank) model differentiates us," says Veronica Meldrum, Vice President of Employee Services. "It provides a framework for a collaborative work environment,  solving problems, and keeping the customer at top of mind in all of our day-to-day operations."

Staff Surveys 

For Meldrum, The H.E.A.R.T. model is one factor that has helped Horizon Health Services earn the distinction of being a Best Place to Work in Western New Yorkfor the 10th year in a row.

"We are as proud today as we were the first time we received the award," says Meldrum.

Another critical factor? Continually seeking staff feedback.

Benefits and Compensation Study

In addition to engaging in surveys with external vendors, Horizon also conducts internal surveys to assess employee engagement. Surveys are just one way for agency leadership to stay connected with employees and address any workforce issues. For example, information from staff surveys was key in a recent revamp of Horizon's benefits and compensation plan.

"Being named a Best Place to Work is a huge honor because it largely depends on results of anonymous surveys our employees complete," explains Meldrum.

Meldrum says that Horizon takes a creative approach to addressing the many factors that complicate staff recruitment and retention today. "We will continue to strive to improve our workplace and the work experience of our employees. Every single person at our organization, whether providing direct service or working behind the scenes, has a critical role."

ATTC Resources for Workforce Recruitment and Retention

Publications: National Workforce Study
National Workforce Report 2017: A National Qualitative Report
Vital Signs: Taking the Pulse of the Addictions Treatment Workforce

Webinar: Workforce Recruitment and Retention: A Review of Strategies
June 28, 2018, 11:00am CT

How does your organization recruit, retain, and reward your staff?  Share your strategies in the comments section below.

Help for the Opioid Crisis: STR-Technical Assistance Available to States and Territories

June 5, 2018

Swan Capris
STR-TA Project Manager

The State Targeted Response Technical Assistance (STR-TA) Consortium website ( and technical assistance (TA) portal is now live and ready to support efforts to address opioid use disorder prevention, treatment, and recovery across the country.

On February 1, 2018, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded the American Academy of Addiction Psychiatry (AAAP) and a coalition of 22 national healthcare organizations a two-year grant to provide all 50 U.S. States and 7 territories with assistance targeting the opioid crisis. The Consortium has been accepting technical assistance requests for MAT (Medication-Assisted Treatment) waiver trainings, mentorships, systems work, and peer recovery support aftercare programs.

The STR-TA Consortium is focusing on making use of evidence-based resources that have already been created and reviewed to avoid recreating the wheel or wasting resources, including those from: AAAP/Providers Clinical Support System, ATTC Network,  Center for Social Innovation, CADCA, Boston Children’s Hospital on SUD, Columbia University, and Research Triangle International, also funded by SAMHSA.

The goal of STR-TA is to be responsive to meet community’s needs by providing training and TA on evidence-based practices in the prevention, treatment, and recovery of opioid use disorders through local experts. This effort has been designed as a tailored, locally driven approach to TA delivery.

We urge you to share this flyer with your colleagues and community. The STR-TA Consortium and a team of TA consultants stand ready to assist STR grantees and others in prevention, treatment, and recovery as they relate to opioid use disorders.

Together we CAN make a difference!

About AAAP:

We’re an organization focused on helping those with substance use disorders and mental disorders by educating, influencing and encouraging excellence in practice, policy and prevention for the field of Addiction Psychiatry and beyond through our partnerships with psychiatrists, faculty, medical students, residents and fellows, non-psychiatrists and related health professionals.

Funding for this initiative was made possible (in part) by grant no. 1H79TI080816-01 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

GetNaloxoneNow: Everything You Need to Know to Save a Life

May 30, 2018

Earlier this year, Dr. Jerome Adams, the Surgeon General of the United States, issued the following  advisory on naloxone and opioid overdose

I, Surgeon General of the United States Public Health Service, VADM Jerome Adams, am emphasizing the importance of the overdose-reversing drug naloxone. For Patient currently taking high doses of opioids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have opioid use disorder, and community members who come into contact with people at risk for opioid overdose, knowing how to use naloxone and keeping it within reach can save a life.

Janie Simmons, EDD, Developer of GetNaloxoneNow
One way that you can be prepared, get naloxone, and save a life is with the online resource, GetNaloxoneNow.  

We posed a few questions about GetNaloxoneNow to Janie Simmons, EDD, principal investigator at NDRI, and one of the developers of the product.

As you'll see from her answers that follow, GetNaloxoneNow is a versatile product that provides rapid training for professionals as well as laypeople.

What is is a novel website (operating out of NDRI-USA and NDRI, Inc.) which houses two overdose prevention, recognition and response trainings; one for laypeople and the other for professional first responders (police officers, firefighters and EMTs). The training for laypeople, which we call the Bystander training, takes approximately 20 minutes while the training for professional first responders takes about 40 minutes.

Each training was put together by an experienced team of overdose specialists (MDs, prevention researchers, curriculum designers and experts with experience training first responders) as well as top-notch graphic designers, animators and professional voice narrators with funding from the National Institutes of Health/National Institute of Drug Abuse (1R43DA029358-01A1 and 1R43DA033746-01). Both trainings were modeled after best-practice models used in Massachusetts and New York and were developed in accordance with theories of multimedia learning to enhance retention.

Anyone with a computer, notebook, tablet or smartphone can access the trainings from work or home. The website also houses numerous links to relevant articles and other online sites supporting overdose education and naloxone dissemination, as well as articles and informational sites on effective drug treatment, harm reduction, and other proven strategies to address the epidemic. In addition, there are links for support for family members and additional info (i.e. on fentanyl risks) for professional first responders. A certificate of completion is provided to those who pass two interactive quizzes and a post-test administered online at the end of the 40-minute training. is supported by the GetNaloxoneNow Facebook page and the #GetNaloxoneNow twitter account. New information (news, articles, studies, reports, commentary) are provided almost daily on these sites.

How many people have been trained through 

As of May 29th, over 70,000 people have taken the trainings since they went online on August 31st, International Overdose Day, in 2014. Currently, an average of 100 individuals register for the trainings (approx. 65 laypeople and approx. 35 first responders) every day.

Is there a cost for the training? 

The trainings are free and we are committed to providing them at no cost to individuals. However, we need to be able to sustain this life-saving project so, beginning in early June, we will be asking $10 for Certificates of Completion. We have found that many organizations, including for-profit and non-profit organizations, schools, universities, drug-treatment programs, and police and fire departments require their staff or students to provide Certificates as proof of completion. We support this practice, of course, but we will start to request a small fee.

The Bystander training also carries one Continuing Education CASAC credit. These credits are required in NY State, and there are reciprocity agreements in place for 47 other states and territories, as well as the US military, to honor these credits for continuing professional education in the field of substance use/misuse. We hope to provide CE credits for other professional groups in the future.

How can states use 

We have a special subscription service for states. States that subscribe receive monthly registration data. For example, we share how many people register for the training, demographic data, where they get on the site (by zipcode) and a visual state-wide map, as well as data on how they answer a series of questions (Have you overdosed; Have you witnessed an overdose; Why you are taking the training (for work, for a family member, etc.).

For First Responders, we also ask if they carry naloxone; if not, if they'd like to carry it; and if they have witnessed or intervened in overdose emergencies. We work with state and/or local DOH representatives to target particular areas of the state or particular demographics with social media campaigns advertising We also either provide a unique page for each state on our website that is made visible and accessible to anyone registering for the training from that state (recognized by zipcode) or we lead the trainee to a web page designated by the state (usually the overdose page of the state DOH) once they successfully complete the training in order to find out more information about overdose and naloxone in their state, and where to obtain naloxone.

What kind of feedback have you received from people who have completed the training? 

Feedback has been overwhelmingly positive. My colleagues and I evaluated both trainings with funding awarded to us through the Center for Drug Use and HIV Research (CDUHR) at New York University (Grant # P30 DA011041). These evaluations assessed the impact of the training on self-reported confidence, knowledge and skills to intervene successfully in an opioid-related overdose emergency among a sub-sample of laypeople and professional first responders and assessed satisfaction with the trainings. Analysis of the post-training surveys indicated high satisfaction with content, format and mode of delivery, and high satisfaction with items related to confidence and overdose reversal preparedness. The study demonstrated the feasibility and preliminary acceptability of the trainings as well as suitability for rapid, cost-effective dissemination. 

Our findings were published in Drug and Alcohol Dependence (
and Substance Use and Misuse (

We have also translated the Bystander training in Spanish and plan to have that online within a few weeks (if not sooner).

Do you have an additional question about Post it in the comments section below: