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Culture-responsive care addresses mental health disparities in tribal communities

Alicia Freeman, a Mental Health First Aid Coordinator at the UNC School of Social Work, stands outside of the Tate-Turner-Kuralt Building in Chapel Hill, N.C. on Feb. 05, 2024. Freeman is working on integrating Youth Mental Health First Aid in Tribal Communities.

This article is part of the Mental Health Collaborative, a project completed by nine North Carolina college newsrooms to cover mental health issues in their communities. To read more stories about mental health, explore the interactive project developed specifically for this collaborative.

Carolina Indian Circle hosts healing circles once or twice every semester, giving Native American students a medium to discuss tragedies or triumphs, academics or relationships — or anything that comes to mind.

Alicia Freeman,  the Mental Health First Aid program manager at the UNC School of Social Work, leads the discussion. She  said culturally relevant practices like healing circles are just one aspect of a holistic approach to mental health care for Native Americans.

Culturally relevant practices take into account cultural stressors, which are unique to Native American experiences, Anna Kawennison Fetter, a postdoctoral fellow in the UNC Department of Psychology and Neuroscience and a member of the Saint Regis Mohawk Tribe in New York, said.

Cultural stressors in Native American communities can look like discrimination, historical grief or trauma and lack of visibility in spaces like universities, Fetter said. Mental health professionals familiar with local tribes and their history are able to provide Native American clients with more conscious, nuanced care, she said.

“Can they work with clients in a manner that's congruent with the client's worldview and perspective?” she said. “Can they have a conversation about what type of help is most supportive to the client?”

She said Native American students at UNC have advocated for culture-responsive therapy services, though it has yet to be supported institutionally, making Fetter’s independent counseling and Freeman’s healing circles some of the few culturally relevant practices available on campus.

Freeman grew up in a rural area in Columbus County, in one of the communities of the Waccamaw Siouan Tribe of North Carolina.

Despite being a state-recognized tribe, its rural location rendered mental health resources few and far between, and Freeman said undiagnosed and untreated mental health and substance use disorders were not uncommon.

Native American people across North Carolina and the United States experience disproportionately high rates of mental illness, suicide and substance use disorders, according to the Indian Health Service. 

Freeman said that although mental health support is becoming increasingly accessible, the remaining disparity has prompted questions about the shortcomings of mental health access among Native American tribes in North Carolina. 

“A lot of tribal communities in North Carolina are very rural areas,” she said. “And so they have to generally drive probably at least 30 minutes or more to access any type of health care.”

A long commute, paired with a lack of internet access, rules out both in-person and telehealth care options for many. Only 57 percent of Native American households in North Carolina had access to high-speed internet in 2022, the lowest proportion among any racial subgroup in the state, according to the N.C. Department of Information Technology.

Another obstacle for the Waccamaw Siouan Tribe lies within the community itself.

The stigma surrounding mental health within the tribe is a pervasive one that has defined the approach of entire generations to mental health care. Freeman said older members of the tribe often believe poor mental health can be treated through prayer, while others believe mental health is best left undiscussed.

In an effort to break this stigma, several mental health professionals are emphasizing the importance of youth mental health care in Native American communities, Freeman said. 

Yolanda Saunooke, a behavior change specialist for Cherokee Choices and member of the Eastern Band of Cherokee Indians, said youth programming is a priority. While Cherokee Choices has been able to recruit temporary mental health professionals for youth programs, getting them to stay long-term with rural tribes has been a challenge. 

“Everywhere is having an issue [with] having people that are able to come and stay for the long haul, and that’s mainly for our kids,” she said. “We're trying to help figure out a lot of different programs to help our youth.”

Cherokee Choices is a program developed to increase education about preventing chronic diseases, which disproportionately impact members of the EBCI, through holistic approaches that include historical grief counseling, Cherokee culture classes and physical health education. 

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Freeman also said her approach values physical, mental and spiritual well-being to the same degree. Though her training in Mental Health First Aid is primarily to provide support in a crisis situation, she said she would like to see more proactive, preventative care for mental health. 

“We're going to go to a doctor annually, hopefully, and get the physical checkup and the regular blood work and everything,” she said. “So why don't we think to do that with our mental health?”


@dthlifestyle |

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The Daily Tar Heel's Collaborative Mental Health Edition