Native Americans are facing a mental health crisis.
They are at least twice as likely to experience serious psychological distress as white, African American, Asian and Latinx people. They also face a higher risk of poverty, violence and trauma, yet they have limited access to social services and healthcare. For Native people in rural communities, healthcare access is harder to access, making the disparities even greater.
“It took generations to get to where we are, and it will take generations to recover,” says Dakotah Lane, MD. As medical director of the Lummi Tribal Health Center — and as a member of the Lummi Nation, original inhabitants of northwestern Washington — he sees the effects of healthcare inequity every day in his community.
Now, through a partnership between the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington and the Lummi Tribal Health Center, a new program is training UW psychiatry residents to deliver culturally humble telepsychiatry care.
This donor-supported program provides critical telehealth care to tribal members. And, with continued support, its founders seek to expand the program’s services to more patients in the region.
Understanding historical and generational trauma
Historical trauma, unequal treatment and race-based prejudices in patient care — both inside and outside tribal healthcare systems — are all factors that impact mental health in Native communities.
“A lot of American Indian communities are in almost a recovery period,” says Lane. “My generation is trying to process what happened to our immediate ancestors, our grandparents and great-grandparents, and trying to understand why we suffer from all of this trauma now.”
One major part of this historical trauma involves residential schools, also called boarding schools. In both the U.S. and Canada, Native American children were taken from their families and sent to live at residential schools until they turned 18. At these schools, they were forbidden to speak their native languages, made to wear Western clothes, forced to give up their traditional practices and forcibly converted to Christianity. Children were punished, often physically, for speaking a Native language. Many of their families were prevented from visiting them.
In the Pacific Northwest, there were residential schools in Tulalip, Washington; Lynden, Washington; and Salem, Oregon. Starting in the 1880s, Lummi children were sent to these and other schools in the area. Residential schools were still in operation as recently as the 1970s, well within living memory.
For generations of children, this forced separation from their families, tribes and cultural traditions had severe, lifelong effects on their personal relationships and mental health. The effects persist today as substance use problems, mental health issues, challenges with healthy parenting and many other areas.
“If you’re stressed, without a safe place, you tend to develop unhealthy habits and poor relationships with other people, including your family,” Lane says. “So they come home from the schools and have kids of their own, but they’re somewhat detached from the community and don’t really know how to appropriately raise a child or handle anger and emotions. They were taught violence in school, and now we expect them to not be violent, and that still continues.”
Another present-day trauma is a human-rights crisis known as Missing and Murdered Indigenous Women and Girls (MMIWG). For decades, Native American and Alaska Native communities have struggled with high rates of assault, abduction and murder of women and girls. A 2016 study by the National Institute of Justice found that 84.3% of American Indian and Alaska Native women have experienced violence in their lifetime, including 56.1% who have experienced sexual violence.
Providing effective and compassionate mental health care to Native communities requires a deep understanding of these and other traumas, as well as a culturally humble approach.
Care informed by culture
Lane isn’t just the medical director of the Lummi Tribal Health Center. He’s also the Lummi Nation’s first physician from its own community, having grown up on the Lummi reservation and nearby Bellingham.
As a tribal member, Lane has a deeply personal understanding of his community’s trauma — and its resilience. Many Native Americans have found strength in reconnecting to their cultural identities and traditions. He fondly recalls salmon fishing with his father and grandfather around the San Juan Islands as a child, and the deeply meaningful ceremony of receiving his Lummi name, Me-Musia.
Early on, Lane felt called to serve his people as a physician, and after medical school, he returned to the reservation in 2016 to practice family medicine at the Lummi Tribal Health Center. In 2019, he hired George “Bud” Vana, MD, as the tribal center’s psychiatrist; one of Vana’s first priorities was creating a resident training program with the UW School of Medicine.
“There’s a real interest among residents to help underserved populations,” says Vana. “We wanted to do that in a way that gave residents the cultural humility and cultural psychiatry training, while allowing the community to benefit from psychiatric access and care.”
Vana teamed up with the AIMS Center’s Jessica Whitfield, MD, MPH, a UW instructor of psychiatry and behavioral sciences, to develop a six-month integrated care rotation for two psychiatric residents per year. The residents directly provide telehealth care to clinic patients, under the supervision of Vana and Whitfield. Through the program, residents also learn about the historical and cultural context of the Lummi Nation, which fosters cultural humility in delivering mental health care.
“One of the unique things about this rotation, thanks to donor support, is how much time residents can take with patients,” Vana says. “It’s difficult to be culturally humble when you have 15 minutes to get through a questionnaire and make a plan. Longer visits give us time for cultural understanding and curiosity, and it’s been really powerful for a lot of our patients and residents.”
The residency program is part of a larger partnership between the UW School of Medicine and the Lummi Nation that was formalized in fall 2022. The partnership creates more training opportunities for medical students and trainees to learn at the Lummi Tribal Health Center.
The ultimate goal is to inspire more physicians to serve tribal communities, but there are plenty of immediate benefits for all of the participants. Native trainees can gain knowledge that they can take back to their own tribes. Non-Native trainees can learn about caring for tribal communities and cross-cultural communication. And tribal members can feel seen, heard and supported while receiving care.
“Patients here in Lummi know that psychiatric care is valuable,” says Lane. “When they’re able to access a psychiatrist in a clinic they trust, it’s a huge relief. Bringing in these residents helps more families get access to psychiatric care.”
Creating a healthy community
Currently, the tribal health center is building a new, larger medical clinic to better serve their diverse community; Lummi tribal members, Native Americans from other tribes in the region and non-Native locals all use the center’s services. Construction was originally planned for spring 2020 and was put on hold during the pandemic, but the center is expected to open in spring 2023.
The new facility will expand the health center’s ability to offer adult and pediatric primary care, dental care, physical therapy, behavioral health services, childcare and more. As the center continues to grow to meet the region’s needs, continued donor support will help the resident training program grow along with it.
When it comes to helping people heal from the generational impacts of trauma, there are no easy answers, and Lane and Vana know that finding solutions will take time and effort. But they’re not giving up.
“Our clinic is here to help create a healthy community,” Lane says. “We are picking up the pieces and starting to put them together.”
Written by Stephanie Perry | Photography: Edmund Lowe, Edmund Lowe Studios, Inc.
