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Honoring Traditions: Integrating Cultural Humility ...
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Welcome to the American Psychiatrics Lookin' Beyond summer webinar series on maternal mental health. This evening, you're joining us for Honoring Traditions, Integrating Cultural Humility into Mental Health Care for American Indian and Alaska Native Birthing Persons. This series presents a valuable opportunity to explore approaches to addressing mental health inequities through an interdisciplinary lens. My name is Dr. Gabriel Contreras, and I'm the Managing Director of the Division of Diversity and Health Equity here at the APA. Before we begin, I would like to respectfully acknowledge the American Psychiatric Association headquarters that sits on occupied territory and ancestral lands of the Naukauk Tank, Piscataway, and the Pamunkey peoples. We honor and pay respects to their elders, past and present. Please take a moment to reflect on the many legacies of violence, displacement, migration, and settlement that brought us together this evening. Thank you. It's my honor today to introduce our moderator, who is also one of our Board of Trustees members, Dr. Mary Hasbaugh Russell. Dr. Russell is a distinguished life member of the APA, practicing in Santa Fe, New Mexico. At the Santa Fe Indian Health Center. Dr. Russell is Navajo and grew up in the Navajo Nation and is the first Navajo woman psychiatrist to devote 25 years to working with the Indian Health Service after receiving her medical degree at the University of Minnesota and returning to the Southwest to complete her residency in psychiatry at the University of New Mexico. That makes me very proud being from Arizona, being her neighbor. She received an APA NIMH fellowship during her residency and created the Steering Committee on Native American Psychiatry, which provided educational and cultural retreats and presentations for residents and faculty on the Navajo Nation. Included in her work with indigenous peoples and professional collaborations, she worked with Navajo medicine men and women to provide cultural orientation for behavioral health staff and the Indian Health Services clinics. She has worked in and she was the lead facilitator to the indigenous cultural competency course for the APA. She presented on the panel discussing missing and murdered indigenous women at the United States, at the United Nations Commission on the Status of Women in March of 2016 and has provided presentations on indigenous knowledge and climate change and wrote a chapter in the book Groundswell Indigenous Knowledge and a Call to Action for Climate Change, edited by her husband, Dr. Joel Neidhardt and daughter artist, Nicole Neidhardt. Her chapters on essential elements of change, focusing on living with two worlds, indigenous and Western cultures in the climate crisis. She is the past chair of the APA Assembly Committee of Minority and Underrepresented Psychiatrists and representative for the Caucus of American Indian, Alaskan Native and Native Hawaiian Psychiatrists. She currently is the Area 7 trustee for the APA Board of Trustees. She co-chaired the APA Board of Trustees Structural Races and Accountability Committee from 2021 to 2022. She continues to be committed to representing diversity and belonging within the APA. And with that, I will pass the virtual microphone to Dr. Russell and thank you so much for being with us this evening. Thank you, Gabriel. I'm really happy to be here in this space with you all today. And I wanted to offer a welcome to this wonderful opportunity to hear our speakers today share their knowledge on integrating cultural humility into mental health care for indigenous peoples. First, I'd like to start off with my own introduction, which will ground me. I am the daughter of the late Bob and Ruth Russell, who were very instrumental in bringing higher education to the Navajo Nation and to many tribal communities because they started the first tribally run community college. And so with that introduction, it does ground me, grounds me in a relationship with you all by connecting me closely to my ancestors as well as other relatives I have established relationships with you all here today. And I would also like to acknowledge where I am situated today. I normally am in the homelands of the Tewa-Tusuke people, but today I am in Montana, just right here on the shoreline of Cooper's Lake. So this is homelands to the Blackfeet, the Flathead Salish, and other indigenous groups here. For me, it's really important, as Gabriel mentioned, that the people who are living here present day, the indigenous peoples, with their ancestors loved and cared for these lands for centuries, because within these lands have come their languages, cultures, ceremonies, values, medicines, and laws. So I am honored to be a guest on this territory. And as a guest on these unseated indigenous lands, it is my responsibility to respect and care for these lands. And as you acknowledge the indigenous territories where you are situated on, wherever you come from, recognize the disruption and displacement of indigenous knowledges, lands, peoples, culture, and ceremony. So take responsibility to be a good ally and carry yourself in a good way on these lands you live, work, and play on. So to set the stage with these esteemed colleagues that we have here today, and I will introduce them one by one as they come on, but I wanted to provide a brief background and historical overview of the indigenous peoples. And American Indian, Alaska Native, Native Hawaiian, and indigenous are terms that I will use interchangeably today, but it is inclusive of indigenous peoples within Turtle Island, Hawaii, and Alaska. And so as psychiatrists, to provide some background, we know that as psychiatrists and mental health professionals, mental health issues are the most common complication during the perinatal period. Indigenous women suffer higher rates of postpartum depression than the rest of the population, but they are underrepresented in the current data for various reasons, such as mistrust of the Western medical system, often feeling traditional birthing practices are ignored, and the birthing experiences has often been centered on Western medical models. It is well known that for indigenous peoples, having cultural ties is a protective factor against mental health issues. Indigenous peoples have different languages, of course, and we have hundreds of languages here on Turtle Island, and different cultural backgrounds, ceremonial practices, so we don't really want to lump ourselves into one category, but when speaking about this particular topic, there are trends that seem to impact indigenous peoples in certain ways. Indigenous cultural strengths include traditional family and kinship roles, connection to one's own community, connection to cultural practices, and language knowledge and revitalization of languages. But in terms of a historical background that it is important for you all to understand, the contact and colonization of indigenous peoples over hundreds of years have profoundly affected their family traditional kinship systems, identities, cultures, and gender roles within their own tribal groups, as well as the disruption of not being able to live on the traditional homelands and their sacred areas. The domination and traumatic abuse of indigenous women, two-spirit families has been pervasive and reflected in the disproportionately high rates of interpersonal violence, murder, sexual assaults, and the missing and murdered indigenous women and relatives epidemic. U.S. government policies perpetuated racism and ongoing injustices with the government boarding school experience, and in Canada, the residential school system. The intention was cultural genocide, as was stated in the Truth and Reconciliation Commission's final report in Canada. Indigenous families were torn apart with children forcibly removed from their homes and not able to return home often from the age of five to 13, thereby, they lost their connections to their families, cultures, lands, languages, and were often victimized and abused, and in many cases, experimented in some of the medical settings that were nearby. Many indigenous women in Canada and the United States were forced to be sterilized against their will up until recent years. This historical trauma and ongoing racism and inequities is the setting in which we are now reclaiming our traditional family roles and value systems and cultural practices and ceremonies, including traditional birthing practices. Our resilience is that we are still here. Our ancestors carried us to our present-day world. It will be an honor now to hear the voices of our speakers' experiences on this vital topic of mental health care for indigenous birthing persons and recentering these indigenous birthing experiences. But to center yourself, to engage in cultural humility today actively, center yourselves within the indigenous knowledges you are learning by looking through the two-eyed scene lens, which Albert Marshall, Mi'kmaq elder, created. Two-eyed scene is looking through one eye, seeing the strengths of Western ways of knowing, and with your other eye, see the strengths of indigenous ways of knowing. Each stands alone and have valuable contributions in their own ways. So I will go ahead and introduce our first speaker, who is Amy Stiff-Arm. And Amy, I am bringing up your bio, and I'm really happy to introduce you here today. Dr. Stiff-Arm is a member of the Ani White Clay Tribe of the Fort Belknap Indian Community. She also is a descendant of the Chippewa Cree and Blackfeet. In 2023, Amy earned a PhD in indigenous health at the University of North Dakota, where she focused on perinatal mental health for indigenous mothers and birth givers. She is the director of the Native American Initiatives Program at Healthy Mothers, Healthy Babies Montana. And so I'll turn it over to you, Amy. Thank you. Thank you, Dr. Russell. It's an honor to be here talking to you all about cultural humility, because that's something that is a value that I feel like has been missing a lot in Western health care systems and education. And so when we're talking about humility and working with indigenous people, it's really missing that, you know, kind of taking away that paternalistic view of how in the past how historically we work with tribal communities or other marginalized groups or other communities that aren't ours, especially when we're thinking of research and Western medicine. So I'm really excited to talk to you all about a project that I did with the organization that I work for now, Healthy Mothers, Healthy Babies Montana, when I was in graduate school. I was asked by Healthy Mothers, Healthy Babies to help lead a project where they were working on a statewide online resource guide for maternal mental health, and they wanted to make sure that the project was indigenous-led. So they knew a little bit about the work that I was doing in school, and they knew I was Native from Montana. I had lived experience, and so they asked me if I would help them kind of engage tribal communities, and really what we were doing is we wanted to make sure that what we were doing, we were doing for the tribes. So what we were doing for the counties is we just had this list, and we were collecting all the information from various sources about who the pediatricians were and where their office were located, where the therapists were, where the substance use treatment centers were, all of this information that would be helpful for, especially in Montana, we have to travel so far, especially Native women for perinatal health care, we have to travel 24.2 miles further than white women to receive that care. And so we're leaving our communities, and not just for perinatal health care, for a lot of appointments that Indian Health Service may not offer, and just the rurality of the state too, for smaller communities that aren't on the reservation or non-Native, we're still traveling to the bigger towns where there are services, and then when it comes time for their provider to make a referral or help them continue care back in their home community, it's hard to remember. They don't know what is happening 70, 100 miles away. So this resource guide was really meant to help mothers, birthing peoples, babies, and families when they're leaving their community to access care and come back. So when I took on the tribal community aspect of this, it was during COVID. And so it was a lot of the programs that usually were doing maternal health work were now focusing on COVID efforts, whether that be mass testing events, or just taking care of people when they're sick and dropping off medicine, tracking all of that. So I was really, I kind of approached this more of a way of like, I didn't want to interfere with their business and what was really important. I used my connections, my family, and people I knew in Montana to get resource guides that maybe they had made for their community, looking up things on the internet to try to kind of fill out these different assets. And what I realized along the way, and when we were like wrapping up, I was like, because of what I was learning in school, I said, this is, we did this wrong. I did this wrong. I think that we should have included the tribes more along the way. Like, I know they're busy, but that's not my decision to make for them. We should have still reached out and attempted to like host meetings. And I told them, it's not too late though, you know, you can go back, you can show them the data that I collected and, you know, just show them and then get their input, get their feedback. And they were like, great, can you lead that for us? And so I guess I kind of talked my way into another contract. But what was important about that is when we're only looking at service categories that are relevant to counties and Western medicine, we're missing the strengths that are with, that are found within our communities and our culture. So just like what was mentioned before, with all the historical trauma and all the impacts of colonization, how our ancestors survived and how we're here today and making changes and preserving our culture and getting education. That is because of the strengths within our culture. And that was a big part of our education at UND was we're not only going to focus on these disparities anymore. We know that's all everybody talks about is how bad it is. We know those things, but we want to start talking about solutions. And there's more and more research coming out about the power of indigenous culture, especially when you're talking about health promotion and whatnot. So what kind of came about from talking to the different communities was that the resource guide as it was, didn't have a space to create, wasn't space to list the strengths of indigenous culture. So after a few meetings, we had to go back to our web page developer and say, Hey, we need to add a completely new category here. And it was a lot of work. And it kind of was almost like, should we even do this? And it was like, we have to do this. We have to do this because we have to, you know, recognize tribal sovereignty and the right to self determine. And they're telling us the, this is our strengths. These are our assets. So we created a native cultural connection category where communities could list things like their cultural preservation program, or maybe their parent language classes. When I was a young, first time mother, I benefited a lot when I lived on the Flathead Indian Reservation in Montana, from parent language classes, and also powwow dance classes for kids, it was a really good time to connect and teach our kids about our, the different cultures and just talk stories, share space with elders, share a meal together. So things like that, we wanted to give communities, we wanted to make sure that all the assets, not just Western medicine. So just like Dr. Russell said, with that two eyed seeing, we're not saying like, don't go to a therapist, we're saying that, you know, we should have access to all modalities of healing, like that's our, that's our right as indigenous people to be able to access that type of health and healing that is in alignment with our culture. So that was a really great project. And it ultimately led me to coming to Healthy Mothers Healthy Babies and starting the Native American initiatives. And now I get to really continue those relationships that were started project. I also do training, I talk, I do cultural safety trainings, which I feel like is kind of it's similar to cultural humility, right? Like humility is really that commitment to self evaluating and understanding that there's always room to learn about other people, other people's culture, or just the way the world is. And then cultural safety is also about addressing those power dynamics that come into play when we're talking about settler colonialism and the impacts on healthcare systems and whatnot. So part of that rebuilding trust here in Montana is helping non native providers understand, you know, those policies that were not taught about, and how those impact health today, like it's not ancient history, there are still impacts today. And really giving creating the space where I'm taking the patient could take that power back and say, you know, I felt safe in this clinical interaction. So that's a that's a big part of the work I do through Native American initiatives and really working since we have to travel from our reservations to receive perinatal healthcare, making sure that those perinatal healthcare providers are aware of the unique needs of indigenous families in Montana. So thank you for your time. And I'm happy to take questions at the end. Thank you, Dr. Stiff. I'm really appreciative of what you've shared with us today. I'd like to also hear from Anna Red Fox, she will be next up. And Anna Red Fox is a tribal member of the Shinnecock Nation of South Hampton, New York. She's a full spectrum indigenous birth worker, and Executive Director of East End Birth Network, Incorporated, and an indigenous doula representative on Suffolk on a maternal morbidity and mortality task force. Go ahead. Thank you. Good evening, everyone. I just wanted to thank you all for having me here. And I am honored to just share a little bit about my journey and becoming a birth worker and working within my community. It has absolutely been a challenge. I had a traumatic birth experience in 2012. In 2016, when I was a young, pregnant mom, I was partnerless, and I did not have access to education or tools, as well as resources, or someone that I could just go and talk to. I knew nothing about midwives. I knew nothing about doulas. All I knew was that I wanted to have a home birth, and I was denied that because it was deemed that it would be safer for me to give birth in the hospital. So in 2016, I had a traumatic birth. And that fueled me about two and a half years later to apply to a full spectrum indigenous doula training. It was 1,200 miles away from my homelands in New York, but I crowd-fundraised, and I was able to travel to Winnipeg, Manitoba in Canada, and I attended a 40-hour full-spectrum indigenous doula training by way of Zigitwin. They are an indigenous-owned and operated doula training organization, and I was one of maybe 14 to 16 other women and birthing people who were accepted in this training. So my goal was to travel to this training and gather all of this knowledge, and because my community is so far removed from birth and body teachings, it's caused me to spend a lot of time over the past five years just reclaiming and rebuilding and re-teaching to other people here what was taken from us. And so as a birth worker, I believe it's my responsibility to educate and share resources and tools and awareness and support, but more so my voice on behalf of indigenous people's maternal and maternal mental health. I myself have two children. They have fueled and confirmed my work as a doula. My first birth, as I mentioned, was in a local hospital, and it resulted in unknown birth trauma, which lingered for five years after giving birth. I was restricted to the hospital bed in distress, and it also caused my baby distress, and immediately after I gave birth, I hemorrhaged, but I was saved by a quick-thinking and skilled doctor. I had support of friends and family, but as I mentioned, there wasn't too much support on the end of the doctors in hearing and listening to my concerns or my wishes and desires for this birth. So in 2021 and 2022, I connected with Postpartum Resource Center of New York, and I was able to bring a six-day intensive training to our nation that would educate not only myself and other doulas, but all of the tribal departments that we have, including health services and our council of trustees who are leaders, and the preschool that we have here on the reservation, so that we have more awareness about maternal mental health specifically, because that's something that is kind of seen as a taboo in my community, so we don't really discuss it too much. After this intense training, I came to understand that I suffered with postpartum depression and anxiety with my firstborn, and I also learned that I had PTSD from birth trauma. In 2021, I was able to have a beautiful birth on my maternal grandmother's lands on the Shinnecock Territory. I had a birth lodge that was built by my partner and his friend, and we had firekeepers and singers and traditional midwife and a Shinnecock doula and community that were there. So through my work, I was able to, as I mentioned, reclaim all of these teachings that have been so far removed from us and kind of just slowly reintegrate them back into our community. My community's health care services do not specifically provide maternal health care, other than your basic services like your pap smears, STD testing, and pregnancy confirmation. We're often given referrals to be seen amongst outside providers that are off territory, and we also do not have resources or services that will really connect you to maternal mental health care providers. And with that said, I've kind of just tried to focus my work on the return of ancestral teachings and culture and language and ceremony and community. Here, I have attended five births to date, and the very first home birth that I attended was in April of this year, and it was on territory. So with the work that I've been able to rebuild for us over these past five years that has dedicated to creating this space for birth to be brought back to the people and to the land. I will accept any questions at the end, but I will just leave off with that. Historically, birth has been viewed in many cultures around the world as ceremony and community events, not medical events, and colonization and westernized medicine has greatly impacted birth and also our lactation and postpartum support and recovery. I, for one, can speak to the distress and safeness that I felt in both of my birth spaces, and they've impacted my healing and postpartum journeys as well. And I think that it's also important to make sure that we are giving birthing people and their families the proper resources and tools that they can use to connect all of the dots and give them these birth experiences that they really do desire and giving them that comfortable space and that sacredness of this journey that they're embarking on. And I think it's also so important in the postpartum period, we really don't think about the impact and the vulnerability that we're feeling. And I think that it's just so important. And one of the ways that we can really combat these tragedies that we've faced and the impacts that they've taken on us are by returning community to birth. So thank you all for having me here today. So touching, Anna. And I really appreciate you sharing your personal experiences, even though some of that has been traumatic, but also just coming to terms with how you're integrating your traditional Indigenous knowledges and really recreating the sacred journey again with our birthing experience. So I'd like to now turn to a friend of mine, Dr. Ted Mala. We have known each other for quite a long time through the Association of American Indian Physicians. Dr. Ted Mala is a physician and Director of Tribal Relations and is retired at the Alaska Native Medical Center in Anchorage, Alaska. He received his MD from the Autonomous University of Guadalajara in 1976 and an MPH from Harvard University in 1980. In 1990, he became the first Alaska Native male physician, as well as first Native Commissioner of Health and Social Services. Also, as the first Secretary General of the International Union of Circumpolar Health, he worked extensively in the circumpolar countries, which resulted in his founding of the Circumpolar Health Institute at the University of Alaska in Anchorage. During that time, he was awarded an NIH Fogarty USSR Fellowship to work in the Siberian branch of the Academy of Medical Sciences, and no bus first. And I don't think I said that right, but in 2001, Dr. Mala was elected President of the Association of American Indian Physicians, and in 2008, he was honored as Indian Physician of the Year. Dr. Mala was also recently inducted into the Royal Order of Kima Mahea in Hawaii and holds the rank of Honorary Ali'i. He has two children and is married to Dr. Marjorie Mala Mau, who is a Native Hawaiian from Honolulu. Dr. Mala, take it over. Thank you. Thank you, Mary. Well, I was thinking about everyone's backgrounds and how my life has not followed any pattern at all. My father died when I was six years old, and my mother died when I was seven. And after that, I was put in boarding school for seven years. So that was quite an interesting start to my life. It was a boarding school that was military, Irish, and Catholic. It was quite a combination. And we were taught to be good Americans, and that's what life was like in the 1950s. Since then, a lot has happened. I'm from the village of Buckland, Alaska, which is up in the Arctic. Our regional hospital is 100 miles away, and our consulting hospital is over 500 miles away. So there were a lot of things that all of us learned that we had to do for ourselves and not really rely on government very much. And one of the major solutions for Alaska Natives are something called traditional healers. Traditional healing has been around. Western medicine's been around a couple hundred years. Traditional healing has been around 10,000 years. So as you could see, we have a long history of not only birthing people, but taking care of them to the best of our ability, and somehow getting people through whatever they needed to get through after all is taken into consideration. If you're interested in traditional healing, I want to mention this before I forget. The National Library of Medicine, which is part of the National Institutes of Health, has done an incredible job of defining and interviewing traditional healers, American Indians, Alaska Natives, and Native Hawaiians. And if you Google something called Native Voices and Healing Ways, you will actually be able to hear from the healers themselves, talking about what traditional healing is to them. I've been the director of traditional healing at the Alaska Native Medical Center for over 13 years. And once we, Alaska Native people, took over our own healthcare in the hospital, one of the first things we did was to open an office of traditional healing. And we hire traditional healers who work in the physical as well as mental areas. We find that a lot of Native people really prefer to go to traditional healing because of the stigma sometimes of going to mental health. We've worked very, very closely with mental health. We have rounds with them, and we discuss different problems and cases with them. And we're kind of the backdoor to mental health at our hospital. We find that a lot of people are less threatened by traditional healing. We have all kinds of patients that come to us from all over the state. Some are here with domestic violence, with alcoholism, with suicide attempts, with problems with having a child. Every single thing you can think of comes through our door. And what we do is try to connect people to different resources. And we welcome them in a Native traditional way. We bring them in, we give them tea that we grow in our own traditional healing garden. We sit down, we share fish, we share seal oil, whatever it is. And we kind of diffuse all the things that they come in with and begin to talk to our healers, some of which are grandmothers, and very non-threatening in a very, very good way. There are lots of things to consider. We've already talked about historical trauma, and we know all those things that happen. The question is, how do we walk in two worlds today, the Native world and the modern world, with one spirit? It's a bit more complicated being Native in the modern world. And so what we try to do is introduce ways of coping and dealing with the world today, and yet having a Native spirit. That's really important because we carry with us so many genes of our ancestors. And there are not a lot of role models, especially when I grew up, there were none that would cope with the modern world. We learned to do subsistence hunting and fishing and living, but dealing with the modern world was a whole different area. It's all of a sudden where we used to be considered good hunters from working in subsistence areas, all of a sudden it changed to how much money do you have? Do you have a job? And in our village, there are precious few jobs, maybe the school teacher, maybe the tribal council, maybe the mayor, not many ways to make money. There are a lot of questions and a lot of things people need to know before we deal with people's lives. And in that, and the beginning of wisdom, in my opinion, are seminars like this that you're listening to. But be sure to look further and go deeper, especially with the National Institutes of Health, and look at the work that they've done trying to define traditional medicine in a world of very modern medicine. And basically healers need to know that. We say that everyone is a healer. Everyone has the ability to be a healer. We're born with that. And a lot of people and problems are sent into our lives, and we have to learn how to deal with them. And this is the beginning of wisdom, is acknowledging that there are two worlds and not everything works for everyone. And there are solutions everywhere that need to be taken into consideration. Thank you. Thank you, Dr. Mala. I really appreciate your words. And I know that you've worked all your career in this area. And so that's been really important. I'd like to now have our final speaker, Nima Sheth, participate for us in her, and with her knowledge. And I'd like to introduce her here. Dr. Sheth is the Senior Medical Advisor, Associate Administrator for Women's Services, Chair of the Advisory Committee for Women's Services, Center for Mental Health Services. She is a psychiatrist by training and has a strong public health background. Prior to her arrival at SAMHSA, she worked at Georgetown University Hospital as Assistant Professor of Clinical Psychiatry. And during her time there, she served as clinician, researcher, and educator, primarily focusing her efforts on improving care of the critically mentally ill and highly traumatized populations, both nationally and internationally. And so that we can hear her words, I will shorten up my introduction of her, and she can share more about herself as well. But she has had extensive experience in working in interdisciplinary teams to solve the complex mental health problems that lie at the nexus of clinical, administrative, and policy issues, as well as advising on clinical considerations and overseeing efforts to increase access to quality mental health care for vulnerable populations. Dr. Sheth, thank you. Thank you so much, Mary. I have a couple of slides to share, so we'll just pull those up here. So today I'd like to share with you all a little bit about the maternal, the National Strategy to Improve Maternal Mental Health. And it is about the US population writ large, but we do point out in particular, indigenous populations and the importance of cultural relevance. So all of the recommendations and priorities that we talk about, that I'll talk about today, are relevant across the board, across cultures. So I'd like to share a little bit about the task force and how it got started. SAMHSA and the Office of the Assistant Secretary for Health co-chair this task force. The purpose of the task force is to evaluate and make recommendations to coordinate and improve federal activities around maternal mental health, but also to partner with non-federal organizations and advocates across the nation to improve the state of maternal mental health across the board. And, excuse me, some of the activities and reports that are required from the task force include an annual, well, in the first year, a report to Congress, and in the second year, a National Maternal Mental Health Strategy, which we actually completed in the first year, which I'll talk about because we were really ambitious and wanted to focus on implementation. So both of those things came out March 14th of 2024. And we'll talk a little bit more in detail about both of those documents. Every year, the congressional language asks us to update the national strategy and the report to Congress as well. And then there is a report to governors that is due sometime after the updating of the national strategy and the report to Congress. And then throughout, the language asks us to solicit public comments from stakeholders for the report and the strategy, which we did this past year through a request for information. And the task force is set to sunset on September 30th, 2027. So the organization of the task force is really interesting and provides us with a lot of flexibility and collaboration because it's organized under a FACA, a Federal Advisory Committee, which means that the document is not a U.S. government document. It is a Federal Advisory Committee document, which is non-federal members who formally advise government in a formal role. So this particular task force is kind of situated within the Advisory Committee for Women's Services, the ACWS at SAMHSA, and is, excuse me, executed through a subcommittee of the ACWS. So it's a subcommittee of the FACA. And then it was further broken down into five different focus areas, each of which were work groups that had two co-chairs, one a federal co-chair and a non-federal co-chair. And the scope of the task force for this past year was the perinatal period, which is the year during pregnancy, as well as the year after pregnancy, up to one year after pregnancy. However, we are open to changing the scope and expanding the scope in future iterations. This is just a brief description and list of the Advisory Committee for Women's Services. Many of these individuals serve on the task force subcommittee and also served as co-chairs of the various working groups. This is a list of all the participating federal agencies. And you can see, of course, Indian Health Services is present, along with a myriad of agencies across Health and Human Services, but also outside of Health and Human Services, like Department of Labor, Department of Defense, and Homeland Security. We just also want to include this slide to say that a lot of the work of the task force, of course, is being built on pre-existing work that we already have in the federal government. So this is not even a comprehensive list of everything, but just some highlights of existing programs within federal government or initiatives that the task force is building on. And I would like to also throw in here, as it's so recent, as the two new programs that SAMHSA has come out with, as well, the Women's Behavioral Health TA Center and the Maternal Behavioral Health Community-Based Services. So the report to Congress has about six chapters in it and goes through a background section. And then in the congressional language, we were asked to highlight a subset of best practices in various areas, such as prevention, screening, treatment, diagnosis. So the task force came up with their kind of three to five best practices that they would want to put forward. So this is the list of best practices kind of as per the task force. It's not meant to be a comprehensive list, but it's a really interesting set of best practices that we consider important and important in terms of scale up as well. And then there's a chapter that details all the federal programs that we have related to services and describes current coordination. So every coordinating committee or work group that exists in the realm of perinatal health and mental health is mentioned here. And by mental health, we also cover substance use, which I'll talk about in just a little bit. And so it's a really good reference chapter if you're ever looking at kind of what is the federal government, what programs exist in what realms. And it also goes through the different topic areas that Congress asks us to cover like prevention, screening, diagnosis, and treatment and community-based approaches. And then we have a chapter that describes overarching themes from listening sessions that were held with state and local government. And we intend to continue that in preparation for the report to governors, but also states and local government are key partners to this work. So we'll continue those conversations. Okay, so now I'll dive into the national strategy a little bit more. The vision of the national strategy is to ensure that perinatal mental health and substance use in this country will be seamless and integrated across all settings and that we're not gonna have a distinction between medical and mental health care and that really models of care are these integrated models of care would be supported and sensitive to the individual's experiences, cultures, and communities. The primary audience for this is the federal government, but an understanding that the federal government cannot do its work in a silo, nor would it want to, that it's really about all of the different partnerships that the federal government has, including with states, public-private partnerships, industry advocates and medical professional societies, communities, especially individuals with lived experience as well. And we talk about that as an entire pillar of the strategy, which I'll get into in just a little bit. And we really try to emphasize a whole of government approach here. This is a diagram or I guess image that kind of summarizes the entire strategy. So we have our five pillars here of the strategy that, I apologize, I have two young kids and they're always carrying something, so please forgive me. But yeah, so our five pillars here that kind of lead up to whole person and dyadic perinatal mental health and substance use care really try to emphasize multi-generational and dyadic approaches throughout the federal, national strategy, as well as the report to Congress. And then the outer terms, equity and access, collaboration, trauma-informed approaches and cultural relevance have to do with cross-cutting themes across the strategy and the report to Congress. So I'm just gonna cover for the sake of time a little bit of the flavor of each pillar. Each pillar has multiple priorities and each priority has multiple recommendations that get a lot more detailed in terms of what that priority is talking to and what the recommendation is calling for. And then each recommendation has a why statement that talks about the rationale for choosing that particular recommendation and a how statement that, or how really section that talks about, that kind of provides a little bit of a roadmap as to how to get to that recommendation, how to accomplish that recommendation and gives more specific examples and details about how to achieve that recommendation. So pillar one is all around building a national infrastructure that prioritizes perinatal mental health and wellbeing. So under this pillar, we have two priorities. One is all around integration and keeping integration at the center, but also keeping mother-infant dyads at the center and multidisciplinary and interdisciplinary care teams. And then the other one is all around a reduction of disparities. So keeping a focus on perinatal mental health and substance use with a focus on reducing disparities. I will say that as much as possible, the task force had a focus on mental health and substance use, as well as gender-based violence. So wherever possible recommendations were made to include gender-based violence interventions, as well as for trauma in general and social determinants of health. So you'll see in a lot of the recommendations, there's recommendations or steps on how to assess and intervene effectively around, you know, social determinants of health as well. Pillar two is to make care and services accessible, affordable and equitable. So we have three priorities here. The first one is all around screening and diagnosis and linkages. So it's all about making sure that not only are folks screened, but there's conversations and safe spaces to provide education and have conversations, and that there's really good linkages and follow-up provided. And then priority 2.2 is around accessible and integrated care services. This talks about a few different things, like increasing reimbursement across the board, including Medicaid services, ensuring that services are flexible and innovative. Innovative, so home-based care models, models that have flexible patient scheduling for evening hours or weekend hours, telehealth support, especially in rural areas, increased infrastructure for enhanced accessibility, are kind of those recommendations are all in this priority. Alternative payment models are also mentioned in this priority. And then the last priority here talks about all about the workforce. So training, expanding and diversifying the perinatal mental health workforce. So there's recommendations on making sure that curricula across the nation, across disciplines within behavioral health, incorporate this topic of perinatal mental health and substance use, and also making sure all the training and technical assistance that we offer in the federal government covers this topic area. So it's just examples of a couple of recommendations in there, but there is more. And then just making the workforce programs more robust, period. And then pillar three is around data and research to improve outcomes and accountability. So we have two priorities here. One is to use data and research to support strategies and innovations that improve outcomes. And this is about lots of recommendations mentioned around a national research agenda, a data linkages, essential repositories for accessibility of data. It also calls on looking at historical abuses of under-resourced populations and research and finding ways to correct those in the future while calling on perinatal populations to be more, for research to be more inclusive of perinatal populations. And then priority 3.2 talks all about accountability, so we cover quality improvement and improving quality improvement measures. And then the funding of PQCs and MMRCs across all 50 states, territories, and DC. Pillar four is promoting prevention and engaging, educating, partnering with communities. So in 4.1, we talk a lot about primary prevention strategies at the community level and community level detection. So strategies that have been evidence-based and work really well around prevention, like centering pregnancy or PrEP. We also talk about other models that have been utilized at the community level, like the HAIR model that came out of University of Maryland to be adapted for this population and to be scaled up. And of course, with other cultures, we would want to make sure that we are doing something similar. So the HAIR model is a good example of that, but there's also other interventions that could be culture-specific that should be scaled up as well at the primary prevention level. And then the last priority in this pillar talks about examples of national campaigns, ways to engage and educate communities and families. And pillar five is a really special pillar. It's all about lifting up lived experience. So we had our USDS colleagues do a special research sprint where they interviewed folks with lived experience along with providers, including doulas, including their health providers, to get a sense of what their experiences were like and what their biggest challenges were and what their recommendations were. And so this is not meant to be a representative sample, but it was about, I think about 11 folks with lived experience and about nine providers, or 10 providers. And really just supplemented this report. And you'll see throughout the report to Congress in the national strategy, there's different quotes that are embedded throughout each of the recommendations and the different components of each document that kind of support what is being said. Interestingly, also there was a list of recommendations that came out of this research sprint, and it just happened that all of the recommendations that came out of those lived experience matched up with the recommendations that are in the national strategy. So there is a table in the national strategy that you'll see that lines up the various recommendations from those with lived experience with each of the task force recommendations, which is really neat to see. So what are our next steps look like? We have implementation planning. So this year, FY25 is really focused on implementation of the strategy. We're tracking that in really specific ways and trying to come up with, trying to track what is already being done, because again, this is not novel. This work has been being done for decades, of course, and we want to build on that and also recognize the work that's already being done. But also what are new steps that have to be taken to achieve the recommendations that are in the national strategy? So I think I've forgotten to mention in the national infrastructure pillar, there are things like six months of paid family leave and universal childcare, embedded childcare within healthcare facilities. Some of those things might take a lot longer than just this year, of course, but what are the steps that we could take to kind of take one step forward towards those types of recommendations? And then there's recommendations that are a little bit lower hanging fruit, like revisiting diagnostic criteria with severity, specifiers, timing, and things like that. So that's something that we might be able to think about more this year. Then we also have a report to governors that we're going to probably be coming out with an FY26. So, however, starting a lot of the, or continuing, I should say, a lot of the partnership and planning with states this year. And then annual updates to the report to Congress and the national strategy. So I will send it back to you, Mary. Thank you. Thank you so much, Dr. Sheff. It's very compelling and it looks like we're going in a good direction with those various strategies and it seems very comprehensive. So now we are going to go ahead and take a few more minutes to take some questions. And I understand Jacqueline Harris, you had a question. Did you want to unmute and let us hear your question? Hi, this is Jacqueline. I want to thank everyone very much for this program. It was extremely informative and I'm happy that you were able to reschedule it. I actually did not have a question for you this evening. I must've hit the button by mistake. Thank you. Well, thank you. So does anyone have any questions of the participants that are here? You can raise your hand. Otherwise we have some questions here. Well. So it doesn't look like anybody's having questions. So one of the questions that I have as I was listening to everyone is looking at, and if anybody wanted to kind of start that conversation is what can we as mental health professionals do better or even not just mental health professionals but obviously if we're having more whole person care any provider that's working with a person who's pregnant that's indigenous, how do we do a better opportunity in creating safe spaces for them and to also help support their cultural background and even just their requests and desires say maybe to have a traditional birth. But what would you say we could do a better job at in terms of providers working with indigenous peoples? Anybody wanna take that? I could. I think something we talk a lot about and Ana had already mentioned this about birth is ceremony. And that time when someone is pregnant is a really sacred time. And it's a really precious, great time for people to wanna make healthy choices or to wanna prepare, prepare for this big life shift. And I think the most important thing like no matter what kind of care they're accessing is for providers to really know about the community that they're serving. Like whose land are you on? Which tribal community is closest to you? And we really encourage providers to learn from the community through building relationships. You're not gonna learn about community strengths in a silo or in a vacuum. You have to go and intentionally create relationships with the tribal communities and then you'll learn what kind of strengths do I need to make room for? So something that we're doing in Montana that feels really simple but hasn't really been happening till the past few years is helping people understand the importance of smudging. So for those who don't know, smudging is the burning of traditional plants. Sacred medicines sort of creates like an incense. And this is something that many people choose to do after their baby's born or maybe during labor. For my daughter, I was able to give her a traditional sage bath after she was born. And so just making space for that. A few years ago when my grandmother passed away, I said, oh, can we smudge here? And they were like, I don't know, I'll get back to you. And that hospital was in the boundaries of a reservation and they never got back to me. And so now we're working with hospitals to make sure that they have, so that providers know what their policy is on smudging and whatnot. If they're not allowed for some equipment or whatever, people are bringing in teas and having that essence there and giving that calming relief and whatnot that people are looking for. So that's just like one simple thing, but there's more strengths and you're gonna learn about those through working with community and make sure that in your policies or in your practice that you're creating space for that. Even if you don't understand it, it's not your worldview. Don't be afraid of it and don't dismiss it. It can be really powerful and healing for your indigenous person you're seeing. Thank you. And Adam, do you wanna contribute? Yeah, I just wanted to add a little piece to that. I think it's very important that when you're coming into these indigenous communities or wanting to strengthen your relationships that you are coming in humbly and with humility and that you are opening your ears and you're actually listening to the community and understanding their needs or maybe it's the historical trauma that they've gone through and it's impacting them so they don't have access to this knowledge or it's kind of a taboo in their community. I know in my community, when I had my home birth, nobody, there was no one that I could go to here and ask them, what are our traditional birth teachings? So I kind of had to go to other communities that were similar to mine and bring that back here. And what I try to do in What's Mineo Birth Work is giving people the space and all of the information and the education so that they can make the decision on their own because it is their desire, it is their birth. And I'm here to help along the way, but I just think it's really important that we bring all of the tools and the resources and especially the information so that they can align with whatever feels right to them and their family. I think that's very important. So how can we create centers where that is welcome? And Ted, maybe you can help us because you've created a center at the Alaska Native Medical Center and it's such a wonderful space. Well, it's something that is a bit traumatic for native people is when providers turn over. It happens quite often and it takes a while to get to know someone. And you really put a lot of faith and trust in that person. And it seems like most of them inevitably leave after a period of time. And so the next person comes along and they need to do their homework on who are these people are coming into? What historical trauma have they encountered? And I would say also meet with traditional native people and talk about what their needs are. What do they look for? If you tell them a particular problem, how do they expect it to be resolved if they expect it to be resolved? There are just a lot of things that happen with every single community, even though, for example, we're considered Eskimo or Inuit each village has its own background and its own history. And one needs to learn that before one comes in trying to have the answers to everything. So I agree with people when they say that people need to have some kind of a background in who the people they're serving and what they expect. And also probably knowing what previous healers have done, both Western and traditional, so that one comes in and explains everything that people can understand. It's just important to do your homework and know your history about Indian health. And what problems exist in the community and what you can do and who you can do it with to resolve a lot of those problems. Yeah, thank you. I think we're going to be closing up and I really appreciate your participation, everyone. We'll have Gabriel go ahead and close. Thank you all so much. I hope everyone enjoyed this evening. As we know, there was a lot of insights, a lot of invaluable knowledge. So we appreciate you taking the time to be with us. Of course, a very special thank you to our esteemed panel and of course, our moderator. We couldn't do this without the support of our board of trustees and also our members and our community partners. So thank you for that. Again, I invite you to join us for the next webinars. I will drop them in the chat room. There's one on August 19th on Closing the White Racial Schizophrenia Spectrum Disorder Diagnosis on Youth of Color. And then for the Maternal Mental Health on August 28th, Exploring the Impact of Weathering on Maternal Mental Health and Stress Being Inherited. So we invite you to join us. And I just want to, once again, thank the wonderful panel. You all, of course, we always knew you would do a phenomenal job and thank you so much for helping make our Maternal Mental Health series stronger. On our team in the Division of Diversity and Health Equity, I appreciate Madonna Delfish for taking the lead on scheduling these as our second year. So thank you all so much and wishing everyone, depending on where you're at, a great afternoon, a great evening, or if you're on the other side, 12 hours ahead, a good morning at that point. So thank you so much for joining us this evening here in D.C. and from anywhere that you found yourself.
Video Summary
The American Psychiatric Association's summer webinar focused on integrating cultural humility in mental health care for American Indian and Alaska Native birthing persons. Dr. Gabriel Contreras introduced the session, setting a respectful tone by acknowledging the land's indigenous peoples. Dr. Mary Hasbaugh Russell, a pioneering Navajo psychiatrist with extensive experience in indigenous mental health, moderated the discussion. Her work emphasized incorporating traditional practices into mental health services.<br /><br />The panel featured several speakers, including Dr. Amy Stiff-Arm, who shared her project on creating indigenous-led maternal mental health resources in Montana. She stressed the importance of recognizing indigenous strengths and incorporating cultural practices like smudging into healthcare settings. Anna Red Fox discussed her journey from experiencing a traumatic birth to becoming a full-spectrum indigenous doula. She underlined the significance of reclaiming traditional birth knowledge and practices within her community.<br /><br />Dr. Ted Mala highlighted the role of traditional healers and the integration of traditional and modern medicine at the Alaska Native Medical Center. He emphasized understanding community histories and the importance of building trust between healthcare providers and indigenous communities.<br /><br />Dr. Nima Sheth outlined the national strategy to improve maternal mental health, focusing on integration and cultural relevance across the healthcare system. She emphasized the need for collaboration and the inclusion of individuals with lived experiences in shaping healthcare strategies.<br /><br />The panel agreed on the need for healthcare providers to engage humbly with indigenous communities, respect cultural practices, and create safe, supportive environments for birthing persons.
Keywords
cultural humility
mental health care
American Indian
Alaska Native
birthing persons
indigenous practices
traditional healers
maternal mental health
healthcare integration
community trust
cultural relevance
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