Consideration for Integrating Evidence-Based Trauma-Informed Approaches into Resource-Low Mental Health Care Systems Serving American Indian Rural Populations

Introduction: On many rural reservations, the health care infrastructure is severely constrained by scarce human resources, underdeveloped infrastructure, weak procurement systems, and limited funding. Overworked health care staff coupled with clients’ poor access to health services hinders the development of patient-centered care and strong relationships between patients and providers. These factors make it complex and difficult to provide quality trauma-focused care for comorbid conditions. We discuss client and counselor barriers in obtaining and delivering mental health care.

 Method: We assessed preliminary health service data from a two-group, single-site waitlist control, randomized pilot study delivering 13-sessions of culturally adapted Cognitive Processing Therapy to reduce posttraumatic stress disorder (PTSD), substance abuse and dependence diagnoses (SADD), and HIV risk behaviors among 28 AI women (age 18-42) from a Pacific Northwest tribal reservation. We compared client attendance data and weekly PTSD symptoms scores; assessed reasons why sessions were not attended and conducted debriefing interviews with 22 of the 28 clients and 4 of the 5 counselors.

 Results: A notable finding was that 13 sessions was difficult to complete for both clients and therapists. Only 33% of the clients completed therapy, far lower than in prior CPT trials (70-80% retention) or PTSD/SADD treatment studies (40-50% retention) with non-AI populations. Although PTSD symptoms fluctuated with attendance, overall, PTSD severity decreased overtime (B= -11.9, SE= 2.1, p< .001), as did SADD, OR= 0.18 SE= 0.09 p<.001, while safer-sex self-efficacy improved, B= 28.8, SE= 12.4, p= .020, controlling for baseline scores. Clients missed slightly over half (56%) of the appointments. However, of these missed appointments 44% were due to counselor behavior such as cancelling (72%) or rescheduling (28%) appointments. Clients reported several reasons for non-attendance including (1) length and structure of treatment (e.g., too many sessions, sessions were too short), (2) treatment burden (e.g., too much homework, seasonal and ceremonial obligations), and (3) practical barriers (e.g., transportation costs, limited counselor availability). Counselor cancelled sessions were due to (1) institutional expectations (trainings, community outreach activities and training); (2) personal time off (vacation time, U.S and Tribal holidays, sick days, and funeral leave), and (3) providing counseling following community-level traumas (i.e., youth suicide)

Conclusion. Supportive infrastructure coupled with robust evidence based intervention that are flexible enough to address system barriers in resource-limited settings are essential to ensure that clients exposed to recurring trauma, substance use, and at risk for HIV are adequately supported.