Telepsychiatric Care of American Indian Veterans with Post-Traumatic Stress Disorder: Bridging Gaps in Geography, Organizations, and Culture

"It Was Broken Here Before": Present day impact of historical trauma in telemental health services in a rural and remote Aleutian Islands Community

Telemental health technology is a feasible tool for providing behavioral healthcare in rural areas. However, there is scant literature about implementing this technology within Indigenous populations. The Aleutian Pribilof Islands Association is an urban-based Tribal Health Organization in Alaska tasked with providing behavioral health services to remote Unangax̂ communities. To expand telemental health services, a formative program evaluation was conducted to examine the acceptability of and barriers to implementing telemental health. Using a qualitative approach, five individuals with lived experience in the same community were interviewed using a semi-structured format. Data were analyzed using critical thematic analysis and situated within the context of historical trauma. Five themes were constructed that showed broken trust as the primary barrier to services, despite the substantial obstacles related to communications infrastructure. When situated within the context of historical trauma, the results show how colonization spurred and has maintained broken trust. The clinical, research, and policy implications resulting from this study point to the need for decolonization and integration of culture in behavioral health services. These findings can be informative for organizations and providers seeking to implement telemental health in Indigenous communities.

Addressing experiences of trauma within Indigenous-focused substance use residential treatment: a systematic review and environmental scan

Indigenous individuals in Canada disproportionally experience higher rates of substance use concerns. This study examined clinical practices currently implemented with Indigenous-led residential treatment facilities to simultaneously address substance use and post-traumatic stress. A systematic review of relevant literature retrieved published approaches to address these concurrent disorders with Indigenous individuals. This review retrieved 35 sources related to trauma and substance use treatment among Indigenous individuals or communities. Among these sources, all leveraged cultural approaches as a dual treatment for trauma symptoms and substance use. Inconsistent results were reported among those sources (n = 3) who analyzed comparisons with wait-list controls or used randomized-controlled designs. Using culture-as-treatment was elaborated upon in the second goal of this study: an environmental scan of Indigenous-led treatment programs and qualitative interviews with 10 treatment center staff to understand how programs may address both substance use and traumatic symptoms among Indigenous-led substance use treatment centers across Canada. When we searched the websites of these centers, we found that approximately 38% (16 of 43) of treatment centers discussed implementing some form of treatment that addressed trauma symptoms in conjunction with primary substance use. Among the 10 staff participants, all discussed how trauma can impede client success in treatment, and ACE-specific programming is useful within their respective treatment programs. Results showed that when manualized treatments are used, they must be adapted to meet the specific needs of Indigenous communities, and culture-as-treatment is a popular approach among Indigenous-led treatment centers, particularly for addressing trauma symptoms.

Scoping review of telehealth use by Indigenous populations from Australia, Canada, New Zealand, and the United States

INTRODUCTION

Telehealth has the potential to address health disparities experienced by Indigenous people, especially in remote areas. This scoping review aims to map and characterize the existing evidence on telehealth use by Indigenous people and explore the key concepts for effective use, cultural safety, and building therapeutic relationships.

METHODS

A search for published and gray literature, written in English, and published between 2000 and 2022 was completed in 17 electronic databases. Two reviewers independently screened retrieved records for eligibility. For included articles, data were extracted, categorized, and analyzed. Synthesis of findings was performed narratively.

RESULTS

A total of 321 studies were included. The most popular type of telehealth used was mHealth (44%), and the most common health focuses of the telehealth interventions were mental health (26%) and diabetes/diabetic retinopathy (13%). Frequently described barriers to effective telehealth use included concerns about privacy/confidentiality and limited internet availability; meanwhile, telehealth-usage facilitators included cultural relevance and community engagement. Although working in collaboration with Indigenous communities was the most frequently reported way to achieve cultural safety, 40% of the studies did not report Indigenous involvement. Finally, difficulty to establish trusting therapeutic relationships was a major concern raised about telehealth, and evidence suggests that having the first visit-in-person is a potential way to address this issue.

CONCLUSION

This comprehensive review identified critical factors to guide the development of culturally-informed telehealth services to meet the needs of Indigenous people and to achieve equitable access and positive health outcomes.

Institutionally based videoconferencing

The delivery of psychiatric care via video-teleconferencing (VTC) technology is thought to have reached a tipping point. As a medical speciality with relatively few material or technical requirements for service delivery, psychiatry has been one of the earliest to embrace the possibility of providing evaluations and treatment at a distance. Such technical infrastructure as is necessary can often be found in the institutions already in existence. It was natural therefore that institutionally based telepsychiatry would lay the foundation for the development of the field. In this article we review the history and development of institutional VTC in a wide variety of clinically supervised settings such as hospitals, outpatient clinics, and forensic settings. We cite evidence supporting institutionally sponsored use and expand on key takeaways for the development and expansion of videoconferencing in these settings. We also speculate on the future direction and development of psychiatric care provided by these arrangements.