Breaking the box

The importance of culturally competent treatment in addressing mental health and addiction

Early in my academic career, I remember being involved in a research project that was looking at collecting data from electronic medical records (EMRs) to better understand what was being done for mental health in primary care practices. It was a very cool project, one of my first as a principal investigator (PI), and one that required me to have some pretty interesting conversations with health systems leaders around what we were doing and why we needed their data.

One site in particular that I was interested in was in Alaska, and included American Indian and Alaskan Native populations. I was used to being able to come in, present to health system leadership, sign our data use agreements, and then move on to the research. In Alaska, I was taught the importance of making sure that I talked to the leaders who represented the people whose data I was going to be using, not just the leaders of the system. This meant a presentation to the Tribal Council that represented the people in the area I was looking to study.

I loved this. As I have written about before, much of thinking of how to approach community came from a brief period of time I trained in Pine Ridge, South Dakota. I knew that there were unique needs in this communities, had seen it first hand, and was glad that the Council was asking me why this study mattered for their people. It was one of my first lessons in understanding that without taking into account the unique needs of each community, including their preferences and desires, we run the risk of being tone deaf, or even worse, bringing forward ideas or solutions that simply don’t work or may even cause harm.

The Tribal Council got me to think about why what I was doing mattered - I mean I thought I knew as I had proposed the topic, gotten the funding, and prepared the team, but that didn’t matter as it ultimately came down to the big “So what?” question for this community. They were there to make sure that I was taking into account the unique cultural nuances of each member of their community. I will never forget this conversation!

For years, the field of mental health and addiction treatment has attempted to use a one-size-fits-all approach to care. We often funnel patients into pre-set models that often fail to meet their individual needs or take into account their unique social or cultural context. These treatment boxes, many (not all) are built around Western medical practices, and may work for some but leave many communities, especially those with cultural histories and traumas, looking for more. As disparities in mental health care become clearer, it seems that we should better recognize the reasons behind this gap and respond by providing care that genuinely reflects the cultural identities of patients.

A Legacy of Distrust and Historical Trauma

To better understand and explain some of the current disparities in mental health treatment, we must first acknowledge the historical tragedies that continue to reverberate within marginalized communities. Throughout history, many groups—particularly Indigenous people and communities of color—have been subject to medical exploitation, testing, and neglect. These experiences have left intergenerational scars and a profound sense of distrust toward the health care system. For instance, Native Americans, like other historically oppressed groups, carry the weight of generational trauma. Many Indigenous communities were subjected to forced removals, cultural erasure, and violent assimilation tactics. In some cases, Native Americans were victims of unethical medical practices that further deepened mistrust in Western medicine.

As a result, seeking help through conventional health care system can feel unsafe or irrelevant for many Native individuals. This mistrust is not merely anecdotal but a key reason why mental health disparities persist, as it presents another reason why these communities often avoid or resist seeking treatment from these systems.

Cultural Competence: A Path Forward for Effective Treatment

A major flaw in traditional treatment programs is their lack of cultural sensitivity. Western medicine often prioritizes clinical approaches like medication-assisted treatment, detox, or cognitive behavioral therapy. While these methods are effective for many, they still fall short of considering the cultural and spiritual needs of entire communities. The absence of culturally relevant care leaves a significant gap, particularly for Indigenous communities who have their own traditions of healing.

Recently there was a powerful piece on NPR about Emery Tahy. His story and experience is a powerful reminder of how transformative culturally competent care can be.

After battling severe alcoholism and depression, Tahy found healing not just in medical treatment but through practices that honored his Native American heritage. The piece describes The Friendship House in San Francisco, a Native-led recovery program, which provided him with ceremonial rituals like sweat lodges and traditional songs that aligned with his cultural upbringing. These practices gave him an opportunity to reconnect with his identity, leading to the place he needed to be for his recovery. And while an inspiring story, this is something we don’t see very often in large part because there are rarely financial mechanisms to pay for this type of care.

The Move Toward Inclusive Treatment Models

Recently, California’s Medicaid program, Medi-Cal, made a significant stride by expanding its coverage to include traditional healing practices. For the first time, Native Americans will be able to access therapies like sweat lodges, music therapy, and ceremonies through Medicaid. Pretty cool, right? For me, this change is not just symbolic but a necessary step in addressing the health disparities Native communities have long faced. Turns out, similar programs are being implemented in Arizona, New Mexico, and Oregon, marking an important step toward better meeting people where they are with the type of care that works best for them.

This integration of traditional practices into formal health care systems is likely long overdue but provides a roadmap of sorts for how we can evolve mental health treatment to meet the diverse needs of our communities. Studies suggest that patients who engage in treatments that reflect their cultural values tend to have higher engagement and more positive outcomes. This new pilot program recognizes that to treat people effectively, we must treat the whole person—mentally, physically, emotionally, and spiritually.

The Road to True Healing

The move toward culturally competent care, while essential, is not limited to Indigenous communities. All cultures have their own ways of coping with trauma, and mental health professionals must work to understand and incorporate these practices if they are serious about reducing disparities in care. The failure to do so leaves many without access to treatments that speak to their specific needs. I can give countless examples here.

Take, for instance, the African American community, where mistrust of the health care system also runs deep due to historical exploitation like the Tuskegee Syphilis Study. Similarly, Latino communities often experience barriers to mental health care due to language differences and the cultural stigma associated with seeking help. Addressing these issues requires an actual mental health system that approaches care from a culturally sensitive perspective—one that acknowledges and integrates the rich traditions, values, and experiences of each group from the start.

Examples like Medi-Cal’s coverage expansion to include traditional healing for Native Americans represents a shift in the right direction. It signals that we are finally allowing our payment and policy practices to catch up with our understanding that mental health treatment cannot be a one-size-fits-all model. There must be a willingness to accommodate and honor the cultural practices that can help people and their families recover and thrive. If we are serious about seeing improvement in mental health outcomes, especially in communities with long histories of trauma, we must commit more intentionally to culturally competent care.

While it won’t heal all the historical wounds, embracing this approach can begin to help many communities.