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Dr. Warrior on How States Need to Include American Indians in Their 988 Plans

Dr. Warrior and campers

Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at​

It was a Monday night when a devastating tornado—an EF5 on the Fujita Tornado Scale—tore through Oklahoma on May 3, 1999. Four-year-old Cara was among the 44 people who died. To process her despair, Cara’s mother, Anitra Warrior, sought out therapy. “I was struggling immensely,” she says. Therapy, though, wasn’t the help she thought it would be.

Warrior is from the Ponca Tribe of Oklahoma, and each time she attempted to include her cultural beliefs during the grieving process, the mental health professional would pathologize her experiences. “There was a major disconnect there,” she says. “If I can’t be truly authentic or present in my sessions, then I will not heal.” 

As a Ponca woman navigating a mental health system embedded in western culture, Warrior realized she didn’t want other American Indians to go through the same experience. Today, Dr. Warrior is a psychologist who provides clinical services to tribal communities in Nebraska, including the Santee Sioux Nation and the Winnebago, Omaha, and Ponca Tribes of Nebraska. 

Three of the tribes are located across rural lands in the northeast part of the state. However, the Ponca don’t have a reservation. In 1887, the United States government removed the tribe at gunpoint from their home along the Niobrara River, forcing 523 Ponca to march 600 miles to present-day Oklahoma. Today, the exile is known as the Ponca Trail of Tears. 

In Oklahoma, more than a third of the tribe died, many from malaria. Among the dead was 16-year-old Bear Shield, Chief Standing Bear’s son. As he was dying, the teen asked his father to take him back home and bury him on their ancestral grounds at the mouth of the Niobrara. “I wanted to go on my own land, land that I had never sold,” the chief testified in U.S. ex Rel. Standing Bear v. Crook

“That’s where I wanted to go. My son asked me when he was dying to take him back and bury him there, and I have his bones in a box with me now. I want to live there the rest of my life and be buried there.” 

Dr. Warrior says that while the U.S. has recognized the tribe, they didn’t return land to the Ponca Tribe of Nebraska. Instead, under the 1990 Ponca Restoration Act, the tribe’s service delivery area includes fifteen federally designated counties in Nebraska, South Dakota, and Iowa. “There are offices throughout that serve tribal members, but it’s fragmented, which can create barriers to care,” she says. 

Propelled by sorrow from the loss of her child and the disconnect she experienced in therapy, Dr. Warrior opened her first clinic out of her home on the Winnebago reservation. Early on, she realized that what didn’t work for her also wasn’t working for others. “Western methodology is forced upon American Indians to heal us, fix us,” she says, “but that’s not always the best approach for us.” Instead, she and her Morningstar Counseling and Consultation staff use culturally adapted evidence-based best practices and focus on understanding the person’s culture and the importance of relationships and community within it. 

“We view our approach as decolonizing behavioral health,” she says, “and going back to incorporating our cultural beliefs.”

Dr. Warrior and her staff refer to the people they serve as relatives, not clients. “We believe everyone is connected; everyone is related,” she says. “So we treat people at our clinics like family.” As a result, boundaries are not the same as those in western patient-client relationships. It’s not uncommon for Morningstar staff to eat and pray with the people they serve. 

“If the person is comfortable, we can invite someone to come in and pray and smudge,” says Dr. Warrior. “We honor the pain they’ve experienced and don’t look to pathologize their reaction to trauma.”

She says the team does a bit of cultural triage. Working with many tribes with their own practices means Dr. Warrior and her staff know there’s much they don’t know. “We tap into the resources we have, do additional research, and outreach tribal nations to have mentors support us,” she says. Taking the extra step is inherent to their approach. “It’s what we do to help our relatives.”

Historically, people have been forced to adapt to existing systems, not the other way around. Instead, Dr. Warrior and her team adapt their services and treatments to best fit the people they serve. She says tilting a pre-existing worldview on its head can take some adjustment for new providers they bring on board, but that the organization’s transparent ethos helps. “We’re very clear how we operate: these are our relatives, and culture is integral to their healing.”

What can be most challenging for new providers is adapting to a dual relationship with the people they serve. “Providers need to be prepared to do some personal disclosure to establish a connection,” says Dr. Warrior. She points out the approach is contrary to how most mental health professionals are trained. “It’s hard-wired in us to see what the problem is, provide services that help the person recover, and move forward,” she says. All of that’s essential, she notes, but for American Indians, the process needs to go beyond what already exists. 

“We need to revisit the past and include what helped us survive as a people.”

Over her career, Dr. Warrior has seen increases in suicidal ideation and attempts among young American Indians, including elementary school children. She points out the Covid pandemic has resulted in further spikes. “Never in my career have I had this many children and adolescents on safety plans,” she says. “I’m on call 24/7 for young kids and teens.”

The pandemic created a whiplash shift in day-to-day lives across the nation. “In Nebraska, kids went on spring break,” says Dr. Warrior, “never to return to that grade in person.” The ease of going virtual varied, depending on the school district. Tribal communities, she points out, rarely have a reliable cellular connection. According to BroadbandNow Research, people in tribal zip codes in the United States have less access to internet connectivity than other parts of the nation. In Nebraska, the Santee Sioux Nation, Winnebago, and Omaha have 58%, 57%, and 56% access to broadband, respectively. People in the Ponca Tribe of Nebraska mostly have high-speed internet, with 95% access to broadband.

“Spotty internet has a direct impact on learning,” says Warrior. “However, it’s not just people in rural areas who face connectivity issues, but also those in urban ones who can’t afford telecom services.” 

During the pandemic, Omaha Public Schools has provided students and staff with 56,400 iPads through T-Mobile, giving them 4G LTE connectivity. The school district handed the devices out in waves, starting with 2,000 last June. In May, OPS renewed the contract for another year, allowing students and staff to continue using the iPads during the summer and 2021-2022 school year. The annual cost is $10.7 million, paid from federal COVID relief funds.

Dr. Warrior notes that 2020 was the year kids were mostly neglected. “School systems and parents were doing their best, but it was a dramatic change that didn’t allow for processing or planning,” she says. Parents experienced heightened stress levels, unsure if they’d keep their jobs or be able to work, and worrying about their mortality from an unknown virus, which, she points out, children absorb.

“We think of children as resilient—that they can pull through anything—but in 2020, they lost rites of passage and were grieving.”

People’s fears of the virus weren’t unfounded. From January to June 2020, American Indians and Alaska Natives were 3.5 times more likely to be diagnosed with Covid and nearly twice as likely to die of the virus than their non-Hispanic White counterparts. The Color of Coronavirus project, run by APM Research Lab, tracked Covid deaths by race and ethnicity in the U.S. from the start of the pandemic until March 2. According to the project, Indigenous Americans experienced the highest age-adjusted Covid mortality rates nationwide, 256 deaths per 100,000 people. In Nebraska, it was even higher, 386.3 deaths per 100,000 people.

Because of Covid restrictions, Dr. Warrior and her team have had to get creative to help serve a population at increased risk of complications and death from the virus and experiencing increases in depression and anxiety. According to Mental Health America’s 2021 report, from January to September 2020, more than 1.5 million people took a Mental Health America screening. American Indian screeners had the highest average percent change over time for suicidal ideation, 1.03 percent. 

Pre-pandemic, Dr. Warrior and her staff’s outreach included running booths at community events, handing out flyers, and having an active Facebook presence. During the pandemic, the team began directly contacting people who might be having a hard time. “We proactively text people, chat with them on Snapchat, go into schools that allow us to, and host outside community dinners and cleanups,” she says. “We’ve had to step up our game.”

She says acquaintances, friends, and family will share with Dr. Warrior or her team members if a person is struggling, sometimes sending a quick message over social media of who the person is and what they’ve expressed. Then Dr. Warrior or a staff member will reach out. “We’ll explain who we are,” she says, “and tell them, ‘We hear you, we see you, and we want to support you.’” 

The pandemic and corresponding social distancing requirements also pushed Dr. Warrior and her staff to turn to an older form of communication, letter writing. She says elementary school kids she works with enjoy getting letters with jokes in them. “I mail jokes to them, and then they mail jokes back to me—their jokes are always way better,” she laughs. Sitting on her desk are Hot Wheel and 3D motion dinosaur stamps.

Dr. Warrior also receives referrals from law enforcement, a relationship that strengthened before and during the pandemic because of three horrendous homicide investigations. In 2020, three American Indian women were found dead on reservations and are believed to have been murdered: Ashlea Aldrich and Lenice Blackbird on the Omaha Indian Reservation and Kozee Decorah on the Winnebago Indian Reservation. “The issue of missing and murdered indigenous women has finally started to gain traction,” she says. 

Dr. Warrior and her staff conduct debriefings for law enforcement. “They regularly experience traumatic events,” she says. In turn, when law enforcement responds to a call where trauma or mental health might be a component, they contact Morningstar staff.

What gives Morningstar a great deal of flexibility and the ability to provide no-fee services is that the Santee Sioux nation funds it through SAMHSA grants. “It’s also has allowed us to create additional positions,” says Dr. Warrior, “like case managers trained in suicide prevention and intervention who provide mentorship at schools.” 

As the U.S. edges nearer to the date that 988 will go live—988 is the three-digit number for mental health, substance use, and suicide crises that telecom companies must make live by July 16, 2022—Dr. Warrior says states need to think about equity and their indigenous populations. She points out that on reservations, 911 isn’t even an option. “If we call 911, operators ask if we’re on a reservation,” she says, “and if so, they direct us to call our local police department.”

“Even though we’re citizens of the state of Nebraska, we aren’t provided 911 emergency services. How is 988 crisis integration going to work for tribal populations?” Dr. Warrior points out that reservation police departments are often limited, and transport to a hospital can take two to six hours. 

In May, Nebraska’s governor, John Peter Ricketts, signed 988 legislation into law that creates the Mental Health Crisis Hotline Task Force. The task force will issue a report with a plan for 988 implementation and recommendations to the legislature by December 17, 2021. The state is also a recipient of a 988 State Planning Grant by Vibrant Emotional Health, the nonprofit organization that runs the National Suicide Prevention Lifeline, where 988 calls will be directed. (Calls route to accredited call centers by the caller’s area code.) The grant will help the state develop a strategic plan to prepare for 988, including infrastructure needs and estimated call volume growth. 

Dr. Warrior hopes Nebraska takes the lead from Washington State by creating a 988 tribal behavioral health and suicide prevention line, which includes $1 million in funding to develop and operate the line, and a tribal 988 subcommittee. The passed Washington State 988 legislation states the committee will “examine and make recommendations concerning the needs of tribes related to the 988 system, and which shall include representation from the American Indian health commission.”

She says reservations are often dislocated from resources like the 911 emergency system and face a shortage of mental health professionals. That’s why she’s involved in FARM CAMP, the Frontier Area Rural Mental Health Camp, and Mentorship Program. Dr. Warrior has held three camps on the Winnebago reservation where high school juniors and seniors learn about psychology and culture and earn three college credits. “The free weeklong camp focuses on graduate-level material,” she says. “We’re trying to plant the seeds, so those from the community are serving the community.”