Table 2.

Themes, subthemes, and examples: challenges to providing quality substance abuse treatment to AI/AN communities

Themes	Subthemes	Examples
Challenges associated with providing clinical support	Barriers to treatment seeking and engagement: sociodemographic	Homelessness
		Lack of transportation
		Legal issues
		High relapse
		Unemployment
	Barriers to treatment engagement and process	Complex trauma histories
		Diversity of patients
		Integrating culture into services
		Lack of motivation
		Stigma of treatment
Challenges associated with the infrastructure of treatment settings	Frontline worker challenges: fatigue and burnout	Emotional and personal investment
		High caseloads
		Paperwork and administrative responsibilities
		Professional boundaries
		Shortage of staff
	Lack of program and treatment resources	Inadequate length of treatment
		Lack of office supplies and space
Challenges associated with the service/treatment system	Barriers associated with providing	Limited housing options
	Adequate aftercare	Limited transportation resources
		Limited treatment options
	Appropriateness of treatments	Pressure to use Evidence-Based Treatments (EBTs)
	Excessive and unconstructive paperwork	Interference with clinical care
		Not pragmatic or useful