Clinical considerations for working with American Indian and Alaska Native communities

Rural communities are notoriously underserved, especially when it comes to mental health care. The Psychology Interjurisdictional Compact (PSYPACT)opens in new window, an agreement allowing licensed psychologists to practice telehealth across state lines, can improve access to care—but clinicians from outside areas may not be prepared to work in those communities if they do not understand the local and cultural nuances that can impact mental health and resilience.

This awareness is particularly important when working with American Indian and Alaska Native (AI/AN) populations. Providing effective care for these individuals requires non-Native psychologists to understand the cultural, historical, and community contexts that shape patients’ experiences.

Another layer of cultural understanding is needed for non-Native psychologists working with AI/AN populations. Beyond their rural identity, AI/AN individuals often hold deep spiritual traditions, strong connections to land and ancestry, and community-centered worldviews that may differ significantly from Western models of health and healing. Present-day racism and transgenerational trauma because of centuries of systemic injustice is another important context that can shape mental health experiences and trust in health care providers.

As a result, typical Western approaches to psychological care may not be effective—and could even impair the therapeutic alliance. “We repeatedly see that Native people don’t show up after their first or second appointment, which could be written off as resistance,” said Iva GreyWolf, PhD, a licensed psychologist in Alaska. “Instead, ask yourself whether you’re creating a welcoming environment for people with a different worldview.”

While psychologists can gain the mindsets, tools, and skills necessary to provide culturally sensitive care through their training, AI/AN populations are underrepresented in the scientific foundations of psychological practice. “Working with Indigenous people requires more analytical prowess in thinking about cultural differences, which may take extra time or even go against one’s existing orientation,” said Joseph Gone, PhD, a professor of anthropology and global health and social medicine at Harvard University, where he also serves as the faculty director of the Harvard University Native American Program.

Taking steps toward cultural understanding and humility can help build trust and rapport for more positive therapeutic outcomes. Read on to learn more about the best practices for working with AI/AN patients, and how to adopt culturally sensitive approaches to support holistic well-being.

Every AI/AN tribe has its own unique practices and beliefs. An American Indian in the southeast United States may see as little in common with an Alaska Native as any two non-Natives from those regions. Taking time to learn about a specific tribe’s history and cultural norms can help build a trusting therapeutic relationship—but psychologists should not rely on patients to explain their culture. “It’s not the job of the community or the people in it to teach you about who they are,” said Maria Crouch, PhD, a clinical-community psychologist and assistant professor adjunct at Yale School of Medicine in the Department of Psychiatry. “That re-creates a settler-colonial dynamic, which can be harmful to therapy.”

If you are able, travel to the Indigenous lands to visit local museums or build relationships with community elders (ideally, foster a relationship where you provide value, too—through acts of service and/or gift giving). If you cannot visit in person, read about the people or establish virtual connections with those who live or work in the area. Researching local organizations such as schools, community centers, or health care organizations can also help you encourage community involvement while developing potential referral sources.

Whether or not you visit in person, try to understand and honor the relationship between the people and their land. For Indigenous communities, the natural world is not only a geographic entity but also the foundation of spiritual and cultural practice. “Our communities are the only Americans whose ancestors didn’t immigrate here, and that has an impact on our worldview, and how we feel, think, and behave,” said Justin Douglas McDonald, PhD, a professor of psychology at the University of North Dakota. While it is important to take steps to understand a person’s practices and beliefs early on, the learning process should be ongoing throughout the therapeutic relationship.

Rather than emphasizing your psychological expertise, create a safe space by centering therapy on the individual’s experience. “Native patients want to know you’re flexible enough to fit your knowledge in the context of their community,” said Deidre Yellowhair, PhD, a research assistant professor of community behavioral health at the University of New Mexico.

When you are comfortable, share who you are, too. “Native communities believe we’re all connected with one another and the land, so people want to know who you are,” said Crouch. Along with your professional background, consider disclosing where you are from or live now to establish rapport. On the website Whose Landopens in new window, you can easily search the tribal land where you live now or where you grew up.

Aim to integrate cultural sensitivity in how you speak: Clinical jargon, Gone said, can be alienating, especially for those apt to seek spiritual help from a trusted healer rather than psychological support from a stranger. The pace at which you speak also matters—it can help to follow the patient’s lead. Native people, as a whole, may speak at a slower rate and are generally more comfortable with silence. “We typically view time differently and are comfortable being in the present moment, so someone talking quickly can be overwhelming,” said Crouch.

Be proactive in asking for clarity if needed. AI/AN cultures may have unique ways of nonverbally communicating—for example, in Crouch’s community, people raise their eyebrows to say “yes” and furrow them to indicate “no.”

Even if you have extensive training in a particular therapy method or treatment modality—or experience with a particular community—it is essential to keep an open mind and be willing to adjust. Therapy with Indigenous communities, Yellowhair said, is most effective when clinicians remain flexible and tailor care to the individual. Rather than assuming an individual with certain symptoms needs a specific intervention, clinicians should apply their own expertise while trusting individuals receiving care as the experts of their own lives—even if it does not always seem to “make sense.” For example, you may think someone only needs cognitive behavioral therapy to improve, but they may also need practical resources to better their quality of life.

Do not assume that all American Indians and Alaska Natives share the same level of adherence to traditional practices. Even within Indigenous communities, people can have a diverse range of experiences. If cultural identity is important, McDonald said, it is vital to incorporate that context in the assessment or treatment, such as by encouraging connection with community members or tribal elders who can provide guidance and support.

Clinicians should also be aware of and avoid harmful stereotypes that have historically affected AI/AN communities. For example, a since-redacted 1970s study by a non-Native psychologist falsely suggested AI/AN people are genetically susceptible to alcohol use disorder. In fact, Crouch said, they have a high abstinence rate from alcohol compared with other ethnic minority groups.

Many of the evidence-based measurements, diagnoses, and treatments psychologists use were not developed based on Native samples or with Native people in mind, said Royleen Ross, PhD, who trained as a clinical psychologist and is a cultural consultant in New Mexico and past president of APA Division 45, Society for the Psychological Study of Culture, Ethnicity, and Race.

Behavior should be understood within a person’s sociocultural context, not judged through a Western lens. Be careful of how your assessment may perpetuate bias. For example, you may meet with someone who did not attend high school and does not have what many consider to be a traditional job. Yet in their community, they may be a revered leader with valuable wisdom and experience. “Try to ‘Indigenize’ your criteria when conceptualizing your case rather than understanding the patient through your own Western lens,” said GreyWolf.

At times, your assessment may not cleanly translate between cultures. For example, someone may experience profound, extended grief after the loss of a community elder. In Indigenous communities, Ross said, the idea of family often extends beyond parents and siblings—and the loss of an elder may represent losing important wisdom and healing abilities. Take time to consider the cultural context and influence as you are developing a diagnosis and treatment plan.

The Cultural Formulation Interview in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, Text Revision), or DSM-5-TR, is a helpful tool in guiding assessment and diagnosis, Crouch said. “That will help you formulate your case conceptualization about an individual based on their expertise and what they tell you about their lived reality,” she said.

While it is important to recognize and treat the symptoms of systemic abuse and injustices that have impacted AI/AN communities and the effects of transgenerational trauma, hyper-focusing on negative experiences minimizes the strengths that have allowed AI/AN populations to survive and thrive amid centuries of systemic injustices and abuse. “Instead of focusing on what’s wrong, ask yourself, Why are some Native people doing so well, in spite of what they’ve been through?” said GreyWolf. When you understand the collective strengths, you can remind individuals about their innate skills and resources and adopt a more strengths-based approach.

If the individual’s experience includes the effects of historical and present-day trauma, depersonalizing it can help them understand their struggles within a broader historical context rather than view them as personal failings. “Reminding the person of the systemic injustices facing Indigenous communities for generations can help take away the internalized message of ‘I’m broken because I’m brown,’” said Yellowhair. For example, she helps disseminate a parental curriculum to teach parenting skills to those whose older family members were affected by the government-mandated boarding schools and associated abuses of the past century. This guidance helps reframe caregivers’ challenges as the result of generational experiences rather than of individual failings. By depersonalizing the challenges, families can begin to heal and practice new parenting skills.

Studies, including Ross’s research, show spiritual and cultural practices are protective factors for AI/AN people—particularly in the realm of intergenerational and transgenerational trauma. “Think about what’s already working for your patient and use that in your treatment recommendations,” said Ross. That may mean encouraging spiritual or cultural practices, such as attending traditional ceremonies or meeting with a village elder.

When you incorporate Western therapeutic concepts or clinical terms, find and emphasize cultural connection points. For example, draw attention to the mindfulness contained in focusing on beats of a drum during a ceremony. Or if you are explaining emotion regulation to a child, you could describe the self-control it takes to listen to and honor an elder when they are speaking. “We’ve always had methods for these things built into our cultural practices, and finding ways to connect the dots back to the person’s culture can establish a much more meaningful connection,” said Yellowhair.

Encouraging cultural connection and culturally sensitive practices can promote “thrivance,” a term used in recent literature to describe active flourishing in AI/AN populations. “Resilience requires continued suffering,” said Crouch. “Thrivance is the process of reclaiming what was stolen by being who we are.”