Yup'ik healing

1. Introduction

Version followed: the programmes that Yup'ik and Cup'ik communities and their tribal health organisations publish for clinicians and partners. These are (a) the Qungasvik ("Toolbox", "Tools for Life") youth suicide and alcohol-misuse prevention programme in its 18-module manual and the Qasgiq model (Qungasvik Team, Rasmus, Allen and colleagues, as presented in 2019 and described in Rasmus et al. 2019 and Allen et al. 2023); (b) Yukon-Kuskokwim Health Corporation's (YKHC) Calricaraq and Qaruyun behavioural-health prevention and wellness work, as profiled by Harvard's Honoring Nations (2016) and as presented in YKHC's January 2025 training; and (c) Southcentral Foundation's (SCF) Traditional Healing Clinic in Anchorage, which serves Alaska Native people generally. The psychotherapist's own culturally responsive work alongside these follows the DSM-5-TR Cultural Formulation Interview (CFI) and Kleinman's explanatory-model questions. An earlier 2009 edition of the toolbox (credited to the Alakanuk Community Planning Group and others) is described as having 36 cultural and bicultural activities. This guide follows the later 18-module manual. [source: NIAAA NativeAIR; Qungasvik Tools for Life slides; SPRC toolbox listing]

What "Yup'ik healing" is here. "Yup'ik healing" is not a single therapy. It is a living set of community teachings, Elders' knowledge and tribally run programmes rooted in yuuyaraq, which communities translate as the Yup'ik way of life. The programmes rest on one shared claim, put in the communities' own words: "Yup'ik culture is prevention." Billy Charles of Emmonak, a research co-investigator, said "our culture... is our prevention, it is intervention." [source: NIAAA NativeAIR; NIMHD feature 2018]

How change is understood to happen (as the communities describe it).

Qungasvik builds individual, family and community protective factors through Elder-guided, land-based and cultural activities. Two of these factors are "reasons for life" (Yuuyaraqegtaar) and "reasons for sobriety" (Umyuangcaryaraq). [source: Qungasvik Tools for Life slides]
The model holds that healing and repair at the level of the community produce outcomes for each young person. [source: NIMHD feature]
YKHC describes Calricaraq as a balanced life in body, mind, emotions and spirit, lived by ancestral principles. Its healing process is put in three Yup'ik phrases: examine the past (Yuvrirluku Cam Cingilga), process the past (Ulligluku taringluku), and heal (Kitugiluten, Ayuqucilinqigluten). Its stated goals are healing, changing perspective, restoring identity, and using that identity to stay well. [source: YKHC/ANTHC Calricaraq session 2025; Honoring Nations Calricaraq report]
These programmes link today's distress to colonisation. They name epidemics, forced boarding-school placement, abuse, and loss of language, parenting knowledge and cultural identity. [source: Honoring Nations Calricaraq report]

Who holds authority. Authority rests with tribal councils, Elders and community leaders. In the YK Delta this includes YKHC's Calricaraq Elders' Council of more than 40 Elders, and some villages supervise their own Calricaraq providers. Qungasvik is tribally directed: the community in qasgiq (a gathering) chooses the Yup'ik experts who teach each activity, and university researchers play a supporting role "at Elders' discretion." In Anchorage, SCF tribal doctors practise within the Traditional Healing Clinic, which runs a Tribal Doctor Training Program and an apprentice programme. The Yup'ik Elder and healer Rita Pitka Blumenstein, who died in August 2021, was reported at her death as the first traditional doctor recognised by the State of Alaska [source: Alaska's News Source 2021]; an SCF symposium booklet names her as the first Tribal Doctor, certified in 1999 when the Elder Advisory Council was set up [source: SCF Tikahtnu Plant Symposium booklet 2021]. Historians describe Yup'ik shamans as healers of body and mind before and during contact. That is an outsider's historical account. [source: Honoring Nations Calricaraq report; Rasmus et al. 2019; SCF clinic article 2024; Litecky 2011 thesis abstract] The psychotherapist does not perform Yup'ik healing, tribal-doctor work, Elders' teaching or any ceremony. Their role is their own assessment and therapy, and collaboration and referral when the client wishes. [synthesis]

2. Framework

There are two linked frameworks: the community programme, and the psychotherapist's own course of work alongside it.

A. Qungasvik / Qasgiq model (community level; for a clinician invited to partner). [source: Rasmus et al. 2019 (CDEMP); UAF CANHR project page; NIAAA NativeAIR]

Entry condition: the community starts the work and invites outside partners in, usually after it has already mobilised around alcohol and suicide. Partners work through the tribal council, Elders and local leaders. They learn the community's history and the legacy of colonisation, how local decisions are made, and which settings already serve as places of intervention. They also build a two-way communication plan that local people can reach. [source: UAF CANHR]
Step 1, historical context: recognise community strengths and ancestral resilience, and place the work within cultural continuity and change.
Step 2, cultural strengths and protective factors: Elders and community members name protections at the community, family and individual levels. Elders decide how Yup'ik and Western terms correspond.
Step 3, community-driven adaptation and delivery: the qasgiq chooses activities to suit the season, place and conditions. A work group of Elders, adults and youth plans each activity and picks the protective factors it will teach. Local prevention coordinators and community instructors then deliver it.
Step 4, outcomes: reasons for life and reasons for sobriety, as the community moves from fragmentation towards its own decisions and interdependence. Youth, Elders and community members come back to the qasgiq to reflect on what worked, which closes the cycle (qasgirarneq, to encircle or complete a cycle).
Programme length and timing: about three years in all. Year 1 runs about nine months and covers qasgiq planning and community strengthening. Years 2–3 deliver 12–18 activities in each nine-month period, from autumn to spring, with a pause in summer for subsistence harvest. One community held 87 qasgiq meetings. Each module runs as one or more sessions of 1–3 hours, at the individual, family or community level. Delivering more modules was linked to more growth in protective factors. [source: Rasmus et al. 2019; NIAAA NativeAIR; Tools for Life slides]
Modules (titles only, as published): Preparing for the Journey; The Land Provides for Us; Neqpiaput: Yup'ik Foods; Telling Stories of Strength; How Powerful You Are; Prayer Walk; Crisis Response Team; Traditional Yup'ik Games; Building Tools for Life; Survival Skills to Gain Confidence; Where We All Come From; Be a Friend; The Whole Human Being; Yup'ik Kinship Terms; Surviving Your Feelings; Strong and Sober; Relationships for a Good Life; Parenting Today. Communities shape each module's form to local practice, while its function, the protective factors it targets, stays the same. For example, the hunted species may differ between communities while the same safety, teamwork and skill factors are taught. The content of each module belongs to the communities and is not given here [source: Tools for Life slides; NIAAA NativeAIR]. NIMHD's HDPulse intervention profile lists implementation guidelines on the Qungasvik website, offers its measurement package and related papers on request, and names the Center for Alaska Native Health Research at the University of Alaska Fairbanks as contact; it describes delivery by community health workers, peers and Elders over 2–3 years [source: NIMHD HDPulse IP-074]. A clinician who wants the current manual should go through that contact and the community, not reproduce modules [synthesis].
Measurement: tribal leaders judged direct surveys about alcohol use and suicidality culturally incongruent and stigmatising, so the trial measured protective factors instead. [source: NIAAA NativeAIR]

B. Calricaraq (YKHC, community level). Staff visit a village only after its tribal leaders formally invite them. They then work with Elders and leaders to build awareness. The flagship is a three-day gathering: day 1 covers historical trauma, day 2 hurtful behaviour and abuse, and day 3 Yup'ik teachings on the path to wellness. As needed, staff also offer tribal-council orientations, talking circles, skill-building workshops, healing ceremonies (run by the community; not described here), school presentations, crisis intervention, and train-the-trainer workshops. Two manuals were written with the Elders' Council. Calricaraq is group and community work, not one-to-one treatment. It runs alongside Western behavioural health, which uses CBT, motivational enhancement, the community reinforcement approach, family therapy, peer services and contingency management, and alongside medication treatment for opioid use disorder. YKHC runs a two-day Calricaraq Indigenous Health & Wellbeing Training for clinicians (10.75 CME hours in January 2025). [source: Honoring Nations Calricaraq report; YKHC/ANTHC session 2025]

C. The psychotherapist's own course (individual or family). [synthesis, built on the CFI and on the published programme structures above]

Phase 1, preparation (before and between clients): self-examination, learning local history, and finding out which tribal health organisation, behavioural-health team, Calricaraq or Qungasvik contacts, and tribal-doctor services serve the client's community. Move on once you can name the referral routes and the local sources of authority.
Phase 2, cultural assessment (sessions 1–3): the core CFI, any supplementary modules indicated, the explanatory model, and questions about healers and programmes. Move on once you and the client share an account of the problem, and the client has said whether and how they want traditional or community resources involved.
Phase 3, joint work (usually brief and focused, as YKHC's wellness clinic model emphasises): evidence-based therapy adapted to the client's framing; coordination with tribal doctors, Calricaraq staff or Elders when the client consents; and integration of what the client brings back from gatherings or tribal-doctor care. Return to Phase 2 if the formulation changes.
Phase 4, transition: handing over to home-community supports. A stated goal of the ANTHC wellness clinic is to "return clients to home services." [source: YKHC/ANTHC session 2025]
Throughout: risk assessment, safeguarding, and coordination with prescribers.

3. Guiding principles

The culture is the intervention. [source: NIAAA; NIMHD] Practically: treat Yup'ik ways of life as the client's main resource, not as a backdrop to "real" therapy.
Community invitation comes first. Calricaraq goes only where tribal leaders ask, and Qungasvik is community-initiated. [source: Honoring Nations; UAF CANHR] Practically: never arrange or promote community programmes, gatherings or healers on your own initiative; connect the client only through the community's own pathways.
Elders guide; Western knowledge supplements. [source: Rasmus et al. 2019; NIMHD] Practically: ask how Elders' guidance fits the client's goals, and treat Elders' teaching as authority on cultural matters.
Collective, relational, cyclical knowledge. Yup'ik knowledge is described as collective, relational and cyclical, in contrast with institutions' individual, linear style. [source: NIMHD] Practically: map family, kin and community ties early. Expect healing to come back round to themes rather than move in a straight line.
Interdependence as a goal. [source: UAF CANHR; Rasmus et al. 2019] Practically: frame goals around contributing to and being supported by family and community, not only around personal independence.
Every person contributes at every life stage, and worth lies in who one is, not what one owns. [source: Honoring Nations] Practically: challenge shame tied to unemployment or income by drawing on this teaching, in the client's words.
Historical trauma is named openly. [source: Honoring Nations; YKHC 2025] Practically: ask about boarding schools, epidemics, and loss of language and parenting knowledge in the family as possible context for the problem, not as a diagnosis.
Grief is shared and not compared. YKHC cites Elder Peter Jimmie: one's pain should not be measured against others'. [source: YKHC/ANTHC session 2025] Practically: do not rank losses, and normalise grief as a shared human experience.
Speaking openly lightens a "heavy heart" or "heavy mind." [source: Honoring Nations] Practically: invite story and talk, and recall YKHC's point that talking can help "without needing advice."
Strengths and protection, not deficit. [source: UAF CANHR; Tools for Life] Practically: with youth, assess and build reasons for life and sobriety alongside risk.
Local form, shared function. [source: NIAAA] Practically: do not import another community's practice. Ask what this client's own community does.
Culturally humble, collaborative, timely care that reduces stigma. [source: YKHC/ANTHC BHWC slides] Practically: offer prompt, short, focused sessions and telehealth for village clients, and treat the client as resilient and able to change.
Describe spiritual matters as the client and community hold them. [synthesis] Practically: use the client's terms, and neither assert nor dismiss spiritual explanations.
The CFI supports judgement and does not replace it. [source: APA CFI form] Practically: use cultural information to inform the diagnosis, not to make it on its own.

4. Intervention inventory

Everything in this section is the psychotherapist's own work. Yup'ik teaching, tribal-doctor care, Calricaraq gatherings and Qungasvik activities are led by Yup'ik Elders, tribal doctors and community instructors. They are named here only so that you can work alongside them. Example language is illustrative.

4.1 Cultural humility and self-examination

Purpose / when: before you work with Yup'ik clients, and again whenever you notice an assumption. The Qungasvik partners treat learning the community's place in its social history, and the legacy of colonisation, as a necessary step for outsiders. [source: UAF CANHR]
Steps: (1) Write down what you believe about Alaska Native drinking, suicide and "culture loss", and where those beliefs come from. (2) Learn the history the programmes name: epidemics, forced boarding-school placement, abuse, loss of language and parenting knowledge, and pressure from values that equate worth with income. [source: Honoring Nations] (3) Learn who serves the client's region: YKHC behavioural health and Calricaraq for the YK Delta; SCF and ANTHC services in Anchorage. (4) If you can, attend YKHC's Calricaraq training or an equivalent course run by a tribal organisation. [source: YKHC/ANTHC 2025] (5) Take your reactions to consultation or supervision. [synthesis]
Example language (illustrative): "I'm not Yup'ik, and there'll be things about your family and village I don't know. If I get something wrong, I'd like you to tell me."
Watch for: speaking about "the Yup'ik" as though they were all alike, or treating culture as only damaged. It is working when your questions follow the client's own terms and the client corrects you openly.

4.2 Locating the client: home community, region and services

Purpose / when: first contact. The programmes are local and differ by community, and a stated aim of care is to return clients to home services. [source: NIAAA; YKHC/ANTHC 2025]
Steps: (1) Ask about the home village, where the client lives now (village, Bethel, Anchorage, elsewhere), and their language preference (Yup'ik, Cup'ik or English). (2) Ask which tribal health organisation they use, and whether they have contact with a behavioural health aide, the local Calricaraq provider, a Qungasvik coordinator or a tribal doctor. (3) Offer an interpreter if the client prefers Yup'ik or Cup'ik. Agree confidentiality first, since small communities make it easy to recognise people. [synthesis] (4) Record the client's own words for the services they use.
Example language (illustrative): "Where's home for you? Who do you go to back home when things get hard: family, Elders, the clinic, anyone else?"
Watch for: guardedness about confidentiality in small, connected communities, and seasonal subsistence work affecting attendance. It is working when you have a map of supports you can actually use.

4.3 Core Cultural Formulation Interview (DSM-5-TR)

Purpose / when: the first or second assessment session, to understand the problem from the view of the client and their social network: what it means, where help can come from, and what they expect from services. It has 16 questions in four domains. [source: APA CFI form]
Steps: (1) Explain why you are asking. (2) Domain 1, cultural definition of the problem (Q1–3): ask how the client and their family or community describe the problem, in their own words. (3) Domain 2, cultural perceptions of cause, context and support: causes (Q4–5); stressors and supports (Q6–7), including Elders, kin and the land; the role of cultural identity (Q8–10), including Yup'ik identity, language and faith. (4) Domain 3, self-coping and past help-seeking (Q11–13): include subsistence activity, church, Elders, tribal doctors, Calricaraq and past barriers. (5) Domain 4, current help-seeking (Q14–16): ask about preferences, and about the relationship with you, including racism or language barriers. (6) Summarise back to the client. Paraphrase the questions rather than reading the form. The APA allows clinicians to reproduce the form for their own patients; modifying or translating it needs APA permission. [source: APA CFI form] A time per interview is [uncertain: not verified]; field-trial clinicians found later interviews took less time. [source: Lewis-Fernández et al. 2017, abstract]
Example language (illustrative): "Sometimes people describe a problem in their own way, or in Yup'ik. How would you or your family talk about what's happening?" / "Is there anything about me or this clinic that makes it harder to talk?"
Watch for: short answers that mean the client does not yet trust you, not that they have nothing to say. Slow down and let them tell it as a story. It is working when the client's account sets the focus of treatment.

4.4 CFI supplementary modules and Informant Version

Purpose / when: to go deeper where the core CFI points. The modules can be used at intake, later, or repeatedly. [source: APA Supplementary Modules]
Steps: choose from the 12 modules. Usually relevant here: Spirituality, Religion and Moral Traditions (Yup'ik teachings, Christian denominations active in the region, and how the client holds them together); Cultural Identity (language, place, kinship); Social Network; Psychosocial Stressors; School-Age Children and Adolescents (for the 12–18 age range that Qungasvik serves); Older Adults; and Caregivers (given to the caregiver). Use the 17-question Informant Version with a family member when the client agrees. [source: APA forms] Pairing these with Yup'ik community services is [synthesis].
Example language (illustrative): "Are there teachings from your Elders or your church that guide you when things are hard? How do they sit together for you?"
Watch for: setting "traditional" against "Christian" when the client does not; many people hold both. It is working when the client's sources of meaning appear in the treatment plan.

4.5 Explanatory model (Kleinman)

Purpose / when: alongside the CFI, or when the client's view of cause or cure differs from yours. [source: Kleinman, Eisenberg and Good 1978, via Tanenbaum handout]
Steps: cover in your own words: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment they think they should get; the main problems it has caused; and what they fear most. Note where the client's model and yours overlap, and negotiate a shared plan. Yup'ik frames you may hear include historical trauma, a "heavy heart" or "heavy mind," losing balance (the opposite of calricaraq), and loss of reasons for life or sobriety. Attribute these to the client and their community. [source: Honoring Nations; YKHC 2025; Tools for Life]
Example language (illustrative): "What do you think started this? What do you think would help most, and who should be part of that?"
Watch for: pressing on to your own model when the client's makes good sense. It is working when the plan uses the client's own words for the goal, such as "getting back in balance."

4.6 Cultural concepts of distress and Yup'ik idioms

Purpose / when: when the client describes distress in cultural or Yup'ik terms. Cultural concepts of distress include idioms, explanations or perceived causes, and syndromes. DSM-5-TR revised its examples to avoid stigmatising or generalising language. [source: APA Section III]
Steps: (1) Ask what the term means to the client and family, rather than assuming. (2) Note YKHC's published framings, such as heavy heart or heavy mind, and grief that is shared. Many other Yup'ik terms used in YKHC materials have no published translation; ask the client or a cultural broker, and do not guess. [source: YKHC/ANTHC 2025; Honoring Nations] (3) None of the cultural concepts of distress listed in DSM-5-TR is Yup'ik [uncertain: not verified]. Do not apply the outdated label "pibloktoq," historically attributed to Arctic peoples; it was removed from the DSM-5 glossary. [source: Teodoro and Afonso 2020] (4) Assess for any co-occurring disorder separately.
Example language (illustrative): "You said your mind feels heavy. Can you tell me more about what that's like, and what lightens it?"
Watch for: treating an idiom as a diagnosis, or missing depression behind it. It is working when the idiom becomes a shared word for tracking change.

4.7 Asking, without judgement, about tribal doctors, Elders and community programmes

Purpose / when: at intake and at reviews. Many Alaska Native people use traditional healing on request or by referral alongside Western care. [source: NLM Native Voices]
Steps: (1) Ask an open question about every source of help: Elders, tribal doctors, Calricaraq gatherings or talking circles, church, subsistence activity, family. (2) Ask what helped and what did not. (3) Ask whether the client wants you to coordinate with any of these, and with whom. (4) If the client uses traditional plant medicines (SCF runs plant education, such as its annual Tikahtnu Plant Symposium, and its Traditional Healing Clinic keeps a teaching garden of mostly Alaska-native plants; the symposium booklet itself warns that natural products are not always safe and advises checking with a pharmacist or physician [source: SCF Tikahtnu Plant Symposium booklet 2021]; YKHC's work in this area is [uncertain]), note it and tell the prescriber, with consent, so any interactions can be checked. Never advise starting, stopping or changing any remedy or medicine. [synthesis]
Example language (illustrative): "Some people see a tribal doctor or go to Calricaraq as well as coming here. Have you done anything like that? I ask because I'd like to support it, not compete with it."
Watch for: the client hiding traditional care because they expect disapproval, given the history of missionaries and clinics suppressing it. [source: Litecky 2011 abstract, historical] It is working when the client tells you about it unprompted at later reviews.

4.8 Distinguishing culturally normative experience from disorder

Purpose / when: when the client reports spiritual experiences, contact with deceased relatives, dreams with meaning, or other experiences that may be normal within Yup'ik or Christian frames, or when psychosis, dissociation or complicated grief is possible.
Steps: (1) Ask how the client's family and community see the experience. Is it expected, respected or worrying? (2) With consent, consult a cultural broker or a community member the client trusts, such as Calricaraq staff or a behavioural health aide. Do not approach Elders without the client's agreement and the community's own channels. [synthesis] (3) Apply the diagnostic exclusions. DSM-5 dissociative identity disorder notes that identity disruption "may be described in some cultures as an experience of possession." It excludes a disturbance that is "a normal part of a broadly accepted cultural or religious practice." Dissociative trance (other specified dissociative disorder) does not apply when the trance is part of accepted collective practice. A university guide citing DSM-5-TR paraphrases both points; whether DSM-5-TR keeps the exact wording is [uncertain: not verified]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder both require the state to be involuntary and unwanted and outside accepted cultural or religious practice. [source: PMC9199574; Lewis 2023 Pressbooks; findacode ICD-11] The DSM-5-TR note that culturally sanctioned beliefs are not counted as psychotic symptoms is [uncertain: not verified]. (4) Still assess distress, impairment, safety, sleep, substance use and negative symptoms. (5) Agree with the client what would mean they need more help.
Example language (illustrative): "When you hear your grandmother, how do you and your family understand that? Is it comforting, frightening, or something else?"
Watch for: two errors, pathologising a respected experience and missing an emerging psychosis or mania. Signs that point towards illness include loss of function, distress the client does not want, and family concern that the experience is "not right." [synthesis] It is working when the client feels understood and the plan names who to call if things change.

4.9 Referral and collaboration with tribal doctors and community programmes

Purpose / when: when the client wants traditional healing or community support alongside therapy.
Steps: (1) Confirm what the client wants. (2) Use published pathways. SCF Traditional Healing Clinic (Anchorage, Alaska Native and American Indian customer-owners): referral through the primary care provider. Tribal doctors offer traditional physical work, traditional counselling and talking circles, and set goals and a plan with the client. Clinic line 907-729-4958 as published in 2024. [source: SCF clinic article 2024] YKHC (YK Delta): Behavioral Health 907-543-6100; Calricaraq 907-543-6114 or calricaraq@ykhc.org, as published January 2025. Calricaraq visits a village only on the tribal leadership's invitation. [source: YKHC/ANTHC 2025; Honoring Nations] (3) Get written consent for each exchange of information, and agree exactly what will be shared. [synthesis] (4) Agree roles. The tribal doctor or Elder leads cultural healing, and you lead psychotherapy and risk management. You do not supervise or judge their methods. [synthesis] (5) Review together with the client how the two strands fit.
Example language (illustrative): "Would you like me to talk with your primary care provider about a referral to the Traditional Healing Clinic? I'd share only what you're comfortable with."
Watch for: referral used as a way to pass on a difficult client, and loss of contact with risk once the referral is made. It is working when the client describes the two kinds of care as supporting each other.

4.10 Integrating Calricaraq, gathering or tribal-doctor experiences into therapy

Purpose / when: after a client attends a Calricaraq gathering, a talking circle or tribal-doctor sessions, since gatherings cover historical trauma, hurtful behaviour and abuse, and Yup'ik teachings on wellness. [source: Honoring Nations]
Steps: (1) Ask what the client wants to bring into therapy. Do not ask for details of any ceremony, and let the client decide what to share. (2) Explore what they learned in YKHC's own frame of examining the past, processing it and healing, if the client uses it. [source: YKHC/ANTHC 2025] (3) Expect painful memories to surface, such as abuse or boarding-school family history, and pace trauma processing accordingly. (4) Link insights to concrete steps: family repair, sobriety, a role in the community. (5) Check sleep, safety and substance use in the days after intense gatherings. [synthesis]
Example language (illustrative): "You went to the gathering last week. Is there anything from it you'd like to work on here?"
Watch for: distress stirred up by the day on hurtful behaviour and abuse, and disclosures that need a safeguarding response (4.15). It is working when the client links what they learned to changes in daily life.

4.11 Grief work in line with Qaruyun guidance

Purpose / when: bereavement, including suicide loss, which can be frequent in small communities. YKHC's Qaruyun (traditional Yup'ik/Cup'ik healing applied to behavioural health care) gives clinicians grief guidance. [source: YKHC/ANTHC 2025]
Steps: (1) Name the feeling. (2) Normalise grief as a shared human experience, without ranking losses (Elder Peter Jimmie's teaching). (3) Use story. YKHC describes anciyaraq as recognising grief by hearing others share personal stories, so group or family settings may suit some clients. (4) Screen for shock, anger, guilt, physical symptoms, isolation, substance use and self-harm. (5) Support self-care: rest, food, water, staying busy, connecting, helping others, and time with children. (6) Listen without rushing to advise. [source: YKHC/ANTHC 2025]
Example language (illustrative): "You don't have to measure this against what anyone else has lost. It's heavy for you, and that matters."
Watch for: grief turning into isolation, heavier drinking or suicidal thinking, and cumulative losses. It is working when the client reconnects with people and routines.

4.12 Protective-factor work with Yup'ik youth

Purpose / when: youth aged about 12–18 at risk of suicide or alcohol misuse, in line with Qungasvik's targets. [source: Tools for Life; NIAAA]
Steps: (1) Alongside the risk assessment, ask about the protective factors the programme names: awareness (ellangneq); reasons for life (Yuuyaraqegtaar); reasons for sobriety (Umyuangcaryaraq); self-efficacy and communal mastery; family relationships; community support, connection with Elders, and social networks. [source: Tools for Life] (2) Build a personal list of the youth's reasons for life and sobriety in their own words. (3) Find land-based, subsistence, family and cultural activities the youth already takes part in or wants to. (4) If the home community runs Qungasvik, connect the youth and family through the local prevention coordinator with consent. Do not deliver Qungasvik modules yourself. [synthesis] (5) Use the CFI adolescent module and involve caregivers.
Example language (illustrative): "What are the things, people and places that make life worth living for you? Who taught you the things you're proud you can do?"
Watch for: reasons for life that rest on a single person or relationship, which leaves the youth fragile if it ends. The programme's evaluation found that youth with lower starting protection, and boys under 15, gained most. [source: Tools for Life] It is working when the list of reasons grows and the youth spends more time with family, Elders and activities.

4.13 Partnering in a community Qungasvik or Calricaraq effort (when invited)

Purpose / when: for a clinician or service invited by a tribe or tribal health organisation to support a community programme.
Steps: (1) Wait for the invitation, and work through the tribal council, Elders and local leaders. (2) Learn local history, decision-making and existing settings. (3) Agree your role. In the Qasgiq model, Western knowledge is supplementary, shared at Elders' discretion, and nobody acts as a "chief." (4) Support the community's own delivery with things like a crisis-response link, referral pathways and help with evaluation, if asked. (5) Accept the community's measurement choices, such as protective factors rather than direct suicide surveys. (6) Plan for the long term, with three-year cycles and a summer pause. (7) Expect start-up to need intensive community organising, coalition building and staff training. [source: UAF CANHR; Rasmus et al. 2019; NIAAA]
Example language (illustrative): "We're here to help with what your community decides. Tell us where you'd like us, and where you wouldn't."
Watch for: outsiders taking over planning or content, and pressure to adopt measures that clash with community values. It is working when the community's qasgiq makes the decisions and asks for your input.

4.14 Suicide risk assessment and safety planning, culturally adapted

Purpose / when: at every intake, and whenever risk rises. Communities have found direct survey questions about suicide stigmatising in research. Clinical risk assessment is still required: ask directly, with care. [source: NIAAA for the research context; synthesis for the clinical stance]
Steps: (1) Explain why you ask, then ask directly about suicidal thoughts, intent, plans, past attempts and recent losses, including suicides in the community. (2) Build the safety plan around the client's own reasons for life (4.12), named family and Elders, and the community's crisis-response arrangements where they exist ("Crisis Response Team" is one Qungasvik module title). [source: Tools for Life] (3) Lethal-means counselling: secure storage or removal of means, agreed with family. In subsistence households, firearms are often working tools, so negotiate storage, such as locked or held by a relative, rather than outright removal. [synthesis] (4) Agree emergency routes for villages with no on-site clinician: YKHC Behavioral Health, telehealth, and the local clinic. [source: YKHC/ANTHC 2025 for the numbers; synthesis for the routing]
Example language (illustrative): "I ask everyone this, because it matters. Have you had thoughts of ending your life? ... Who back home would you want to know if things got this heavy again?"
Watch for: recent suicides in the network (contagion), anniversaries, intoxication, and young men aged 20–29, whom the programme materials identify as having the highest rate. [source: Tools for Life] It is working when the plan names real people and steps the client says they will use.

4.15 Safeguarding

Purpose / when: when any practice or situation harms the client or a child, or delays urgent medical care. Calricaraq itself addresses hurtful behaviour and abuse as a theme. [source: Honoring Nations]
Steps: (1) Follow your mandatory reporting duties for child abuse, elder abuse and domestic violence under Alaska and tribal procedures. (2) Separate culture from harm. Yup'ik teachings and tribal healing are not the harm, but abuse can occur in any setting. (3) Where possible and safe, involve the tribal health organisation's protocols and tribal child-welfare bodies. (4) Make sure that use of traditional healing never delays urgent medical or psychiatric care. Coordinate rather than replace. (5) Keep the client and family informed. [synthesis]
Example language (illustrative): "What you've told me means I need to make sure the children are safe. I'd like to work out with you how to do that in a way that respects your family."
Watch for: fear that reporting will repeat the history of children being removed. It is working when safety is secured and the family stays engaged.

4.16 Coordinating with substance-use and medication treatment

Purpose / when: alcohol or opioid use. YKHC runs its medication treatment for opioid use disorder with weekly integrated meetings of providers, behavioural health, pharmacy and case management, and is working Calricaraq's cultural and spiritual component into the programme. [source: YKHC/ANTHC 2025]
Steps: (1) Assess use with the client's reasons for sobriety in mind. (2) Coordinate with the prescriber and case manager, with consent. Never advise on medicines; route all medication questions to the prescriber. (3) Offer evidence-based approaches that YKHC also uses (CBT, motivational enhancement, community reinforcement, family therapy), framed in the client's terms. (4) Support links to Calricaraq or Qungasvik if the client wishes.
Example language (illustrative): "What are your reasons for staying sober, the ones that are really yours? Let's build from those."
Watch for: stigma, which YKHC addresses partly by giving its programme a Yup'ik name, and village access barriers that call for phone groups or telehealth. It is working when the client stays in contact across settings.

4.17 Working with family, interpreters and kin

Purpose / when: throughout, given the relational and collective framing of healing. [source: NIMHD; Rasmus et al. 2019]
Steps: (1) With consent, invite the family members the client chooses, using the CFI Informant Version or Caregivers module. (2) Map kinship in the client's terms ("Yup'ik Kinship Terms" is a Qungasvik module, so kin roles carry weight). (3) Use trained interpreters. Agree confidentiality and check for existing relationships with the client, since communities are small. (4) Support family repair and parenting, which a Qungasvik module, "Parenting Today," also addresses. [source: Tools for Life; APA forms; synthesis for steps 3–4]
Example language (illustrative): "Who in your family should be part of this, and who would you rather wasn't?"
Watch for: family members speaking for the client, and interpreter conflicts of interest. It is working when family support shows up in the client's daily life.

4.18 Working with historical and intergenerational trauma

Purpose / when: when the client links their distress to colonisation, boarding schools, epidemics or family breakdown, as the programmes do. [source: Honoring Nations]
Steps: (1) Invite the family history without pressing. (2) Validate it as context and not a deficit. (3) Use trauma-focused therapy at a pace the client chooses, with the usual safety, consent and stabilisation steps before any exposure work. (4) Link back to strengths: ancestral resilience and cultural continuity, which is Step 1 of the Qasgiq model. [source: Rasmus et al. 2019] (5) Name racism in services when it has happened (CFI Q16). [source: APA CFI form; synthesis for steps 1–3]
Example language (illustrative): "Your grandparents went through a lot. Alongside the pain, what did they pass on that helped them survive?"
Watch for: overwhelm, and the client feeling defined only by trauma. It is working when the client tells a story that includes survival and strength.

4.19 Brief, accessible, telehealth-supported format

Purpose / when: for rural village clients and moderate-acuity adults. The ANTHC Behavioral Health Wellness Clinic model emphasises timely access, brief focused sessions, telehealth and returning clients to home services. [source: YKHC/ANTHC 2025, BHWC slides]
Steps: (1) Offer the first appointment quickly. (2) Agree a short, focused set of sessions with clear goals. (3) Use telehealth or phone where travel is a barrier. (4) Plan the handover to local supports from the start.
Example language (illustrative): "Let's agree what you'd most like to change in the next few sessions, and who back home can carry it on with you."
Watch for: lost connections in remote settings, and clients being sent away from their communities when local support could work. A published Alakanuk example kept youth in tribal life through a talking circle instead of sending them away. [source: Honoring Nations] It is working when the client stays connected to home services.

5. Handling problems

Most guidance here is [synthesis] unless a source tag is given. The sources address community-level challenges, not individual therapy difficulties.

Stuck client or few words in the CFI. Do not push with more questions. Shift to story: ask about the home village, the land, or someone they learned from. Return to the CFI domains over several sessions. Silence may be respectful reflection, not resistance.
"Resistance" that is mistrust of services. Name the history openly: missionaries and Western institutions pressed healers to give up their authority, and boarding schools separated families. [source: Litecky 2011 abstract; Honoring Nations] Ask what would make the service safe, and use CFI Q16 on the clinician–patient relationship.
Overwhelm after a gathering or during trauma work. Pause processing and return to stabilisation. Involve the supports the client chooses. Check sleep, substance use and suicide risk within days.
Non-attendance. Ask about subsistence seasons, travel, weather, funerals and community obligations. Qungasvik itself pauses in summer for the harvest. [source: Rasmus et al. 2019] Offer phone or telehealth and flexible timing, and do not read absence as low motivation.
Rupture over culture. For example, you questioned a tribal doctor's role, or used a term the client found stigmatising. Acknowledge it directly, apologise, ask how to repair it, and record the client's preferred terms.
The client wants you to take part in or explain a ceremony. Decline the role kindly. Point them to the Elders, tribal doctors or Calricaraq staff who hold that authority, through community channels.
You want to add "Yup'ik techniques" to your practice. Don't. Qungasvik modules and Calricaraq content are made by communities, adapted locally, and delivered by people the community chooses. Outsiders deliver them only when invited and directed. [source: Rasmus et al. 2019; Honoring Nations] Whether Yup'ik bodies have issued a formal statement on outsiders reproducing practices is [uncertain: not verified]. Treat the principle of community invitation as binding.
Disagreement between the client's family or Elders and your recommendation. Say what you are worried about, especially risk, and ask for their view. Look for a plan both can support, such as therapy plus Elder support. Where risk is acute, act on risk and explain why.
Client uses traditional plant remedies alongside prescribed medicines. Do not advise. With consent, tell the prescriber and pharmacist so interactions can be checked.
Conflicting allegiances (church and traditional teaching). Use the CFI spirituality module. Do not force a choice. Qungasvik materials pair Yup'ik teaching with framings such as Ikayuulluta Agayutmek, "together with the help of our Creator." [source: Tools for Life]
Confidentiality in small communities. Agree up front who may know the client is in therapy. Take care with interpreters and referrals. Check before any contact with village services.
Measuring progress when standard scales feel alien. Track the client's own markers, such as balance, reasons for life and sobriety, family connection and community roles, alongside any required measures. Programme developers judged protective-factor measures more acceptable than direct suicide surveys. [source: NIAAA]
Clinician fatigue and vicarious trauma after repeated community losses. Get regular supervision, and consult tribal-organisation colleagues where possible.
When the community has no Calricaraq or Qungasvik provider. Ask the tribal health organisation or YKHC Calricaraq about requesting services. Requests come from tribal leadership. [source: Honoring Nations] Meanwhile, support the client's own family, Elder and land-based connections.

Sources

Web sources:

Publications cited by the pages above (this guide relies on those pages' accounts of them; details [uncertain]):

Allen J, Charles B, Fok CCT, Lee K, Grogan-Kaylor A, Qungasvik Team, Rasmus S (2023). Culturally grounded strategies for suicide and alcohol risk prevention delivered by rural Alaska Native communities: a dynamic wait-listed design evaluation of the Qungasvik intervention. American Journal of Community Psychology 71(1–2):184–197. doi 10.1002/ajcp.12621 (citation confirmed by NIMHD HDPulse and the University of Michigan Deep Blue record).
Allen J, et al. (2018). Prevention Science 19(2):174–185. doi 10.1007/s11121-017-0798-9.
Mohatt GV, et al. (2014). American Journal of Community Psychology 54(1–2):153–169. doi 10.1007/s10464-014-9646-2.
Rasmus SM, Charles B, Mohatt GV (2014). Creating Qungasvik (A Yup'ik Intervention "Toolbox"). American Journal of Community Psychology.
Alakanuk Community Planning Group et al. (2009). Qungasvik Toolbox (earlier 36-activity edition), via qungasvik.org.
Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258.
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM-5-TR).

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