Diné (Navajo) chantways and hand-trembling

1. Introduction

Version followed: Diné healing as Navajo Nation and Navajo-serving institutions publish it (Office of the Navajo Nation President and Vice President; Diné College; the Indian Health Service (IHS) Chinle Service Unit and its Office of Native Medicine; Sage Memorial Hospital), with federal museum material (National Library of Medicine, Smithsonian National Museum of the American Indian) and outsiders' clinical scholarship (Coulehan 1980; Rhoades 2009) as attributed context. The psychotherapist's own procedures follow the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules.

What it is. Diné (Navajo) healing is a living ceremonial and spiritual healing system held by Diné communities and their medicine people. It is not a therapy technique, and a psychotherapist does not practise it. The major healing ceremonies (chantways such as Blessingway and Enemyway, some of which include sandpaintings) are conducted by singers, the hataałii (also written hatałii). A separate kind of practitioner, the diagnostician or hand-trembler, identifies the cause of an illness, after which the sick person seeks a singer for the fitting ceremony. One physician-author describes the diagnostician as often working in a trance state. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] (outsider's account). Medicine people organise through bodies such as the Diné Hataałii Association and the Diné Medicine Men Association. [source: https://cronkitenews.azpbs.org/2020/11/10/pandemic-spotlights-clash-between-modern-traditional-navajo-ways/]

Core idea of how change happens, as described. In the account of one non-Navajo physician, Navajo people understand harmony as the natural state of all things, and illness as disharmony: a loss of right relationships with family, clan, other beings and the natural and spiritual worlds. The causes named include natural forces (such as lightning), spirits, witchcraft and contamination. On this view the symptom is a sign of the underlying disharmony, and ceremony restores right relationship. The whole family gathers around the patient, and this also benefits the community. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] The Smithsonian's National Museum of the American Indian says the Enemy Way "heals and restores balance," or hózhó, and "counters the negative effects of sustained proximity to death." [source: https://americanindian.si.edu/why-we-serve/topics/cultures-of-war/] Diné College describes Sa'ah Naagháí Bik'eh Hózhóón as the Diné traditional living system, which places Diné life in "harmony with the natural world and the universe." [source: https://dinecollege.edu/about_dc/educational-philosophy] These are the tradition's concepts, reported as the tradition and its scholars hold them.

The psychotherapist's role. You work alongside this system. You assess culturally (CFI, explanatory model), distinguish culturally normative experience from disorder, and, when the client wishes, collaborate with or refer to medicine people through the pathways that Diné communities and their health facilities set. You also help clients integrate ceremonial and clinical care, and you safeguard. You give no ceremony content, songs, prayers, sacred objects or diagnostic methods, and you do not judge which ceremony a client needs. [synthesis]

2. Framework

Diné ceremonies follow their own order, timing and authority, which belong to the hataałii and the family. They are not described here. The framework below is the psychotherapist's own pathway alongside them. Its phase structure is [synthesis], built on the CFI and on IHS and Navajo programme sources.

Phase 0: preparation (before seeing Diné clients).

Goal: know your own assumptions, and know the local Diné healing pathways.
Content: learn which services exist where you work. The IHS Chinle Service Unit was one of the first IHS facilities to set up an Office of Native Medicine, which has native healers on staff who advise clinicians and administration. [source: https://cybercemetery.unt.edu/archive/oilspill/20121010051300/http://www.ihs.gov/ipc/documents/IPC_CaseStudy_Chinle_508.pdf] Sage Memorial Hospital runs a traditional programme led by a Traditional Practitioner who supports the medical unit. [source: https://sagememorial.com/category/news/page/9/] In October 2024 federal approval allowed Arizona, California, New Mexico and Oregon to cover traditional health care practices under Medicaid and CHIP when provided at IHS, Tribal and urban Indian facilities. [source: https://www.ihs.gov/newsroom/pressreleases/2024-press-releases/biden-harris-administration-takes-groundbreaking-action-to-expand-health-care-access-by-covering-traditional-health-care-practices] In Arizona, AHCCCS traditional healing is delivered and billed by IHS and Tribal 638 facilities; each facility, with its Tribal community, decides which services it offers and checks that practitioners are qualified, and urban Indian organisation healers can take part through agreements with those facilities. [source: https://azahcccs.gov/AmericanIndians/TraditionalHealing/] The New Mexico Health Care Authority announced on 10 March 2026 that New Mexico Medicaid covers traditional healing by certified traditional healers for Native American members in participating communities, reimbursed to IHS providers [source: https://www.hca.nm.gov/2026/03/10/new-mexico-medicaid-now-covers-traditional-healing-practices-for-native-american-members/]; the Office of the Navajo Nation President and Vice President announced Turquoise Care coverage through IHS and Tribal 638 facilities, with referral to certified traditional healers, and says the Navajo Nation is "the first to implement this program." [source: https://opvp.navajo-nsn.gov/250324-traditional-healing-services/] Check current eligibility with the state Medicaid office or the facility before telling a client what is covered; coverage in Utah is [uncertain].
Move on when: you can name the local referral route, or the person to ask about it.

Phase 1: cultural assessment (first one or two sessions; [synthesis]).

Goal: understand the problem in the client's own terms, including any Diné, Christian, Native American Church or biomedical framing.
Content: the core CFI (16 questions in four domains), the Informant Version with a family member if the client agrees, and the supplementary modules as needed (Explanatory Model; Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Social Network; Patient-Clinician Relationship; Older Adults; School-Age Children and Adolescents). APA says the CFI can be used "by any clinician providing services to any individual in any care setting". The modules can be given at the first evaluation, later in care or repeatedly. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] The usual time the core CFI takes is [uncertain]. The DSM-5 field trial found that later interviews "required less time". [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]
Move on when: you can state the client's explanatory model, their help-seeking so far (including any diagnostician or singer), and what they want from you.

Phase 2: formulation and differential.

Goal: weigh culturally normative experience and belief against psychiatric disorder, without pathologising and without missing illness.
Content: the DSM-5-TR culture chapter and cultural concepts of distress. DSM-5-TR's possession-form DID criterion and its exclusion of experiences that are a normal part of a broadly accepted cultural or religious practice (exact DSM-5-TR wording [uncertain]). ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder, both of which require the state to be involuntary and unwanted and not part of accepted cultural or religious practice. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://www.findacode.com/icd-11/code-1807490186.html]
Move on when: the formulation names both the cultural meaning and any clinical risk.

Phase 3: collaboration and referral (only if the client wishes).

Goal: make sure that a client who wants traditional healing can reach it through legitimate community and facility pathways, and that both sides of care are coordinated with consent.
Content: IHS policy since 1978 recognises the value of traditional beliefs, ceremonies and practices. When a patient asks for a native practitioner, "every effort will be made to comply". This can mean contacting a practitioner, providing privacy for a ceremony, or authorising contract funds. [source: https://journalofethics.ama-assn.org/article/indian-health-service-and-traditional-indian-medicine/2009-10]
Move on when: the client has the contact they want, or has decided against it. Consent to share information is documented.

Phase 4: ongoing therapy and integration.

Goal: continue evidence-based treatment of the presenting problem while respecting the client's ceremonial path, and help them integrate what ceremony meant to them.
Format: individual or family sessions. The count follows the presenting problem, since Diné healing sets no therapy session count. [synthesis]
Move on when: treatment goals are met. Ending or continuing follows the usual clinical criteria.

Throughout: safeguarding and medical safety. Watch for delays in urgent medical care, for medicine changes made without the prescriber, and for any harm. Follow your reporting duties. [synthesis]

3. Guiding principles

Authority rests with Diné medicine people and communities. In practice: you never choose, recommend or evaluate a ceremony, and you never vouch for a practitioner yourself. Ask the client, their family or the facility's traditional medicine office. Medicine people's associations hold standing in Navajo civic life. The Diné Medicine Men's Association approved the Chinle Service Unit's culturally based strategic framework. [source: https://cybercemetery.unt.edu/archive/oilspill/20121010051300/http://www.ihs.gov/ipc/documents/IPC_CaseStudy_Chinle_508.pdf]
Ceremonial process is private. In practice: ask about meaning, effect and support, never about steps, songs or objects. A Diné nurse-researcher writing about a cleansing ceremony said she was obligated to the Navajo Nation and to the chanter to keep the ceremonial process private, and she did not describe it. [source: https://healthsciences.arizona.edu/news/blog/healing-power-ceremony-integrative-health-benefits-dine-cleansing-practice]
Both systems are commonly used together. In practice: expect clients to use a hospital and a singer for the same illness, and treat this as ordinary rather than a conflict. Clinicians report that many seriously ill Navajo patients use both. The Many Farms project concluded that patients believed both systems "work." [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] [source: https://journalofethics.ama-assn.org/article/indian-health-service-and-traditional-indian-medicine/2009-10]
Meaning of illness matters as much as its biology. In practice: ask what the illness means and where it came from before you explain your own model. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf]
Family and community are part of healing. In practice: ask who should be involved, and offer the CFI Informant Version or family sessions if the client agrees. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
No single "Navajo" view. In practice: do not assume a Diné client is traditional, Christian or Native American Church, or all three. Ask. Navajo leaders differ, some favouring Western medicine and others accepting both, and some young people are less engaged with tradition. [source: https://cronkitenews.azpbs.org/2020/11/10/pandemic-spotlights-clash-between-modern-traditional-navajo-ways/] Research listed by the Navajo Epidemiology Center includes a study of identity and healing in three Navajo religious traditions. [source: https://nec.navajo-nsn.gov/Research/Navajo-Healing-Practices]
Attribute, don't adjudicate. In practice: describe spirits, witchcraft, contamination and hózhó as the client and tradition hold them, neither confirming them as fact nor dismissing them. [synthesis]
Neither pathologise nor miss illness. In practice: a belief or experience shared by the client's community is not a symptom in itself. Distress, impairment, involuntariness and departure from community norms decide whether something is clinical. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [synthesis]
Client choice, consent and confidentiality. In practice: involve traditional healing only if the client wishes, and share information only with written consent. [synthesis]
Historical context of suppression. In practice: name the history and expect understandable mistrust. The American Indian Religious Freedom Act of 1978 was passed mainly to protect American Indian religions, and it gave impetus to IHS respect for traditional medicine. [source: https://journalofethics.ama-assn.org/article/indian-health-service-and-traditional-indian-medicine/2009-10] The specifics of Diné boarding-school and other historical trauma are [uncertain: not verified] here. Explore them with the client. [synthesis]
Medicines and herbs stay with the prescriber and the healer. In practice: never advise on herbs, or on starting, stopping or changing medicines. Route those questions to the prescriber. One scholar quoted in the press noted that herbs cannot prevent, treat or cure COVID-19. [source: https://cronkitenews.azpbs.org/2020/11/10/pandemic-spotlights-clash-between-modern-traditional-navajo-ways/]
Outsiders do not seek ceremonies. In practice: neither you nor a non-Diné client should seek out Diné ceremonies outside legitimate community and facility pathways. Attend only on the family's and practitioner's invitation, and never record or photograph. [synthesis]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is a Diné ceremony, chant, sandpainting or hand-trembling diagnosis, and none should be presented as one. The CFI content is paraphrased, so use the APA forms themselves. APA lets clinicians reproduce the CFI for use with their own patients, but modifying or translating it needs APA permission. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with Diné clients, so that your own beliefs about religion, Indigenous people, "real" medicine and spirituality do not distort assessment. [synthesis]
Steps: (1) Write down what you assume about Navajo healing and where those assumptions came from (films, fiction, tourism, training). (2) Note any pull to romanticise ceremony or to dismiss it. (3) Identify gaps you need to fill, such as local services, Diné language and clan concepts, using community sources rather than guesswork. (4) Take cases where culture shaped your reasoning to supervision or consultation, ideally with a Diné clinician or cultural adviser. (5) Revisit after each new Diné client. [synthesis]
Example language (illustrative): "I'm not Diné, and I won't know everything about how your family understands this. Please correct me when I get something wrong."
Watch for: curiosity that turns into extracting ceremonial information for your own interest. Treating the client as a cultural teacher. Using generic "Native" ideas in place of Diné specifics. It is working when the client corrects you freely and brings up traditional matters without being asked.

4.2 Mapping the local Diné healing pathways

Purpose / when: at intake to a service, and before any referral, so that you can offer legitimate routes rather than improvised ones.
Steps: (1) Ask your facility whether it has a traditional medicine office or practitioner. The Chinle Service Unit's Office of Native Medicine has native healers who advise clinicians and administration. [source: https://cybercemetery.unt.edu/archive/oilspill/20121010051300/http://www.ihs.gov/ipc/documents/IPC_CaseStudy_Chinle_508.pdf] Sage Memorial Hospital's Traditional Practitioner supports the medical unit, with plans for ceremonial spaces and a joint traditional and modern curriculum. [source: https://sagememorial.com/category/news/page/9/] (2) Learn your facility's policy on private space for ceremonies, which IHS policy contemplates. [source: https://journalofethics.ama-assn.org/article/indian-health-service-and-traditional-indian-medicine/2009-10] (3) For New Mexico Medicaid (Turquoise Care) members, learn how the facility refers to certified traditional healers. Services may include traditional herbs, prayers and ceremonies, in clinical settings, at home or in ceremonial spaces. [source: https://opvp.navajo-nsn.gov/250324-traditional-healing-services/] The certifying body is [uncertain: not verified]. (4) Record names of roles, not of individual practitioners, in shared resources. [synthesis] (5) If no programme exists, the default route is the client's own family and community. [synthesis]
Example language (illustrative): "Some people here also see a medicine person. The clinic has a traditional medicine office, and if you ever want that, I can tell you how people usually get in touch. It's entirely your choice."
Watch for: offering a referral the client did not ask for, which can feel like being typecast. Outdated programme information. It is working when the client knows the route and uses it, or declines it, on their own terms.

4.3 Core Cultural Formulation Interview

Purpose / when: early assessment of every client, including Diné clients, and whenever the meaning of symptoms, help-seeking or engagement is unclear. The CFI supports clinical understanding and decision-making. It is not meant to be the only basis for a diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Introduce it as wanting to understand the problem from the client's point of view. (2) Domain 1, Cultural Definition of the Problem: how the client and their family and community describe the problem, and what troubles them most. (3) Domain 2, Cultural Perceptions of Cause, Context and Support: what they think caused it (record a spiritual, relational, environmental or biomedical cause in their words), stressors and supports, and the role of cultural identity, including clan, language, religion and place. (4) Domain 3, Cultural Factors Affecting Self-Coping and Past Help Seeking: what they have done themselves, whom they have consulted (family, a diagnostician, a singer, church, a Native American Church roadman, IHS), and what got in the way. (5) Domain 4, Cultural Factors Affecting Current Help Seeking: what help they want now and from whom, and the clinician-patient relationship, including concerns about a non-Native clinician, racism and language. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] (6) Summarise back in the client's own terms. [synthesis]
Example language (illustrative): "In your own words, what's been going on? How would your family describe it?" ... "Some people have also gone to a medicine person or a hand-trembler, or to church. Have you or your family looked for help like that?" ... "What would help most right now, and from whom?"
Watch for: short answers that may reflect wariness about disclosing traditional practice to a non-Diné clinician. Revisit later rather than pressing. Note when the client names a cause in Diné terms, and keep their wording. It is working when the client's account of cause and help-seeking widens over sessions.

4.4 CFI Informant Version and supplementary modules

Purpose / when: the Informant Version for a family member or friend when family understanding shapes care, for example with older clients, adolescents or clients who are unwell. The supplementary modules for in-depth assessment, at first evaluation, later in care or repeatedly. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) Get the client's consent before interviewing a relative. (2) The Informant Version starts with the informant's relationship to the client and then covers the same four domains. (3) Choose modules by need. Explanatory Model, when cause and meaning are central. Spirituality, Religion and Moral Traditions, for the place of Diné ceremony, Christianity or the Native American Church. Cultural Identity, for clan, language and generation. Coping and Help-Seeking, for prior consultations. Social Network and Psychosocial Stressors. Patient-Clinician Relationship, when trust is in question. Older Adults or School-Age Children and Adolescents, by age. Caregivers, completed by the caregiver. (4) Fold the findings into the formulation. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Example language (illustrative): "Would it help if I also heard from your grandmother about how the family sees this? Only if you're comfortable with that." ... "Is faith or tradition part of how you're getting through this?"
Watch for: family members speaking over the client, and conflict between family members over traditional versus church paths. Keep the client's view central. It is working when you understand the family's model as well as the client's.

4.5 Exploring the explanatory model (Kleinman)

Purpose / when: whenever the client's understanding of cause, course and treatment may differ from yours. Use it with the CFI Explanatory Model module.
Steps: paraphrasing Kleinman's eight questions, ask (1) what the client calls the problem, (2) what caused it, (3) why it started when it did, (4) what it does to them and how it works, (5) how severe it is and how long it will last, (6) what treatment they think they should receive, (7) the chief problems it has caused, and (8) what they fear most about it. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] Then (9) set the client's model beside your own, and (10) negotiate a plan both can accept. [synthesis] A physician working with Navajo patients similarly urged clinicians to ask about patients' ideas of the origin and meaning of symptoms. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf]
Example language (illustrative): "What do you call what's happening? What do you think started it, and why now?" ... "What kind of help do you think this needs? It's fine if part of that is something I don't provide."
Watch for: the client naming witchcraft, contamination or a broken relationship as a cause. Record it in their words and do not debate it. If the client fears that naming such a cause will be dangerous or shameful, do not press. It is working when your plan can sit beside their model without either replacing the other.

4.6 Asking about diagnosticians and singers without judgement

Purpose / when: whenever help-seeking comes up, and routinely at intake. Many Navajo patients use both systems, and some do not volunteer it. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf]
Steps: (1) Ask in a normalising way. (2) Ask whether a ceremony has happened or is planned, and what it meant to the client and family, not what was done. (3) Ask whether the healer gave any guidance the client wants you to know about, such as things to avoid or a time to rest, and respect it. (4) Ask whether the client took any herbal or traditional preparation, without asking which or how. If so, tell them to let their prescriber or physician know. (5) Note the date and the client's view of how it went. [synthesis]
Example language (illustrative): "Has your family had anything done for this traditionally, like seeing a hand-trembler or having a ceremony? You don't need to tell me any details. I'm asking so I can fit around it." ... "Did the medicine person ask you to do or avoid anything that I should respect in our work?"
Watch for: your own questions drifting into ceremonial detail, so stop and return to meaning. Clients who think you are testing their beliefs. Instructions that conflict with urgent medical care, which belongs under safeguarding (4.13). It is working when the client mentions ceremonial plans unprompted.

4.7 Cultural concepts of distress and the normative-versus-disorder differential

Purpose / when: when an experience or belief could be culturally normative or a symptom: trance-like states, perceived spiritual causes, hearing or seeing ancestors or spirits, beliefs about witchcraft, intense grief after deaths, or post-combat reactions.
Steps: (1) Use the DSM-5-TR culture chapter. 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: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] No Diné-specific concept is listed among the DSM-5-TR examples in the secondary list available. [uncertain] [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] (2) Treat a perceived cause such as witchcraft, contamination or broken relationship as an explanation, which is a cultural concept, not as a delusion in itself. (3) A trance in a recognised practitioner during their role, such as a diagnostician, is part of accepted practice and not a disorder. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] [synthesis] (4) Apply the criteria. DID allows identity disruption described as possession, but excludes experiences that are a normal part of a broadly accepted cultural or religious practice (DSM-5 wording; DSM-5-TR wording [uncertain]). ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary and unwanted, not part of accepted cultural or religious practice, and causing significant distress or impairment. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://www.findacode.com/icd-11/code-1807490186.html] (5) Ask whether the family and community see the experience as normal or as illness, and use a cultural broker if unsure (4.8). (6) Screen for psychosis, mood disorder, PTSD, substance use and medical causes in the usual way. [synthesis] A DSM-5-TR note that culturally shared beliefs are not psychotic symptoms is [uncertain: not verified].
Example language (illustrative): "In your family and community, would what you've been experiencing be seen as something normal, or as something wrong?" ... "Has anyone you trust, a relative or a medicine person, said what they think it is?"
Watch for: two errors. One is diagnosing psychosis from a shared belief alone. The other is calling everything "cultural" and missing escalating symptoms, such as functional decline, beliefs the family does not share, command hallucinations, or self-neglect. It is working when the family's view and the clinical picture are both on the record.

4.8 Consulting cultural brokers and working with interpreters

Purpose / when: when you cannot judge whether an experience is normative, when the client prefers Diné (Navajo) language, or when a Diné concept needs explaining. Native healers on staff at Chinle advise clinicians, which is one model of in-house cultural consultation. [source: https://cybercemetery.unt.edu/archive/oilspill/20121010051300/http://www.ihs.gov/ipc/documents/IPC_CaseStudy_Chinle_508.pdf]
Steps: (1) Ask the client's permission before consulting anyone, and share the minimum needed. Where possible, de-identify the question. (2) Ask your facility's traditional medicine office, a Diné colleague or a family member the client names. (3) Use a trained medical interpreter, and do not use children as interpreters. Brief the interpreter on confidentiality and on not adding interpretation of their own. Ask the client whether they mind the interpreter being from their community. (4) Ask the broker about meaning and norms, not about ceremonial content. [synthesis]
Example language (illustrative): to the client: "Would it be okay if I asked someone from the clinic's traditional medicine office how this is usually understood? I wouldn't use your name." To the broker: "Without going into anything that shouldn't be shared, would most families see this as within the normal range?"
Watch for: a broker related to or known by the client, which raises confidentiality concerns. A broker's personal view standing in for community norms. The client feeling discussed behind their back. It is working when the consultation sharpens the differential and the client knows it happened.

4.9 Collaboration and referral with Diné medicine people (only when the client wishes)

Purpose / when: when the client asks for traditional healing, or says it is part of their path, and wants the two kinds of care coordinated.
Steps: (1) Confirm it is the client's wish, not yours or a relative's alone. (2) Use established routes: the facility's traditional medicine office or practitioner, a Turquoise Care referral where it applies, or the client's family. IHS policy says that when a patient asks for a native practitioner, "every effort will be made to comply". This can mean contacting a practitioner, providing privacy for a ceremony, or authorising contract funds. [source: https://journalofethics.ama-assn.org/article/indian-health-service-and-traditional-indian-medicine/2009-10] [source: https://opvp.navajo-nsn.gov/250324-traditional-healing-services/] (3) Get written consent for any exchange of information, specifying what may be shared, such as dates and general wellbeing, and keeping clinical detail to a minimum. (4) Leave the choice of ceremony and practitioner to the client, family and medicine people. Diagnosis of cause in the Diné system belongs to the diagnostician, and the ceremony belongs to the singer. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] (5) Agree how clinical care continues alongside, including medication, therapy appointments around ceremony dates and crisis plans. (6) Check in afterwards (4.11). [synthesis]
Context from elsewhere: two trials of collaboration with faith and traditional healers outside North America are context only, not Diné evidence. In COSIMPO (Gureje et al., The Lancet 2020, Nigeria and Ghana), collaborative shared care between traditional and faith healers and primary care workers gave a greater fall in psychosis symptoms, and harmful practices fell more than in the control arm. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] In a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication reduced symptoms, but days in chains were not significantly reduced. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]
Example language (illustrative): "You said you'd like a medicine person involved. The clinic's traditional medicine office can help with that. Would you like me to let them know you're interested, or would you rather contact them yourself or through your family?" ... "What, if anything, would you like me to share with them?"
Watch for: pressure from you or a relative, and financial strain, since families contribute money and resources to ceremonies. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] Watch also for a referral to an unaffiliated or commercial "healer" outside community pathways. It is working when the client experiences the two kinds of care as joined rather than competing.

4.10 Supporting Diné veterans: homecoming and Enemyway

Purpose / when: with Diné service members and veterans, especially with combat stress or PTSD. Navajo practice includes ceremony before deployment and after return. The NMAI says the Enemy Way "heals and restores balance," and reports "a correlation" between resolving post-traumatic stress and taking part in such ceremonies, in both customary practice and contemporary research. [source: https://americanindian.si.edu/why-we-serve/topics/cultures-of-war/] The National Library of Medicine says the VA and its health professionals support the Enemy Way and other traditional ceremonies for returning Native veterans. A Navajo spiritual leader quoted there speaks of removing a warrior's "armor" to help him reconnect with home. [source: https://www.nlm.nih.gov/nativevoices/exhibition/healing-ways/native-heritage/navajo-code-talkers.html] The research behind that correlation is not identified here, so treat it as a museum's summary, not as trial evidence that Enemyway treats PTSD [uncertain: secondary, unverified]. No controlled study of Enemyway for PTSD is cited in this guide.
Steps: (1) Ask about military service and whether the client or family follows Diné homecoming traditions. (2) If the client wants a ceremony, use the VA or IHS traditional healing contact, or the family (4.9). The VHA Office of Tribal Health states that a Whole Health personalised plan can include traditional healing or a healer, that VA chaplain services work with tribal elders and traditional healers, and that local and national traditional healing policies are still being developed; Rural Native Veteran Navigator staff help Native veterans coordinate care across VA, IHS and tribes. [source: https://www.nihb.org/wp-content/uploads/2025/07/09-Joshua-Wear_VA-Tribal-Health.pdf] Arrangements differ by VA facility; ask the local facility what it offers [uncertain]. (3) Offer evidence-based PTSD treatment alongside, and agree its timing with the client around ceremony dates. (4) Afterwards, explore what changed for the client and family (4.11). (5) Involve family and community in reintegration if the client wishes, since NMAI describes community participation as recognising sacrifice and supporting return to everyday life. [source: https://americanindian.si.edu/why-we-serve/topics/cultures-of-war/] [synthesis for steps 1-4]
Example language (illustrative): "Some Diné veterans have ceremonies when they come home. Is that something you or your family have thought about? We can work on the nightmares here either way, alongside anything you do traditionally."
Watch for: framing ceremony as a replacement for trauma treatment, or trauma treatment as a replacement for ceremony. Ongoing suicide risk, so assess it in the usual way regardless of ceremony. Veterans who are not traditional and do not want this raised again. It is working when symptoms and the client's sense of reconnection both improve.

4.11 Integrating ceremonial experience into therapy

Purpose / when: after a ceremony or traditional consultation the client chooses to bring into therapy.
Steps: (1) Invite the client to share what it meant, how they feel and what changed in their relationships, without asking for content. (2) Respect any guidance or restrictions the healer gave. (3) Link the client's sense of restored balance or relationship to their therapy goals in their own words. (4) Note changes in symptoms and functioning in the usual way. Ceremonies can relieve symptoms and restore function even when a physical disease remains. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] (5) If distress worsened, explore it without blaming the ceremony, and adjust care. [synthesis]
Example language (illustrative): "You mentioned the ceremony last month. Without telling me anything that should stay private, how have things been since? Has anything shifted with your family?"
Watch for: expecting a cure of a physical disease, which is not a claim to reinforce. Physical illness still needs its own medical care. Guilt or self-blame if symptoms continue. It is working when the client can name what helped and carry it into daily life.

4.12 Working with families and clan relationships

Purpose / when: when the family is central to the illness, its meaning or its healing, as in Navajo ceremonial healing, where the family gathers around the patient. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf]
Steps: (1) Ask whom the client counts as family, including extended family and clan relatives. (2) With consent, invite them to a session or use the CFI Informant Version. (3) Map supports and conflicts, including differences over traditional, Christian or Native American Church paths. (4) Agree roles in the care plan. (5) Respect who in the family makes decisions, while protecting the client's own consent. [synthesis]
Example language (illustrative): "Who in your family should be part of this, if anyone? Some people want their aunts or grandparents involved. Some prefer to keep it private."
Watch for: family pressure against the client's wishes, in either direction. Confidentiality in small communities. Elder abuse or coercive control presented as family authority. It is working when the family becomes a resource rather than a battleground.

4.13 Safeguarding and medical safety

Purpose / when: throughout, whenever a client's health or safety is at risk, whatever its cultural framing.
Steps: (1) Ask whether any urgent medical care is being delayed, and if so encourage prompt medical contact without dismissing the ceremony. Both can happen. (2) For any herbal or traditional preparation, tell the client to inform their prescriber, and never advise on it yourself. Route medicine questions to the prescriber. (3) In infectious-disease emergencies, follow public-health guidance on gatherings. During COVID-19, people visiting healers were exposed to the virus, several healers died, and in-person ceremonies were paused, with some moving to remote options. [source: https://cronkitenews.azpbs.org/2020/11/10/pandemic-spotlights-clash-between-modern-traditional-navajo-ways/] (4) Assess suicide risk with standard practice, with lethal-means counselling limited to safe storage and removal. (5) Report abuse, neglect or exploitation as your jurisdiction requires (tribal, state or federal), whoever is involved, including anyone using a healer's role for harm. Distinguish legitimate practice from abuse with a cultural broker, not by assumption. [synthesis]
Example language (illustrative): "I respect that the ceremony is important. I'm also worried about the chest pain. Can we make sure you see a doctor this week, as well?" ... "Please tell Dr. ___ about anything traditional you're taking. I can't advise on that, but they need to know."
Watch for: missed medical emergencies, medication stopped without the prescriber, financial exploitation, and anyone, Diné or not, selling "Navajo ceremonies" outside community pathways. It is working when safety risks are addressed without the client feeling their tradition was attacked.

4.14 Addressing historical suppression, intergenerational trauma and racism in services

Purpose / when: when mistrust, disengagement or grief connect to colonial history, past suppression of religion, or racism in health care. The American Indian Religious Freedom Act of 1978 was passed to protect American Indian religions. [source: https://journalofethics.ama-assn.org/article/indian-health-service-and-traditional-indian-medicine/2009-10]
Steps: (1) Use the CFI Patient-Clinician Relationship questions to invite concerns about you and the service. (2) Acknowledge history without making the client teach it. (3) Explore family history of boarding schools, relocation or loss of language, if relevant and if the client wishes. Diné-specific details are [uncertain: not verified] here. (4) Name and repair any racism the client experiences in your service, and escalate it institutionally where needed. [synthesis]
Example language (illustrative): "Many Native people have had bad experiences with clinics, and some of that history goes back generations. If anything here feels like that, I want to know."
Watch for: defensiveness in yourself, treating historical trauma as the explanation for everything, and missing current stressors. It is working when the client raises concerns about care directly.

4.15 Documentation and confidentiality

Purpose / when: every time traditional healing is discussed.
Steps: (1) Record only what is clinically needed, such as "client reports family arranged a traditional ceremony, which they describe as helpful," and never ceremonial content. (2) Do not record practitioners' names unless the client wants coordination and has consented. (3) Keep consent forms specific about what goes to whom. (4) Remember that small-community records may be seen by staff who know the family. [synthesis]
Example language (illustrative): "I'll just note that you had a ceremony and that it helped. Nothing more. Is that okay?"
Watch for: template notes that ask for ceremony details, and copying traditional-healing notes to other services by default. It is working when clients are willing to discuss traditional care because it is handled discreetly.

5. Handling problems

The sources give little direct guidance on these problems. Everything in this section is [synthesis] unless a source is cited.

Client won't discuss traditional healing (wariness, not resistance). Many patients use both systems without telling clinicians. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf] Do not press. Say once that it's welcome and that you will never ask for details, then return to it later through the CFI help-seeking questions. Illustrative: "You don't have to tell me anything about it. I only mention it so you know it won't be judged here."
Client asks you to perform, recommend or judge a ceremony or practitioner. Decline clearly and warmly. Explain that this belongs to medicine people and the family, and point to the facility's traditional medicine office or the family route (4.2, 4.9). Illustrative: "That isn't mine to decide or do. A medicine person and your family are the right people for that. I can help you find the clinic's contact."
You are invited to a ceremony. Attend only if the client and family invite you and the practitioner agrees. Consider boundaries and dual relationships with your supervisor. Never record, photograph or describe it afterwards. Decline if attending would compromise the therapy.
Non-Diné client wants a "Navajo ceremony". Do not facilitate it. Explain that Diné ceremonies belong to Diné communities and their medicine people, and explore what need the request expresses.
Family conflict between traditional, Christian and Native American Church paths. Keep the client's own wishes central. Use family sessions to map positions without taking sides, and remember that combinations are common. [source: https://cronkitenews.azpbs.org/2020/11/10/pandemic-spotlights-clash-between-modern-traditional-navajo-ways/]
Client stops or changes medication after a ceremony, or plans to. Do not argue or advise. Ask what led to the decision, and promptly link the client with the prescriber. Assess any risk. Illustrative: "Let's get Dr. ___ involved before anything changes, so you have support whichever way you go."
Symptoms persist or worsen after a ceremony. Avoid both "it didn't work" and "give it time". Explore the client's understanding, which may include further consultation, and re-evaluate clinically. Watch for guilt and for financial strain on the family. [source: https://cdn.mdedge.com/files/s3fs-public/jfp-archived-issues/1980-volume_10-11/JFP_1980-01_v10_i1_navajo-indian-medicine-implications-for.pdf]
Possible psychosis framed as witchcraft or spiritual harm. Hold both possibilities. Ask whether family and community share the interpretation, look for functional decline and beliefs that go beyond the shared frame, and consult a cultural broker. If risk is present, act on it while respecting the client's request for traditional help in parallel (4.7, 4.13).
Practitioner availability or cost barriers. Healers' numbers and influence are described as declining, and during the pandemic many healers struggled to visit patients. [source: https://cronkitenews.azpbs.org/2020/11/10/pandemic-spotlights-clash-between-modern-traditional-navajo-ways/] Medicaid may cover traditional healing for eligible members through IHS and Tribal facilities in Arizona (AHCCCS) and New Mexico (Turquoise Care). [source: https://azahcccs.gov/AmericanIndians/TraditionalHealing/] [source: https://www.hca.nm.gov/2026/03/10/new-mexico-medicaid-now-covers-traditional-healing-practices-for-native-american-members/] [source: https://opvp.navajo-nsn.gov/250324-traditional-healing-services/] Help the client find out what applies to them. Do not source practitioners yourself.
Overwhelm during cultural assessment. Break the CFI into parts across sessions, and pause if historical or family trauma surfaces. Use grounding and the client's own coping resources. The modules can be given later in care. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Rupture after a cultural misstep (for example, asking for ceremonial detail, mispronouncing terms or a stereotyping remark). Name it and apologise specifically, without dwelling, and ask how the client would like to proceed. Take it to supervision. Illustrative: "I asked about something that wasn't mine to ask about. I'm sorry. I'll be more careful."
Non-attendance around ceremonies, travel or family obligations. Treat it as an expected part of the client's life, not as non-adherence. Plan sessions around known dates, and offer telehealth or flexible scheduling.
Veteran declines both ceremony and trauma therapy. Respect the choice. Keep a crisis plan and a low-pressure open door, and offer family or peer involvement if the veteran wishes.
Confidentiality worries in a small community. Discuss them explicitly at intake. Minimise the record (4.15) and consider interpreter and broker choice carefully (4.8).
Safeguarding concerns involving a healer or a ceremony. Separate the tradition from the conduct. Consult a cultural broker and your supervisor, and follow tribal, state or federal reporting law. A cultural framing never overrides a duty to report.

Sources

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