Sun Dance · Atlas

1. Introduction

Version followed: the Sun Dance as Plains nations and their recognised spiritual leaders publicly describe it, especially the Lakota proclamation of 13 March 2003 by Chief Arvol Looking Horse, with Canadian and US historical accounts as attributed outsider context. The psychotherapist's own procedures follow the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules.

What it is. The Sun Dance is a sacred annual ceremony of Plains nations. It is not a therapy, and a psychotherapist does not perform, lead or adapt any part of it. The Canadian Encyclopedia describes it as held by "several First Nations in the Prairies", naming the Kainai (Blood) Nation in Alberta. It says the ceremony "reaffirms spiritual beliefs about the universe" and includes prayers for family, the Earth and communities, requests for spiritual aid or responses to a vision, and the renewal of kinship ties [source: https://www.thecanadianencyclopedia.ca/en/article/sun-dance]. A New-York Historical Society exhibit describes the Lakota Sun Dance as an annual summer gathering that renewed community solidarity, redistributed wealth to poorer members, renewed spiritual bonds with the buffalo and other beings, and expressed Lakota values of spiritual wholeness, personal sacrifice and responsibility to others [source: https://actsoffaith.nyhistory.org/SECTION-3/Sacred-Ceremonies.html]. The Canadian Encyclopedia reports that some participants make personal sacrifices through piercing and flesh offerings [source: https://www.thecanadianencyclopedia.ca/en/article/sun-dance]. This guide gives no further detail of ceremony content, songs, prayers, sacred objects or preparation. Other nations often named as holding Sun Dances or related ceremonies (Dakota, Nakota, Cheyenne, Arapaho, Cree, Saulteaux, Shoshone and others) each have their own names, forms and authorities [uncertain: not sourced nation by nation].

Suppression and survival. In the United States, officials targeted the Sun Dance from 1882. The Code of Indian Offenses issued through the Office of Indian Affairs banned traditional dancing, the work of medicine people and other religious practices. Agents raided gatherings, withheld rations from participants and starved or imprisoned repeat offenders, and Lakota people kept the dance alive in hidden places [source: https://actsoffaith.nyhistory.org/SECTION-3/Sacred-Ceremonies.html]. The National Indian Law Library (Native American Rights Fund) describes the 1883 Code and the 1884, 1894 and 1904 regulations as never authorised by Congress, and says the prohibition "was not formally removed" until the American Indian Religious Freedom Act of 1978 [source: https://nill.narf.org/resources/civilization_policy.html]. The exhibit dates the Code's rescission to 1934 and the resumption of public Lakota Sun Dances to 1951 [source: https://actsoffaith.nyhistory.org/SECTION-3/Sacred-Ceremonies.html]. The US National Library of Medicine's Native Voices timeline records that in 1934 Commissioner of Indian Affairs John Collier issued a circular supporting religious freedom for American Indians and questioning bans on ceremonies, which opened the way to a public revival [source: https://www.nlm.nih.gov/nativevoices/timeline/453.html]; the University of North Dakota's catalogue record for the 1883 Code notes that legal suppression of Indigenous religious practice persisted until the 1978 Act [source: https://commons.und.edu/indigenous-gov-docs/131]. Read together, 1934 marks the federal policy reversal and 1978 the first statutory affirmation of Native religious freedom [synthesis]; the exact legal effect of the 1934 circular is [uncertain]. With a client, saying that the ban lasted into the 1930s and that legal protection for Native religion came only with the 1978 Act stays within both sources. In Canada, the Indian Act of 1895 banned the Sun Dance with other ceremonies, the pass system helped enforce it, and amendments in 1951 removed the prohibition. Some communities continued in secret, while others stopped for fear of persecution [source: https://www.thecanadianencyclopedia.ca/en/article/sun-dance].

Who holds authority. Authority rests with each nation's own spiritual leaders, keepers and ceremonial communities, not with clinicians, scholars or outside organisations. For the Lakota, the 2003 proclamation was issued by Chief Arvol Looking Horse as 19th Generation Keeper of the Sacred White Buffalo Calf Pipe, following a meeting on 8–9 March 2003 at Eagle Butte, South Dakota. It limits participation in the centre of the Sun Dance to Native people, asks non-Native people to "understand and respect our decision", and asks non-Native supporters outside the arbour to remain in prayer. It states that ceremonies should not carry a price, and that the Keeper cannot direct medicine people about whom they treat or where they travel [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]. Earlier, on 10 June 1993, Lakota Summit V, a gathering of US and Canadian Lakota, Dakota and Nakota Nations, passed a declaration against those who "appropriate and misrepresent" Lakota spirituality [source: https://www.hss.mun.ca/worldreligions/resources/aboriginalSpirituality/159.html].

How change happens, from the therapist's side. The ceremony's meaning belongs to its tradition and is not a clinical mechanism. For the therapist, change comes from culturally responsive care: understanding the client's own account of their distress and healing, respecting their ceremonial life and its authorities, addressing the harms of suppression and racism, and working alongside the community when the client wishes [synthesis; source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].

2. Framework

This is a framework for the psychotherapist's own work alongside a client whose life includes the Sun Dance, as a dancer, supporter, family member or community member. Session counts and phase criteria are [synthesis]; no published clinical protocol specific to this context is cited, and the steps are the writer's synthesis built on the APA cultural-assessment materials [synthesis].

Phase A: Preparation (before and between clients). Goal: know the history of suppression, the published statements of cultural authority, local services (Indian Health Service, tribal health, Indigenous health programmes) and your own assumptions. Moving on: you can name the nation's own authorities and local referral routes without relying on the client to teach you [synthesis; source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/].

Phase B: Engagement and cultural assessment (sessions 1–3, 50–60 minutes each). Goal: complete the core CFI and any modules indicated, the explanatory model, and a risk screen. The CFI has 16 questions in four domains: cultural definition of the problem; perceptions of cause, context and support; self-coping and past help seeking; and current help seeking [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. The time needed is not given in APA forms; the DSM-5 field trial found later interviews "required less time" [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]; a figure of 15–20 minutes for the core CFI is [uncertain]. Moving on: you can state the client's own name for the problem, its cause and the help they want, in words they confirm.

Phase C: Formulation and shared plan (sessions 2–4). Goal: a cultural formulation agreed with the client, including whether and how they want contact with a spiritual leader, elder or traditional health programme, with written consent. Moving on: the client confirms the plan and any collaboration consents.

Phase D: Ongoing therapy alongside ceremonial life (weekly or fortnightly, length set by the presenting problem). Goal: treat the presenting problem with evidence-based methods fitted to the formulation, while respecting the ceremonial calendar (Sun Dances are usually held in summer [source: https://actsoffaith.nyhistory.org/SECTION-3/Sacred-Ceremonies.html]) and any community commitments the client keeps. Plan around absences rather than treating them as non-adherence [synthesis].

Phase E: Integration and review (after significant ceremonial events and at agreed reviews). Goal: help the client connect what they choose to share of their experience to their goals, re-run parts of the CFI where helpful (the modules can be repeated during treatment [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]), and review outcomes. Ending: goals met, or care continued within community or other services by the client's choice.

3. Guiding principles

The therapist stands alongside, never inside, the ceremony. Practical meaning: you do not perform, simulate, teach or adapt any part of the Sun Dance, and you do not ask to attend [synthesis; source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/].
Authority belongs to the nation's own spiritual leaders. Practical meaning: questions about who may take part, what is required or what an experience means go to the client's own leaders, not to you or to books [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/].
Respect published requests about participation. Practical meaning: the 2003 proclamation limits the centre of the Lakota Sun Dance to Native people; never encourage a non-Native client, or yourself, to seek entry [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/].
The client decides what is shared. Practical meaning: no uninvited questioning about ceremonies; the Indian Health Service notes many patients prefer not to discuss these matters [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/].
Attribute spiritual meaning; neither affirm nor dismiss it. Practical meaning: write "the client describes…" or "in Lakota understanding as the client explains it…", never a clinical judgement on the truth of a vision or prayer [synthesis].
Hold the history in the room. Practical meaning: the ceremony was criminalised in both countries within living family memory; expect wariness of clinicians and institutions and treat it as reasonable [source: https://www.thecanadianencyclopedia.ca/en/article/sun-dance; source: https://nill.narf.org/resources/civilization_policy.html].
Use the CFI to support, not replace, clinical judgement. Practical meaning: the CFI informs understanding and decision-making and is not the sole basis for a diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Avoid both pathologising and missing illness. Practical meaning: experiences that are part of accepted collective religious practice are excluded from dissociative trance diagnoses, but a person can still have a disorder that needs treatment [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574].
Collaboration only with consent and through legitimate community pathways. Practical meaning: contact a spiritual leader or traditional health programme only when the client asks, using routes the community recognises, never a commercial or self-appointed "ceremony" [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/; source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/].
Physical health stays in medical hands. Practical meaning: you never advise on medicines or on readiness for the physical demands of ceremony; route medical questions to the client's physician or prescriber [synthesis].
Minimal documentation of sacred matters. Practical meaning: record what is clinically needed (e.g. "client participates in community ceremony; plans absence in July"), not ceremonial detail [synthesis].
Cultural humility over cultural expertise. Practical meaning: you are a learner about this client's tradition; examine your own assumptions, including romanticising and appropriating attitudes [synthesis].

4. Intervention inventory

Every intervention below is the psychotherapist's own work. None reproduces or adapts the ceremony. Example language is illustrative unless quoted. [source for CFI structure: 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 first contact and throughout; essential when the client's tradition is one your profession and government once helped suppress [synthesis].
Steps: (1) Learn the suppression history in both countries and the 1993 and 2003 statements from Lakota authorities [source: https://www.hss.mun.ca/worldreligions/resources/aboriginalSpirituality/159.html; source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]. (2) Write down your own beliefs, curiosities and attractions about the Sun Dance, including romantic, fearful or appropriating ones. (3) Commit not to ask to attend and not to seek out ceremonies yourself. (4) Identify local Indigenous-led services and your nearest Indian Health Service, tribal or Indigenous health contacts. (5) Arrange supervision or consultation with an Indigenous colleague where available [synthesis].
Example language (illustrative): "I'm not from your community, and I won't pretend to know your ceremonies. I'd like to understand what matters to you, at the pace you choose."
Watch for: curiosity that turns sessions toward your interest rather than the client's goals; a client spending time educating you; a pull to treat the client as a spiritual teacher. Working: the client sets what is discussed and does not appear to be managing your reactions [synthesis].

4.2 Core Cultural Formulation Interview

Purpose / when: first or second session with any client, to understand the problem from the client's and their social network's perspective [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. APA describes it as for "any clinician" with "any individual in any care setting" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Steps: (1) Use the official APA form; clinicians may reproduce it for use with their own patients without permission, 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]. (2) Work through the four domains in order: cultural definition of the problem; cultural perceptions of cause, context and support (including the role of cultural identity); cultural factors in self-coping and past help seeking (including barriers); cultural factors in current help seeking (preferences and the clinician–patient relationship). (3) Use the client's own words for the problem throughout the rest of care. (4) Note where a supplementary module would deepen a subtopic; the core form shows which module expands each one [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. (5) Let the client raise ceremony; do not prompt for ceremonial detail [synthesis].
Example language (illustrative): "How would you describe what's been happening, in your own words?" / "What have you already done to deal with this, including anything in your family or community?"
Watch for: brief or guarded answers in the help-seeking and relationship domains, which may reflect experience of racism or past institutional harm; the CFI is not the only basis for diagnosis. Working: you can summarise the client's view in words they accept [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf; synthesis].

4.3 Spirituality, Religion and Moral Traditions module

Purpose / when: when the client indicates that ceremony, prayer or spiritual commitment is part of their life or their account of the problem. It is one of 12 supplementary modules and can be used at first evaluation, later in care, or repeatedly [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: (1) Ask permission to explore spiritual life. (2) Use the module's topics to learn what role spiritual practice plays in coping, identity and community belonging, at the level the client chooses. (3) Ask whether spiritual practice helps, strains, or both. (4) Clarify any community expectations that affect treatment (e.g. times of year when the client will be away). (5) Do not ask what happens inside ceremonies [synthesis].
Example language (illustrative): "You mentioned your ceremonies. You don't need to tell me anything about them. I'd just like to know whether they're a source of strength right now, or whether anything about them feels hard."
Watch for: discomfort if questions approach sacred content; respond by withdrawing the question. Working: the client volunteers how spiritual life relates to their goals [synthesis].

4.4 Cultural Identity and Patient–Clinician Relationship modules

Purpose / when: when identity (nation, language, enrolment, mixed heritage, urban or reserve/reservation life) or the therapeutic relationship itself is part of the problem or a barrier [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. The core CFI asks about the clinician–patient relationship, for example perceived racism and language barriers [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Steps: (1) Invite the client to describe their identity in their own terms. (2) Ask how your own background may affect working together. (3) Name openly that services have a history of harm and ask what would make this setting safer. (4) Agree concrete adjustments (e.g. an Indigenous support person present, different scheduling, a different clinician) [synthesis].
Example language (illustrative): "Sometimes people from your community have been treated badly by services like this one. If anything I do feels like that, I want to know."
Watch for: the client deferring to you out of politeness; identity questions touching enrolment or belonging (the 2003 proclamation, for instance, restricts carrying an eagle feather in the rites to enrolled members [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]), which can be painful for clients of mixed or disrupted heritage. Working: the client names a concern about the relationship and it is addressed [synthesis].

4.5 Explanatory model (Kleinman)

Purpose / when: after the core CFI or alongside its first domains, when you need the client's full account of the illness, its cause and its proper treatment [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]. The CFI also has an Explanatory Model module [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. Original source: Kleinman, Eisenberg and Good (1978), Annals of Internal Medicine [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader].
Steps: Ask, in your own words, the eight areas: 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 should receive; the chief problems it has caused; and what they fear most about it [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]. Then compare the client's model with your clinical model and negotiate a plan that respects both [synthesis].
Example language (illustrative): "What do you think caused this?" / "What kind of help do you think would make the most difference: from me, from your family, from your community?"
Watch for: explanations involving spiritual imbalance, broken relationships or unfulfilled commitments. Record these as the client's account, attributed, without endorsing or correcting them. Working: the plan includes elements the client named [synthesis].

4.6 Informant interview and family involvement

Purpose / when: when family or community members hold important knowledge or help make decisions, or when the client cannot give a full account. The Informant Version has 17 questions, opening with the informant's relationship to the patient [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
Steps: (1) Obtain the client's consent and agree what may be shared. (2) Interview the informant using the Informant Version. (3) Note differences between family members' views, e.g. traditional and Christian family members who hold different views of ceremony after generations of suppression [synthesis]. (4) Feed back to the client before using the information.
Example language (illustrative): "[Client] asked me to talk with you because you know them well. How do you see what's been going on?"
Watch for: family conflict over ceremonial participation; informants speaking for the client. Working: the client feels supported rather than talked about [synthesis].

4.7 Asking about ceremonial life and spiritual helpers without judgement

Purpose / when: early in care, to learn what help the client already uses, while respecting privacy. The Indian Health Service policy directs staff to respect patients' privacy about their beliefs, avoid uninvited questioning or interference, and inform patients of their freedom to practise their traditional religion [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/].
Steps: (1) Ask one open question about sources of help, including spiritual leaders, elders and ceremonies. (2) Accept "I'd rather not say" without follow-up. (3) If the client does speak, ask only about how it relates to their wellbeing and to therapy. (4) State plainly that you will not judge or try to replace their ceremonial life [synthesis].
Example language (illustrative): "Some people I work with also have elders, spiritual leaders or ceremonies they turn to. Is anything like that part of your life? Either answer is fine."
Watch for: the client testing whether you will dismiss or romanticise their tradition. Working: the client mentions their spiritual life later without being asked [synthesis].

4.8 Distinguishing culturally normative experience from disorder

Purpose / when: when a client reports visions, dreams, voices of relatives or spiritual beings, altered states, or a calling, within or outside ceremony, and you must decide whether a disorder is present.
Steps: (1) Use the client's and community's frame first: does the client, and do respected people in their community, regard the experience as expected within their tradition? (2) Apply the manuals' cultural exclusions: DSM-5 dissociative identity disorder criteria note that identity disruption "may be described in some cultures as an experience of possession" and exclude disturbances that are "a normal part of a broadly accepted cultural or religious practice"; dissociative trance (other specified dissociative disorder) is likewise excluded when it is part of accepted collective cultural or religious practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. DSM-5-TR keeps these points in substance; exact DSM-5-TR wording is [uncertain] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder both require the state to be involuntary and unwanted and not part of accepted cultural or religious practice, with significant distress or impairment [source: https://www.findacode.com/icd-11/code-1807490186.html; source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. (3) Look for features that point to illness regardless of culture: experiences the client finds alien, unwanted or frightening; spread outside ceremonial or culturally expected contexts; decline in functioning, self-care or sleep; concern from the client's own community or spiritual leader. (4) With consent, consult a cultural broker, Indigenous colleague or a community member the client trusts. (5) If uncertain, keep assessing over time rather than diagnosing at once [synthesis]. Note: a DSM-5-TR statement that culturally sanctioned beliefs should not be counted as psychotic symptoms is [uncertain: exact DSM-5-TR wording not sourced].
Cultural concepts of distress: DSM-5-TR uses cultural concepts of distress (idioms, explanations or perceived causes, and syndromes) and revised its examples to avoid "stigmatizing or generalizing language" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. None of the named DSM-5-TR examples is specific to Plains nations [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]; use the CFI to elicit the client's own idioms instead [synthesis].
Example language (illustrative): "Is this kind of experience something people in your community would understand, or does it feel different from that?" / "Has anyone you trust in your community said anything about it?"
Watch for: pathologising sacred experience (harm: shame, disengagement, distrust) and missing psychosis, mania or a dissociative disorder because it is framed spiritually. Working: the client agrees with how the experience is understood, and risk is managed [synthesis].

4.9 Physical health and medical liaison around ceremony

Purpose / when: when a client with a physical or mental health condition, or on prescribed medicines, plans to take part in a ceremony that sources describe as involving personal sacrifice, including piercing and flesh offerings [source: https://www.thecanadianencyclopedia.ca/en/article/sun-dance].
Steps: (1) Ask whether the client wants their physician or prescriber involved. (2) Encourage, without pressure, a medical conversation for conditions where demanding physical activity matters (e.g. heart disease, diabetes, pregnancy, recent surgery, eating disorders). (3) Never advise starting, stopping or changing medicines; route those questions to the prescriber. (4) Agree a plan for seeking medical help if the client becomes unwell. (5) Respect that preparation and readiness are matters for the client and their spiritual leader [synthesis].
Example language (illustrative): "That's your decision and your leader's. Would it help to talk it through with your doctor too, given your heart condition?"
Watch for: clients stopping medicines without medical advice; wounds or illness after ceremony that are not being treated; eating-disorder clients for whom any preparatory restriction may carry extra risk. Working: the client has the medical information they want and a plan for help [synthesis].

4.10 Collaboration and referral with community-sanctioned spiritual leaders and programmes

Purpose / when: when the client asks for their care to include, or be coordinated with, an elder, spiritual leader or traditional health programme. The Indian Health Service policy (SGM 94-08, 29 July 1994) states that when a patient or family asks for help reaching a traditional practitioner "every effort will be made to comply", including privacy for a ceremony in a hospital room and paying for healer consultations where necessary, with practices "as defined by the tribe's or village's traditional culture" [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/]. In Canada, Truth and Reconciliation Commission Call to Action 22 asks health-system leaders to recognise the value of Aboriginal healing practices and use them in treating Aboriginal patients, working with Aboriginal Elders and healers where patients request it [source: https://www.cmaj.ca/content/192/9/E208] [source: https://www.cbc.ca/newsinteractives/beyond-94/recognize-the-value-of-aboriginal-healing-practices-and-use-them-in-the-treatment-of-aboriginal-patients].
Steps: (1) Let the client name who they want involved; never choose a healer for them. (2) Use routes the community recognises: tribal health departments, IHS or tribal facility traditional-medicine programmes, Indigenous health services or Elder programmes in Canadian health systems. (3) Obtain written consent specifying what you may share and with whom. (4) Agree roles: the leader holds spiritual matters; you hold psychological treatment, risk and liaison with medical care. (5) Review regularly with the client [synthesis]. Evidence from other settings: in Nigeria and Ghana, collaborative shared care between traditional and faith healers and primary care workers reduced psychosis symptoms and harmful practices more than usual care (COSIMPO, Gureje et al., The Lancet 2020) [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 care reduced symptoms but did not significantly reduce days in chains [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. These are not Sun Dance studies and are cited only as evidence about collaboration [synthesis].
Example language (illustrative): "Would you like me to be in touch with anyone in your community about your care? You decide who, and what I can share."
Watch for: pressure (from you or a service) to involve a healer the client did not ask for; anyone who charges a fee to run a Sun Dance or similar ceremony, against the 2003 proclamation's statement that ceremonies should not carry a price [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]. Working: clear roles, no contradictory advice reaching the client, client satisfied [synthesis].

4.11 Working with historical and intergenerational trauma

Purpose / when: when the client's distress connects to the suppression of ceremonies, boarding or residential schooling, land loss or family disruption. Maria Yellow Horse Brave Heart describes historical trauma as losses and injustice inflicted on Native people, and argues that health interventions in Native communities should account for it. Her Historical Trauma and Unresolved Grief Intervention (HTUG) uses elements of traditional ceremony and spirituality, has been offered to many tribes, and includes the Lakota Wiping of the Tears ceremony; participants reported working through grief, including memories of boarding-school abuse [source: https://ireach.wsu.edu/p4nh/restoringstrength/]. HTUG is delivered with Indigenous cultural authority; a non-Indigenous therapist does not deliver its ceremonial elements [synthesis].
Steps: (1) Ask, when relevant, about family experiences of schooling, suppression of practice and loss. (2) Name the history as fact: the Sun Dance was banned in Canada from 1895 to 1951 and suppressed under US regulations from the 1880s [source: https://www.thecanadianencyclopedia.ca/en/article/sun-dance; source: https://actsoffaith.nyhistory.org/SECTION-3/Sacred-Ceremonies.html]. (3) Frame present symptoms partly as understandable responses to collective and family trauma, without reducing the client to it. (4) Use evidence-based trauma or grief treatment fitted to the formulation, alongside community-led healing the client chooses. (5) Where available and wanted, refer to Indigenous-led historical-trauma programmes [synthesis].
Example language (illustrative): "Your grandparents' generation could be punished for keeping these ceremonies. It makes sense that some of that still lives in your family."
Watch for: the client feeling their individual story is lost in a collective narrative; anger toward services, including yours, which deserves acknowledgement rather than interpretation. Working: less shame, more connection to family and community, reduced symptoms [synthesis].

4.12 Integrating ceremonial experience into therapy

Purpose / when: after a ceremony season or a significant spiritual experience, when the client chooses to bring it into therapy.
Steps: (1) Invite, do not require, reflection. (2) Ask about meaning and consequences for the client's life (relationships, commitments, sobriety, goals), not about ceremonial content. (3) Do not interpret visions or spiritual experiences; if the client wants interpretation, that is for their spiritual leader. (4) Link what the client values to concrete therapy goals. (5) Check for physical or psychological after-effects needing care (sleep, mood, wounds, exhaustion) [synthesis].
Example language (illustrative): "Is there anything from this summer you want to carry into the work we're doing?"
Watch for: your own urge to explain or psychologise; mood or sleep changes that persist. Working: the client draws on the experience as a resource in daily life [synthesis].

4.13 When ceremonial commitments are disrupted

Purpose / when: when illness, incarceration, distance, family conflict, grief or community disputes prevent a client from keeping a commitment they hold sacred, and this causes distress [synthesis].
Steps: (1) Hear the distress without minimising its spiritual weight. (2) Ask whether the client has spoken with their spiritual leader; encourage that if they wish, as the leader holds authority over the commitment. (3) Address the psychological parts in therapy: guilt, shame, fear, grief. (4) Help with practical barriers (e.g. letters to employers or institutions supporting religious leave, with consent) [synthesis]. In US federal and many state settings, AIRFA (1978) affirms Native religious freedom [source: https://nill.narf.org/resources/civilization_policy.html]; how it applies in a given workplace or institution is [uncertain]; do not give legal advice.
Example language (illustrative): "This commitment matters deeply to you. What has your leader said, or would you like to talk with them?"
Watch for: suicidal thinking linked to guilt or loss of belonging; screen and follow standard risk assessment. Working: the client has a path forward agreed with their own spiritual authority [synthesis].

4.14 Veterans and reintegration

Purpose / when: with Native veterans whose healing includes community ceremonies. An anthropology thesis on Oglala Lakota veterans at Pine Ridge (Perkins 2010) describes the sweat lodge, Sun Dance, powwows, the Native American Church, the Wiping of the Tears ceremony and other practices as helping veterans "heal mentally, physically, and spiritually" and reintegrate [source: https://digital.library.txst.edu/items/0e440a18-5fff-4b6a-8c7f-8f3bfaae83d8/full]. This is an outsider's account [synthesis].
Steps: (1) Assess military stress and PTSD with standard measures. (2) Use the CFI to learn what the veteran's community offers. (3) Coordinate with VA or IHS services and community programmes if the veteran wishes. (4) Offer evidence-based PTSD treatment alongside, not instead of, community healing [synthesis].
Example language (illustrative): "What has your community done to welcome you home, and has any of that helped?"
Watch for: you replacing community roles; untreated PTSD hidden by a strong public role. Working: symptom change plus restored community ties [synthesis].

4.15 Non-Native clients who want to join the Sun Dance

Purpose / when: when a non-Native client seeks to take part, has paid to attend an event presented as a Sun Dance, or describes Indigenous spirituality as central to their own identity [synthesis].
Steps: (1) Explore what the client is seeking (belonging, healing, meaning). (2) Share, if relevant, that Lakota authorities have published requests: the 2003 proclamation limits the centre to Native people and asks non-Native supporters to remain in prayer outside the arbour [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]; the 1993 Lakota Summit V declaration opposes appropriation [source: https://www.hss.mun.ca/worldreligions/resources/aboriginalSpirituality/159.html]. (3) Do not facilitate access. (4) Help the client meet the underlying need through their own heritage and community [synthesis].
Example language (illustrative): "The leaders of that tradition have asked that people outside it respect certain limits. What are you hoping to find, and where else might you find it?"
Watch for: exploitation by paid "ceremony" providers, physical harm at unsanctioned events, and a client's defensiveness. Working: the client finds meaning without appropriation [synthesis].

4.16 Safeguarding

Purpose / when: when a person is harmed or at risk, e.g. a minor pressured into practices without appropriate consent, coercion or abuse by anyone claiming spiritual authority, sexual exploitation, a medical emergency left untreated, or fraud at commercial events [synthesis].
Steps: (1) Follow your jurisdiction's child and adult protection law and professional reporting duties. (2) Distinguish the tradition from an individual's harmful conduct; harm by one person does not indict a ceremony. (3) With consent, and where safe, involve legitimate community authorities. (4) Get urgent medical help for any medical emergency. (5) Never name or identify ceremony participants beyond what reporting requires [synthesis].
Example language (illustrative): "What you've described worries me for your safety. Your ceremonies aren't the problem here; what this person did is. I need to talk with you about what happens next."
Watch for: both errors: misreading accepted sacrifice as self-harm, and missing abuse presented as tradition. Working: safety secured with the client's trust as intact as possible [synthesis].

4.17 Language, interpreters and cultural brokers

Purpose / when: when the client prefers an Indigenous language for some topics, or when you need cultural consultation [synthesis].
Steps: (1) Ask about language preference. (2) Use interpreters or cultural brokers acceptable to the client; in small communities, check confidentiality and kinship links first. (3) Brief the broker on the clinical purpose; never ask them to disclose sacred matters. (4) Debrief after sessions [synthesis].
Example language (illustrative): "Are there things that are easier to say in your own language? We can arrange someone you're comfortable with."
Watch for: the broker becoming a gatekeeper or the client censoring because of kin ties. Working: fuller and more comfortable communication [synthesis].

5. Handling problems

Published sources address few of these directly. Guidance below is [synthesis] unless a source is given.

Client will not discuss ceremonies or spiritual life. Respect it; the IHS policy notes many patients prefer not to discuss these matters and rules out uninvited questioning [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/]. Work on the presenting problem; leave the door open once ("If it ever becomes relevant, you're welcome to bring it in").
Wariness, distrust or testing of the therapist. Treat it as a reasonable response to a history in which ceremonies were criminalised and services caused harm [source: https://nill.narf.org/resources/civilization_policy.html]. Name it, use the CFI relationship questions, offer choices (an Indigenous clinician, a support person, a different setting).
Stuck therapy because the plan ignores the client's model. Return to the explanatory model (4.5) and ask what help the client believes they need; renegotiate goals in their terms.
Absences during the ceremony season. Not non-adherence. Plan breaks in advance, agree a contact and crisis plan for the period, and schedule a review session afterwards.
Overwhelm after a ceremony or during grief work. Slow the pace; return to stabilisation and coping; ask whether the client wants their spiritual leader or family involved; review risk.
Rupture from a clinician mistake (e.g. a dismissive comment, asking about sacred content, mispronouncing or misnaming the nation, an appropriating remark). Acknowledge it directly, apologise without defending, ask what repair would look like, and change practice. Seek consultation.
The therapist wants to attend or learn the ceremony. Do not ask. The published Lakota position limits the centre to Native people [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]. Take the wish to supervision. If a client invites you to a public, non-sacred community event, weigh boundaries and dual-relationship rules before accepting, and never photograph or record.
Disagreement between ceremonial requirements and medical advice. Do not adjudicate. Help the client get clear medical information (4.9) and talk with their spiritual leader; support their informed decision; follow safeguarding law only where serious harm is imminent.
Unclear whether an experience is sacred or a symptom. Use 4.8; delay diagnosis where safe; consult with consent; monitor function, sleep and risk.
Family conflict over participation (e.g. traditional and Christian family members). Use the informant interview (4.6) and family sessions to make room for both views; place the conflict in the history of suppression without taking sides.
Clients of mixed heritage, without enrolment, or reconnecting after adoption or foster care. Identity questions can be painful, and some published protocols tie certain roles to enrolment [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]. Explore belonging and loss; support reconnection through the client's own nation's legitimate pathways, not commercial events.
Commercial or self-appointed "Sun Dance" providers. The 2003 proclamation states ceremonies should not carry a price [source: https://ictnews.org/archive/looking-horse-proclamation-on-the-protection-of-ceremonies/]. Help clients who were harmed by such events with standard trauma care; consider safeguarding or consumer-protection reporting where relevant.
Confidentiality in small communities and dual relationships. Check kin links before involving brokers or interpreters; keep notes minimal on sacred matters; agree with the client what goes in records shared with other services.
Documentation and outcome measurement. Use standard symptom and functioning measures plus the client's own goals in their words; repeat parts of the CFI at reviews [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Suicide risk. Follow standard risk assessment and safety planning; include protective factors the client names (ceremony, family, community) and, with consent, people in the community who can help.

Sources

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