Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 097
Guide XI-097

Midewiwin and the shaking tent

NanabozoUpper Great Lakes
A 36 · L 53 · M 1119 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the psychotherapist's own culturally responsive practice, built on the DSM-5-TR Cultural Formulation Interview (APA 2022) and its supplementary modules, alongside the Midewiwin and the shaking tent (jiisakaan) as Anishinaabe institutions and services, The Canadian Encyclopedia (an outsider's reference account) and published ethnography describe them. This guide is not a guide to the tradition itself. It gives no ceremony procedure, songs, prayers, sacred objects, initiation steps or divination methods.

What the tradition is, as its institutions and sources describe it. The Midewiwin (often called the Grand Medicine Society) is a spiritual society historically found among the Anishinaabe of the Upper Great Lakes, the northern prairies and the eastern subarctic. Its members, the Mide, serve as spiritual leaders and healers, and the society is described as "an essential part of the worldview" of the Ojibwe and some related peoples. [source: https://prod-front.thecanadianencyclopedia.ca/en/article/midewiwin]

  • Origins. In Ojibwe accounts, the Creator (Kitchi Manitou) gave the Midewiwin to the cultural hero Nanabozo. Archaeologists link Midewiwin materials to at least 800 to 1,000 years ago, before European contact. [source: https://prod-front.thecanadianencyclopedia.ca/en/article/midewiwin]
  • Structure. Membership has four to eight grades (degrees), depending on the community. Each higher grade carries more knowledge and healing responsibility. Initiation events were historically recorded as line drawings on bark scrolls. Today's initiates learn sacred stories and songs and practise herbal remedies. This guide does not describe those practices. [source: https://prod-front.thecanadianencyclopedia.ca/en/article/midewiwin]
  • Where it is practised now. The largest societies are in parts of Ontario, Manitoba, Wisconsin and Minnesota, and the encyclopedia notes that "only a few" lodges exist in North America. One lodge is the Three Fires Midewiwin Lodge, which a tribal website describes as welcoming Anishinaabe people who are seeking spiritual knowledge and healing through the original sacred lifeway. [source: https://prod-front.thecanadianencyclopedia.ca/en/article/midewiwin] [source: https://www.scit-nsn.gov/midewiwin/index.htm]
  • The shaking tent. In the Ojibwe People's Dictionary, jiisakaan means "a shaking tent", jiisakii means "s/he operates a shaking tent", and jiisakiiwinini means "an operator of a shaking tent". [source: https://ojibwe.lib.umn.edu/browse/ojibwe/j?page=3] A secondary reference work documents the ceremony among the Cree, Innu, Menominee, Ojibwe, Odawa and Saulteaux. It says people seek it out to communicate with spirits, to cure illness, or to locate missing persons. These are the purposes as the reference reports them; the guide neither affirms nor dismisses them. [source: https://ebsco.com/research-starters/religion-and-philosophy/shaking-tent-ceremony] Anishnawbe Health Toronto, an Indigenous health centre, lists Shake Tent ceremonies in the fall, winter and spring among the services of its Traditional Team. [source: https://aht.ca/service/traditional-service/]
  • Suppression. US federal policy from 1883 told agents to stop dances and the practices of "medicine men". It enforced this through Courts of Indian Offenses, which operated until 1934. [source: https://teachingamericanhistory.org/document/courts-of-indian-offenses/] In Canada, an 1895 amendment to the Indian Act prohibited Indigenous festivals, dances and ceremonies, and the bans on the potlatch and sun dance were lifted in 1951. [source: https://thecanadianencyclopedia.ca/en/timeline/the-indian-act] The encyclopedia describes the Midewiwin as "a resilient spiritual institution" that survived religious and cultural persecution. [source: https://prod-front.thecanadianencyclopedia.ca/en/article/midewiwin] Whether any specific statute named the Midewiwin or the shaking tent: [uncertain: not verified].

How change happens, for the therapist. Within the tradition, healing is understood and directed by Mide practitioners, Elders and healers, and Anishnawbe Health Toronto frames it as spiritual, mental, physical and emotional wellness. [source: https://aht.ca/service/traditional-service/] The therapist's part is different. Change happens when the client's own understanding of the problem and their chosen healing pathway are understood and respected. When the client wants it, the therapist links them to community-sanctioned healers. Assessment avoids both pathologising normative spiritual experience and missing illness. The therapist then helps the client integrate cultural healing with psychological treatment. The First Nations Mental Wellness Continuum Framework names culture as the foundation for wellness. Its four outcomes are hope, belonging, meaning and purpose. [source: https://www.sac-isc.gc.ca/eng/1576093687903/1576093725971] [synthesis]

2. Framework

This is a framework for the therapist's work alongside the tradition. It is not a manualised therapy, and the phases, session counts and transition criteria below are [synthesis]. They draw on the CFI guidance that the core interview can be used at intake and its modules at any point in care. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]

  • Phase 0: Preparation (before the first client, then ongoing).
    • Goals: examine your own cultural position. Learn the history of suppression and the local Indigenous services, such as Indigenous health centres, tribal behavioural health and Elder programmes. Arrange cultural consultation.
    • Criterion to proceed: you know which local bodies a client could be referred to, and you have a consultation route.
  • Phase 1: Engagement and cultural assessment (sessions 1 to 3).
    • Goals: trust, safety and the core CFI. Add supplementary modules as needed, such as Spirituality, Religion and Moral Traditions, Cultural Identity, Explanatory Model, and Coping and Help-Seeking. Use the Informant Version with family if the client consents. Do a risk assessment.
    • Format: individual sessions, with family where the client wishes.
    • Criterion to proceed: you can state the client's explanatory model in their own terms, along with their help-seeking history and their wishes about traditional healing.
  • Phase 2: Cultural formulation and differential (sessions 2 to 4).
    • Goals: integrate the cultural information with diagnostic assessment. Distinguish culturally normative spiritual experience from disorder, consulting a cultural broker or Elder if the client consents. Agree shared goals.
    • Criterion to proceed: the client agrees with the formulation and the goals. Any urgent medical or psychiatric need is addressed.
  • Phase 3: Collaboration or referral (only if the client wishes; timing set by the client and the community).
    • Goals: make a consented link to a community-sanctioned Elder, healer or traditional programme, through legitimate community pathways. Agree what information is shared, if any.
    • Criterion to proceed: the client has made contact, or has decided not to, and the roles are clear.
  • Phase 4: Concurrent treatment and integration (usually 6 to 20 sessions, depending on the presenting problem).
    • Goals: evidence-based psychological treatment for the presenting problem, adapted to the client. Integration sessions after ceremonies or teachings. Work on identity, connection and intergenerational trauma.
    • Criterion to proceed: agreed goals are met, the client has supports in place, and community connections are sustained.
  • Phase 5: Ending and continuity.
    • Goals: review the gains, keep the community connections going, plan for relapse, and leave an open door to return.
  • Throughout: safeguarding, risk review, liaison with the prescriber on medicines, and consent checks.

3. Guiding principles

  • Authority rests with the community. Mide lodges and their leaders, Elders, and the traditional teams of Indigenous health services hold authority over Midewiwin and jiisakaan knowledge. For example, a Grand Chief of the Midewiwin Lodge encouraged a Shingwauk Kinoomaage Gamig project to record teachings. [source: https://sootoday.com/local-news/shingwauk-u-to-preserve-secret-midewiwin-teachings-115337] Practical meaning: defer to community bodies on what is appropriate, and never set yourself up as an interpreter of the tradition.
  • The therapist does not practise the tradition. Counsellors in an Ontario study referred clients to traditional healers when a service such as a sacred ceremony was beyond their role. The authors advise against mainstream-only practitioners adding Indigenous elements themselves. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546] Practical meaning: never lead, imitate or simulate a ceremony, and never use sacred items as therapy props.
  • The client leads. The counsellors in that study held that traditional healing should be "instigated by clients". [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546] Practical meaning: offer an open door, but do not suggest ceremonies or push traditional healing.
  • Restricted knowledge stays restricted. Mide practitioners historically "vehemently opposed" writing down oral teachings. [source: https://sootoday.com/local-news/shingwauk-u-to-preserve-secret-midewiwin-teachings-115337] Practical meaning: do not ask clients to describe what happened in a lodge or a tent. Record only what the client chooses to share and agrees to have recorded.
  • Attribute, don't adjudicate. Practical meaning: describe spirit helpers, spiritual causes of illness and the messages of a shaking tent as the client and their tradition hold them. Do not state them as fact and do not dismiss them. [synthesis]
  • Neither pathologise nor miss illness. DSM-5-TR excludes experiences that are a normal part of broadly accepted cultural or religious practice from dissociative diagnoses, and ICD-11 does the same for trance and possession trance disorders. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] Practical meaning: assess distress, impairment and the community's own view before you diagnose.
  • Know the history. Ceremonies and healers were targeted by US and Canadian law into the mid-20th century. [source: https://teachingamericanhistory.org/document/courts-of-indian-offenses/] [source: https://thecanadianencyclopedia.ca/en/timeline/the-indian-act] Practical meaning: expect clients to keep practices private and to distrust services, and treat that as reasonable rather than as resistance.
  • Culture is the foundation, and communities control services. The First Nations Mental Wellness Continuum Framework places Elders, cultural practitioners and kinship within its culture foundation and calls for First Nations control of services. [source: https://www.sac-isc.gc.ca/eng/1576093687903/1576093725971] Practical meaning: support community-led options before your own.
  • Use only legitimate pathways. Practical meaning: refer only through recognised community bodies or Indigenous health services, never to people offering ceremonies commercially or outside community sanction. [synthesis]
  • Medicines are for the prescriber. Practical meaning: give no advice on herbal remedies, and never suggest starting, stopping or changing any medicine. Route all such questions to the prescriber, and with consent, to the client's healer. [synthesis]
  • Consent and confidentiality at every link. Practical meaning: get written, specific consent before any contact with a healer or Elder. Remember that small communities make anonymity fragile. [synthesis]
  • Look after yourself in relationship. Counsellors in the Ontario study described Elders supporting their self-care and helping with burnout. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546] Practical meaning: seek cultural supervision; do not work in isolation.

[source for section 2 assessment tools: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]

4. Intervention inventory

The interventions below are the therapist's own. None of them is a Midewiwin or shaking-tent practice. The CFI material comes from APA documents. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Session-level steps are [synthesis] unless they are cited.

4.1 Cultural self-examination and humility

  • Purpose: to reduce bias and the risk of appropriation before and during the work. Use it at the outset and whenever you notice curiosity, scepticism or romanticising.
  • Steps:
    1. Write down what you believe about spirit healing, ceremonial secrecy and Indigenous peoples, and where those beliefs came from.
    2. Learn the suppression history (the 1883 Courts of Indian Offenses; the 1895 Indian Act amendment) and the history of local residential or boarding schools. [source: https://teachingamericanhistory.org/document/courts-of-indian-offenses/] [source: https://thecanadianencyclopedia.ca/en/timeline/the-indian-act]
    3. Notice any urge to learn ceremonies for your own interest, and keep it out of the work.
    4. Bring reactions to supervision, cultural supervision if possible.
  • Example language (illustrative): "I'm not Anishinaabe and I don't know your traditions from the inside. I'd like to understand what matters to you, and I'll follow your lead on what you want to talk about."
  • Watch for:
    • Questioning that is driven by fascination.
    • Assuming every Indigenous client is traditional. Many are Christian, some combine traditions, and some have no affiliation.
    • Treating one community's ways as "Indigenous" in general.
    • Signs it is working: the client corrects you freely and brings cultural material up unprompted.

4.2 Mapping legitimate local resources and protocol

  • Purpose: to know where referral is legitimate before a client asks. Use it in Phase 0, then update as you go.
  • Steps:
    1. Identify Indigenous-governed services near you, such as an Indigenous health centre with a traditional team or a tribal behavioural health department that hosts traditional healers. For example, the Saginaw Chippewa Indian Tribe lists a visiting traditional healer and traditional counselling at its behavioural health facility. Anishnawbe Health Toronto's healers give guidance to its psychiatry and counselling staff. [source: https://www.scit-nsn.gov/midewiwin/index.htm] [source: https://aht.ca/service/traditional-service/]
    2. Find out their access rules. Anishnawbe Health Toronto, for example, requires clients to register and to self-identify as Indigenous, and they book through a Traditional Services Coordinator. [source: https://aht.ca/service/traditional-service/]
    3. Ask those services, not individual practitioners, how a clinician should ask for consultation and what protocol applies. Learn about any offering only as the service explains it, and do not write it up as a procedure.
    4. Record the contacts and the pathway, not ceremony details.
  • Example language (illustrative), to a service: "I'm a psychotherapist. Some of my Anishinaabe clients ask about traditional healing. What is the right way for me to support a referral, or to ask for consultation from your traditional team?"
  • Watch for:
    • Individuals marketing "Mide" or shaking-tent services to non-members, or for fees outside community structures. Do not refer to them.
    • Services that have paused ceremonies. Anishnawbe Health Toronto noted that ceremonies were paused during a move. [source: https://aht.ca/service/traditional-service/]
    • Signs it is working: there is a named pathway you can offer within one session.

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

  • Purpose: to understand the problem from the client's and their network's perspective, including meaning, causes, supports, help-seeking and expectations of care. It supports clinical decision-making and is not the only basis for diagnosis. APA states it can be used by any clinician in any setting. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
  • Steps:
    1. Introduce the interview as a way to understand the client's own view.
    2. Work through the 16 questions in their four domains, paraphrasing as needed:
      • Cultural Definition of the Problem (Q1–3);
      • Cultural Perceptions of Cause, Context and Support (Q4–10);
      • Cultural Factors Affecting Self-Coping and Past Help Seeking (Q11–13);
      • Cultural Factors Affecting Current Help Seeking (Q14–16), including the clinician–patient relationship, perceived racism and language barriers.
    3. Use the client's own words for the problem in later sessions.
    4. Note which subtopics need a supplementary module.
    5. APA allows clinicians to reproduce the form for use with their patients. Modifying or translating it needs APA permission. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
  • Duration: in the DSM-5 field trial, later interviews took less time. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/] A figure of about 15 to 20 minutes for the core CFI is [uncertain].
  • Example language (illustrative):
    • "People understand problems like this in different ways. How would you describe what's been happening, in your own words?"
    • "Is there anything about your background, family or community that makes this harder, or helps?"
  • Watch for:
    • Short answers on the help-seeking and relationship questions. They may reflect mistrust grounded in history, so return to them later.
    • Clients who mention a lodge, an Elder or a tent and then pull back. Do not press.
    • Signs it is working: the client's own terms and causes appear, and the client asks questions back.

4.4 CFI Informant Version

  • Purpose: to include a family member's or friend's view. Use it when the family is central to help-seeking, or when the client cannot fully self-report. It has 17 questions; Q1 asks about the informant's relationship to the client. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
  • Steps:
    1. Get the client's consent and agree with them what may be discussed.
    2. Interview the informant separately or jointly, as the client prefers.
    3. Compare the informant's explanatory model with the client's.
    4. Note any family role in deciding about traditional healing.
  • Example language (illustrative): "How does your family understand what's happening to them? Has anyone in the family suggested going to an Elder or to ceremony?"
  • Watch for:
    • Disagreement within the family. Some members may hold to Christian, traditional or no faith, and may disagree about ceremonies.
    • Pressure on the client to follow one path.
    • Signs it is working: the family's views are clearer and the client still controls the decisions.

4.5 Supplementary modules

  • Purpose: to assess in depth. APA lists 12 modules: Explanatory Model; Level of Functioning; Social Network; Psychosocial Stressors; Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Patient–Clinician Relationship; School-Age Children and Adolescents; Older Adults; Immigrants and Refugees; and Caregivers. They can be used as add-ons, as standalone tools, or repeatedly during care. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
  • Steps:
    1. Use Spirituality, Religion and Moral Traditions when the client mentions Midewiwin, ceremonies or spiritual causes.
    2. Use Cultural Identity for questions of language, clan, Two-Spirit identity, or disconnection through adoption, child-welfare removal or residential or boarding school history in the family.
    3. Use Coping and Help-Seeking to map Elders, healers, churches and services.
    4. Use Patient–Clinician Relationship where racism or mistrust is present.
    5. Use School-Age Children and Adolescents or Older Adults by age.
    6. Ask only what the client is willing to say about restricted practices.
  • Example language (illustrative): "Does spirituality, or a particular way of life, play a part in how you're coping? You only need to tell me what you're comfortable sharing. Some things may not be for sharing outside your community, and that's fine."
  • Watch for:
    • Turning the module into a cultural inventory of the client.
    • Fatigue. Spread the modules across sessions.
    • Signs it is working: you know what the client draws on, without them disclosing protected content.

4.6 Explanatory-model inquiry (Kleinman)

  • Purpose: to elicit the client's model of illness so that treatment fits it. The questions come from Kleinman, Eisenberg and Good (1978). [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader] [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]
  • Steps: ask, in paraphrase:
    1. what the client calls the problem;
    2. what caused it;
    3. why it started when it did;
    4. what it does 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;
    8. what they fear most about it.
    Then write a short shared summary that holds both models. This may include spiritual causes, such as an imbalance or a broken relationship with spirit helpers, if that is how the client puts it. Do not supply such causes yourself.
  • Example language (illustrative): "What do you think caused this? And what kind of help do you think would work best: from me, from an Elder, from your doctor, or from a mix?"
  • Watch for:
    • Clients giving a "clinic-friendly" model to avoid judgement. Signal that both models are welcome.
    • A fear of being seen as "crazy" for a spiritual explanation.
    • Signs it is working: the client states a model that includes the spiritual dimension, and the goals reflect it.

4.7 Asking about traditional help-seeking without judgement

  • Purpose: to learn whether the client is involved with a Mide lodge, Elders or ceremonies such as the shaking tent, or wants to be, so that care is coordinated. The Ontario counsellors made their openness visible and let clients decide. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546]
  • Steps:
    1. Ask routinely, as part of help-seeking.
    2. Normalise using both kinds of help.
    3. Ask what the client is willing to share, and whether you may record it.
    4. Do not ask about the content of ceremonies, teachings or what was said or heard in a tent.
    5. Ask whether the healer has given guidance the client wants you to know about, such as on timing or on avoiding certain things.
  • Example language (illustrative): "Some people I work with also see an Elder or a traditional healer, or take part in ceremony. If that's part of your life, I'd like to work alongside it. You decide what, if anything, you tell me about it."
  • Watch for:
    • The client fearing that disclosure will lead to child-welfare involvement or ridicule.
    • Your own note-taking reaching into sacred detail.
    • Signs it is working: the client tells you about upcoming ceremonies or teachings so that sessions can be timed around them.

4.8 Distinguishing culturally normative experience from disorder

  • Purpose: to avoid pathologising communication with spirits, dreams, visions or experiences connected with a shaking tent, and also to avoid missing psychosis, mania, dissociative disorder or trauma.
  • What the manuals say:
    • DSM-5 DID Criterion D excludes disturbance that is "a normal part of a broadly accepted cultural or religious practice". DSM-5-TR keeps this in substance; whether it keeps the exact wording is [uncertain]. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]
    • Dissociative trance under other specified dissociative disorder does not apply when it is part of accepted collective practice. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]
    • ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary and unwanted, and outside accepted cultural or religious practice. [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]
    • The DSM-5-TR culture note on psychotic symptoms is [uncertain: not verified].
  • Steps:
    1. Establish whether the experience occurred within community practice and is understood as such by the client and their community.
    2. Assess whether it is wanted or unwanted, distress, functioning, duration, and spread beyond the ceremonial context.
    3. Screen for core features of psychosis, mania, substance effects, trauma and neurological causes.
    4. With consent, consult a cultural broker or an Elder recognised by the client's community about whether the experience fits community norms.
    5. Record the reasoning, with the experience attributed to the client's frame.
  • Example language (illustrative): "When this happens, does it feel like part of your spiritual life, something your family or community would recognise? Or does it feel unwanted, frightening or out of place?"
  • Watch for:
    • Experiences that persist outside ceremony, disorganisation, sleep loss, grandiosity, or the community itself saying "this is not right". These point towards illness.
    • Clinicians dismissing spiritual experiences, or accepting a spiritual frame so readily that treatable illness is missed.
    • Signs it is working: the formulation is accepted both by the client and, where consulted, by the cultural advisor.

4.9 Eliciting idioms of distress (cultural concepts of distress)

  • Purpose: DSM-5-TR describes cultural concepts of distress as idioms, explanations or perceived causes, and syndromes. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] The DSM glossary examples are mainly from other regions. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] An Anishinaabe-specific entry in DSM-5-TR is [uncertain: not verified]. Use the concept as a way of listening, not as a checklist.
  • Steps:
    1. Note the words the client uses, in English or Anishinaabemowin, for distress, its causes and imbalance.
    2. Ask what the words mean to them and to their family.
    3. Avoid applying ethnographic labels from outsider literature that the client has not used.
    4. Use the client's words in the formulation and the goals.
  • Example language (illustrative): "Is there a word in your language, or one your grandparents used, for what you're going through?"
  • Watch for:
    • Over-reading a word as a syndrome.
    • Clients who have lost the language. Name this gently, because it may be a grief in itself.
    • Signs it is working: the client recognises their own language in your summary.

4.10 Collaboration and referral with community-sanctioned healers and Elders

  • Purpose: to support a client who wants traditional healing alongside therapy.
    • In the Ontario study, counsellors consulted Elders regularly, and sometimes an Elder guided the therapy process. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546]
    • Programme models exist. At Anishnawbe Health Toronto, healers guide the psychiatry and counselling staff, and at Saginaw Chippewa a traditional healer works at the behavioural health facility. [source: https://aht.ca/service/traditional-service/] [source: https://www.scit-nsn.gov/midewiwin/index.htm]
    • Trial evidence from other regions supports collaboration with traditional and faith healers for psychosis. In COSIMPO (Gureje et al., The Lancet 2020, Nigeria and Ghana), collaborative shared care reduced PANSS symptoms more than usual care and reduced harmful practices. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] In the Ghana prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric care lowered 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] Neither trial involved Anishinaabe healers. Applying their findings here is [synthesis].
  • Steps:
    1. Confirm that the client wants it. Ask which community, lodge or service they are connected to, if any.
    2. Refer only through a legitimate pathway: the client's own community and Elders, an Indigenous health centre's traditional team, or a tribal behavioural health programme.
    3. Explain that you will not take part in, attend or observe ceremonies unless the community invites you and the client wants it. Even then, defer to the community's rules.
    4. Get written consent naming what may be shared, with whom, and for how long. The default is to share minimal information.
    5. Agree roles. The healer or Elder leads the spiritual healing. You lead psychological treatment and risk management. The prescriber leads on medicines.
    6. Agree how urgent concerns will be communicated.
    7. Review in session how the referral is going.
  • Example language (illustrative):
    • To the client: "If you'd like to see an Elder or a healer, I can help you connect through [local service] or your community. You decide whether I talk with them, and what I say."
    • To a healer, with consent: "[Client] has asked me to let you know they're seeing me for low mood. I'm not asking about your work with them. I want to make sure we're not pulling in different directions, and that you can reach me if you're worried about their safety."
  • Watch for:
    • Referral used to offload a client in crisis. The risk stays yours.
    • Clients sent to people outside community sanction.
    • Confidentiality leaks in small communities.
    • Conflicting advice about medicines. Route it to the prescriber.
    • Signs it is working: the client experiences the two kinds of care as complementary, and there is a clear route for urgent concerns.

4.11 Interpreters and cultural brokers

  • Purpose: to support language access (Anishinaabemowin, or Cree and other languages where the shaking tent is also practised) and to give cultural context on norms. [source: https://ebsco.com/research-starters/religion-and-philosophy/shaking-tent-ceremony]
  • Steps:
    1. Ask the client whether they want an interpreter or broker, and who. A relative or a community member raises confidentiality issues.
    2. Brief the interpreter or broker on confidentiality.
    3. Ask the broker about norms, not about ceremonial content.
    4. Debrief afterwards.
  • Example language (illustrative): "Would it help to have someone from your community, or an Anishinaabemowin speaker, help us? You choose who, or whether at all."
  • Watch for:
    • The broker's own standing in the community affecting what the client discloses.
    • The broker becoming the therapist.
    • Signs it is working: the client speaks more freely, and misunderstandings drop.

4.12 Integration after ceremonies or teachings

  • Purpose: to help the client connect what they experienced or were advised in ceremony, lodge teachings or a shaking tent with their daily life and therapy goals, without your interpreting sacred content. [synthesis]
  • Steps:
    1. Ask the client whether they want to bring anything from the experience into therapy.
    2. Focus on effects and meaning as the client chooses to describe them, such as feelings, decisions and relationships. Do not focus on what was done.
    3. Defer interpretation of the spiritual content to the client and their Elder or healer.
    4. Link it to the goals: what the client wants to do differently.
    5. Screen for distress, destabilisation or re-traumatisation, and for sleep loss.
    6. Respect any guidance the healer gave, such as on timing, unless it creates a safety risk. In that case, discuss it with the client and, with consent, the healer.
  • Example language (illustrative): "You don't need to tell me what happened. Is there anything you came away with that you'd like to work on here?"
  • Watch for:
    • Acute distress, new frightening experiences, or a sense of being cursed or punished that does not ease. Assess and coordinate.
    • Your own curiosity leading the session.
    • Signs it is working: the client reports more clarity, connection or resolve, and their functioning holds steady or improves.

4.13 Working with historical and intergenerational trauma, suppression and racism

  • Purpose: to address the effects of colonisation, the criminalisation of ceremonies and healers, residential and boarding schools, and racism in services.
    • One counsellor in the Ontario study combined CBT psychoeducation with education about the effects of colonisation, and the study presents a strong identity as part of healing. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546]
    • Historical background: the Courts of Indian Offenses targeted "medicine men" from 1883, and the Indian Act banned ceremonies from 1895 until 1951. [source: https://teachingamericanhistory.org/document/courts-of-indian-offenses/] [source: https://thecanadianencyclopedia.ca/en/timeline/the-indian-act]
  • Steps:
    1. Ask, gently, about family history of school attendance, child removal, and loss of language and ceremony.
    2. Provide psychoeducation linking historical trauma to current symptoms where the client finds that fits.
    3. Validate any secrecy and mistrust.
    4. Name racism the client has met in services.
    5. Pace trauma processing, following the safety and consent steps of whatever trauma treatment you use.
  • Example language (illustrative): "For a long time it was against the law for many families to practise their ceremonies openly. Some people still feel they have to keep things quiet, especially around services like this one. That makes sense to me."
  • Watch for:
    • Overwhelm when family history surfaces.
    • Clients who do not identify with a "historical trauma" frame. Don't impose it.
    • Shame about disconnection from the tradition.
    • Signs it is working: self-blame reduces, and the client's account of their distress includes context.

4.14 Goals built on hope, belonging, meaning and purpose

  • Purpose: to frame goals in terms First Nations bodies use. The First Nations Mental Wellness Continuum Framework (Health Canada and the Assembly of First Nations, 2014) names hope, belonging, meaning and purpose, with culture as the foundation. [source: https://www.sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • Steps:
    1. Ask the client what each of the four would look like in their life.
    2. Include goals for cultural connection if the client wants them, such as language classes, community events, or contact with Elders through community pathways.
    3. Track progress alongside symptom measures.
  • Example language (illustrative): "When things are going well for you, what gives you a sense of belonging, or of purpose?"
  • Watch for:
    • The framework applied to Métis, Inuit or urban clients who may not identify with it. Ask.
    • Cultural goals imposed by the therapist.
    • Signs it is working: the client names concrete belonging and purpose activities and keeps them up.

4.15 Medicines, herbal remedies and prescriber liaison

  • Purpose: to keep the client safe when they use both Mide herbal healing and prescribed medicines. Herbal remedies are part of Mide practice. [source: https://prod-front.thecanadianencyclopedia.ca/en/article/midewiwin]
  • Steps:
    1. Ask whether the client takes any traditional medicines alongside prescribed ones. Do not ask what they are made of or how they are prepared.
    2. Advise nothing about starting, stopping or changing any medicine.
    3. With consent, tell the prescriber that traditional medicines are in use, so the prescriber can assess interactions.
    4. Encourage the client to tell both the prescriber and the healer about each other's treatment.
  • Example language (illustrative): "I can't advise on medicines of any kind. But it would be safest for your doctor and your healer to know about each other. Would you be OK with me letting your doctor know you also use traditional medicines?"
  • Watch for:
    • A client stopping prescribed medicine abruptly. Contact the prescriber.
    • New physical symptoms. Refer to medical care.
    • Signs it is working: the prescriber is informed, and the client feels respected rather than policed.

4.16 Safeguarding

  • Purpose: to protect clients when any practice, by anyone, causes harm. This includes restraint, abuse (including sexual abuse), exploitation by people falsely claiming spiritual authority, or delay of urgent medical or psychiatric care. It applies equally to harms in mainstream services. [synthesis]
  • Steps:
    1. Assess the concern on its facts, separating a harmful act from a tradition.
    2. Avoid both under-reacting ("it's cultural") and over-reacting (treating ceremony as abuse).
    3. Follow your jurisdiction's reporting duties.
    4. Where appropriate and safe, consult Indigenous child-welfare or community authorities. Where possible, use Indigenous-governed services.
    5. For minors, follow child-protection law, and never name the young person in shared records beyond what the law requires.
  • Example language (illustrative): "What you're describing worries me for your safety, whatever the setting. Can we think together about who needs to know?"
  • Watch for:
    • Fears about child welfare that make families conceal things. Explain the limits of confidentiality early.
    • A practitioner using claimed spiritual authority to demand sex, money or isolation. This is not a community-sanctioned practice. [synthesis]
    • Signs it is working: the client is safe and keeps their cultural connection.

4.17 Working with families, community and Two-Spirit clients

  • Purpose: wellness in this framework is relational and kinship-based. [source: https://www.sac-isc.gc.ca/eng/1576093687903/1576093725971] Some Indigenous services run dedicated Two-Spirit programmes; Anishnawbe Health Toronto has a Two Spirit Trans Program where healers teach. [source: https://aht.ca/service/traditional-service/]
  • Steps:
    1. Map kinship and clan supports where the client wishes.
    2. Offer family sessions if the client wants them.
    3. For Two-Spirit or LGBTQ+ clients, ask about acceptance in both Indigenous and non-Indigenous settings, and offer Two-Spirit-specific services where they exist.
  • Example language (illustrative): "Who in your family or community do you turn to? Is there anyone you'd want to bring in to a session?"
  • Watch for:
    • Family conflict over traditional versus Christian practice.
    • Exclusion experienced in any setting.
    • Signs it is working: the client's support network widens.

4.18 Adapting evidence-based treatment

  • Purpose: to deliver standard treatment for the presenting problem, such as CBT for depression or trauma-focused therapy, in a way that fits the client's explanatory model and does not conflict with the client's healing. [synthesis]
  • Steps:
    1. Choose the treatment for the diagnosis.
    2. Adapt the examples, metaphors and homework to the client's life, using only teachings the client offers. Do not import Medicine Wheel or other teachings yourself unless the client or their Elder brings them.
    3. Check in regularly that the therapy feels compatible with their path.
  • Example language (illustrative): "Does this way of working fit with how you see things, or with what your Elder has told you? If not, let's adjust it."
  • Watch for:
    • Homework that clashes with ceremonial timing.
    • Clients feeling that therapy competes with their tradition.
    • Signs it is working: symptom scores improve and the client stays engaged.

4.19 Cultural supervision and therapist self-care

  • Purpose: counsellors in the Ontario study relied on Elders and community relationships for guidance and self-care, and they built competence through long-term community involvement. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546]
  • Steps:
    1. Arrange regular consultation with an Indigenous clinician or an Elder offered through an Indigenous service, following its protocol.
    2. Bring cases to that consultation with the client's identity protected.
    3. Attend public community events as a guest only when you are welcome.
  • Example language (illustrative), to a consultant: "I'd like guidance on whether I'm handling a client's connection to ceremony respectfully. I won't share identifying details."
  • Watch for:
    • Using Elders as free labour. Follow the service's arrangements for recognising their time.
    • Burnout.
    • Signs it is working: you have fewer blind spots and get feedback from community partners.

5. Handling problems

The sources say little about problems in this work. Except where cited, the guidance in this section is [synthesis].

  • The client asks you to explain, endorse or join a ceremony.
    • Say plainly that it is not your role. Neither confirm nor dismiss spiritual claims. Redirect the client to their Elder, lodge or traditional service.
    • Illustrative: "That's a question for your Elder. I'm not the right person to answer it, but I can help you think about how to ask."
    • The Ontario counsellors referred clients when a sacred service was beyond their role. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546]
  • The client wants a ceremony but has no community link, for example after adoption or child-welfare removal, or as an urban client.
    • Connect them with an Indigenous health centre or a friendship or community organisation that has intake for traditional services. [source: https://aht.ca/service/traditional-service/]
    • Warn gently against commercial "ceremony" providers.
    • Work on any grief or identity distress about the disconnection.
  • Mistrust, silence or "resistance".
    • Treat it as reasonable, given the criminalisation of ceremonies and healers. [source: https://teachingamericanhistory.org/document/courts-of-indian-offenses/] [source: https://thecanadianencyclopedia.ca/en/timeline/the-indian-act]
    • Slow down. Explain what you record and who sees it. Use the CFI Patient–Clinician Relationship module. Do not interpret the silence as pathology.
    • Trust is built through your conduct and reputation over time. [source: https://cjc-rcc.ucalgary.ca/article/download/58946/44398/160546]
  • Stuck: the explanatory models conflict.
    • Return to the explanatory-model summary. Look for goals both models share, such as sleep, safety and relationships.
    • With consent, ask the client's Elder or healer how they see the treatment fitting together.
    • Don't argue about causes.
  • Overwhelm after a ceremony, teaching or disclosure of family history.
    • Stabilise with grounding and paced work. Check sleep, safety and supports.
    • Defer trauma processing.
    • If frightening experiences persist outside the ceremonial context, assess for psychosis, mania or dissociation (4.8), and with consent coordinate with the healer and the prescriber.
  • Non-adherence to therapy or medicines.
    • Explore whether therapy or medication feels like it conflicts with the client's path.
    • Do not advise on changing medicines. Route the question to the prescriber.
    • Respect seasonal and ceremonial commitments in scheduling; ceremonies at Anishnawbe Health Toronto, for example, follow the seasons. [source: https://aht.ca/service/traditional-service/]
  • Ruptures.
    • Name the moment and own your part, for instance an intrusive question about sacred matters or a dismissive comment.
    • Repair in the client's terms. Invite feedback using the CFI relationship questions. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
    • Illustrative: "I think I asked about something that wasn't mine to ask. I'm sorry. Tell me if I do that again."
  • Pressure to record or report sacred details (from an agency, a court or a supervisor).
    • Record only what is clinically necessary, attributed to the client. Leave out ceremonial content. Get advice on your jurisdiction's legal duties.
    • The Mide historically opposed writing down oral teachings. [source: https://sootoday.com/local-news/shingwauk-u-to-preserve-secret-midewiwin-teachings-115337]
  • Safety concern in a ceremonial or healer relationship.
    • Apply 4.16. Separate a harmful act from the tradition. Report as required. Where safe, involve Indigenous-governed bodies.
  • The client feels pulled between traditional and Christian or other faith commitments.
    • Use the Spirituality, Religion and Moral Traditions module. Stay neutral and support the client's own resolution. Offer referral to the relevant faith leader or Elder, as the client wishes. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
  • You feel drawn to the tradition yourself.
    • Keep it out of the therapy. Take it to supervision. Approach any personal interest only through community-sanctioned public avenues, never through clients.

Sources

Web sources:

Books and articles cited:

  • Benton-Banai, E. The Mishomis Book: The Voice of the Ojibway. University of Minnesota Press (copyright 2010 edition per the publisher listing; original publication year [uncertain]). An Anishinaabe-authored account whose topics include the Midewiwin.
  • 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.
  • Gureje, O., et al. (2020). COSIMPO cluster randomised trial. The Lancet.
  • Ofori-Atta, A., et al. Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. British Journal of Psychiatry, 212(1) (year listed as 2019 by the repository; volume 212 is the 2018 volume [uncertain]).
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