Haudenosaunee medicine societies

1. Introduction

Version followed: what Haudenosaunee institutions themselves state (the Haudenosaunee Confederacy's 1995 policy on medicine masks, as excerpted and reported in secondary sources; representations of the Haudenosaunee Standing Committee on Burial Rules and Regulations recorded in US repatriation notices; the Confederacy's own "Medicine" page), with outsider scholarship as attributed context; for the therapist's own work, the DSM-5-TR Cultural Formulation Interview (CFI) and its DSM-5 supplementary modules and Informant Version.

What it is. The Haudenosaunee (Six Nations: Mohawk, Oneida, Onondaga, Cayuga, Seneca and Tuscarora; older literature says "Iroquois") maintain medicine societies. The best known outside the community are the False Face Society and the Husk Face Society. This is not a therapy and not a method a psychotherapist can learn or use. It is a living ceremonial and healing tradition held by the societies and their communities. This guide describes the tradition only at the level Haudenosaunee bodies make public, and then sets out the psychotherapist's own culturally responsive work alongside it. [source: https://www.govinfo.gov/content/pkg/FR-1996-03-25/html/96-7051.htm] [source: https://www.haudenosauneeconfederacy.com/medicine/]

How the tradition describes healing (attributed, not asserted). The Confederacy's "Medicine" page describes healers treating sickness by both physical and spiritual means. It says illness was understood to have spiritual as well as natural causes, and that healing involves trust in the medicine and reliance on the Creator. It says each community has its own medicines and directs those who wish to learn to the elders. [source: https://www.haudenosauneeconfederacy.com/medicine/] The Confederacy's mask policy, as excerpted by an outside commentator, says the medicine societies protect the use and strength of sacred medicines for individual and community welfare, that the wooden and corn husk masks represent the power of the original medicine beings, and that their use is "solely for the members of the respective medicine societies." [source: https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/] Haudenosaunee representatives in repatriation proceedings stated that the masks represent "the power of particular medicine beings," are owned collectively by the False Face Society (wooden masks) and the Husk Face Society (corn husk masks), and are needed by traditional religious leaders for present-day ceremonies. [source: https://www.govinfo.gov/content/pkg/FR-1997-09-03/html/97-23366.htm]

Associated concerns (outsider account). An encyclopedia entry by a non-Haudenosaunee scholar associates the False Face Society with restoring community well-being and individual health, and with ailments of the joints and shoulders, toothache, earache, swelling and nosebleeds. [source: https://thecanadianencyclopedia.ca/en/article/false-face-society] The same entry says masks are now carved for sale rather than ritual use. This conflicts with Haudenosaunee representations in the repatriation notices that the masks are needed for present-day ceremonies; this guide follows the Haudenosaunee statements. An Onondaga Nation statement on masks returned by the National Museum of the American Indian likewise says they are to be used by traditional Haudenosaunee people for their ongoing health and well-being. [source: https://www.onondaganation.org/government/policy/haudenosaunee-statement-on-repatriation] [uncertain: sources conflict]

Core idea of change for the therapist. Change in therapy comes from the therapist's own work: understanding the client's meanings of distress and healing through the CFI and explanatory-model inquiry, protecting the client's freedom to use their own medicine pathways without interference, and coordinating care with community services when the client wishes. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/] [synthesis]

Who holds authority.

The medicine societies themselves hold the masks, their use and knowledge; the policy reserves these for society members. [source: https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/]
The Haudenosaunee Grand Council is reported as the issuer of the mask policy: a 2010 Indigenous Law Bulletin article on Haudenosaunee repatriation attributes the mask policy to the Grand Council, the traditional government of the Haudenosaunee, as a "Policy Statement on Medicine Masks" of 1995, and reports that it prohibits the sale of medicine masks, states that no masks may be made for commercial purposes, and asks museums and private collectors to return masks and other sacred objects to their proper caretakers. [source: https://www.austlii.edu.au/au/journals/ILB/2010/12.html] Other secondary reports give the same 1995 date and style it a Grand Council or a Confederacy policy. [source: https://pages.vassar.edu/theirsorours/?p=320] [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/] The policy's full text is not quoted in this guide; the points cited elsewhere follow these reports and the SFU IPinCH commentary [uncertain: secondary].
Faithkeepers and traditional religious leaders of the nations: the repatriation record names faithkeepers among those who received returned masks and states that traditional religious leaders need the masks. [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/] [source: https://www.govinfo.gov/content/pkg/FR-1996-03-25/html/96-7051.htm]
The Haudenosaunee Standing Committee on Burial Rules and Regulations acted for the Cayuga, Mohawk, Onondaga, Seneca Nation of Indians, Tonawanda Band of Seneca and Tuscarora in US repatriation claims; the Onondaga Nation is described as the repository for repatriated objects. [source: https://www.govinfo.gov/content/pkg/FR-1996-03-25/html/96-7051.htm] [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/]
Elders of each community, to whom the Confederacy directs people seeking to learn about medicines. [source: https://www.haudenosauneeconfederacy.com/medicine/]

What Haudenosaunee bodies ask of outsiders. As reported, the policy holds that no one outside the medicine societies should possess or see the masks, prohibits reproductions, rejects exhibition and the circulation of images, and calls mockery or misrepresentation a violation of the masks' sacred functions; interference with the societies' duties is a violation of Haudenosaunee freedom. [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/] [source: https://pages.vassar.edu/theirsorours/?p=320] [source: https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/] Some Haudenosaunee carvers disagree and sell masks; Confederacy members regard such sale as harmful. [source: https://pages.vassar.edu/theirsorours/?p=320] [source: https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/] For the therapist this means: no images, replicas, descriptions of ceremonies or mask use in clinical materials, art therapy or teaching, and no attempt to arrange participation for anyone.

2. Framework

The medicine societies have no published "phases" for outsiders, and none are given here. What follows is the psychotherapist's own pathway of care alongside them. Phases, session counts and transition criteria are [synthesis] built on the CFI's documented uses. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]

Phase 0. Preparation (before first contact).

Goal: know your own position and the local landscape: which Haudenosaunee nation or community the client may belong to (on-reserve, territory or urban), the community-run services there (for example, at Six Nations of the Grand River, the Department of Well-Being's Mental Health and Addiction Services and the Kanikonriio (Good Minds) Child and Youth Program), and, in US federal settings, the IHS Traditional Cultural Advocacy policy. [source: https://www.hnhbhealthline.ca/printService.aspx?id=183016] [source: https://info-bhn.cioc.ca/record/SIM1425] [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/]
Move on when: you can name at least one community-run service and you have checked your materials and room for anything the mask policy objects to. [synthesis]

Phase 1. Engagement and cultural assessment (sessions 1 to 3).

Goal: safety and risk screen, then the core CFI (16 questions, four domains), with the Informant Version for family where the client agrees. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
Format: individual, 50 to 90 minutes; time for the core CFI is not stated by the APA forms and the field trial abstract gives no minutes. [uncertain]
Move on when: you have the client's own name for the problem, their explanatory model, their help-seeking so far (including any community medicine they choose to mention) and their preferences for care. [synthesis]

Phase 2. Cultural formulation and shared plan (sessions 2 to 4).

Goal: add supplementary modules as needed (Spirituality, Religion and Moral Traditions; Cultural Identity; Explanatory Model; Coping and Help-Seeking; Social Network; Patient-Clinician Relationship; age-specific modules; Caregivers); diagnostic differentiation; agree what therapy will and will not do. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Move on when: the client agrees a written plan that states their goals in their own words and whether, and how, they want therapy to connect with community services. [synthesis]

Phase 3. Parallel care and collaboration (ongoing; typically 8 to 20 sessions, weekly or fortnightly). [synthesis]

Goal: evidence-based therapy for the presenting problem, adapted to the client's meanings; collaboration with community-run services only with written consent; the client's own medicine pathway is left to the client and the community.
Move on when: goals are being met, or the client chooses to shift care toward community services.

Phase 4. Integration and review (every 6 to 8 sessions, and at ending). [synthesis]

Goal: repeat relevant CFI modules (they can be given repeatedly during treatment), review the plan, help the client integrate what they draw from community, family and therapy, as they choose. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]

Phase 5. Ending and continuity. [synthesis]

Goal: a relapse-prevention plan that names the people and services the client will use, including community supports; warm handover where wanted.

3. Guiding principles

The tradition is not yours to practise or explain. Never perform, simulate, describe or interpret medicine society practice; your role is your own clinical work. [synthesis, consistent with the policy reported in https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/]
Respect the mask policy in everything you produce. No images, replicas, mask-making exercises, or ceremony content in your office, notes, handouts, teaching or case presentations. [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/]
No uninvited probing. The IHS policy directs staff to avoid "uninvited probing or interference" in private beliefs; in practice, ask open questions once and let the client decide how much to say. [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/]
Do not dilute or modify. The same policy says to avoid procedures that would "interfere with, dilute, or modify" traditional beliefs; in practice, do not reframe the client's understanding into clinical language unless they want that. [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/]
Accommodate when asked. If a client asks for help contacting their own community's healing resources, make every reasonable effort, through the client and the community's own channels. [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/]
Attribute, never adjudicate. Medicine beings, spiritual causes of illness and the power of masks are described as the tradition holds them, neither asserted as fact nor dismissed. [synthesis]
The client defines their relationship to tradition. Haudenosaunee people differ in practice and belief; let the client say where they stand, and do not assume membership or non-membership of any society. [synthesis]
Culture as foundation and strength. The First Nations Mental Wellness Continuum Framework holds that culture is the foundation of wellness and names hope, belonging, meaning and purpose as outcomes; in practice, frame goals in these terms where they fit the client. [source: https://www.sac-isc.gc.ca/eng/1576093687903]
Cultural safety is judged by the client. Ask regularly whether the work feels safe and respectful; the CFI's clinician-patient relationship question covers this directly. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
The CFI informs but does not decide diagnosis. Use it alongside other clinical data. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Neither pathologise nor miss illness. Culturally normative experience is not a symptom; real disorder still needs treatment. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]
Consent governs every contact with others. Speak with family, community services or knowledge holders only with the client's specific, informed, revocable consent. [synthesis]
History is present in the room. Removal and sale of masks, and their return, carry meaning; one commentator frames repatriation as healing for generations of trauma. Expect services and therapists to be judged against that history. [source: https://pages.vassar.edu/theirsorours/?p=320]
Medicines are not your remit. Never advise on plant medicines or on starting, stopping or changing any medication; route questions to the prescriber. [synthesis]
Safety and safeguarding apply to everyone. Risk assessment and legal duties continue regardless of cultural context. [synthesis]

4. Intervention inventory

Every item below is the psychotherapist's own work. None of it is a medicine society practice, and none of it should be presented to the client as one. Example language is illustrative wording, not quoted from any source.

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with any Haudenosaunee client; to notice assumptions (for example, that the client "practises tradition", or that False Face masks are folk art) and power differences. [synthesis]
Steps: (1) Write down what you believe about Haudenosaunee medicine and where the belief came from (museum, film, souvenir, textbook). (2) Check it against what Haudenosaunee bodies publish (section 1); drop what comes from images or sales the Confederacy objects to. (3) List what you do not know and will not ask the client to teach you. (4) Take the gaps to supervision or to a cultural consultant (4.12), not to the client. (5) Repeat after any session where you felt surprise, discomfort or fascination. [synthesis]
Example language (illustrative, to yourself or supervisor): "What am I curious about here that is not the client's business to satisfy?"
Watch for: curiosity about ceremony details; wanting to show cultural knowledge; treating the client as a cultural informant. Working: your questions stay on the client's distress, goals and preferences.

4.2 Preparing a culturally safe setting and materials

Purpose / when: before first contact; to avoid harm from images or objects the Confederacy has asked not be displayed or reproduced. [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/]
Steps: (1) Remove any mask images, replicas or souvenir masks from the room, waiting area, website and slides. (2) Check psychoeducation handouts, art-therapy prompts and teaching cases for mask imagery or ceremony description; remove them. (3) Have local community-run service contacts and crisis lines ready (for example, the Six Nations crisis line listed in the Kanikonriio record). [source: https://info-bhn.cioc.ca/record/SIM1425] (4) Make sure intake forms ask about spiritual and cultural supports as optional, open questions. [synthesis]
Example language (illustrative, on an intake form): "Are there cultural, spiritual or community supports you would like us to know about? You do not have to answer."
Watch for: a client noticing or commenting on imagery; colleagues who see masks as decor. Working: no client raises objects in the room as a barrier.

4.3 Core Cultural Formulation Interview

Purpose / when: at intake or early in care with any client, to understand the problem from the client's and their network's perspective, possible sources of help and expectations of services. The DSM-5-TR core CFI has 16 questions in four domains. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Introduce it as a way to understand the client's own view. (2) Domain 1, cultural definition of the problem: the client's own words and what concerns them most. (3) Domain 2, cultural perceptions of cause, context and support: causes, stressors, supports, and how identity (nation, clan, community, language, residence) shapes the problem. (4) Domain 3, self-coping and past help-seeking, including barriers. (5) Domain 4, current help-seeking: preferences and the clinician-patient relationship, including concerns about racism and language. (6) Summarise back in the client's own terms. (7) Note which subtopics need a supplementary module. The form may be reproduced by clinicians 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] Time: the APA forms give none; a DSM-5 field trial found later interviews took less time. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/] [uncertain: minutes not stated in these sources]
Example language (illustrative): "People understand what they are going through in many ways. I'd like to hear how you understand it, in your own words, and what you hope help will look like."
Watch for: the client answering as if expected to give a "cultural" answer; long silences, which may be reflection rather than refusal [synthesis]. Working: the client corrects or adds to your summary.

4.4 Informant Version and involving family

Purpose / when: when the client wants a family member or friend involved, or cannot give a full account; the Informant Version has 17 questions, the first on 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 to who is involved and what may be shared. (2) Interview the informant separately or jointly, as the client prefers. (3) Note where accounts differ without ranking them. (4) Feed back to the client what you will use. [synthesis]
Example language (illustrative): "Your aunt sees this a bit differently. Can we look at both views together?"
Watch for: family members disclosing society or ceremonial matters on the client's behalf; stop and redirect to the client's consent. Working: the family feels consulted, the client feels in control.

4.5 Spirituality, Religion and Moral Traditions module

Purpose / when: when spiritual or traditional life is relevant to the problem or to coping. It is one of 12 DSM-5 supplementary modules, usable as an add-on or standalone, at any point and repeatedly. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) Ask what spiritual, religious or moral traditions matter to the client (Longhouse tradition, Christianity, both, neither, or other). (2) Ask how these relate to the problem and to coping. (3) Ask whether anything in their tradition is private and not for discussion, and agree to respect that. (4) Record only what the client agrees may be recorded. [synthesis]
Example language (illustrative): "Some things belong to your community and aren't for me to know. Tell me only what you want me to understand about how this helps or weighs on you."
Watch for: your own questions drifting to what happens in ceremonies. Working: the client names supports and limits clearly.

4.6 Cultural Identity module

Purpose / when: when identity, belonging, language or community ties shape the problem (for example, disconnection from community, urban living, mixed heritage). [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) Ask which nation, clan or community the client identifies with, if any, and how strongly. (2) Explore language, family and community ties. (3) Explore experiences of exclusion, racism or loss of connection. (4) Link to the FNMWCF outcomes of hope, belonging, meaning and purpose where they fit. [source: https://www.sac-isc.gc.ca/eng/1576093687903] [synthesis]
Example language (illustrative): "Where do you feel you belong, and where has that felt hard?"
Watch for: shame about not knowing language or tradition; avoid implying the client "should" know. A thesis on Haudenosaunee-framed prison healing programmes states that reconnection is a critical first step in a healing journey. [source: https://digitalcollections.trentu.ca/node/23574] Working: the client names steps toward connection that they choose.

4.7 Explanatory-model inquiry

Purpose / when: whenever the client's understanding of cause or cure may differ from yours. Kleinman, Eisenberg and Good (1978) set out questions on what the client calls the problem, its cause, why it started when it did, how it works, how severe it is and how long it will last, what treatment they should receive, the main problems it causes and what they fear most. The CFI also has an Explanatory Model module. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
Steps: (1) Ask the questions conversationally, not as a checklist. (2) Accept spiritual or relational explanations as the client's model, without endorsing or disputing. (3) Find the overlap between their model and yours (for example, both may see the problem as affecting body, mind and relationships). (4) Agree a plan that fits both. [synthesis]
Example language (illustrative): "What do you think started this? ... And what do you think would help it heal?"
Watch for: the client testing whether you will mock a spiritual explanation; respond with interest, not evaluation. Working: the client offers more of their own view over time.

4.8 Asking about community medicine and help-seeking without judgement

Purpose / when: at intake (CFI Domain 3 and the Coping and Help-Seeking module) and at reviews, to know what other help the client uses, so care can be coordinated and safe. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) Ask once, openly, whether the client uses any community, traditional or spiritual help. (2) If yes, ask only what affects therapy: is it helping, and is there anything you should do or avoid. (3) Do not ask what was done, by whom, or about masks or societies. (4) Ask about any plant medicines only so the prescriber can be informed (4.14). (5) Respect a choice not to discuss it, as the IHS policy requires. [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/] [synthesis]
Example language (illustrative): "Some people also go to their own community for help. You don't need to tell me details. Is there anything about that I should keep in mind so we work well together?"
Watch for: disclosure followed by worry or withdrawal; reassure about privacy and records. Working: the client mentions community help naturally later.

4.9 Patient-clinician relationship and cultural safety check

Purpose / when: early and at each review; the CFI asks about the clinician-patient relationship, including perceived racism and language barriers, and there is a supplementary module on it. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) Name the difference between you and the client openly. (2) Ask about past experiences with services, including racism. (3) Ask what would make the work feel safe. (4) Repeat at reviews and after any rupture. [synthesis]
Example language (illustrative): "I'm not from your community, and services haven't always treated Haudenosaunee people well. If anything I do feels off, I want to hear it."
Watch for: polite agreement that hides mistrust; missed sessions after a misstep. Working: the client tells you when something did not fit.

4.10 Cultural concepts of distress and the client's own idioms

Purpose / when: when the client describes distress in terms that are not diagnostic categories. DSM-5-TR says cultural concepts of distress include 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-5-TR examples (as listed in secondary sources: ataque de nervios, dhat syndrome, hikikomori, khyâl cap, kufungisisa, maladi dyab, nervios, shenjing shuairuo, susto, taijin kyofusho) include no Haudenosaunee concept. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] [uncertain: list taken from a secondary source]
Steps: (1) Use the client's own words for their state. (2) Some Haudenosaunee healing programmes frame wellbeing through the Good Mind (Kan'nikonhrí:io) and Crooked Mind (Wake'nikonhrèn:ton); if the client uses such terms, ask what they mean to them rather than defining them yourself. [source: https://digitalcollections.trentu.ca/node/23574] (3) Record the idiom alongside, not instead of, any diagnosis. (4) Do not invent a "Haudenosaunee syndrome". [synthesis]
Example language (illustrative): "You said your mind hasn't been good lately. What does a good mind feel like for you, and what pulls you away from it?"
Watch for: using community terms as therapy jargon, which can feel like appropriation. Working: the client uses their own terms to set goals.

4.11 Distinguishing culturally normative experience from disorder

Purpose / when: when a client reports experiences that may be meaningful within their tradition (for example, significant dreams or a sense of contact with spiritual beings) and you are also weighing psychosis, dissociation, trauma or mood disorder. [synthesis]
Steps: (1) Ask how the client and their family and community understand the experience, and whether it is expected or troubling within their own framework. (2) Check the diagnostic exclusions. DSM-5 dissociative identity disorder notes that identity disruption "may be described in some cultures as an experience of possession" and excludes disturbance that is a normal part of a broadly accepted cultural or religious practice; DSM-5 dissociative trance (other specified dissociative disorder) likewise excludes trance that is part of a broadly accepted collective practice. [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] A DSM-5-TR study guide paraphrases the same points. [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] [uncertain: exact DSM-5-TR wording] ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice. [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] (3) Look at the whole picture: distress, functioning, sleep, risk, other psychotic or mood symptoms, substance use, and whether the person's own community sees the experience as a problem. (4) If unclear, seek cultural consultation (4.12) with the client's consent before diagnosing. (5) Whatever the cultural meaning, treat risk and severe impairment as clinical priorities. [synthesis] A DSM-5-TR culture note that culturally sanctioned beliefs should not be counted as psychotic symptoms is reported but its wording is not sourced here. [uncertain]
Example language (illustrative): "In your family, is this kind of experience something people would expect, or does it worry them? ... How is it affecting your sleep, your work, the people around you?"
Watch for: two errors: labelling meaningful experience as psychosis, and explaining away a developing illness as "cultural". Working: the client and family agree with the formulation, and the plan addresses any impairment.

4.12 Cultural consultation, cultural brokers and language

Purpose / when: when you need help understanding context, when language is a barrier, or before a significant diagnostic decision. [synthesis]
Steps: (1) Ask the client whom they would trust to help you understand, if anyone. (2) Prefer consultation through community-run services or organisations the client names, not individuals you find yourself. (3) Share only what the client consents to share; consult de-identified where possible. (4) Ask the consultant about context, not about ceremony or society matters. (5) If the client prefers to speak Kanien'kéha, Onondaga, Seneca or another Haudenosaunee language, ask whether and how they want an interpreter, given small communities and confidentiality. [synthesis]
Example language (illustrative): "Would it help if I spoke with someone from a service you trust, without using your name, to make sure I'm understanding this properly?"
Watch for: consultants put in the position of revealing protected knowledge; a client who feels exposed in a small community. Working: consultation sharpens the formulation without breaching privacy.

4.13 Collaboration and referral with community-run services

Purpose / when: when the client wants their therapy linked to community healing, cultural or land-based programmes. [synthesis]
Steps: (1) Ask what the client wants: information only, a referral, joint planning, or nothing. (2) Use community-run routes. Examples: Six Nations of the Grand River's Egowadiya'dagenha' land-based programme (adults; self-referral or referral by family, doctors, hospitals, police or providers, with the person's consent; intake by phone), which offers mental wellness activities incorporating Indigenous healing practices and cultural supports; and the Kanikonriio (Good Minds) Child and Youth Program for ages 0 to 18. [source: https://www.hnhbhealthline.ca/printService.aspx?id=183016] [source: https://info-bhn.cioc.ca/record/SIM1425] (3) In US Indian Health Service settings, the Traditional Cultural Advocacy policy says that when a patient asks for help obtaining a native practitioner, "every effort will be made to comply", including privacy or space for a ceremony and, when necessary, contract health funds for healer consultation. [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/] (4) Never contact a medicine society, or arrange anything with one, yourself; access to medicine societies is the community's matter. [synthesis, consistent with https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/] (5) Get written consent naming each party and the information to be shared; agree how you will communicate and who leads on what. (6) Review together at each review point. [synthesis] Context on collaboration evidence from other regions: in Nigeria and Ghana, the COSIMPO cluster trial (Gureje et al., The Lancet, 2020) found that collaborative shared care between traditional and faith healers and primary care workers gave greater reductions in psychosis symptoms, and harmful practices fell more than in controls. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] A Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)) found 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] Neither study involved Haudenosaunee communities; how far they apply here is [uncertain].
Example language (illustrative): "There's a land-based programme run in your community. Would you like information, a referral, or would you rather keep that separate from our work?"
Watch for: pressure (from you or services) to use cultural programmes; some clients want therapy kept separate. Working: the client reports that the pieces of care fit together.

4.14 Coordinating physical health care and medicines

Purpose / when: when the client reports bodily complaints (outsider accounts associate the False Face Society with complaints such as joint pain, toothache, earache, swelling and nosebleeds) or uses plant medicines alongside prescribed drugs. [source: https://thecanadianencyclopedia.ca/en/article/false-face-society] [synthesis]
Steps: (1) Encourage medical assessment of physical symptoms, without framing community medicine as a substitute or as wrong. (2) If the client mentions plant medicines, do not ask about preparation or amounts; ask whether their doctor or prescriber knows, and offer to help them tell the prescriber. (3) Never advise starting, stopping or changing any medicine. (4) If a delay in urgent medical care seems likely, say so clearly and follow your duty of care. [synthesis]
Example language (illustrative): "Both can matter. Would you be OK letting your doctor know what else you're using, so they can check everything works well together?"
Watch for: the client hiding medicine use for fear of judgement. Working: the prescriber has a complete picture and the client feels respected.

4.15 Integrating healing experiences into therapy

Purpose / when: when the client brings meaning, change or questions from community healing, cultural or land-based programmes. [synthesis]
Steps: (1) Invite reflection on effects only: what changed, what they feel, what they want to carry forward. (2) Do not ask for or record the content of ceremonies. (3) Link the changes to the client's own goals. (4) If the experience raised distress, work with the distress using your usual methods, and suggest the client also take questions of meaning to the people in their community who guided them. [synthesis]
Example language (illustrative): "You don't need to tell me what happened. What feels different since, and how do you want that to show up in your week?"
Watch for: you interpreting spiritual meaning; the client disclosing protected matters and then regretting it (offer not to record it). Working: the client links community and therapeutic gains in their own words.

4.16 Strength-based goals: hope, belonging, meaning and purpose

Purpose / when: when setting or reviewing goals with First Nations clients in Canada and, adapted, elsewhere. The First Nations Mental Wellness Continuum Framework (Assembly of First Nations and Health Canada, 2014) puts culture at the foundation and names these four outcomes. [source: https://www.sac-isc.gc.ca/eng/1576093687903]
Steps: (1) Explain the four outcomes and ask which matter to the client. (2) Build goals under each in the client's words. (3) Identify cultural, family and community strengths the client wants to draw on. (4) Track progress at reviews. [synthesis]
Example language (illustrative): "When things are going well for you, where does your sense of purpose come from?"
Watch for: the framework imposed on a client who does not identify with it. Working: goals are concrete and owned by the client.

4.17 Working with historical trauma, appropriation and repatriation

Purpose / when: when the client's distress involves colonisation, suppression of tradition, racism, or the display, sale and return of sacred objects. [synthesis]
Steps: (1) Acknowledge the history without asking the client to educate you. (2) Validate distress about museum display, sale or mockery of masks; the policy itself treats these as violations. [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/] (3) Recognise that returns can carry meaning; one commentator frames repatriation as helping Indigenous peoples heal from generations of trauma. [source: https://pages.vassar.edu/theirsorours/?p=320] US law provides a route: masks have been determined sacred objects or cultural patrimony in NAGPRA notices. [source: https://www.govinfo.gov/content/pkg/FR-1996-03-25/html/96-7051.htm] (4) Use trauma-focused methods the client agrees to, at their pace. [synthesis]
Example language (illustrative): "It sounds like seeing that on display felt like an injury to more than just you."
Watch for: your own guilt or defensiveness; politicising the session against the client's wishes. Working: the client feels the wider context is understood and can focus on what they want to change.

4.18 Responding to clients who are not Haudenosaunee and seek involvement

Purpose / when: when a non-Haudenosaunee client wants to join a medicine society, obtain or make a mask, or use False Face imagery in healing or art. [synthesis]
Steps: (1) Explore what the client hopes to find (meaning, healing, belonging). (2) Explain plainly that the Confederacy's policy reserves the masks and their use for society members and objects to reproduction and display. [source: https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/] (3) Help the client find meaning and support within their own traditions or communities. (4) Do not suggest workshops or practitioners offering "False Face" healing to outsiders. [synthesis]
Example language (illustrative): "The Haudenosaunee have asked outsiders not to use or copy these masks. What is it you are looking for, and where else might you find it?"
Watch for: the client feeling rejected; redirect to the need underneath. Working: the client pursues the need through respectful routes.

4.19 Safeguarding

Purpose / when: whenever there is risk to the client or others, including harm from any source, delay of urgent medical care, or abuse disguised as tradition. [synthesis]
Steps: (1) Standard suicide and self-harm risk assessment and safety planning; lethal-means counselling limited to storage and removal. (2) Know local crisis lines, including community-run ones. [source: https://info-bhn.cioc.ca/record/SIM1425] (3) Follow child-protection and adult-safeguarding law; seek advice from community-run or Indigenous child and family services where the law allows and the client agrees. (4) Do not assume a traditional practice is abuse, and do not accept harm because it is called tradition; get cultural consultation where you can. [synthesis]
Example language (illustrative): "I respect your traditions. My job is also to make sure you're safe, so I need to ask some direct questions."
Watch for: mistrust of child-protection systems given their history; explain your duties early. Working: risk is managed and the alliance holds.

4.20 Records, confidentiality and protected knowledge

Purpose / when: throughout; protected knowledge and small communities raise particular privacy risks. [synthesis]
Steps: (1) Record only what is clinically needed and what the client agrees to. (2) Do not record ceremony, society or mask details even if disclosed. (3) Remove such material from case presentations, teaching and publications. (4) Tell the client who can read their records. [synthesis]
Example language (illustrative): "What you just told me sounds private to your community. I won't write it down unless you want me to."
Watch for: requests from researchers or trainees for "cultural" case material. Working: the client trusts you with what matters clinically.

4.21 Children and young people

Purpose / when: for clients under 18; the CFI has a School-Age Children and Adolescents module and a Caregivers module. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: (1) Obtain caregiver consent and the young person's assent. (2) Use the age-appropriate module and the Caregivers module. (3) Ask young person and family how they want culture and community involved. (4) Offer community-run youth services where they exist (for example, Kanikonriio for ages 0 to 18 at Six Nations). [source: https://info-bhn.cioc.ca/record/SIM1425] (5) Never name the young person in consultation. [synthesis]
Example language (illustrative): "Who in your family or community do you feel good around?"
Watch for: differences between young person and family about tradition; hold both views. Working: the young person engages and the family feels respected.

5. Handling problems

The sources above do not address therapy difficulties directly; everything in this section is [synthesis] unless a source is given.

The client is guarded or gives short answers. Mistrust may be well founded given the history of services and of sacred objects taken from communities. Name it, slow down, explain confidentiality and records, and let the client set the pace. Do not read reticence about tradition as resistance; the IHS policy recognises a right not to discuss these matters. [source: https://www.ihs.gov/IHM/sgm/1994/sgm-9408/]
The client tests whether you will judge spiritual explanations. Respond with curiosity about meaning and effects, not about truth. If you slip into dismissal, repair at once: "I spoke as if my way of seeing it was the only one. That wasn't fair."
You realise you asked about ceremony or masks. Stop, acknowledge it, and say you will not ask again: "That's not mine to ask about. Let's come back to what you wanted help with." Remove any recorded detail if the client wishes.
The client is stuck (no change after 6 to 8 sessions). Repeat the explanatory-model and help-seeking questions; check whether the plan fits the client's model; ask whether community, family or land-based supports would add something and whether they want a referral; review diagnosis, including trauma, substance use and depression.
Overwhelm when discussing historical trauma or appropriation. Shift to stabilisation and grounding; agree a pace; link to community supports the client chooses; resume trauma processing only with consent.
Non-attendance or dropping out. Consider practical barriers (distance to territory, transport, community obligations such as ceremonial seasons, funerals), and mistrust. Offer flexible scheduling and contact by the client's preferred route. Ask, without probing, whether timing of community obligations needs to be planned around.
Rupture over a cultural misstep (an image in the room, a careless phrase). Take responsibility without excessive apology, fix what can be fixed (remove the image), and ask how to proceed. Check the relationship at the next session.
The client wants you to coordinate directly with a healer or society. Explain that you will follow the community's own pathways and the client's lead: you can share information with a service the client names, with written consent, but you will not approach a society. [synthesis, consistent with https://www.sfu.ca/ipinch/outputs/blog/appropriation-month-false-face-masks/]
Family or community views conflict with the client's. Hold both; use the Informant Version or a joint session if the client agrees; keep the client's consent central.
Diagnostic uncertainty about an unusual experience. Do not diagnose in a hurry. Use 4.11, get cultural consultation with consent, monitor functioning and risk, and treat acute risk regardless.
Medication concerns. If the client wants to stop or reduce prescribed medicine in favour of community medicine, do not advise either way; arrange an urgent discussion with the prescriber and stay with the client's reasons.
A medical problem is being delayed. State your concern plainly and support the client to see a doctor; involve safeguarding only where the law requires.
A non-Haudenosaunee client is set on obtaining a mask or "False Face" treatment. Return to the need underneath (4.18); explain the community's stated position; do not help locate sellers or practitioners.
Your own discomfort, guilt or fascination. Take it to supervision and cultural consultation, not to the client (4.1).
Services or colleagues display masks or use them in teaching. Raise it with the service, citing the community's published position, and suggest removal. [source: https://ictnews.org/archive/cayuga-museum-receives-replica-wampum-belt-for-returning-haudenosaunee-spiritual-objects/]

Sources

Haudenosaunee institutions and community-run services

Repatriation records and reporting of the mask policy

Scholarship (outsider accounts)

False Face Society (The Canadian Encyclopedia)
Supporting the Good Mind and the Healing Journey: An Inquiry into Indigenous Healing Service Delivery (Trent University PhD thesis, 2024)
Fenton, W. N. (1987). The False Faces of the Iroquois. Norman: University of Oklahoma Press. Bibliographic record: CiNii. Cited for orientation only; its content is not used here.

Policy frameworks

Cultural assessment and diagnosis

APA: DSM-5-TR Cultural Formulation Interview
APA: DSM-5-TR Section III
APA: Cultural Formulation Interview, Informant Version
APA: Cultural Formulation Interview Supplementary Modules
Feasibility, acceptability and clinical utility of the Cultural Formulation Interview (Lewis-Fernández et al., 2017)
Feasibility, acceptability and clinical utility of the CFI (repository record)
DSM-5-TR webinar slides (UNMC BHECN)
Teodoro and Afonso (2020), Revista Portuguesa de Psiquiatria e Saúde Mental
PMC article 9199574, quoting DSM-5 and ICD-11 dissociation and possession criteria
DSM-5-TR dissociative disorders study guide (University of Missouri System Pressbooks)
ICD-11 6B62 Trance disorder (third-party mirror of WHO text)
WHO: Traditional medicine in ICD-11, frequently asked questions
Tanenbaum: Explanatory Models of Illness handout
Dinos et al. (2017), Cambridge Core reader
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.

Collaboration with traditional and faith healers (other regions)

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