Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 100
Guide XI-100

Medicine-wheel teachings

Great Plains; Canada
A 40 · L 49 · M 1116 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: there is no single medicine wheel. This guide follows how Indigenous-led Canadian bodies frame holistic wellness for services: the First Nations Mental Wellness Continuum Framework (Health Canada and the Assembly of First Nations, summary report dated December 2014, released 2015) and the Thunderbird Partnership Foundation Indigenous Wellness Framework Reference Guide (2020). An Anishinaabe educator's account of medicine-wheel teachings (Bell, 2014) is used as attributed context. The psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI). [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971] [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] [source: https://www.edcan.ca/?p=42654]

What it is. Medicine-wheel teachings are not a therapy. They are teachings held by particular Nations, Elders and traditional teachers, often drawn as a circle divided into four. The four parts can stand for directions, seasons, times of day, stages of life, or aspects of the person. Bell, who is Anishinaabe (bear clan, Kitigan Zibi First Nation), writes that teachings and drawings vary between Nations while the core ideas stay shared: wholeness, interrelationship, interconnectedness, and balance and respect. She also writes that "each nation culturally determines for itself how it knows what it knows." [source: https://www.edcan.ca/?p=42654] One counselling article describes the wheel as traditional to Great Plains cultures [source: https://www.communitycommons.org/entities/ca3a9da3-2d93-4a9a-b59a-a708bdc5d0d8]. Some Nations do not use it at all, as secondary summaries report [source: https://en.wikipedia.org/wiki/Medicine_wheel_(symbol)] [uncertain: secondary source].

How it is used in health services. Canadian Indigenous health programmes often describe wellness as balance among spiritual, emotional, mental and physical life. The First Nations Mental Wellness Continuum Framework describes mental wellness as that balance, strengthened through four outcomes: hope, belonging, meaning and purpose. Culture is at the centre of the model, and Elders and cultural practitioners appear in its culture and community layers. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971] Thunderbird's guide links the spiritual, emotional, mental and physical dimensions to the same four outcomes. It deliberately attaches no compass directions, because the meanings of the sacred directions vary by region. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] Neither framework document uses the term "medicine wheel" in the sections cited [uncertain: not verified across the full documents]. In Vancouver, two Elder-led clinics define wellness through the Medicine Wheel as a balance of mental, spiritual, emotional and physical health, and their physicians are mentored by Elders. [source: https://www.doctorsofbc.ca/health-collaboration-jccs/2023/traditional-indigenous-approach-brought-clinics-offering-western]

Core idea of change (as these sources frame it). Distress is understood as imbalance or disconnection across the whole person and their relationships with family, community, land and creation. Healing restores balance and connection, grounded in culture, identity and language, and is expressed as hope, belonging, meaning and purpose. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971] [source: https://thunderbirdpf.org/?p=7063]

The psychotherapist's place. Medicine-wheel teachings belong to Elders and Knowledge Keepers whom their communities sanction. The psychotherapist does not teach them or lead ceremonies. The psychotherapist's work is culturally responsive assessment, formulation and therapy alongside the teachings: using the client's own framework when the client wants that, and collaborating with community-sanctioned Elders and cultural staff. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] [synthesis]

2. Framework

No source gives phases, session counts or progression criteria for "medicine-wheel therapy", because no such manualised therapy exists. The structure below is [synthesis]. It is organised around the service continuum in the First Nations framework (health promotion and prevention; early identification and intervention; crisis response; coordination of care and care planning; detox; trauma-informed treatment; support and aftercare). [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]

Phase A: Engagement and cultural assessment (about sessions 1–3) [synthesis]

  • Goals: safety and trust; learn the client's Nation, community, language, and relationship to teachings, including none, partial, reclaiming, Christian or syncretic; complete the core CFI; screen for risk.
  • Format: individual 50–60 minute sessions, with family or an informant if the client wishes; an interpreter or cultural liaison where needed.
  • Move on when: the client has said in their own words what the problem is and what helps, and whether they want cultural teachings or Elder involvement in their care.

Phase B: Holistic formulation and goals (about sessions 2–5) [synthesis]

  • Goals: a shared formulation that holds the client's explanatory model next to the clinical one; strengths and needs across spiritual, emotional, mental and physical life; goals framed as hope, belonging, meaning and purpose where the client finds this fitting.
  • Move on when: the client recognises the formulation as theirs, and the goals are agreed and written in the client's words.

Phase C: Treatment alongside cultural supports (ongoing) [synthesis]

  • Goals: evidence-based psychotherapy for the presenting problem, such as trauma-focused, depression or substance-use work; coordination with Elders, cultural programmes, prescribers and system navigators the client chooses; regular review of balance across the four dimensions.
  • Format: weekly or fortnightly sessions; case conferences with consent.
  • Move on when: symptoms and functioning improve, and the client has stable connections (family, community, cultural, clinical) that do not depend on the therapist.

Phase D: Integration, aftercare and ending [synthesis]

  • Goals: consolidate gains; plan support and aftercare, which the framework names as part of the continuum; set out how to re-engage.
  • End when: the client's own supports are in place and a relapse or crisis plan exists.

3. Guiding principles

  • Culture as foundation. Indigenous knowledge is the starting point, and other frameworks are integrated afterwards. In practice, ask about culture early and treat it as a strength, not an add-on. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • Nation-specificity, not pan-Indian generalisation. Treatment centres offer culture based on the local people, because culture is defined by land, language and Nation. In practice, never assume a client's teachings, colours or directions; ask. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] [source: https://www.edcan.ca/?p=42654]
  • Authority rests with sanctioned Elders and teachers. Thunderbird's guide says cultural interventions are facilitated by people whose skills are sanctioned by their community and their teachers, and that interventions should not be appropriated for use by everyone. In practice, the therapist refers and collaborates, and does not teach or lead. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf]
  • Holism and balance. Wellness is a balance of spirit, emotion, mind and body (Elder Jim Dumont, as quoted by Thunderbird). In practice, assess all four dimensions, not only symptoms. [source: https://thunderbirdpf.org/?p=7063]
  • Strengths-based outcomes. Hope, belonging, meaning and purpose are the outcomes. In practice, frame goals and progress in these terms when the client agrees. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • No right or wrong wheel, but whose wheel it is matters. Bell writes that "there is no 'right' or 'wrong' way of representing or using Medicine Wheels." In practice, follow the version the client or their teachers hold; do not correct it, and do not supply your own. [source: https://www.edcan.ca/?p=42654]
  • Self-determination and community ownership. The framework calls for First Nations control of services. In practice, defer to community-run services and the client's choices about cultural care. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • Cultural safety and trauma-informed care. Both are named priorities in the framework. In practice, name colonisation, residential schools, child-welfare removal and racism in services as context without making the client explain them. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971] [synthesis]
  • Two-Eyed Seeing. Elder Albert Marshall's concept of holding Indigenous and Western knowledge side by side is cited in Nipissing First Nation's health curriculum. In practice, hold both explanatory models without ranking them. [source: https://ecampusontario.pressbooks.pub/indigenoushealthandwellness/?p=179]
  • Pace and relationship. In one case study, a client contrasted a rushed physician visit with counselling that let him set the pace. In practice, do not hurry rapport or cultural disclosure. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf]
  • Respect for spiritual privacy. Clients may share some spiritual experiences only with certain people. In practice, ask whether they have someone to talk to about spiritual matters, and do not press for details. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf]
  • Attribution of spiritual concepts. Spirit, ancestors, animal helpers and the drum are described as the client and their tradition hold them, neither stated as fact nor dismissed. [synthesis]

4. Intervention inventory

Everything below is the psychotherapist's own work. Medicine-wheel teachings themselves, and any ceremony, prayer, song or sacred item linked to them, come only from Elders and Knowledge Keepers whom the client's community sanctions. This guide gives none of their content. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf]

4.1 Cultural humility and self-examination

  • Purpose / when: before and throughout work with First Nations, Métis or Inuit clients, and before using any four-part wellness model. [synthesis]
  • Steps: (1) Name your own position: settler, Indigenous from another Nation, or Indigenous from the same Nation, and what that means for power and trust. (2) Check where your knowledge of the medicine wheel came from. Popular four-colour versions spread partly through a 1972 popular book (Seven Arrows) and New Age workshops. Cheyenne critics disputed that book's claims of Cheyenne origin, and the scholar Andrea Bear Nicholas has argued that uncritical pan-Indian adoption displaced many Nations' own oral traditions. [source: https://en.wikipedia.org/wiki/Medicine_wheel_(symbol)] [uncertain: secondary source] (3) Learn whose land you work on and which local Indigenous services and Elders programmes exist. (4) Seek supervision or consultation from Indigenous colleagues. [synthesis]
  • Example language (illustrative): "I'm not Indigenous, and I don't hold any teachings. If something I say doesn't fit how your people see things, I want you to tell me."
  • Watch for: reaching for a generic wheel diagram; feeling you "know" the client's culture from training; client deference or politeness masking disagreement. It is working when the client corrects you freely.

4.2 Asking whether, and which, teachings matter to this client

  • Purpose / when: first or second session, and again whenever the client mentions culture, Elders or balance. Bell writes that each Nation determines its own ways of knowing, and Thunderbird notes that the meanings of the directions vary by region. [source: https://www.edcan.ca/?p=42654] [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf]
  • Steps: (1) Ask about Nation, community, clan or kinship if the client wishes to share, and language. (2) Ask open questions about what, if anything, from their culture helps them; do not mention the medicine wheel first. (3) If the client raises the wheel or another teaching, ask who taught it and how they use it. (4) Accept every answer, including disconnection, reclaiming, Christian faith or a mix. Urban clients' practices may be creative or syncretic. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf] (5) Record the client's own terms. [synthesis]
  • Example language (illustrative): "Some people find their culture or teachings part of how they stay well, some are still finding their way back, and some don't connect with that. Where are you with it?" / "You mentioned the wheel. Who shared those teachings with you, and how do you use them?"
  • Watch for: shame about loss of language or culture, often linked to residential school or child-welfare history; testing whether you will judge. It is working when the client uses their own terms unprompted.

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

  • Purpose / when: structured cultural assessment at intake, with any client. APA describes the CFI as designed for use by any clinician, with any individual, in any care setting. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
  • Steps: Use the official APA form. It has 16 questions in four domains: cultural definition of the problem (Q1–3); cultural perceptions of cause, context and support (Q4–10, including cultural identity); cultural factors affecting self-coping and past help seeking (Q11–13); and cultural factors affecting current help seeking (Q14–16, including the clinician-patient relationship, such as perceived racism or language barriers). Clinicians may reproduce the form for use with their own patients; modification or translation needs APA permission. It informs clinical judgement and is not the sole basis for diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] Time needed: field-trial clinicians found later interviews took less time; a figure in minutes is [uncertain]. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/] When cultural identity or help seeking comes up, let the client describe balance, Elders or ceremony in their own words. [synthesis]
  • Example language (illustrative): "People explain problems in different ways. How would you describe what's been going on, in your own words?" / "Is there anything about who you are, your family, your community or your background, that makes this harder or easier?"
  • Watch for: the client giving a "clinical" account to please you; replies to Q16 about past racism in services. It is working when the client's own definition and expectations are recorded and shape the plan.

4.4 CFI supplementary modules and informant version

  • Purpose / when: deeper assessment at intake or later in care, repeated as needed. APA's twelve modules include Cultural Identity; Spirituality, Religion and Moral Traditions; Explanatory Model; Social Network; Coping and Help-Seeking; Patient-Clinician Relationship; School-Age Children and Adolescents; Older Adults; Immigrants and Refugees; and Caregivers. The core form shows which module expands each subtopic. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
  • Steps: (1) Use Cultural Identity when the client describes complex or reclaimed identity. (2) Use Spirituality, Religion and Moral Traditions when teachings or ceremony matter. (3) Use Social Network for kinship, clan and community. (4) Use the Informant Version (17 questions) with a family member the client chooses. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] (5) Use the youth or older-adult modules as relevant. Paraphrase the questions to fit the client while keeping their intent. [synthesis]
  • Example language (illustrative): "Are there spiritual or cultural practices that help you, and is there anything about them you'd want me to understand, or that you'd rather keep private?"
  • Watch for: reluctance to discuss spiritual matters with outsiders. Respect it and ask whether they have someone to talk with about those matters. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf]

4.5 Eliciting the explanatory model (Kleinman)

  • Purpose / when: whenever the client's view of cause or cure may differ from yours, for example when they describe the problem as imbalance, disconnection or a spiritual matter.
  • Steps: Kleinman, Eisenberg and Good (1978) set out eight questions, paraphrased here: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment they think they should receive; the main problems it has caused; and what they fear most. [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] Write their model next to yours, and negotiate a plan both can accept. [synthesis]
  • Example language (illustrative): "What do you think brought this on, and why now?" / "What kind of help do you think would set things right?"
  • Watch for: your urge to translate "out of balance" into "depressed" too early. It is working when the plan includes what the client believes will help.

4.6 Holistic four-dimension wellness review (client-led)

  • Purpose / when: with clients who use a four-part model, or whose service uses one (for example Thunderbird's Indigenous Wellness Framework), to map strengths and needs. Thunderbird links balance across spiritual, emotional, mental and physical life to hope, belonging, meaning and purpose. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] Thunderbird also publishes a Native Wellness Assessment; its versions, training and licensing are [uncertain: not verified]. Do not use it without the publisher's authorisation.
  • Steps: [synthesis] (1) Ask whether the client would like to look at their wellbeing in a whole-person way. (2) Use the client's own labels and order; if they hold a wheel teaching, follow it and attach no directions or colours yourself. (3) For each dimension, ask what is strong and what is depleted. (4) Note links between dimensions, for example poor sleep (body) feeding hopelessness (spirit). (5) Repeat every 4–6 sessions as a review.
  • Example language (illustrative): "You talked about being out of balance. Would it help to look at how your spirit, feelings, thinking and body are each doing, in whatever way makes sense to you?"
  • Watch for: the review turning into you teaching a model; the client feeling tested on culture. It is working when the client links the dimensions themselves and picks where to start.

4.7 Goal setting through hope, belonging, meaning and purpose

  • Purpose / when: after formulation, to frame goals in the outcomes the First Nations framework names: purpose (a role in daily life, such as education, work, caregiving or cultural ways of being); hope (belief in the future, grounded in identity, values and spirit); belonging (connection to family, community and culture); meaning (understanding how one's life is part of creation and history). [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • Steps: [synthesis] (1) Offer the four outcomes as one possible frame. (2) For each, ask what a small sign of progress would look like. (3) Pair each goal with concrete steps and with the client's chosen supports, clinical or cultural. (4) Review at set intervals alongside standard outcome measures.
  • Example language (illustrative): "If your sense of belonging grew a little over the next month, what would you notice: who would you be seeing, where would you be?"
  • Watch for: goals that rely on cultural access the client does not yet have; romanticising culture as a cure. It is working when goals are specific, owned by the client, and reached.

4.8 Asking about Elders, helpers and spiritual supports without judgement

  • Purpose / when: at assessment and during treatment. A case study recommends asking about a wider range of supports, which for that client included ancestors, animal helpers, the drum, a friend who drummed with him and an older man in an elder role. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf]
  • Steps: (1) Ask who and what helps, including people, practices, places and the land. (2) Ask whether they see or would like to see an Elder or cultural helper, and what they would want you to know or not know. (3) Record supports as resources in the plan. [synthesis]
  • Example language (illustrative): "Besides me and your doctor, who or what helps you heal: people, places, practices? Is there anyone you can talk to about the spiritual side?"
  • Watch for: expecting disapproval; supports the client values but cannot currently reach. It is working when the client describes these supports openly.

4.9 Collaboration and referral with community-sanctioned Elders and cultural programmes

  • Purpose / when: when the client wants teachings, an Elder or cultural programming as part of care. Thunderbird's guide states that cultural interventions are facilitated by people sanctioned by both community and teachers, that some ceremonies require a cultural teacher, and that treatment centres offer culture based on the local people. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] Examples of partnership models include Vancouver's Elder-led primary-care clinics, where Elders and Knowledge Keepers mentor physicians. [source: https://www.doctorsofbc.ca/health-collaboration-jccs/2023/traditional-indigenous-approach-brought-clinics-offering-western] The First Nations framework names system navigators and case managers as part of collaboration. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • Steps: [synthesis] (1) Ask which community or Nation's Elders the client would trust. Teachings from another Nation may not fit. (2) Find routes through Indigenous-run health services, Friendship Centres, band or community health offices, or your agency's Indigenous liaison, not through unvetted private offerings. (3) Ask the client, or the service's cultural staff, about the protocols for approaching an Elder. Protocols differ between communities, and some must be learned properly. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] (4) Get written consent specifying what may be shared, with whom, and for what purpose. Elders are not bound by your professional confidentiality rules, so agree what is shared. (5) Agree roles: the Elder holds the teachings and ceremony, and you hold the psychotherapy, risk management and clinical records. (6) Keep the referral open-ended; the client decides what to bring back.
  • Example language (illustrative): "You said you'd like to reconnect with teachings. Would it help if I found out what the Indigenous health centre offers? You decide what, if anything, I share with them."
  • Watch for: pressure on the client to take part in culture; you or your service "borrowing" an Elder for tokenistic roles; confusion of roles. Collaboration with traditional and faith healers has been tested in other regions: in a Nigeria–Ghana cluster trial (COSIMPO; Gureje et al., The Lancet, 2020), shared care for psychosis reduced symptoms more than control and reduced harmful practices. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] In a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication reduced symptoms, but days in chains did not fall significantly. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] These trials are from different traditions and contexts, and no comparable trial of medicine-wheel-based collaboration was found [uncertain: not verified].

4.10 Distinguishing culturally normative experience from illness

  • Purpose / when: when the client reports visions, dreams with guidance, hearing or sensing ancestors or spirits, or other experiences that a clinician unfamiliar with them could misread. In DSM-5-TR, the dissociative-trance and possession criteria exclude states that are a normal part of broadly accepted cultural or religious practice. [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299] ICD-11 Trance disorder (6B62) and Possession trance disorder (6B63) require that the state is 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] The DSM-5-TR wording on culturally sanctioned beliefs versus delusions is [uncertain: not verified].
  • Steps: (1) Ask how the client and their family or community understand the experience. (2) Ask whether others in their community would see it as expected, meaningful or concerning. (3) Assess distress, impairment, involuntariness, and course; look for other features of psychosis, mania or dissociation. (4) With consent, consult a cultural broker or an Elder the client trusts. (5) Avoid both pathologising and missing illness. [synthesis]
  • Example language (illustrative): "In your family or community, how would people understand what you've been seeing? Does this feel like something meaningful to you, or something frightening and out of control?"
  • Watch for: a client hiding experiences for fear of being labelled; deterioration in sleep, self-care or safety, which calls for urgent assessment whatever the cultural meaning.

4.11 Integrating teachings and cultural experiences into therapy

  • Purpose / when: when the client returns from time with an Elder, a cultural programme or the land and wants to make sense of it in therapy. [synthesis]
  • Steps: [synthesis] (1) Let the client choose what to share; do not ask about the content of ceremonies. (2) Ask what it meant and what changed in their spirit, feelings, thinking or body. (3) Link insights to goals. (4) Do not interpret or rank the teachings; if the client is confused by a teaching, suggest returning to the person who gave it.
  • Example language (illustrative): "You don't need to tell me anything that's meant to stay there. Is there something from that time you'd like to carry into what we're working on?"
  • Watch for: distress after cultural experiences, for example when they stir grief or trauma, which needs gentle processing and possibly a pause; idealising the therapist as a spiritual guide. It is working when cultural and clinical gains reinforce each other.

4.12 Medication and shared decision-making

  • Purpose / when: when a client resists or stops medication for cultural or spiritual reasons. Wendt and Gone recommend open conversation and shared decision-making rather than a blanket stance. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf]
  • Steps: (1) Explore the client's views without arguing. (2) Never advise starting, stopping or changing a medicine; route all questions to the prescriber. (3) With consent, tell the prescriber about the client's concerns and use of traditional medicines, so the prescriber can assess interactions. [synthesis]
  • Example language (illustrative): "It sounds like the medication doesn't sit right with how you see healing. That's important for your doctor to hear. Would you like help talking with them about it?"
  • Watch for: abrupt stopping and relapse signs; the client feeling forced to choose between medicine and culture.

4.13 Addressing intergenerational trauma, colonisation and racism in services

  • Purpose / when: throughout care. The First Nations framework lists the intergenerational impacts of colonisation, and people in care or institutional systems, among specific population needs, and makes trauma-informed treatment part of the continuum. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971] CFI Q16 asks about the clinician-patient relationship, including perceived racism. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
  • Steps: [synthesis] (1) Acknowledge historical suppression of Indigenous practices, residential schools and child-welfare removals as context, without asking for a history the client has not offered. (2) Ask about experiences of racism in health services and with you. (3) Include family and community history in the formulation where the client wishes. (4) Use evidence-based trauma treatment, paced and adapted, alongside cultural supports the client chooses.
  • Example language (illustrative): "A lot of Indigenous people have had bad experiences with services like this one. If anything I do feels like that, I'd really want to know."
  • Watch for: retraumatisation through intrusive history-taking; collective grief surfacing as individual symptoms; clinician guilt taking up space in the session.

4.14 Working with family, kinship and community

  • Purpose / when: when the client places healing within family, clan or community. The framework places kinship, clan, Elders and community at its core. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • Steps: (1) Use the CFI Informant Version or Social Network module with people the client names. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] (2) Offer family sessions or joint planning. (3) Map supports and stresses in the community, such as small-community confidentiality concerns. (4) Agree confidentiality boundaries explicitly. [synthesis]
  • Example language (illustrative): "Who in your family or community would you want involved, if anyone, and what should stay just between us?"
  • Watch for: confidentiality risks in small communities; family conflict about traditional versus Christian or mainstream approaches.

4.15 Protecting against appropriation and exploitation; safeguarding

  • Purpose / when: when a client is drawn to, or harmed by, ceremonies or teachings offered outside legitimate community pathways, or when you or your service consider using medicine-wheel imagery. Thunderbird states that cultural interventions should not be appropriated for use by everyone. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] On 10 June 1993, Lakota Summit V, a gathering of US and Canadian Lakota, Dakota and Nakota Nations, passed a declaration against those who appropriate and misrepresent Lakota spirituality. [source: https://www.hss.mun.ca/worldreligions/resources/aboriginalSpirituality/159.html] Secondary sources report that self-styled teachers charged fees for workshops and titles built on composite medicine-wheel teachings and were protested by Indigenous activists. [source: https://en.wikipedia.org/wiki/Medicine_wheel_(symbol)] [uncertain: secondary source]
  • Steps: [synthesis] (1) Do not use medicine-wheel diagrams, colours or directions in your materials unless an Indigenous organisation or community you serve has authorised them and specified the version. (2) If a client is seeking ceremony, ask how they found it, who sanctions the leader, and whether a community is behind it; direct them to Indigenous-run services. (3) Assess for exploitation: payment demands, isolation from family, sexual contact, pressure to stop medical care or medicines, unsafe physical conditions. (4) Follow child-protection and adult-safeguarding duties where there is abuse, neglect or delay of urgent medical care, while recognising that legitimate practices have been misread as harmful in the past.
  • Example language (illustrative): "It sounds like this group means a lot to you. Can I ask how you came to them, and whether a community or Elders you know stand behind them?"
  • Watch for: your own or your agency's use of Indigenous imagery for branding; signs of coercion, financial or sexual exploitation; physical harm.

4.16 Cultural formulation and care coordination

  • Purpose / when: after assessment, and at reviews, to bring all of the above into the record and the plan. The DSM-5-TR culture chapter includes the Outline for Cultural Formulation alongside the CFI. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
  • Steps: (1) Write a cultural formulation: cultural identity; cultural conceptualisation of distress, including the client's explanatory model; psychosocial stressors and supports, including cultural ones; cultural features of the clinician-client relationship; overall implications for diagnosis and care. (2) List all providers: Elders or cultural programmes (with consent), prescriber, navigator, community services. (3) Plan crisis response and aftercare, which the framework names as part of the continuum. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971] (4) Share the plan with the client in plain language. [synthesis]
  • Example language (illustrative): "Here's how I've written up what you've told me about what's going on and what helps. Does this sound like you? What would you change?"
  • Watch for: records that quote or describe teachings or ceremonies the client shared in confidence; keep these minimal and agreed with the client.

5. Handling problems

The sources consulted say little about clinical difficulties. Unless a source is cited, the guidance below is [synthesis].

  • The client wants you to "do the medicine wheel" with them or teach it. Explain that the teachings belong to Elders and Knowledge Keepers sanctioned by their community, and offer to help connect them (4.9). You can still use their own words about balance in therapy (4.6). Cultural interventions should not be appropriated for use by everyone. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf] Illustrative: "Those teachings aren't mine to give, but I can help you find someone who holds them, and we can work with what balance means to you here."
  • Your service has already adopted a generic four-colour wheel. Raise it with Indigenous staff or partner organisations. Ask whose teaching it is and whether the local Nation authorised it. Thunderbird attaches no directions to its framework because meanings vary by region. [source: https://docs.fntn.ca/VC16995/Handouts/Indigenous%20Wellness%20Framework%20Reference%20Guide.pdf]
  • The client's teachings differ from what you have read. Follow the client's teachings and do not correct them. Bell writes that there is no right or wrong way to represent the wheels. [source: https://www.edcan.ca/?p=42654]
  • The client feels disconnected or ashamed of not knowing teachings. Normalise this as an effect of colonial policy rather than a personal failing. Do not push cultural reconnection; offer it as an option, through Indigenous-run services, at the client's pace.
  • The client rejects anything cultural, or is Christian or follows another faith. Respect this fully. Do not treat Indigenous identity as requiring traditional practice. Use the CFI and evidence-based therapy without a four-part frame.
  • Stuck: the client talks about imbalance but nothing changes. Return to the explanatory model (4.5): what do they believe would restore balance, and what is in the way, practically and emotionally? Check for untreated depression, PTSD, substance use or physical illness, and refer to medical care where needed.
  • Overwhelm after cultural or ceremonial experiences. Use stabilisation and grounding, slow the pace, and with consent liaise with the Elder or programme. Do not process ceremony content the client wants to keep private.
  • Non-attendance. Consider transport, cost, family obligations, community events, mourning periods, and seasonal land-based activities. Offer flexible scheduling, outreach or telehealth, and avoid discharging for missed sessions without contact.
  • Rupture over racism or cultural misstep. Name it and apologise specifically, without defensiveness. Ask what repair would look like, and take it to supervision. CFI Q16 can open this conversation. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
  • The client keeps spiritual matters out of therapy. This may be a cultural norm about who hears what. Ask whether they have someone to talk to about spiritual matters, and respect the boundary. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf]
  • The client stops medication, citing culture. Do not advise on the medicine. Encourage a conversation with the prescriber and support shared decision-making; monitor relapse signs and risk. [source: https://mail.indigenouspsych.org/Resources/Publications/Wendt%20&%20Gone,%202016,%20TCP%20case%20study.pdf]
  • Unusual experiences: cultural or clinical? Use 4.10. If there is acute risk, such as suicidal intent, inability to care for self or danger to others, act on risk first, using standard risk assessment and crisis pathways, while still involving family and cultural supports the client wants.
  • Suicide risk. Assess and manage according to current standard practice, including safety planning and lethal-means counselling about safe storage and removal. Involve family, community and cultural supports with consent. Crisis response is part of the First Nations continuum. [source: https://sac-isc.gc.ca/eng/1576093687903/1576093725971]
  • The client is involved with an unsanctioned "shaman" or paid ceremonies. Explore without shaming. Ask who sanctions the leader and what the community says, and watch for exploitation (4.15). Point the client towards Indigenous-run services.
  • Small-community confidentiality concerns, including the Elder knowing the client's family. Agree precisely what is shared (4.9), offer choices of Elder or programme, and document consent.
  • Your own discomfort or over-identification. Use Indigenous consultation or supervision, and keep roles clear: you are not the client's spiritual guide.

Sources

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