Okay. I think we can go ahead and get started this morning again. Welcome. It's a pleasure to have a chance to speak with you today about what I consider to be a very important topic that's quite close to my heart. I've given decades of my career so far to trying to unpack some of the things I want to share with you today. So I'm looking forward to it. I've been asked really to speak about challenges to evidence-based practice in American Indian and indigenous community mental health. I should say that I'm not going to spend a lot of time going over American Indian and indigenous communities in the United States. There's some background that I'll either presume or we can talk more about in the Q&A portion. Let me just start by saying there are some 570 plus American Indian tribal nations in the United States that are recognized by the federal government. And so a very large number of diverse peoples are enfolded in that even as the population is quite small. So there's latest U.S. census shows some 7 million people identified as American Indian or Alaska Native or indigenous. And that's an upper bound for reasons I can say later. But that's what I want to talk to you about is for our communities. I am myself an enrolled tribal member at Fort Belknap Indian Reservation in north central Montana. I am a Ani Grosvant. And so I'm very pleased to come and share some perspectives. I'm a psychologist not a psychiatrist. I am clinically trained and my work is community engaged because I'm thinking and working with indigenous people about mental health concerns. And as a consequence all of my work is culturally attuned because when you talk to native people about mental health concerns culture is inevitably part of that conversation. My purpose today is to try to explain a bit about indigenous community misgivings about evidence based practice and mental health services. Being a psychologist I'm going to be talking about really psychosocial psychotherapeutic counseling kinds of interventions primarily. We can talk more in the Q&A and exchange if you want to think about the psychopharm element or aspects of it as well. And the history is that in the work that I do I am often asked to speak to these issues in part because you know there's not enough of us in these kinds of professions and academic positions to be able to express as much as people want and need to know. I'm also the current president of the Society of American Indian Psychologists and so in part I try to represent my constituency in that respect too. I'm going to talk in four parts today and the first part is really to unpack an early career lesson and to share with you something that shaped my career and my inquiry that will give rise to some of the insights I want to present today. So let's start with an early career lesson and you know at least a little bit of brief background. When it comes to American Indian mental health disparities or inequities I think that the research has clearly shown and what is casually observable to anyone who spends time in some of our reservation communities is that there are epidemic levels of distress in many of our communities. In particular when it comes to psych epidemiology you've got pretty high prevalence of trauma, of substance abuse and of suicide in particular. So just to be clear when I talk about mental health inequities we're not talking about Alzheimer's or autism or schizophrenia. We're talking about trauma, addiction, suicide. What we might properly frame as post-colonial pathologies. The community mental health services that are on offer for us is provided really or financed by the U.S. federal government. It's primarily provided either through the Indian Health Service or through contracts that tribes have with the Indian Health Service to deliver these services. The thing about the Indian Health Service and every other aspect of Indian affairs through our long history in the United States is that they're always endemically underfunded and so we have a large unmet need when it comes to treatments and services available to support people contending with mental health problems. And so you might think in the context of this underfunded under-resourced that we have pronounced mental health problems, we have underfunded mental health services. The solution is simple. Just expand mental health services. Let's get enough funding. Let's get enough providers. Let's just really throw everything we can at this problem and that should resolve these disparities, right? Well, it's this early career lesson in which that simple sense of resolution became a lot more complicated. After getting my doctorate, I taught at the University of Chicago for a bit and then my first post-doctoral research project was to go home to my own reservation. Again, the Fort Belknap Indian Reservation in north central Montana. We have Ani, Grovance, and Nakota Assiniboine people there. And I wanted to bracket or hold at bay all that I knew I had been taught or socialized into with respect to mental health professional understandings and activities and instead to approach the question of mental health and its treatment in open-ended and discovery-oriented fashion. More like an anthropologist would do in this respect to trying to really try to gauge and understand how people in the community think about these things. And so I was after local construals of problem drinking, depression, cultural intersections, and so on. And I interviewed members of extended family and service providers and professionals and administrators, but the interview that most stood out to me in terms of illuminating some of these questions was with an individual, a middle-aged grassroots traditionalist person on our reservation who in our work together chose to go by his Indian name of Traveling Thunder. And Traveling Thunder had a pretty distinct take on mental health problems and ways to remedy them. In fact, he offered what in medical anthropology we would refer to as an explanatory model. These are the models that people carry in their minds that they share so that they're sort of stock ways of understanding and making sense of things. And in Traveling Thunder's explanatory model for problem drinking, depression, and culture and so on, he really talked about four historical eras by way of explaining why we suffer from these inequities and what needs to be done about them. So the first era he talked about was this area that sounded like paradise as he discussed it. And it really was this era of pre-colonial existence in which, according to him, Native people, our people lived in perfect harmony and balance owing, he said, to a strict observation of indigenous custom. That following and adhering to those customs is what led to this idyllic sort of existence. But of course that didn't last. In the second era, an era I've labeled conquest based on his descriptions, he was describing this history of colonial contact in which he said colonial subjugation entailed the annihilation of indigenous custom, the suppression, the eradication, and the dismissal as uncivilized or savage, and therefore needing to go and people needed to be assimilated. So this indigenous custom that he observed as being responsible for harmony prior to the colonial encounter, he then observed had been annihilated or destroyed through colonial contact. This gave rise to a third era, this era of loss, in which he traced some of the post-colonial effects of this history of subjugation. The way I best describe it is it has to do with this notion of anomie. Anomie is a term, especially a psychological anomie. It means no law, literally, but it means sort of no purpose, no identity, no sense of who you are, where you belong, what you're supposed to do. And he tracked this anomie as giving rise to forms of pathology, like problem drinking and depression. In addition to this, he really identified the so-called white man system, as he repeatedly referred to it, as the original pathogen, if you will, the source, the origin of these mental health inequities in this era of post-colonial effect really was this white man system that continued to subjugate, that continued to denigrate, that continued to dismiss indigenous lives and reality as bona fide. Fortunately, according to Traveling Thunder, this wasn't the end. There was a fourth era, an era of revitalization, we might say, in which there was the potential for a post-colonial remedy. And he really charted this from the beginning of the American Indian movement in 1969 through the 1970s in particular, in which there was great interest in tribal communities in response to a return to indigenous customs and traditions, especially sacred and ceremonial customs and traditions. And so you get a sense here of the full circle of this historical account, in which you've got strict observation of custom that originally allowed harmony and balance, being disrupted in all these ways, leading to these impacts, but that the solution at this point would be a return to this indigenous sacred custom that could put things right again. Now just in terms of unpacking his explanatory model based on this interview and these historical ideas, he did identify a really clear pathological process. He talked, and if I had time I would show you in the quotes, that this is literally the mechanism, the chain of causality that he placed. That cultural repression through the colonial subjugation would lead to this kind of anemia I've described, that in turn would lead to substance abuse, then to depression, then to the sense of complete worthlessness, and finally to suicide. Interestingly, he offered very little elaboration of personal distress. He wasn't talking about individuals really. Instead, he offered an almost completely non-biological, non-psychological account of the origins and impacts of these problems. In contrast to what we are taught in the mental health professions about genetic predispositions and aberrant brain chemistry, or even in psychology around early childhood psychodynamics, family history, that kind of stuff. He didn't talk about that at all. I shouldn't say quite at all. I was a psychologist talking to him and asking questions about depression and problem drinking, so there was a little bit that he was obviously reflecting my own framing back to me a little bit about this. But instead of emphasizing these things, he really emphasized history, culture, and spirituality. This account was one that was not at the level that mental health professionals typically think. Instead, it was these other ways of framing the problem. Moreover, he really, of course, underscored the pathogenic aspects of the white man system. Basically, he identified colonization as the cause of American Indian distress, and in doing so, he really emphasized systemic factors over intrapersonal or even interpersonal factors within the community. It's really these systems, the white man system, that originated and then maintained these problems. He emphasized shared community vulnerabilities. This was why he was not really talking about individuals or this person or that family. He was really talking about our entire community has gone through this process together, and it has this impact that touches us all. If we were to step back from this today, 20-odd years later, we would recognize this explanatory model as what now is called historical trauma, as it's circulating through indigenous communities around mental health and health in general. It's really a kind of prototype for that. The one distinction I'll draw out here, which we can discuss later if you like, is that he never referenced psychological trauma. Again, he wasn't offering a particular psychological account, and historical trauma, by invoking trauma, obviously has that psychological component, so there's a sense in which what Traveling Thunder is talking about is recast just a little bit with respect to psychology in this broader explanation about historical trauma. Well, as you hear this, you might wonder, like I did, what then is the relevance of, especially psychosocial or counseling interventions and mental health services for people who have experienced what Traveling Thunder is describing as this long colonial subjugation and its impacts. So I asked him. I said, okay, I got you. Now, let's say you have a loved one who's going through a really tough time and crisis. Under what conditions would you take that person down to the behavioral health services clinic in the Indian Health Service on the reservation and get them some help? Well, he grew quiet in response to that. He thought soberly for what felt like a long time, probably 10 or 15 seconds, and then here's what he had to say about that. I guess it's like a war, but they're not using bullets anymore. They want to wipe us out, and therefore the Indian problem will be gone forever, but they're using a more shrewder way than the old style of bullets. If you look at the big picture, you look at your past, your history, where you come from, and you look at your future, where the white man's leading you, I guess you could make a choice. Where do I want to end up? And I guess a lot of people would want to end up looking good to the white man. Then it'd be a good thing to go to the white psychiatrist in the Indian Health Service and say, well, go ahead and rid me of my history, my past, and brainwash me forever so I can be like a white man. I guess that'd be a choice each individual will have to make. Well, obviously he wasn't interested in making that choice, and that was his point in telling me this, but in stating this, he's really pinpointing mental health treatment, at least as he construed it in the context of reservation IHS behavioral health services, as a cross-cultural encounter, that this is foreign, it's not what we do, how we think, what would fit us. But more importantly, I would say, he was identifying mental health services as really a form of neo-colonial cultural proselytization, this brainwash me forever so I can be like a white man. And Native people in this nation have experienced this kind of coercive assimilation for a long time, whether it was the federal Indian boarding school system or the industrial schools that were farmed out to different Christian missionary organizations. Basically, Indian civilization entailed conversion to Christianity for a long part of that history. And so when I talk to Indian audiences, I'll ask them provocatively, I wonder if mental health services in our communities are like missionaries for a new millennium. Are we promoting conversion-style tactics in the kinds of services that we offer? So returning back to my original question I posed for you, is it as simple as simply expanding mental health services? I felt like what I learned early on from Traveling Thunder is no, it's not so simple. Because first, we have this problem of cultural difference in which the mental health field, counseling, psychotherapy originate in a very distinctive cultural setting that's quite different from indigenous American histories and communities. And in fact, the differences that were probably very easy to draw a sharp contrast 200 years ago, persist in ways that are still observable today. And they reflect things like selfhood. What is the kind of self-configuration that predominates in your everyday experience? Is it egocentric or individualist? Is it sociocentric or collectivist, as psychologists might say? And those kinds of differences in self-configuration imply a lot of things about how you want to understand relationality, how you interact with other persons, whether human or other than human, which then gets at the level of cosmology and the degree to which you understand powers of the universe and what it means to be in right relationship with those powers who happen to be people or persons as well. And so the point here is that the norms, routines, and logics of the mental health clinic are not those of the tribal community, especially that part of the tribal community that's more traditionalist in its orientation. Not everyone is, and that's an important point too. But there are people who are, and so the question becomes what about this cultural difference? Well, we navigate cultural differences in lots of spheres or domains of life. It's not often too big a problem to come to mutual understandings, to negotiate a way forward together. The problem we have here, though, is not just one of cultural difference. It's a problem of cultural dominance. It's a problem of colonial subjugation that colors everything in Indian life today. Because of this legacy of colonial subjugation, you can't have a conversation on equal footing where people can just of goodwill come together and navigate these differences. You've got this shadow cast from these long histories. So I mentioned the federal Indian boarding schools. The slogan of those boarding schools, which was all about coercive assimilation of Indian young people, taking out a family and community and trying to make them into white people, except in the context of great racism, that you can't actually ever be treated as white. But that was the goal. And the slogan invented by the military officer who invented this program is kill the Indian, save the man. It was the idea that all that's cultural is like rude savagery and we have to assimilate and Christianize in order for Indian people to have a future in America. These power asymmetries endure. And so the problem here, from this very early career lesson of mine, was that these differences are not just ones you can broach and bridge through goodwill. There's this long history of domination that makes all of this colored by power, by ideology, and by vulnerability. Let me shift now to talking about evidence-based practice in mental health. And I'll move pretty quickly through this because you know this, I think, but I just want to make sure we're clear when I'm speaking to you, we share that background. Evidence-based practice is primarily concerned with mental health therapies. All therapies are themselves human artifacts. We invent these things. They come with built-in cultural orientations, cultural assumptions. And so it's helpful in some instances to try to illuminate what those cultural assumptions and orientations are, especially if they're likely to diverge in important ways. And so a comparison of the kind of therapeutic logics that give rise to different approaches to what we consider to be the therapeutic can be really illuminating. And so what I want to do next is talk about evidence-based practice in mental health as a way of illuminating the therapeutic logic there, before then going on in the next section to talk about some indigenous therapeutic approaches. So we think about professional mental health treatments. Obviously, we've got psychosocial and psychopharmacological. For my purposes today, I want to talk to you about psychosocial stuff. But like I say, we can visit about the pharmacological afterwards if you like. Evidence-based practice obviously originated in medicine, but then in mental health and psychology was really developed in some ways that are a little bit distinctive, and I want to share some of that with you. So the definition of evidence-based practice in psychology provided by Alan Kasdan has these three components. It's often referred to as a three-legged stool. You've got best research evidence as one leg. You've got client values and preferences as another leg. And you've got clinician expertise as the third leg. And basically, you need all three of these to stand in a sturdy way on what we consider to be evidence-based practice. In psychology, you know, the best available research evidence has been formulated through what have been described as empirically supported treatments. And there have been whole efforts in clinical psychology to try to develop criteria for when we know that a particular intervention targeted to a particular disorder for people, you know, has been empirically supported or not. Obviously, it involves randomized controlled trials and multiple replication and disorders being clearly diagnosed and good evidence that there's cause and effect relationships between a person going through psychotherapy and getting better or recovering from mental health problems. So empirically supported treatments then arise from experimental demonstrations, randomized controlled trials that show causal efficacy, that show cause and effect relationships in robust ways between a treatment and an outcome. The goal then is that you would then replicate these favorable efficacy results across studies. It's not enough to have one study or two studies or just studies from a single lab. Then, ideally, if the evidence remains consistent, you would want to expand these to effectiveness trials, not the artificiality of a randomized controlled trial where you've got a manualized book that therapists adhere to and you've got someone supervising the therapist. You screen out half the participants because they're not the right kind of disorder you have. Then you expand it to real-world work-a-day settings, like a big health system. And you can still do randomized controlled trials in some instances, but it's much less tightly controlled. And the idea here is to be able to show that there's still some benefit even in real-world conditions where therapists aren't supervised and where they're not necessarily adhering to the manual, the treatment manual, to make sure they're doing it technically as described and so on. You know, in the substance abuse field, when there's been this expansion to effectiveness trials, the effect size drops off, you know, which you might imagine because it's just not as tightly controlled and so on. But still, if you could imagine that there's some benefit that continues to persist, then ultimately, especially if you've got lots of studies and strong evidence, you incorporate these into clinical practice guidelines. I served on the American Psychological Association's clinical practice guideline development panel for the treatment of adults with post-traumatic stress disorder, and there were over 100 RCTs that we drew on for trying to develop what those guidelines might look like. And once you've got guidelines, of course, you want to disseminate and implement these therapies that are, you know, shown to be most effective. That's hard to do because how many clinicians really want to learn how to do the therapy, want to be supervised in how to do the therapy and get the feedback that's necessary to take up new practices and new habits? Very difficult. But this is, of course, the logic of evidence-based mental health services in the psychosocial domain. Why is there such an interest in our professions around evidence-based practice? Well, the need for mental health treatment eclipses the availability. That's very true in Indian country, but it's, of course, true in the United States more broadly. There's so many people who don't get any help ever. If everyone who needed help or could benefit from help sought help, there probably wouldn't be enough people to offer. So in addition, many mental health treatments, especially as they're offered by clinicians in everyday life, you walk into a therapist's office, you sign up for help, you talk about what you need, that person gets to work with you. That stuff has not been rigorously evaluated. It's often not the structured kind of therapy you imagine when you think about a manualized evidence-based psychotherapy. Clinicians obviously believe that their treatments work best. They wouldn't do it if they didn't think it was efficacious. But we know that clinician beliefs and everyone's beliefs in efficacy can be mistaken. A colleague in psychological clinical science, Scott Lilienfeld, identified 26 different reasons for why we can conclude that a therapy helped someone when it really didn't. An obvious one that you can recognize is that we ebb and flow through symptomatic experiences and distress, and obviously people are most likely to try to get help when they're in a very extreme point of distress. And even if they'd done nothing in a week or two weeks or a month, they'd probably feel a little better. And so when a treatment coincides with this kind of ebb and flow, you could conclude the treatment's what helped them, but we don't know, absent experimental controls, whether it was the treatment or whether they just would have gotten better on their own anyway. That doesn't mean they recovered fully, but they feel better, and the treatment gets the benefit for that, unless you control for that. So clinician beliefs and everyone's beliefs can be mistaken about these things. Some treatments have, of course, been shown to cause harm. So I don't know if you remember facilitating communication for young people with autism, which swept the nation and the world until all kinds of allegations of sexual abuse started to come through these communications that were guided by a therapist, but from a person with autism, on a keyboard. And it turns out a simple high school science fair experiment could have shown that actually it's the clinician support communicator who's making those messages, not the autistic person. But no one did that until it was sweeping the world and all kinds of people had been trained. So a critical incident stress debriefing for on-site after a disaster, trying to forestall trauma, actually getting people to try to process that on-site immediately afterward probably causes more PTSD than it prevents. So obviously people think there's good reason to imagine that these treatments will help people, but until you study them, you don't always know that. And there are these instances where actually they've harmed people because there hasn't been quality control and good scientific study in advance. In the end, the famous clinical psychologist Paul Neal talked about the importance of credentialed knowledge. We're licensed providers and professionals. All that is about is simply the fact that it's not fair, it's not right, it's not ethical to have a caveat emptor, let the buyer beware approach to mental health treatment. People are very vulnerable positions, and they're counting on our professions to know what to do and to do the right thing and to make sure we don't do harm. And so the knowledge that we proffer has to have some credentialing if we're going to follow through on those ethical commitments. There are some implications of evidence-based practice that are important to point out. Really, evidence-based practice envisions a kind of standardization of approaches or techniques in mental health treatment. It's about identifying the treatments that most work and trying to get clinicians to do that and not whatever else they do, which is often eclectic, often unstructured, often supportive, but in vague ways. It's trying to standardize around scientifically supported approaches. Efficacy is understood to depend on treatment mechanisms. Those mechanisms aren't always so clear unless you do dismantling studies and so on. But it's the technique. That's why the manualized therapy is important in making sure clinicians are adhering to the structured way that it's been proposed and studied. Therapists are understood to be roughly interchangeable, provided you have the training and you're a cognitive behavioral therapist. It really doesn't matter who you are as a person. You should be able to swap in for anyone in any system and still have good results. Therapist expertise is really comprised of technical proficiency, that is, knowing how to do the structured treatment. If it's cognitive therapy, do you know how to assign thought records? Are you helping the client to process the thought records, the homework that they're assigned every week and so on? And, of course, client tailoring. Obviously, you have to engage a client. You have to make it make sense to the client. You have to try to motivate a client to do something. So technical proficiency and client tailoring are both required for this. And yet, especially as it's discussed, it's fidelity to the technique that's really more important here. Client tailoring can go too far. It can undo whatever the mechanisms are postulated to be, and you could tailor so much that then you lose the efficacy that the RCT sort of confirmed as what's happening here. So I think what I want to underscore about this logic or rationale of therapeutic activity is there's really an emphasis on the technical and even more so than the relational. And I draw that out because I want to make a contrast in this next section. So now let me give an example of unpacking the therapeutic logic or rationale of an American Indian healing tradition so we can have some sense of comparing and contrasting a bit here. American Indian healing practices are really diverse, have been for a very long time, but they do have some high-order commonalities. And one thing is that healing and health in general is understood to be a sacred matter. These are religious understandings about how the therapeutic works in most instances. And I want to give an example from the Northern Plains today. I'm showing you a cover of a book. This book was a collaboration between a community psychologist named Jerry Mohat and a Lakota medicine man named Joseph Eagle Elk. And they collaborated together, I think, in the 1980s, 1990s, and this book was published before the turn of the millennium. So Joseph Eagle Elk was a Lakota medicine man who basically was what's known as a heoka in that tradition. A heoka is someone who is selected by the thunder being to take on a sacred role. The role is the heoka, in which they have certain ceremonial participation and obligations. And becoming a healer or a doctor is part of that often. Joseph Eagle Elk really followed in the role of the trajectory of Black Elk. If you've ever heard of Black Elk Speaks, the Lakota visionary Black Elk was also a heoka, also did doctoring kinds of things before converting to Catholicism because the Jesuit priests on his reservation were not tolerant at all of what he was up to. In any case, as a heoka, Joseph Eagle Elk practiced healing or doctoring traditions, and there's an excerpt in this book of a case, and I just want to share the aspects of this case for you so that we can together then kind of unpack what the therapeutic logic is behind this. The case is called The Fish and the Man. And the case goes like this. There is an Indian Health Service clinic on the Wind River Reservation in Wyoming in which a white therapist is working with a client. The client is depressed because the client has been diagnosed with cancer and is struggling with trying to go through cancer treatment. The therapist feels stymied and doesn't know what to do, has an acquaintance with Eagle Elk from the past, and so calls him up on the phone and says, Look, I've got this patient I kind of don't know what to do. Maybe you could consult your spirits and find out if they have any advice. Now what Lakota doctoring typically entails is, in Uipi ceremonies, a calling of spirits that then tell truths about the cases in question and offer guidance in that way. This is usually done when a person is there, however, and so Eagle Elk said, Well, I've never asked my spirits without the person being there, but I can ask them and I'll see what they say. So he goes, and the next time he's in ceremony, he asks the spirits who come about this case, and he said, to my surprise, they spoke right up. And what the spirits told him was cancer is like a flower. It can grow, it can bloom, but it can also be arrested, and we're going to arrest this cancer with this young man at this point. But what he really needs to do is he needs to go fishing. And specifically, he needs to hook a fish, pull it out of the water, hold it in his hands, look it in the eye, and say, I wish you a long life, and then pray to the fish. And when you're done praying to the fish about whatever's on your mind, whatever concerns you have, whatever you need, you're to stop and to listen, and the fish will answer you and tell you something. Sends word back to the therapist about this. Therapist talks to the client, and they say, Well, you're facing cancer. We'll try anything. So they try to go fishing eventually. The cancer, according to the doctors, did arrest for a time. And they tried to go fishing. It was hard to do. It took them a year or something to go fishing. And they went to their favorite fishing hole and couldn't get a fish. They found, alongside the road, a pond where they stock fish. You pay to go in, and you can fish that way. And they cast their line in one of the ponds, and they still couldn't get a fish. So the owner took pity on them and said, Look, I just stocked this pond. You could just pull something, hook through there, you'll get something. And so they pulled the fish out, and the therapist stood back. The young man unhooked the fish, held it in his hands, looked it in the eye, and wished it a long life. And then the therapist said he could see him mumbling, praying, whatever, to this fish. Then he stopped, and he said to everyone in shock, This fish made a sound. It was something like, MRAH! MRAH! MRAH! Now, I don't know how often you've done fishing. I've never heard a fish make a sound. The young man almost dropped this fish. He was so startled. And the therapist heard this from standing ten feet away. And so the young man was elated. He didn't quite know what to make of it exactly. He said that was very unusual. He let the fish go back in the pond, and then they left. The end of the story, as Eagle Elk recounts it, is that this young man died of cancer. Not that much longer. The cancer resumed, or what have you. And so Eagle Elk is puzzling this out in his mind. What happened here? And the best he offers is that this young man and his therapist were really caught between the white man way and the Lakota way. They didn't really lend their whole minds to understanding or accepting this Lakota approach. If they had, they would have come to ceremony. Because, yeah, the fish talked, but they don't know what the fish said. And the spirits could have interpreted what the fish had said. And maybe there would have been something in there that was good for the man. But because he didn't do that, that may be what happened here. Now, Eagle Elk's not confident. He's trying to understand what was going on here. And this was the best he could make of it. The one thing about these kinds of traditions is they're quite mysterious. And these religious views often involve a lot of mystery. So he wasn't sure. Okay, so what I want to do is kind of unpack the therapeutic logic here a little bit. And let me just say that I'd never heard of a recommendation to go fishing in response to this sort of consultation before. But these kinds of consultations are common. Across the northern plains, this is a recognizable approach to healing and doctoring. And so given healers' ritual protocols, what they do to call spirits, for example, or to call for help from spirit beings, are often standardized. Like they have to be done exactly as taught by spirit patrons. But the recommended treatments are not necessarily at all. And so the question here is whether there was ever any other go fishing kind of recommendation from these spirits to any other person. Eagle Elk didn't say there was. And maybe there isn't. The efficacy of these approaches depends on, and this is a religious concept that doesn't translate well into English, called will slash power here, which has to do with the idea that if you think, if you have great power in your own thought, thought creates reality. That's the underlying religious principle. And ceremony involves harnessing collective thought towards certain outcomes that can bring it into being. And so efficacy of these approaches depends on this thought mechanism of expressing will and exercising power of the persons involved rather than technical mechanisms. It's interpersonal in that sense. It's about calling on spirit beings to ally their thought with yours, for example, to try and make the world come into shape the way you're hoping it will be. Healers are not interchangeable, but rather remain the single most important therapeutic variable. You know, you go to this person for this problem, this person for this problem. You might think these people are fake and these ones are real. So you restrict, but in any case, it's not interchangeable in the way that we think of the mental health professions. Competent ritual management of all of the associated interpersonal interactions is really what's crucial here. It's the medicine person working with people and usually their relatives and supporters and friends and, of course, the powers, the spirits that come, what have you. And it's all about managing those relationships with the understanding and recognition that there can be harm. There's risk to doing so. And so violations of ritual protocol, like not calling the spirits in the way you've been taught ceremonially or ill will among people engaged in the ceremony are dangerous for patients. If someone's jealous of you or resentful to you and they're in that ceremony and that thinking is part of it, it can harm the patient. Fear, therefore, can be an intelligible response to ritual exercises of power. Often when you're in these kinds of ceremonies for the first time or things happen that you can't explain and it can be very disconfitting. Ultimately, I would say here we recognize an emphasis in this therapeutic approach of the relational over the technical. The technical is how you perform the ceremony, but it's all about managing these relationships between powers and people, other human people, in ways that matter. And so I want to just pull this out a little bit now to talk about the nomothetic-idiographic distinction. You might recall that nomothetic has to do with that which is general across cases and applicable to any given individual only in probabilistic terms. You know, an RCT has 1,000 people and there's some benefit, but that's all about probability. It has to do with a statistical chance that it will help more people than not or however it shows. The ideographic has to do with that which is distinctive to a given case and may be only applicable to that individual. When we think about offering evidence-based mental health services, we've got both going on. We've got the nomothetic that comes from the science and the probabilities, and then we're working with a person, and whether that person's helped or not is like yes or no. There's no probability about that. They will or they won't benefit from it, and you've got to tailor it to them and try to make it make sense to them, and you see what happens. But the point here is that when it comes to professional mental health treatment, you've really got nomothetic aspirations when it comes to evidence-based practice. It's all about those probabilities. What makes the best sense to try to apply in this instance? Whereas I think with something like the fish and the man, you're talking about an ideographic commitment in this healing practice in which there's no fishing here for cancer. This was one instance where that's what the spirit said to do for this one person, and that's it, maybe never done again. So there's no generality to it in the sense that we would hope that something like exposure therapy for post-traumatic stress disorder would generalize. And I think it raises the question of could there even be an evidence-based form of traditional healing practices in this sense? And my inkling is no, but maybe there are examples of other kinds of approaches where there might be. I'm not sure. This is just a, you know, I'm trying to draw some contrast for you. There are other contrasts between professional indigenous therapeutic systems that's worth pulling out, you know, dualism and holism. Psychiatry and psychology, mental health is its own kind of domain, and biomedicine, that's separate from other domains. That's, you know, this Cartesian stuff, right? But in indigenous healing and therapeutic approaches, there's much more of a holistic integration, not necessarily differentiating between these domains or spheres of existence and experience. Secular versus sacred is probably the biggest one. You know, we develop these evidence-based practices because we have great ingenuity, and we try to think through what would work, and we can, you know, devise and test them. But there's no sense of anything going on above people's psychology, whereas indigenous therapeutic approaches are almost inherently sacred. They're about power. They're about religion, essentially. Rational versus mystical. You know, we unpack these and develop these evidence-based treatments through harnessing our powers of rationality and then testing them through our powers of rationality, through experimentation and statistical inference and those sorts of things. You know, Eagle Elk's saying, I don't really know what happened here. Here's some ideas that I've come up with, but it's a mystery. And when they're dealing with higher powers that are much superhuman, yeah, it's going to stay a mystery in many instances. And, of course, the technical versus relational, which I went to some effort to try and unpack, because as one of these, I want you to have a little more in-depth. We could do that for all of these, but there's not time here today. Another big difference is the presumption of psychological mindedness. Psychological mindedness has to do with the degree to which you take the self as an object of interest and reflexively look inward and all of the things that come with that. Responsibility for self-management is part of that. Not everyone has that. In fact, I would nominate the idea that most people in the world are not particularly psychologically minded. It's kind of a distinctive aspect of Western individualism, which is premised on great wealth and affluence. You don't have to be sociocentric, because you plundered the world and have enough for a lot of people in the West. But I don't think the psychological mindedness that attends that sort of thing is necessarily found all around the world. This responsibility for self-management, the kind of introspective reflexivity that's taken for granted in psychotherapy and mental health, the cultivation of a kind of deep interiority, where you spend a lot of time thinking about, where am I, what are my values, what are my goals, how do I plot a way in life here as an individual? And, of course, expressive self-referential talk, giving rise to the uniqueness of myself through conveying that through talk. And, of course, talk is part and parcel of most psychotherapeutic endeavors, some more so than others. Okay. Final section. I want to reflect now on what I've come to call an alternative science. And I'm using the term science here. It looks funny, I suppose. But what I'm calling attention to are the fact that knowledge-making in the sciences, psychoanalysis, psychotherapy, psychology, psychiatry, which, of course, are modern. They began to emerge in the late 18th century. That these knowledge claims and understandings and taken-for-granted assumptions and orientations are, in fact, historically contingent. They're a function of modes of living, like modernity, that are required for them to make sense. And they may not necessarily be with us the way we see them now forever. So we didn't have it before the late 1900s, and we may not have it again in quite this way. Our knowledge about these things, so much of which is beyond the empirical, so much is theorized, so much is bound by the way we make sense of things, that those sensibilities are always on the move in cultural terms. The human modes of life are always on the move. And so an alternative science is trying to capture what's going on, how we think about it now, with the recognition that it might change over time. This alternative science has to do with an indigenous community mental health discourse. It's drawing very much on Traveling Thunder and what he talked about in terms of this explanatory model. I would say it's distinct from, but parallel to, a professional psychiatric discourse. That is, it's not identical or isomorphic with how psychiatrists and mental health professionals think about these sorts of things, but it is somewhat systematic and somewhat coherent in a way that does provide this alternative approach. It contests and recasts key concepts and approaches. In today's terms, people would often say it's about decolonizing psychiatry. And it's evident everywhere I go in Indian country, aspects or elements of it. I'm not saying that anyone you ask is going to tell you this. This is an academic take, an academic expression and understanding of these things that tries to synthesize it all. Most people don't have it all synthesized, but I'm telling you that it's there nonetheless. And there are four domains that I'll just walk through in the short time we have left. Distress, well-being, treatment, and evaluation, and what this alternative science might say about that with respect to mental health issues. So just a few more highlights today before we wind up. Let's start with the domain of distress. This alternative science, I think, is not interested in DSM disorders. DSM disorders can be criticized for being too radically decontextualized from life, social circumstances, and so on. You think of things like a major depressive disorder, which used to be differentiated from grief in a way that it's closing in a little bit for reasons that are justifiable. But the idea of a major depression as an abstraction that is not anchored to divorce, loss of job, or to other kinds of experiences that people have in native communities is just a kind of rarefied way of talking about that distress that has purposes in psychiatry, but I don't think it resonates with people in native communities, whether it's substance use disorders, PTSD, these sorts of... they're just so plucked out of the broader context that I'm not sure they are all that valued. They're selectively incomplete. If you've been in a colonial arrangement for a long time, there's a lot of anger, a lot of rage. And, of course, if you're segregated from the rest of the world in ways, that rage and anger comes out against your own people, your own loved ones, etc. We don't have disorders of rage, really, in the DSM. I guess intermittent explosive disorder or something like that, but it's not really developed. We don't have disorders of identity in quite the same way. Anomie being kind of the logic for how post-colonial loss is expressed in Native people, is really a way of talking about identity and the disorders of identity that arise from colonial subjugation, but that's not really what you'd find in the DSM. And there's measurement issues. One thing that in Psychepe with Native communities, what's very odd is that the internalizing disorders are always lower than Middle America. Major depression is lower in Native communities, despite the incredible demoralization that you can find, and the contending with poverty, and all of that. And so what's going on with that? Is it a problem of measurement, or is there actually a bona fide difference in that respect that we might identify as an inequity that favors Native people? Anyway, not DSM disorders, but rather historical trauma. That's the way we would talk about it now. Again, that's basically traveling thunder. It's a radical recontextualization of current-day suffering, in which historical trauma can be thought of as the wedding of two already existing familiar concepts, historical oppression and psychological trauma. You put those together, and that's really what historical trauma is meant to capture. In work that my students and I have done, we identify, in the way people talk about indigenous advocates, talk about historical trauma, the four C's of historical trauma. Colonial in origin, that's the most important thing. We're not talking about a natural disaster. We're talking about colonial subjugation. It's collective in the way traveling thunder didn't talk about individuals. It's shared by everyone in the community. It's cumulative. That is, it comes through, first it's being chased by the army, and then it's being settled on a reservation, and then it's being starved to death on that reservation because the rations you were promised don't show up, and then it's the Indian agent stealing your resources. All of those things, over time, snowball to sort of lead to this legacy of disadvantage and of risk. It's cross-generational. The biggest signature innovation of historical trauma is that ancestral suffering somehow is passed down to current-day people. When we see these inequities and disparities in health, especially behavior health kinds of statuses, it's because of ancestral experiences, according to historical trauma. Again, traveling thunder's explanatory model is, like I said, a prototype of this. Without the psychology, though, that's the distinction. In terms of this domain of distress, it's not DSM disorders, but historical trauma. That's the alternative science aspect of this domain. The next domain has to do with well-being. What is it that we're trying to restore someone to if they come in crisis or suffering and we're trying to help them? Well, I'd say it's not neoliberal individualism, which might be a way of talking about the kind of normative aspects of a good life lived in suburban America, in which you have free agents navigating free markets in autonomous pursuit of happiness and wealth. That's familiar to a lot of Americans, I think. Obviously, not all. It doesn't cross class. It doesn't cross gender entirely in the same ways, but I think it's familiar. That's not what most Native people, particularly in reservation settings or Indian communities, are trying to be restored to. Rather, it's a form of relational selfhood, in which one is more sociocentric and one's typical or resting or familiar self-configuration and your connections to others in your community are kind of who you are and how you live. And so it has to do with kinship roles and obligations, establishing those, making sure that those are attended to properly. That includes responsibility for or to non-human relatives. So you have obligations to spirit beings in your midst or as you understand them, and a good life for the community depends on right relationships with those beings. And I think it implies a kind of attention to other kinds of emotions than we typically think about. Psychologist Paul Ekman identified the six universal basic human emotions. Sad, glad, mad, those sorts of things. Again, abstracted from people's lived experience. And I would suggest to you that in sociocentric self-configurations, the emotions that matter most are not abstracted in that way. They're embedded in relationships and in relationality. So the kinds of emotions that I think we would want to have a fine-tuned attention to would be, first of all, say pity. It's a funny word. I don't know if we use it so much in everyday life. But in northern plains, religious traditions, pity is everything. That's how you get power and help from the beings above. They're very distant. They're very busy. And you're trying to call down from them their attention so that they'll give you some kind of gift or some kind of power or do something for you. It's as pitiable, as pitiful as possible. You go to the high mountains, and you pray and fast, go without food and water for days. You might cut off a finger in sacrifice, and you bleed, and you cut your skin. And you ritually cry. You wail and moan and try to get them to notice you the way a parent would notice a crying baby. And if they take pity on you, they might visit you, they might give you health and help and those sorts of things you want. Respect is the corresponding social emotion that moves up. In the northern plains, religious ideas have a hierarchy. You've got high, powerful beings. You've got lowly, lowly humans. Maybe there's a range of pantheon of beings that have different powers in between. Pity moves down. Respect moves up. You've got to show respect to people who have power maybe to hurt you if you're not careful. Pity and respect are two real obvious ways of thinking about social emotions, but loneliness. The medical anthropologist, Teresa O'Neill, did ethnographic research on the Salish Flathead Indian Reservation in western Montana about depression and really found that the language for these emotions there is not sadness, it's loneliness. Which, of course, is sort of like sadness, but combined and fused in a relational context. In the reservation settings, again on the northern plains, people are talking about insane jealousy, how domestic violence arises, for example. So you can almost imagine a disorder of jealousy that plays out in ways that are damaging, pouting, hostility, suspicion, resentment, and of course, love. So there's a whole different way to reframe what kind of emotions get talked about when you talk about mood disorders. What would the mood disorders be of the social emotions? So, in this second domain, we talked about the domain of distress, now we're talking about the domain of well-being. It's not neoliberal individualism, but instead relational selfhood that we're conceiving of here. Third domain, treatment. I've already unpacked a lot of this already. Not empirically supported interventions or evidence-based practice. These, of course, are cultivated through human ingenuity and technical proficiency. They're certified by distant and rarefied expertise. Researchers publishing in journal articles and having statistical accounts for why you should have confidence this can help you. Dependent, at least to some degree, I think all of them are dependent to some degree on psychological mindedness. Some are more dependent than others. Insight therapies are obviously dependent on all kinds of psychological mindedness. As a professional, those are the funnest ones to engage with people about. There are other forms that maybe require less of it, but there's still a sense you have to take yourself on as a project. You have to be willing to look at your own behavior and to be able to articulate it in words in ways that a therapist can help you with. So, not so much interest in that in this alternative science. Instead, an interest in reclaimed traditional healing practices. Why reclaimed? Well, because a lot of these were made war on essentially by a population of native people. A lot of them are gone. A lot of them persisted, fortunately, by a family here or a family there keeping these things alive. So there's kind of a reclamation and a revitalization of these approaches to the therapeutic. Often this is captured in community settings that I've been in by folks who know something about mental health or advocates or providers or administrators saying we don't need the latest, greatest evidence-based practice. It's the idea that we can look back to our own ceremonial and inherently therapeutic traditions. Reclaim and revitalize those. That's what will help our community to recover from what is mental health crisis or distress. These obviously are mediated by ritual leaders using prayer and ceremony. So again, it's religious. And it's dependent on these powerful non-humans who circulate blessings and life. So, in the domain of treatment, again, the distinction in this alternative science is not an interest so much in empirically supported treatments but rather reclaimed traditional healing practices. Finally, the fourth domain I'll talk about is evaluation. And evaluation is concerned with how do we know what works? Important question. How do we know what works? And I would say that in the communities I've worked, there's not that much interest in or a feeling of being impressed by scientific outcome studies. Scientific outcome studies, I think, have advantages and benefits that we recognize. It's an extension, really, of rationality. Evaluation is a rational endeavor. And we need to extend our rationality to see things beyond what we can see patterns and so on off the tops of our heads. Statistics and these sorts of things are like cognitive prostheses. They allow us to identify patterns that we wouldn't otherwise see. So, it's an extension of this rationality. It tends to presume a mechanistic materialism. If you talk about disorders and treatments and mental health research settings, people always want to say, what's the mechanism? What is the sequence of things that happens that leads from therapeutic intervention to beneficial outcome? And, of course, it adopts a selective skepticism. I mean, the whole idea here is, well, how do you know that works? How do you know it's not doing harm? And beyond that, what can you do to sort of show it works? You know, show me, show us, before we give money, before we give legitimacy, show us that it works. I say it's selective because, well, I don't need to tell you all about the way pharmaceutical companies have cooked the books or the way in which people who are making their way through research, you know, do pee hacking. I mean, there's a lot of reasons why what we consider to be established knowledge is still in question, if you want to think about it, in many instances. Not all, but in many instances. In any case, the idea here is that the scientific outcome studies are not really what resonates or of interest. Increasingly, and this is the part where I think it's still coming into the fore, there's an interest in indigenous ways of knowing. And I noticed this coming really from Native American and indigenous studies in the United States and in Canada, where there's an interest in academic circles in which Native people are engaged in knowledge production about trying to identify and celebrate and promote indigenous ways of knowing. And so what does that mean? Well, there's what academic people say about it. But I just want to talk about an example I had. I did a collaborative partnership with the Blackfeet Nation in Montana, their addiction treatment program. And I invited them to think about, okay, what would it look like if we were to start, first and foremost, with Blackfeet therapeutic tradition, and then secondarily build an addiction treatment program around that? Because what you have now is you're starting with Hazleton model style groups, treatment for addiction, that's what everyone does around the world. And then, of course, you have a cultural counselor, you have a few groups on cultural stuff, but it's sort of dressed in beads and feathers. What would it look like to start with Blackfeet therapeutic tradition and accommodate that? And so they said, yeah, they were really interested in doing that. And one way we went about it is we needed to go consult with the Blackfeet Crazy Dog Society. This is a group of neo-traditionalists who are all about restoring what they call the old Blackfeet religion into practice on the reservation. Not pan-Indian stuff, not northern plain stuff, but the Blackfeet religion. And so I found myself with a cultural counselor who was helping to move this along in this ceremonial lodge, talking to these ritual leaders. We were there for a couple hours before it was sort of our turn. And it was our turn, and I looked to the cultural counselor, thinking he would go ahead and explain what we were there for and what we wanted in terms of their consultation. And he said, okay, Joe, take it away. So I said, well, look, we're here because we're engaged in this project of trying to harness Blackfeet therapeutic tradition for addiction, and we probably want to study it because out in the professional world, people do not yet know that participation in these traditions and these ceremonies remedies addiction. And before I could get any further, the lodge erupted in laughter. And it took 15 seconds to subside. People thought it was ridiculously hilarious that people outside of the reservation setting do not yet know that ceremonial and traditional practices remedy addiction. And so I think what this is indexing is the authority of narratively conveyed personal experience as really the highest level of authority of knowing something. You know, what a scientist says from, you know, thousands of miles away in a research paper, it means nothing. What matters is what experience did I have, and how did it help me? Now, of course, evidence-based practice is completely arrayed against this. It's suspicious of personal experience, you know, and I think with some reason. But the point here is that indigenous ways of knowing are increasingly explaining how there might be an alternative approach to evaluating and determining what works. And I think the clearest way this comes out is when people in our community object to evidence-based practice and said, no, no, we have practice-based evidence. We have thousands of years of helping our own people ceremonially with things that they've needed help for, and we don't need a scientific study to prove to anyone why it works, how it works. We have practice-based evidence instead. All right, so just to summarize this alternative science, this alternative indigenous mental health discourse, when it comes to these four domains, in Indian country, in the communities I've been and worked with, here's what I see. When it comes to distress, it's not mental disorders of the type that the DSM classifies, but historical trauma. When it comes to well-being, it's not trying to restore people to neoliberal individualism, but really trying to underscore and buttress a relational selfhood. When it comes to treatment, it's not empirically supported interventions or evidence-based practice, but reclaimed healing traditions. And when it comes to evaluation, it's not scientific studies, but indigenous ways of knowing. Let me now close with some summary observations, and then we can have an exchange. How should we navigate the kind of deep cultural discordance and persistent power asymmetries that we find at the intersection of community mental health services and American Indian indigenous life? Cultural competence has serious limitations here. Now, maybe we've moved beyond cultural competence in many respects to cultural humility or structural competence. I mean, there's other ideas that have come along in a long time. But cultural competence still tends to resonate in most of our fields as mental health professionals and providers, which is about trying to make sure that the therapist is sensitive and doesn't say or do ignorant, stupid things that would alienate clients or patients. But the cultural competence does nothing to address the actual technologies that we use, the therapies that we use, which have their own embedded assumptions and orientations. So in that sense, it's really limited for the kinds of things I'm talking about. We need to recognize that clinical intervention is inherently, always will be, a form of cultural prescription. There's no transhuman therapeutic approach when it comes to these sorts of things. We need, therefore, to acknowledge the hazards of therapy as potentially forms of neocolonial cultural proselytization for American Indian people, other indigenous people, but probably for other communities as well. I mean, what about for working class men? We don't have the colonial history, so it's a different kind of political valence, but it doesn't necessarily fit that well. And therefore, I think we need to take seriously the indigenous claims I hear everywhere I go in Indian country, that our culture is our treatment, and to try to begin to appreciate and unpack and respect and make sense of what people are saying when they offer that critique. There is much diversity among contemporary American Indian people. I mean, I want to underscore that. I'm talking about a subset of Native people who are more traditionally oriented. That's not everybody, and in some communities that's not even most people. And there are folks in our community who take to psychotherapy like a duck to water. It's no problem. But there are others, not just one or two, swaths of others for whom it's incomprehensible. And so what I'm talking about, really, is how do we make sense of this endeavor, particularly given the sensitivities that are ideological, that have to do with histories of colonial subjugation and ongoing power asymmetry. So that's why I wanted to spend time today presenting to you about indigenous misgivings concerning evidence-based practice so that you have a better understanding of all that's going on underneath that and the kinds of projects and approaches that might be necessary to overcome it. I've written and thought a lot about this over the past 30 years, and I have a website. My last name is Gone, the English word Gone. My great-grandfather was sent to government boarding school. The practice there was they would take your father's name, give it to you as a surname. His father's name was Gone to War. They clipped it, didn't like the whole thing, so we're the Gone family, but my website is Gone to War in recognition of that. And I'll try to make all my publications available for free download there, at least until I get in trouble for doing that. So thank you. You've been great. I'm looking forward to our exchange here for the remainder of our time. Thanks. And it looks like we have maybe 23 minutes at the most. Wow, isn't that a coincidence? Ending at exactly the same moment. Please. Yeah, and I guess they are recording this, so if you do have a question or a comment, please step to the microphone. That way people can hear a little better. Thank you so much for your talk. Really appreciate it. I work at a rural community hospital in central Minnesota, and there's talks of potentially having a partnership with a nearby reservation about 40 miles away. And our current patient population is very homogenous. Our staff also, very little diversity. And so this comes at a great time, because I don't have a lot of experience working with indigenous populations either and really want to start that learning process. So thank you for everything you have on your website. I was just looking at it and look forward to watching those videos and recommending these sources. Any other books or places to start or important publications that you recommend? Yeah. So I think getting yourself oriented through some of the things you already talked about, I mean the books, articles, and there's a number of these that speak to different elements or facets, certainly beyond my own work, in ways that could be helpful. But the single most important thing in engaging in something like that, I think, is community consultation. So the challenge here is that Native people have been decided for by government authorities and other societal elites for so many long histories, where Indian policy shifts and swings from this point to that point, and ultimately most of it doesn't work. So outsiders deciding what's right and what's best and then it not working. So the remedy for that, the remedy really for colonial injury, is consultation and recognition of valorization, legitimation of tribal interests and concerns. So I would recommend for the setting that you're talking about, how about pull together a board of people from that community? Try to attract some researchers from universities who have time to do projects or are interested in those projects. In Minnesota, there should be folks like that. So that there can begin to be processes of tribal consultation that direct and guide all that you're talking about, and could identify research projects that would develop maybe new ways of doing things and keeping track of outcomes to the degree you can. We're not going to see a rash of randomized controlled trials in Indian country. It's too hard and the populations are too small and so on. But I do think that the consultation is the key, and they will guide you and tell you what's important and following that lead is crucial. Thank you. I actually have another question more pertinent to your talk. So this idea of psychological mindedness, I wanted to understand a little bit more which of your experiences led you to feeling that it was so specific to the western hemisphere? Because as you talked more about things that shape even the American Indian community's approach to mental health, like things like framing depression in the context of historical trauma, developing that relational selfhood, so much of that seems deeply psychologically minded. And in various eastern cultures, I feel like that psychological mindedness is cultivated even younger, maybe in the perspective of the community, like framed in the community as well. But so much of that is developed from the beginning. And in a sense, it almost feels deeper because it starts with all those customs and those cultural practices. So I was wondering what you meant by that sort of being exclusionary to the Western hemisphere. And also, I was wondering if maybe you meant that, or I was trying to understand it, that in a lot of other cultures, psychotherapy or having an individual guide in that sense is seen as a luxury. And so there's more resistance to developing the psychological mindedness further with a psychotherapist, I don't know. Yeah, the kind of psychological mindedness I'm referring to, which has to do with taking the self as a project of cultivating a deep interiority, of figuring out your emotional states and processes, of giving voice to all that through verbal communication to others. You know, that probably crystallizes most in suburban America, maybe even suburban American women. I think there's lots of ways you could try to cultivate the class and gender dynamics of that. The opposite of psychological mindedness is sort of sociocentric obligation. So the signature of that is duties and roles. And the question around the world is, are you more likely to be in a place in a family, for example, where what comes with that is a bunch of duties. It's really not up to you to try chart your own path, make sense of how you want to express yourself. I mean, to be a good person is to follow through by realizing your role and its obligations in a really visible, impactful way. American egocentric individualism is all about inventing the self and charting the self through life in some way that, of course, you move away from home to go to college. Of course, you move away from there, your friends, to go get your first job. Of course, you make your way up the ladder of hierarchy to get better salaries and better jobs, and it takes you all over the world to do so. Your everyday social obligations are always shifting because there's different people you're involved with, and it's defined. So anyway, I'm just trying to unpack it a little bit for what I think the contrast looks like. And my point is that I think most of the human population on the planet today still is more about roles and duties than it is about finding yourself, expressing yourself, charting your own path, even if it takes you far away from the people you love and the people you're obliged to care for. So if that helps a bit, that's probably all I can say about it for now. Thank you. Yeah. Thank you so much for a wonderful talk. I really enjoyed it. I'm Dawn Morales. I work at the National Institute of Mental Health, and I'm familiar with colleagues at SAMHSA, Indian Health Service, and other federal entities that are under varying degrees of pressure to implement evidence-based practice when it comes to delivering care in Indian country. I am aware of your provocative but evidence-based argument that that is a harm, at least at times, but I'm curious to know what is your vision for what would be a wise thing for them to do, mindful of the fact that they think that their duty to the American taxpayer is to implement evidence-based practice because that's a wise custodian of taxpayer dollar move, and it is efficacious, right? Yeah. Yeah, I think a couple of things bear saying. One is that you can start to deconstruct the confidence that people have, that the approaches that have been studied and the people they've been studied with generalize out. So in psychology, we're often very aware that our knowledge base is crafted out of research participants that hail from Western, educated, industrialized, rich and democratic societies or weird societies. Again, weird societies are the exception in the world, not the majority, and it has to do with affluence, has to do with histories of colonial plunder and individuality, individualism, and all of those sorts of things. So almost, let me say it this way, in an annual review of psychology article that's now probably 15 years old, so we need to update it, a review of all of the randomized controlled trials for mental health interventions for Americans revealed that exactly zero American, Indian, and indigenous peoples have been included in randomized controlled trials. So if we've never been studied, particularly if it's never been studied in reservation settings where these kinds of traditional orientations might be most common, how do we know? How presumptuous is it? What kind of arrogance is behind the idea that what we have found to work best for the populations we study generalizes to Native people? Now, I think there's lots of instances where the costs of presuming that and exporting that are not necessarily so high that we would warn against it. But you're talking about a colonized population where there's great sensitivity to further control and constraint by outsiders. And so I think the potential for harm is a lot higher in Native communities, it's high in black communities, there's other communities for who it's high as well. And so that presumption, I think, needs to be challenged. Now, what could NIMH or NIH do instead? Fund research that looks at these alternatives and tries to seriously consider. Now, what that entails is a relaxation of the scientific rigor that's assumed to be the most helpful around randomized controlled trials because they're just not possible in a lot of these settings. So, but if you're between a rock and a hard place, what's the right thing to do is the question. And I think that that's sort of where I would begin. And of course, there are people doing this, that people have RO1s from some of the NIH institutes to do work like this, although it's often more prevention work than treatment work. I apologize for burying my question, but what I specifically asked was what was your vision for what wise federal colleagues who are supposed to be doing this would do? And I think what I heard you say was that better research needs to be conducted. Is that correct? A different research, different research, right? And I'd also say that I think it gets back to community collaborations and partnerships. So it's community, what people in the NIH world would say community-based participatory research, right? And which requires funding and investment before the beginning, so the partnership could be established. So I would love to see NIH fully embrace a CBPR approach to research projects with native and indigenous communities that provided funding for a year or two, even to get the questions refined and the problems identified and the approaches ironed out in deep participatory collaboration, which is how to be anti-colonial in this context. Because a different funding mechanism is needed because that kind of funding mechanism doesn't exist where you get money for a year to develop the project. There are precedents. NIDA has done a little bit of this and NIDA is probably the most forward thinking of the institutes that I'm familiar with around these, maybe health disparities as well, but it's not every institute that does this, that's right. And I will say this too. I think a decade of mental illnesses or brain diseases has set us back tremendously. I mean, it's so clear that addiction, trauma, suicide in Indian country is marred by the presumption that those are brain diseases. These are post-colonial pathologies that require a completely different approach to be able to remedy. Yes, all right, thank you very much. Thank you for a great talk. I'm Steve Dantlock from Philadelphia. Understanding that your talk was about the feelings and sense in the Native American community about psychotherapeutic approaches, I wonder if you could comment generally about whether there's any difference when we're talking about the most serious forms of psychopathology, fluorid psychosis, schizophrenia, severe affective disorders that quite clearly would require medication in typical communities would generally require hospitalization. Is the attitude the same in the Native community about the forms of treatment that we would prescribe or does it differ? Yeah, of course, that's an empirical question and I don't know that we have good data about it. One thing I would say is that I don't think most community members are that familiar with schizophrenia, which is really rare, or some of these other conditions that would benefit most from because the irony here is that the conditions that require the serious mental illness it requires and might benefit from the kind of medication you're talking about tend to be pretty rare. So we don't have an epidemic of OCD or autism or those kinds of things. And so I don't know that there's much of a community consensus about it because I don't know that most people have really thought about it or are that aware of it. A family who has someone who has schizophrenia, though, obviously is grappling with all those issues and I don't know that there would be a patterning of their responses beyond what they make sense of over the course of their interactions in the Montana-Wyoming IHS region with the one psychiatrist who consults for all of the reservations, for example. And more than likely, of course, they're not talking to a psychiatrist at all. They're talking to a general practitioner whose own knowledge about these things is kind of limited. And so I think it would be kind of more like one-off instances where it's pretty hard to have a general pattern that you could point to about how community members think about those rare conditions that you're describing. Please. Thank you very much. I really enjoyed it. I'm Larry Merkle from University of Virginia. I'm an anthropologist and a psychiatrist, so what you're talking about is close to my heart also. I just wanted to respond to her question a little bit. When I teach this stuff, the metaphor that I use to help explain individual, egocentric versus a more sociocultural focus is a musical metaphor. That in the West, we train people to be individual violinists. That you're supposed to be a soloist. You're supposed to take the music and bring yourself into it, and your performance of somebody's piano sonata or violin sonata is based on how it feels to you and you come out with that. In other parts of the world, you're a quartet or an octet or a symphony orchestra, and yeah, your individuality is there. You have your part to play, and you need to really play it the best you can, and that's important, and your value is based on how well you do that, and there may be moments when you can improvise and when you're supposed to bring out a little bit of extra things, but it's really based on how well you join with everybody else in your coherence and connection with them, because it's the whole product that really matters, so just to help you understand. It's wonderful. Thank you for that. Love it. Other comments, questions? Good morning. Thank you for your talk. Sorry I was a little late. I was trying to maximize sessions this morning. I am a new provider with the Indian Health Services, and I'm working with the Apache people in Arizona currently, and something that I'm noticing is I'm actually finding a lot of, I predominantly have been working with women who are more willing to come talk with me, but I'm actually finding a lot of women trying to strive for more individualism, you know, not giving everything to all the different members of their family and who are draining everything from them and having a lot of guilt about, you know, is my role supposed to be this in the community or, and kind of trying to give themselves the permission to focus on themselves, and it's been kind of very interesting to see and experience, and I think while, you know, it is kind of the historical benefit to, or the historical thinking that is supposed to be about the group, but it seems like now people are trying to figure out how to give themselves the permission to look a little bit into themselves, and, you know, I'm happy to help, you know, kind of help them process that, but I'm also trying to figure out how to, what I can do to most respect the community tradition while kind of encouraging the growth without being an outside person saying, yes, you should definitely do this or that, and not in a, I don't want to be callous about it, you know what I mean? So I'm trying to figure out how to walk that line and kind of, I'm a remote provider, so I go out there just quarterly, so things that I can do when I'm out there to learn more and integrate myself more in the community, I guess, with the highest yield in the short time that I'm there. Yeah, well, I think it's fantastic, your idea about spending time in the community and trying to get to know more people and learn more things, and I think trying to identify some elderly women who have status in the community for their traditional perspectives might be useful, because I think if you approach such people respectfully and in the way you're talking about the dilemma you're wanting to get some help with, people will definitely assist you with that and try to explain and educate in those sorts of things. I think that's the way, one really important way forward, because I think it's, until you know what the community traditions are, it's a little hard to know how to guide and coach women experiencing that. Now, I think what the women patients you're describing are contending with is exactly this interface of selfhood and its shifts and its potentialities, its affordances in modern life, and so the ambivalence about the roles and duties approach versus the kind of autonomous agent approach is exacerbated by the fact that the colonial project has so decimated our communities and our families and our ways of life that people with the roles and duties orientation are just overwhelmed, because there's so many people in our families who are not able to reciprocate in the way that was required for that to really work well, and it is often women, it is often older women who carry the burden of obligation and responsibility for looking after family members that can just really overrun their ability to sort of have peace of mind and to thrive in the ways that they need to. So I think the right way to approach is to get a sense again, like we just discussed about what some of those customs and norms might be, but then, you know, to just consistently acknowledge and ask, it's about questions instead of, you know, it's about acknowledging a lack of expertise and just helping people to navigate their way through it, because there's not a right answer. People have to decide that for themselves, but it's appreciating the dilemma and helping people think through that dilemma and what they want and what they don't want is probably what's gonna be useful to that person. Thanks so much. Yeah. Thanks for your talk. I have no experience in dealing with Native American, but I'm wondering how they view us coming to their land and providing mental health treatment to them when they have different views. Do they have a lot of transparence towards us when we start working with them or not? Yeah, I mean, it's telling that one of the main ways that Native people in reservation settings encounter mental health providers is by court order. You know, so it's go to jail or get help or we're gonna pack you off to addiction treatment or whatever it is. That's one thing that's worth noting, because obviously when you're coerced into those kinds of interactions and relationships, it's hard to know what will come of it. It seems like the debt could be stacked against its benefit. I don't think, I mean, there's enough distress in crisis that desperate people will look for help no matter where they can find it. And so a clinician on a IHS service on a reservation often has a longer list of people than they can see, certainly longer than they can see when the person wants to be seen. So crises come and go. There's that ebb and flow of distress I talked about where a person in crisis needs you right now. They wanna see you this week and maybe for the next three weeks. And often they can't be seen. And so they're not helped in the crisis and they're not interested in help outside of the crisis because once you step back from it and you're not so desperate and overrun, it doesn't make a lot of sense to you for reasons of all cultural orientation and so on. So I think the dynamics of community life and of help seeking can differ in ways that make it hard to know what a provider or clinician can or should do when the resources are strapped the way they are. How do native people feel about non-native people? It runs the gamut. I have relatives who hate white people and they will say, I hate white people. Under-white, they don't tell white people that necessarily, but they will say that. And they have reason for why they feel that way. And other people are comfortable and confident mostly around white people. And I'm talking about people who live in segregated reservation settings where there aren't tons of white people except in these weird positions of authority or of service provision or something like that. So it runs the gamut. And so trust obviously is an issue and that's an issue to be made therapeutically salient, I think, early on. And attending to how the relationship's working with respect to those trust dynamics seems really important because otherwise how can anything else good happen? What about non-white immigrant? Do they have different feeling about those physician providers or not? Yeah, I think that could run the gamut too. So, you know, one thing about the Indian Health Service is that we get a lot of folks cycling through really to get their loans repaid from their doctoral studies. So they're only there for two years, three years. Everyone knows they're not there because they care about Indians. They're there to get their loans repaid. So that exacerbates that trust issue. And so anyone that comes through who's not native could be cast with some sense of reservation or even suspicion that they don't really care. And especially if English is your second or third language, you speak with an accent, I think people can be a little more put off by that. So I think there is the bridge to make there. I mean, so anyway, I think that there are dynamics also around that. It's not the same though. I mean, I don't know. They're not gonna say they hate Asian Indian people. They don't have any reason to do that. But it doesn't mean that there's trust exactly. But for them, I think immigration, legal immigration or non-legal immigration doesn't exist. They're all a forward to their native land out there. Do they view us less threatening because we followed and we did not colonize. We came to the country. So do you think they view us differently? Again, I think it's gonna run the gamut because on the one hand, right. You're not the colonial subjugators that they're familiar with. On the other hand, you're coming to native lands. What gives you the right to do that? I mean, so, and it has to do with the broader relationship to me. Anyway, I don't think that native people in general though are antagonistically oriented. I think that especially if you show any kind of initiative to engage and to want to be respectfully connected, Indian people are very welcoming. And you just have to have the right attitude. So with the right attitude, I think you could be welcomed in. But that's outside of the therapy room. They're not gonna come knocking on your door for that. You have to get outside and meet people and do stuff in the community. Then there might be a chance that some people will come knock on your door if they've seen you around, if they know that you're asking respectful questions and you're talking to people about their perspectives. But without that, I don't think people are gonna come knocking on your door. Okay, thank you. Yeah. On that note, folks, I think we need to end. It's been great to have you this morning. Thanks for coming out. And look forward to it. Thank you.

evidence-based practice

indigenous community

mental health

trauma

substance abuse

suicide

underfunding

indigenous healing practices

cultural worldview

decolonizing psychiatry

relational selfhood

community-driven approach