what traditional elders believe about mental health training

Here's my latest paper that I've just revised. I'd sure appreciate some feedback or comments.

Lewis

What Traditional Indigenous Elders say about Cross Cultural Mental Health Training



Lewis Mehl-Madrona, MD, PhD
Departments of Family Medicine and Psychiatry
University of Saskatchewan
Saskatoon, Saskatchewan, Canada

And

Southwest College
Santa Fe, New Mexico, USA


Address communication to:
Dr. Mehl-Madrona
P.O. Box 9309
S. Burlington, VT, USA, 05407
808-772-1099
Fax: 306-655-4894
Email: mehlmadrona@gmail.com



Abstract. As part of the process of creating a cross-cultural mental health training program, a group of 19 traditional healing elders from both the United States and Canada were asked their opinions about the core values and principles that should be part of all mental health training. This exploration was part of an intuitive inquiry process in which the author was the subject and the elders, co-investigators, who helped him to explore his biases and those of the various cultures in which he was trained and practiced. The paper is structured to match the author’s experience beginning with the introduction he gave the elders about himself and proceeding with a story one of the elders told him in response to his question. Conversations with the elders were open-ended, in a narrative inquiry format, and were summarized using modified grounded theory techniques to explore what was common to all discussions. Summarizing principles that emerged were presented back to the elders iteratively until 12 unanimous concepts or principles resulted for consideration for use in the education of people who will provide services to indigenous people. While none of these principles and ideas are necessarily new (in the sense that they have not previously appeared in the literature), their joint presence is new and the process with elders through which they emerged has not previously been described. Implementing these ideas would change the way that psychiatry, psychology, and social work are taught and practiced. It is hoped that their assemblage in this form can impact mental health training programs to include more culturally appropriate concepts and practices for indigenous peoples. These ideas may also be relevant to the training of all human service providers who work in indigenous communities. A community-based, cross-cultural health and healing program was developed at Southwest College based around these 12 ideas.

A number of authors have commented upon what future mental health practitioners should be taught to be effective and appropriate with indigenous people, though rarely have traditional cultural healers been asked for their views. Equally rarely have the knowledge keepers of indigenous communities been asked how they define mind and mental health and what would properly constitute mental health services from their points of view. Multiple perspectives exist within any indigenous community, ranging from highly Christianized to a Western medical perspective to traditional cultural healing. The focus of this paper was to explore what a relatively diverse group of traditional cultural healers believed important as attributes for mental health providers to hold or principles that should guide training. We also wanted to explore what mental health services meant to them. This work was done in preparation for developing a cross-cultural training program for human service providers that would include elders as community mentors and adjunct faculty on equal status with academically trained faculty. Our goal was to summarize the core values and principles needed to train mental health providers to work in harmony with traditional cultural healers. The term indigenous will be used in this paper to refer to the people who have lived in a place long enough to develop local knowledge and practices about that place, though they might not have been the original inhabitants of that place (for example, Dene in Arizona are indigenous though they have only been there from about 1100 A.D.).
Though much anthropological literature exists related to indigenous healing, relatively little has been written to guide mental health professionals to work effectively in indigenous contexts. The literature that does exist includes a discussion of values in A Gathering of Wisdoms, (Swinomish Tribe Mental Health Project, 1991). An especially helpful chart describes what mental health workers can learn from Native American culture. The Sacred Tree describes the integration of western and indigenous therapies as do articles by Michael Tlanusta Garrett (Garrett & Garrett, 1994; Garrett & Pichette, 2000). Garrett discusses seven practical recommendations for effectively counseling Native American clients. Duran (2006) further amplifies the problems that white practitioners may have when they work with Native American clients. Some of my elders would argue that the European notion of counseling or psychotherapy is inappropriate and so flawed as merit abandonment.
Since I work collaboratively with traditional healers in much of my clinical practice, I have had extensive discussions with them about what students should know. We have discussed trainees who are unacceptable and trainees who are desirable. This paper is about their views. I will attempt to present this in an indigenous way, first by situating myself, then by telling a story, and then by explaining my methodology, describing the elders and telling what they said, and ending with a story to dramatize the conclusions (as they would do).
In my work with indigenous communities (Mehl-Madrona, 2005), I have repeatedly observed the repetitive overuse and failure of the “one cause-defective brains” model of mental health. I have watched new graduates appear in communities armed with a vast array of knowledge from their medical or graduate training. They are surprised when no one comes to see them. James Gustafson (1976) wrote a paper on the relative immaturity of Lakota people which made them unable to use psychoanalysis as a healing method. He failed to grasp the vast cultural differences that led people to suspect anyone who sat silently behind a couch as a bit strange and unhelpful. The blank screen was not a part of indigenous socialization. Talking to someone who gave no feedback held no interest to the people.
Modern professionals are attempting to educate indigenous people in the current model of mental health. We teach them to come alone to appointments. Worse, neighbors bring a child for his or her appointment with no knowledge of the situation at school or at home. The child is delivered to the professional to be fixed. Drugs are expected. Traditional healers, or knowledge keepers in relation to health and disease, would immediately suspect a paradigm that excluded the community. Elders consistently point to the need for community involvement in healing and well-being (Linik, 2004). They believe that indigenous people are embedded in families. Elders have told me that disease exists in relationships and not within people (Mehl-Madrona, 2003); therefore addressing disturbed relationships also addresses disease. Mental health professionals have largely ignored the potential benefits of local knowledge for securing or improving the life situation of the local population. In order to be able to correctly assess the general significance and particular relevance of local knowledge in a given situation, it is important to see the context in which that local knowledge is located. Wittgenstein (1953) wrote that, for all our claims about 'things', all our theories must be tested in practice.
Duran & Duan (1995), Colmant et al. (2004), and Lux (2004) stress the cultural changes brought about by colonization through its impact upon people who attended residential schools. The devastating impact of the residential schools is largely undiscussed in conventional psychology circles. In a semester class on aboriginal mind and mental health (see http://groups.google.com/group/aboriginalmind) at the University of Saskatchewan (which has almost 10% aboriginal students), none of my non-aboriginal senior students initially had any understanding of residential schools or what residential schools had done to the people. These students were preparing to enter graduate programs in psychology and social work. Lux (2004) has written the most eloquently about the residential school experience in which children were removed from their homes at ages 5, 6, and 7, placed in overcrowded “schools”, mostly operated by the Anglican or Catholic churches, forced to work to maintain the school, disallowed any contact with their families and cultures (including punishment for speaking their language), and often physically, sexually, and/or emotionally abused. This practice lasted from the 1880s well into the 1970s (Lux, 2004). Currently, lawsuits have resulted in claims being paid by the perpetrators and the government of Canada to First Nations people, but these monetary payments do little to change the effects of residential schools.
In my work on reserves, I have largely abandoned the individual appointment model. I have stopped expecting people to come to buildings for appointments at preset times. I go out to the people, to encounter them where they are – in their homes, others’ homes, grocery stores, tribal offices, powwows, parking lots, schools, and more. I include relevant family and community members. I have recognized that many of the problems we address are related to lack of jobs, housing, and meaning. The people’s meaning and purpose have been lost. In Canada, the Indian Act, enacted in the 1870s and continually revised and modified until the 1960s, denied indigenous people the opportunity to own land, run businesses, or to be educated (Lux, 2004). It gave the Indian Agent authority to control virtually every aspect of an aboriginal person’s life, including marriage; sexuality; and religion, Traditional ceremonies were made illegal. A similar act existed in the United States, though the U.S. did not deny its native peoples the right to own property or to be educated. Charles Eastman was an Oglala man who attended Dartmouth College and then Boston University School of Medicine and served as the physician for Wounded Knee for 40 years from the 1880s to the 1920s, writing 19 books about his people, many of which are still in print (Eastman, 2003; http://en.wikipedia.org/wiki/Charles_Eastman). His education would not have been possible in Canada.
In Canada, whether they wished to join the modern world or not, all doors were shut. Marriage to a non-Indian ended the person’s Indian status. The only means to gain an education was to become a minister or a priest. The economic differences between the haves and the have-nots grew larger by the year. Today, aboriginal people are the poorest in Canada. Since real estate is a primary way wealth is defined, the act of preventing them from owning real estate while the Europeans claimed the desirable land guaranteed a culture of despair. Medications do not necessarily address that despair. Through its avoidance of the indigenous knowledge about the importance of meaning and purpose in maintaining health, psychiatry and psychology fail to teach their students about the social determinants of mental illness and about community interventions that could address these matters. Community interventions are largely relegated to social work by physicians and psychologists. Current mental health efforts have not sufficiently mobilized local knowledge for mental health. Current practices aspire towards "authorities" who are largely external, thereby restricting the establishment of competent leadership and sustainable structures in local communities for promoting mental health. List most common mental health problems in indigenous populations and similarity to other populations.
Indigenous people have survived in their unique, local environments and have developed extensive knowledge systems that relate to those environments, including how to manage the apparently universal concepts of pain and suffering, though not all peoples define mind or mental health. Because the term "local knowledge" refers to a dynamic process of acquisition and integration of contemporary information and experience, it is difficult to effectively apply those aspects that relate to pain and suffering within biomedical definitions of mental health. However, as we discuss how to apply local knowledge to mental health and addiction problems, it is evident that the overall community is often hampered by deteriorating social structures, thereby forcing its members to look after their own individual needs and survival, undermining traditional values and stories that put the needs and survival of the group above that of the individual. This leads them to the biomedical paradigm of the individual seeking treatment in isolation from others. This situation in many communities does not support the application of existing knowledge. Due to the fact that knowledge gained through oral traditions, apprenticeship, or life experience is no longer fully and systematically used, we now have a "fragmented" local knowledge system (Mersmann 1993). A consequence of this situation is the difficulty of local communities and individuals to actively integrate external mental health practices into the local knowledge system in a way that maintains its integrity.

Methods

I defined elders in the manner suggested by my colleagues at the University of Saskatchewan (James Waldram (1997) and Valerie Arnault-Pelletier (2008)) as people performing actions within communities to reduce pain and suffering, recognized by sufficient members of their community as having the skills and training and experience necessary to do so, and recognized as embodying the traditional values and beliefs of that community.[1] Healing elders typically use the historical healing practices of their family/tribal group or community. Typically when a community member is asked about an elder, they would acknowledge that this person is respected by many even if they look to a different elder for guidance. Most indigenous people have one or more elders upon who they rely for guidance and healing – sometimes family members, sometimes not. The elders participating in this project were those with whom I had already spent many hours, attending their ceremonies, sharing clients with them, and watching them work. These pre-existing relationships provided a crucial foundation for my being able to sit with them and discuss how mental health practitioners should be trained. These elders were regularly approached by members of their community for healing and prayers and were recognized as spiritual people.
Gaining knowledge from an elder differs from conventional research practice. I gave each elder tobacco, sometimes colored cloth or prayer ties, and usually a gift each time I sat with them. This acknowledged their teaching me. I was the subject who was trying to learn. Unlike a conventional study with multiple subjects and one researcher, I had one subject (me) and multiple researchers (teachers). These elders found the usual research format of consent forms and confidentiality and data collection highly amusing and would never participate in such nonsense, as one said. Rather they were my teachers and were satisfied when I could repeat back what they had said correctly. They were offered co-authorship, but all declined, believing that writing papers was trivial and should be left to me as “my thing.” “This was your journey,” one said. “Now you tell your people about it. Our people already know all these things.” The beginning of any journey in indigenous communities is to situate oneself. Who am I and where do I come from?

Situating Myself.

I am a multi-cultural person, born in southeastern Kentucky near the Tennessee border. I came from a long line of Cherokee people who escaped Andrew Jackson’s Trail of Tears, forced march of our people to Oklahoma in 1836. My ancestors hid in the Appalachian Mountains of Kentucky and slowly assimilated with the white culture, primarily Scottish, also called “hillbillies” – the people famous for blue grass, fiddle playing, and sometimes moonshine making. My father’s people were the result of the Fur Trade – a combination of French Canadian and Oglala from the Wounded Knee area of South Dakota. My mother and father met at a USO dance in Kentucky where the U.S. Air Force sent my father.
I grew up within my maternal grandmother’s Christianity, which later I discovered to be so far from conventional as to be Cherokee in disguise. For example, she adamantly maintained that Mary was more powerful than Jesus because Mary gave birth to Jesus. She saw Mary as the chief of the women and Jesus as the chief of the men. Her other quirks taught me about culture, assimilation, and slowly but surely led to my interest in indigenous healing and mental health. I come from the generation in the United States who began to reclaim our heritage and culture after our mothers’ generation had eschewed all connections and struggled to fit in as white. For most of my generation, out fathers were absent or dead as was mine. My life events and my patients' experiences forced me to address the question of what is healing and what is the proper calling for psychology. So little of what I observed with the traditional healers matched what I was taught in my training. So much of it went against the assumptions and values of the mainstream. The knowledge of the healers was dismissed as unimportant and not relevant by my professors in medical school, psychiatry residency, and psychology graduate school. As I discussed this with my elders, I was told that they would work with me because I shared their core values. However, they said they would have nothing to do with me were I to to operate from the values and practices I was learning in my mainstream education. This posed a problem, since we needed to consider how to bridge conventional training with traditional cultural healers and train students to recognize this bridge regardless of not having grown up with indigenous people or in an indigenous community.

A Story

In keeping with the indigenous style of presentation, I will relate an example of a story about being multi-cultural in the modern age and about one of the elders who helped me struggle with these concepts. When I entered the tipi, Old Ben was in the midst of a story. He was always in the midst of a story, having melded his life into the art of never being caught starting or ending. Old Ben was surviving into the 21st century in the patch work way common to many contemporary shamans. On the weekends he led ceremony. During the week he worked as a printer. Like many modern day Native Americans, Ben’s life context was even more complex -- he was a Navajo - Lakota mix living in Hawaii. He had come to Hawaii years before with the military, had started school while serving at Hickam Air Force Base, and had stayed. He had planned to go back to South Dakota or Arizona where the seasons changed, but never did. He still talked about moving back home to the reservation, though he probably never would.
Like a true resident of the Rainbow State of Hawaii, Ben borrowed freely from all cultures at will, changing the names to fit his audience. Ben’s knowledge was a priceless and unique blend of everything that had ever crossed his awareness, packaged through his gift of semantic mutation. His consciousness treated stories in the way that viruses treat DNA. As he heard and recalled stories, he substituted, deleted, and recombined various parts of the stories until something brand new resulted never before seen or heard. Maybe all healers work this way.
Ben was telling a story about an ancient one who gave up his voice so that his family might never go hungry. This man was a great healer and storyteller but was perpetually poor. A spirit offered him a trade -- his voice and his ability to heal for prosperity. “The healer’s wife was overjoyed,” Ben was saying. “Finally she would always have meat on their table and the things in life which she felt she had deserved for all those many year that she had lived with the healer. A deer brought itself to their lodge and lay down for their food. The choicest roots began to grow behind their lodge. Barren bushes grew berries.
“Things were worse for the healer than he could have ever imagined,” Ben continued. “He had not realized how many little things in life that we do are healing. He could not make the softest touch for these are often more healing than the grandest ceremony. He could not reassure or comfort his wife and children. In fact, there was little he could do, for most of what we do in life is healing to someone or something. “Unfortunately, his wife soon grew tired of prosperity for what is wealth without love? What is prosperity without comfort or joy? What is the satisfaction of hunger and thirst without gentle companionship? Soon the healer and his family were more despairing than they had ever been.
“This is sort of a variant of ‘the grass is always greener,’” Ben said. “The man was now helpless for he had lost the capacity to heal himself and that is what makes us human. His wife vowed to help him but what could she do? She resolved to take him to all the best healers even in distant lands, to whatever it took to make thing right again.”
It was a motley bunch inside this tipi set in the tropics of Volcano, Hawaii, where Ben held court. He came down the volcano each morning to Hilo on the weekdays and stayed at his house on the slopes during the weekend. People found him, the same way they found Papa, the local Hawaiian healer or other kapunas (teachers) and kahunas (healing elders) that the local people respected and used. Today the tipi that sat in his backyard contained a blind radio announcer from Kona, This was a true cross-cultural dialogue about health and well-being. I wished all my students could have been there.
The kind of cross-cultural dialogue that existed at Ben’s house is rarely found within psychology and psychiatry. Medicine presents a global technology that is proposed to be universally true because of its basis in “science.” The restrictions of contemporary “scientific psychiatry or psychology” are rarely discussed. Mehl-Madrona (2007) describes how treatment is always context dependent, working or not working in accordance with its fit into the master narratives and beliefs of the people who are being treated and requiring the development of a shared story for how people work together to facilitate wellness. While this is less obvious for an acute surgical procedure, it is crucial for recovery from surgery and becomes all the more obvious, the closer one moves to the realm of emotional suffering. Modern medicine and psychology are relatively indifferent to the keen observations and analysis of indigenous knowledge keepers regarding health, illness, and well-being. It is fairly limited by its insistence on the randomized, controlled trial as the ultimate basis for knowledge production and to its preference for treatments that are not individualized or relational.
Many believe as does Duran (2006) that one must be raised within a culture to truly understand it. Others believe that one must speak the language to understand a culture. Laubin & Laubin (1957) influenced the preservation of Lakota culture without being raised within that culture as did Adolf Hungry Wolf' (2006) for the Blackfoot people. Some who were raised within Native culture nevertheless, adopted the colonial knowledge system (Duran and Duran, 1995).
My method of intuitive inquiry began with an explanation of what I believed and had experienced about the topic, then proceeded to explore what others believe and have experienced in a review of the literature. Then I engaged in an inner dialogue, highlighting what changed as a result of my research and noting any intuitive breakthroughs. Then I returned to the literature to explore how the new perspectives relate to existent theoretical and empirical literature and to the greater context (Braud & Anderson 1998, 2005). Then I had my discussions with the elders and wrote down after each meeting what I remembered about our discussions (note taking would not have appropriate). Modified grounded theory within this framework was used to guide my reflections upon the discussions and dialogues held with the elders. Notes using theoretical memo writing were made in the margins; these notes were summarized through theoretical coding and laid out along with my reactions to the discussions. The categories that emerged were taken back to the elders for further discussions. Through an iterative, back and forth process, we all agreed upon 12 categories stood out in all of our discussions.
The elders who engaged in the dialogue about these concepts are summarized in Table 1. I used an open ended, narrative style dialogue with each elder over several meetings. The general topic for discussion included their views on 1) mind, 2) mental health, 3) the disorders they recognize of mind and mental health, 4) who should be involved in healing mental health problems, 5) what should they know, and 6) how they should be trained? Of course, the elders said what they wished. I had previously been trained by several of them in the “art of listening,” which is crucial to studying with elders and means the acquired ability to remember and render an entire discussion without notes or recordings. They sometimes wandered far from the original topics, compatible with a narrative approach. What I learned from our discussions was presented to the elders for their review and critique, as an indigenous adoption of a grounded theory model (Glaser & Strauss, 1967; Glaser, 1978; Glaser, 1992). The elders and I formed “think tanks” to discuss what I had learned from all of our discussions. We strived for ideas on which everyone could agree should guide the training program being creating. We called this process “quality improvement in advance”. This iterative process resulted in unanimous agreement on 12 concepts that seemed crucial to an indigenous understanding of mind and mental health. The majority of the elders represented my origins and locations – Cherokee, Northern Plains people (Ojibway, Lakota, Cree), or were from Arizona. The sample described in Table 1 represents the results of a cross-cultural group of healers who engaged in dialogue and came to same unanimous conclusions. They do not represent the views of any community or particular cultural group.

Table 1. Elders guiding this project.
Description
Background
Culture/Language
Values
65 year old male.
Bachelor’s degree from University; married to a physician; three sons; musician; healer.
Eastern Cherokee;
Learned medicine ways from his father and grandfather. Practiced traditional medicine since age 25.
55 year old male.
Retired policeman.
Lakota
Studied with Fools Crow (see Mails,1979); Received his initiation in a vision on top of Bear Butte.
66 year old female.
Master’s Degree; affirmative actions
Officer; cross-cultural consultant.
Arikara-Hidatsu;
Received her medicine training from her grandmother.
52 year old male.
20 years in the U.S. Army; retired and took up medicine ways; served in Viet Nam.
Yaqui
Received his medicine training from his grandfather.
45 year old female.
Housewife; Gradually became healer as people came to her; family tradition of healers
Mayan
Received training from her grandmother and from local Mayan healers.
46 year old male.
Employed as a printer.
Tohono-O’odham
Received his training from local healers; Also Native American Church Roadman.
45 year old female.
Health Department employee.
Penobscot
Received her training from her grandmother.
58 year old male.
Retired Worker for the Highway Department.
Cree
Received his training from his grandfather.
52 year old female.
Retired from Indian Education.
Cree
Received her training from her grandmother and other female relatives.
55 year old male.
Worked in lumber industry. Retired to do medicine full time.
Carrier
Received his training from his grandfather and from Arapahoe healers.
40 year old male.
Drug and Alcohol Counselor, using traditional medicine.
Cree
Received his training from elders in Alberta.
55 year old male.
Retired Teacher.
Cree;
Received his training from his grandfather and from an Arapahoe healer.
40 year old female.
Former Teacher; Quit to do medicine full time.
White Mountain Apache.
Received her training from her grandparents.
55 year old female.
Retired Teacher; Quit to do medicine full time.
Ojibway;
Received her training from her grandparents and other local elders.
40 year old male.
Cab driver.
Caribe.
Received his training from an uncle and relatives.
65 year old male.
Itinerant healer; travels around the U.S.
Lakota.
Received his training from relatives.
42 year old male
Physician and also traditional healer.
Haida.
Received training from his grandparents and great-grandparents, trained by local elders as well.
40 year old male
Physical therapist; artist.
Seneca.
Trained by other healing elders. No family tradition in past two generations, but rumors of medicine people before that.
48 year old male
Physical therapist.
Taino from Puerto Rico.
Trained by family members.

Key concepts of Indigenous Knowledge about Mental Well-being

1. Genuinely listening is very importance for the healing process. One elders said, “People tell you what’s wrong if you listen. They tell you how to help them. They tell you what needs to be done.” A related common theme was the importance of listening to the spirits who inform healers what to do. For some, the person’s spiritual helpers and guides speak to their spiritual helpers and guides. The underlying principle appeared to be that all healing emerged from dialogue that happens on many levels. Dialogue means “talking in order to listen”. One Cree elder spoke about listening to his dreams before someone consulted him. The dreams gave him important information about what to do to help that person. Other elders spoke about the importance of story. Their ideas were similar to those of narrative psychology (Mehl-Madrona, 2007; Charon, 2006). Several elders spoke about suffering existing within the context of a story, for all we are is story. In explanation of that, they said that all that is left when we die are the stories told about us. They believed that the self that we believe we are is just the story we tell ourselves to make sense of all the stories that have been told about us. The story lives us as we live the story. They stressed that to understand an illness it is necessary to place it within the context of the story that the person is living. To help a person, we must hear as many stories that are being or have been told about that person as is possible. They acknowledged that we can never hear them all, but we can try.
There are traveling healers especially within the Native American Church of North America, but also within other traditions as Richard Harris, the Arapahoe elder who brought the sweat lodge tradition to many Saskatchewan elders in the 1970s. These healers come to communities to lead ceremonies and stay at the homes of those who need healing and who put up the ceremony. Within this context, they spend time hearing all possible combinations of relatives to gain a perspective on all the stories being told about the person and the illness. I have observed healers talking to all possible combinations of relatives to gain a perspective on all the stories being told about the person and the illness. Some agreed that the illness itself had a story to tell, as did ancestors who had a perspective on the illness as it had come to reside within the person. They commonly consulted these ancestors during dreams or ceremony.
For example, I watched a Cree elder diagnose celiac disease in two hours. In this disease, people have antigen-antibody responses in their gut to the ingestion of gluten, a constituent of wheat and some other grains. Anxiety and depression are common. The woman who was diagnosed had been to a number of psychiatrists for her anxiety and depression, and had always received medications. The elder carefully reconstructed her story from her life before the first symptom through the beginning of the illness through its blossoming to the present time. Within an hour, he began to suspect that the woman was suffering from something she was eating. He pursued this line of questioning and discovered that her worst days were when she had deserts. He inquired about her favorite deserts. All contained dairy, wheat, and sugar. Eventually he told her to stop eating deserts. “You need to fast,” he said. “Fast four days. Then drink only good water for one day. Add another food each day. It’s probably one of those European foods,” he said. “Our bodies can’t handle them. It’s not natural for us. We eat caribou, fish, rabbit, and berries. Breads and cakes and chips and even a lot of vegetables make us sick. Our blood is different. This is a common statement I hear in the far north of Saskatchewan among the Dene people. It is a general belief used to explain why medication is undesirable. The clues were more obvious in retrospect, but the powerful listening skills of the elder had brought them out.
This woman had suffered for eight years, plagued by mental fog, anxiety, and depression. Though friends had suggested that she might have food allergies or a food-related illness, she couldn't believe that a food-related illness could cause such severe symptoms and her doctors concurred. She had gall bladder surgery in the belief that her symptoms arose from an incipient cholecystitis; though surgery did not improve her symptoms. Each successive physician blamed stress and depression for her troubles. The elder then did a ceremony to remove her illness. Immediately afterwards, words came into her mind that she had to stop eating grains. Two months later she was amazingly better on a grain free diet. When she cheated and ate chocolate cake, her symptoms returned in full force, disappearing again when she fasted and cleared the cake from her system. Each time she went off her diet, her symptoms returned, strengthening her belief that she did have celiac disease and that dietary therapy could help.
Several elders attempted to explain the importance of listening by saying that most of the professionals who they met were convinced of the superiority of their knowledge compared to that of the elders. When they encountered these attitudes, the elders acted “stupid”. To them, listening implied respect and respect mattered. Mental health workers who cannot demonstrate respect cannot work with elders. Several elders also mentioned the importance of listening to remember – the essence of an oral tradition for knowledge transfer is the importance of listening. This theme of listening and story are eloquentlydiscussed in The Lost Art of Healing (Lown, 1999). Incorporation of this first principle of indigenous knowledge into our training programs would mean abandoning our insistence that we know best in order to listen to people’s unique stories about their illnesses and lives. We would emphasize teaching students the skills of listening more than the skills of diagnosing.

2. Teach a Relational Model of the Self. None of the elders espoused a structural model of the self. They did not believe in a Platonic self existing independently of an external world that can be discovered. The elders believed that mind and self arises through a process of relational, social development. They saw each person as internalizing all the stories that had ever been told about him or her into an identity which eventually became a story about all the stories. They did not share the European concept of an “authentic” self, for they did not believe in a self except as a unifying story to guide our behavior. The elders did not separate mind and brain. They saw mind as derived from spirit which requires an earthly robe (body) to operate in the physical realm. They believed that people with damaged brains have constraints upon their sense of self, mind, and capability, but for non-impaired people, they saw the self as being a story which arose through relationships, through incorporating all the stories people tell around the person. “Self” is mediated through other people – first, the mother or other primary caretakers; second, through peers; and third, through the broader media that presents and re-presents the stories of culture.
White and Morgan (2007) believe that we construct a model (or a narrative) about ourselves based upon the results of our reflections, and then we perform that narrative in the world, consistent with the elders’ views. They agreed that the performance of a self narrative gives us corrective feedback to further refine our story that we tell ourselves about who we are. Western people tell themselves Siddhartha-like stories, in which they uncover their true self. Indigenous people tell stories about relationships and connections when asked “who are you?” Indigenous concepts of self and self-knowledge are more dependent upon relationship input and are inter-connected.
The elders’ views resembled that of Wittgenstein (1980), who said, “understanding is like knowing how to go on; it is an ability”; but “I understand”, like “I can go on”, is an utterance, a signal. For the elders, insight represented an awareness of a path to follow, a way to go on. Understanding for them was an ability to perceive. They did not believe in a mental state from which our acts spring but rather spoke of people’s behavior being determined by the stories and the contexts in which they found themselves. The elders’ concepts of self relied upon the creation of self through interaction with others. It is, as White said, "a performed Self", a co-creation arising from relationships with others and within landscapes of experience and meaning. These landscapes coalesce to form a topology which is local culture, practices, and knowledge. The concept of self is embedded in this local geography of meaning and values.

3. Teach how to help people and groups find their own solutions to problems rather than relying on externally imposed solutions. The elders were consistent in their belief that imposing an answer on someone or a family or a community would not work. People must find their own answers. They must consult their own guides and spirit helpers. They must be empowered to receive their own divine guidance. They helper or elder was only present to facilitate the conversation. The elders’ perspective was consistent with the view that increasing emphasis on the individual in communities and increasing isolation of problems from group concern leads to social disruption and consequently prohibits the formation and utilization of the necessary social relationships for the development of local solutions. It is then that communities turn to external experts to impose their distant solutions.
I told them a story about two indigenous men from my practice. Murray was chronically suicidal, frequently presenting to the emergency department to demand yet another psychiatric admission on threat of killing himself. John was chronically depressed and suicidal also, drinking frequently to excess. I had acquired both of them from being on-call. John gave up on psychiatric medications and sought healing from one of the elders. Murray did eventually kill himself, though luckily for me, after he had left me for a “better” psychiatrist (one who would give him benzodiazepines). John began to thrive outside the mental health system, continuing to work with the traditional elder, changing his life in accordance with the guidance he received in ceremony. One elder responded to these cases, saying, “It’s obvious when you doctors try to be ‘big shots’ and tell people what to do, it doesn’t work. The elder helped him find his own answers. Other people’s answers never work,” she said. “They just make you feel worse because they don’t work. You have to find your own answers.” They said that we should teach people how to help people find their own answers. We need to teach them the skills of empowerment and help them to trust their ability to self-heal.
The view of narrative philosophies is similar to that of indigenous groups and locates the self as a participant in a world in which he or she is continually acting and being acted upon. The elders discussed connectivity meaning our connections with everything around us, within us, and to that which encompasses us. They discussed accountability; that we are accountable to others to whom we relate for our actions. They emphasized the relational self over the individual self. The relational self maximizes relational quality with a desirable side effect being improvement in one’s own quality of life. Gilligan (1993) discusses “female ethics” in a similar vein, as relationship preserving over all, even if accompanied by self-sacrifice. Indigenous teaching stories are replete with examples of the individual sacrificing for the greater good of the community or of other loved ones. Coe (2006) asserts that this theme is so universal among indigenous people that it may be a required value for survival. She comments upon its absence in contemporary global modernist cultures and wonders if these cultures are destined for destruction on the basis of lack of sustainability, lack of resource preservation, concentration of wealth in the hands of a few, destruction of diversity, and extreme individualism. For narrative philosophy as well as indigenous thought as demonstrated by this group of elders (see White & Epston, 1990), the self is a story that we have internalized about others’ descriptions of how they see us. Every day that story is re-enacted as a new telling to an audience who participates in any revisions or re-authoring of the story on that day. Both narrative philosophers and indigenous people, believe that those to whom we relate each day participate in the shaping of our lives and our story about who we are.
In both views, stories told actually create the lives they describe as much as they represent them; and the control of those stories lies in the network of relationships in which the person is involved. This network includes spirits or non-physical entities and other living beings as consciousness such as rivers, mountains, and trees.
The elders agreed with Freedman and Combs (1996:35) who wrote: “Different selves come forth in different contexts, and no one self is truer than any other….While no self is 'truer' than any other, it is true that particular presentations of self are preferred by particular people within particular cultures.” The preferred Self is that Self which people can first recognize in their experiences and stories, and which they can then project into the future in the form of a story they would like to be telling, then living, themselves. Similar to White (2007), indigenous concepts of self “invite us to challenge modern notions of the self as a unitary and essential core of being that seeks expression through some singular voice that can, with 'genuine' authority, represent its own interests” (White 2007).

4. Teach that people are self-healing. Inevitably the Elders returned to the idea that nature heals herself and that we are a part of nature. They trusted this principle explicitly. They didn’t have to know how to help someone. Their job was to start a conversation between those who suffered with Nature, with spirits, and even with specific elements of nature such as rivers, land, and mountains. They were confident that healing would unfold as the information was shared. They didn’t agree with concepts of diagnosis, treatment plans, and what they considered to be external manipulation. They focused upon the mysteries inherent in 'dialogical' forms of activity in which surprises appeared and led to healing outside of what we could have predicted.
A conversation emerged with one elder about birth. I took this conversation to all the elders. All believed this was one of the most mismanaged areas of medicine. I related being attracted to birth because of its power and beauty, and the sense of journey or pilgrimage implicit in being born or giving birth. I shared my ideas that fear of birth dramatically intensifies pain and amplifies the production of hormones that can stress the baby. Then the epidural drops the blood pressure, reduces muscle tone needed to guide the baby down the birth canal, and stops or slows down labor. The hormone oxytocin is used to restart the stalled labor. Worrisome fetal heart rate patterns ensue, leading to a diagnosis of fetal distress, resulting in the cesarean. I told the elders about my work with women to help them feel empowered to give birth (see Mehl-Madrona, 2004). They were enthusiastic about the story. “All we need to know,” one said, “is already within us. It’s this modern world that tricks us to not believe in the information we receive. You have to teach people to have faith again,” she said. “You have to teach people again to see themselves as part of nature. Then they can believe in their own healing abilities. Look at strip mines. Nature even eventually covers up that mess and heals it. The same happens with people.”

5. Teach students to be selfless of intent. Time and again, the Elders emphasized the power of intent and the need for selfless intent. They saw this as intending to be healing without thought of reward or recompense. For some, it took the form of never profiting from their healing. Others were willing to profit, but only if their work succeeded. Still others were willing to profit regardless in the sense of being paid or gifted for their time, but all insisted that it was necessary to hold the highest good of the person or people being healed in the highest light above all considerations of personal reward. “Even praise can become a reward that interferes with healing,” one elder said.
I told the Elders about two doctor friends who burned out and left medicine. We looked at the growing disparity between the conventional medicine institutions pursuing profit and healing, which must often ignore personal gain. I described how my practice had transformed from 15-minute office visits to week-long intensive retreats, and how I approached the problem of people not having enough money for a visit or for what they needed. The Elders agreed that young people needed to be comfortable and make a nice salary, but they also agreed that healing was a calling and people needed to approach it from a selfless point of view. They emphasized that the healer may be the only person who believes that the sick person can get well.
This led us to the question of community. Profit-driven medicine responds to shareholders and not communities. The elders believed that healing should begin with community instead of tacking it on as an after thought. In contrast, they saw our current system appearing to work more for the insurance companies and their shareholders, managed care companies and their boards and executives, the administrators who direct the flow of dollars. The elders said that they could only work with health practitioners who were relatively pure of intent. These practitioners had to care more for other people than herself, and that we had to nurture that care and concern by taking good care of them.

6. Teach students to be passionate about their work. This point was emphasized by the Elders. They thought it helped for students to have their own illness and to have healed it first. “This is the best training,” one said. “Or at least they have to do everything that they ask others to do. They can’t stand back and make suggestions for things they have not done. That is not honest.” These elders did believe that practitioners should have to take the medications they prescribed even though that would not make sense to the biomedical practitioner. They had learned all their herbs and other therapies that way and didn’t see why it didn’t also apply equally to drugs. They believed that self-healing would generate the passion necessary to inspire quality work. They spoke of other motivations that could inspire passion – for example, illness in other family members, spirit calling, and more.
Several elders told stories about people who had come to their communities to fulfill obligations incurred by government funding of their education or because salaries were higher in indigenous communities by virtue of being rural and/or remote. “You could tell their heart wasn’t in it.” “They just went through the motions.” “They didn’t reach out to people in the community.” “They were happiest when no one came to the appointment.” In contrast, they told stories about people who were passionate and left their offices to go out into the community to encounter the people, who went looking for the people who needed help. They approved when practitioners showed genuine interest in the people and their culture and appeared to be excited about their work. Passion was seen as contagious. “You can tell when someone really likes what they do and the people they do it with.”

7. Assist students to maintain some independence from politics. The elders were insistent that healers need independence from laws, politics, and the medical establishment. They insisted that they could answer only to the Creator and to the people who came to see them and none other. The historical context for this, of course, was the Indian Act in Canada (1857), which made spiritual ceremonies and healing illegal and definitely healing illegal. Similar laws were enacted in the United States (see Waldram, 1997 and Lux, 2004).
I told the elders a story that they found entertaining and exemplary of their approach. In 1997, I gave a workshop in Pittsburgh and was invited to help start a complementary medicine program at one hospital within a health system of 29 hospitals through the University of Pittsburgh Medical Center. The Center was slated to begin with therapeutic touch provided by nurses and one part-time acupuncturist, under the direction of a Steering Committee, and under the supervision of an administrator in the Department of Surgery. My job would be to help the Center grow and expand and to develop more modalities and add more practitioners, while assuring high quality care. The job looked impossible from the beginning: do research, meet the community, give presentations, write papers, and most importantly for the institution, see patients and generate income.
We began with a different philosophy that illness could be a messenger, and that our experience of our bodies in either sickness or health, could provide us with self-understanding and meaning. I gave lectures in the community that illness was an interactive product of mind, body, and spirit; the choices we make about the way we live have a tremendous impact upon the quality of our lives and our health; and that the source of healing lies both within us and within the spiritual dimension. Almost immediately, practitioners began calling to work with us. They spanned the gamut from excellent to questionable, but many seemed to be just what we needed, and all provided resumes for us to circulate among existing staff, so that we could interview those who seemed most intriguing. Each staff member had an opportunity to comment on whom we would accept. All of our staff practitioners were independent contractors, with their own practices in the community, all interested in contributing time to our Center.
Our success drew national recognition. Unfortunately, with a new administrative appointment the decision was made to dismantle the program because the approaches were “unproven” and not “evidence-based”. This occurred despite medical staff petitioning administration that we were admirably caring for some of their most difficult patients and that we were benefiting the entire medical staff. Even a program for teaching pregnant women hypnosis to use during labor was cancelled because hypnosis was considered an unproven therapy. This experience brought home to me the perspective of the elders, that healing should be independent of politics. Since that experience, I have kept my healing work outside of institutions for the most part. I saw how conventional medicine could make indigenous healing ineffective -- by taking away the relationship, the community, the time, and treating the various therapies as interchangeable units, just like drugs.
I have seen traditional healing be sometimes spectacularly successful. It has much to offer, but, if done poorly, can be useless. Although there are many hospitals and health care systems where traditional healing is welcomed, it also true that when traditional healing is placed within a conventional medicine system, freedom to practice can be lost, providers can be limited in the number of visits allowed with each patient, how long they can spend with patients, what modalities they can use for any patient, or being allowed to work only with specific diagnoses. The elders had knowing nods in hearing this story. “Of course that would happen,” one said. “It’s all about greed.”

8. Teach students the importance of faith, hope, and the power of the activated mind. The elders agreed that hope is only necessary for those of us who struggle in the throws of uncertainty. Like patients with life-threatening illnesses, or those with chronic illness for whom medicine has no answers, or the depressed, the homeless, and the disenfranchised, when we can't be certain an answer or a cure is forthcoming. Hope springs from a different source than knowledge. The spring nourishing the waters of hope requires no science to make it flow. I told several of the elders a story I told a patients who was terrified of dying, but deeply religious, having studied Buddhism for many years. I shared a guided meditation I did with a man, framing our shared concepts in Buddhist terms. The elders agreed that this was a good example of how they thought.

Being in the present moment does not mean your body will not die. Your body may die, and you may not even notice. You are not this body. You are the ocean and not the wave, rolling onto the shore.

While you are suffering through this chemotherapy, I want you to remember that you are not the body who suffers. The body is like a wave in the ocean. Your pain is also like a wave in the ocean. It peaks, crests, and then rushes toward the shore. When it reaches the shore, it is gone. The nausea, too, will pass. You may live another fifty years, but eventually your body will pass. You could remember that you are not this body. This body is merely the vehicle through which you negotiate this physical reality of this time and space. You will not disappear with this body.

The past of this body is full of pain. The past of this body is caught in the causes and conditions that created cancer. Some of these conditions may continue and may be sustaining and feeding your cancer and ill-being in general.

You are feeling uncomfortable for many good reasons. The current body conditions are not favorable. You feel you are on the right course. You need this medicine [the chemotherapy]. How can your body accommodate to this medicine.

It is like being cold, being out in the cold. We cannot deny that we feel cold when we are cold. We cannot deny feeling nauseated when we feel this. We cannot deny pain when it is present. But consciousness is like a searchlight. What is illuminated can eclipse all else. What is caught in shadow does not go away. Rather it is no longer prominent. Consciousness can rotate again and catch the unpleasant in its light. Or we can linger on other matters.

Let the searchlight of consciousness begin to rotate. Like a lighthouse on Martha's Vineyard. Your body is nauseated, yes. But so what. There are other experiences to enlighten. There are other possibilities for this present moment. Your body will take care of itself. The nausea is not dangerous. The discomfort you are feeling is not an alarm. You know what is happening. You are having chemotherapy. There are other places to explore, other states of mind to visit.

9. Teach students to prefer empowerment over treatment. I told the Elders about a man with nine angioplasties in three years, who was never told that these procedures could help relieve his pain and improve his quality of life, but would not necessarily, prolong his life. He was never told about the Dean Ornish program, the importance of exercise, or the Mediterranean diet, all of which have been shown in rigorous studies to prolong life (Koertge, 2003). I used his story to wonder about the difference between treating people and empowering them to think for themselves. This patient was used to finding the "best" doctors, and then doing whatever they told him to do. But how does one define best? In his city, best often meant, most aggressive, willing to do the most procedures, or willing to act more quickly than anyone else. Yet good medicine sometimes means doing nothing or motivating patients to do for themselves. It sometimes means giving patients the information to make their own decisions, and supporting them to do so.
The Elders were in agreement. While not all used to the term “empowerment,” the concept was quite familiar. “We cannot fix anyone,” they said. “Only the Creator has that power. And we cannot make anyone do what spirit tells them to do. We can only tell them stories to uplift and inspire them and to make them believe in their own power to act and in the power of spirits to respond to what they do.” Another said, “If you hear enough good stories of other people getting well, you begin to believe that you can, too.” A third said, “When know when someone is really on the road to getting well, because suddenly there’s that spark of knowing that what they do really matters and that every little step they take toward getting well makes a difference.”

10. Teach students the importance of community. In our discussions, a story arose that I shared with the elders. No matter how hard I struggled with Joseph, nothing changed. His chronic fatigue became more chronic. His fatigue deepened. His joints hurt. Despite what I thought were my best efforts, he continued to decline. At my wit's end, I called one of my elder advisors who suggested that I asked Joseph to bring everyone he knew to our next appointment. We went around the circle, with each person holding the Talking Stick being able to talk to their heart's content without interruption, all addressing the question of why Joseph wasn't getting better. By the end of that 2-hour session, they had given me a treatment plan and told me exactly how to proceed with Joseph. I wondered why I hadn't done this much earlier. Armed with this advice, my work with Joseph changed radically, as did he. The group he brought continued to meet monthly to struggle with the question of how each of them individually and the group collectively could help Joe toward recovery. I realized that any attempt on my part to claim effectiveness was shortsighted. We all did it together. The elders said that was similar to what happens in a healing lodge. Some also used talking circles. They agreed that the community has much more power to heal than the individual does. Another remembered one of her elders her said that the old ceremonies weren’t as powerful anymore because the community wasn’t as strong as it used to be.
I told another story about Gayle. She was depressed, not improving despite my most inspired efforts. I imagined that I was doing the best guided imageries, the best storytelling, the best cognitive behavior therapy, but was still seeing no change. After further discussion with my elder advisor, I made a similar request of Gayle. Twenty-five people arrived, only ten less than the number Joseph brought. Gayle's community was much stronger and more focused. The community decided without any intervention on my part that Gayle needed to sell her mother's house now that her mother was dead and get on with her life. She needed a car, and she needed to go "drive about." The group arrived with that idea from the Australian aboriginal concept of "walk about." They said no one walks about in America; of course, they drive.
The group pushed, prodded, and even did things for Gayle to help her follow the commitments she made in that first session. Further meetings followed her progress. By the summer she was in her car, camping in Arizona. Her depression was rapidly clearing, with minimal help from me. After two years of drive about, she settled in a small Colorado, mountain town, where she happily continues to reside. Luckily in both situations, we had a large waiting room and could meet after hours. These patients taught me to request a meeting of a person's entire community when that person isn't improving despite our best efforts. This practice has saved many a fruitless session. The elders told me that community contains the wisdom which the individual lacks. Collective minds offer more wisdom than individual minds. This is why, the Elders said, ceremony is done with more than one person. Everyone’s prayers and intent matter. The elders agreed that these two stories illustrated their principle of the importance of community.

11. Teach students that only Creator can give prognoses. Since medical school I have been collecting stories of survivors from illness who worked with the elders who were my teachers for this paper. These were people who beat the odds (Mehl-Madrona, 2008). In discussing these stories with the elders, we realized that the vast majority of those survivors learned that there were many positive messages inherent in their illness discovered on the road to recovery. One of them was gratitude, or how important it is to feel fortunate. One element of being fortunate is to rediscover spirituality in our lives; not only the belief in God, but the love and forgiveness that is necessary in our hearts and the welcoming of helpers and friends along the way. The elders said we must do this while learning how to overcome the disease with good nutritional habits, exercise, faith in the treatments we choose, stress management, hope, love, and support from relatives and friends. We learn to see each day's progress as leading toward the capability of being able to take charge in our own wellness plan.
They said all faiths have similar goals in mind...the importance of knowing what life is, the necessity of knowing the time we have here on this planet and maybe even more important, how love grew between those that were thrown into this era of pain. Within this context, they said, only Creator knows what the final outcome will be. It is wrong to tell people how long they will live. We cannot know that. Powerful transformations and healings do happen and we should not try to convince people of the inevitability of their imminent death. Nor should we try to white wash the severity of their illness and how serious it is. No matter what, healing is always possible and Creator trumps all of our scientific predictions, they said.

12. Teach students that all healing is ultimately spiritual healing.

The elders agreed that all healing was fundamentally spiritual healing. Without the spirit’s permission, no healing could occur. For them, spiritual healing represented the “deepest” healing with others lagging behind. This occurs in sharp contrast with most hospitals recognizing elders as spiritual advisors, but not as healers. Spiritual healing was seen as the most fundamental form of healing, the other methods riding on top of it. All agreed with the idea that the individual’s spirit had to want to get well before any intervention – even surgery – could work. The spirits willingness to be well was a necessary ingredient. One elder told a story about a man who came for healing of his colon cancer. This elder received a very strong message from his spirit guides that this man’s spirit wanted to leave this world. Nevertheless, the elder did his best to help. The cancer surgery was surprisingly a complete success. The several cancers that had been found had coalesced into one more or less contiguous and very removable tumor. The surgeons were thrilled and predicted complete recovery. On the way out of the hospital, as he was walking out the front door of the hospital, the man dropped dead from a massive heart attack. The man’s spirit has its wish.


Sidebar: Discussions with traditional healing elders from the U.S. and Canada raised 12 common points that were unanimously accepted as guideposts for training mental health workers who wish to work with aboriginal people. These guideposts are:

1. Teach students the importance of listening.
2. Teach Self is relational and identity is narrative.
3. Solutions must be internally derived.
4. People are spontaneously self-healing.
5. The healer should be selfless of intent.
6. Healers need to be passionate about their work.
7. Healers have to maintain some independence from political structures.
8. The importance of faith, hope, and the power of the activated mind.
9. Empowerment is different from treatment.
10. The importance of community
11. Only Creator can give prognosis.
12. All healing is ultimately spiritual healing.

Discussion

Perhaps we should follow the elders’ advice and adopt some of these considerations into our thinking about how to teach. Effective psychotherapists are those who are enthusiastic about what they do (Stratton, 2007). The client must also believe in the therapist. At least, with regard to indigenous populations, there are concerns that make a therapist seem caring and believable, that are not always addressed in conventional training. As the elders say, perhaps they should be. Psychotherapy research also indicates that patients, not therapist interventions, result in therapeutic change (Bohart and Tallman, 1999). The relationship is more important but patients do the work, even with poor therapists. Perhaps these items stressed by the elders would help even poor therapists be more effective or become better therapists.
A literature does exist on what students need to learn to work effectively in indigenous communities. Vella (1994), for example, recognized the need for students to learn how to listen and how to engage in genuine dialogue from positions of social equity. Thrup (1989) wrote about the need to teach students how to recognize clues that could lead to the development of empowering solutions to problems emerging from the dialogue of all those who were affected by the problems. Barnes (2000) wrote that we need to recognize problems as belonging to communities instead of individuals and to address the needs and resources of communities instead of stigmatizing individuals as defective or inferior. Krippner and Welch (1992) emphasized the need to teach acceptance of the spiritual dimension and to expect help from this arena, while Csordas (1983) wrote about the need to teach faith in nature and in the spontaneity of healing. Kakar (1982) commented on the dialectic between being able to expect a decent standard of living and needing to learn how to manifest selflessness of intent and how to hold another’s highest good as our focus. Krippner et al. (2004) added that we need to allow and encourage our students to be passionate about their work, to reject clinical detachment and obstructive professionalism in favor of a warm humanity. Myers et al. (2000) wrote that we need to help our students cultivate a sense of humor that is contagious. Peeling and Napoleon (2006) wrote that we must encourage students to stay somewhat independent from the political intrigues of modern health care, so that they can do their work.
Frequently we hear that we should teach students to cultivate faith and hope and to believe in the power of mind, especially of minds in community (American Public Media, 2006). Mihesuah (2003) wrote that we should teach students to empower instead of fixing or treating (Mihesuah, 2003). What all this suggests is that appropriate training for working with indigenous people is different from currently offered mainstream training programs in the mental health fields, which are often concerned with teaching students how to be expert professionals who apply solutions to fix or treat problems, expecting their patients to comply with expert advice. Spirituality is rarely discussed. Clinical detachment and professionalism is emphasized. Humor is rarely encouraged. From reflecting upon this list I concluded that our trainees need to be more humble. They need to work hard to develop their abilities to listen and to grasp the story that the person is living. The must appreciate the power of community and ground their activities in the idea of a relational self and a narrative identity. They should foster dialogue and trust in the self-healing nature of systems. We should fuel their passions, protect them from political structures, and insist that they consider the power of faith, hope, and mind. Their therapies should empower more than treat and they should refrain from labeling and predicting the future based upon labels as much as possible. I was struck by the strong parallels between the narrative movement and aboriginal thought, and suspect that this area of psychology may be most simpatico with aboriginal people and their needs.
If we believe these elders, perhaps mental health training should be modified. Perhaps we should emphasize learning how to listen without theory and teach theory-less interviewing and dialogical skills before we teach theory. We should increase our exposure of students to non-European or mainstream world views, to how other cultures see the world differently from their own, not as an object of study, but as a potentially equal point of view to the standard perspective (logical positivism) of conventional social science, psychology, and medicine. We should use community mentors, such as elders, from communities in which our students will work. They should be equal collaborators with adjunct faculty appointments. We should include more training on methods of work that involve communities and larger groups than just the individual. We should include more training on intuition, spirituality, and more exploration of our own motives, intent, and values.
While students must learn what is generally accepted by mainstream practitioners and licensing boards and they must be competent in the standard practices of their field, perhaps more humility is indicated in our convictions about “the truth”. Indigenous world views could be as valid as those of contemporary social and medical science. They may be more valid for those people who hold them. Including narrative perspectives could allow the student to be more flexible in moving through a broad range of world views and more able to work with world views that are not his or her own.
In the training program that resulted from this inquiry (http://groups.google.com/group/crossculturaltraining), we chose to include a community mentor (elder) throughout the training, to ask the student to begin learning the language of the culture in which he or she will work and to reflect upon the relationship of language and consciousness. We will teach classes on generating genuine cross-cultural dialogue, indigenous models of mind and mental health, traditional cultural healing, and indigenous-friendly therapies, as well as the more conventional courses required for licensure. Our outcome measure will be retention in ethnic, rural, and remote communities. Our graduates should have more staying power through gaining a genuine respect for the culture in which they will work and engaging members of that culture in mutually satisfactory ways.

Closing Story. In keeping with indigenous principles and methods, I wish to close, as suggested by one of the elders, with a story – this one from the Pima people of central Arizona (Mehl-Madrona, 1998). This was the story one of the elders first told me when I began our discussions. He simultaneously viewed contemporary psychotherapy as a foolish coyote who falls from the sky and indigenous healing for mind and mental health as a resilient coyote who comes back from the dead. Coyote is one of those traditions from the indigenous world, and he has much to say about mental health, though he often seems to have none. Coyote stirs us up and makes us laugh (first at him, later at ourselves when we realize we are acting just like him). Coyote keeps challenging all our assumptions, annoying and irritating us. He doesn’t accept anything on face value or “because authority says so.” When we think we have killed him off, we realize we miss him. The somber silence is overwhelming. We need levity. We ask for Coyote to come back, and discover that he has reappeared everywhere. This is indigenous knowledge. It can’t be suppressed. Whenever it is “killed”, like the Hydra, it reappears in greater quantity than before. In keeping with an indigenous approach to presenting this material, I tell the story this elder told me as his conclusion to our discussion. At the end, he told me that Coyote was the only true psychotherapist. (For more on coyote, see Mehl-Madrona, 2008b):

One evening Coyote came to listen to Buzzard tell a story about the time he flew to the Land Above. Buzzard told about flying up, flying way up into the clouds, higher than he had ever flow before, so high that he himself was terrified, until he came to an opening in the sky that looked like the mouth of a cave. Coyote was so excited, he couldn't help but interrupt. "Tell more," he would say. "Tell it faster, Brother Buzzard."
Buzzard snuck through the entrance and discovered a whole other world. There were people singing and dancing. There were animals and plants. He feared the hole in the sky would close up and he wouldn't be able to get back to his own kind. Coyote interrupted again, calling out in a most irritating voice, "Can you get back, Buzzard? You've got to take me there. You've got to show me this place." After the story ended, Coyote slinked up to Buzzard and begged to go with him to the Land Above. Buzzard didn't really want to take Coyote, but Coyote was so insistent that Buzzard could not say no.
Buzzard knew that coyotes love games of chance. He demanded that Coyote not play any of his games of chance with the Sky People. Coyote, on the other hand, figured that he would really clean up with the Sky People. They would not be familiar with his particular games, and he would have the expert's advantage. Buzzard and Coyote worked out a compromise on the gaming, and Buzzard prayed to the Wind to lift them up and carry them into the Land Above. Coyote clung tightly to Buzzard's back, shivering with fear at the great heights and trying not to look down. After a while, he could even open his shivering eyes.
When they arrived and Coyote climbed off his back, Buzzard admonished him to be back at the cave entrance by sunset. Buzzard needed the last bit of the sun's rays to carry them safely down. Coyote wasn't listening. He was preoccupied with what he was going to win from the Sky People. Coyote had a wonderful time. He tried to trick all the people in the sky with his games, but he had finally met his match. The Sky People had their own games of chance, which fascinated him so that he didn't notice time passing--until suddenly it was dark. He had missed the rendezvous! He was stuck in the sky.
Coyote ran lickety-split to the opening to the cave, but Buzzard had already left. He saw Buzzard's tracks leading to the opening and ending just at the point at which Buzzard would have jumped into the blue. Coyote looked down and couldn't even see the ground because it was so far down. Coyote did not want to live in the Sky. In his frenzy, he figured that his only course was to jump. Terrified as he was, he backed up and ran toward the opening. Three times he ran and three times he stopped short, panting with fear. On the fourth try he jumped. Two days later a big bag of bones hit the ground with a thud. It was Coyote finally landing on the ground.
Coyote's burial was prepared and his bones were placed on the hillside in the proper way in a sacred place. When the prayers and songs ended, the animals returned to their homes, sadly humming Coyote's last song. Complaining about Coyote's tricks had been fashionable, but no one wanted to be rid of that trickster. Someone has to challenge the rules that have no reason or meaning.
Little did the animals know that night would see the Great Spirit answer their prayers. Spirit took every piece of bone and spread it all over the earth. Every fragment of bone became a coyote. When the animals awoke in the morning, every distant hill had a little coyote howling at the moon, imploring it to stay awake. Next evening, every distant hill had a little coyote howling at the moon to come out and play....

References

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[1] Exceptions occur in highly Christianized communities in which the elders use Christian methods and principles of healing, sometimes more or less meshed with their former cultural practices. This is common in the North of Saskatchewan, where the first author spends one week per month.

Contemporary Psychiatry and Diagnostic Labeling

Here is a discussion that Barbara and I have been having on the Coyote Medicine discussion group. I liked it and thought it would fit nicely on this blog so others could potentially read it and join in.

She's responding to an article posted by Kirmaier et al, regarding Inuit Models of Mind and Mental Health which is available at http://groups.google.com/group/coyotemedicine.

I read this article when I was thinking, why not dissolve the idea of mental illness and go back to what seems to get pathologized or at least what it is in a person that makes other people think something needs to be done.

So I really responded to the different ways of describing an illness, the idea that illness is seen as "accidental, due to the breaking of taboos, soul loss and/or the action or intrusion of evil spirits" (p. 16) and the specific nature of the illnesses that's described in the next few pages. So, there is a sense of suffering, and there seem to be various elements to it - the person does or doesn't have awareness, the suffering is permanent or brief and transitional, the suffering mind has some thoughts or none at all (seeming). Treatments within the community ranged from none (e.g. acceptance of epilepsy that it was a moment of spirit bonding) to support and prayer (for sadness) to beating a person, if they were afflicted with "Quajimaillituq: "he does foolish things and does not know what he does" (a term also used for rabid dogs during the violent phase of their illness). In this state, individuals were hyperactive or agitated, with incoherent or disjointed speech, loose associations, paranoid suspicions and compulsive rituals. They avoided sleep, were aggressive, blasphemous and might harm self and others."

I notice that both "sad, troubled, quiet" and epilepsy are considered to have possibilities of some kind of transition to the divine in them (the former mostly for men).

Mostly, I wonder if we can bring something into western discussions of madness (the preferred term these days among my friends who disapprove of psychiatric categorization) by considering the way we pathologize states of consciousness by the way we ascribe meaning to them - e.g., we reduce the meaning of most states of consciousness to a kind of binary of, 'trouble for the rest of us' or 'not trouble for the rest of us' and then medicate accordingly. A friend of mine who was diagnosed a long time ago and went off medications in the 80s is now a professor (he teaches a 'history of madness' course - an initiative that is spreading to a few universities) bemoans the intolerance for someone who just needs to withdraw for a while,for example, and suggests also that there be a mad voice at every table to provide the 'mad' perspective (another old anti-psychiatry activist I know is working to revise our conception of what hearing voices means). People I know who suffer want the relief of medications, regardless of what they suppress or toxify, and it seems arrogant of me to expect that they 'should' undergo a personal journey that could be really hard because I believe that Gaia would like it better and could benefit from the multiplicity of voices (maybe suppression of the 'mad' thoughts detracts from the beauty of the collective consciousness - but I don't want to sentimentalize mental illness). I'm making a documentary essay film to puzzle through all this.

Barbara

Also I was struck by the notion of treatment specific to the meaning of the illness. Is it fair to say we treat the social condition of 'annoying to us' rather than find healing ideas that might actually work for the troubling condition? E.G. 'needs to eat the food of home' works as it treats the illness, but is way to simple for the likes of us, I suspect. Lewis, I think you once said that to properly heal you need to expect that you will be able to heal, and that some medicine doesn't seem to carry that expectation. I think this article speaks to that idea. Barbara And I know the DSM officially requires distress to the sufferer, but I can't help feeling that the sufferer might feel a lot less distress if we were more accommodating.

Lewis MehlMadrona

Dear Barbara.
I agree. It appears to me that all cultures define pain and suffering though not all define mind or mental health or even health at all. I suspect we should revert to the position that healers exist to help with the reduction of pain and suffering and that all cultures have individuals who perform those functions. Do you know any cultures that do not have such roles for people to assume.

When these roles are institutionalized, the problems begin. My sense is that the healer role has been corrupted by contemporary global modernist cultures into a different role than indigenous societies intended. The current role is more expert-salesperosn than healer. I turn to Foucault for illumination on this. His perspective that current events can best be understand from the history of how they came about -- a sort of archaeology as it were, makes sense to me. Foucault talks about knowledge production enterprises which encompasses Medicine. Medicine produces products and experts, both of which need consumers. Foucault's perspective that the labeling and isolation of madness arose with th petite bourgeoisie because a consciousness of the need for appearances arose and wherever you go, there are people who annoy and irritate others. These people are dealt with when the annoyance and irritation becomes sufficiently great, as in the Inuit paper when they beat someone who is agitated (having the desired effect of the person calming down). Before pharmaceuticals, exclusion was sufficient, a kind of quarantine approach to the annoying and the irritating. Then a brainstorm occurred. A profession of experts could be created to ride herd over these individuals -- shepherds if you will. These shepherds came to be called psychiatrists eventually. Naturally these shepherds had to do what they could to consolidate their position as experts and to increase their status in the eyes of other experts and other knowledge systems. They had to dominate the various available knowledge systems. So this is what I see today -- psychiatrists have found ways to dominate all other theories and have relied upon what they uniquely (at least in the past) could do, which is prescribe drugs. It works for the pharmaceutical industry which is a self-fulfilling prophecy of promising drugs to ease all pain and suffering and using its power and money to infect the public with the "better living through chemistry" story. So people demand "better living through chemistry" and now the "expert-salespeople" try to accomodate them.

I see that what some of us are trying to do is to hold onto another vision of healing -- an indigenous vision that re-posits the healer as a role separate from the knowledge-expert system of psychiatry and independent of the pharmaceutical industry, which psychiatry is not. We must, I believe, keep separate the conversation about biology and mind and brain from the expert-knowledge system that is called psychiatry. For me, we all have brains and brains are shaped and maintained in their present configurations by environment, past and present. We can believe in brain without believing that drugs are the only ways to change brains. Social interaction, I believe, changes brains more powerfully than chemistry.

My conclusion is that we are minority voices, stories that need to be told and maintained for the good of society, because diversity is important. We need biodiversity to enhance survival potential. I suspect that the story that modern global psychiatry tells is unsustainable. The costs are too high for the planet to maintain. The social interactionist story, as in the WHO studies of schizophrenia, or the psychosis projects of Altoonen, Burke, Laing, Mosher, Perry, etc. are more sustainable. Humans helping humans is less profitable overall but more affordable in the long term. People need meaning and jobs more than pharmaceutical company stockholders need dividends and more than psychiatry experts need status and power. However, the economy will have to get much worse before than becomes a trend. Perhaps the third world countries are lucky in this regard.

That's why I started these discussion groups and my other collaborative online projects (see My Projects at http://mehlmadrona.mysite.com). Because we minority voices (post-modern, semi-urban, neo-shamanic healers) need each other to keep a little toe hold in the world. We are as annoying and irrtating to the mainstream as are "the mad" to the petite bourgeoisie. So we must keep telling each other our stories and hold each others hands in an unbroken circle and keep doing our projects and demonstrating that our stories also work (though I am very unimpressed with the pharmacological story for suffering in that it rarely works without creating as much suffering in the form of side effects as it purports to relieve; and I admit exceptions, like a couple of people I see who were very paranoid and were helped by risperidone and quetiapine, respectively, to suffer less. Interestingly, they had no side effects. I suspect that enveloping them in a loving human community, the ultimate holding environment, would have worked better. But it just wasn't available. And this is the most interesting aspect to me about the knowledge-expert system of psychiatry, that it aims to become unemotional. That it promotes a kind of social aim to make love and community and emotion bad or disturbing. I suspect this is so because people consume more if they are isolated and unfeeling and disconnected. I suspect that it's in the service of global capitalism. Certainly, the modern "psychotherapies" lack soul -- like CBT or IPT, and are proud of their lack of soul or warmth or humor or love or connectedness (though I know people who do CBT who demonstrate all these qualities, so my argument is about the "official" presentation of the technique rather than what people actually do, since I actually use all the CBT "techniques" and have for years without calling them CBT.). Enough for now.

This has been the start of a good discussion and I hope others join us.

Lewis