Working with Native American Patients & Clients - The 3 C's

On April 15, 2016, Dr. Antony Stately (Ojibwe) and Jennifer Waltman (Lakota), a doctorate of psychology student, presented at the MPA Annual Convention on Working With Native American Patients & Clients. The presentation addressed the 3 C’s of integrating Indigenous consideration into your practice:  Context (Understanding the story); Comfort (Building it); Communication (Tools & Techniques for Indigenous relationship building). A recap of the presentation is provided below applying information from both research and applied experience working in the community and intended for generalization.

Context. Understanding historical trauma (HT) for Native Americans is key to conceptualizing the significant stigma related to issues of mental health and the greatest health disparity in Minnesota.  Native Americans commonly use humor to disguise trauma. Humor conversely provides strength to explore distress that may contribute to misdiagnosis and confusion for many non-Native healthcare providers. 

HT is the collective and cumulative emotional wounding across generations that results from cataclysmic events affecting a community.1 The wounding is held individually and collectively within the community and generationally transmitted.2 A wide body of research provides evidence that even family members who have not directly experienced the trauma can feel the effects of the event generations later.3 Only recently has the mental health field focused on the impact of intergenerational transmission of trauma on the individual.4 The reactions from general society towards survivors of substantial trauma have a significant impact on their health and wellness and their ability to integrate their traumatic experiences.5

Contextualizing Native American history through a population health lens might bridge growing discrepancies in mental health needs.  Many Native patients that report experiencing HT encounter a pervasive societal reaction that includes: indifference, disbelief, avoidance, repression, and denial of their community’s historical experiences.6 Native patients sometimes experience increased sensitivity to stressful events that act as reminders of a colonized status that predispose them to heightened trauma responses and symptoms.7

Healthcare providers working with Native American patients often report feeling overwhelmed by the diversity within Indian Country (over 566 Federally Recognized Tribes), limited understanding of Sovereignty, Tribal Law, and issues of Self Determination.8 Contextualizing HT with Native patients can be simplified to seven phases to improve comfort and communication with all patients.9

  1.  Phase 1: Manifest Destiny (1492-1776)
     Colonization: introduction of disease and alcohol
  2.  Phase 2: Economic Competition (ongoing)
    Sustenance loss of physical and spiritual world; continues in contemporary issues, most recent economic policy in gaming and cannabis farming on Sovereign land with some Tribal communities with more than 80% unemployment and Standing Rock Sioux in current fight against oil pipeline in rural North Dakota.
  3. Phase 3: Invasion/War Period
    Extermination and genocide (Largest mass hanging in US History – Mankato, Minnesota 38 Santee, 1862 – President Lincoln had ordered the execution of 303 Native American men by public lynching; Wounded Knee Massacre, 1890).
  4. Phase 4: Reservation Period: (1887-1943)
    Confined and relocated, forced dependency on the oppressor, lack of security. Tribes were effectively stripped of self-determination.
  5. Phase 5: Forced Boarding School Period: (1880-1930s - continued)
    Thousands of children were forcefully removed from their families and placed in Christian boarding schools.  The children were forced to learn English, cut their hair, and not allowed to practice traditional ways. This phase destroyed the traditional family system; children returned as young adults having experienced years of beatings and rape.
  6. Phase 6: Relocation and Termination Period: (1950s and 1960s)
    Native people were moved from reservations to urban areas such as Los Angeles, San Francisco, New York City, Minneapolis, Chicago, etc.  People moved into areas of extreme racism and viewed as second class with a loss of governmental system and community.  Promises of economic opportunity never delivered; it was experienced as another example of broken treaties.
  7. Phase 7: Child Welfare Policies: (Through the late 1970s)
    A significant number of Native children were removed from their homes and placed in non-Native adoptive or foster homes.  Federally funded studies in the early 70s showed that in the states with the largest Native populations, between 25% and 35% of all Native children had been removed from their homes.

Comfort.  Non-Native providers are invited and needed to work with Native American patients.  Native patients report comfort working with non-Natives when they have a contextual understanding of their history and experience in this society.10 Thomason’s research determined that Native clients felt more welcomed when offered water, coffee, or tea.  Intake paperwork should be minimized before a face-to-face meeting. Practitioners might consider talking a little about their background and use self-disclosure to encourage clients to talk about themselves. Ask clients about their tribe and their understanding of their problem. Native patients report stronger therapeutic alliances when therapists have shown an interest to understand clients’ tribal identification, acculturation type, and how culture plays a role in their lives.5

Communication.  When working with Native patients, consider the simple application of common factors. Research determined that building rapport and alliance are more important than technique or theory; this is consistent with Native patients with minor nuance.10 According to the work of Trimble, providers should listen respectfully. Be careful not to interrupt when clients are speaking and answering questions, be patient! Avoid excessive emphasis on getting answers to standard intake interviews. An interesting difference, Native participants in Trimble’s study were unequivocal that non-Native providers get involved in the local community and learn as much as possible about the local tribes (or urban community). Native participants believed that cultural competence is not something learned in school or by reading. Instead, they suggest that providers should meet Native people, find a Native mentor, and spend time in the community. When asked, Native clients endorse the importance of incorporating Native American spirituality into therapy.8 Thomason’s research was careful to clarify that most Native patients believe that non-Native providers should not attempt to use tribal spiritual or healing methods or ceremonies in treatment.

In summary, an Indigenous approach to relationship building of provider and the Native patient can be integrated into your practice with applied Context (HT); Comfort (consider the Native patient experience); and Communication (listen with applied evidence gathered from Native research participants).  Our field can bridge the disparity and eliminate mental health stigma!

Jennifer A. Waltman is in the Counseling Psychology (Psy.D.) Program at Saint Mary’s University of Minnesota and a Pre-Doctoral Behavioral Health Intern with Hennepin County- NorthPoint Health and Wellness Center.  She had the privilege to clinically train with the Shakopee Mdewakanton Sioux Community; Allina Mental Health Outpatient Clinic and Abbott Northwestern Hospital; Clinic for Attention Learning and Memory (CALM), and The Meadows inpatient treatment center for trauma, addiction and co-occurring disorders located in Wickenburg, Arizona.  As a student of Dr. Robin McLeod, she is inspired to get involved and to use her voice and be heard. 


  1. Brave Heart, M. Y. H., Chase, J., Elkins, J., & Altschul, D. B. (2011). Historical trauma among indigenous peoples of the Americas: Concepts, research, and clinical considerations. Journal of psychoactive drugs, 43(4), 282-290.
  1. Danieli, Y. (1998). International handbook of multigenerational legacies of trauma. Springer Science & Business Media.
  1. Mohatt, N. V., Thompson, A. B., Thai, N. D., & Tebes, J. K. (2014). Historical trauma as public narrative: A conceptual review of how history impacts present-day health. Social Science & Medicine, 106, 128-136.
  1. Walters, K. L., & Simoni, J. M. (2002). Reconceptualizing Native women's health: An “indigenist” stress-coping model. American Journal of Public Health, 92(4), 520-524.
  1. Gachupin, F. C., & Joe, J. R. (2012). Health and social issues of Native American women. Santa Barbara, Calif: Praeger.
  1. Heart, M. Y. H. B., & Deschenie, T. (2006). Historical Trauma and Post-Colonial Stress in American Indian Populations. Tribal College, 17(3), 24.
  1. Heart, B., & Horse, M. Y. (2000). Wakiksuyapi: Carrying the historical trauma of the Lakota. Tulane Studies in Social Welfare, 21(22), 245-266.
  1. Thomason, T. (2012). Recommendations for counseling Native Americans: Results of a survey. Journal of Indigenous Research, 1(2), 4.
  1. Sotero, M. (2006). A conceptual model of historical trauma: Implications for public health practice and research. Journal of Health Disparities Research and Practice, 1(1), 93-108.
  1. Trimble, J. E. (2010). The virtues of cultural resonance, competence, and relational collaboration with Native American Indian communities: A synthesis of the counseling and psychotherapy literature. Counseling Psychologist, 38(2), 243- 256. 
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