Traditional Healing Concepts and Psychiatry: Collaboration and Integration in Psychiatric Practice by Dr. Jay Shore
Psychiatric Times
June 30, 2015 | Special Reports, Cultural Psychiatry
Although psychiatry brings tremendous value to the amelioration and treatment of mental distress and illness, at times it falls short in providing holistic care within a patient’s broader cultural framework. Traditional healing and medicine often offer a more comprehensive, patient-centered approach to mental health treatment, which can encompass a patient’s spiritual beliefs, cosmology, and world view. For certain patients, a combination of Western psychiatric treatment and traditional healing has significant potential to alleviate symptoms within the context of physical health, spiritual life, and social milieu. In some traditions, mental health is particularly relevant, cross-cutting various conceptualizations of symptoms and illnesses. Based on our experience, we share a model for psychiatrists interested in collaborating with traditional healing and medicine.
Our focus is on traditional medicine arising from a country’s indigenous cultures. We spotlight specific examples of North American indigenous healing traditions that figure importantly in our clinical and program experience with rural Native American veterans. Our purpose is to illustrate the possible synergies that promise greater benefit for these patients than either practice pursued independently.
The use of traditional medicine is found in cultures throughout the world, and it is often encountered by US psychiatrists working with immigrant and refugee populations. Incayawar and colleagues1 provide a number of specific examples of other cultures and conceptual models of collaboration between psychiatrist and traditional healers.
Traditional healing and mental health
The literature pertaining to traditional healing practices in mental health is largely descriptive and therefore is limited in its rigor by today’s scientific standards.1 Indeed, there is an active debate as to whether current Western scientific methods are appropriate for examining the nature, processes, and outcomes of traditional healing. Part of this debate revolves around a historical monopoly of the study of traditional healing by Western, nonindigenous researchers whose views typically lie outside the cultural perspectives that inform a particular healing tradition.2
The description of indigenous healing traditions in North America dates to the 1500s, when early European settlers began co-opting and adapting treatments with Native American traditional healing.3 The earliest reports from “modern” psychiatry date to the 1940s and are best illustrated by the Leightons’4 work on psychotherapeutic aspects of the Navajo religion. Since the 1940s, a rich body of literature augmented by more recent epidemiological research began to document the importance of concurrent use of biomedical and traditional healing among Native Americans across a diverse range of tribes.1,5-7 Gone8 described parallel therapeutic processes and the possibility of integrating Native American concepts and healing traditions into psychotherapy.
Several major themes have emerged. Among them are the importance of concurrent, rather than mutually exclusive, pursuit of biomedical and traditional healing, and the feasibility as well as benefit of combining these approaches as treatment for Native American patients.9 However, this literature is largely silent with respect to how clinicians can address these issues in their individual practices and programs.
Incorporating traditional healing in practice
The Table presents our model for incorporating traditional healing in psychiatric practice; 5 key components influence the successful inclusion of traditional healing:
• The psychiatrist
• The patient
• The Western system of care in which treatment takes place
• The traditional healing in the context of the community
• The traditional healer/practitioner
For each of these components, we identify factors that can either facilitate or impede therapeutic implementation. By highlighting these factors, we hope to provide guidance on how to incorporate traditional healing in the clinical setting to maximize the likelihood of successful patient engagement. Our experience has shown that many of the impeding factors can be minimized if clinicians are able to identify them and develop plans to overcome these barriers.
The psychiatrist
Openness toward and a desire to use traditional healing are perhaps the most important qualities for a psychiatrist to embrace in order to move with comfort between different frameworks for disease, illness, and healing. The psychiatrist must commit to becoming a “serious student” of the specific healing tradition and culture within which he or she hopes to work.9 Moreover, he must understand the need to collaborate with cultural facilitators as needed. Specific recommendations are presented in the Figure.
While the psychiatrist is encouraged to pursue all of these activities, the most valuable may be identifying and working with mentors who represent the healing tradition of interest and with psychiatric colleagues who have experience working with traditional healers. Our VA programs support two types of cultural facilitators: employees referred to as tribal/telehealth outreach workers (TOWs) and volunteers who are tribal veterans’ representatives (TVRs). TOWs and TVRs are most often veterans as well as members of the specific community in which they work. Each engages community members in the treatment system and educates health care professionals about key aspects of the local context critical to therapeutic process and patient outcomes.10,11
The patient
It is important to recognize whom to appropriately engage in dialogue about traditional healing and its personal relevance. The Table lists general patient characteristics that suggest a potential place for traditional healing in the process of care. The psychiatrist performs a detailed cultural history as well as a general history of the patient, with general components as outlined by the DSM-5 cultural formulation. The cultural history consists of information on native language, cultural background, spiritual views, and personal religious history. The general history includes cultural beliefs surrounding healing, mental health, and medical illness, as well as any past experience with traditional healing. Ultimately, the patient decides whether to engage a traditional healer in the treatment process.
The psychiatrist provides education, links to information, and referral to local options, but he does not prescribe traditional treatments or practices. It is appropriate to discuss the risks and benefits of traditional treatment in the context of other medical illnesses. For example, a patient with depression, diabetes, and cardiovascular disease who wishes to participate in a Northern Plains Sweat Lodge Ceremony should be informed of the potential impact on health resulting from dehydration and fasting. In such cases, the patient should be encouraged to discuss this type of ceremony with his primary care physician and the Sweat Lodge leader so that he can anticipate and minimize the potential medical risks.12 Once it is determined that the patient is seeking traditional healing, the patient and psychiatrist embark on a sustained dialogue about the perceived effects of the treatment.
Western system of care
One of the most important factors for psychiatrists who work for a health care system is knowing how their system regards traditional healing—namely, whether there is formal acknowledgment, policies, and structures in place to support collaboration with traditional healers. An example of such a formal system endorsement can be found in the Indian Health Service, which for several decades has endorsed and provided guidance for mental health professionals who work with traditional healers.13
In some instances, patients might request the involvement of traditional healing in a hospital or clinic setting. This works best when the health care system has processes in place to guide the collaboration. The first step is that a dialogue takes place between the Western medical treatment team and the traditional healer(s) about roles, treatment processes of the two systems, and pathways of communication regarding patient care.
Traditional practice
Clinicians who actively endorse both Western medicine and traditional healing can initiate conversations with patients on these issues and can help develop respectful, appropriate lines of communication with local traditional healers. A willingness on the part of traditional healers to involve non-community members in traditional healing—as observers, consultants, or even collaborators—is strongly related to the historical relationships that are part of the cultural identity of the principals and deeply affect whether special, often protected, knowledge is shared.
In addition to the factors noted above, traditional healers will vary in their interest and willingness to collaborate with Western practitioners. Respectful, authentic inquiries by the latter, in an effort to meet the needs of their patients, often are well received. Although constrained by local protocols regarding disclosure and protection of special knowledge, many traditional healers welcome the opportunity to educate patients and Western practitioners about their healing traditions and treatments.
Special considerations: psychiatrist as traditional practitioner
Some psychiatrists may be familiar with or acquire training in a specific technique or intervention (the roots of which spring from local healing traditions) that can pose special challenges. A psychiatrist actively engaged in traditional healing practices should be well versed in such practices, exquisitely sensitive to determining when they are appropriate, and openly endorsed by the community. The psychiatrist must be clear about patient informed consent for treatment as well as the conceptual model guiding his therapeutic efforts and recommendations. Awareness of potential ethical issues that can arise when providing traditional treatment, including dual roles, boundaries, and providing spiritual treatments to patients, is essential, as is consultation with colleagues who are well versed in both the Western and the traditional systems.