Indigenous Knowledge Approach to Successful Psychotherapies with Aboriginal Suicide Attempters.

INTRODUCTION: Suicide is disproportionately common among Aboriginal people in Canada. METHODS: Life stories were collected from 54 Aboriginal suicide attempters in northern Saskatchewan. Constant comparison techniques and modified grounded theory identified common themes expressed. RESULTS: Three common plots/themes preceded suicide attempts: 1) relationship breakup, usually sudden, unanticipated, involving a third person; 2) being publicly humiliated by another person(s), accompanied by high levels of shame; and 3) high levels of unremitting, chronic life stress (including poverty) with relative isolation. We found 5 common purposes for suicide attempts: 1) to "show" someone how badly they had hurt the attempter, 2) to stop the pain, 3) to save face in a difficult social situation, 4) to get revenge, and 5) don't know/don't remember/made sense at the time, all stated by people who were under the influence of alcohol and/or drugs at the time of their suicide attempt. We found 5 common beliefs about death: 1) you just cease to exist, and everything just disappears; 2) you go into the spirit world and can see and hear everything that is happening in this world; 3) you go to heaven or hell; 4) you go to a better place; and 5) don't know/didn't think about it. DISCUSSION: The idea of personal and cultural continuity is essential to understanding suicide among First Nations youth. Interventions targeted to the individual's beliefs about death, purpose for suicide, and consistent with the life story (plot) in which they find themselves may be more successful than one-size-fits-all programs developed outside of aboriginal communities.

Epistemological Flexibility in Person-Centered Care: The Cynefin Framework for (Re)Integrating Indigenous Body Representations in Manual Therapy.

BACKGROUND: Chiropractic, osteopathy, and physiotherapy (COP) professionals regulated outside the United States traditionally incorporate hands-on procedures aligned with their historical principles to guide patient care. However, some authors in COP research advocate a pan-professional, evidence-informed, patient-centered approach to musculoskeletal care, emphasizing hands-off management of patients through education and exercise therapy. The extent to which non-Western sociocultural beliefs about body representations in health and disease, including Indigenous beliefs, could influence the patient-practitioner dyad and affect the interpretation of pillars of evidence-informed practice, such as patient-centered care and patient expectations, remains unknown. METHODS: our perspective paper combines the best available evidence with expert insights and unique viewpoints to address gaps in the scientific literature and inform an interdisciplinary readership. RESULTS: A COP pan-professional approach tends to marginalize approaches, such as prevention-oriented clinical scenarios traditionally advocated by osteopathic practitioners for patients with non-Western sociocultural health assumptions. The Cynefin framework was introduced as a decision-making tool to aid clinicians in managing complex clinical scenarios and promoting evidence-informed, patient-centered, and culturally sensitive care. CONCLUSION: Epistemological flexibility is historically rooted in osteopathic care, due to his Indigenous roots. It is imperative to reintroduce conceptual and operative clinical frameworks that better address contemporary health needs, promote inclusion and equality in healthcare, and enhance the quality of manual therapy services beyond COP's Western-centered perspective.

From benzos to berries: treatment offered at an Aboriginal youth solvent abuse treatment centre relays the importance of culture.

First Nations and Inuit youth who abuse solvents are one of the most highly stigmatized substance-abusing groups in Canada. Drawing on a residential treatment response that is grounded in a culture-based model of resiliency, this article discusses the cultural implications for psychiatry's individualized approach to treating mental disorders. A systematic review of articles published in The Canadian Journal of Psychiatry during the past decade, augmented with a review of Canadian and international literature, revealed a gap in understanding and practice between Western psychiatric disorder-based and Aboriginal culture-based approaches to treatment and healing from substance abuse and mental disorders. Differing conceptualizations of mental health and substance abuse are discussed from Western psychiatric and Aboriginal worldviews, with a focus on connection to self, community, and political context. Applying an Aboriginal method of knowledge translation-storytelling-experiences from front-line workers in a youth solvent abuse treatment centre relay the difficulties with applying Western responses to Aboriginal healing. This lends to a discussion of how psychiatry can capitalize on the growing debate regarding the role of culture in the treatment of Aboriginal youth who abuse solvents. There is significant need for culturally competent psychiatric research specific to diagnosing and treating First Nations and Inuit youth who abuse substances, including solvents. Such understanding for front-line psychiatrists is necessary to improve practice. A health promotion perspective may be a valuable beginning point for attaining this understanding, as it situates psychiatry's approach to treating mental disorders within the etiology for Aboriginal Peoples.

Effects of a Life Story Interview on the Physician-Patient Relationship with Chronic Pain Patients in a Primary Care Setting.

Introduction: Within family medicine it is generally accepted that the more we know about patients' lives, the better the care we provide. Few studies have sought to quantify this historical assumption. We wondered if knowing their chronic pain, patients' life stories would improve the physician-patient relationship in a family medicine residency training program clinic. Methods: We selected patients in chronic pain with depression and/or anxiety who were considered difficult. After a lead in period to establish stability of ratings, we obtained a life story interview for 125 such patients after administering the doctor-patient relationship questionnaire to them and their physicians. Patients completed the McGill Pain Inventory (MPQ), the Zung Anxiety Inventory, and the Center for Epidemiological Studies Depression Scale. Physicians completed the Jefferson Physicians Empathy Scale. Questionnaires were repeated every 4 months. Results: The quality of the physician-patient relationship increased significantly over the course of the year for patients (increase of 0.60, standard deviation [SD] = 0.13, 95% confidence interval [CI] = 0.57 to 0.63, p < 0.001) and for doctors (increase of 0.77, SD = 0.20, 95% CI = 0.72 to 0.81, p < 0.001). The perceived level of pain on the MPQ decreased significantly on the sensory component (71.2 ± 7.6 to 11.7 + 9.4, 95% CI = 0.589 to 9.411, p = 0.0270 and the affective component (4.2 + 3.4 to 2.1 + 4.3, 95% CI = 0.131 to 4.069, p = 0.037). Anxiety and depression ratings did not change. Physicians' empathy ratings increased significantly over the course of the year from a mean of 117.2 (SD = 10.2) to 125.1 (SD = 16.1) for a difference of 7.90, which was significant at p = 0.0273 with a 95% CI of -14.85 to -0.915. Discussion: Knowing the patient's life story improves the physician-patient relationship for both patients and physicians. When the physician-patient relationship improves, the perceived level of pain decreases. Physicians' empathy ratings increase. While the interview requires 90-120 min, it is billable, and can be done by medical students, medical assistants, social workers, or behavioral health. Conclusions: Obtaining life stories of chronic pain patients is a cost-effective way to reduce pain while simultaneously improving the physician-patient relationship and increasing physician empathy.

Narrative Approaches to North American Indigenous People Who Attempt Suicide.

INTRODUCTION: Suicide is a major problem within North America's indigenous communities. There is debate about the best way to approach indigenous people who have attempted suicide. Conventional methods of cognitive behavior therapy have been criticized for not being indigenous friendly. METHODS: Case files from an academically affiliated, rural psychiatric practice focused primarily on indigenous patients were reviewed for 54 indigenous patients who attempted suicide. Grounded theory methods were used to identify common strategies for approaching those patients who were able to stop attempting suicide. A comparison population had a greater than 90% incidence of a second attempt. RESULTS: Nine major strategies within a narrative approach that appeared to be successful with this population were identified. Introducing novel contradictory ideas to the beliefs people held about suicide appeared helpful. Using stories to introduce the idea that the desired effects of suicide might not be forthcoming seemed beneficial, including the use of story to find means other than attempting suicide to reach the same ends. Creating stories of a positive future appeared helpful. Finding ways to bring humor into the discussion and to refer to and involve traditional culture in which suicide was rare aided in changing perspective. Of 29 patients engaged in this narrative approach, 26 had no further suicide attempt. Retention in counseling was high, and patients reported enjoying the process. CONCLUSION: A narrative approach to indigenous people who attempt suicide is compatible with indigenous culture and appears to be successful.

An Ultra-Brief Mindfulness-Based Intervention for Patients in Treatment for Opioid Addiction with Buprenorphine: A Primary Care Feasibility Pilot Study.

Objectives: To demonstrate the feasibility and acceptability of a brief mindfulness-based intervention taught by physicians for patients with opioid addiction and to determine if the intervention reduces likelihood of relapse or treatment failure within 6 months. Design: A prospective, feasibility, single-group, cohort pilot study. Setting: A Family Medicine teaching clinic serving a mixed urban and rural population in Bangor, Maine. Subjects: Adult patients initiating outpatient treatment for opioid addiction with buprenorphine (N = 40). Interventions: Study physicians conducted a 10- to 12-min education session for all patients starting treatment during the enrollment period, including a 5-min mindfulness exercise. Enrolled subjects received an MP3 player loaded with six mindfulness audio exercises (5-19 min) and were instructed to practice at least 5 min daily and record their practice in a logbook. Outcome measures: Acceptability and subjective usefulness to recovery were evaluated at 2, 4, and 6 months of follow-up, with qualitative analysis of themes in recorded poststudy interviews. Logbook entries and tablet-based surveys provided data on home mindfulness practice, classified as "high" or "low." Relapse or treatment failure was documented. Results: Feasibility and acceptability were demonstrated with 82% enrollment and 100%, 97%, and 90% completion of follow-up visits at 2, 4, and 6 months, respectively, among those still in treatment. Sustained positive impressions of the intervention and exercises remained at 6 months. Relapse or treatment failure was reduced in the "high" practice uptake group compared with "low" practice uptake (11% vs. 42%, p = 0.033). Conclusions: In contrast to more intensive 8-week models of meditation training, this study demonstrates that even a brief single training session can induce sustained home meditation practice that subjectively helped patients in recovery for opioid addiction and was associated with lower risk of relapse. Brief mindfulness-based interventions may be useful to increase access to mindfulness training in this population.

What traditional indigenous elders say about cross-cultural mental health training.

Although a number of authors have commented on what mental health practitioners should be taught to be effective and appropriate with indigenous people, rarely have traditional healers been asked for their views. This paper explores what a diverse group of traditional healing elders believe are the important attributes for mental health providers to embrace and what principles they should adopt to guide their training. How indigenous people understand the meaning of mental health is also examined. The research presented was conducted in preparation for developing a cross-cultural training program for human service providers that would include traditional elders as community mentors and adjunct faculty on equal status with academically trained faculty. The goal is to identify and summarize the core values and principles needed to train mental health providers to work in harmony with traditional healers. The term indigenous used in this paper refers to people who have lived in a place long enough to develop local knowledge and practices about that place, even though they might not have been the original inhabitants. For example, the Dene in Arizona are indigenous even though they have only occupied that area from about 1100 ad. Last, the paper is presented in an indigenous way, first by situating the author, telling a story, explaining the methodology, describing the elders and what they said, and ending with a story to dramatize the conclusions as indigenous elders would do.

Prevalence of psychiatric diagnoses among frequent users of rural emergency medical services.

OBJECTIVE: This study aimed to determine whether there was an increased prevalence of psychiatric disorders among frequent users of rural emergency medical services. METHODS: In a matched comparison design, I compared frequent users of the emergency departments of 2 rural hospitals, both affiliated with an academic centre, with randomly selected users and with randomly selected users who had the same medical diagnoses. The main outcome measures were psychiatric diagnoses on a structured clinical interview, along with medical diagnoses and number of emergency department visits in the past year. RESULTS: Ninety-three percent of frequent users had at least 1 DSM-IV psychiatric diagnosis, differing from 50% of random users matched for presenting complaint. A random user group, not matched for presenting complaint, showed 28% prevalence of DSM-IV diagnoses. Frequent users were more often state insured (Medicaid) and less often insured privately. The most common diagnoses among frequent users were major depression, generalized anxiety disorder, adjustment disorder, somatoform pain disorder, substance abuse and dependence, and dysthymia. The treating emergency department physician mentioned a psychiatric diagnosis for only 9% of frequent users. CONCLUSION: Frequent users have a disproportionately high prevalence of psychiatric disorders (under-documented by their physicians), which may affect their pattern of emergency department use. This suggests the need for better recognition, diversion, and management.

A Patient-Centered Approach to a Rural General Practice in Distress and the Search for a Solution.

CONTEXT: A general practice in rural UK (Cumbria) was overwhelmed by staff burnout. OBJECTIVE: To present a case study for how the staff of a practice came together, used data, agreed on a plan for improvement, implemented the plan, improved subjective distress, and objectively evaluated the intervention. DESIGN: We conducted an audit using the electronic health record for patients coming to the practice 5 or more times annually from 2008 to 2012 (frequent attenders). We planned an intervention to reduce utilization (frequency of visits) while still serving patients. The intervention used a genogram, psychoeducation, and up to six 30-minute sessions of solutions-focused psychotherapy, in which difficult interpersonal relationships were identified and efforts were made to resolve 1 major problem related to those relationships. MAIN OUTCOME MEASURES: Quantitative data (number of visits per year) and qualitative data about the changes that resulted in the practice from the audit and the intervention. RESULTS: The frequency of visits for patients with mental health conditions (41.0% of all frequent attenders in the practice) dropped significantly from 2007 to 2012 (p = 0.019; initial visits per year, 10.0, standard deviation = 2.51; final visits per year = 5.6, standard deviation = 3.8). The frequency of visits for patients without mental health diagnoses did not change. CONCLUSION: Intervening with frequent attenders of primary care who have mental health conditions improved their symptoms and reduced their health care utilization, with beneficial impact on practitioners and improvement in the morale of the staff.

The impact of acupuncture and craniosacral therapy interventions on clinical outcomes in adults with asthma.

OBJECTIVE: Synergy has been proposed between modalities operating at different levels of action. Acupuncture and craniosacral therapy are two very different modalities for which synergy has been proposed. This study sought to test for such synergy and to determine if complementary therapies would improve pulmonary function and quality of life for people suffering from asthma, as well as reducing anxiety, depression, and medication usage. DESIGN: Subjects were randomly assignment to one of five groups: acupuncture, craniosacral therapy, acupuncture and craniosacral, attention control, and waiting list control. METHODS: Subjects received 12 sessions of equal length with pretreatment and posttreatment assessment of pulmonary function, asthma quality of life, depression, and anxiety. Medication use was also assessed. RESULTS: Synergy was not demonstrated. When treatment was compared with the control group, statistically treatment was significantly better than the control group in improving asthma quality of life, whereas reducing medication use with pulmonary function test results remained the same. However, the combination of acupuncture and craniosacral treatment was not superior to each therapy alone. In fact, although all active patients received 12 treatment sessions, those who received all treatments from one practitioner had statistically significant reductions in anxiety when compared with those receiving the same number of treatments from multiple practitioners. No effects on depression were found. CONCLUSIONS: Acupuncture and/or craniosacral therapy are potentially useful adjuncts to the conventional care of adults with asthma, but the combination of the two does not provide additional benefit over each therapy alone.

Collaborative Management of Neurocognitive Disorders in Primary Care: Explorations of an Attempt at Culture Change.

INTRODUCTION: Minor neurocognitive disorder (MiND; previously mild cognitive impairment) is a transitional zone between normal cognitive function and early stages of major neurocognitive disorder (previously called dementia). Of people with MiND, 5% to 10% progress to major neurocognitive disorder. Simple interventions such as memory activities, balance exercises, and anti-inflammatory diets have been shown to improve cognitive ability. Also, education and support in group settings have proved beneficial for patients with MiND. DESIGN: Survey evaluation of outcomes of geriatric consultation and prospective educational study. MAIN OUTCOME MEASURES: We collaborated with an academic training program to introduce into primary care the ideas of educational activities and participation in group medical care for people with MiND. Educational programs were developed and presented to family medicine residents and practicing physicians, and their knowledge was assessed before and after education. RESULTS: Two group programs were implemented: one at our hospital and one at a local skilled nursing facility. These were initially envisioned as time-limited, but participants insisted on their continuance. Thirty-two different patients attended the groups for at least six sessions. Participants enthusiastically reported positive change on qualitative interviews and showed improvement in cognition, balance, and self-esteem. Family medicine residents and practicing physicians both shifted toward lifestyle medicine and significantly changed their views on the efficacy of treatments. Despite these activities, community physicians making referrals for geriatric consultations did not change their discussions with patients and families about exercise, diet, cognitive enhancement, and socialization for MiND. CONCLUSION: Group visits that emphasized support for increased exercise, improved diet, more movement and balance, and cognitive enhancement appear to please and benefit patients with MiND. Physicians are more open to these approaches with training after initial skepticism. A struggle exists to convince the profession that lifestyle change may be beneficial in MiND.

Adjunctive Treatment of Psychotic Disorders with Micronutrients.

OBJECTIVE: To evaluate the effect of micronutrients (minerals and vitamins) on adult psychosis when added to conventional medications by using a placebo-controlled randomized design with a 1-month open-label run-in. DESIGN: Longitudinal comparison study following a randomized, controlled trial that had failed because participants declined to undergo randomization. Setting/Locations: Rural primary care and psychiatry clinic in northern New England (town of 16,000 people). PARTICIPANTS: People older than age 18 years diagnosed with a psychotic disorder who were receiving medications. INTERVENTION: Fifty consecutive clients seen in 1 month's time were invited to participate; 19 completed a 1-month open-label phase of the addition of a micronutrient to their medication regimen; all 19 then withdrew rather than risk randomization to a placebo. This finding itself was important, so the study was restructured to compare the response of those 19 patients during 24 months of micronutrients + medication to the response of the 31 people who declined participation, enriched by an additional 28 consecutive patients recruited over the second month of the study. This yielded a total of 59 patients who received medication without micronutrients. OUTCOME MEASURES: All clients were evaluated with the Positive and Negative Symptom Scale and the Clinical Global Impression scale at study baseline and after 3, 6, 9, 12, 15, 18, and 24 months. Psychosis was confirmed with clinical interview by using Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, criteria. All participants had normal physical examinations and laboratory studies. RESULTS: Outcomes were similar for both groups until 15 months, although the micronutrient group used significantly less antipsychotic medication throughout that time (p < 0.001). At 15 months, the micronutrients + medication group exhibited significantly fewer symptoms than the medication-only group, a difference that was even stronger at 24 months. CONCLUSIONS: Micronutrients may appear to be a beneficial long-term, adjunctive strategy for people with psychotic disorders, allowing for smaller doses of medication to achieve the same effectiveness with fewer side effects.

Integration of Complementary and Alternative Medicine Therapies into Primary-Care Pain Management for Opiate Reduction in a Rural Setting.

BACKGROUND: Opiates are no longer considered the best strategy for the long-term management of chronic pain. Yet, physicians have made many patients dependent on them, and these patients still request treatment. Complementary and alternative medicine (CAM) therapies have been shown to be effective, but are not widely available and are not often covered by insurance or available to the medically underserved. METHODS: Group medical visits (GMVs) provided education about non-pharmacological methods for pain management and taught mindfulness techniques, movement, guided imagery, relaxation training, yoga, qigong, and t'ai chi. Forty-two patients attending GMVs for at least six months were matched prospectively with patients receiving conventional care. RESULTS: No one increased their dose of opiates. Seventeen people reduced their dose, and seven people stopped opiates. On a 10-point scale of pain intensity, reductions in pain ratings achieved statistical significance (p = 0.001). The average reduction was 0.19 (95% confidence interval [CI] 0.12-0.60; p = 0.01). The primary symptom improved on average by -0.42 (95% CI -0.31 to -0.93; p = 0.02) on the My Medical Outcome Profile, 2nd version. Improvement in the quality-of-life rating was statistically significant (p = 0.007) with a change of -1.42 (95% CI = -0.59 to -1.62). In conventional care, no patients reduced their opiate use, and 48.5% increased their dose over the two years of the project. CONCLUSIONS: GMVs that incorporated CAM therapies helped patients reduce opiate use. While some patients found other physicians to give them the opiates they desired, those who persisted in an environment of respect and acceptance significantly reduced opiate consumption compared with patients in conventional care. While resistant to CAM therapies initially, the majority of patients came to accept and to appreciate their usefulness. GMVs were useful for incorporating non-reimbursed CAM therapies into primary medical care.

Mental disabilities in an Aboriginal context.

Aboriginal (meaning original peoples) North American mental health is acknowledged to be in a more precarious state than that of the dominant cultures. Disability arises from the conditions of poverty, homelessness, and lack of resources that are compounded for North American aboriginal people by the historical trauma of conquest, being placed on reservations, residential schools, and continued discrimination. We present culturally sensitive and syntonic intervention programs that can reduce the impact of Aboriginal mental disabilities and discuss the commonality among these programs of celebrating culture, language, and tradition.

Reiki Reduces Burnout Among Community Mental Health Clinicians.

BACKGROUND: Clinicians working in community mental health clinics are at high risk for burnout. Burnout is a problem involving emotional exhaustion, depersonalization, and reduced personal accomplishment. Reiki is a holistic biofield energy therapy beneficial for reducing stress. The purpose of this study was to determine if 30 minutes of healing touch could reduce burnout in community mental health clinicians. METHODS: We utilized a crossover design to explore the efficacy of Reiki versus sham Reiki, a pseudo treatment designed to mimic true Reiki, as a means to reduce symptoms of burnout. Subjects were randomized to whether they started with Reiki or sham. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and the Measure Your Medical Outcome Profile Version 2 (MYMOP-2) were used as outcome measures. Multilevel modeling was used to represent the relations among variables. RESULTS: Reiki was statistically significantly better than sham Reiki in reducing burnout among community mental health clinicians (p=0.011). Reiki was significant in reducing depersonalization (p<0.001), but only among single people. Reiki reduced the primary symptom on the MYMOP also only among single people (p=0.03). CONCLUSIONS: The effects of Reiki were differentiated from sham Reiki. Reiki could be helpful in community mental health settings for the mental health of the practitioners.

Complementary medicine treatment of uterine fibroids: a pilot study.

CONTEXT: Women are seeking alternatives to medications and surgeryfor the treatment of uterine fibroids; therefore, it is important to know whether these therapies work and are cost-effective. OBJECTIVE: To report on the treatment of women with uterine fibroids using a suite of nonpharmacological and nonsurgical therapies and to compare this alternative treatment to a matched sample of similar women using standard medical approaches. DESIGN: Matched comparison to standard-of-care control group. SETTING: Academic family practice department and clinic, including a center for complementary and alternative medicine. PARTICIPANTS: Thirty-seven menstruating women, aged 24 to 45 years, with palpable uterine fibroids, and their matched controls, who were enrolled in conventional treatment. INTERVENTION: The treatment program consisted of weekly traditional Chinese medicine, body therapy (somatic therapy, bodywork), and guided imagery. Treatment lasted as long as 6 months. MAIN OUTCOME MEASURES: Changes in fibroid size, changes in bothersome symptoms, and patient satisfaction. RESULTS: Fibroids shrank or stopped growing in 22 patients among the treatment group and 3 among the comparison group (P <.01). Cost of care averaged $3800 per patient in the treatment group and was significantly greater than costs for the comparison group for the study period. Bothersome symptoms of fibroids responded equally well to pharmacological or nonpharmacological therapies. All measures of patient satisfaction were significantly higher among the treatment group compared to those receiving conventional care. CONCLUSIONS: As reported previously in the Chinese medical literature, alternatives exist to pharmacological and surgical methods for treating uterine fibroids, though they are not inexpensive.

Hypnosis to facilitate uncomplicated birth.

Prior research by the author showed that psychosocial factors distinguished complicated from uncomplicated birth outcome. The purpose of this study was to determine if prenatal hypnosis could facilitate uncomplicated birth. Following a psychosocial assessment, 520 pregnant women in their first or second trimester of pregnancy were randomized to receiving prenatal hypnosis or attention-only groups. The author provided all of the hypnosis in a manner similar to that taught by David Cheek. The goal was to reduce fear of birth and parenthood; to reduce anxiety; to reduce stress; to identify specific fears that might complicate the labor process (addressing them whenever possible); and to prepare women for the experience of labor. The attention-only group was matched to a no-contact comparison group. Women receiving prenatal hypnosis had significantly better outcomes than women who did not. Further assessment suggested that hypnosis worked by preventing negative emotional factors from leading to an complicated birth outcome. Attention only was associated with minimal differences in outcome over the no-contact group. The routine prenatal use of hypnosis could improve obstetric outcome.

Introducing healing circles and talking circles into primary care.

We report on the incorporation of a North American aboriginal procedure called "the talking circle" into primary care in areas serving this population. Communication is regulated through the passing of a talking piece (an object of special meaning or symbolism to the circle facilitator, who is usually called the circle keeper). Twelve hundred people participated in talking circles in which 415 attended 4 sessions and completed pre- and postquestionnaires. Outcome measures included baseline and end Measure Your Medical Outcome Profile version 2 forms. Participation in at least 4 talking circles resulted in a statistically significant improvement in reported symptoms and overall quality of life (p < 0.001 and effect sizes ranging from 0.75 to 1.19). The talking circle is a useful tool to use with Native Americans. It may be useful as a means to reduce health care costs by providing other alternative settings to deal with stress-related and other life problems.

Meta-analysis of the use of narrative exposure therapy for the effects of trauma among refugee populations.

BACKGROUND: Narrative therapies, especially narrative exposure therapy, are used to treat the effects of trauma in refugees and to prevent psychiatric illness. These methods involve helping the person to tell the story of what happened to them until it no longer elicits anxiety. METHODS: We reviewed all quantitative studies related to narrative exposure methods for treating trauma or posttraumatic stress disorder in refugees. We focused on studies with sufficient information to calculate effect sizes and statistical power. RESULTS: We found 7 quantitative studies for which effect size and power could be calculated. The total average effect size for all interventions was 0.63 (medium). The average effect size for studies in which interventions were administered by physicians, adequately trained graduate students, or both was 0.53. The effect size for studies in which the counselors were themselves refugees was 1.02. The 95% confidence intervals for the effect sizes of narrative exposure therapy did not reach below 0. CONCLUSION: Studies demonstrating the effectiveness of narrative methods have adequate effect sizes and statistical power. Empowering lay counselors to treat their fellow refugees in future studies is warranted.

Relationships between level of spiritual transformation and medical outcome.

CONTEXT: Culturally defined healers operate in most of the world, and to various degrees, blend traditional healing practices with those of the dominant religion in the region. They practice more or less openly and more or less in conjunction with science-based health professionals. Nonindigenous peoples are seeking out these healers more often, especially for conditions that carry dire prognoses, such as cancer, and usually after science-based medicine has failed. Little is known about the medical outcomes of people who seek Native North American healing, which is thought by its practitioners to work largely through spiritual means. OBJECTIVE: This study explored the narratives produced through interviews and writings of people working with traditional Aboriginal healers in Canada to assess the degree of spiritual transformation and to determine whether a relationship might exist between that transformation and subsequent changes in medical outcome. DESIGN: Before and after participation in traditional healing practices, participants were interviewed within a narrative inquiry framework and also wrote stories about their lives, their experiences of working with traditional healers, and the changes that the interactions produced. The current study used a variety of traditional healers who lived in Alberta, Saskatchewan, and Manitoba. SETTING: Urban and Rural Reserves of the Canadian Prairie Provinces. PARTICIPANTS: One hundred fifty non-Native individuals requested help from Dr Mehl-Madrona in finding traditional Aboriginal healing and spiritual practitioners and agreed to participate in this study of the effects of their work with the healers. INTERVENTION: The healers used methods derived from their specific cultural traditions, though all commonly used storytelling, These methods included traditional Aboriginal ceremonies and sweat lodge ceremonies, as well as other diagnosing ceremonies, such as the shaking tent among the Ojibway or the yuwipi ceremony of the Dakota, Nakota, and Lakota, and sacred-pipe-related practices. OUTCOME MEASURES: The research team used a combination of grounded theory modified from a critical constructivist point of view and narrative analysis to rate the degree of spiritual transformation experienced. Medical outcome was measured by a 5-point Likert scale and was confirmed with medical practitioners and other family members. RESULTS: A 5-year follow-up revealed that 44 of the reports were assessed as showing profound levels of persistent spiritual transformation, defined as a sudden and powerful improvement in the spiritual dimension of their lives. The level of spiritual transformation achieved through interaction with healers was associated in a doseresponse relationship with subsequent improvement in medical illness in 134 of 155 people (P < .0001). CONCLUSIONS: The degree and intensity of spiritual transformation appeared related to the degree of physical and psychological change among people interacting with traditional North American Indigenous healers. Further research is warranted.