Erasing poverty and racism would have a tremendous impact on improving mental health in America. Broadly speaking, systemic change in colonial societies is required. The assumptions of natural hierarchies and belief in the supremacy of certain people over others in colonial societies (such as the US) have contributed to widespread intergenerational poverty and racism. Many of the mental health challenges that Indigenous people face are directly or indirectly impacted by the consequences of poverty and racism (https://link.springer.com/chapter/10.1007/978-3-030-92825-4_6). Trauma and substance misuse, for example, have been associated with the experiences of racial bias and discrimination (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6338088/). Addressing poverty and racism would be necessary steps to overcome the inherent inequities and injustices that negatively impact Indigenous people in many societies, including Indigenous Americans (https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62). Racial inequities and injustices add up to billions of US dollars in additional healthcare and mental healthcare costs for all minoritized groups including Indigenous Americans (https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/). 

Systemic change is also necessary to restore the natural environment, a source of holistic healing for Indigenous people (a.k.a., people that originated in the environment, Merriam Webster Collegiate Dictionary Tenth Edition). The natural world has been viewed as sacred by Indigenous people — the foundation of life, healing, and restoration, whereas the exploitation of natural resources has been foundational to colonialism. Those unhealthy materialistic habits still reside within colonial societies today, resulting in climate change and environmental degradation. Ceasing exploitation and committing to restore the natural environment would be extremely helpful to improving the mental health of Indigenous people. 

Finally, related to the points above, professionals should conceptualize treatment culturally, holistically, and collectively when working with Indigenous American communities. Rather than simply individualizing treatment and care, promote collective healing relationships with nature, community, and family as part of your services, enlisting elders and community leaders to educate you on how to accomplish this (https://www.tandfonline.com/doi/abs/10.1080/07347324.2020.1741330). A long-term commitment to ally with Indigenous communities on their terms would be tremendously beneficial.    

Healthy relationships are foundational for psychological health and well-being. Indigenous people tend to have holistic, egalitarian worldviews emphasizing the importance of harmony with others and within self (https://digitalcommons.usu.edu/kicjir/vol3/iss1/4/

and https://journals.sagepub.com/doi/abs/10.1177/00221678211049875). Psychological well-being occurs when people engage in egalitarian relationships that balance the collective needs of others with self. Egalitarian relationships that respect others as equal partners of a sacred planetary system also help to improve intrapersonal relationships with one’s self. Psychological wellness results from these respectful relationships that embrace the reality of planetary interdependence. Self-oriented activities in pursuit of self-interests at the expense of others disrupts relationships—creating disharmony and imbalances—and dysfunction in relationships. I have termed the pursuit of self-interests that harms others, knowingly or unknowingly, as relational psychopathology to reflect the psychological dysfunction inherent in disharmonious and imbalanced relationships. Reducing relational psychopathology and the harmful pursuit of self-interests to other not only enhances psychological health and well-being, it also will reduce conflict and disharmony with others.

Living in harmony and balance with others also contributes to happiness from the perspective of Indigenous American psychology. Happiness is not a goal to be achieved or something material to be obtained—it is a way of being and becoming as a human creature. Happiness results from actively and intentionally engaging in healthy egalitarian living on a daily basis.

Elders would not necessarily view these disorders as resulting from biochemical or neurochemical imbalances, but rather from holistic systemic imbalances. Holistic systemic imbalances might be interpreted as the consequence of disharmonious relationships with others (interpersonal imbalances) or with self (intrapersonal imbalances). The sources of the disharmony often result from self-oriented behaviors that wound others psychologically. Anxiety is driven by fear, which can be healthy if one is truly threatened, but the fear becomes toxic if the threat is exaggerated and chronic. Depression is often driven by unresolved anger and sadness. Among both conditions, the emotions have risen to a level of toxicity that has harmed relationships with others and self (hindering intrapersonal growth). Those imbalances are made manifest in different ways. Western psychology might refer to these manifestations as individual symptoms or discrete disorders, whereas Indigenous elders likely would view them holistically. From an elder’s perspective, depression and anxiety may be different manifestations of a systemic wound. The treatment would be holistic, involving treating the whole person and their relationships with others. 

Colonialism has created a wounding so profound that the elders have referred to it as a soul wounding. The soul wounding has contributed to a wide array of physical and psychological manifestations. Western medicine and psychology would refer to the manifestation of these conditions as anxiety, depression, diabetes, obesity, substance abuse, or suicide, among many others. The extensive prevalence of these “disorders” in Indigenous communities have been classified as epidemics or disparities by western science. Elders have asserted that these manifestations and their disparities did not occur prior to the colonial soul wounding in their communities (science has supported those assertions). The elders would also suggest that both individual soul wounds that contribute to anxiety and depression (and other psychological concerns) and the collective soul wounding that has sickened the people for generations would need to be addressed simultaneously to heal the whole person, their communities, and the societies in which they now dwell.

Western oriented treatment approaches can be effective for treating mental health problems, including substance misuse and trauma, if the Indigenous client is highly acculturated (i.e., is comfortable with mainstream culture), if the therapist is trusted by the client, and if the treatment has been culturally adapted under the advisement of the Indigenous community (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872612/pdf/arcr-38-1-47.pdf). However, there are also significant differences that need to be considered between Indigenous substance use and trauma when contrasted with the mainstream of society that need to be accounted for in treatment (https://www.tandfonline.com/doi/abs/10.1080/07347324.2020.1741330). For example, therapists often highlight losses and other negative consequences associated with substance misuse to motivate change, but many of the losses that Indigenous people have experienced are not related to substance use at all. Trauma experienced by Indigenous communities has been collective and intergenerational, compounding individual experiences of trauma. Indigenous clients often have complex clinical presentations because their traumas are holistic-systemic that require a holistic-systemic approach to care. 

Indigenous people tend to embrace the power of stories to teach life lessons, so mainstream therapies that utilize storytelling may be helpful. Retelling the stories of collective and historical traumas with culturally resilient endings may be effective. The stories may begin with collective and historical trauma but guide the narratives past the trauma to lessons of healing, strength, and cultural resilience, making collective healing and wellness the central psychological foci of the narratives. Psychologists and other mental health professionals can also help Indigenous people by helping to transform the societies that continue to traumatize others. 

Psychologists and other mental healthcare professionals must begin to think much more holistically about their treatment methods. Reductionistic approaches to treatment and therapy are not culturally responsive to community need. A community and intergenerational approach to collective healing will be much more effective than traditional individualized care. Collectivist communities would benefit from collectivistic approaches to therapy and treatment that include whole families and communities. Since the traumas are intergenerational, it will likely take intergenerational interventions to restore psychological wellness. Intergenerational commitments by mental health professionals to Indigenous people will be a necessity—the temptation to want to check-off the boxes in western-oriented care will need to be shelved. 

There is a distinction to be drawn between human pain and human suffering, where pain is a normal and sometimes healthy part of living—perhaps even educational. However, suffering is detrimental and typically avoidable. Human suffering is often a consequence of relationship violations resulting from relational psychopathology. The bad news is that there have been so many relationship violations that human suffering is widespread, and as discussed above, often intergenerational in its experience. Poverty and racism are two examples of how relationships may be violated to such a degree that they cause widespread suffering across space and time. Other important sources of suffering are environmental exploitation and other forms of social inequities and injustices. Hierarchical belief systems have been used to justify relational psychopathology and suffering as natural and inevitable in ways that avoid responsibility.

The good news is that the circumstances that create suffering are often modifiable behaviors: Psychologists can advocate for the behavior changes needed to address relational psychopathology and therefore reduce human suffering. Life can be difficult enough without compounding the misery. Unfortunately, human creatures often create their own misery when seeking after self-interests in the context of an interdependent natural existence. Widespread suffering in an interdependent existence also ensures that the misery is shared broadly and across time. The COVID-19 pandemic has been a reminder that human creatures are only as psychologically healthy as the most vulnerable among us. Climate change is another example of how suffering impacts us all. In an interdependent planetary existence and with the passage of time—no one is immune from systemic suffering. Suffering can be overcome if humans embrace the realities of an interdependent and egalitarian existence and take seriously the importance of healthy balances and harmonious relationships with others.

Indigenous people have long understood the connectivity of all entities in the natural world and the importance of balances between those entities to promote systemic harmony. Our ancestors have long observed that those balances were being significantly challenged by colonial environmental exploitation and its resulting degradation. Observing such violations of the sacred natural order have been profoundly disturbing for Indigenous people who value the sacredness of the natural order. It was inevitable that the deteriorating health of the natural world would ultimately harm the physical and psychological well-being of its dwellers that depend upon that natural world for life and sustenance. 

Colonialism with its assumptions of hierarchy falsely assumed that humans have supremacy over the natural world (an anthropocentric view of the natural world). Anthropocentrism is problematic when considering relationships with others in an interdependent natural order, favoring the self-interests of one species over all others and justifying environmental exploitation as a right of the human species regardless of consequences to others. The short-sightedness of colonial anthropocentrism did not allow a broad view that perhaps human creatures were harming themselves by their careless disregard for the environment in which they lived. Colonial anthropocentrism contributed to lack of insight or concern about the broad and intergenerational impact of pollution and other types of environmental degradation to other species or other humans, including those of future generations.

Native American psychology considers the health of the natural world to be an important factor in human psychological health and wellness (see also the answer to question 1). An Indigenous American conceptualization of cosmology does not conceive of artificial boundaries that define the human world apart from, or superior to, the rest of nature. (https://books.google.com/books?hl=en&lr=&id=GjiKEAAAQBAJ&oi=fnd&pg=PA187&ots=FT5AtTndzB&sig=8QxFdAtST0XKNIVUQepveoqc-Vo#v=onepage&q&f=false). It would be in the collective best interests of the planet (including for human creatures) that anthropocentric values and self-interested destruction of nature be discarded for respectful relationships with others, including with the natural world that births and sustains us.

Some historical events are so profoundly traumatic that the consequences of the trauma echo across generations biologically and psychologically, negatively impacting the health and mental health of people in the past, present, and future. Examples of events that have been linked to intergenerational trauma include war, genocide, racism, slavery, and the collective oppression and cruelty of colonialism. Indigenous people have experienced many of the aforementioned experiences, and therefore mental health professionals working with Indigenous people can expect that their clients have been impacted and may present as traumatized. In addition, the consequences of intergenerational trauma create circumstances in which Indigenous people are vulnerable to additional traumas related to unhealthy relationships, substance abuse, or victimization.

Indigenous people may be at great risk for relapse due to the complexity of their trauma experiences, so holistic trauma work may be needed. However, it is important to note that despite the complexities of intergenerational trauma and its soul wounding, Indigenous people are inherently strong. The trauma work should tap into the cultural strengths of clients and their communities to find the reserves of spiritual strength needed to seek reconciliation and restoration.  

I will use a well-known mainstream model of health behavior change to describe the discipline’s progress toward accepting and integrating alternative paradigms of psychology (such as those that assume interdependence rather than independence, reductionism rather than holism, or egalitarianism rather than hierarchicalism): Psychology has moved into the contemplation stage of change rather than the precontemplation stage of the past. Current events have challenged longstanding assumptions of mainstream psychology in ways that have been difficult to dismiss, opening the door a crack to examining new paradigms and their assumptions. Australian and Canadian psychologists have acknowledged and apologized for excluding Indigenous perspectives from the discipline of psychology (https://aps.onlinelibrary.wiley.com/doi/abs/10.1111/ap.12300; https://cpa.ca/docs/File/Task_Forces/TRC%20Task%20Force%20Report_FINAL.pdf), but apologizing is not enough to change the perspective of disciplines. The New Zealand Psychological Society is further along the trajectory of recognizing the parity of an Indigenous cultural paradigm with the mainstream (https://www.psychology.org.nz/about/who-we-are/bicultural-commitment). The American Psychological Association recently apologized for many of its acts of racism on behalf of psychology in that country (https://www.apa.org/about/policy/racism-apology and https://www.apa.org/about/apa/addressing-racism/historical-chronology) and is now contemplating organizational changes toward advocacy of antiracism (https://www.apa.org/about/policy/dismantling-systemic-racism) and promotion of mental health equity across historically minoritized people such as Indigenous Americans (https://www.apa.org/about/policy/advancing-health-equity-psychology). More than any other time in colonial times I see American psychology introspectively examining its limitations, which represents an opportunity to examine the strengths of alternative paradigms of psychology in the context of the noticeable weaknesses in the mainstream paradigm to address contemporary psychological problems of global concern. The door has opened a crack but whether the crack widens is up to us.

As psychology globalizes, alternative paradigms will find greater acceptance and more advocates. However, will those in the mainstream embrace paradigms that have vastly different tenets than their own western worldview? Perhaps, if need and necessity drives them to alternative points of view to address psychological concerns. I believe the discipline will move toward paradigmatic parity when a majority in the profession embrace cultural humility in their practice of the profession, realizing that diversification will contribute to improved psychological outcomes in serving the global community.  

For more in depth information related to these questions, I would recommend these books:

Blume, A. W., Skewes, M. C., & Gardner, S. (2021). Indigenous Relapse Prevention: Sustaining recovery in Native American communities. San Diego: Cognella.

Blume, A. W. (2020). A new psychology based on community, equality, and care of the earth: An Indigenous American perspective. Santa Barbara, CA: ABC-CLIO/Praeger.