Empirical Findings From Psychotherapy Research With Indigenous Populations: A Systematic Review, Article, 2016 October 13

Journal of Consulting and Clinical Psychology
Empirical Findings From Psychotherapy Research With
Indigenous Populations: A Systematic Review
Andrew Pomerville, Rachel L. Burrage, and Joseph P. Gone
Online First Publication, October 13, 2016. http://dx.doi.org/10.1037/ccp0000150
CITATION
Pomerville, A., Burrage, R. L., & Gone, J. P. (2016, October 13). Empirical Findings From
Psychotherapy Research With Indigenous Populations: A Systematic Review. Journal of
Consulting and Clinical Psychology. Advance online publication. http://dx.doi.org/10.1037/
ccp0000150 
Empirical Findings From Psychotherapy Research With Indigenous
Populations: A Systematic Review
Andrew Pomerville, Rachel L. Burrage, and Joseph P. Gone
University of Michigan
Objective: Although the dire mental health needs of Indigenous communities are well established in the
literature, the empirical evidence for psychotherapeutic treatment for these populations is perceived to be
scant. This review is intended to determine gaps in the literature for this population by asking how much
empirical work has been published, what types of research are being conducted, which topics are most
prevalent among the existing literature, and what can be concluded about psychotherapy with Indigenous
populations based on this literature. Method: A systematic review of empirical psychotherapy research
on Indigenous clients of Australia, Canada, New Zealand, and the United States was conducted across
10 databases. Results: A total of 44 studies were found, with just 2 examples of controlled outcome trials.
The most common research topic was treatment evaluation, but only 4 treatment evaluation studies
examined individual psychotherapy with adults. Looking across all topics, treatment for substance use
disorders comprised the majority of studies on specific mental health problems. Conclusions: Moving
forward, it will be important for researchers to examine individual psychotherapy for Indigenous clients
and to consider treatment for disorders unrelated to substance use. A preference for the inclusion of
cultural practices and education in psychotherapy was clear across the literature, but the limited
inferences that can be drawn from the existing research make it impossible to come to any conclusions
about the specific roles or effects of cultural practices. Overall, empirical research is badly needed for
psychotherapy with Indigenous populations at this time.
What is the public health significance of this article?
The works in this review suggest that the incorporation of cultural education and cultural practices
into therapy with Indigenous clients may be protective of client retention, but further research is
required to clarify these effects. Programs that tailor psychotherapy to address the needs of
Indigenous clients may be improved by core structural changes to therapeutic practice which take
into account specific practices of local Indigenous communities. Research on Indigenous clients in
psychotherapy is slim and a significant research push is needed to make more confident empirically-
backed recommendations for Indigenous psychotherapy clients than is possible at this time.
Keywords: aboriginal, American Indian, indigenous, psychotherapy, systematic review
Repeated calls have been made for research concerning psycho-
therapy with Indigenous clients, for three primary reasons: First,
Indigenous populations throughout the world appear to face far
higher incidence of mental illness than other ethnoracial groups
(Williamson et al., 2014); second, the cultural gap between Indig-
enous perspectives and “therapy culture” appears to require greater
adaptations than are typically called for in working with other
populations (Tseng, 1999); and, finally, it is generally believed that
very little research on this topic exists (Craven & Bodkin-
Andrews, 2006). Despite an increasing number of calls for both
evidence-based treatments (Drapeau & Hunsley, 2014) and cul-
tural competence (Fernando, 2012) in both research and practice,
it appears true that little attention has been given to Indigenous
peoples as psychotherapy clients. One existing review of the
literature found only two controlled outcome studies for Indige-
nous populations; both were for preventive treatments, not treat-
ments for clients with existing mental health problems (Gone &
Alcántara, 2007).
The challenges associated with the lack of serious research into
the topic are further compounded by the high rates of psychiatric
distress facing Indigenous populations worldwide. Recent reviews
of research with American Indians and Alaska Natives have found
Andrew Pomerville, Rachel L. Burrage, and Joseph P. Gone, Depart-
ment of Psychology, University of Michigan.
The authors acknowledge Mark MacEachern with the University of
Michigan Taubman Health Sciences Library and Susan Turkel with the
University of Michigan Hatcher Graduate Library for their assistance in
crafting the search conducted for this study. This study was undertaken
during the third author’s tenure as the Katz Family Endowed Chair in
Native American Studies at Montana State University in Bozeman, Mon-
tana. Additionally, the third author wishes to express his gratitude to the
John Simon Guggenheim Memorial Foundation for fellowship support
during the preparation of this article.
Correspondence concerning this article should be addressed to Andrew
Pomerville, Department of Psychology, University of Michigan, 2250 East
Hall, 530 Church Street, Ann Arbor, MI. E-mail: pomervil@umich.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Journal of Consulting and Clinical Psychology
© 2016 American Psychological Association
2016, Vol. 84, No. 9, 000
0022-006X/16/$12.00
http://dx.doi.org/10.1037/ccp0000150
1
much higher than average reports of alcohol dependence and
posttraumatic stress disorder (PTSD) compared with national sta-
tistics, along with youth suicide rates over three times the national
average (Gone & Trimble, 2012). Australian Indigenous popula-
tions face similar or worse health outcomes than groups in the
United States, with rates of hospitalization for mental health prob-
lems at two to four times typical rates; Australian Indigenous
youth in particular exhibit rates of suicide more than triple the
average (Hunter, 2007). In addition, both national populations face
similar problems in terms of lack of access to mental health
services and marginalized statuses as invisible communities (Gone
& Trimble, 2012; Hunter, 2007). Comparable disparities exist for
Indigenous populations in Canada (Towle, Godolphin, & Alexan-
der, 2006) and New Zealand (Harris et al., 2006).
These populations also share historical legacies of colonization
and contemporary experiences of ethnoracial discrimination,
which have had profound and demonstrable impacts on mental
health and general well-being (Gone & Trimble, 2012; Harris et
al., 2006; Kirmayer, Simpson, & Cargo, 2003; Sherwood, 2013).
Indigenous communities in these four countries—united by their
British colonial histories—also share a resurgent push for
resilience-focused approaches in mental health with a renewed
interest in blending contemporary psychotherapy practice with
cultural traditions (Brady, 1995; Gone, 2010; Marsh, Coholic,
Cote-Meek, & Najavits, 2015; Vicary & Andrews, 2000). Other
work in psychology has considered how traditional cultural values,
as well as contemporary experiences as occupied peoples within
English-speaking settler colonial nation-states, might render it
appropriate to design culturally relevant interventions that span
these Indigenous groups (e.g., Haring, Hudson, Erickson, Taualii,
& Freeman, 2015). Given these similarities, including common
features of new modes of psychotherapy treatment under develop-
ment, our review considers the body of empirical psychotherapy
research on these Indigenous groups taken together.
A systematic review of suicide prevention efforts with Indige-
nous clients across these same four countries found only one study
featuring a psychotherapy treatment for existing mental health
problems (Harlow, Bohanna, & Clough, 2014). To the best of our
knowledge, ours is the first systematic attempt to identify the
empirical literature concerning psychotherapy proper for these
Indigenous populations. Systematic reviews are comprehensive,
strategic, replicable searches of the literature on a given topic using
multiple bibliographic databases in an attempt to capture all rele-
vant studies on that topic (Leucht, Kissling, & Davis, 2009). A
systematic review of the empirical psychotherapy research with
Indigenous clients should allow us to capture all relevant, properly
indexed studies within the databases that we search. This system-
atic and replicable search strategy will allow us to answer four
questions about this body of literature. First, how much empirical
research has been conducted with Indigenous clients? Second,
what types of research have been conducted? Third, what major
findings have been reported in this literature? Fourth, what is
currently known about psychotherapy with Indigenous populations
on the basis of these findings?
Method
The Institute of Medicine (IoM) has established guidelines for
conducting systematic reviews (IoM, 2011). The purpose of a
systematic review is to summarize the knowledge about a specified
topic on the basis of comprehensive searches of both the published
and unpublished literature. So important is the identification of all
relevant sources that the IoM recommends consultation with pro-
fessional reference librarians in the formulation of bibliographic
search strategies in response to particular research questions. We
adapted the IoM-recommended procedures in conducting this
study. A systematic search on the topic under consideration was
conducted across 10 bibliographic databases. Each study was then
examined individually to determine whether it met preset inclusion
criteria. Information from included studies was extracted into
thorough written summaries for each identified article across 9
domains of interest. This information served as the basis for this
narrative review. Such an approach is sometimes referred to as a
qualitative review to distinguish it from systematic reviews in
which a quantitative meta-analysis is conducted (Albarracín,
2015)—this should not be confused with qualitative meta-analysis,
which is not the same as a narrative systematic review (see
Timulak, 2009). Using the terminology of Brugha et al. (2012), the
results are presented here as both narrative summary and individ-
ual study results.
While this article embraced the IoM guidelines, several adapta-
tions to typical systematic review methodology were made for the
purpose of this study. Given the limited state of psychotherapy
research with our target populations (Harlow et al., 2014; William-
son et al., 2014), effect sizes were not calculated, the psychometric
properties of measures were not analyzed, no measurements of risk
of bias were conducted, and no meta-analysis was performed.
Specifically, our purpose was not simply to explore efficacy or
comparative effectiveness of psychotherapeutic interventions for
specific disorders, but rather to comprehensively examine both
observational and controlled outcome studies, whether the data
were analyzed quantitatively, qualitatively, or both. As a result,
many conventional procedures associated with systematic reviews
devoted to assessing treatment efficacy or comparative effective-
ness were incongruous with both the goals and methods of this
study. Given the methodological diversity and preliminary status
of empirical findings in this domain, one goal of this review was
simply to provide an understanding of the “state of the science” for
empirical research concerning psychotherapy with Indigenous
populations, including a review of thematic content more so than
a systematic evaluation of the methodology of these studies since
the findings in this domain have yet to accumulate across studies.
Search Strategy
On the basis of earlier precedents as well as the recommenda-
tions of consulting reference librarians, the following 10 abstract-
ing and indexing databases were searched: Bibliography of Native
North
Americans;
CINAHL
Complete;
Ethnic
NewsWatch;
Global Health; PsycARTICLES; PsycINFO; PubMed; Social Ser-
vices Abstracts; Web of Science–Science Citation Index; and Web
of Science–Social Science Citation Index. Major databases used in
other similar articles (e.g., Harlow et al., 2014) were identified for
inclusion by the authors, including PsycARTICLES and Psy-
cINFO, PubMed, and the Web of Science databases. Additional
databases were selected in consultation with two university librar-
ians. One librarian was employed at [University of Michigan
Hatcher Graduate Library] as a social sciences librarian. The other
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2
POMERVILLE, BURRAGE, AND GONE
was employed with the [University of Michigan Taubman Health
Sciences Library] as an informationist and specialist in systematic
reviews. Again, the employment of librarians and information
specialists as part of the systematic review search effort is one of
the guidelines established by the IoM (2011). The final list of 10
databases was based on this consultation between the authors and
these two librarians as to the most likely sources to find research
on psychotherapy for Indigenous clients.
Keywords were optimized for the different databases, making
use of their different categorization systems as applicable, and
the finalized search terms for each database were confirmed
with the two university librarians prior to executing the
searches. All searches used the same essential set of terms for
both psychotherapy and the populations of interest, adjusted to
each database as necessary. PsycINFO, PsycARTICLES, &
Global Health were searched together in a single search with the
same search string, as were Science Citation Index & Social
Science Citation Index. Table 1 provides two examples of the
search strings used. Initial searches were conducted between
September 19th and September 25th in 2014, and a secondary
search was conducted 18 months later to ensure that the review
reflected the most up-to-date research. All search results were
up-to-date as of February 7th, 2016.
Eligibility Criteria
In order to be included, studies needed to have some form of
data collection, with combined responses reported from at least
two participants. Definitions of three key terms—Indigenous pop-
ulations, psychotherapy, and clients—were adopted as inclusion
criteria. Because of the limited number of publications on the
topic, other common limits used in systematic reviews were not
included here (no limits were placed on publication date, method,
or publication type). Unpublished materials including dissertations
were thus included if they met these criteria. This is in keeping
with typical systematic review criteria that extend not only to
unpublished academic work but also to findings from government
reports and other nonacademic sources as appropriate (IoM, 2011).
Studies in languages other than English were excluded, with the
following exception: an additional check of all databases for
articles in French or Spanish was conducted on July 25th, 2016 by
the first author to determine whether and to what degree empirical
research in these especially relevant languages (i.e., Spanish for
research in the United States, and French for research in Canada)
were not overlooked. This search returned three articles in Spanish
and 10 articles in French. Based on the English abstracts of these
articles, none of these articles met the criteria for inclusion as
outlined below. Book reviews and review articles were excluded.
The first author, a graduate student in clinical psychology with
previous experience in conducting meta-analysis, was responsible
for the initial process of determining eligibility of studies. An
assessment of eligibility was made based on titles and abstracts
alone with studies removed if they clearly did not meet inclusion
criteria. The remaining articles were examined for eligibility based
on checks of the titles, abstracts, and full text of articles. Following
this process, the second author—a graduate student in clinical
psychology and social work—independently conducted the same
analysis as a check on this search process. The first and second
authors met to discuss all articles for which there was not complete
agreement on inclusion. Consensus was determined during this
meeting by taking a strict line-byline reading of the inclusion
criteria set forth below for each article on which there was dis-
agreement.
Indigenous populations.
In keeping with scholarly precedent
within the published North American literature on such topics, the
populations under consideration for this study are the Indigenous
peoples of the United States, Australia, Canada, and the Pacific
Islands, including New Zealand. This was defined as American
Indians and Alaska Natives, Hawaiian Native people, First Nations
and Metis of Canada, Inuit people, Indigenous people of Australia,
and Indigenous Pacific Islanders including but not limited to
Maori. Pacific Islanders are understood to be those people of
Polynesian, Micronesian, or Melanesian descent. Studies on other
Table 1
Bibliographic Search Strings for Four Databases
PubMed
PsycInfo, PsycArticles, and Global Health
(“Psychotherapy”[MeSH Terms] OR “Psychotherapy”[All Fields] OR
“Reality Therapy”[All Fields] OR “Insight Therapy”[All Fields]
OR “Solution-Focused Therapy”[All Fields] OR “Narrative
Therapy”[All Fields] OR “Psychoanalysis”[All Fields] OR
“Hypnotherapy”[All Fields] OR “Behavior Therapy”[All Fields]
OR “Group Therapy”[All Fields] OR “Cognitive Therapy”[All
Fields] OR “Client Centered Therapy”[All Fields] OR
“Existentialism”[MeSH Terms] OR “Existentialism”[All Fields]
OR “Guided Imagery”[All Fields] OR “Hypnosis”[MeSH Terms]
OR “Hypnosis”[All Fields] OR “Hypnotherapy”[All Fields] OR
“Emotion Focused Therapy”[All Fields])
(“Psychotherap” OR “Behavior Therapy” OR “Client Centered Therapy”
OR “Cognitive Therapy” OR “Emotion Focused Therapy” OR
“Existential Therapy” OR “Guided Imagery” OR “Group Therapy” OR
“Hypnotherapy” OR “Insight Therapy” OR “Narrative Therapy” OR
“Psychoanalysis” OR “Reality Therapy” OR “Solution Focused
Therapy”)
AND (“Indians, North American”[MeSH terms] OR “Oceanic
Ancestry Group”[MeSH terms] OR “Pacific Islander”[All Fields]
OR “First Nations”[All Fields] OR “Indigenous”[All Fields] OR
Metis[All Fields] OR “Inuits”[MeSH Terms] OR “Inuits”[All
Fields] OR “Inuit”[All Fields] OR Maori[All Fields] OR
Aboriginal[All Fields] OR “Alaska Native”[All Fields] OR
Hawaiian[All Fields] OR “Native American”[All Fields] OR
“American Indian”[All Fields]).
AND (“Indigenous Populations” OR “Alaska Natives” OR “American
Indians” OR “Inuit” OR “Pacific Islanders” OR “Maori” OR “First
Nations” OR “Aborigin” OR “Hawaiian” OR “Metis”)
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3
PSYCHOTHERAPY RESEARCH WITH INDIGENOUS POPULATIONS
populations, including Indigenous people of other regions of the
world, were excluded. Studies that featured clients from multiple
ethnoracial or national groups were included only if they provided
specific, separate results on Indigenous clients.
Psychotherapy.
Only articles about psychotherapy were in-
cluded in this review. For the purpose of this study, psychotherapy
was operationalized as attempts to make personal adjustments to
life challenges facing an individual in the primary context of
mental health, deployed to individuals or small groups through the
use of psychological means, provided directly (face to face) by a
single clinician or small teams of clinicians. “Small groups” are
defined as containing no more than 30 clients. Although consid-
erably larger than what is often thought of as effective group size
for group therapy (see Kivlighan, London, & Miles, 2012), a size
of 30 was selected to allow for a broad definition of therapy that
might capture any relevant treatment programs. “Small teams of
clinicians” are defined as including no more than five clinicians,
including only those directly delivering some form of treatment
using psychological means. Cases that appeared to meet this rule
but did not explicitly state the number of clinicians were included
in order to maximize inclusion of relevant studies. “Psychological
means” are defined as attempts to adjust a person’s attitudes,
behaviors, or life situations using any forms of talk therapy,
behavior therapy, somatic therapy, and other therapies associated
with psychology and its associated disciplines, including activity
therapies such as art therapy.
To be included in the review, therapy needed to be conducted
within the broad arena of mental health professionals or parapro-
fessionals in disciplines such as psychology, psychiatry, and social
work. Thus, excluded from this review were treatments that rely
only on tribal elders or traditional healers as therapists. Treatments
where elders and/or traditional healers are brought in as part of
treatment or act in tandem with psychotherapists were included in
this review. Preventive approaches that pooled participants from
preexisting settings with no measure of distress or questions re-
garding distress were also excluded.
Psychotherapy clients.
For the purpose of this review, we
were interested in Indigenous psychotherapy clients. As such, to be
included, studies needed to focus at least partially on questions
related to clients in therapy. Studies assessing training programs
for clinicians were excluded, as were assessments of treatment
centers that were not focused on the psychotherapeutic treatment
provided. Studies about clinician experiences in psychotherapy to
the exclusion of impacts or implications for clients were excluded.
Extraction of Study Information
Information from each of the consensually identified studies
was extracted by the first author for this review. For each study,
findings, research method, treatment method (if specified), partic-
ipant status (e.g., clinician, client, community member), number of
participants, gender, age, ethnoracial identity, and specific distress/
diagnosis under consideration (if specified) were summarized in
written form. This in-depth extraction process was recorded in
written summaries of 1–2 single-spaced pages in length for each
article—collectively yielding 46 pages of summary—to facilitate
analysis for this review. These article summaries are available on
request from the first author.
Results
After an initial return of 2,634 articles in a search across the 10
databases, 33 peer-reviewed articles and an additional 11 disser-
tations on this topic were identified. Three of the peer-reviewed
articles were based on the included dissertations. Figure 1 presents
these results in a PRISMA flow diagram (Moher, Liberati, Tet-
zlaff, Altman, & the PRISMA Group, 2009). The initial screening
by the first and second authors yielded disagreement about the
inclusion of 23 articles. Following the consensus meeting between
these authors, 21 of the disputed articles were found to not meet
criteria. Two of the disputed articles were found to meet criteria
and subsequently included.
Research on Indigenous peoples of the United States dominated
the studies found here, as seen in Table 2. Qualitative analyses
were featured in over one half of the publications, which may
reflect the predominance of open-ended research with these pop-
ulations. Our findings indicate a sudden increase in research on
Indigenous populations, with over one third of the articles being
published between 2010 and 2016. However, as can be seen in
Figure 2, this shift may represent ever-evolving trends in psycho-
logical research and is not necessarily indicative of sustained
interest or funding for research regarding Indigenous clients in
psychotherapy. In addition to a recent drop off in publications
since the high mark of seven published in 2011, it should be noted
that there were zero publications between 1976 and 1986, which
appears as a single point in this figure but that represents 10 years
in which no empirical work in this domain was identified. Among
the 23 publications addressing treatment for specific mental health
diagnoses, substance use disorders were the most common, with
14 publications addressing treatment for some form of substance
use. Seven publications looked at treatment for anxiety and/or
depression. Two addressed treatment for posttraumatic stress dis-
order (PTSD). No studies were found addressing many of the more
serious mental illnesses including bipolar disorder, schizophrenia,
any personality disorder, or any eating disorder. Across the entire
body of literature, cultural adaptations to therapy and assessments
of acculturation were emphasized.
Aside from these findings, the literature was too scattered to
present coherent conclusions regarding how to conduct evidence-
based or empirically supported treatment with Indigenous clients.
However, the literature did group into broad categories that are
broken down for further analysis subsequently. For this review,
research studies were classified into four categories based on
thematic description of each study recorded during the extraction
process: treatment evaluations (n  20), therapy expectations (n 
10), client experiences (n  7), and clinician perspectives (n  7).
Treatment Evaluations
The treatment evaluation research was divided into research on
adult clients (n  11; as shown in Table 3) and adolescent clients
(n  9; as shown in Table 4), with a single peer-reviewed study
based on a dissertation in each of these categories (Brave Heart,
1998; Brave Heart-Jordan, 1995; Listug-Lunde, 2004; Listug-
Lunde, Vogeltanz-Holm, & Collins, 2013). No studies were found
on psychotherapy with Indigenous youths under 11 years old.
The state of the treatment evaluation research with Indigenous
clients would be best described as preliminary. Only one con-
trolled outcome trial for assessing treatment efficacy or effective-
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4
POMERVILLE, BURRAGE, AND GONE
ness was found across the entire body of literature for adults
(Nagel, Robinson, Condon, & Trauer, 2009) and only a single
example of such a trial was found with adolescents, reported in the
literature in both a dissertation and a subsequent associated peer-
reviewed publication (Listug-Lunde, 2004; Listug-Lunde et al.,
2013). The former is self-described as an “early pilot study”, and
the latter found no difference between a classroom-based treatment
and treatment-as-usual.
As a consequence, our review is unable to answer an important
question for the profession, namely which psychotherapeutic treat-
ments “work” for Indigenous clients with specified mental health
problems. As a result, the efficacy of novel or adapted treatments
and the generalizability of established empirically supported treat-
ments for use with these populations is currently unknown relative
to typical definitions of empirical support (Borkovec & Caston-
guay, 1998). In fact, two of these studies point to dissatisfaction
with the commitment to disseminate empirically supported treat-
ments for use with Indigenous clients, as reported by both clini-
cians and community members (Gone, 2009; Goodkind et al.,
2011).
Group versus individual therapy.
Among the articles with
adult clients, over 60% were focused on either group or residential
treatment; that is, only four articles were identified across the
treatment evaluation literature that explored individual psychother-
apy treatments for adult Indigenous clients. All studies on adoles-
cents focused on group, residential, or classroom-based treatments;
no interventions comprising individual therapies for Indigenous
youth were identified. Some studies reported that group treatments
were especially relevant to Indigenous clients because they are
perceived as “collectivist” rather than “individualist” (e.g., Ashby,
Gilchrist, & Miramontez, 1987; Kahn, Lewis, & Galvez, 1974).
Targeted problems.
Among studies with adults, substance
use disorder was the most common mental health problem being
addressed, comprising five of the 11 publications in this category.
As seen in Table 3, there was also a single study on treatment for
anxiety and depression and a single study on “historical trauma”
comprising two publications (for an explication of Indigenous
historical trauma, see Kirmayer, Gone, & Moses, 2014). Two
studies were focused on evaluation of a treatment program that
was aimed at multiple mental health problems broadly defined as
opposed to a single specified disorder (Gone, 2009, 2011). As seen
in Table 4, PTSD and substance use were the most common
disorders in the adolescent literature, with two studies evaluating
treatment for each of those conditions.
Databases searched: Bibliography of Native North Americans (n = 252), CINAHL 
Complete (n = 701), Ethnic NewsWatch (n = 591), PsycINFO, PsycARTICLES, & Global 
Health (n = 589), PubMed (n = 333), Social Services Abstracts (n = 33), Web of Science – 
Science Citation Index & Social Science Citation Index (n = 135) 
 
Citations returned across all databases (N = 2,634) 
Remaining after duplicates removed 
(n = 2,343) 
Screened by title/abstract 
(n = 2,343) 
Excluded (n = 858) 
Full-text citations assessed 
for eligibility  
(n = 1,429) 
Excluded (n = 1,385) 
Full-text citations 
excluded, by reason: 
Not about psychotherapy 
(n = 1,023) 
Not about population 
(n = 675) 
Not about clients 
(n = 356) 
Met criteria but not 
empirical 
(n = 175) 
Total excluded 
(n = 2,299) 
Included for analysis & 
review 
(n = 44) 
 
Doctoral Dissertations 
(n = 11) 
Peer-Reviewed Articles 
(n = 33) 
Figure 1.
PRISMA flow diagram, adapted from Moher et al. (2009).
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5
PSYCHOTHERAPY RESEARCH WITH INDIGENOUS POPULATIONS
Research designs.
Only three of 11 publications with adults
used an experimental or quasi-experimental design with compar-
ison groups (Fisher, Lankford, & Galea, 1996; Nagel et al., 2009;
Villanueva, Tonigan, & Miller, 2007). Nagel et al. (2009) also
used a qualitatively analyzed component as part of the study to
establish how to adapt the treatment for Indigenous Australian
clients. Two studies evaluated treatments on the basis of single-
group quantitative designs (Brave Heart, 1998; Brave Heart-
Jordan, 1995; Dickerson et al., 2014; Mathieson, Mihaere, Col-
lings, Dowell, & Stanley, 2012), with Dickerson et al. (2014) and
Mathieson et al. (2012) also using a qualitatively analyzed com-
ponent as part of the study. One study used a nonexperimental
quantitative design (D’Silva, Schillo, Sandman, Leonard, & Boyle,
2011). Three studies used qualitative designs (see Table 3). One of
the studies with adolescents used an experimental design (Listug-
Lunde, 2004; Listug-Lunde et al., 2013). Five studies used single-
group quantitative designs (Ashby et al., 1987; Beckstead, Lam-
bert, DuBose, & Linehan, 2015; Goodkind, Lanoue, & Milford,
2010; Kahn et al., 1974; Smallbone, Crissman, & Rayment-
McHugh, 2009). Two studies used qualitative approaches to eval-
uate ongoing treatment programs (see Table 3).
Cultural adaptations.
The undertaking of cultural adapta-
tions across the treatment evaluation literature was nearly univer-
sal; nine adult studies included extensive cultural adaptation, with
seven focused on Indigenous-specific treatment programs that
went beyond adaptation of existing therapies to the incorporation
of cultural practices as a part of the therapeutic endeavor. Although
cultural adaptations were present in seven studies with adolescent
clients, only a single study (Ashby et al., 1987) used an approach
specifically designed for Indigenous clients rather than using an
adaptation of an existing therapy approach.
Treatments with changes to the “core” (as opposed to the
“surface”) constituents of the intervention (see Castro, Barrera, &
Holleran Steiker, 2010) that essentially reimagined psychotherapy
in Indigenous terms (incorporating cultural practices and educa-
tion) were associated with more positive impressions generally.
Two important exceptions, however, were Villanueva et al. (2007),
and Nagel et al. (2009); both conducted treatment tests with
comparison groups and found statistically significant differences
for motivational treatment approaches. Relevance was also impor-
tant; adaptations were described as needing to occur in contexts
that respected the diversity of Indigenous traditions, including the
consideration of the gendered nature of some traditional practices
(Dickerson et al., 2014) and cultural taboos specific only to some
specific Indigenous groups (Goodkind et al., 2010).
Examples of two adaptation efforts.
In a single group study,
Goodkind et al. (2010) evaluated Cognitive Behavioral Interven-
tion for Trauma in Schools (CBITS), a classroom-based form of
cognitive behavioral therapy (CBT) for PTSD, with surface adap-
tations to treatment in which minor changes were made to an
existing psychotherapy. Imagery in many of the exercises was
altered to contain more nature-centered themes, changes were
made to avoid taboos around discussing the dead, and some
participants were referred out for traditional healing depending on
the individual’s connection and interest regarding traditional prac-
tices. Minor additional adjustments were made on the fly as
problems presented themselves. Statistically significant improve-
Table 2
Characteristics of 44 Reviewed Studies
Characteristic
n
%
Nation of study
United States
33
75.0
Canada
5
11.4
Australia
5
11.4
New Zealand
1
2.3
Decade
1970s
2
4.5
1980s
1
2.3
1990s
9
20.5
2000s
15
34.1
2010s
17
38.6
Method of data analysis
Quantitative
20
45.5
Qualitative
16
36.4
Both
8
18.2
Note.
Percentages may not add up to 100% due to rounding.
0
1
2
3
4
5
6
7
8
1972
1973
1974
1975
1976-1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Number of Arcles by Year of Publicaon
Number of Arcles
Figure 2.
Empirical articles published on Indigenous psychotherapy clients, 1972–2015. See the online article
for the color version of this figure.
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6
POMERVILLE, BURRAGE, AND GONE
Table 3
Characteristics of Treatment Evaluation Studies (Adults; n  11)
Author and yeara
n
Participant type
Age
Population
Treatment
Method
Disorder
Research question
Findings
Brave Heart-Jordan
(1995) (Dissertation)
45
Clients
M  43
AI (U.S.)
Group
Quantitative
(IS)
Historical
trauma
Are traditional healing
approaches effective for
historical trauma?
Group therapy with traditional
healing was effective.
Brave Heart (1998)
45
Clients
M  43
AI (U.S.)
Group
Quantitative
(IS)
Historical
trauma
Dickerson et al. (2014)
21
Clients, Clinicians,
Community
Leaders
19–71
AI/AN (18),
Other (3)
(U.S.)
DARTNA
Both (IS)
Substance use
disorder
Does DARTNA work, and how
can it be improved?
DARTNA was liked by
clients; should connect with
local tribal activities.
D’Silva et al. (2011)
141
Clients
18–65
AI (Ojibwe)
(U.S.)
FDL Program
Quantitative
(DS)
Substance use
disorder
Does a culturally tailored
approach work?
Results were better than with
past non-tailored treatments.
Fisher et al. (1996)
791
Clients
N/A
AN (210), Other
(581) (U.S.)
Residential
Quantitative
(IS)
Substance use
disorder
Can cultural adaptations reduce
dropout rates for AN clients?
Adaptations eliminated the gap
in treatment dropout.
Gone (2009)
19
Clients, Clinicians,
Administrators
20s 60s
First Nations
(Canada)
N/A
Qualitative
N/A
How does an indigenous center
approach mental health?
Indigenous treatment
challenges current ideas of
evidence-based therapy.
Gone (2011)
19
Clients, Clinicians,
Administrators
20s 60s
First Nations
(Canada)
N/A
Qualitative
N/A
How does critical cultural
engagement facilitate healing?
Cultural practices blend with
therapy and community
efforts
Mathieson et al. (2012)
20
Clients, Clinicians
20–65
Maori (N.Z.)
UBI-M
Both (IS)
Anxiety,
depression
Can ultra-brief interventions be
adapted for Maori clients?
Results suggest potential for
use of UBI-M with Maori.
Nagel et al. (2009)
49
Clients
M  33
Indigenous
Australian
MCP
Both (IS)
Substance use
disorder
Is MCP better than treatment-as-
usual for substance use
disorder and well-being?
MCP with cultural adaptations
was more effective than
treatment-as-usual.
Thomas and
Bellefeuille (2006)
6
Clients
20–65
Aboriginal
(Canada)
Group
Qualitative
N/A
What are client perspectives on
an aboriginal treatment
program?
Treatment should be holistic &
have depth in adaptation
Villanueva et al.
(2007)
25
Clients
M  35
AI (U.S.)
CBT, TSF,
and MI
Quantitative
(IS)
Substance use
disorder
Is there a difference between
TSF, CBT, and MI in
outcome?
MI was statistically
significantly more effective.
Note.
Statistics are presented for clients only; study did not report age or racial/ethnic background of clinicians. AI  American Indian; AN  Alaska Native; U.S.  United States; N.Z.  New
Zealand; DARTNA  Drum-Assisted Recovery Therapy for Native Americans; FDL  Fond du Lac; UBI-M  Ultra Brief Intervention for Maori; MCP  motivational care planning; CBT:
cognitive-behavioral therapy; TSF: 12-step facilitation; MI  motivational interviewing; IS  inferential statistics; DS  descriptive statistics.
a Peer-reviewed studies that were based on dissertations appear directly below the relevant dissertation in this table, with the columns on research questions and findings left blank as research questions
and findings in the peer-reviewed studies did not differ from those of the dissertations on which they were based.
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
7
PSYCHOTHERAPY RESEARCH WITH INDIGENOUS POPULATIONS
Table 4
Characteristics of Treatment Evaluation Studies (Adolescents; n  9)
Author and yeara
n
Participant type
Age
Population
Treatment
Method
Disorder
Research question
Findings
Ashby et al.
(1987)
9
Clients
12–17
AI (U.S.)
Group
Quantitative
(DS)
PTSD
Is a native-specific group
treatment
acceptable/effective?
Native-specific treatment was
acceptable and effective.
Beckstead et al.
(2015)
229
Clients
12–18
AI/AN (U.S.)
DBT
Quantitative
(IS)
Substance Use
Disorder
Is DBT combined with cultural
practices effective to treat
indigenous youth substance
use?
The combined approach
demonstrated clinically
significant improvements
Dell et al. (2011)
15
Clients
12–14
First Nations and
Inuit (Canada)
EAL
Qualitative
Substance Use
Disorder
Can equine-assisted treatments
be healing for indigenous
youth?
Equine based treatment is
relevant for indigenous
youth.
Goodkind et al.
(2010)
23
Clients
12–15
AI (U.S.)
CBITS
Quantitative
(IS)
PTSD
Is CBITS an effective
treatment for AI youth with
PTSD?
Improvements were found,
but reverted at six months.
Goodkind et al.
(2011)
111
Clinicians, Community
Members/Leaders
N/A
AI (78), Other
(34) (U.S.)
N/A
Qualitative
N/A
What are challenges with AI
youth services and causes of
disparities?
Services are too mainstream,
not tailored to AI
worldviews.
Kahn et al. (1974)
15
Clients
16
AI (O’ohdam)
(U.S.)
Group
Quantitative
(DS)
N/A
Can group therapy be used in
the treatment of AI youth?
Group therapy reduced
truancy and conduct
problems.
Listug-Lunde
(2004) (D)
17
Clients
11–14
AI (U.S.)
CWD-A
Both (IS)
Depression
Is CWD-A effective as a
treatment with AI youth?
CWD-A was as effective as
treatment-as-usual.
Listug-Lunde et al.
(2013)
16
Clients
11–14
AI (U.S.)
CWD-A
Both (IS)
Depression
Smallbone et al.
(2009)
159
Clients
11–18
Indigenous (56),
Other (103)
(Australia)
N/A
Quantitative
(IS)
N/A
Does cultural competence
training Indigenous youth
sex offender treatment
engagement?
Cultural competence
enhanced engagement
independent of client race.
Note.
AI  American Indian; PTSD  posttraumatic stress disorder; AN  Alaska Native; U.S.  United States; DBT  dialectical behavior therapy; EAL  equine-assisted learning; CBITS 
cognitive-behavioral intervention for trauma in schools; CWD-A  Adolescent Coping with Depression; IS  inferential statistics, DS  descriptive statistics.
a Peer-reviewed studies that were based on dissertations appear directly below the relevant dissertation in this table, with the columns on research questions and findings left blank as research questions
and findings in the peer-reviewed studies did not differ from those of the dissertations on which they were based.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
8
POMERVILLE, BURRAGE, AND GONE
ments in PTSD and anxiety symptoms were found after the end of
treatment and at 3-months follow-up, along with a reduction in
avoidant coping. A 6-month follow-up found that the PTSD symp-
toms and avoidant coping had returned to pretreatment levels. The
authors suggested that “the attenuation of our positive findings, as
well as concerns with feasibility and acceptability, suggest that
more deep structure adaptations to CBITS may be warranted for
AI youth in rural reservation communities” (Goodkind et al., 2010,
p. 869).
Fisher et al. (1996) presented a model of residential treatment
with core adaptations for Alaska Natives in therapy for substance
use disorder. Group therapy was made less confrontational, the
number of meetings was reduced, and the groups were led by
native counselors. “Cultural awareness activities” were added to
treatment; these included subsistence hunting trips, drum and
dance groups, production of traditional crafts and foods, atten-
dance and involvement in community cultural events, and educa-
tion on traditional cultural practices across different Alaska Native
language groups. Alaska Native clients were given orientation to
the treatment center and the urban environment in which it was
located. They were also given additional individual therapy ses-
sions, particularly early on in treatment. These changes reportedly
eliminated a previously existing gap in treatment retention be-
tween Alaska Native clients and others.
The state of treatment evaluation research.
Treatment eval-
uation work remains limited in accumulation and interpretability,
owing to the lack of controlled outcome studies with samples large
enough to detect causally robust and clinically meaningful effects.
Several trends are suggested by this literature that might be used to
inform practice casually, but the limitations of the methods and
findings for these studies—and their general lack of replication—
render it impossible to offer any evidence-based recommendations
at this time.
Therapy Expectations
Ten publications examined therapy expectations of Indigenous
peoples, including one peer-reviewed publication based on in-
cluded dissertations (Jackson, 2003; Jackson, Schmutzer, Wenzel,
& Tyler, 2006), as shown in Table 5. Although five of these
publications were about expectations regarding psychotherapy
generally, others examined preferences for specific therapeutic
modalities (see Table 5). Five of the publications did not specify a
disorder in considering expectations of therapy. Three publications
concerned treatments for substance use disorders, and two con-
cerned treatments for depression (see Table 5). All seven publica-
tions that used solely quantitative approaches utilized nonexperi-
mental quantitative designs. Two studies used a qualitative design,
and one study used both qualitative and quantitative approaches
(see Table 5).
This subset of the literature is based on nonclinical populations
and thus does not necessarily reflect the needs of actual Indigenous
clients, but instead may reveal what clients might prefer upon
entering therapy. In keeping with the results surrounding cultural
adaptation in the treatment evaluation literature that we described
earlier, studies suggested that Indigenous participants emphasized
the importance of respect for and knowledge about local Indige-
nous culture on the part of therapists (Dickerson, Robichaud,
Teruya, Nagaran, & Hser, 2012; Dussair, 1993; Stewart, Swift,
Freitas-Murrell, & Whipple, 2013; Vicary & Bishop, 2005) and
that significant preference differences between Indigenous and
non-Indigenous clients may indicate the need for cultural adapta-
tions (Fiferman, 1990; Jackson, 2003; Jackson et al., 2006; Stewart
et al., 2013).
Client Experiences
This category contains seven studies as presented in Table 6.
Four of seven studies concerned experiences in group or residen-
tial treatment, with one of these four also including unspecified
individual therapy. These four studies were all addressed to treat-
ments for substance use disorders. The remaining three studies
examined client experiences of individual therapy without refer-
ence to specific psychotherapeutic approaches or to specific dis-
orders. One of seven studies used a quasi-experimental design
(Dickerson et al., 2011). Four of seven studies used nonexperi-
mental quantitative designs, one of which also included a qualita-
tive component. Two studies used only a qualitative design (see
Table 6).
The importance of cultural awareness and cultural adaptation
was again emphasized in this category. One dissertation, however,
contradicted this trend and did not find a statistically significant
difference between American Indians whose attachment to tribal
values was high and those for whom it was low, on a measure of
what they found important in therapy for substance use disorders
(Wilson, 1997). The author noted that the results may not be
broadly applicable, however. Of the six other articles, half in-
cluded questions or measures of cultural attributes, and all of these
found the inclusion of cultural adaptations to be connected to
positive client experiences. Specifically, three studies noted the
importance of adaptation. Edwards (2003) noted that traditional
cultural components were among the primary parts of a treatment
that clients found helpful. Lokken (1996) found in her dissertation
that a group of American Indian analog clients felt cultural adap-
tation was necessary and that nondirective and humanistic ap-
proaches would be preferred. Another dissertation found that
American Indian clients rated the therapeutic alliance as more
important than did typical non-Indigenous samples and also found
that they valued discussion of cultural issues in therapy (Lopez,
2006).
Two studies noted the high rates of dropout for Indigenous
clients (Fickenscher, Novins, & Beals, 2006; Dickerson et al.,
2011). Taking these two studies in the context of the broader
literature emphasizing clients’ preference for culturally relevant
treatment, it may be that significant adaptations could ameliorate
the problem of dropout, as found by one study already mentioned
in the treatment evaluation category (Fisher et al., 1996). However,
as with the rest of this review, the limited nature of the client
experiences literature resists any strong conclusions.
Clinician Perspectives
Our final category concerns clinician perspectives on Indige-
nous clients, and included seven studies as shown in Table 7. One
study was aimed at perspectives on a treatment for depression and
anxiety, one was on therapy for historical trauma, and the other
five did not address specific disorders (see Table 7). One study
used both qualitative and quantitative approaches, with a nonex-
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9
PSYCHOTHERAPY RESEARCH WITH INDIGENOUS POPULATIONS
Table 5
Characteristics of Therapy Expectations Studies (n  10)
Author and yeara
n
Participant type
Age
Population
Treatment
Method
Disorder
Research question
Findings
Arnold (1994)
(Dissertation)
128
Students
18–50
AI (U.S.)
N/A
Both (IS)
N/A
How do AIs rate MHPs for helping
with problems?
MHPs rated below family,
community, spiritual help.
Calabria et al.
(2013)
116
General Population
18–72
Indigenous (110) Other
(6) (Aus.)
CRA/
CRAFT
Quantitative
(DS)
Substance use
disorder
Are CRA and CRAFT acceptable to
Indigenous community members?
Community members rated
CRA and CRAFT highly.
Dickerson et al.
(2012)
18
Clients, Clinicians,
Community
Leaders
27–64
AI/AN (U.S.)
DARTNA
Qualitative
Substance use
disorder
What is the potential for drumming
in treatment?
Drumming in treatments
may be relevant &
effective.
Dussair (1993) (D)
110
General Population
18–65
AI (Eastern Cherokee)
(U.S.)
N/A
Quantitative
(DS)
N/A
How do Eastern Cherokee values
inform counseling preferences?
Respect & comfort w/
cultural differences are
important.
Fiferman (1990)
(Dissertation)
50
Students
18
AI (25), White (25)
(U.S.)
Multiple
Quantitative
(IS)
Depression
Is there a difference between AI and
White preferences for modality?
AI clients are more likely to
prefer humanistic
approaches.
Gilder et al.
(2011)
36
Community
Members/Leaders
N/A
AI (U.S.)
MI
Quantitative
(IS)
Substance use
disorder
Is MI acceptable for use with AI
youth for substance use disorders?
Community members found
MI acceptable in most
cases.
Jackson (2003)
(Dissertation)
82
General Population
M  35
AI (41), White (41)
(U.S.)
CBT
Quantitative
(IS)
Depression
Are CBT components equally
applicable to White and AI
people?
AIs rated CBT lower on
some scales; CBT needs
adaptation.
Jackson et al.
(2006)
82
General Population
M  35
AI (41), White (41)
(U.S.)
CBT
Quantitative
(IS)
Depression
Stewart et al.
(2013)
172
Students
M  24
AN (67), White (105)
(U.S.)
N/A
Quantitative
(IS)
N/A
How do AN and White students
differ in treatment preferences?
Assessment of acculturation
should inform ANs
treatment.
Vicary and Bishop
(2005)
70
General Population
N/A
Aboriginal (Australia)
N/A
Qualitative
N/A
How can mental health services
better serve aboriginal needs?
Services should be holistic
& culturally grounded.
Note.
AI  American Indian; AN  Alaska Native; U.S.  United States; CRA  community reinforcement approach; CRAFT  community reinforcement and family training; DARTNA 
Drum-Assisted Recovery Therapy for Native Americans; MI  motivational interviewing; CBT  cognitive-behavioral therapy; IS  inferential statistics, DS: descriptive statistics; MHP  mental
health professional.
a Peer-reviewed studies that were based on dissertations appear directly below the relevant dissertation in this table, with the columns on research questions and findings left blank as research questions
and findings in the peer-reviewed studies did not differ from those of the dissertations on which they were based.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
10
POMERVILLE, BURRAGE, AND GONE
Table 6
Characteristics of Client Experience Studies (n  7)
Author and yeara
n
Participant type
Age
Population
Treatment
Method
Disorder
Research question
Findings
Dickerson et al. (2011)
558
Clients
M  37
AI/AN (279),
Other (279)
(U.S.)
N/A
Quantitative
(IS)
Substance use
disorder
What are the differences in dropout
rates between AI/AN and other
clients?
AI/AN clients are more likely to
drop out of treatment.
Edwards (2003)
12
Clients
23–51
AI (U.S.)
Residential
Qualitative
Substance use
disorder
What aspects of a native-specific
treatment do clients find healing?
Sense of community allowed
healing work to be done.
Fickenscher et al.
(2006)
86
Clients
13–18
AI (U.S.)
RSATP
Quantitative
(IS)
Substance use
disorder
What determines dropout from
treatment among AI youth?
Age, desire for help, and legal
problems predict drop-out.
Hendrie and Hanson
(1972)
136
Clients
N/A
First Nations &
Metis (64),
Other (72)
(Canada)
N/A
Both (IS)
N/A
What differences exist for therapy
referrals after inpatient
treatment?
Indigenous clients were less likely
to be referred for outpatient
therapy.
Lokken (1996) (D)
12
Clients (analog)
22–38
AI (U.S.)
N/A
Qualitative
N/A
Is individual therapy for AI clients
an effective approach?
Participants reported therapy
could be helpful if adapted.
Lopez (2006) (D)
113
Clients
18–64
AI (U.S.)
N/A
Quantitative
(IS)
N/A
How important are ethnicity &
alliance to AI clients?
Culturally aware therapists & the
alliance were rated highly.
Wilson (1997) (D)
60
Clients
18–73
AI (U.S.)
Group
Quantitative
(IS)
Substance use
disorder
Do AI values influence what
clients find important in therapy?
No difference was found between
clients with high and low AI
values.
Note.
AI  American Indian; AN  Alaska Native; U.S.  United States; RSATP  Residential Substance Abuse Treatment Program; IS  inferential statistics; DS  descriptive statistics.
a Peer-reviewed studies that were based on dissertations appear directly below the relevant dissertation in this table, with the columns on research questions and findings left blank as research questions
and findings in the peer-reviewed studies did not differ from those of the dissertations on which they were based.
Table 7
Characteristics of Clinician Perspective Studies (n  7)
Author and yeara
n
Participant type
Age
Population
Treatment
Method
Disorder
Research question
Findings
AuCoin Lee
(1997)
10 Clinicians
N/A
AI (4), White (5),
Latina (1) (U.S.)
N/A
Qualitative
N/A
How do AI clients differ in their
therapeutic needs?
Major shifts in approach may be
needed due to cultural
differences.
Bennett-Levy et
al. (2014)
5 Clinicians
N/A
Indigenous Australian CBT
Qualitative Anxiety, Depression Is CBT acceptable for use with
Indigenous Australian clients?
Clinicians found CBT
acceptable with some cultural
adaptations.
Cadieux (2010)
(D)
10 Clinicians
N/A
AI (U.S.)
N/A
Qualitative
N/A
What do experienced AI clinicians
recommend for treating AI clients?
Clinicians should seek education
and local AI community
contacts.
Limb and Hodge
(2011)
50 Clinicians
M  49 AI (42), Other (8)
(U.S.)
Spiritual
Ecogram
Both (IS)
N/A
Do Spiritual Ecograms align with AI
values?
Spiritual Ecograms were rated
moderate, requiring changes.
Martin (2012) (D)
6 Clients, Clinicians
19–70
AI (U.S.)
N/A
Qualitative Historical Trauma
How should therapy be adapted for
AI clients?
A humanistic and holistic AI
approach is recommended.
Wihak and Merali
(2005)
8 Clinicians
N/A
White (U.S.)
N/A
Qualitative
N/A
How can clinicians apply knowledge
of Inuit spirituality?
Learning via contact & being
reflective allows application.
Wihak and Merali
(2007)
8 Clinicians
N/A
White (U.S.)
N/A
Qualitative
N/A
What ethical adaptations are made by
clinicians working with Inuit clients?
Adaptations were made to rules of
confidentiality and boundaries.
Note.
AI  American Indian; U.S.  United States; CBT  cognitive-behavioral therapy; IS  inferential statistics, DS  descriptive statistics.
a Peer-reviewed studies that were based on dissertations appear directly below the relevant dissertation in this table, with the columns on research questions and findings left blank as research questions
and findings in the peer-reviewed studies did not differ from those of the dissertations on which they were based.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
11
PSYCHOTHERAPY RESEARCH WITH INDIGENOUS POPULATIONS
perimental design for the quantitative portion (Limb & Hodge,
2011). The other six studies used qualitative methodologies.
In keeping with the other categories, clinicians in these studies
reported that it was important to adapt therapeutic approaches to
Indigenous cultural values and needs. In the study using both
quantitative and qualitative approaches, Limb and Hodge (2011)
found that clinicians rated spiritual ecograms as moderately con-
sistent with American Indian values on a quantitative scale, though
it was rated lower by those who were older and those who had
greater clinical experience. Qualitative studies of clinicians gen-
erally noted the belief in a need for “holistic” client-directed
approaches and knowledge of the local community’s specific
cultural practices and values (AuCoin Lee, 1997; Cadieux, 2010;
Martin, 2012; Wihak & Merali, 2007).
Three articles elaborated on these specific practices and values with
American Indians on the Wind River reservation (AuCoin Lee, 1997)
and Inuit communities in Canada (Wihak & Merali, 2005; Wihak &
Merali, 2007). Although it provided similar contextual information
for Indigenous Australians, Bennett-Levy et al. (2014) considered this
question in the specific context of CBT, finding that clinicians felt
CBT requires some adaptation for use with these populations and that
with these adaptations it could be effective.
Summary
The state of the research as reviewed here makes it difficult to
draw clear conclusions about psychotherapy with Indigenous cli-
ents. Cultural and spiritual practices are clearly an emphasis within
this literature, but strong evidence for or against the inclusion of
such practices is lacking. Further research into psychotherapy with
Indigenous clients is vital at this time to make strong recommen-
dations about the best solutions for addressing the pressing mental
health needs of these populations.
Discussion
The absence of controlled outcome trials in the empirical psycho-
therapy literature with Indigenous populations is a serious gap that
renders evidence-based recommendations for specific treatments im-
possible at this time. Across the entire body of psychotherapy litera-
ture with Indigenous clients, only four experimental or quasi-
experimental studies have been found. This gap in the research is a
serious problem, especially given that those studies that have inves-
tigated the topic have found differences between Indigenous therapy
clients and other ethnoracial groups (e.g., Fiferman, 1990; Villanueva
et al., 2007). Research evaluating individual psychotherapy for ado-
lescents appears to be completely lacking, and the state of research
with adult clients comprises only the four studies already noted. No
research, whether evaluative or otherwise, considered Indigenous
clients under the age of 11. This finding was disquieting given the
importance of early intervention for any number of youth behavioral
health concerns ranging from behavior problems (e.g., McNeil, Ca-
page, Bahl, & Blanc, 1999) to autism spectrum disorders (e.g., Koe-
gel, Koegel, Ashbaugh, & Bradshaw, 2014). In addition, research has
largely focused on substance use disorders to the exclusion of other
serious mental health conditions. Given the alarmingly high rates of
mental health problems within Indigenous populations as discussed
earlier, the need for increased research in this area at this time is
especially imperative.
In answer to our first research question (“How much. . .?”), this
systematic review identified more empirical work on the topic than
the authors would have predicted. On the basis of past reviews of the
literature on Indigenous clients (e.g., Gone & Alcántara, 2007), the
authors expected the body of literature to be considerably smaller than
the 44 results found here. It is worth noting, however, that eight of the
articles found, or 18%, were dissertations that were not later published
as articles in peer-reviewed journals. This may indicate a further gap
between the body of knowledge of which clinicians are aware and the
full range of work that has been conducted in this area. Although it is
difficult to pinpoint the exact reason for this research-publication gap,
it is worth noting that the handful of “pipeline” PhD programs tailored
for American Indian students in clinical psychology in the United
States emphasizes training in professional practice more so than in
research productivity. Moreover, financial support for these graduate
students frequently entails a “pay back” requirement based on full-
time clinical service delivery to the exclusion of research careers upon
graduation (Indian Health Service, 2014). In answer to our second
research question (“What types. . .?”), much of the work is at the
earliest stages of development as indicated by the high percentage of
observational and open-ended inquiry in this literature. However, this
also reflects a stated preference for qualitatively inquiry with Indige-
nous research participants, a key reason for the adoption of qualitative
methods in many of the studies reviewed here (see also Wendt &
Gone, 2012). This absence of an accrual of knowledge across studies
may explain the disparity between our expectations and our actual
findings regarding how much literature exists at this time.
In answer to our third research question (“What major find-
ings. . .?”), there was a predominant concern with cultural adaptations
and their importance to treatment and retention. However, only two
controlled outcome trials were identified and much of the rest of the
literature was too scattered to yield strong conclusions. In answer to
the final research question (“What is currently known. . .?”), as we
have noted, it is difficult to provide a definitive characterization of
established knowledge about psychotherapy with Indigenous clients.
There is simply not enough empirical research—including replication
of questions and methodologies across studies—to draw well-
supported conclusions about any aspect of psychotherapy undertaken
with Indigenous populations from this research corpus.
Indigenizing Psychotherapy
These trends also speak to a broader tension within the literature at
this time. As noted earlier, some studies have found a sense of
community discontent with current evidence-based practice and its
potential application to treatment of Indigenous populations and the
methods that are used to establish them (Gone, 2009; Goodkind et al.,
2011). Indeed, in response to institutional pressures to implement
empirically supported treatments, some Indigenous mental health
professionals and advocates have insisted that “we already know what
works in our communities” (Gone & Alcántara, 2007, p. 360) and
proposed that Indigenous therapeutic approaches (such as traditional
healing) should be accorded legitimacy in clinical contexts despite the
lack of scientifically controlled outcome research. In contrast to
evidence-based practice, such advocates contend that centuries of
cultural tradition support the use of traditional therapies on the
grounds of “practice-based evidence” (Isaacs, Huang, Hernandez, &
Echo-Hawk, 2005). Thus, some efforts have been made to juxtapose
these “Indigenous ways of knowing” with current scientific ap-
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12
POMERVILLE, BURRAGE, AND GONE
proaches to knowledge (e.g., Gone, 2016; Rowan et al., 2015). Craft-
ing such approaches specifically for use in mental health treatment
evaluation in a way that will be acceptable to both Indigenous com-
munity members concerned with cultural reclamation and psycholo-
gists concerned with empirical rigor remains a serious hurdle, how-
ever (Gone, 2009).
Furthermore, whether and how to adapt psychotherapy for Indig-
enous clients remains a topic of debate that is visible within this
literature. There are at least four positions that mental health research-
ers and professionals might adopt regarding the role and significance
of cultural adaptation for psychotherapy with Indigenous populations.
One position is that mental health services for Indigenous clients are
generally of such low quality that promoting empirically supported
treatments in these settings without the distraction of cultural adapta-
tion is already challenging enough. In this view, established treat-
ments might be expected to benefit Indigenous clients (Miranda et al.,
2005), and so dissemination and implementation of empirically sup-
ported psychotherapeutic treatments such as motivational enhance-
ment therapy for alcohol use disorder or exposure therapy for PTSD
in clinical settings that serve Indigenous populations would be the
most pressing priority. A second position is that mental health services
for Indigenous clients require sophisticated in-session adaptations of
empirically supported treatments by therapeutically deft clinicians
who have been trained to think fluidly about culture and context. In
this view, cultivation of cultural competence among clinicians would
be the order of the day (Sue, Zane, Nagamaya Hall, & Berger, 2009),
in which professional training includes orientation and experience to
cultural differences in general and Indigenous cultural practices spe-
cifically (Gone, 2004).
A third position is that mental health services for Indigenous clients
require significant adaptations prior to dissemination in these settings
to ensure cultural relevance and resonance. In this view, established
treatment protocols would benefit from symbolic or structural adap-
tation in response to local cultural orientations and practices prior to
delivery with Indigenous clients. For example, Venner, Feldstein, and
Tafoya (2006) adapted motivational interviewing following consulta-
tion with tribal community constituents to achieve greater cultural
relevance with this approach. Finally, a fourth position is that mental
health services for Indigenous clients are culturally “Eurocentric,” and
any benefit that empirically supported treatments might yield within
these settings are offset by their assimilationist tendencies such that
bottom-up development of Indigenous therapeutic alternatives is the
order of the day. Development of such alternatives requires extensive
community consultation that can result in unusual, albeit self-
determined, treatment approaches in Indigenous community settings.
For example, Gone and Calf Looking (2011, 2015) created and
piloted a radical alternative to the treatment of substance use disorders
on the basis of local therapeutic traditions among the Pikuni Blackfeet
in Montana.
On the basis of this view, it would seem that the first of these
positions is unpopular with stakeholders in Indigenous mental health,
but the scientific evidence is not strong enough to speak to any
conclusions about whether it is valid. It may be that even if cultural
components are not an “active ingredient” of psychotherapy with
Indigenous clients with mental illness, it is necessary to add adapta-
tions in order to make treatment acceptable enough that Indigenous
clients will participate. At the same time, we simply do not know
enough to suggest that empirically supported treatments validated
with other groups will work for Indigenous clients, or that Indigenous-
specific psychotherapy approaches would not be the better choice. An
expansive, systematic, and rigorous program of research will be
required to begin answering these questions and to address these gaps
in the literature.
Limitations
There were several limitations apparent in this review. Our search
strategy considered several Indigenous populations together; how-
ever, only five empirical studies from outside North America were
found. Future reviews may benefit from finding access to and utilizing
databases specific to mental health in other nations. However, a recent
systematic review of child psychometric measures across these same
Indigenous populations by Australian researchers also found that little
work was published in Australia, Canada, and New Zealand, with the
bulk of the studies focusing on Indigenous groups in the United States
(Williamson et al., 2014). The studies from other nations that were
identified described similar concepts surrounding psychotherapy with
Indigenous clients of the Pacific and those of North America, dem-
onstrating the potential of taking a broad view on Indigenous mental
health treatment.
The definition of psychotherapy limited treatment approaches un-
der consideration to individual clinicians or small teams of clinicians,
of no more than five. Some studies included here may have included
larger teams, but could not be excluded because the number of
clinicians was not specified. In focusing on psychotherapy for mental
health, our review may have excluded some relevant counseling
literature. Preventive and supportive therapies intended for broad
populations with no current mental health concerns were intentionally
excluded, but research on these topics may have implications for
mental health and Indigenous wellness beyond the context of psycho-
therapy to which this study was limited. Finally, obvious limitations
exist in attempting to generalize so broadly across such a diverse set
of peoples. Caution is warranted in interpreting and extrapolating
from this review. The individual context of the psychotherapy client
is always vitally important to consider.
Conclusion
This review has confirmed that a sizable, albeit limited, body of
empirical research on psychotherapy with Indigenous clients exists.
Qualitative work and pilot studies compose the majority of the liter-
ature, with very few controlled outcomes trials. The inclusion of
cultural practices is viewed positively by those involved in Indigenous
mental health, but the extent to which these practices have a specific
effect on therapy is not well understood at this time. Despite the
inability to offer empirically supported treatment recommendations
on the basis of this review, these studies provide some potential future
research questions for psychotherapy researchers and researchers con-
cerned with Indigenous populations. Future research should investi-
gate the role of cultural adaptations in therapy with Indigenous clients
and the effectiveness of Indigenous-specific approaches to mental
health. New treatment evaluation research should address individual
psychotherapy approaches and treatments for disorders aside from
substance abuse. Research addressing the psychotherapeutic needs of
Indigenous populations is sorely needed at this time, and this review
may provide some specific direction for researchers taking up this
worthy challenge.
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13
PSYCHOTHERAPY RESEARCH WITH INDIGENOUS POPULATIONS
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Received September 15, 2015
Revision received July 26, 2016
Accepted August 1, 2016 
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