Ainu practice · Atlas

1. Introduction

Version followed: Ainu culture and spirituality as described by Japan's 2019 Ainu Promotion Act (Act No. 16 of 2019, official English translation), Upopoy (National Ainu Museum and Park, operated under the Foundation for Ainu Culture) and Ainu organisations, with outsider ethnography as attributed context; the psychotherapist's own work follows the DSM-5-TR (2022) Cultural Formulation Interview (CFI) and its DSM-5 (2013) Informant Version and Supplementary Modules.

"Ainu practice" is not a single therapy. It names the living culture, spirituality and historical healing practices of the Ainu, whom the 2019 Act describes as "indigenous people of the northern part of the Japanese archipelago, in particular Hokkaido" [source: Japanese Law Translation, Act No. 16 of 2019, Art. 1]. Upopoy describes Ainu spirituality as one that "holds that spirits dwell in every part of the natural world"; kamuy (spiritual beings, including animals, plants, fire, water, wind, mountains and rivers) are held to be everywhere and "always watching over humans" [source: Upopoy English site]. Outsider ethnography reports that illness was traditionally linked to improper treatment of the dead or of other beings, and that shamans (in Ainu, tusu, a term used in the scholarly literature) diagnosed and treated illness in trance; among the Hokkaido Ainu these were usually women, with male elders guiding the work and taking over healing after diagnosis, while among the Sakhalin Ainu shamanism was open to men and women [source: Encyclopedia of World Cultures, vol. 5, East and Southeast Asia (1993), "Ainu", an outsider account] [uncertain: secondary, unverified]. How far tusu practice continues today is [uncertain].

Who holds authority: Ainu people themselves and their own organisations and elders, not the state, museums or researchers. The Ainu Association of Hokkaido (founded 1946; Hokkaido Utari Association from 1961; Ainu Association of Hokkaido again from 2009 [source: Ainu Association of Hokkaido, Outline of the Association]) is the largest Ainu organisation and channels key welfare and scholarship support, but one scholar notes it is "not a representative body for the community as a whole" (about 2,300 members in 2016) [source: Morris-Suzuki 2018; Minority Rights Group]. Other Ainu groups and many unaffiliated Ainu people exist, so no single body speaks for every client.

The psychotherapist does not perform Ainu ceremony, prayer or healing, and this guide gives none of their content. The therapist's core idea of change is that distress is understood and eased when it is assessed in the client's own terms (identity, spirituality, family and community, the history of colonisation, assimilation and discrimination), when therapy does not repeat the dismissal and appropriation Ainu people have experienced, and when the client is supported, if they wish, to reconnect with Ainu community, language and culture through Ainu-led pathways [synthesis, drawing on the CFI's stated purpose and the sources above].

2. Framework

This is a framework for the therapist's culturally responsive work, not an Ainu protocol. Phases, session counts and transition criteria are [synthesis]; the CFI content is [source: APA DSM-5-TR CFI].

Phase 0. Preparation (before and outside sessions). Goal: the therapist learns the history (1869 annexation and renaming of Ezochi as Hokkaido; Meiji-era bans on Ainu language in schools and government and on many practices including traditional hunting and fishing; the 1899 Hokkaido Former Aborigines Protection Act; the 1997 Ainu Culture Promotion Act; the 2008 Diet resolution; the 2019 Act) and examines their own position, especially if they are ethnically Japanese (Wajin) [source: Minority Rights Group; Act No. 16 of 2019]. Move on when the therapist can discuss this history without needing the client to teach it.
Phase 1. Engagement and safety (sessions 1-2). Goal: a safe frame; ask about identity only if relevant and let the client name themselves. Many Ainu have hidden their identity, sometimes from their own children, and some learn of Ainu ancestry late [source: Duncan 2023]. Move on when the client has said what they want help with and how much (if at all) Ainu identity matters to it.
Phase 2. Cultural assessment (sessions 1-3). Goal: the core CFI (16 questions, four domains), plus the Informant Version and supplementary modules as needed [source: APA CFI forms]. Time required is [uncertain]; the field trial reports later CFIs took less time [source: Lewis-Fernández et al. 2017 abstract]. Move on when you can state the client's own name for the problem, causal ideas, supports, past help-seeking and expectations of you.
Phase 3. Formulation and differential diagnosis. Goal: a cultural formulation; distinguish spiritual experience held within the client's tradition from disorder, using DSM-5-TR and ICD-11 exclusions for culturally accepted practice. Move on when the formulation has been checked back with the client.
Phase 4. Collaborative plan. Goal: agreed goals and methods; with consent, links to Ainu organisations, municipal Ainu livelihood consultation staff, human-rights consultation, cultural centres or elders the client chooses. Move on when the client has agreed which links, if any, they want.
Phase 5. Treatment, integration and review. Goal: evidence-based treatment for any disorder, adapted to the formulation; integrate cultural experiences the client brings; revisit modules repeatedly, as the APA allows [source: APA Supplementary Modules]. End or step down when goals are met and community supports are in place.

Format: individual, with family or informants where the client consents; in Japanese (or the client's language) unless the client wishes to use Ainu terms, which the therapist accepts without demanding translation [synthesis].

3. Guiding principles

Ainu people hold authority over Ainu culture. Practical meaning: name Ainu organisations and elders the client chooses as the source on Ainu matters, not textbooks or yourself [source: Act No. 16 of 2019, Art. 3, respect for "the Ainu people's own intentions" (paraphrase); synthesis].
No single spokesperson. Practical meaning: do not assume the client belongs to, or agrees with, the Ainu Association of Hokkaido or any group [source: Morris-Suzuki 2018].
Identity is the client's to disclose. Practical meaning: never record or announce Ainu identity without consent; concealment is often a response to discrimination [source: Duncan 2023; Morris-Suzuki 2018].
Attribute, do not adjudicate, spiritual concepts. Practical meaning: speak of kamuy, souls and spirits as the client and their tradition hold them, neither as fact nor as symptom [synthesis].
No ceremony, no appropriation. Practical meaning: do not perform, imitate, record or request details of ceremonies, prayers or tusu practice; do not use Ainu designs or rituals as therapy props [synthesis, informed by the history of remains and objects taken by researchers, Minority Rights Group].
Discrimination is real and unlawful. Practical meaning: treat reports of discrimination as credible; the 2019 Act, Art. 4, prohibits discrimination against Ainu people [source: Act No. 16 of 2019].
History is part of the presenting problem. Practical meaning: include dispossession, assimilation and language loss in the formulation when the client links them to their distress [source: Minority Rights Group; synthesis].
The CFI supports, but does not make, diagnosis. Practical meaning: use it alongside a full assessment, never as the sole basis for a diagnosis [source: APA CFI].
Avoid both pathologising and missing illness. Practical meaning: apply the cultural-practice exclusions for trance and possession, and still assess for psychosis, depression, substance use and risk [source: ICD-11 6B62/6B63; DSM-5-TR DID and OSDD as paraphrased in secondary sources].
Consent governs every link with community. Practical meaning: contact organisations, family or elders only with explicit, specific consent; in small communities confidentiality risks are high [synthesis].
Reconnection is offered, not prescribed. Practical meaning: language and culture programmes may support wellbeing, but the client decides whether to engage [source: Duncan 2023, a commentary drawing on non-Ainu evidence; synthesis].
Medicines go to the prescriber. Practical meaning: never advise on starting, stopping or combining herbal or prescribed medicines [synthesis].

4. Intervention inventory

All interventions below are the psychotherapist's own culturally responsive work. None is an Ainu healing practice. Example language is (illustrative) unless quoted.

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with any Ainu client, or any client who mentions Ainu ancestry [synthesis].
Steps: (1) Learn the core history from Ainu-led or official sources: Upopoy, the Foundation for Ainu Culture, the Ainu Association of Hokkaido, Hokkaido University's Center for Ainu and Indigenous Studies [source: Sapporo City related-links page]. (2) Note your own ethnic and institutional position (for example, a Wajin clinician in a Japanese public service). (3) List assumptions you hold (that Ainu culture is extinct, purely touristic, or uniform). (4) Take uncertainties to supervision, not to the client [synthesis].
Example language: (illustrative) "I know some of the history, but I don't know what it has meant for you or your family. I'd rather learn that from you, at your pace."
Watch for: asking the client to educate you; curiosity that serves your interest rather than their goals; romanticising or exoticising. Working: the client corrects you freely and brings cultural material without being asked [synthesis].

4.2 Respectful inquiry about identity

Purpose / when: at intake, when identity may bear on the problem. Many people with Ainu ancestry do not acknowledge it publicly because of discrimination, and official counts are considered serious underestimates [source: Morris-Suzuki 2018]; some families hid identity from their children [source: Duncan 2023].
Steps: (1) Ask an open question about cultural and family background, not "Are you Ainu?" (2) Accept the client's own word for themselves. (3) Ask what may and may not go in the record. (4) If ancestry is newly discovered or contested in the family, treat that as a possible focus of work [synthesis].
Example language: (illustrative) "Some people tell me their family background matters to what they're going through, and some don't. Is there anything about your background you'd like me to know?" / "How would you like me to write this in your notes, if at all?"
Watch for: fear of being recorded or identified; family conflict over disclosure; shame linked to past discrimination (in a 2008 Hokkaido University survey, 44.1% said discrimination had made them feel embarrassed about being Ainu [source: Morris-Suzuki 2018]). Working: the client decides disclosure and seems relieved, not exposed.

4.3 Core Cultural Formulation Interview (DSM-5-TR)

Purpose / when: at initial assessment, to clarify the problem from the perspective of the client and their social network: its meaning, sources of help and expectations of services [source: APA CFI]. APA describes it as for "any clinician" in "any care setting" [source: APA Section III].
Steps: follow the 16 questions in four domains, in your own words: (1) cultural definition of the problem (Q1-3); (2) cultural perceptions of cause, context and support, including the role of cultural identity (Q4-10); (3) cultural factors in self-coping and past help-seeking, including barriers (Q11-13); (4) cultural factors in current help-seeking, including preferences and the clinician-patient relationship (Q14-16) [source: APA CFI]. Use the official APA form; clinicians may reproduce it for their patients, but translation or modification needs APA permission [source: APA CFI]. A Japanese translation exists [uncertain: not verified].
Example language: (illustrative) "In your own words, what would you call what's been happening?" / "Have you talked with anyone in your family or community about it, and what did they say?" / "Is there anything about who I am, or about this service, that makes it harder to talk here?"
Watch for: Domain 4 may surface distrust of Japanese institutions, researchers or clinicians; receive it without defensiveness. The CFI is not the sole basis for diagnosis [source: APA CFI]. Working: you can summarise the client's own account and they agree with it.

4.4 CFI Informant Version

Purpose / when: when a family member or friend is involved and the client consents; 17 questions, starting with the informant's relationship to the client, then the same four domains [source: APA Informant Version, DSM-5 2013].
Steps: (1) Obtain the client's consent for what may be shared. (2) Interview the informant separately or jointly as the client prefers. (3) Note where the family's account differs, for example on whether Ainu identity or spiritual explanations matter [synthesis].
Example language: (illustrative) "From where you stand, what do you think is going on for them, and what does your family usually do when someone is struggling like this?"
Watch for: intergenerational differences over identity and disclosure; an informant speaking over the client. Working: you gain context without the client feeling bypassed.

4.5 CFI Supplementary Modules

Purpose / when: for in-depth assessment, as add-ons or standalone tools, at first evaluation, later or repeatedly [source: APA Supplementary Modules].
Steps: choose modules that fit: Cultural Identity (Ainu, Japanese, mixed or uncertain identity, language); Spirituality, Religion and Moral Traditions (kamuy, ancestors, how the client relates to Ainu spirituality, if at all); Explanatory Model; Social Network; Psychosocial Stressors (discrimination, poverty, rural employment); Coping and Help-Seeking (Ainu organisations, community centres, elders); Patient-Clinician Relationship; Older Adults (people who lived through intense assimilation pressure); School-Age Children and Adolescents; Caregivers [source: APA Supplementary Modules for module names; synthesis for the Ainu-specific focus].
Example language: (illustrative) "Are there spiritual or traditional ways of understanding this that matter to you or your family? You don't have to explain anything you'd rather keep private."
Watch for: do not ask for content of ceremonies or prayers; accept a refusal to explain. Working: you know whether, and how, spirituality is a resource for the client.

4.6 Explanatory-model inquiry (Kleinman)

Purpose / when: when the client's understanding of cause or treatment may differ from biomedical or psychological models [source: Kleinman, Eisenberg and Good 1978, via Tanenbaum handout and Dinos et al. 2017].
Steps: ask, in your own words, about eight areas: what the client calls the problem; its cause; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment they think they should receive; the chief problems it has caused; what they fear most [source: Tanenbaum handout, paraphrase]. Record answers in the client's words and use them in the formulation.
Example language: (illustrative) "What do you think caused this?" / "What kind of help do you think would make a difference?" / "What worries you most about it?"
Watch for: the client may give a biomedical answer first and a spiritual or relational one only once trust grows (for example, a link to the dead, to kamuy or to family history); ethnography reports illness traditionally being linked to improper treatment of the dead or other beings [source: Encyclopedia of World Cultures, "Ainu", outsider account] [uncertain: secondary, unverified]. Hold such explanations as the client's, alongside your own. Working: the client sees their view reflected in the plan.

4.7 Cultural concepts of distress

Purpose / when: to check whether the client's idioms of distress or causal explanations fit what DSM-5-TR calls cultural concepts of distress (idioms, explanations or perceived causes, and syndromes) [source: APA Section III].
Steps: (1) Listen for the client's own words for distress (in Japanese or Ainu). (2) Do not force them onto a DSM-listed concept; none of the concepts in the secondary list of DSM-5-TR cultural concepts cited here is Ainu [source: UNMC slides; the DSM-5-TR list itself is uncertain]. (3) Note any culturally specific idiom in the formulation and ask what it means to the client [synthesis].
Example language: (illustrative) "When you say it feels like that, what does that mean in your family? How do people usually talk about it?"
Watch for: importing Japanese majority idioms (for example hikikomori) without checking fit; treating Ainu spirituality itself as a syndrome. Working: the idiom helps you and the client talk about the problem.

4.8 Distinguishing culturally held spiritual experience from disorder

Purpose / when: when a client reports experiences such as sensing spirits or kamuy, meaningful dreams, messages from the dead, or trance-like states.
Steps: (1) Ask whether the experience is understood and accepted within the client's family, community or tradition. (2) Ask whether it is wanted or unwanted, and whether it causes distress or impairment. (3) Apply the exclusions: ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice [source: ICD-11 text via findacode and PMC9199574]; DSM-5-TR dissociative identity disorder and dissociative trance are excluded when the experience is a normal part of a broadly accepted cultural or religious practice [source: DSM-5 wording via PMC9199574; DSM-5-TR paraphrase via Lewis 2023; exact DSM-5-TR wording uncertain]. (4) Assess for psychosis, mood disorder, substance use, trauma and risk in the usual way. (5) Where unsure, consult, with consent, someone the client recognises as knowledgeable in their community [synthesis].
Example language: (illustrative) "In your family or community, how would people understand an experience like this?" / "Is it something you welcome, or something you want help to stop?"
Watch for: many Ainu clients may not hold traditional beliefs at all; do not assume. Red flags for illness: functional decline, distress the client and family see as illness, disorganisation, risk. Working: neither the experience nor any illness is missed or mislabelled.

4.9 Asking about help from elders, community and cultural practice

Purpose / when: during help-seeking questions (CFI Q12-15) and whenever the client mentions community or spiritual help.
Steps: (1) Ask neutrally whether the client has sought help from family, elders, Ainu organisations or cultural activities. (2) Ask what helped and what did not. (3) Ask whether they would like you to coordinate with anyone. (4) Do not ask for details of ceremonies or prayers [synthesis].
Example language: (illustrative) "Some people find support through family, community or cultural activities. Has anything like that been part of your life, and has it helped?"
Watch for: fear that you will disapprove; or the opposite, a client who feels cut off from community and ashamed of it. Working: the client talks openly about all their sources of help.

4.10 Collaboration and referral with Ainu-led and Ainu-specific services

Purpose / when: when the client wants practical, cultural or human-rights support beyond therapy.
Steps: (1) Ask which kind of support the client wants. (2) Offer options as published: the Ainu Association of Hokkaido, which describes itself as an organisation of Ainu living in Hokkaido that works to improve Ainu social status and to preserve, transmit and develop Ainu culture, with loans, education and employment work, culture programmes, and management of the Hokkaido Ainu Center in Sapporo for the Hokkaido Government [source: Ainu Association of Hokkaido, Outline of the Association]; its 2024 plan describes livelihood consultation staff (seikatsu sōdan-in) in municipalities where Ainu live, education consultants in municipal boards of education for bullying, discrimination and study difficulties, employment promotion staff at Hello Work offices, and certification of eligibility for a scholarship programme for Ainu living outside Hokkaido [source: Ainu Association of Hokkaido, FY2024 business plan]; Ainu livelihood consultation staff (Ainu seikatsu sōdan-in) placed by Hokkaido municipalities that run community centres (seikatsukan); the Foundation for Human Rights Education and Awareness Promotion's free telephone line for Ainu people facing harassment, discrimination or privacy violations; Legal Affairs Bureau human-rights consultations (in person, phone, internet, LINE); for culture and language, the Foundation for Ainu Culture, Upopoy in Shiraoi, the Hokkaido Ainu Comprehensive Center and the Hokkaido Museum [source: Cabinet Secretariat consultation page; Sapporo City related-links page]. (3) With written consent, coordinate; share only what the client agrees. (4) If the client names an elder or community member they trust, ask how they want that person involved [synthesis]. (5) Outside Hokkaido, note the 2019 Act's principle that Ainu live throughout Japan [source: Act No. 16 of 2019, Art. 3]; the Association's 2024 plan aims to set up a fair and transparent certification process for Ainu living outside Hokkaido [source: Ainu Association of Hokkaido, FY2024 business plan]; which local Ainu groups operate outside Hokkaido is [uncertain], so ask the client.
Example language: (illustrative) "There are a few Ainu-specific services, some practical, some cultural, some for discrimination. Would any of them be useful, or would you prefer we keep this between us for now?"
Watch for: the Association is not representative of everyone [source: Morris-Suzuki 2018]; some clients will want nothing to do with organisations. Evidence that collaboration between health workers and traditional or faith healers can improve outcomes comes from West Africa, not from Ainu settings (COSIMPO trial; Ghana prayer-camp trial) [source: Gureje et al. 2020, The Lancet (COSIMPO); Ofori-Atta et al., Br J Psychiatry 212(1)]; do not over-generalise. Working: the client uses the link and reports it as their own choice.

4.11 Working with discrimination and racism

Purpose / when: when the client reports discrimination in marriage, education, work or online, or carries its effects [source: Minority Rights Group; Morris-Suzuki 2018].
Steps: (1) Believe and validate; name it as discrimination when the client does. (2) Separate the event, its meaning and its effects (shame, hypervigilance, concealment). (3) Offer, if wanted, the human-rights routes in 4.10, and for online abuse the Illegal and Harmful Information Consultation Center or the Online Defamation Hotline [source: Cabinet Secretariat consultation page]. (4) Use standard evidence-based methods for resulting anxiety, depression or trauma, adapted to the formulation [synthesis].
Example language: (illustrative) "What happened to you was discrimination, and it is prohibited under the law. How has it affected you since?"
Watch for: self-blame; minimising to protect the therapist; your own discomfort if you belong to the majority group. Working: shame lessens and the client's options feel wider.

4.12 Historical and intergenerational trauma in the formulation

Purpose / when: when the client links their distress to family or community history: dispossession of land, assimilation, language bans, forced farming on poor land, removal of remains and grave goods by researchers [source: Minority Rights Group].
Steps: (1) Let the client lead on how much history to bring in. (2) Map family history and its effects (for example silence about origins, loss of language). (3) Link history to present patterns only with the client's agreement. (4) Pair with present-focused coping and strengths, including survival and revival [synthesis]. Repatriation of remains (Hokkaido University returns in 2016 after a 2012 lawsuit; a skull returned from Berlin in 2017) may stir grief and anger [source: Minority Rights Group].
Example language: (illustrative) "You've mentioned your grandmother never spoke about where the family came from. How do you think that silence has shaped you?"
Watch for: the term "intergenerational trauma" is a clinical frame, not an Ainu term; use it only if it fits for the client [synthesis]. Working: history becomes understandable rather than overwhelming.

4.13 Supporting identity and cultural reconnection

Purpose / when: when the client wishes to explore or reclaim Ainu identity, language or community.
Steps: (1) Explore what reconnection would mean and what feels risky. (2) Point to Ainu-led or official public routes the client can choose: language courses and radio, Upopoy programmes, cultural centres [source: Duncan 2023; Upopoy]. (3) Support the client through mixed feelings (belonging, not feeling "Ainu enough", family reactions) [synthesis]. (4) Do not direct the client to ceremonies; access to ceremony is a matter for Ainu communities and their elders [synthesis].
Example language: (illustrative) "What would it be like to learn more about that part of your family? What would you hope to find, and what worries you?"
Watch for: Duncan's link between heritage language and mental health draws on evidence from other Indigenous peoples, not Ainu data [source: Duncan 2023]; tourist-oriented settings may feel commodified [source: Duncan 2023]. Working: the client's sense of belonging grows on their own terms.

4.14 Interpreters and cultural brokers

Purpose / when: most Ainu clients will speak Japanese; Ainu is critically endangered (two native speakers reported) [source: Duncan 2023]. A cultural broker may still help with context.
Steps: (1) Ask the client if they want anyone to help explain cultural matters. (2) Choose a broker the client trusts and agrees to; check for conflicts in small communities. (3) Agree confidentiality in advance [synthesis].
Example language: (illustrative) "Would it help to have someone you trust, who knows the community, join us for part of a session?"
Watch for: brokers being asked to speak for all Ainu; confidentiality breaches. Working: the formulation becomes clearer without loss of privacy.

4.15 Family and community work

Purpose / when: when family disagreement over identity, disclosure or spiritual explanations is part of the problem.
Steps: (1) With consent, hold a family session or use the Informant Version (4.4). (2) Invite each generation's account. (3) Look for shared values beneath disagreements [synthesis].
Example language: (illustrative) "It sounds as if each of you has had a different way of living with this history. Could we hear each one?"
Watch for: pressure on younger members to disclose or to conceal. Working: family members can disagree without rupture.

4.16 Integrating cultural or spiritual experiences

Purpose / when: when the client brings an experience from cultural participation or a spiritual experience they want to make sense of.
Steps: (1) Ask the client what the experience meant to them. (2) Explore effects on mood, relationships and identity. (3) Do not interpret its spiritual content; that belongs to the client's tradition and those it recognises [synthesis].
Example language: (illustrative) "What stayed with you afterwards? How has it changed how you see things?"
Watch for: distress after the experience, which may need assessment; never ask the client to describe restricted content. Working: the experience is integrated into the client's life story.

4.17 Safeguarding and medical safety

Purpose / when: whenever there is risk of harm to the client or others, including children, or delay of urgent medical care.
Steps: (1) Follow standard risk assessment and local safeguarding law. (2) Distinguish real harm from cultural difference by consulting supervisors and, with consent, people the client trusts. (3) Never advise on starting, stopping or combining herbal or prescribed medicines; refer to the prescriber or doctor [synthesis]. (4) For suicide risk, use current standard practice, including safety planning and lethal-means counselling (safe storage and removal) [synthesis].
Example language: (illustrative) "I'd like you to tell your doctor about everything you're taking, including traditional remedies, so they can check it's safe together."
Watch for: stereotyping Ainu families as risky; missing risk from fear of seeming racist. Working: the client is safe and stays engaged.

5. Handling problems

The sources do not address clinical problems in therapy with Ainu clients; all guidance here is [synthesis] unless tagged.

Client does not want identity discussed. Respect it; keep the CFI's identity questions open-ended and return only if the client links identity to the problem. Do not record identity without consent.
Client asks the therapist to explain or perform Ainu ceremony, prayer or healing. Decline clearly and warmly; say that these belong to Ainu communities and those they recognise, and offer to help the client find Ainu-led routes (4.10, 4.13). (Illustrative: "That isn't mine to do or teach. I can help you think about who in the community you might ask, if you want.")
Distrust of the therapist or service (rupture). Name the history of research and institutional harm without making the client manage your guilt [source for history: Minority Rights Group]; use CFI Q16 and the Patient-Clinician Relationship module; offer choices about pace, recording and who else is involved. Repair by acting on feedback.
Therapist error (stereotyping, exoticising, treating culture as a museum piece). Acknowledge it specifically, apologise once, ask what would help, take it to supervision.
Stuck: client caught between identities or family loyalties. Shift from resolving to holding both; use family work (4.15); externalise the pressure of discrimination rather than locating the problem in the client.
Overwhelm when history is raised. Return to the present, use grounding and stabilisation from standard trauma care, and pace historical work in small amounts with the client's consent.
Non-adherence (missed sessions, not using referrals). Explore practical barriers (cost, distance in rural Hokkaido, work in seasonal industries; Ainu households had lower average income in the 2008 survey [source: Morris-Suzuki 2018]) and fit with the client's model (4.6). Adjust format before concluding disengagement.
Diagnostic uncertainty about spiritual experiences. Use 4.8; seek consultation, with consent, from someone the client trusts in their community; keep monitoring rather than deciding early.
Disagreement with an Ainu organisation or a referral. Do not take sides in community politics; return to what the client wants. Remember that no organisation represents everyone [source: Morris-Suzuki 2018].
Small-community confidentiality. Clarify who may be told what; avoid informal contact with community figures without consent.
Herbal or traditional remedy alongside medication. Do not advise; encourage the client to tell their prescriber, and with consent tell the prescriber yourself.
Requests to use Ainu motifs, words or objects in therapy. Only if the client initiates it with their own items and meanings; the therapist does not introduce them.

Sources

Web sources:

Books and papers cited:

Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258.
Gureje O, Appiah-Poku J, et al. (2020). COSIMPO cluster randomised trial. The Lancet.
Ofori-Atta A, et al. Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. British Journal of Psychiatry 212(1). Year [uncertain].

Uncertain points: whether Ainu organisations publish their own research-ethics guidance [uncertain] (the Association's 2024 plan commits it to a round table on research on Ainu remains and grave goods with the Japanese Society of Human Genetics, the Japanese Archaeological Association and the Japanese Society of Cultural Anthropology, and to responding to research ethics committees; the Japanese Society of Cultural Anthropology's 2024 statement apologises for past research attitudes and reaffirms its 1989 position calling for research based on sufficient communication with Ainu people, sharing of results and training of Ainu researchers); the current status of tusu practice [uncertain]; whether an authorised Japanese translation of the CFI exists [uncertain].

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