An underlying conflict that shapes all the characters to some extent is that between Native American (called in Canada "First Nations") and white society. David Plume, a militant Native American activist in the American Indian Movement (AIM), shows strong distrust of white society and reputedly once killed a white man. In contrast, Jake Pretty Weasel both internalizes his identity issues and exhibits conflict with his wife through aggression and violence, before taking his own life.

Rose Sampson, who is Native, had suffered internal conflicts because she married a white man, but the two of them came into conflict with social rules because he was not allowed to live on Blackfoot lands, and she moved with him to Canada. Further, their sons, Will and Jake, grew up torn between the two types of society. Will had been living in Toronto and had a white girlfriend, but did not feel fully at home in a city where he constantly fought against stereotypes; he has returned to Medicine River. Another aspect of Will’s internal conflict is his identity issues stemming from his father’s abandonment and never having known him. Will also comes into conflict with his brother, Jake, over their different approaches to commitment to Native life.