Diana Kopua’s life resembles the stories she uses in her work. From a psychiatric community nurse to the head of the department of psychiatry for Hauora Tairawhiti in Gisborne, New Zealand, her 13-year long, arduous journey is both deeply personal and profoundly political. Kopua says she did this to “become a wedge that kept the door open to allow for indigenous leaders” in her world to change the system. One may call her a storyteller, but a story-gatherer might be more appropriate.
As a psychiatrist, Kopua deals in human distress but her interest does not lie in neat psychiatric classifications; instead, she focuses on understanding suffering through Maori creation stories, Purakau. She has developed Mahi a Atua, “an engagement, an assessment, and an intervention” to address the mental distress and suffering among the Maori of New Zealand. Mahi a Atua is not just a set of techniques or a culturally sensitive new therapy, but a drastically different way of conceptualizing the lived experience of the Maori.
Recently, along with art and culture expert Mark Kopua and critical psychiatrist Pat Bracken, she published a paper on this approach in Transcultural Psychiatry. Their work can be seen as an alternative to Western pharmaco-therapeutic interventions currently being promoted throughout the global South via the global mental health movement.
Researchers have critiqued the exporting of Western psychiatric practices, often citing the famous WHO study that reported better outcomes for people diagnosed with mental disorders in the developing world. As the only Ngati Porou (a Maori nation) psychiatrist in the world, working with a population known for poor mental health outcomes, Kopua’s work offers insight into what can be learned from local, Indigenous, and traditional healing methods.
There are many now calling for a “paradigm shift” in Western psychiatry, and in our interview, we covered topics ranging from the specifics of the Mahi a Atua approach, the global mental health movement, and the importance of language and narratives in how we understand our world and ease our suffering.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ayurdhi Dhar: Can you tell us what Mahi a Atua is and how the approach works?
Diana Kopua: I developed Mahi a Atua in the mid-nineties. At that time, I was a psychiatric community nurse working attached to a Maori mental health service. Kaupapa Maori service is a service that is developed to specifically grow and sustain Maori approaches for Maori who come into mental health services.
Pre-colonization we had a strong understanding and connection with our relationship and our position in the environment, with the natural elements, and now many of us as Maori are disconnected from our culture, from our language, and our knowledge of our ancestry. I had just completed a total immersion Maori language course, which is where I learned these stories. When I went back to work in mental health, I saw how valuable these stories would be in conversations with people who were coming in with distress.
I then went on to work with adolescents. The more I shared these stories, the less I used traditional psychiatric assessment tools. I guess it felt right. We were in the right environment to be able to test these ideas, and it worked. The service became involved in training psychiatric registrars, the doctors training to be psychiatrists.
Most of the registrars, not being indigenous to New Zealand, nor born in New Zealand, were fascinated with Maori culture. But through the psychiatric assessment, they got to pathologize Maori. There was some reluctance, even from my Maori colleagues. They felt uncomfortable or lacked confidence in their Maori identity; they would resort back to the Western frames of knowledge. So, we decided to involve ourselves in Mahi a Atua and present it to a national forum.
We presented it nationally, we got some really good feedback, but what I noticed is people continued to look to the psychiatrist and the psychologist for the answers and to discuss the problems from a Western perspective. I decided to go to med school to become a psychiatrist to gain power. During that journey, I met my husband Mark in 2009, who is the other author [on the research article]. The joining of us as a couple is inseparable to the joining of his strength in his world and mine in the psychiatric world with the same agenda, which was that our Maori ways of knowing should be front-footing this community and the issues that pertain to Maori.
When you talk about how we utilize it, it’s actually about us as individuals in our community indigenizing our spaces. How do we ensure that our knowledge system is prioritized? To do that we have to remain active learners. Even though we might be experts in psychiatry, we’re not experts in the way of knowing that is indigenous. Therefore, when we’re working with Maori, how do we maintain this state of active learning? I don’t see that that often with psychiatrists.
Also, people who are using Mahi a Atua try to embrace negative feedback. In 2009 I came across Scott Miller and Barry Dunkin’s approach of feedback informed treatment. That resonated with me because to grow our collective performance in developing Mahi a Atua, we needed to learn ways of being able to receive negative feedback and give negative feedback.
When it came to individuals and working with families in distress, it followed a particular format, which is to offer a Karakia, an incantation or a prayer consisting of what the family valued, not of what we did. As a system, we decided that we would address institutional racism and promote indigeneity by going back and learning and, reinstating our traditional prayer. Then we will tell you who we are and where we are from. The objective is to connect, to find a connection.
After we do that, and very similar to Open Dialogue, it is about finding the meaning behind the distress, having a shared dialogue. Then, one of the two coworkers in the room will draw, and the other one will write a story. We use our creation stories, and some of them can take two minutes, some ten. Different Atuas (Maori gods) are personifications of the natural environment. You can use these as a psychological, structural framework. When we finish hearing the story, we then have a conversation: getting curious about the characters in the story and what resonated most with you. The objective is to try and shift your lens to think about the problem from a different perspective and listen to each other.
We have a saying “nothing about the families without the families,” so we have a conversation with each other and allow the families to listen and to respond to thoughts, and then we collectively weave together some ideas about what the next step is. Tolerating uncertainty, believing in spirituality and relationship, and valuing a connection to story; our connection to our creation stories strengthens our connection to each other and then creates a space that allows families who are in distress to narrate their own story. In essence, that’s Mahi a Atua.
Dhar: What is the importance of language, of words we use to define experience, in all of this?
Kopua: My father grew up in a small town on the east coast of the North Island, Tikitiki. He and many others were punished for speaking their native tongue. So, at home, they spoke the language Maori, and that’s how they would conceptualize their emotion and their experience. With psychiatry, when we know that you are severely sad, we’re looking for it to fit into the right criteria. But here we find the meaning behind that distress but without imposing a knowledge system that is foreign to our country.
Mahi a Atua is being able to reinstate what was taken from us so that we can reconceptualize and reimagine what it’s like for us to feel as a people who were colonized. We had land, language, and culture taken away from us.
When we are asked to talk from a word, that word never translates well into a Maori word well. When you’re continuously pathologizing indigenous people who are expressing a reality of being colonized, then my job, as a psychiatrist, is to make them aware of the political context that psychiatry and psychology sit within. So, as we share stories, language matters so much. We find phrases and keywords that show some Maori gods experienced distress and problems too.
Some amazing things come out of the stories, for example, noho tatapu, is a word for being in a state of restriction referring to the time when our primal parents, the sky and the earth, were held in a tight embrace. Over time they became frustrated with the tightness and the lack of movement. While we share these stories, people start to realize that when families come into our office, they’re in a state of noho tatapu. Hearing that story and allowing them to understand the restriction and the meaning behind it works on so many different cultural, political, and social levels, and also introduces a new language for us to utilize, to conceptualize a new way of understanding distress that is unique for us as colonized Maori.
Dhar: We live in a time of increasing cultural homogenization. So, where do you see this approach going, an approach that is based upon a connection to the past, and not to “modern” psychiatric practices?
Kopua: We are quite hopeful. We live in a small town with just under 50,000 people. We formed a critical mass. It became a movement. Social media has become our friend; we are able to disperse and join hands with those people who want to promote indigenous ideology to change the pathetic outcomes in our society for Maori.
All we did was created a critical mass, and it’s gaining momentum. We’re not the only ones. The Waitangi tribunal just released the recommendations about the Primary Health Organization being racist, and that’s holding the crown to account, and we are excited about that.
Dhar: Some might ask how local can you go? Today it’s a group of 50,000 people. Do you start developing new knowledges for groups of 10,000 and 15,000? Is this feasible?
Kopua: The voices from critical psychology and psychiatry are saying that families have the solutions. They have the resources within them. We need to design the system that respects and validates them as the solutions. I believe communities have the solutions to their problems, and we need to think about how we invest. We don’t need to be the answer. I think that is paternalistic. We know now with this service that we developed that we have halved the number of young people who needed to be referred to secondary services.
We have results. We stopped diagnosing, which means that we stopped making the doctor as the thing we needed to go to. We stopped needing medication. What has been done to our communities is that they are convinced that we, the psychiatrists and psychologists, are the experts and we must undo this.
I don’t think many psychiatrists disagree that it has become ridiculous. I don’t think it’s about doing away with psychiatry and psychology per se, but I do think that there are some gatekeepers sitting at all tiers that hold on to the psy-disciplines. At an individual level that they have spent a lot of time and money investing in these tools to equip them to help the community, so to be now told by people like me that it’s not helpful and that it’s damaging is a threat to the professional integrity and the professional identity.
Dhar: I think you have called it a one-way stream of expertise.
Kopua: Yes, and here in New Zealand, it takes such a long time to actually exit services, especially if you’re a Maori, the moment you put your foot in the door, you have a huge chance of a bad outcome.
Dhar: I read about that. The diagnostic and outcome figures are terrible for the Maori. Do you think they are real figures or the results of institutional racism and colonization?
Kopua: They’re all of the above. If we didn’t have the DSM or the ICD, what would it look like? The service that we have developed, and there is a formal public report; it tripled the number of Maori who self-referred into the service for help. At a time where the governments are looking for how to increase access, we did that.
They’re not being pathologized. The outcomes are pretty good: inpatient admissions have been reduced, fewer people are under compulsory treatment now. But in that same report, evaluating that service, you have general practitioners and primary health organizations and clinicians who might not like that shift.
Dhar: There was pushback when you were trying to talk about this?
Kopua: So, at a national level, there are just over a dozen indigenous Maori psychiatrists. And one of my colleagues had quite a few people ringing him saying, “What’s Dr. Di up to down there?” Also, our PHOs are private, the Primary Health Organization. They are not local to our community. What we’ve had is a disconnect from the data and what they are doing; the national statistics that show inequity. That created some huge pushback which gets in the way of us who are trying to revolutionize the way that we work.
Mahi A Atua was considered to be something that didn’t give people a choice. And yet, the formal report shows that we saw people sooner. We involve families more and use feedback informed treatment. Our outcome measure was actually valuing family voice. That wasn’t appreciated because I believe institutional racism has us all thinking that the current configuration of the systems and the resources are allocated fairly.
Dhar: How does your approach and its underlying ethic fit in the critique that has arisen around the global mental health movement?
Kopua: The strengthening of the classification system, the DSM is a perpetuating of colonization without a doubt. The global mental health movement and the WHO, they want better outcomes. The policies, however, do not reflect the lived experience of those people who are colonized. And they need to.
If we acknowledged that the classification system is doing more damage to Maori, then we have to address the question, “What needs to happen next?” And it’s more than just the classification system. It’s more than psychiatry. If you look at our education system, our criminal justice system, our ministry of children, and social development, the iniquities are throughout all of those sectors. Working as collectives is absolutely essential. Coworking allows us to tap our colleague on the shoulder and say, “Hey, I’m not sure the family understood that” or “Hey, I think I saw you talked over the family.”
How the classification system impacts our community’s confidence is through the myth of meritocracy, which is that if I work hard enough, I can achieve everything that I desire. It’s not true. And I guess that’s what Mahi a Atua is about. Some tribes were forced off the land overnight. Poverty is the real issue, but we’re impoverished for a reason. And so colonial history and the meaning behind it, it’s a huge part.
When we meet people coming in because they might be depressed or have an anxiety disorder, it’s a disconnected way of looking at it. And I think it’s disconnected because we are so connected to the mental health act, the diagnostic tools, and medication, and when we think that we’re being holistic, that means CBT.
Dhar: What is something that would be considered not necessarily problematic among the Maori, but the moment the language is translated, it becomes a disorder?
Kopua: Let’s go straight to hearing voices. Pre-colonization most of us as indigenous people had a connection to the spirit world, but it’s hard to fathom right now. Can you imagine a child being able to tell their parents freely that they heard voices? But our reality is the moment a child tells their parents that they hear voices, the parents will want him to push that statement out like he didn’t say it. They are going to tell them, “Don’t tell anyone else.” This is for those of us that are disconnected or don’t have any pathway to follow to learn more about this in a spiritually enriching way.
Most of the psychiatrists agree that culture matters but the structures and the way that we are resourced through funding has everything to do with the diagnoses and this concept of evidence-based treatments. No one’s interested in the evidence that’s found in practice, practice-based evidence. But I know that our spiritual healers have so many anecdotes of families who get fantastic outcomes from them. Because it’s not something that we talk about openly, publicly, how the hell are we meant to even grow?
Dhar: In my research in very rural parts of the Himalayas, there was a woman whose mother used to hear voices and see people dancing while she was farming. She would dance with them instead of feeling distressed or fear.
Kopua: As indigenous psychiatrists coming into a community, where the majority of the population are Maori, a significant proportion of the clinicians are Maori, but the people who make all the important decisions, are from overseas. What I noticed is that when I came in, you may as well have said that I was hearing voices. I was just having this little chuckle to myself because I thought, well, I may as well have been hearing voices and you people couldn’t hear them, and you didn’t want to hear them, and you just wanted to shut the voices down.
I was thinking of how isolating that can be, but what if you’re in a community that values that experience. My cousin is a voice hearer. I have nieces and nephews and friends; I have learned from their experience.
Dhar: It opens up a whole set of responses to the experience of voice-hearing other than just fear. Are you aware of any similar work across the world that excites you?
Kopua: I know you mentioned Open Dialogue; I think that their work is amazing. I just wonder though about indigenous populations. Open Dialogue is great. I don’t know that when you’re bringing it into another country, whether we are getting it right. I think that communities have so many solutions, but we don’t get enough time.
Dhar: You’ve talked about the historical context, like the Tohunga Suppression Act. Can you speak a little bit about that?
Kopua: It contributed to the reduction and the number of Tohunga who contributed to healing. The Tohunga Suppression Act contributed to the demise of facial Mukku, of our cultural arts. And so being able to reinstate those arts is collective healing. To bring back our language is collective healing.
The legislation in New Zealand is colonization in action. We had our Maori mothers who were told that breastfeeding was dirty, not just in public, just doing it. I told you about not being able to use our language. We weren’t allowed to buy land as a collective. That’s still going on today. We’re building motorways through people’s indigenous lands.
When people come from overseas, and they don’t have an understanding of the impact of colonization on indigenous people, I think that they actually themselves perpetuate racism. They know the answer because they are experts in psychiatry. That goes against everything that I value and that I believe in. So really, I’m considering turning away from psychiatry. To addresses individuality, meritocracy; it restores our histories.
Dhar: What do you have to say to people who say we can integrate Mahi a Atua with psychiatric knowledge, or with something like CBT?
Kopua: All of our ideas are adjuncts. They are additional to, and even though they are with the best intention, they are adjuncts, and it’s not okay. In fact, in the service that we developed, it’s the mainstream service, the front door for those in distress. It’s a Maori methodology, but it’s a mainstream service. We’re flipping it on its backside and we made it the mainstream.
I have this set of knowledge, and I think it’s what we call clinical knowledge. But what does the word ‘clinical’ mean? There is this expectation that clinical is Western. We’ve been trying to find a word that takes out clinical because we often use that word to validate our basic assumptions that are absolutely racist, with no idea that it’s come from a racist space.
Dhar: Can you give me an example of that?
Kopua: A 30-year-old Maori man whose mother works in a high-end organization and the father is separated. They wanted Mark and me. In our service, you can ask for who you want. So, we underwent the process with them. This man who was suicidal, so down and in a dark space, came alive as he’s listening to the story.
Now, he comes into our service, and we measure him, and he does really well. But for the PHO, who we were meant to be working in partnership with, they wanted documentation on clinical pathways for someone like that. And to say that we did Mahi a Atua means that there is a clinical risk. Because we didn’t do a clinical assessment, but from a Maori paradigm, we did everything that is consistent with what we value. The family and the man were engaged, and they came back again and again. And one of the problems we have for Maori is a) they walk in too late and b) they stop coming. That is from a system that values clinicians who behave clinically.
Dhar: This happens with schizophrenia, that people stop coming in for treatment and taking their medication, and they are labeled treatment-resistant.
Kopua: Maybe that’s the role of global mental health, and more research need to comes out because there is a lack of knowledge about how to withdraw someone from a major tranquilizer, preparing families to be in partnership. We’re not very good at that. Being able to de-diagnose.
One of my trainees noticed that when we see families, we’re undoing the damage that’s happened. Wouldn’t it be great if we strengthened our trainees in this area and became a sub-specialty of psychiatry that was more critical and came up with more resources for psychiatrists to undo the damage that the institution has done in the first place?