‘Collaborative and Indigenous Mental Health Therapy: Tātaihono – Stories of Māori Healing and Psychiatry’: Book Review

Tehseen Noorani reviews Wiremu NiaNia, Allister Bush and David Epston’s Collaborative and Indigenous Mental Health Therapy: Tātaihono – Stories of Māori Healing and Psychiatry (Routledge, 2017).

Māori cultural therapist Wiremu NiaNia and Pākehā [settler of European origin] psychiatrist Allister Bush, aided by narrative therapist David Epston, offer an inspiringly bold and reflexive collection of five case stories of Māori and Pacific Islander youths facing psychosis-like distress with possible spiritual explanations. Showcasing ways of working that are culturally sensitive and indigenous knowledge-centered, the authors also offer analyses of colonialism and collaboration in the Aotearoa New Zealand mental health context.

From the start it is clear that Wiremu is more than ‘just’ a cultural therapist. He is an expert on wairua [spirit] and an adept in matekite, which he explains as “a kind of seeing that pertains to sickness and death” (1). Wiremu also evidences a knack for rapidly connecting with the young people he is asked to meet. The connection produces insight for everyone – for Wiremu, knowledge of spiritual problems; for the clients, relief that someone else can sense what they can, sharing the burden and the responsibility for transformation; and for Allister’s psychiatric lens and other skeptical onlookers, a provocation of materialist assumptions.

Whether to us in the bookending chapters, or to Allister and the young people he works with in the case story chapters, Wiremu explains key ideas in Māori cosmogony: that we are spiritual beings first and foremost; the centrality of mauri [life force], tapu [something sacred or forbidden], mana [spiritual authority] and much more (3-4).[1] Even for readers interested in creative solutions not necessarily bound by Maori cosmogony, there is much to learn from Wiremu’s analyses and proposed treatments, including in the use of karakia [prayers] and engagement with kaitiaki [guardians]. I was reminded of Alejandro Jodorowsky’s psychomagic and Daniel Foor’s ancestral healing.

The text is clear and crisp, at times painstakingly-reflexive, forcing the reader to slow down and engage. Successive sections of chapters are written by ‘Wiremu’, ‘Allister’, the client, and others. The use of different voices in the presentation of the cases works beautifully, each adding a layer to the same story and a lens through which to view the other layers-cum-lenses, consolidating trust in the stories as sturdy objects for inspection, learning and musing upon. The polyphonic format of the book also affords a cautiousness, as narratives hold each other in tension, enabling certain risky possibilities to take root – that what looks like psychosis can sometimes actually be about wairua; that distressing voices and visions contain the gift of one day being able to use one’s mana to help others; that what gets called schizophrenia might actually be “a doorway that has been jammed open and everything just pours in” (63).

The use of long transcript excerpts adds a performative dimension. One can feel Wiremu’s light-hearted touch, for instance in giving permission through breezy asides that are then qualified as jokes. I found clients’ meetings with Wiremu nail-biting to read, as he forges deep connections through his kōrero [explanations] and thoughtful, humored dialogues on matters both serious and strained.

One senses the dignity which the authors extend to all who contributed to the book. The front cover is a painting entitled ‘Ki Te Ao Marama’ [‘Into the World of Light’] by Tangi, profiled in chapter 7. The authors include details from clients’ lives many years after initial meetings, pointing to the value of mental healthcare services that are closely and durably connected with local communities. This reminded me of current challenges being faced by attempts to globalise the Open Dialogue method of working with psychosis that originated in the relatively-unchanging communities of Western Lapland.

A central question of the book, both in general and through each case, is how we can distinguish psychosis from spiritual experiences. In their collaboration, Wiremu and Allister are engaged in a detective work, figuring out what to try next while keeping open the possibilities that other interpretations could offer. This includes the use of neuroleptics to ease distressing experiences long enough to be able to try to work with them as wairua-related. Yet in any particular case story, they remain wedded to a project of finding out whether the distress is biomedical or spiritual in nature. For example, George explaining he has had non-distressing spiritual experiences in the past affirms the spiritual origins of his present distress. In the most complex case story (Tangi), Allister notes of the choice between psychosis and spiritual experience, “it could be a combination of both” (126, see also 116).

I found myself trying to establish whether Allister’s psychiatric approach or Wiremu’s spiritual approach was dominant, either in each case story or in the ‘cross-talk’ between their sections of text yet kept being undone. Undoubtedly, the cases highlight the power and possibility of addressing psychosis-like experiences as wairua-related, and at times psychiatry comes close to being indigenous healing practices’ mere technician. Yet near the end of book there is an address to (those who can foster) a new generation of Māori psychiatrists (145), and given that each case story was peer-reviewed by psychiatrists with two chapters previously published in mental health journals, psychiatrists are a clear key audience for this book. Rightly so given the institutional power of psychiatry. There is much of value for those interested in the practice of psychiatry, including how psychiatry can play a contained role in pluralistic therapeutic approaches, what a ‘best practice’ of psychiatry done by sensitive and open-minded psychiatrists could look like, and how Allister’s lengthy and citation-filled discussions of cases amply demonstrates the multiplicity within psychiatry itself, pushing at psychiatry’s boundaries in ways very much befitting the case study tradition mainstream psychiatry has long-neglected.

In the final chapter entitled Tātaihono, where Allister and Wiremu reflect on their process, the way this tension is resolved draws on the long-established Māori model of health configured as a house with four walls – spiritual, mental, physical and social. Then what matters is that each realm is accorded its proper jurisdiction – here, psychiatry that of the mind and matekite that of wairua – and allowed enough space by the other. For instance, one senses relief in Allister’s use of multiple examples to note that Wiremu does not think every problem is a spiritual problem (156-158). It is important that this structuring image originates in a Māori approach to health, but this too is not without contestation, particularly in assumptions that each of the ‘walls’ might be treated separately. What goes unacknowledged in this book is that the ‘mental’ realm is conceded to psychiatry. What of psychotherapy or psychology? Wiremu’s practice may find much more in common with Western transpersonal or phenomenological approaches, and even in the history of psychiatry, prior to the hegemony of the biochemical in research and practice. Might these be helpful bridges to guard against the allure of the exotic that, despite the authors’ care, this book will inevitably invoke?

Given that we can never really know what might work for alleviating someone’s distress or providing meaning, this is a deeply hopeful book. It is not just Wiremu’s approach or the collaboration that is hopeful. There can also be something liberating about biomedical psychiatry’s approach, wherein some bad experiences aren’t expected to have meaning, some dysfunctions are not ‘for a reason’ and some horrors can’t be redeemed. My impression of the synergy between Allister and Wiremu’s practices is less that the former deals with mind and the latter spirit (though maybe if these terms are reconfigured), but that the one is concerned more with fragmentation, failure, loss and the ceding of responsibility, while the other is oriented towards meaning-making, synthesis and the activating of responsibility.

This book is an exciting beacon for collaborative possibilities. I wonder how extendable Wiremu’s work, here with young people who have had what would be considered ‘first-episode’ psychotic breaks, is to other ages, more chronic states, and/or wholly other cultural contexts, including where one cannot key into clients’ Māori or Pacific indigenous worldviews. Referrals for matekite came from a social worker, teacher, mothers, psychiatrists and the local Early Intervention Service, suggestive of a larger infrastructure sensitive to indigenous spiritual problems. Expanding on the sketch in chapter 2 to document these sensitivities could also reveal a fascinating background story to the work foregrounded here, with implications for whether and how such non-pathologizing engagement could occur elsewhere.

At a time when texts on social approaches to psychiatry are largely coming out of the mental health service user/survivor or anti-psychiatric traditions, this book reminds us of just how much mileage a project framed by neither still has. Indeed, it is tempting to believe that Wiremu, through the kind of collaboration he has with Allister, is contributing to repopulating Aotearoa with tohunga [healers] long-suppressed under colonialism. The two of them are working towards a next book. It will be a pleasure to read more of what they have to say.

[1] The authors are careful to note the provisionality of their translations of Māori concepts, and also provide a helpful glossary at the end of the book assembled through guidance from Wiremu, the online Māori dictionary and several other sources. This sensitivity to mistranslation is well-warranted: for instance, some Māori scholars argue not to conflate ‘wairua’ with ‘spirit’, noting that wairua is a much broader concept and that there are ongoing disagreements over how to define it (personal communication with Professor Helen Moewaka Barnes, January 2020).

Dr Tehseen Noorani is in Anthropology at Durham University and a book reviews editor for The Polyphony. He is completing a monograph on the implications of emerging psychedelic therapeutics for psychiatry.

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