Advances in Psychiatry: Understanding Indigenous Cultures

July 25, 2014

Epidemiological research has shown that the Māori people of New Zealand are approximately twice as likely to have serious psychiatric illness compared with non-Māori. Here, a child and adolescent psychiatrist describes her work in Aotearoa, New Zealand.

He tapu te upoko: the head is sacred.

Epidemiological research has shown that Māori are approximately twice as likely to have serious mental illness compared with non-Māori.1 My experience is that improving Māori self-determination in mental health and addiction services has a positive impact on not only the individual and family but also the wider population.

My work in child and adolescent psychiatry takes me around Aotearoa, New Zealand, in different roles related to advocacy and mentorship, legislation, assessment and treatment, and research. As one of very few Māori clinicians, I provide assessment for young people—the vast majority of whom are Māori2—before the youth court. Being able to bring a culturally nuanced opinion to assist the court is deeply rewarding.

I am also a member of the New Zealand Mental Health Review Tribunal as a deputy psychiatrist. This is an exacting role which requires listening to the perspectives of patients treated against their will under our legislation. I have co-authored a book chapter that interrogates the issues regarding Māori and use of the New Zealand Mental Health Act.3(pp 249-267) Māori are more likely to be detained under the Act, but the reasons for this are unclear.

Māori tend to present later in a more acute phase of psychiatric illness; often it is accompanied by police action and with more complex presentations. So it may be that the Act is being used appropriately. However, there is also reason to consider potential bias in assessing Māori. This might influence how “mental disorder” in Māori is misunderstood because of mental health professionals’ variable cultural competency. In addition, there is some evidence that risk of dangerousness to others is assessed differently in Māori.

Culture and traumatic brain injury
Another area of special interest is the neuropsychiatry of traumatic brain injury (TBI)—an area in which Māori are over-represented.4 We do not yet have adequate research to explain why this is the case. It could be that Māori are more likely to live in poverty, and this conveys a raft of related risks that we know contribute to increased likelihood of TBI, such as increased adverse life events.5

I am an advocate for greater awareness in our profession about the neuropsychiatry of brain injury.6 Building Māori community literacy around the importance of he tapu te upoko is essential in preventing TBI and ensuring early intervention. The feedback from Māori primary health care workers has been positive.

Observing the lack of culturally responsive approaches for Māori with brain injury led to me to embark on doctoral and post-doctoral research. This work focused on Māori marae wānanga (a learning forum that takes place in traditional meeting houses) and distillation of findings to describe a Māori theory of TBI. Working on marae provides an opportunity to ensure that cultural protocols are incorporated into research methods. This theory proposes that, concurrent with the physical injury, a culturally determined injury occurs, and a cultural response is therefore indicated.

I have developed an approach based on this theory called te waka oranga.7,8 Te waka oranga brings the whānau (family) and health workers together to paddle the healing journey canoe, bringing the healing and recovery destinations to the whānau. My post-doctoral research (presently in the early stages) involves refining and testing the validity of a tool for front-line staff to enable them and whānau to describe the cultural needs profile of whānau where there is a potential TBI. I will also be testing te waka oranga with whānau and their health workers in the community.

Working clinically and engaging in community research is exciting—and hard! From the outset, I recognized that my own whānau would need to be asked for permission for me to do this work and to be involved in its evolution. This process of community partnership is central to my goal that my research withstands scrutiny from my own people and from Western science.

I am privileged to mentor and support other Māori embarking on their journeys of learning, questioning, and discovery. At Te Whare Wānanga o Awanuiārangi, we have almost 50 doctoral students. Working with them provides another source of inspiration in working towards healthy thriving Māori communities.

He tapu te upoko—a belief that has been handed down from our ancestors—is a Māori cultural belief that many of us have grown up with. The importance of caring for the mind because of its sacred status is proving a useful tool in building community resilience to TBI and fostering mental health.


Dr Elder is Professorial Fellow in Indigenous Mental Health Research, Director of Te Whare Mātai Aronui Te Whare Wānanga o Awanuiārangi, and Post Doctoral Fellow at Health Research Council of New Zealand. She reports no conflicts of interest concerning the subject matter of this article.


1. Oakley Brown MA, Wells JE, Scott KM, Eds. Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington, New Zealand: Ministry of Health; 2006.
2. Cunningham C, Triggs S, Faisandier S. NZ Crime and Safety Survey 2006: Analysis of the Māori Experience. Wellington, New Zealand: Ministry of Justice. Accessed July 25, 2014.
3. Elder H, Tapsell R. Māori and the mental health act. In: Dawson J, Gledhill K, Eds. New Zealand’s Mental Health Act in Practice. Wellington, New Zealand: Victoria University Press; 2013.
4. Feigin VL, Theadom A, Barker-Collo S, et al. Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurol. 2013;12:53-64.
5. McKinlay A, Kyonka EG, Grace RC. An investigation of the pre-injury risk factors associated with children who experience traumatic brain injury. Inj Prev. 2010;16:31-35.
6. Elder H. An examination of Māori tamariki (child) and taiohi (adolescent) traumatic brain injury within a global cultural context. Australas Psychiatry. 2012;20:20-23.
7. Elder H. Indigenous theory building for Māori children and adolescents with traumatic brain injury and their extended family. Brain Impair. 2013;4:406-414.
8. Elder H. Te Waka Oranga. An indigenous intervention for working with Māori children and adolescents with traumatic brain injury. Brain Impair. 2013;14:415-424.