Entangling Bicultural and Indigenous Psychiatry

“For what you see and hear depends a good deal on where you are standing.”

― C.S. Lewis, The Magician’s Nephew

In his recent “Second Thoughts” column, Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA, FACPsych, FRSC, opened the door to bilingualism and biculturalism in psychiatry. It was a column to be welcomed and, in response, I want to extend his ideas. To do so, however, opens up some awkward and deeply unsettling issues. I will make the comment that, in a globalizing world with global population movements, these issues are likely to intensify, not diminish.

In his column, Di Nicola raises large questions. He explores how psychiatrists manage the intricacies of bilingual and bicultural interaction and also remain models of cultural adaptation for their patients. Amongst his questions, one is critical: “What does culture mean for psychiatry today?” It is a particularly critical question as psychiatry addresses a transient, interconnected world with pressures on its existing models and knowledge systems.¹

His column focuses on questions for immigrant physicians, especially in their training and enculturation but I want to pick up its complementary pole. This moves from the immigrant to the indigenous. The indigenous in psychiatry immediately raises different, quite uncomfortable questions. As Genevieve Cox and associates write²:

“Engaging in decolonizing research forces researchers to consider the ways that colonial oppression plays a role in marginalizing and exerting epistemic superiority over Indigenous knowledges.”

Decolonization and Biculturalism

That brief statement compresses a host of concerns into 1 sentence: bicultural practice, western colonization, domination, inequality, and alternative knowledge systems. In what follows, I want to unpack their implications for bicultural psychiatry.

Indigenous knowledges constitute both ontologies and epistemologies—the divergent worldviews and practices—to which different peoples are powerfully attached. These, as a host of scholars have emphasized, are diverse and profoundly at odds to western rationalism.³ Following global colonization by western powers, particularly in the nineteenth and twentieth centuries, these worldviews were rapidly relegated to a faint set of voices on the margins.⁴ Yet, over recent decades, they have grown in confidence and capacity. They demonstrate an increasing sophistication in challenging the assumptions of a Western individualistic rationalism rooted in post-Enlightenment thought—sometimes by drawing directly on western critical theory to do so.⁵

Genevieve Cox and associates describe how indigenous knowledge emphasizes a deeply collective perspective, one which interweaves experience of the natural world with spiritual and social practices. They write that relational and place-based Aboriginal cultural memory “provokes an interspecies intimacy, which is itself productive of deeper insights into relational patterns and constellations.”

The growth of confidence, voice, and capacity is reflected in a move away from earlier deficit or problem narratives towards strength-based ones, commonly advocating a relational approach over a biomedical or intrapsychic one.

Indeed, indigenous writers such as Jon Keller-Munoz⁶ go further, arguing that Western psychiatry itself is “poorly equipped to effectively address the psychological and social complexities emerging within Indigenous societies.”⁷

These strong challenges come out of an ongoing, collective experience of dispossession: historical trauma, loss, colonization, and genocide; poverty, cultural trauma, and violence.⁸ Grosfoguel goes further and includes “epistemicide”: the destruction of indigenous knowledge systems.⁹

Little wonder that McKean and associates call for policy shifts that move from treating illness as an individual experience towards collective theory of change models.¹⁰ These models explicitly recognize and promote psychological wellbeing across indigenous experience, particularly addressing such factors as the social determinants of mental health.

Indigenous and Western

At this point, we confront the profound conceptual divide between indigenous and western knowledge systems. I describe below how this continues to haunt bicultural psychiatry. As the Aboriginal scholars, Tempone-Wiltshire and Yunkaporta write, indigenous knowledges are located in a relationship with landscape and nonhuman others; this is where Aboriginal cultural knowledge, meaning, and memory are stored.¹¹ These knowledges are embedded:

“…in tangible cultural practices—drawing upon objects, landscapes, ritual, and ceremony — as forms of embodied, haptic, and distributed cognition. Memory is also encoded in language, specifically orality—a tradition that retains sensuous contact with the world through its integration of place-, body-, and sound-based expression.”

These constitute a huge storehouse of indigenous knowledge, from therapeutic practices to farming, such as the Mayan use of more than 500 plant compounds for gastrointestinal ailments and pain relief.¹² This way of knowing, or traditional epistemology, is rooted in a deep, systematic understanding of the land based on seasonal cycles, not detached scientific observation. Julien Tempone-Wiltshire highlights the contrast to western knowledge, which generally abstracts, reduces, categorizes, and renders such oral, embodied, collective sensory systems as static, textual inscriptions.¹³

Against this stands the view that indigenous knowledge is not science.¹⁴ Or that it should be treated as complementary and simply doing science differently.¹⁵ Perhaps Nadine Hosny, on decolonizing clinical psychology in the Global South, sums up the dilemma most simply: “Where do we go from here?”¹⁶

Where, indeed? To return to Di Nicola’s opening questions, how do we frame a bicultural dialogue in psychiatry—moreover, how do we frame a genuinely relational psychiatry which doesn’t reduce one to another?

Case Example: Indigenous Psychiatry in Aotearoa New Zealand

I write from a society in which these questions are constantly and energetically negotiated: Aotearoa, New Zealand. The very name, Aotearoa New Zealand, as I will describe, represents the complexly contested and connected nature of indigenous-pākehā exchange.

Why ‘pākehā’ – a common term here for White New Zealanders? Joan Costello¹⁷ responds this way: Pā – means to come into contact; Ke – is related to the word ‘rerekē’, different, or unique; Hā – is to share and exchange the breath. Pā-ke-hā.

How does one exchange breath? During a hongi, a Māori greeting ceremony, host and guest softly press their noses together. Their breath, their mauri or life-force, spirit if you prefer, are also exchanged. Here, at once, is both the gulf and the meeting between western and indigenous ontologies, literally joined by the pressing of noses. In the west, we press the flesh but never noses; in Māoritanga, this is the expectation—a close, sensory experience.

So with Aotearoa New Zealand. The phrase ao tea means white cloud, describing the land Māori first encountered, whilst roa means long, the length of the country and its coastline. Aotearoa New Zealand, not the nation’s official title, reflects its uneven conjoining between the British Crown and Māori tribal groups through the founding Treaty of Waitangi. This has become a document endlessly debated and reinterpreted by all parties from 1840 to 2025. It has also created a rare form, internationally, of ceaseless bicultural engagement, one enshrined and enacted through a Treaty.¹⁸

How does this matter for bicultural psychiatry? The nature of negotiated recognition offers potential models for creating mutual recognition across cultural divides. I give examples here. It offers models because they directly address the issue of equal exchange, decolonization and accommodating dissimilar ontologies. These must be central to any psychiatry of genuine recognition and respect. These requirements percolate through every layer of higher education, including medical training and psychiatry, as the case Aotearoa health physicians illustrates.

As they percolate, they encounter complex confrontations that rearticulate the tensions of colonialism and privilege within higher education. Smith and associates write bluntly from the perspective of te ao Māori on white fragility¹⁹:

“White fragility is not a fleeting sense of anxiety or discomfort, but rather an extended reluctance to explore how racism embeds itself into our social structure.”

As they continue,

“Indigenous peoples must learn white customs, while relinquishing their own; white people are not required to reciprocate. Within a [higher education] context, white fragility is the resistance by non-Indigenous peoples (most of whom are white) to acknowledge the varied ways coloniality infiltrates university systems.”

The lead author, Hinekura Smith, vividly describes how these tensions play out routinely in higher education:

“Do I start with institutional pōwhiri (formal Māori welcoming process), conducted in English so non-Māori can equate being “welcome” with “feeling safe”? Is it the selective cultural acceptance of singing “Te Aroha” (a beautiful, simple eight-word Māori song) for the thousandth time so that “everybody” (mostly non-Māori) feels included?”

Hinekura Smith discloses that she, herself, is a white Māori:

“I am a Māori woman with white skin. My whole life, my white skin has afforded me privilege in white spaces, particularly in education, until my views and positionality out me as the ‘other’.”

I highlight her experience simply to emphasize the complexity of bicultural experience: how it is anything but binary; instead, it is shot through with unresolvable contradictions over identity, appearance, privilege, belonging and place.

This may be common experience to anyone of mixed ethnic heritage, but it also resonates powerfully with Di Nicola’s commentary. It highlights the dilemmas psychiatrists face anywhere around loyalties, identities, privilege, and integration within and across different cultures and trainings.

From Difference to Dialogue and Diagnosis

Smith and associates, just quoted, also describes how moments of connection and conjunction are created, even given the tensions she outlines:

“Storytelling offers a way to center Indigenous experience, creating a context for uncomfortable conversations and an opportunity to share our insights with readers who can connect to these ideas and push the decolonial dialogue further.”

Storytelling, however, requires institutional frameworks and new practices to sustain that dialogue and mutuality.²⁰ Laura Sharp and colleagues describe, for instance, a global mental health initiative which, drawing on Paulo Freire’s critical pedagogy, includes flipping classrooms to invert and open up student-teacher learning practices.²¹

In Aotearoa, two broad models of learning practice have received wide support. One, in particular, is psychiatrist Mason Durie’s Te Whare Tapa Wha.²² This metaphorical model creates a meeting house containing 4 pillars. Each pillar supports an aspect of wellbeing: spiritual (taha wairua), mental and emotional (taha hinengaro), physical (taha tinana), or family and social (taha whānau), all grounded on the land (whenua) as a foundation.

Immediately, it is clear how indigenous and western discourses overlap, whether it is through Māori concepts or through the active use of western rating scales.²³ The Meihana model extends these practices, creating a clinical framework that uses the image of a double-hulled canoe. The model can identify comorbidities of depression and chronic illness or, in social settings, mental health stigma. Likewise, there are meeting-points between such conditions as autism (takiwātanga), ADHD (aroreretini - attention goes to many things) or schizophrenia (ngā whakāwhitinga - standing at the crossroads). Yet these communal, metaphorical models, often with their own treatments,²⁴ must still make headway against the dominant rationalism of western medical models.²⁵

Biculturally, then, contestation and cooperation remain constant companions not simply in Aotearoa but across global psychiatry, however much goodwill and determination attends decolonizing strategies.

Thinking Differently: Ziran (自然)

One further ambiguity faces bicultural psychiatry. The social scientists John Law and Wen-yuan Lin draw our attention to the term ziran (自然).²⁶ It is just one term in a vast Chinese lexicon which returns us to epistemological complexity. In the context of Asian medicine, the term disturbs what we mean by medicine, or even nature itself (ziran (自然), very loosely translated as nature here). It raises the question of what takes place when we translate sensory experience into symbolic language.

Law and Lin comment, biculturalism involves thinking differently through the practice of Chinese medicine. Yet, such thinking differently begins, itself, to dissolve the very categories of Chinese and Western.²⁷ They take the instance of shi (勢) meaning, very loosely, “to be” in English. This term, they remark enigmatically, indexes a way of living and knowing foreign to, but potentially productive for, Euro-American traditions. What does this mean?

Here is the conundrum. Social scientists Law and Lin watch a Taiwanese Dr Lee examine a patient and declare²⁸:

“Your pulse is like a guitar string. That means you have ‘depleted-fire’ (xu¯ huoˆ, 虛火) in the liver (meridian) … You are busy and stressed; you’re exhausted and irritable.”

As they comment on the difference between western and eastern diagnostic systems:

“To state the obvious, there is no room for meridians or chi in biomedicine, because they cannot be found anatomically or physiologically—they simply don’t exist.”

Similar murkiness circulates about ziran (自然) or nature. Although nature seems intrinsic to indigenous ontologies, let alone human nature of the west, what does nature actually mean? In which cultural world, and in what sense, do we understand it within respective ontologies; or can we not? Law and Lin explore these difficulties in The Stickiness of Knowing,²⁷ without resolving them, but they quote a comment from Francois Juillen’s On the Universal.²⁹ The quote captures some of the elusive cultural and linguistic paradoxes around the bilingual and the bicultural—and suggests how neither can be reduced to a simple binary:

“A language, a culture, or a thought, in its divergence, furnishes other engagements with (another glimpse of) the unthought. And its fecundity is measured by the power of this engagement and this glimpse.”

Concluding Thoughts

Such subtleties capture some of the complexity surrounding any practice, psychiatric or otherwise. They also apply to any cross-cultural encounter where the unsaid shapes the said. These nuances also return us to Di Nicola’s initial questions. They circulated around how we engage with bilingual and bicultural psychiatry. In particular, when he asks, what does culture mean for psychiatry today?

As Law and Lin emphasize, cultures are shot through not just with issues of colonial domination, power and violence; cultures also articulate how the world is apprehended through different worldviews and sensibilities. Let alone how these sensibilities are articulated in the first place. In turn, they shape the way psychiatrists attend to suffering, wherever, globally, it is presented, a point to which Arthur Kleinman, MD, PhD, has repeatedly returned.³⁰

A bicultural psychiatry, likewise, carries its own diverse sensibilities, both as an institution and as a working practice. These sensibilities, in turn, are brought into contact with patients whose distress is shaped and communicated through their respective cultural comprehensions. Finally, it is how a bicultural psychiatry, whether immigrant or indigenous, navigates these endlessly changing encounters; it also marks the expression of its humanity and its capacity to minister in the face of suffering.

Dr Farnsworth is a practicing psychotherapist in Aotearoa, New Zealand’s southernmost city, Dunedin. He is 1 of 6 Life Members of the New Zealand Association of Psychotherapists (APANZ). He is also an active social scientist and has taught for 30 years across a variety of university teaching positions. He has published internationally in a wide variety of fields, including social exclusion and poverty, the Enlightenment, digital mimicry, social and dynamic theory, methodology and the cultural unconscious.

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