Dr Diana Kopua shares her thoughts about ADHD in relation to Māori health and Mātauranga Māori, in an interview by Dr Paul Skirrow

Dr Diana Kopua, Ngāti Porou

Dr Diana Kopua, a Ngāti Porou woman, grew up in Porirua near the Takapūwāhia marae, which she said led to her feeling connected to a Māori community even though living away from her iwi. During her early nursing career at Porirua, she witnessed the transitioning of people into the community from the Porirua hospital system. Diana noted that racism against Māori was prominent in nursing education at that time. Later, Diana was scouted by Māori leaders to work in Te Whare Mārie, the specialist Māori mental health service in Wellington. Realising that psychology and psychiatry held particular influence in the system, Diana attended medical school, qualified as a psychiatrist, and went on to champion the Mahi a Atua approach she developed as a nurse. Diana has held the positions of Head of Department in Tairāwhiti DHB and Associate Dean at Otago University, and in 2020, she was awarded the prestigious Dr Maarire Goodall supreme award for outstanding and influential Māori doctor of the year for her contribution to Māori Health.

Dr Paul Skirrow, tauiwi

I grew up in the North of England (Leeds/Liverpool) and moved to Porirua in 2012, where I still live. Like most English people, my genealogy is pretty messy. My family has managed to find paper records that go back to as far as the 11th century, which trace my British, Celtic and Romany ancestors, but we believe that our name originally came from Viking invaders who settled in Yorkshire around the 9th Century. I’m a clinical psychologist by training and have guest-edited the current edition of the JNZCCP on ADHD. In doing so, I was curious that I had not been able to find any discussion of ADHD involving mātauranga Māori (Māori knowledge systems), and very little about how it currently affects Māori; this appeared to be almost completely missing from the literature. I initially approached Dr Diana Kopua after she was recommended to me by several of my Māori colleagues. I wanted to explore how ADHD may be understood in terms of a mātauranga Māori framework. In speaking to Diana, however, I quickly realised that my view was much narrower than I had understood, that maybe I was looking in the wrong places and even asking the wrong questions.

Oranga Māori Within a Racist (Mental Health) System

When I first approached Diana for an interview for the Journal, she was quick to point out that even the initial starting point could be seen to be biased towards a particular worldview.

"What we know is that our journals promote a knowledge and a system that conforms with the dominant culture, the Western culture and Western paradigm and Western knowledge systems."

Diana and her colleagues have written extensively about institutional racism within the New Zealand (NZ) mental health system (e.g. Kopua et al., 2021c). In that context, Diana pointed out that the discussion of ‘ADHD’, along with ‘assessment’ and ‘treatment’ can be considered problematic, as they are understood without considering historical injustices that are still not reconciled (Moewaka Barnes & McCreanor, 2019), which have led to significant inequities for Māori in mental health. These systemic issues require practitioners to reframe their formulation. Ironically, a significant step forward would be to realise that our own inattention to these issues, avoidance and restlessness when discussing these uncomfortable topics, and decisions to quickly pursue an ADHD pathway may be less than an impulsive act that lacks critical reflection when working with Māori. Simply describing behaviours that focus on an individual struggling to conform within a society that does not reflect a Māori worldview is no longer acceptable. We have an opportunity to sit with these whānau and engage in conversations that stop them from thinking ‘they’ are the problem.

Indeed, criticism of the ‘medical’ model of distress is not confined to Indigenous writers. The Critical Psychiatry Network (Middleton & Moncrieff, 2019) of which Diana is a member, has extensively critiqued the validity of diagnostic terms such as ADHD (Moncrieff & Timimi, 2011). Where medicine usually relies on tests and procedures to validate diagnoses, in psychiatry (even though it has now existed for more than a century) there remains relatively little evidence to support a biological basis to most ‘disorders’ described by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In Diana’s view, not only has this medicalised approach failed Māori, but it has also really failed all of us, disconnecting us from our context.

"The criteria that focus on individual symptoms implies that the individual’s subjective experience, their story, doesn’t matter—but it does matter."

Regardless of how convinced you are that ADHD is a discrete, biological ‘disorder’, Diana argue that the subjective experience and personal story an individual comes with can only be understood in context of the larger historical, political, cultural and social narratives affecting them. Focusing on evaluating ‘criteria’ in a mental health assessment makes it far easier to overlook the importance of the person’s context.

Decolonising Mental Health

In our interview, Diana stressed the importance of recognising and respecting different knowledge systems (including medicine). However, the medical model, and society as a whole, generally does not respect Indigenous knowledge; in fact, it has frequently tried to suppress it (Rolleston et al., 2020). Rather than focusing on which knowledge system is ‘right’, Diana suggested that the most important consideration is the outcome for whānau and that they should be able to choose a framework that most resonates with their situation and who they are.

Diana emphasised the importance of open and honest discussions about how racism is perpetuated to develop a collective critical consciousness that values Indigenous stories. In that context, Mahi a Atua (e.g. Kopua et al., 2020) is a vehicle to amplify Indigenous knowledge systems, particularly Māori Indigenous knowledge, while reducing the dominance of the Western knowledge system in working with people in distress. Diana’s aim is to prioritise and elevate Indigenous knowledge to create a more equitable and culturally responsive approach to mental health and well-being.

"In areas where psychiatry isn’t prominent, we keep thinking that we need to scale it up; in fact, we need to scale it down. When I think about Mahi a Atua, [the aim] is to scale up Indigenous knowledge systems, particularly Māori Indigenous knowledge systems, and scale down the Western knowledge system when it comes to working with people in distress and with concerning behaviours."

Mahi a Atua and the Power of Pūrākau

Mahi a Atua is an approach that incorporates a Māori ontology and epistemology, exploring words, ideas, images and narratives through the use of pūrākau or creation stories (Cherrington, 2003; Kopua et al., 2020). Pūrākau are considered to be central to a Māori worldview (e.g. Marsden, 2003), from which tikanga and other cultural practices derive. The practice of Mahi a Atua is also centred on the idea of wānanga, which is rooted in Māori culture and epistemology and has no direct translation into English. Wānanga involves a process of gathering, discussing, learning and transmitting wisdom. One crucial aspect of wānanga is the simultaneous embrace of the past and the present. Holding onto the past is seen as vital in gaining clarity for the future. In a healing context, Diana explains it can be considered a ‘meeting of the minds’ in order for a clinician and the whānau to create meaning together.

Diana described her approach to working with families by emphasising the importance of incorporating Māori stories and tikanga into the therapeutic process.

“When we are thinking about mātauranga Māori in a colonised racist society, it’s about strengthening our story again, stories that are ours and have tikanga and morals stored within them.”

Diana has previously spoken about how mental health settings are extremely intimidating, particularly for Māori (see Graham & Masters-Awatere, 2020) and her approach strongly emphasises the importance of decolonising the space as a precursor to decolonising a mental health narrative. Part of the Mahi a Atua approach involves changing the working environment, including the presence of Māori artwork that references the pūrākau, inviting the whānau to explore these stories as soon as they walk in.

In relation to ADHD, Diana spoke about the relevance of the creation story—noho tatapū—where, while locked in the embrace of Ranginui and Papatūānuku, the Atua Uepoto was curious and did not sit still in the darkness, but instead went to investigate a glimmer of light between them. In the story of noho tatapū, without Uepoto’s curiosity, the world and humankind might never have existed. Diana explains how this story allows for a discussion of the conflict between restrictions imposed upon us (from parents, teachers, society) and our own curiosity and desire for freedom, without it ever being labelled as ‘bad’ or pathological.

Taking it Further: Becoming Mataora

“The pūrākau of Mataora tells the story of an ariki (high chief) who had believed he was not accountable to anybody. However, guided by the love he had for his wife, Niwareka, Mataora became a kaitiaki for changing attitudes, beliefs and behaviour; firstly his own and then actively influencing changes in those around him.” (Kopua et al., 2021a).

In a short, 1-hour interview, we were barely able to scratch the surface of this topic with Diana. Together with her husband and tohunga, Mark Kopua, Diana has written extensively about Mahi a Atua (Kopua et al., 2020, 2021b), and how it has been operationalised as Te Kūwatawata in a health setting in Tairāwhiti (Kopua et al., 2021a, 2021b) as well as other regions and schools (Kopua et al., 2021a). Much of Diana and Mark’s writing, together with that of the psychologist Dr Michelle Levy, is freely available on the Mahi a Atua website. Mahi a Atua also offers trainings in how to become Mataora (a change agent) both in person and online through their website.

Reflection and Conclusion

I began this discussion with a reflection that perhaps I had been asking the wrong questions in my attempts to understand ADHD in a mātauranga Māori context. According to Te Reo Hāpai, the Māori name given to ADHD is ‘aroreretini’ or ‘mind goes to many things’; however, as has been argued elsewhere (Smale, 2020), renaming a Western concept does not immediately render it compatible with mātauranga Māori. Indeed, doing so may actually obscure our continued failure to adequately address the needs of Māori (see Smale, 2020). Diana argues that in fact, the psychiatric classification system is a barrier to reimagining how services are positioned in society, and that the reliance of that knowledge system increases inequity for all people in mental distress.

Perhaps better questions, for which I am still searching for answers, are ‘How do we, as a country, tackle inequity that is now hard-wired into our systems?’ ‘How do we approach health in a way that respects, values and validates every individual and every whānau?’^[1] It is my sincere hope that psychology, like Mataora, can move from being part of the problem to part of the solution.

Acknowledgements

Sincere thanks to Dr Diana Kopua for giving her time, consideration, energy and great wisdom in helping to shape this paper. Further thanks to Dr Luke Rowe, Tawhiti Kunaiti and Maire Ransfield for their feedback, early guidance and suggestion to approach Dr Kopua, as well as Irie Schimanski for his feedback on a later draft of this paper.