The kaupapa answer to a clinical crisis

Māori have some of the most urgent needs in our mental health system, but extremely limited options when it comes to accessing a culturally competent psychologist.

Here’s clinical psychologist Carrie Clifford on why that must change.

 

When there is political will and funding, quick change can and does occur in mental health systems and in workforce development.

Recently, the Minister for Mental Health, Matt Doocey, said: “We simply cannot sit around and do nothing, while New Zealanders are stuck on waiting lists without the support they need.” I absolutely agree.

So why is New Zealand delaying the funding of a kaupapa Māori clinical psychology training programme, when the need in our Māori communities is so urgent?

As a Māori clinical psychologist working in a stretched mental health system, I ask myself this question whenever I add another referral for a Māori client to our growing waitlist, when I hear whānau speak about their negative past experiences, and when I’m trying to find support for a client yet cannot think of a culturally safe service or a psychologist to refer to them to.

I often wonder what it would take to train a large cohort of Māori psychologists each year, to meet the needs of the Māori community and fill the gaps in our profession.

We are critically short of not only Māori clinical psychologists, but also Māori educational and community psychologists, as well as the Māori psychology lecturers and researchers needed to train them.

A Māori-focused clinical psychology training programme — one that teaches clinical psychology while prioritising mātauranga Māori, Māori ways of healing and knowing, and trains clinicians to understand and meet the diverse needs of Māori communities — is absolutely critical and long overdue.

If the mental health minister doesn’t want to sit around and do nothing for those who urgently need mental health care, this is an obvious place to start.

For almost 50 years, both Māori and non-Māori psychologists have raised concerns that Māori clients don’t have access to Māori psychologists and practices that incorporate mātauranga Māori.

In a 2018 Waitangi Tribunal claim, Maōri psychologist Dr Michelle Levy noted that the Crown organisations that train and hire psychologists have “failed to ensure that psychology, as an academic discipline and profession, adequately meets the needs and demands of Māori”.

She also highlighted that there was no pathway to allow Māori to train as specialised kaupapa Māori psychologists. That hasn’t changed in the seven years since her claim.

The vast majority of psychological theories, measures, treatment approaches, and research used in Aotearoa today are imported from overseas, typically from the US and Europe. Our profession is based on models created for people from western, educated, industrialised, rich and democratic nations.

Imported psychological theories can’t properly reflect Māori holistic concepts of hauora and mental health. They focus primarily on the individual and don’t incorporate the significance of whakapapa and a relational understanding of the world.

Nor do these theories account for the history of colonisation, intergenerational trauma, and cultural dislocation, which impact Māori wellbeing. They fail to consider the factors that directly influence Māori mental health difficulties: Aotearoa’s historical, socio-economic, cultural and political context. Critically, they also fail to consider the strengths of Māori communities and the healing practices within te ao Māori.

This absence affects every stage of a psychologist’s engagement with Māori clients.

Assessment tools often don’t contain culturally relevant material, so they don’t capture the ways Māori typically present with distress, leading to misdiagnosis.

Inequities continue at a service design and entry criteria level. For example, Māori are more likely to be referred for externalised symptoms of distress (substance use and self-harm) than internalised emotional conditions such as anxiety and depression, despite higher prevalence rates of the latter.

Many whānau have experienced situations that lead to distrust in systems and healthcare. This mistrust, and the extended time required to build trust, can often be misinterpreted as a lack of engagement or effort on the client’s part, or even as a symptom of a mental health condition.

Similarly, misunderstandings of cultural experiences — whether these involve breaches of tikanga, spiritual experiences, or experiences of racism and discrimination — are frequently incorrectly labelled.

The resulting therapeutic approaches are narrow and don’t include Māori approaches to healing.

In my experience working with Māori clients, I’ve seen how some cases of mental health challenges like depression, anxiety and even memory and concentration difficulties can be better understood through the lens of ongoing discrimination, intergenerational poverty and housing instability.

I’ve also seen clients struggling with workplaces that proclaim Māori values but exploit Māori cultural labour. And so many whānau are trying to cope with the generational loss of te reo and cultural identity.

It’s unsurprising that these clients have difficulties with mood, worry and anxiety and have challenges concentrating, remembering, and achieving their potential.

I find it far more effective to address their mental health challenges within the broader context of their cultural and social reality, rather than framing their issues solely as disordered or distorted thoughts, feelings and behaviours, or as imbalances in brain chemistry.

This underlines the crucial role of Māori psychology researchers, academics, and psychologists in ensuring the psychology profession meets the needs of the community.

Despite the continued advocacy for Māori mental health workforce improvement, the idea of a kaupapa Māori training programme remains nothing more than an idea, despite relentless advocacy over decades to universities and the broader profession.

The specific needs and desires of Māori communities continue to be sidelined or absorbed into larger conversations about the psychology workforce and unmet community needs.

Yet Māori are continuously overrepresented in negative mental health statistics, and they remain unlikely to be treated by Māori kaimahi in psychology services.

Māori clinical psychologists comprise six percent of the total clinical psychology workforce. Over the last six years, only seven percent of newly registered clinical psychologists in Aotearoa were Māori.

Out of the 2,003 clinical psychologists registered in 2023, only 125 were Māori. Many of those 125 also work in full or part-time academic and teaching roles, or advisory roles across the public and private sectors. The number of practising Māori clinical psychologists available to the general public, “on the ground”, is unknown, but significantly less than 125.

Also of concern, over the last six years, on average, 43 percent of newly registered clinical psychologists in Aotearoa had been trained overseas. They therefore have little to no awareness of Māori communities, and the necessary awareness, knowledge, and skills to work with Māori.

The psychology board is creating programmes to educate these clinicians about New Zealand’s unique context, but this is a mere band-aid over the issue. We are simply not producing (and retaining) enough psychologists to meet the critical need of Māori clients. Political parties all seem to agree that this is problematic.

It’s useful to think about why we need Māori clinicians. Psychologists work intimately with clients’ thoughts, feelings, and behaviours in response to their context, all of which sit within important cultural considerations.

A clinician who is unable to create and maintain a culturally safe space will struggle to engage and retain clients. They’re unlikely to access the information required to make an accurate assessment, to properly formulate the issues behind the person’s mental health challenges, or to provide culturally appropriate intervention and treatment. Effective therapy, quite obviously, requires clinicians who are culturally aware, skilled, knowledgeable and safe.

Simply training more Māori in western clinical psychology programmes is not necessarily the solution. That approach assumes that Māori clinicians either already have, or will go and separately learn, the additional skills required to successfully bring these two knowledge systems together.

A kaupapa Māori training programme would go some way to solve those problems. It would allow clinicians to be trained in the required clinical work alongside the necessary awareness, knowledge and skills to meaningfully engage whānau Māori in a culturally relevant way. Kaimahi who can do this will enrich the wider profession and become our future clinical and cultural supervisors and academics.

But even this approach doesn’t consider how the profession meets the needs of those who speak te reo as their first language. Conducting psychological and neuropsychological assessments in a language that isn’t the client’s strongest or preferred reo greatly diminishes the tests’ accuracy and efficacy.

I cannot overstate the challenges for whānau in finding reo-speaking clinicians who can accurately assess and support them. In an area of health where early detection of issues and early intervention are so critical, this gap only perpetuates inequalities.

The current political approach to address some of these long-standing problems and gaps in the system is to train Māori in roles with shorter qualification times, for example, as assistant (or associate) psychologists or as health improvement practitioners.

Again, these are imported solutions that don’t fit our uniquely local context.

Māori tend to show up in our mental health system with more complex presentations and in severe distress, largely due to delays in accessing services. If there are only lower-qualified Māori assistants or practitioners available to help them — kaimahi trained to deal with mild or moderate cases — those clients will remain unlikely to receive the care they need.

We need to be very cautious of the “something is better than nothing” approach. Psychology is not food dispensing. It’s quite obvious that an under-qualified surgeon would do harm. Similarly, an under-qualified therapist working beyond their scope and knowledge can do incredible harm.

Decision-makers must also understand that therapeutic processes — building a trusted relationship, conducting thorough and accurate assessments, processing trauma and learning therapeutic skills — all take time. Inadequate intervention, due to skill or time restrictions, can significantly exacerbate psychological difficulties and distress, contribute to the mistrust of the profession and prevent people from seeking help in the future.

We know what to do. There are working examples in the health sector. The kaupapa Māori nursing training programme in Porirua is a successful pathway that supports Māori nurses and trains them to meet Māori community needs.

It may not be possible or, as others have argued, even appropriate, for the six current universities that offer clinical psychology courses to create kaupapa Māori clinical training programmes.

But with the right funding model, another wānanga or tertiary provider could tackle the problem, especially if they’re tasked solely with meeting Māori community needs.

None of these arguments is intended to take away from the fact that there are psychologists who are doing great, culturally safe, and meaningful work in Aotearoa. There are also individual Indigenous psychology courses and models, such as the Meihana Model developed by Suzanne Pitama, that are being woven into psychology training programmes.

Psychology is not the only way to heal and understand mental health. But Māori who choose this form of support should have the option of seeing a Māori psychologist, or at least one who can understand their worldview and experience and incorporate that knowledge into their therapeutic journey. The fundamentals of the profession have not shifted enough to meet the needs and aspirations of Maōri and reduce inequities in this area.

If the minister is determined to address those who have some of the most urgent needs in our mental health system, he cannot ignore Māori.

Clinicians who understand psychology and also have knowledge that can help whānau bridge the gap between western therapies and mātauranga Māori are one of the most obvious solutions.

A unique psychology for Aotearoa is desperately needed. Yet, we continue to import psychological theories and workforce models from overseas and ignore the possible ideas, solutions and mātauranga here in Aotearoa.

If we continue to do this, we shouldn’t be surprised when the next lot of data shows that we’re still failing to create better outcomes for Māori.

 

Dr Carrie Clifford (Waitaha, Kāti Māmoe, Kāi Tahu) is a Fulbright-Ngā Pae o te Māramatanga scholar. As a registered clinical psychologist working at a kaupapa Māori mental health service, her research and clinical work explore the cultural and therapeutic benefits of pūrākau (Māori oral narratives) in mental health services, and, more broadly, the bringing together of mātauranga Māori and western psychology in a way that is meaningful for tangata whenua.

E-Tangata, 2025