Atlas›Domain XI · Traditional medicine & indigenous healing›Guide 123
Guide XI-123

Hawaiian lāʻau lapaʻau, hoʻoponopono, lomilomi and kahuna

Mary Kawena Pukui1972Hawaiʻi
A 37 · L 51 · M 1215 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: traditional Native Hawaiian healing as Hawaiʻi law (Act 162, 1998; Act 153, 2005) and Papa Ola Lōkahi's recognised kupuna councils define it; family hoʻoponopono as Mary Kawena Pukui codified it with Queen Liliʻuokalani Children's Center (QLCC) staff in Nānā i ke Kumu (Vol. 1, 1972), using the published summaries by Meyer (1995) and Chun (2006); the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI). This guide does not cover Morrnah Simeona's later individual adaptation, Self I-Dentity through Hoʻoponopono, which belongs with Domain XIV. Details of Nānā i ke Kumu here come from these secondary summaries [uncertain: not verified against the primary text].

What it is. This is not one therapy. It is a living Indigenous healing tradition with several practices, each with its own practitioners and its own lines of authority. Hawaiʻi statute names four: lāʻau lapaʻau (herbal or plant-based healing), lāʻau kāhea (spiritual healing; one Hawaiian legal scholar glosses it as healing through suggestion and positive thinking, and a clinical teaching page glosses it as prayer), lomilomi (Hawaiian massage) and hoʻoponopono (family conflict resolution and "setting to right"). The statute also covers "similar practices" of traditional healers. [source: https://data.capitol.hawaii.gov/sessions/sessionlaws/Years/SLH1998/SLH1998_Act162.pdf] [source: https://data.capitol.hawaii.gov/sessions/sessionlaws/Years/SLH2005/SLH2005_Act153.pdf] [source: https://hoku.law.hawaii.edu/sites/hoku.law.hawaii.edu/files/content/Programs%2CClinics%2CInstitutes/APLPJ_12.1_donlin.pdf] [source: https://geriatrics.stanford.edu/ethnomed/ethno-med/hawaiian_pacific_islander/culturally-appropriate-care/fund/health_practicies.html] Kāhuna (singular kahuna) are the traditional experts. Donlin (2010) describes them as "keepers of secrets and traditional knowledge" who were historically chosen by genealogy, lineage and conduct. Their knowledge passes orally through lineage and apprenticeship and varies by locality. [source: Donlin 2010, above] The word kahuna also has wider meanings beyond healing [uncertain: not verified].

How change happens, as the tradition holds it. In the Hawaiian understanding described by a Waimānalo Health Center study, illness (maʻi) is imbalance. Health (ola) depends on harmony (lōkahi) among mind, body and spirit, and in one's relationships with others, family, gods and the environment. The healer's task is to find the source of the imbalance and correct it. [source: https://hawaiijournalhealth.org/past_issues/hjhsw8203_0072.pdf] Papa Ola Lōkahi says its healing work "seeks the knowledge of the source of illness which lies within our ancestral past and environment." [source: https://www.papaolalokahi.org/program/traditional-healing-kupuna-councils] In hoʻoponopono, healing comes from naming the fault (hala) truthfully, untangling the emotions it caused (hihia), confessing and forgiving (mihi), and mutually releasing (kala), all under an impartial leader (haku) and within a spiritual frame. The family's relationships, and with them its members' wellbeing, are restored. [source: https://narf.org/nill/documents/peacemaking/1995-meyer-to-set-right.pdf] These are spiritual understandings held by the tradition. They are described here as practitioners hold them and are neither asserted nor dismissed.

Your role as a psychotherapist. You do not practise any of these traditions unless you are trained in them and recognised by Hawaiian cultural authority. Your work runs alongside them: culturally responsive assessment, understanding the client's explanatory model, telling culturally normative experience apart from disorder, collaborating with and referring to recognised practitioners when the client wants this, integration, and safeguarding. [synthesis]

Who holds authority.

  • Kupuna councils. Under Act 153 (2005), traditional healers certified by a kupuna council convened by Papa Ola Lōkahi are exempt from the state medical licensing law. Each council is independent of the state, has at least three Hawaiians proficient in traditional healing, and sets its own rules for recognising practitioners. [source: Act 153, above]
  • Papa Ola Lōkahi recognises eight kupuna councils: five on Oʻahu, linked to Waiʻanae Coast Comprehensive Health Center, Na Lei Hulu No Ke Ola Mamo, Waimānalo Health Center, Kōkua Kalihi Valley and Waikīkī Health; Hoʻōla Lāhui on Kauaʻi; Hui No Ke Ola Pono on Maui; and Moku o Keawe Nā Kūpuna on Hawaiʻi Island. It also notes that some practitioners do not belong to a council. [source: Papa Ola Lōkahi, above]
  • What a council needs. To be recognised, a council must be affiliated with a Native Hawaiian Health Care System or a federally qualified or rural health centre, set membership and recognition guidelines, and list at least three Native Hawaiian practitioners with their moʻokūʻauhau (genealogy). [source: https://www.papaolalokahi.org/wp-content/uploads/Kupuna-Council-Brohure_Papa-Ola-Lokahi.pdf]
  • The kāhuna's own position. The master practitioners convened after Act 162 issued a "Kāhuna Statement" holding that certification belongs to the Hawaiian community through its kūpuna, not to government. [source: Donlin 2010, above]
  • Hoʻoponopono. Authority rests with the haku, a respected elder known to the family and not involved in the dispute, and with the family's spiritual guidance. [source: Meyer 1995, above] Clinical adaptation grew from the work of Pukui and QLCC (now Liliʻuokalani Trust). Hawaiian social workers carried it forward, among them NASW Social Work Pioneer Lynette Paglinawan, who taught hoʻoponopono to social workers and co-authored Nānā i ke Kumu Vol. 3 (Liliʻuokalani Trust, 2020). [source: https://naswfoundation.org/Our-Work/NASW-Social-Work-Pioneers/NASW-Social-Workers-Pioneers-Bio-Index/id/920] [source: https://kawaiola.news/columns/e-onipaa-kakou/nana-i-ke-kumu-helu-ekolu-look-to-the-source/]
  • Lomilomi is also practised under Hawaiʻi's massage licensing, which was the only route left for it after the state repealed its healing law in 1965. [source: Donlin 2010, above]

2. Framework

A. The tradition's own structure: family hoʻoponopono as published. This is given for orientation only. A recognised haku leads it, never the therapist. [source: Meyer 1995, summarising Pukui et al. 1972]

  • Preconditions. A haku is chosen first. The process does not begin unless every participant accepts five conditions: commitment to solving the problem, complete truthfulness (ʻoiaʻiʻo), a shared spirit of aloha or a commitment to restore it, confidentiality, and acceptance of the haku as fair and impartial.
  • Opening. The haku opens with prayer (pule wehe). Its content is not reproduced here.
  • Kūkulu kumuhana. The problem is stated clearly and objectively, and the family's emotional, physical and spiritual strength is pooled towards a shared goal. The haku can call on this again when someone is stuck in hostility.
  • Mahiki. The core discussion. The family works through layers of acts and feelings one problem at a time. Participants speak only when permitted and address the haku, not each other, so that anger is deflected.
  • Hoʻomalu. A silent time-out the haku can call at any point to cool tension, rest, eat or reflect. It may last minutes, hours or days.
  • Mihi. Confession, apology and forgiveness. The haku steps back, and members speak directly and truthfully to one another.
  • Kala. Members release each other from the fault. Meyer distinguishes this from "forgive and forget": the event is remembered but no longer hurts.
  • Closing. The haku closes with prayer (pule hoʻopau). Its content is not reproduced here.
  • Last resort. Where a member refuses to take part or to embrace the family with aloha, and all other options have failed, the family may cut that member off. Meyer's glossary gives the term mo ka piko, "to sever the umbilical cord", symbolically cutting off an ʻohana member [source: Meyer 1995].
  • Format. Sessions are private, unhurried, often held in the family home, and may run for hours or over several days. There is no set session count. The haku decides whether to continue, pause, postpone or end. [source: Meyer 1995]
  • Contemporary use. QLCC had to adapt the process to family schedules, gaps in language and concepts, and non-Hawaiian family members. [source: https://crdg.hawaii.edu/products/wp-content/uploads/2019/07/sample_ho_oponopono.pdf] Shook's book gives seven case studies of adaptation, from social work with Hawaiian families to drug abuse. [source: https://uhpress.hawaii.edu/title/hooponopono-contemporary-uses-of-a-hawaiian-problem-solving-process/] In 1994 the Native Hawaiian Bar Association began Naʻau Pono, a hoʻoponopono demonstration project taking family-court referrals. [source: Meyer 1995]

B. The psychotherapist's parallel framework [synthesis; built on the CFI, which can be used at first evaluation, later in care or repeatedly (source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf)]

  • Phase 1: engagement and cultural assessment (usually 1–3 sessions). Goals: build trust, cover the core CFI and relevant modules, map the explanatory model, ʻohana (family) and any healer involvement, and screen risk. Move on when you and the client have a shared description of the problem in the client's own terms and know what help they are seeking.
  • Phase 2: shared formulation and plan (1–2 sessions). Goals: combine the cultural formulation with the diagnostic assessment, decide whether the experiences are culturally normative or signs of disorder, and agree on whether and how traditional healing fits. Move on when the client has made an informed choice, which may be therapy only, therapy alongside healing, or healing with the therapist on standby.
  • Phase 3: collaboration or referral (when the client wants it). Goals: connect with a recognised practitioner through a kupuna council or Native Hawaiian Health Care System, and agree consent, information-sharing and roles. Move on when a working arrangement exists or the client decides against it.
  • Phase 4: parallel care and integration (the length of therapy). Goals: keep your own treatment going (for example, trauma-focused or family therapy), help the client make meaning of healing experiences, and monitor safety, medicines and progress. Re-assess at agreed reviews.
  • Phase 5: review and closure. Goals: review the CFI questions again, review outcomes in the client's own terms (for example, restored relationships or feeling pono) as well as standard measures, and plan continuing community supports.

3. Guiding principles

  • The tradition belongs to its community. Do not lead, imitate or rename your own sessions as hoʻoponopono, lomilomi or lāʻau kāhea. Refer to recognised practitioners. [source: Act 153; Papa Ola Lōkahi; Donlin 2010] [synthesis]
  • Name who holds authority. Point clients to kupuna councils and Native Hawaiian Health Care Systems, not to self-styled kāhuna. [source: Papa Ola Lōkahi]
  • Cultural humility and outsider status. If you are not Kanaka Maoli, say so and ask to be taught. Accounts written by outsiders, including some quoted here, are context, not authority. [synthesis]
  • Remember the history. Religious practice was outlawed in 1830, language in 1896 and healing practices in 1905, according to the Waimānalo study. Licensing of healers was granted and withdrawn several times, and the state's healing law was repealed in 1965. Expect wariness of clinical services. [source: Oneha et al. 2023; Donlin 2010]
  • Ask without judgement. Patients fear being judged for using traditional healing, and this is a known barrier to telling clinicians. Make it routine to ask. [source: Oneha et al. 2023]
  • The whole person and the ʻohana. Lōkahi links mind, body, spirit, family, gods and land. Include the family and spiritual relationships in your formulation. [source: Oneha et al. 2023]
  • Attribute spiritual concepts. ʻAumākua (family guardian spirits), mana and hala are described as the client and tradition hold them, neither confirmed nor dismissed. [source: Meyer 1995; Kumukahi] [synthesis]
  • Healing is time-intensive and not commercial. Traditionally, healing was given without charge, with gifts (hoʻokupu) accepted. Commercial fees are contested within the community. [source: Donlin 2010; Oneha et al. 2023]
  • Assessment first. The CFI informs, but does not replace, the diagnostic assessment. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
  • Avoid both pathologising and missing illness. Culturally sanctioned experiences are not psychotic symptoms, but real disorder still needs treatment. [synthesis; see 4.6]
  • Consent and confidentiality govern every contact with healers. [synthesis]
  • Never advise on medicines or herbs. Send questions to the prescriber or pharmacist. [synthesis]
  • Touch is for recognised or licensed practitioners only. It requires explicit consent before and during, the client may stop it at any time, and it is never sexual. The therapist does not touch. [synthesis]
  • Safeguarding overrides confidentiality conditions. A family's confidentiality condition does not cancel mandated reporting. [synthesis]
  • Not a treatment for physical disease. No practice described here is presented as a treatment for cancer or other physical disease. [synthesis]

4. Intervention inventory

Everything below is the psychotherapist's own work, done alongside Hawaiian healing and never in place of it. Unless a section says otherwise, the steps are [synthesis] built on the sources cited. Example language is illustrative.

4.1 Cultural humility and self-examination

  • Purpose / when. Use before and throughout work with Kanaka Maoli clients or clients who use Hawaiian healing, including non-Hawaiian clients drawn to commercial "hoʻoponopono" or "Huna" products.
  • Steps.
    1. Write down your own position: your ancestry, your relationship to Hawaiʻi, and what you have learned about Hawaiian healing and where it came from (tourist, commercial or community sources).
    2. Learn the basic history of suppression and licensing [source: Donlin 2010; Oneha et al. 2023].
    3. Learn the names of the local kupuna council and Native Hawaiian Health Care System, so you know the referral pathways [source: Papa Ola Lōkahi].
    4. Get consultation from a Hawaiian cultural adviser or a colleague trained in this area, for example graduates of programmes such as the University of Hawaiʻi Hawaiian Learning Program for MSW students [source: NASW Pioneers page].
    5. Correct your own vocabulary: use the community's own terms and spelling, and avoid exoticising.
  • Example language. "I'm not Hawaiian and I'm not trained in Hawaiian healing. I'd like to understand how you and your family see this, and I'll follow your lead on what's appropriate for me to know." (illustrative)
  • Watch for. Assuming that every Hawaiian client wants traditional healing, which is stereotyping. Romanticising. Mixing up commercial products with community practice. It is working when the client corrects you freely and brings cultural material without being asked.

4.2 Routine, non-judgemental enquiry about traditional healing

  • Purpose / when. Ask at intake and at reviews. Fear of being judged stops people telling clinicians that they use traditional healing [source: Oneha et al. 2023], and undisclosed use matters for safety, especially with plants (see 4.10).
  • Steps.
    1. Normalise the question by asking everyone.
    2. Ask about each practice by its own name: lāʻau lapaʻau, lomilomi, hoʻoponopono, lāʻau kāhea, and church or other spiritual help.
    3. Ask who the practitioner is in role terms only ("a kupuna in your family", "a healer at the health centre"). You do not need names.
    4. Ask what the client got out of it and whether they want you to know more or to work with that person.
    5. Write down the use and the client's preferences.
  • Example language. "Many people I see use family or Hawaiian healing alongside counselling: plants, lomilomi, hoʻoponopono, prayer. Has any of that been part of how you or your ʻohana deal with things?" (illustrative)
  • Watch for. Short, guarded answers, which may mean distrust. Back off and come back to it later. It is working when the client tells you about it without being asked at later sessions.

4.3 DSM-5-TR Cultural Formulation Interview, core version

  • Purpose / when. A 16-question interview with four domains: Cultural Definition of the Problem; Cultural Perceptions of Cause, Context and Support; Cultural Factors Affecting Self-Coping and Past Help Seeking; and Cultural Factors Affecting Current Help Seeking, which includes the clinician–patient relationship, for example perceived racism and language barriers. APA describes it as designed for any clinician, any individual and any setting. It supports understanding and decisions but is not the sole basis for diagnosis. Clinicians may reproduce it for use with their own patients. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
  • Steps.
    1. Use the official APA form; do not reproduce or alter its items.
    2. Introduce it as a way to understand the problem from the client's point of view.
    3. Work through the four domains in order, using the client's words. Note the terms they use, for example being out of balance, not pono, or carrying hala.
    4. In Domain 2, include the ʻohana, ancestors and land as possible causes and supports.
    5. In Domains 3 and 4, record use of healers and kupuna, and what the client expects from you.
    6. Summarise back and check that you have it right.
    7. Fold the results into your diagnostic formulation.
    8. How long the core CFI takes is not given in the APA forms, though clinicians in the field trial needed less time after their first interview [uncertain: not verified] [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/].
  • Example language. "Sometimes people describe problems in their own way, which may be different from how doctors describe them. How would you describe what's been happening?" (illustrative)
  • Watch for. Running it as a checklist. Clients pausing at the questions on racism or the clinician relationship. Stay with those moments. It is working when the formulation includes the client's own name for the problem and their own idea of what would help.

4.4 CFI supplementary modules and Informant Version

  • Purpose / when. To go deeper where the core CFI points. There are 12 modules. The most relevant here are Explanatory Model; Spirituality, Religion and Moral Traditions; Cultural Identity; Social Network; Coping and Help-Seeking; Patient–Clinician Relationship; Older Adults; School-Age Children and Adolescents; and Caregivers. They can be used as add-ons or standalone, at any point in care. The 17-question Informant Version is for a family member or friend. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
  • Steps.
    1. Choose modules from the core form's cross-references.
    2. Use the Spirituality module to cover the client's relationship to akua and ʻaumākua, church and Hawaiian practice, in the client's terms.
    3. Use Cultural Identity to cover identity as Kanaka Maoli, mixed ancestry, ties to place, and language (ʻōlelo Hawaiʻi).
    4. Use Social Network to map the ʻohana and kūpuna.
    5. With consent, use the Informant Version with a family elder, especially before any family process.
  • Example language. "Is there anyone in your ʻohana whose view on this matters a lot, someone we should hear from?" (illustrative)
  • Watch for. Talking to an informant without the client's consent. An informant overriding the client. It is working when the family's and the client's views can both be seen, side by side, in your formulation.

4.5 Exploring the explanatory model (Kleinman)

  • Purpose / when. To learn the client's model of the illness before negotiating care. Kleinman, Eisenberg and Good (1978) set out eight questions, paraphrased here: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment they should get; what the main problems are that it has caused; and what they fear most. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
  • Steps.
    1. Ask the questions in conversation, not as a list.
    2. Listen for relational and spiritual explanations that sources describe in Hawaiian thinking: imbalance, broken relationships, an unresolved family wrong, or a strained relationship with an ʻaumakua [source: Oneha et al. 2023; Chun 2006 sample].
    3. Reflect the model back.
    4. Negotiate a shared plan that respects it. For example, the client may want family reconciliation to come first, and therapy can help them get ready for it.
    5. Write down where your model and the client's agree and where they differ.
  • Example language. "What do you think set this off? Some people talk about something being out of balance in the family, or something not made right. Does anything like that fit for you?" (illustrative; offer it only if the client has hinted at it)
  • Watch for. Putting Hawaiian concepts into the client's mouth. Treating a spiritual explanation as a sign of psychosis. It is working when the client uses their own model to explain why the plan makes sense.

4.6 Normative experience versus disorder

  • Purpose / when. Use when a client reports dreams, visions, signs, ancestral presences, hearing ʻaumākua, or trance-like states. Chun records accounts of a cause being revealed through dreams, visions or signs [source: Chun 2006 sample]. No Hawaiian-specific cultural concept of distress appears among the DSM-5-TR named examples [uncertain: not verified].
  • Steps.
    1. Ask whether the client's family or community would see the experience as normal, meaningful or worrying.
    2. With consent, consult a cultural adviser or kupuna.
    3. Check the diagnostic rules. DSM dissociative identity disorder Criterion A allows that identity disruption may be described as possession; Criterion D excludes disturbances that are a normal part of a broadly accepted cultural or religious practice. Dissociative trance is excluded when it is part of accepted collective practice. DSM-5-TR keeps these points in substance, but its exact wording is [uncertain: not verified] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. ICD-11 6B62 Trance disorder and 6B63 Possession trance disorder require the state to be involuntary, unwanted and outside accepted cultural or religious practice, with significant distress or impairment [source: https://www.findacode.com/icd-11/code-1807490186.html]. DSM-5-TR's note that culturally sanctioned beliefs are not psychotic symptoms is [uncertain: not verified].
    4. Look for signs of disorder whatever the cultural frame: loss of functioning, distress, disorganisation, a lasting mood disturbance, substance use, risk, and whether the family itself is worried.
    5. Formulate with both lenses and explain your reasoning to the client.
  • Example language. "In your family, how would people understand hearing your tūtū's voice like that? Is it something welcomed, or something that worries them?" (illustrative)
  • Watch for. Missing psychosis or mania because "it's cultural". Diagnosing psychosis from beliefs alone. It is working when the client and the family accept your formulation, and treatment, if needed, is accepted without shame.

4.7 Helping a client or family consider hoʻoponopono

  • Purpose / when. Use when a client or ʻohana raises hoʻoponopono, or when family conflict, an unresolved wrong or estrangement is central and the client identifies with Hawaiian practice. You prepare and support them. A haku leads the process, and you never do. [source: Meyer 1995; Chun 2006 sample] [synthesis]
  • Steps.
    1. Ask what the client knows and what their family's experience of it has been. Modern families often know it only vaguely and need the conditions explained [source: Meyer 1995].
    2. Give a plain account of the published outline: a haku chosen first; the five conditions (commitment, truthfulness, aloha, confidentiality, an impartial haku); statement of the problem; layered discussion through the haku; cooling-off periods; confession and forgiveness; mutual release; and opening and closing prayer [source: Meyer 1995]. Do not describe prayer content or present yourself as an authority on it.
    3. Make clear that you cannot lead it. Help the family find a respected elder or a recognised practitioner through the local kupuna council or Native Hawaiian Health Care System (see 4.8).
    4. Check readiness with the client: Can they commit to full truthfulness? Can they hear others' accounts? Is anyone in the family unsafe? (See the safety screen below.)
    5. Run the safety screen before encouraging any family process. Look for current intimate partner violence, child abuse or sexual abuse, coercive control, severe mental illness, active substance dependence, or a member under pressure to attend. In these cases a process built on confrontation and mihi can put the person at risk or silence them. Talk with the client about safer options and about the limits of the confidentiality condition (mandated reporting).
    6. Help the client prepare what they want to say about their own part and their hurt, in their own words. Do not script mihi.
    7. Offer integration sessions afterwards (4.12).
  • Example language. "From what's been published, hoʻoponopono asks everyone to agree to tell the whole truth, keep things confidential and accept the haku as fair. Does your family feel ready for that? Is there anyone it wouldn't be safe for?" (illustrative)
  • Watch for. A survivor being pushed to forgive an abuser. Pressure on someone to attend. Your own wish to "use" the practice. It is working when the client chooses freely, a recognised leader is found, and family contact afterwards is safer and less tangled (less hihia).

4.8 Collaboration and referral with recognised practitioners

  • Purpose / when. Use when the client wants help from a traditional healer, or wants you to work with one. The Waimānalo model described integration within a health centre. E Ola Mau describes approaches ranging from networking with healers to co-treatment. [source: Oneha et al. 2023; Papa Ola Lōkahi]
  • Steps.
    1. Find the pathway: the island's kupuna council, often based at a community health centre, or a Native Hawaiian Health Care System (Ke Ola Mamo, Hoʻola Lāhui Hawaiʻi, Hui Mālama Ola Nā ʻŌiwi, Hui No Ke Ola Pono, Na Puʻuwai), or Papa Ola Lōkahi for information [source: Papa Ola Lōkahi].
    2. Get the client's written consent naming exactly what may be shared, and with whom.
    3. Approach with respect. Ask how the practitioner prefers to communicate, and accept that knowledge may be kept private (huna) [source: Donlin 2010].
    4. Agree roles: what you will keep doing (for example, risk monitoring or trauma therapy), what you will not do, and how you will contact each other in a crisis.
    5. Do not ask the healer to justify the practice in Western terms.
    6. Review with the client how the collaboration is going.
    7. Respect cultural exchange norms. Ask the council how to acknowledge the practitioner's time; traditionally, gifts (hoʻokupu) rather than fees [source: Donlin 2010].
  • Example language (to the client). "Would it help if I spoke with the kupuna council at the health centre, with your OK, about what you're hoping for?" (illustrative)
  • Example language (to the practitioner). "My client asked me to reach out. I'm the counsellor. I'd like to know how I can support what you're doing, and what you'd want me to stay out of." (illustrative)
  • Watch for. Sharing more than the client consented to. Treating the healer as an "adjunct" who works under you. It is working when the client experiences one coherent circle of care.

4.9 Helping clients judge offers and tell versions apart

  • Purpose / when. Use when a client meets paid "hoʻoponopono", "Huna" or "kahuna" products, or confuses family hoʻoponopono with Simeona's individual method. That method, described as cleaning subconscious memories that appear as problems [source: https://research-portal.uws.ac.uk/en/publications/morrnah-nalamaku-simeonas-updated-hooponopono-bridging-indigenous/], is covered in Domain XIV.
  • Steps.
    1. Explain that the family process described by Pukui involves an ʻohana, a haku and a shared process [source: Meyer 1995]. Individual and commercial forms are different practices.
    2. Help the client check any practitioner's links to a kupuna council or community health centre.
    3. Name the red flags reported in the literature, such as uncertified healers advertising very high fees [source: Donlin 2010]. Add your own: promises to cure physical disease, advice to stop medicines, sexualised touch, and isolation from family [synthesis].
    4. Respect the client's choice, and keep your safety monitoring going.
  • Example language. "What you've read about sounds like a different practice from family hoʻoponopono. Would it help to check with the health centre's kupuna council about what fits what you're looking for?" (illustrative)
  • Watch for. Coming across as dismissive of the client's spiritual seeking. It is working when the client chooses with full information.

4.10 Plants and medicines: disclosure, not advice (lāʻau lapaʻau)

  • Purpose / when. Use whenever a client uses plant remedies alongside prescribed medicines. Patients often do not tell clinicians about herbal products, and herbal products can interact with medicines [source: https://archives.starbulletin.com/2001/10/21/news/story8.html]. In the Waimānalo study, a community resident stressed that people need education before using plants [source: Oneha et al. 2023].
  • Steps.
    1. Ask which remedies the client uses, in general terms. Do not ask about preparations or amounts.
    2. Encourage them to tell their prescriber or pharmacist and their healer about everything they take.
    3. With consent, tell the prescriber that the client uses traditional remedies.
    4. Never advise starting, stopping or changing a remedy or a medicine.
    5. If you see a medical warning sign (new confusion, jaundice, rash, a seizure, or a sudden mood change), refer urgently for medical care.
    6. Do not present lāʻau lapaʻau as a treatment for cancer or other physical disease. Health claims belong to the tradition and their evidence status is not established here [uncertain: not verified].
  • Example language. "I'm not the right person to advise on plants or medicines, but it's important your doctor and your healer both know everything you're taking. Would you be OK with me letting your doctor know?" (illustrative)
  • Watch for. A client stopping psychiatric medication because they are using a plant remedy. One patient in the Waimānalo study said they no longer needed pain medication [source: Oneha et al. 2023]. Route these questions to the prescriber. It is working when the prescriber knows what the client takes and the client feels free to tell you.

4.11 Lomilomi and touch: consent and safety

  • Purpose / when. Use when a client receives or is considering lomilomi. Kamehameha Publishing describes it as a prayerful practice and a form of preventive care, traditionally done within families. A kahuna lomilomi, trained over many years, attends to the whole person, including their links to gods and ancestors. [source: https://kumukahi.org/units/na-kanaka/mauli-ola/lomilomi] Lomilomi is also practised under Hawaiʻi's massage licensing [source: Donlin 2010].
  • Steps.
    1. You do not touch the client and you do not give technique advice.
    2. Discuss the client's rights: explicit consent before and during treatment, the right to stop at any time, and the right to ask for changes. Touch is never sexual, and genital and other intimate areas are off limits. These are general principles; how individual practitioners handle consent is [uncertain: not verified].
    3. For trauma survivors, plan ahead: what they want the practitioner to know, signals to pause, and coping skills for flashbacks.
    4. Ask about medical conditions that may need clearance first, for example recent injury or surgery, clotting problems or blood thinners, osteoporosis, pregnancy, or skin conditions. Suggest checking with their doctor. Complications specific to lomilomi are [uncertain: not verified].
    5. Check the practitioner's council recognition or massage licence.
    6. Process the experience afterwards.
  • Example language. "Whatever the practice, you can say stop at any point, and good practitioners will check in with you. Would it help to think through what you'd want them to know beforehand?" (illustrative)
  • Watch for. Disclosures of sexualised or coercive touch, which call for safeguarding and reporting steps. Dissociation during bodywork. It is working when the client reports feeling safe and in control.

4.12 Integration after healing experiences

  • Purpose / when. Use after hoʻoponopono, a healer visit or lomilomi, to help the client make meaning of the experience and carry changes into daily life.
  • Steps.
    1. Invite an account in the client's own words. Do not ask for sacred or private content; the client decides what to share.
    2. Explore meaning: what feels set right, what is still tangled, and what has changed in their relationships.
    3. Link this to the goals you agreed in therapy.
    4. Watch for distress the experience stirred up, such as old trauma, grief or shame.
    5. Plan how to keep up repaired relationships, for example family routines.
    6. Re-assess the CFI items on help-seeking.
  • Example language. "You don't need to tell me anything that should stay with your family. What feels different since then?" (illustrative)
  • Watch for. Feeling responsible for what others did, after mihi. Pressure to stay silent about harm. It is working when the client reports relief, clearer relationships and a stable mood.

4.13 Working with the ʻohana

  • Purpose / when. Use when the family is central to the problem or to recovery. Hoʻoponopono itself is family-based [source: Chun 2006 sample].
  • Steps.
    1. With consent, invite family members, starting with the Informant Version (4.4).
    2. In family sessions, use ordinary family-therapy methods, without Hawaiian ritual elements and without calling them hoʻoponopono.
    3. Respect family hierarchy and elders while protecting each person's voice and safety.
    4. Consider an interpreter or cultural broker if elders prefer ʻōlelo Hawaiʻi, or if a concept needs bridging.
    5. Plan how your family work and any traditional process will run in sequence.
  • Example language. "How does your family usually handle it when something has gone wrong between people?" (illustrative)
  • Watch for. Elders speaking for younger members. Confidentiality conflicts between members. It is working when members describe the problem more alike and conflict lessens.

4.14 Historical and intergenerational trauma, and racism in services

  • Purpose / when. Use when distrust, shame about culture, or grief over lost language and practice appear. Sources record that healing practices were banned, licensed and banned again, that language and religion were suppressed, and that kāhuna practised in secret [source: Donlin 2010; Oneha et al. 2023]. The Waimānalo participants linked integration with healing to decolonisation [source: Oneha et al. 2023].
  • Steps.
    1. Name the history when it is relevant.
    2. Invite the client's family story about culture and healing.
    3. Make room for reconnection the client chooses, such as community, language or cultural programmes.
    4. Address racism the client has met in health care directly, using CFI Domain 4.
    5. Repair your own mistakes openly.
  • Example language. "Some families were taught to hide Hawaiian healing because it was against the law. Was that part of your family's story?" (illustrative)
  • Watch for. Treating culture as pathology, or making history the explanation for everything. It is working when the client draws on cultural identity as a strength.

4.15 Safeguarding

  • Purpose / when. Use whenever any practice, or anything presented as one, causes or hides harm: abuse revealed or kept secret within a family process, coercion to attend, sexual or coercive touch, delay of urgent medical care, stopping essential medicines, or exploitation by fee-charging "healers". [synthesis]
  • Steps.
    1. Assess risk with standard tools.
    2. Explain the limits of confidentiality early, including before any family process.
    3. Report as the law requires. A family or practice confidentiality condition does not override mandated reporting.
    4. Separate the practice from the harm. Do not blame the tradition, and tell the relevant kupuna council about misconduct by someone claiming its recognition, if the client consents.
    5. Refer urgently for medical care when needed.
    6. Do not name minors in any communication outside the required reports.
  • Example language. "What you've told me means I have to involve child protection. That's about safety, not about your family's culture or hoʻoponopono." (illustrative)
  • Watch for. Harm framed as tradition, and tradition mistaken for harm. It is working when the person is safe and still connected to culturally appropriate supports.

5. Handling problems

The Hawaiian sources describe how the haku handles difficulties within hoʻoponopono. Everything addressed to the therapist below is [synthesis] unless a source is cited.

  • The client is stuck: "nothing is making it right." Within hoʻoponopono, the haku can return the family to kūkulu kumuhana, their shared purpose, when someone is stuck in hostility, or call hoʻomalu, a cooling-off period [source: Meyer 1995]. In therapy, go back to the explanatory model (4.5). Ask what "set right" would look like and whether some piece of the problem is still unnamed. Check for depression, trauma or substance use that would keep the person stuck whatever the cultural frame.
  • Resistance to you, or distrust of the service. Expect this, given the history (4.14). Ask CFI Domain 4 questions about the clinician relationship directly. Offer the client a Hawaiian practitioner or a cultural broker. Do not take it personally, and do not push for disclosure.
  • Resistance to traditional healing ("that's old-fashioned" or "that's not Christian"). Pukui herself recorded that by 1958 many people saw hoʻoponopono as a remnant to be left behind [source: Chun 2006 sample]. Respect where the client stands. Never prescribe culture. Faith and Hawaiian identity can coexist in whatever way the client chooses.
  • Overwhelm during or after a family process. Advise the client that they can ask the haku for hoʻomalu, a pause, which the published process allows [source: Meyer 1995]. In therapy, use grounding and stabilisation and slow down any trauma work. If a process brings up abuse memories, treat it as a trauma activation and assess safety.
  • A family member refuses to take part, or is cut off. The published process allows, as a last resort, cutting off a member who refuses [source: Meyer 1995]. A client who is cut off may be grieving and at risk. Assess for suicide risk with standard practice, and support their connections outside the family.
  • Non-adherence or dropping out of therapy for healing. Respect the choice. Keep the door open, agree a safety plan and crisis contacts, and, with consent, offer to stay in touch with the healer. Collaborative care with traditional and faith healers has improved psychosis outcomes elsewhere: COSIMPO (Gureje et al., The Lancet, 2020) found greater symptom reduction and fewer harmful practices with shared care in Nigeria and Ghana [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]. In a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding medication reduced symptoms, but days in chains were not significantly reduced [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. These are evidence from other countries, not from Hawaiʻi.
  • The client stops medicines because of a plant remedy or a healer's view. Do not argue and do not advise. Link the client urgently with the prescriber, and with consent tell the healer about the clinical concern. If risk is acute, follow crisis procedures (4.10).
  • Rupture: you used a Hawaiian term wrongly, or seemed to appropriate the practice. Acknowledge it plainly, thank the client, ask how to do better, and get cultural consultation. Never use hoʻoponopono language as a therapy technique to repair the rupture.
  • The client wants you to "do hoʻoponopono" with them. Explain that it is led by a recognised haku within the family. Offer to help find one (4.8) and to continue your own work alongside. You can still work on honesty, repair and forgiveness with ordinary therapeutic methods, without the Hawaiian frame.
  • The family's confidentiality condition clashes with your duties. Explain mandated-reporting limits before any process and again in therapy. The family's condition does not bind you (4.15).
  • Conflicting authorities. Some practitioners do not belong to a council [source: Papa Ola Lōkahi], and practice varies by locality and lineage [source: Donlin 2010]. Do not judge legitimacy yourself. Defer to the client's community and to council guidance, and record what the client chose.
  • A non-Hawaiian client wants Hawaiian healing. Whether non-Hawaiians may be recognised as practitioners or served is debated within the community, and councils decide what is pono [source: Donlin 2010]. Direct the client to community pathways and away from commercial imitations (4.9).
  • A practitioner wants payment, or the client feels exploited. Traditional healing was usually given freely, with hoʻokupu (gifts), and commercialisation is contested [source: Donlin 2010]. Help the client weigh it up, and raise misconduct with the relevant council if the client consents.
  • Spiritual crisis, or a possible psychotic or manic episode framed as spiritual. Assess with both lenses (4.6) and consult a kupuna or cultural adviser. If there is risk to life, impaired capacity, or the client cannot care for themselves, follow emergency procedures. Explain this to the family as safety, not as a judgement on the experience.
  • Minors. Get consent from guardians and assent from the young person. Check that the young person's own voice is heard in any family process. Apply safeguarding (4.15) and never name minors in records shared outside the required channels.

Sources

Web sources

Books and articles cited

  • Pukui MK, Haertig EW, Lee CA (1972). Nānā i ke Kumu (Look to the Source), Vol. 1. Honolulu: Queen Liliʻuokalani Children's Center (as cited by Meyer 1995). Liliʻuokalani Trust describes it as a source book of Hawaiian cultural practices, concepts and beliefs for helping professions, first published 1972. Cited here through Meyer 1995 [uncertain: primary text not seen].
  • Paglinawan L, Paglinawan R (Likeke), Kauahi D, Kanuha VK (2020). Nānā i ke Kumu, Helu ʻEkolu, Vol. 3. Liliʻuokalani Trust.
  • Shook EV (1985). Hoʻoponopono: Contemporary Uses of a Hawaiian Problem-Solving Process. Honolulu: University of Hawaiʻi Press, for the East-West Center Institute of Culture and Communication (NYPL catalogue record, c1985).
  • Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258.
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