Samoan fofō · Atlas

1. Introduction

Version followed: Samoan fofō as Samoan healers and Samoan and Pacific scholars describe it (Macpherson and Macpherson 1990; Firestone et al. 2025 interview study with taulāsea in Samoa and Aotearoa New Zealand), placed alongside the psychotherapist's own culturally responsive work: the DSM-5-TR Cultural Formulation Interview (CFI), Kleinman's explanatory-model questions, the Fonofale model of health (Pulotu-Endemann, explanatory paper dated 2001 and 2021 presentation) and Le Va's Real Skills Plus Seitapu competencies (2009).

What it is. Fofō is a living Samoan healing tradition, not a psychotherapy. The word is used both for the healer and for traditional massage. Auckland University Press describes Samoan Medical Belief and Practice as the first comprehensive study of Samoan medicine, reporting the beliefs and practice of contemporary indigenous healers called fofo, and states that the tradition continues alongside Western medicine in Samoa and in Samoan migrant communities [source: https://aucklanduniversitypress.co.nz/samoan-medical-belief-and-practice/]. In the 2025 interview study, fofo is glossed as traditional massage; healers (taulāsea) specialise in one or more treatment methods, which may include plant-based massage, vai (plant medicines), prayer, diet advice and prescribed routines; healers describe their work as having a deep spiritual aspect and as an act of service [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download] [source: https://www.scimex.org/newsfeed/samoan-traditional-healers-holistic-approach-diet-expertise-and-spirituality]. Healers in that study described feeling for and realigning the to'ala, which they understand as a life-essence; this is the healers' own understanding, reported here as they hold it [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download]. Healers who treat infants and children are named in one Samoan-authored thesis as fofō o le 'ila [source: https://openrepository.aut.ac.nz/bitstreams/0e5d41e5-2484-4a2c-9d09-56208eccdb43/download]. Samoan families in Aotearoa may urge a relative with mental distress to consider "fofo Samoa (Samoan healing)" [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download].

Who holds authority. Authority rests with the healers and their families: training is a long apprenticeship that begins in childhood and is passed on by relatives, and access is through family and village networks and word of mouth [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download]. Healers deliberately keep plant and procedure knowledge confidential; the 2025 study omitted it at their request to protect it [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download]. In Samoa, a law-journal article reports that the Healthcare Professions Registration and Standards Act 2007 places traditional healers among the allied health professions and gives them the same liability as medical practitioners [source: https://pacliirms.austlii.edu.au/journals/JSPL/2012/6.pdf]; the Ministry of Health recognises the traditional health care system and registers traditional birth attendants [source: https://opus.lib.uts.edu.au/bitstream/10453/18490/1/2011006190.pdf]. Whether a separate national register of fofō exists is [uncertain: not verified]. In Aotearoa New Zealand a regulatory body for fofō is not known [uncertain: not verified]; the relevant authorities for the clinician are Pacific-led providers, Pacific workforce bodies such as Le Va, the client's family, church and community, and the healer the family recognises.

Core idea of change (as the sources hold it). Samoan-authored mental-health writing describes the self as relational, tied to family, ancestors, land and the spiritual world; health is harmony with God or gods, other people and the environment, and distress arises from disharmony such as broken relationships, breaches of protocol and dislocation from land [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf]. Healers say they aim to rebalance the body's wellbeing [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download]. For the psychotherapist, change comes from accurately understanding the client's and family's explanatory model, restoring safety and relational connection, and coordinating care so the client can use both Samoan healing and mental-health services without conflict or harm [synthesis]. The psychotherapist does not perform fofō and does not give massage.

2. Framework

No published source sets out phases for a psychotherapist working alongside fofō. The sequence below is the clinician's own culturally responsive work, assembled from the CFI, Fonofale and Seitapu [synthesis]. Fonofale is a model of health rather than a therapy; its author says the person using it (the "Viewer") needs to be culturally and clinically competent in Pacific worldviews [source: https://www.mpp.govt.nz/assets/Resources/Pacific-Wellbeing-Strategy/Fonofale-presentation-to-Pacific-Wellbeing-Talanoa-May-2021.pdf].

Phase 0. Preparation (before and between clients). Goal: check your own competence against Seitapu levels (Essential, Practitioner, Leader), identify local Pacific providers, Samoan-speaking colleagues, interpreters and cultural advisers [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf]. Move on when you know whom you can consult.

Phase 1. Engagement and cultural assessment (sessions 1 to 3, individual and, if the client wishes, with family). Goal: relationship built in culturally appropriate ways, presenting problem understood in the client's and family's terms. Tools: core CFI (16 questions, four domains), CFI Informant Version with a family member, relevant supplementary modules, Kleinman's questions, Fonofale mapping, and a non-judgemental question about fofō and other help [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. APA gives no administration time; the field trial found later interviews took less time, and any minute estimate is [uncertain] [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]. Move on when you can state the client's explanatory model, the help already used (including fofō), the family's view, and initial risk.

Phase 2. Differentiation and safety (runs alongside Phase 1). Goal: tell culturally normative spirit-attributed experience apart from disorder needing treatment, screen physical safety of any massage or other treatment the client is receiving, and check safeguarding. Move on when risk is assessed and urgent medical or psychiatric needs are met.

Phase 3. Shared plan and collaboration (with consent). Goal: a written plan the client and family agree to, naming who does what: therapist, prescriber, GP, Pacific provider, church and, if the client wishes, the healer. Move on when consent and information-sharing limits are recorded.

Phase 4. Ongoing therapy and integration (weekly or fortnightly, length set by the presenting problem). Goal: evidence-based treatment for any disorder, adapted to the relational and spiritual frame, and integration of what the client experiences in Samoan healing. CFI modules can be repeated during treatment [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].

Phase 5. Review and ending. Goal: review against the client's and family's own markers of wellbeing across the Fonofale dimensions, plan relapse responses and keep links with family, church and Pacific services [synthesis].

3. Guiding principles

Alongside, never performing. You work with the client's use of fofō; you never massage, diagnose by Samoan methods or give Samoan remedies [synthesis].
Relational self. Identity is held through family, ancestors, land and responsibilities (fa'asinomaga, tofi); assess the person within these ties, not alone [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf].
Harmony as the health goal. Ask what relationship, protocol or belonging has been disturbed, as well as which symptoms are present [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf].
Family as foundation. In Fonofale, family is the floor and culture the roof, with spiritual, physical, mental and "other" pou between them; involve family where the client wishes [source: https://www.hauora.co.nz/assets/Fonofalemodelexplanation.pdf].
Spiritual explanations are held, not judged. Samoan sources report that mental illness may be understood as linked to spirits or to a breach of tapu; record this as the client's understanding, neither stating it as fact nor dismissing it [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf] [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download].
More than one description. Services should acknowledge more than one description of self and illness; a psychiatric diagnosis and a Samoan explanation can coexist in the plan [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf].
Spirituality is often blended. Christian, traditional and other beliefs may sit together; not every Pacific family is religious [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf] [source: https://openrepository.aut.ac.nz/bitstreams/0e5d41e5-2484-4a2c-9d09-56208eccdb43/download].
Tapu as boundaries. Seitapu frames tapu as sacred bonds and cultural safety; behave respectfully in words and body language [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf].
Client choice. The client decides whether to use fofō, mental-health care or both; do not push towards or away from either [synthesis].
Protect healers' knowledge. Do not ask for plant names, recipes or techniques; ask only what you need for safety [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download].
Touch belongs to consent. Any massage the client receives should involve explicit consent before and during, the right to stop at any time, and never sexual or genital touch; the therapist does not touch clients therapeutically [synthesis].
Medical safety first. Healers themselves refer severe cases to hospital; urgent medical care must never be delayed, and medicine decisions go to the prescriber [source: https://www.scimex.org/newsfeed/samoan-traditional-healers-holistic-approach-diet-expertise-and-spirituality].
Language carries meaning. Translation alters meaning; use Samoan-speaking staff or qualified interpreters and cultural advisers [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf] [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf].
Stigma and privacy. Mental illness may be "a hush hush subject"; expect reluctance and protect confidentiality, including within the community [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download].
Clients and families judge the worker. In Seitapu, consumers and families monitor and assess the worker's competence; invite their feedback [source: https://www.mpp.govt.nz/assets/Resources/Pacific-Wellbeing-Strategy/Fonofale-presentation-to-Pacific-Wellbeing-Talanoa-May-2021.pdf].
Pacific-led care where possible. Samoan-authored sources call for services designed and largely staffed by Samoan people and for traditional healers working alongside psychiatrists [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf].

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them is fofō, and none involves the therapist touching the client. Healers' diagnostic methods, plant medicines, massage techniques and prayers are not described here; they belong to the healers and their families [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download].

4.1 Cultural humility and competence self-check (Seitapu)

Purpose / when: Before seeing Samoan clients and at supervision; Fonofale's author places the Viewer's cultural and clinical competence at the centre [source: https://www.mpp.govt.nz/assets/Resources/Pacific-Wellbeing-Strategy/Fonofale-presentation-to-Pacific-Wellbeing-Talanoa-May-2021.pdf].
Steps: (1) Read the Le Va Real Skills Plus Seitapu areas (Family, Language, Tapu) and rate yourself at Essential, Practitioner or Leader level [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf]. (2) Write down your own assumptions about massage healers, spirits and church, and where they came from [synthesis]. (3) Identify a Pacific cultural adviser or Samoan-speaking colleague for consultation. (4) Record gaps and a learning plan; bring Samoan cases to supervision with a Pacific supervisor where available [synthesis].
Example language (illustrative, to a colleague): "I'm seeing a Samoan family whose son has been to a fofō. Could I talk through how I'm framing this so I don't miss something important or cause offence?"
Watch for: Defensiveness when a family corrects you; treating all Pacific peoples as one culture (Seitapu stresses diversity between and within families). It is working when you seek consultation early and families say they felt respected.

4.2 Culturally safe engagement and language

Purpose / when: Every first contact and home visit; Seitapu treats rapport as built culturally, not clinically [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf].
Steps: (1) Ask who the client wants present and in what language. (2) Use correct greetings and respectful body language; Le Va gives examples such as saying "tulou" and lowering yourself when passing a seated person, and on home visits removing shoes and waiting to be invited to sit [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf]. (3) Allow time; Pacific processes are relational. (4) If the family wishes to open or close with prayer, allow time for it and do not lead it yourself unless asked and appropriate [synthesis, consistent with Seitapu's reference to prayer where appropriate]. (5) Use a qualified interpreter or cultural adviser where language is a barrier; avoid using the client's children as interpreters [synthesis].
Example language (illustrative): "Before we start, who would you like to be part of this conversation? And would you prefer to speak in Samoan or English? We can arrange an interpreter."
Watch for: Polite agreement that hides disagreement; elders deferring to you out of respect. It is working when family members speak freely and correct your understanding.

4.3 Core Cultural Formulation Interview (DSM-5-TR)

Purpose / when: First assessment with any client; APA describes the CFI as usable by any clinician with any client in any setting. It supports, but is not the only basis for, diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Steps: Use the APA form (clinicians may reproduce it for their own patients; translation or modification needs APA permission). Cover its four domains in order: (1) cultural definition of the problem; (2) cultural perceptions of cause, context and support, including the role of cultural identity; (3) self-coping and past help seeking, including barriers; (4) current help seeking, preferences and the clinician-patient relationship [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. Under past help seeking, ask specifically about fofō, taulāsea, church, pastors and family remedies. Under the relationship domain, ask about past experiences of racism or misunderstanding in services. Write a short formulation in the client's own words.
Example language (illustrative): "People describe problems like this in different ways. How would you and your family describe what has been happening?" / "Have you or your family seen anyone else for help, such as a fofō, your minister or someone in the family?"
Watch for: Short answers to causal questions may reflect stigma or fear of being judged. The CFI field trial found clinicians rated it more feasible after first use and later interviews took less time [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]. It is working when the client's own explanation and help-seeking map are on record.

4.4 CFI Informant Version with family

Purpose / when: When family are central to decisions or the client cannot give a full account (e.g. during psychosis) [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
Steps: (1) Get the client's consent to involve the family member and agree what may be shared. (2) Use the 17-question Informant Version, starting with the informant's relationship to the client, then the same four domains. (3) Note where the family's explanation differs from the client's. (4) Feed back a combined understanding to both, with consent [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [synthesis for steps 1, 3, 4].
Example language (illustrative): "From your side as her aunt, what do you think is happening, and what does the family think would help?"
Watch for: A senior family member speaking for the client; disagreement about whether to use Samoan healing first, which a Samoan family study reports as a source of conflict [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download]. Make space to hear the client alone.

4.5 CFI supplementary modules

Purpose / when: To go deeper on a domain, at first evaluation, later or repeatedly [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: Pick the modules the core interview points to. Most often useful here: Explanatory Model; Spirituality, Religion, and Moral Traditions; Coping and Help-Seeking; Social Network; Cultural Identity; Immigrants and Refugees (for migrants); Patient-Clinician Relationship; Caregivers (given to the caregiver) [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. Paraphrase rather than read in a way that feels like an interrogation [synthesis].
Example language (illustrative): "Your faith seems important in how you are coping. Could you tell me more about what your church and your beliefs mean in all this?"
Watch for: Over-long assessment that delays help; spread modules across sessions. It is working when the plan reflects spiritual and family supports the client named.

4.6 Explanatory-model questions (Kleinman)

Purpose / when: When the client's understanding of the illness differs from a biomedical one, or before negotiating treatment [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader].
Steps: Ask, in your own words, the eight areas: 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 the client thinks they should receive; the main problems it has caused; what they fear most [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]. Then summarise both models side by side and negotiate a plan [synthesis].
Example language (illustrative): "What do you think started this, and why now?" / "What are you most afraid this will lead to?"
Watch for: Explanations involving broken relationships, breaches of tapu or protocol, or spirits [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf] [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf]; record these without correcting them. It is working when the client feels their account has been taken seriously and agrees to a plan that fits it.

4.7 Fonofale mapping

Purpose / when: To organise a holistic picture with Pacific clients; Fonofale was developed with Samoan, Cook Island, Tongan, Niuean, Tokelauan and Fijian participants [source: https://www.hauora.co.nz/assets/Fonofalemodelexplanation.pdf]. The author's materials describe the model's parts but give no step-by-step clinical procedure, so the steps below are [synthesis].
Steps: (1) Draw or describe the fale: family as floor; culture as roof (including beliefs in both traditional healing and Western medicine); four pou: spiritual, physical, mental and "other" (gender, sexuality, age, socio-economic status); encircled by environment, time and context [source: https://www.hauora.co.nz/assets/Fonofalemodelexplanation.pdf]. (2) Ask the client to say what is strong and what is weak in each part. (3) Note where fofō, church, family and services sit in the picture. (4) Use the map to set goals in each pou and review it at the end. Use only at a level your competence supports; the author ties use to cultural and clinical competence and to Seitapu [source: https://www.mpp.govt.nz/assets/Resources/Pacific-Wellbeing-Strategy/Fonofale-presentation-to-Pacific-Wellbeing-Talanoa-May-2021.pdf]. A further development, the Kalisi Model (2020), focuses on implementation; its content is [uncertain: not verified].
Example language (illustrative): "Some Pacific health workers use the picture of a fale. If your family is the floor and your culture the roof, which posts feel shaky right now?"
Watch for: The model used as a tick-box; clients raised in Aotearoa may relate to it differently from island-raised clients, which the model's "context" dimension anticipates. It is working when the client adds their own content and uses it to explain priorities.

4.8 Asking about fofō and other healing, without judgement

Purpose / when: At assessment and at every review. Samoan people may use healers first or at the same time as Western care, and healers do not require patients to avoid Western medicine [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download].
Steps: (1) Normalise: say many families use both. (2) Ask who they have seen, for what, how often, and how it has helped. (3) Ask whether the treatment involves massage, plant medicines taken by mouth or on the skin, steam or heat, or fasting, so you can check safety, without asking for recipes or techniques. (4) Ask whether the healer gave advice about diet, routines or other care, and whether it conflicts with medical advice. (5) Ask the client's wishes about telling their doctor and about any contact between you and the healer [synthesis].
Example language (illustrative): "Lots of Samoan families see a fofō as well as a doctor. I won't judge either way; it helps me to know so we can keep everything safe and working together."
Watch for: Hesitation or denial, which may reflect earlier dismissal by services [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf]. It is working when the client volunteers updates about healing without being asked.

4.9 Cultural concepts of distress and telling normative experience from illness

Purpose / when: When the client or family attributes distress to spirits, a breach of tapu or broken relationships, or when there are unusual experiences such as hearing or seeing the dead, possession-like states or talking to oneself. Samoan sources report that mental illness may be understood as possession by spirits or as linked to breached sacred boundaries [source: https://openrepository.aut.ac.nz/bitstreams/0e5d41e5-2484-4a2c-9d09-56208eccdb43/download] [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download].
Steps: (1) Use DSM-5-TR's frame: cultural concepts of distress include idioms, explanations or perceived causes, and syndromes [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. No Samoan-specific concept appears in the DSM-5-TR examples (which include ataque de nervios, khyâl cap, kufungisisa, susto and others) [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]; treat Samoan spirit attributions as a perceived cause, not a diagnosis [synthesis]. (2) Ask family and, with consent, a Samoan cultural adviser or minister whether the experience is seen as expected within their community, and whether this episode looks different from that [synthesis]. (3) Apply diagnostic exclusions: in DSM, possession-form identity disruption counts towards dissociative identity disorder only when it is not a normal part of a broadly accepted cultural or religious practice, and dissociative trance likewise excludes accepted collective practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] (exact DSM-5-TR wording [uncertain]) [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require that the state is involuntary, unwanted and outside accepted cultural or religious practice, with significant distress or impairment [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. (4) Assess function, duration, distress, risk, sleep, substance use and physical causes regardless of the explanation. (5) Remember Samoan families have reported psychiatric diagnoses, especially psychosis, given for what they described as migration trauma [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf]: avoid both over- and under-diagnosis.
Example language (illustrative): "In your family's understanding, is this something that happens to people and passes, or does it feel different this time? What would tell you it has gone beyond that?"
Watch for: Rapid decline, not eating or sleeping, self-harm or violence risk, confusion or fever (possible medical cause): these need urgent assessment whatever the explanation [synthesis]. It is working when the family and you agree on signs that mean extra help is needed.

4.10 Physical-safety and touch screen for clients receiving fofō

Purpose / when: Whenever a client receives massage or heat, steam or plant treatments from a healer. Published complication series for Samoan fofō massage are [uncertain: not verified]. General reports show forceful manipulation of the neck in other massage traditions has been linked to vertebral fracture, epidural haematoma, disc prolapse and stroke, with older people with osteoporosis and people with ankylosing spondylitis at higher risk [source: https://annals.edu.sg/wp-content/uploads/dlm_uploads/2021/08/V49N11p915.pdf]. In Samoa, a 2010 Supreme Court case ([2010] WSSC 20), as reported in a law-journal article, concerned a patient who died in hospital after a traditional herbal steam treatment; the post-mortem found burns among the causes, and the family had not sought medical care for a serious infection; the article reads the case as holding that patient or family consent does not remove a healer's liability [source: https://pacliirms.austlii.edu.au/journals/JSPL/2012/6.pdf].
Steps: (1) Ask what the treatment involves physically, in general terms. (2) Check for conditions that call for medical advice first: osteoporosis or fragile bones, recent injury or surgery, spinal or neck problems, bleeding problems, pregnancy, skin infection or wounds, fever, diabetes with reduced sensation, frailty, and serious infections that need medical treatment [synthesis]. Suggest the client check with their GP; do not give instructions about techniques, heat or durations. (3) Talk about consent: the client can agree or decline before treatment, ask for it to change or stop at any time, bring a support person, and should never experience sexual or genital touch; any treatment near intimate areas should be discussed in plain clinical terms and consented to [synthesis]. (4) Ask after each treatment about pain, bruising, burns, numbness, weakness, dizziness or worsening, and route these to medical care. (5) Record the discussion.
Example language (illustrative): "I'm not here to stop you seeing the fofō. Because of your back problem, could you check with your doctor first? And remember you can always ask the healer to go gently or stop."
Watch for: Embarrassment about raising consent with a respected healer; severe pain or new neurological symptoms after treatment (urgent medical review); any report of sexual or coercive touch (safeguarding, 4.15). It is working when the client knows they can say stop and reports any harm promptly.

4.11 Collaboration and referral with community-sanctioned healers

Purpose / when: When the client wishes their healer, family elders, minister or a Pacific provider to be part of care. Samoan-authored sources call for traditional healers to work alongside Samoan psychiatrists, and for clinicians to engage church pastors, traditional healers, family elders and Pacific NGOs [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf] [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download]. Healers describe themselves as gatekeepers who refer severe cases to Western care [source: https://www.scimex.org/newsfeed/samoan-traditional-healers-holistic-approach-diet-expertise-and-spirituality].
Steps: (1) Ask whether the client wants any contact, with whom, and what may be shared; get written consent. (2) Make contact through the family or a Pacific provider, in the way the family judges respectful; consider a cultural adviser to accompany you [synthesis]. (3) In any meeting, ask how the healer understands the problem and what they advise, share only what the client agreed, and agree warning signs that mean hospital or crisis care. (4) Do not ask the healer to change their practice, and do not endorse or refer to a particular healer yourself; the family and community recognise healers [synthesis]. (5) Record roles in the shared plan. Evidence from elsewhere: in Nigeria and Ghana, collaborative shared care between traditional and faith healers and primary care (COSIMPO; Gureje et al., The Lancet 2020) reduced psychotic symptoms more than usual care and reduced harmful practices [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]; in a Ghanaian prayer camp, adding psychiatric medication reduced symptoms but did not significantly reduce days in chains (Ofori-Atta et al., Br J Psychiatry 212(1)) [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. An equivalent Samoan trial is [uncertain: not verified]. WHO's Traditional Medicine Strategy 2014-2023 supports safe, regulated integration of traditional practitioners into health systems [source: https://www.who.int/activities/implementation-of-the-WHO-traditional-medicine-strategy-2014-2023].
Example language (illustrative): "Would it help if I spoke with the fofō, or with your minister, so we are not giving you different messages? You decide what I can share."
Watch for: The healer feeling inspected; you becoming a go-between in family conflict. It is working when the client receives consistent messages and escalation happens early.

4.12 Interpreters and cultural advisers

Purpose / when: Whenever language, protocol or meaning is uncertain. Seitapu requires workers to know where to find people with advanced language skills and to use qualified interpreters or cultural advisers; Samoan sources welcome cultural consultants in services [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf] [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf].
Steps: (1) Brief the interpreter or adviser beforehand on purpose and confidentiality, and check they are acceptable to the client (small communities). (2) Speak to the client, not the interpreter. (3) Ask the adviser afterwards about meanings that may have been lost, such as terms for spirit, tapu or family obligations [synthesis].
Example language (illustrative, to the adviser): "When she used that word for what is happening, what does it carry for Samoan families that I might miss?"
Watch for: Interpreter softening or omitting stigmatising content; Seitapu asks workers to be sensitive to stigmatising language about mental illness. It is working when the client's meanings are captured in their own words.

4.13 Working with family and church

Purpose / when: Throughout care. Family is central to recovery, and identity may be tied to "family, village and church" [source: https://www.leva.co.nz/uploads/files/resources/Lets-Get-Real-Real-Skills-Plus-Seitapu-Working-with-Pacific-Peoples.pdf]. Families report prayer, church attendance and fasting (anapogi) as central coping and healing, and reconciliation through ifoga as helping restore relationships [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download].
Steps: (1) Map family roles, obligations and decision-makers. (2) Support family decision-making while protecting the client's own voice. (3) Explain diagnoses and treatment plainly, in Samoan where possible. (4) Ask about the client's and family's fasting or other practices so you can check physical safety (e.g. with medicines or medical conditions, routed to the doctor). (5) Where the client wishes, include their minister. Do not conduct or arrange ifoga or other ceremonies; they belong to families and their leaders [synthesis].
Example language (illustrative): "Who in the family usually makes decisions about health, and how would you like them involved?"
Watch for: Shame about a crisis becoming public in church, which families report [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download]; a church that dismisses traditional explanations as pagan [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf]. It is working when family are informed and supportive rather than excluded or controlling.

4.14 Integrating healing experiences

Purpose / when: After the client has seen a healer, or when Samoan healing and therapy both shape recovery [synthesis].
Steps: (1) Ask what the experience meant and what changed. (2) Link it to the client's goals across the Fonofale dimensions. (3) Carry forward what helped (e.g. diet and routine advice that fits medical advice, restored relationships). (4) Explore any fear, shame or obligation arising from it; healers in the 2025 study hold that patients' non-compliance or payment may bring sickness on the healer or their family, which may weigh on a client [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download].
Example language (illustrative): "What did you take away from seeing the fofō? Is there anything from it you'd like us to build on here?"
Watch for: The client feeling they must choose sides. It is working when the client describes one coherent recovery story.

4.15 Safeguarding

Purpose / when: When treatment harms, when urgent medical care is delayed, or when a child or vulnerable adult may be at risk [synthesis].
Steps: (1) Ask directly, without accusation, about pain, injury, restraint, food or fluid restriction, coercion or sexual touch in any treatment. (2) Act on urgent medical need first. (3) For children, remember that healers for infants and children are a recognised Samoan role [source: https://openrepository.aut.ac.nz/bitstreams/0e5d41e5-2484-4a2c-9d09-56208eccdb43/download]; neither treat traditional care as abuse by default nor accept injury explained as tradition; consult your safeguarding lead and follow local reporting duties. (4) Record facts, and tell the client what you must report and why. (5) In Samoa, healers carry legal liability like medical practitioners, and consent does not remove it [source: https://pacliirms.austlii.edu.au/journals/JSPL/2012/6.pdf].
Example language (illustrative): "Part of my job is to make sure no one is hurt. Has any treatment ever left marks, burns or pain that worried you?"
Watch for: Fear that disclosure will shame the family or the healer. It is working when risk is addressed and the family stays engaged.

4.16 Medicines and the prescriber

Purpose / when: When the client takes or is offered psychiatric or other medicines and also uses plant medicines or healer advice [synthesis].
Steps: (1) Ask what the client takes, including plant medicines, without asking what is in them. (2) Never advise starting, stopping or changing a medicine. (3) With consent, tell the prescriber or GP about all treatments in use. (4) Respect concern raised in Samoan sources about sedation used as treatment rather than containment [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf] by helping the client bring such worries to the prescriber.
Example language (illustrative): "That is a good question for your doctor. Shall we write it down so you can ask, or would you like me to call them with you?"
Watch for: Stopping medicines without telling anyone. It is working when the prescriber knows the whole picture.

4.17 Addressing migration, stigma and structural barriers

Purpose / when: With migrant clients and families facing service barriers. Samoan families report language barriers, unanswered calls, being sent to police in crises, and pressures of weakened extended family, financial strain and limited access to traditional healing [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download] [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf].
Steps: (1) Use the CFI Immigrants and Refugees module where relevant. (2) Name stigma openly and normalise help-seeking. (3) Give the family a clear crisis pathway in plain language. (4) Link to Pacific providers and advocate within your service [synthesis].
Example language (illustrative): "Many families feel they have to keep this quiet. Everything you say here stays private unless someone's safety is at risk."
Watch for: Missed appointments driven by cost, transport or shame rather than disinterest. It is working when the family can reach help in a crisis.

5. Handling problems

The sources describe barriers but give few concrete responses. Responses below are [synthesis] unless a source is cited.

Client hides use of fofō. Likely fear of dismissal, which Samoan sources say families have met in services [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf]. Normalise use of both systems, explain you ask only for safety, and return to the question later rather than pressing.
Family split between Samoan healing first and mental-health care first. A Samoan family study reports exactly this conflict [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download]. Hold a family meeting with a cultural adviser; frame the plan as "both, safely" with agreed warning signs for escalation; keep the client's own wishes central.
Client wants to stop medication in favour of the healer. Do not advise on the medicine. Explore the reasons (side effects, sedation, stigma, healer advice as understood), and arrange a joint conversation with the prescriber. Note healers in the 2025 study say they do not require patients to avoid Western medicine [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download].
Client asks you to recommend a fofō, or to give massage yourself. Decline both. Recognition of healers comes from families and communities; suggest the client ask family, church or a Pacific provider. Explain that your role does not include touch.
Physical harm or worsening after treatment. Arrange medical review promptly; for new neurological symptoms, severe pain, burns, fever or collapse, urgent care. Document, and consider safeguarding (4.15). Avoid blaming the healer in front of the family; focus on safety.
Report of sexual or coercive touch. Treat as a safeguarding and possible criminal matter: support the client, follow reporting duties, and offer trauma-focused support. Tradition is never a justification.
Psychotic or severe symptoms explained as spirit affliction. Respect the explanation and still assess risk and capacity. Use the family's own markers of "beyond the usual" (4.9). If urgent care is needed, explain it as additional help, invite the family's chosen spiritual support to remain involved, and use Pacific liaison staff where available.
Rupture after the client feels their beliefs were dismissed. Name it, apologise for the specific misstep, and re-ask the explanatory-model questions. Seitapu gives clients and families a role in judging the worker's competence; invite that feedback directly [source: https://www.mpp.govt.nz/assets/Resources/Pacific-Wellbeing-Strategy/Fonofale-presentation-to-Pacific-Wellbeing-Talanoa-May-2021.pdf].
Silence, polite agreement or "resistance". Often respect, shame or stigma rather than opposition; mental illness may be a hush-hush subject [source: https://openrepository.aut.ac.nz/bitstreams/921531bc-4f7e-4a8c-8375-e4d9d32cb59e/download]. Slow down, spend time on relationship, offer a Samoan-speaking colleague, and check understanding by asking the client to explain the plan back.
Stuck or not improving. Revisit the Fonofale map and CFI modules to find a neglected domain (spiritual, family obligations, finances, migration); review the diagnosis; consult a Pacific clinician or adviser.
Non-adherence to the plan. Ask whether the plan conflicts with healer advice, church commitments, fasting or family obligations; rebuild the plan around them where safe.
Overwhelm in sessions. Shorten sessions, include a trusted family member if the client wishes, ground the conversation in practical next steps, and pace assessment across sessions.
Church dismisses Samoan healing as pagan, or the healer dismisses services. Samoan sources note some churches take this view [source: https://dulwichcentre.com.au/wp-content/uploads/2023/07/Just-Therapy-chapter-12-Honouring-Samoan-ways-and-understandings.pdf]. Do not take sides; support the client to decide what to use, and seek allies among ministers or healers open to working together.
Client fears harming the healer by not complying or by paying. Healers in the 2025 study hold these beliefs [source: https://mro.massey.ac.nz/bitstreams/77acf8ef-8d92-4046-90da-94091624826b/download]. Explore the client's sense of obligation respectfully; suggest the family or minister help negotiate any change rather than you.
Healer declines contact. Respect it; continue to coordinate through the client and family, and keep your own safety checks in place.
Small-community confidentiality. Interpreters, advisers or healers may know the family. Check acceptability with the client before involving anyone.
You are not Samoan or Pacific. Seek consultation, be open about limits, and refer to or co-work with Pacific providers when the client prefers; the Fonofale author ties use of the model to the Viewer's cultural and clinical competence [source: https://www.mpp.govt.nz/assets/Resources/Pacific-Wellbeing-Strategy/Fonofale-presentation-to-Pacific-Wellbeing-Talanoa-May-2021.pdf].

Sources

Samoan healing, Samoan mental health and Pacific models

Cultural assessment and collaboration

Books cited

Macpherson C, Macpherson L (1990). Samoan Medical Belief and Practice. Auckland University Press.
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 (article; pages [uncertain]).

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