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Researching the Health Needs of Elderly Indian Migrants to New Zealand

DeSouza, R. (2006). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, 20 (1&2), 159-170.

The older adult population in New Zealand is increasing and becoming more ethnically diverse. With this change comes a requirement for health and social service professionals to become more knowledgeable about the cultural needs of their clients and to provide care that is cognisant of language, culture and religion. Indians have a long history of settlement in New Zealand; however this has not been reflected in policy or service provision. The reasons for this include a focus on the bicultural relationship with indigenous Mâori and a relatively small Indian population. The Immigration Act 1987 has led to an increase in the cultural diversity of migrants and the number of Indians. Policy has not kept pace with demographic changes and there is a need to develop the health sector to work with Indians and other migrants. This article begins by tracing the changing demographics of age and ethnicity in New Zealand and the relationship with migration policy. Indian history, settlement and health in New Zealand are explored then a brief overview of existing research is presented along with the identification of gaps and recommendations for an expansion of current health research and practice agendas such as cultural safety and ethnicity data collection.

Keywords: Indians, health, settlement, Asian, older adults, New Zealand

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My World, Diversity and New Zealand

Plenary presentation at the New Zealand Diversity Forum, August 22, 2006. Te Papa Tongarewa, Wellington.

Thank you for inviting me to speak at this plenary session of the Diversity Forum. I’ve been asked to talk about my world, diversity and New Zealand from an ‘ethnic’1 point of view. The theme of my talk is to ‘Get lost’. There is something about going out of town to conferences and meetings that is very liberating. I feel like I am much more open to new experiences and meeting people because I am not stuck in my routines, tasks and schedules. Getting lost means stepping out of your comfort zone, and being open to expanding your internal and external boundaries.

Getting lost isn’t really that difficult, some of us do it without trying! I always get lost in Wellington! My family has had a habit of getting lost. From my great grandfathers’ who both went to Burma (who said that astronaut families are a new trendy kind of thing!). Then my grandparents got lost in Tanzania and so did my parents. I was born in a place called Tabora, which was founded by Arab slave traders in 1852, captured by the Germans in 1891 and a prosperous, thriving town. It was the administrative centre of German East Africa. From 1852 to 1891, Tabora was the slave capital of East Africa, ivory and humans were traded for guns, beads and cloth. Tabora is also famous as a base for many great explorers, it was the place where Stanley uttered those unforgettable words “Dr Livingstone, I presume.”

In 1975, my parents decided to get lost again, this time in New Zealand and I have made it a habit to get lost regularly ever since! Migration forces you to ‘get lost’. Disorientation and the loss of reference points mean that some people never survive while others thrive. Migration leads us to develop new reference points, networks, rituals and experiences. Depending on the kind of pre- migration experiences we’ve had we might be traumatised, grieving and exhausted. When we arrive, the reception of the receiving country can influence how happy we are about the experience and, equally, if our expectations are met. If not, we can lose heart and face. Yet, if we allow ourselves to get lost in the experience of resettling and be open to new ways of doing things we can benefit enormously.

There is an expectation that migrants need to find their feet. They are the ones who are lost and need to discover our reference points so they can become just like the receiving community. But, I would like to argue that all of us need to ‘get lost’ and on a regular basis! What I mean by this is that we all need to be willing to take a trip to a place we’ve never been. A new New Zealand where there are wonderful adventures to be had. We don’t have to go around the world to get lost, as TV host Phil Keoghan says “just put yourself in a situation that is removed from your everyday life and become immersed in it. Go with the flow – it expands your horizons, opens you up to new influences, and tests your resourcefulness and adaptability’. Unless you prefer to hark back to the dark days of assimilation. I think this is the gift of migration. For migrants but also for the receiving community, who are given an opportunity to re-evaluate what they consider valuable and important without leaving home.

The opportunity to expand our internal and external boundaries is going to increase with the continuing demographic changes that are occurring in New Zealand. These changes are not only an increase in ethnic diversity, but also linguistic and religious diversity. They pose opportunities and challenges for not only receiving communities, but also for long term settled communities, like Chinese and Indian communities who have been here since the late 1800s. There are opportunities and challenges ahead for Māori and Pacific peoples who fear that their needs and aspirations might be lost among the competing claims that newcomers bring.

We’ve had very few conversations about how we are all going to live together; the only ones I’ve heard are about the Treaty partners, and those leave the rest of us out. There are additional issues for us to get lost in, such as moving from models of deficits to models of strength and resourcefulness. Examining multiple and intersecting identities, moving beyond what is a fashionable cause and hierarchies of deserving. I am thinking of a research project I’ve just completed which showed that white migrants struggle with being lost too. Their needs go unconsidered as it is assumed that they will ‘fit in’ and are a close match to people already here. How do we go about actively embracing the people around us, building bridges not walls or silos? Passive acceptance means we don’t have to get lost; we don’t even have to try. But we can then idealise or demonise the people around us because we’ve partaken in the highly consumable aspects of their culture, the food and the festivals. Trouble is we can enjoy the food without caring about the cooks.

I’d like to suggest some ways forward, moving beyond discussions of bicultural and multicultural to consider how we can all live together and what vision can guide us. I want to draw on some ideas from Ghassan Hage about multi-cultural co-existence versus multicultural interaction. I then want to say something about how we become inter-cultural by, accepting the ‘other’ in ourselves. I think it is easier to identify the problems than come up with solutions so I’d also like to give an example of a successful initiative.

Hage says that coexistence involves existing alongside one another. We acknowledge each other’s existence but this existence operates on the premise that we can respect one another as long as we do not rub up against each other. In effect we live in silos right next to each other but watch out if there is any seepage into the public arena. Interaction requires more effort because engagement and irritation are a necessary part of the process, it means getting to know each other as a living multiculturalism where we don’t glorify or demonise ‘others’. To move from coexistence to interaction requires all of the people who live in New Zealand to literally get lost, to step out of our comfort zones and to start getting to know each other. Messy, untidy, unpleasant bits included. This is harder than it sounds, very easy for the liberal middle classes who have the benefit of distance, harder when you are fighting for the same piece of socio-economic pie. Vin D’Cruz tells us for this to happen we must make some internal shifts and embrace the ‘other’ in ourselves. Lorde agrees, urging “each one of us here to reach down into that deep place of knowledge inside herself and touch that terror and loathing of any difference that lives there.” Only through a process of empathy and transformation can we live with difference. Going deep into ourselves to embrace our own loathing of difference requires us to get lost.

Me with Chief Human Rights Commissioner Roslyn Noonan

Richard Brecknock talks about moving from the multicultural, where we acknowledge and celebrate our differing cultures, to the intercultural where we focus on what we can do together as diverse cultures in shared space to create wellbeing and prosperity. An assumption of an intercultural vision is the recognition that diverse societies are more innovative, productive and competitive. Immigrants and ethnic communities have a greater facility to move within and between communities and high intercultural networking capacity. However, this capacity isn’t always well optimised especially when there is no vision and where socio-economic inequalities exist and ethnic community groups are siloed, the challenge then is to enhance the abundance of talent and entrepreneurship in ethnic communities.

The Aotearoa Ethnic Network is a partner in the Human Rights Commission’s New Zealand Diversity Action Programme, and aims to contribute to the dialogue on how we can all live together. An inter-cultural, inter-sectoral network with over 300 members from all over New Zealand, it provides a space for discussion and debate for those interested in ethnic issues. The AEN Journal, launched in July this year, promotes critical debate on issues facing migrants and refugees, ethnic, diasporic and religious communities. Race Relations Commissioner Joris de Bres writes about the genesis of the Diversity Action Programme in the July issue and the need to have “networks and spaces where people were able to meet across ethnicities or cultures, and that while many people ‘wanted to do something’ there were no readily available mechanisms through which to do so in concert with others”. AEN goes some way to achieving this.

To conclude, thanks for a wonderful two days at this Forum. I know that we have identified problems and we have a way to go, but look how far we have come and how far we can go!

Further reading

  • Aotearoa Ethnic Network. See: http://www.aen.org.nz.
  • Brecknock, R. (2005). Intercultural city. See:http://www.brecknockconsulting.com.au/02_projects/ic.htm
  • D’Cruz, J.V. & Steele, W. (2001) Australia’s Ambivalence Towards Asia: Politics, Neo/Post-colonialism, and Fact/Fiction. Monash: Monash Asia Institute, Monash University Press.
  • De Bres, J. (2006). Guest Editorial. Aotearoa Ethnic Network Journal. 1 (1).
  • Hage, G. (2005). We need interaction not just co-existence. Australian Financial Review.
  • Keoghan, P., & Berger, W. (2004). N.O.W. : No opportunity wasted : 8 ways to create a list for the life you want. Emmaus, Pa.: Rodale.
  • Lorde, Audre. (1984). Sister Outsider. Trumansberg, New York: Crossing Press.
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What does it mean to be Goan?

This piece was previously published in the Goanet Reader: July 29th 2005

Issues of celebration and connection, reflected in food and song

Food is one of the many things that make life not only pleasurable but memorable. I recently met a young Goan man who is completing a degree who asked me if I could come to his birthday party and share some sorpotel and vindaloo recipes as the celebration wouldn’t be a celebration with them, especially with him being so far away from home. This led me to reflect on the importance of food and consider writing something for Goanet Reader.

As you all know Goans have been a highly mobile population and are scattered all over the globe as a result of colonisation, and in a bid for a better life and education for their children. At the beginning of the millennium I undertook a research project to explore how Goan women in Auckland New Zealand coped with the dual transitions of migration and motherhood as becoming a parent in a new county is a common aspect of migration which is also under-researched.

It is well known that migrants draw on cultural resources and links such as the notion of homeland, language, religion, everyday social rituals such as food, drink, dance and song, family, morals, community, landscape, histories and occupations.

Researchers of migrant communities have found that connection with one’s ethnic community is vital for collective cultural maintenance. This takes the forms of being involved in community-type social networks in order to maintain their culture, taking part in ethnic institutions, making trips “home” and marrying within the community. These were all identified in my research as significant, but for this piece I have chosen to focus on the importance of traditional food in maintaining Goan culture and in relation to the perinatal period. I have also incorporated words from the Goan women that participated in the research (with deep and heartfelt thanks).

Food has a symbolic and social significance that is deeply embedded in a culture and is used to express many things such as love, friendship, solidarity and the maintenance of social ties.  The significance of food is heightened with migration, where it is the most resistant aspect to the acculturation process for migrant communities. Frequently, food is integrated into the host culture, as those Goans living in the United Kingdom or from Africa will attest to as seen by the incorporation of Indian foods into African and British communities.

Traditional food and celebration are pivotal to the construction of Goan identity and an important part of ‘everyday’ food, religious festivals, weddings and special events. Food also has historical significance as seen by the impact of Portuguese, Muslim and Indian cultures apparent in Goan cuisine. Conversion to Catholicism by the Portuguese meant that foods moved from being taboo to consumable and differentiated Goans from other Indians, making them more Western.

The special foods that go with events during the year are very traditionally Goan, for example we have Christmas sweets. Besides Christmas sweets, I associate eating Pilao on a Sunday and not just any other thing, very Goan. and having your fish curry and rice as well (Lorna).

 

Fish curries and coconut curries and I had learn to cook when I was quite young and I had wanted to get into the kitchen and dad would go to the marketplace and buy all this yummy fish and come home and cook it up and basically you’d eat Goan and things like that (Rowena).

Goan fish curry is ubiquitous in most households in Goa, eaten regularly and served with rice. Pilao is possibly from Muslim times prior to Portuguese rule, made with basmati rice and flavoured with whole spices like cardamom and stock. The Goan sweets that are mentioned by Lorna originate from Portugal and the Konkan region and they are produced and exchanged with friends and neighbours at Christmas time. Every sweet has coconut in it in milk form or thinly sliced. In Rowena’s quote below, food is a way of acknowledging the family and social ties:

We often had picnics, which had all the favourite dishes like sorpotel, xacuti, food were very important in terms of being social and the family (Rowena).

Xacuti is a complicated and painstaking Goan dish made with chicken or lamb that involves the roasting of all the seasonings before they are ground to a paste. Sorpotel is a ceremonial dish made from pork that is prepared for feast days, Christmas, weddings and other special occasions. The following anonymous poem does more to illustrate the place of sorpotel in the connections of Goans to ‘home’.

SORPOTEL

For the hotch potch known as Haggis, let the Scotsman yearn or yell For the taste of Yorkshire pudding, let the English family dwell. For the famed Tandoori Chicken, that Punjabis praise like hell But for us who hail from Goa, there’s nothing like SORPOTEL!

From the big wigs in Colaba, to the small fry in Cavel From the growing tribes in Bandra, to the remnants in Parel. From the lovely girls in Glaxo, to the boys in Burma Shell There’s no Goan whose mouth won’t water, when you talk of SORPOTEL!

And Oh! for Christmas dinner don’t you think it would be swell If by some freak of fortune or by some magic spell We could, as they have in Goa a bottle of the cajel And toddy leavened sannas to go with SORPOTEL!

In this poem, sorpotel becomes a metaphor for migration and connection to home. The names of the Mumbai (Bombay) suburbs, with their differing social capital, in the second verse illustrates that no matter where in the world a Goan is, sorpotel is the social leveller. Cajel refers to a distilled liquor made of cashew and toddy is fermented coconut or palm juice, which is frequently used like yeast to make sannas, a type of rice cakes made in moulds with a batter of ground rice, toddy, coconut and sugar and then steamed. The predilection for sorpotel has been influenced by the historical context of Goans being a colonised people and as such it is an apt metaphor for the richness of the culture located in a small geographic area.

Food plays a significant part in weddings as well, as seen by these words by Flora:

The day after the wedding, It was in my mother-in-law’s house they made that plain white rice with samarachi curry with dried prawns that is supposed to be a typical dish for second day wedding lunch, then third day at my mums place, it was the three days festivities. You must be knowing about that (Flora).

The samarachi codi refers to a curry made with coconut milk. Food is significant from the most private and everyday to the ritualised public celebrations like weddings. Such events and networking with other Goans or Christian Indians were another strategy for cultural maintenance.

Perinatal Rituals

Having a child is one of the most culturally and spiritually significant events for women and their families and the significance of this transition is validated through ritual. It is thought that cultures that have supportive rituals for new mothers have lower rates of postnatal distress (PND) and that women in Western countries are at high risk of developing PND Rituals reflect the vulnerability and special status of the new mother and include being restricted to the home, being given assistance, being given special foods and massage.

In Indian communities the experience of pregnancy and birth is traditionally marked by nurturing and celebration of the status of women who are to become mothers. This nurturing is highlighted through the giving of special foods and assistance. Movements of new mothers are restricted to the home for forty days due to their perceived vulnerability postpartum. During this forty day period, assistance is given with personal care and the physical body is taken care of through massage and ensuring the mother has an opportunity to relax. Parturition is thought to generate a state of hotness and therefore weakness. Grandmothers can play an active part in the preparation of special food and ensuring a nourishing diet that includes foods such as ghee, nuts, milk and jaggery1 which are given to return the body to balance.

This attentiveness and “endless care” that is received from the extended family (Shin & Shin, 1999, p.611) can be lost in the process of migrating. This celebration of the status of the new mother in ‘developing countries’ subverts the notion of ‘West is best’ and the backwardness of the East, that was taken for granted in my post-colonial upbringing. A recent article in NEXT magazine in New Zealand have suggested that rituals need to be re-instated to celebrate the status of motherhood (Sarney, 1999). Greta found that the shift from a social process of pregnancy to an individualised one a painful loss:

Everyone else does things for you and you know in that way you are just pampered. You get all these supposedly nourishing treats and foods and things you know. Like all these pulses and the sweets that you normally have. I’m not very sweet tooth, but I think they do help in a way you know. The nourishing factors. You know things like that. At the same time being here makes you think of all these things that you take for granted back home (Greta).

Focused individual care is given to new mothers, and family members take on roles in relation to food preparation and hospitality as in Lorna’s story:

You know you get your massages and things. Mum looks after the cooking because that takes away a lot of time and then you don’t have to worry about that. Goan things like moong, godshem and other lentils millet, tizan, and things like that, you know what that is. I guess you would have had that if you were coming from the traditional villages I’m sure, but ahh we have lost a lot of culture on the way. Yeah yeah I guess you also have many more people around you in India so that if you are busy with doing something someone else can entertain make the tea or conversation (Lorna).

Migrating reminded Lorna of the loss of traditions that began with the move from traditional villages to urban settings prior to the migration to New Zealand. The drive for upward mobility (in the Western sense) in Goa and the concomitant loss of traditional ‘old fashioned’ rituals has resulted in loss of forms of nurturance from many cultures.

Being separated from family and culture meant were impediments to conducting traditional rituals. For some Goan women it meant not having anyone to consult who was bicultural and could see the importance of special food. Migration can lead to separation from family and trusteed advisers leading to a ‘vacuum of knowledge’ . Rowena was anxious about the appropriate food to be eating and struggled to create a new frame of reference and develop a sense of what she ‘should’ be doing. Rowena sought guidance but ultimately was unable to cook any of the things that she thought might be useful because her husband worked long hours and there were no extended family members available to help her enact traditional rituals:

No, in fact I didn’t know what to eat, but the hospital kept saying eat a normal diet. Do I have to have spicy food? They said since you’ve been eating it all your life and during pregnancy, you don’t have to drink milk to get milk, just eat well. Because being alone I had to cook my own stuff, so I just continued eating my normal things (Rowena).

This example again highlights the tensions of attempting to fulfil cultural expectations but also fit into what was appropriate in the new culture.

Bringing family in to support rituals

Several participants brought mothers and mothers-in law to New Zealand because it was unusual to have a baby ‘by yourself’, to help with tradition, food preparation, care of the baby and allow the new mother to rest. Lorna, Greta and Flora chose to bring family members over where possible to provide both support and assistance with rituals. Lorna was fortunate in being able to bring her mother over to help out, and points out the alien notion of the individualising of a major life event like birth:

Then you come to a place with no-one around you, you don’t really know if you can make it alone. You know you are not very independent in a way, so it is unfamiliar to have a baby on your own. Yeah, so that’s why, so you just sort of have Mum over everybody has Mum over, it’s a Goan thing to do, it’s an Indian thing to do (Lorna).

Greta was supported by both her mother and mother-in-law who came to New Zealand to assist with care of the baby and other household tasks which included food preparation and advice. Greta’s example illuminates the richness and significance of cultural rituals in the postpartum period:

Fenugreek seeds and jaggery and coconut milk and she kept giving me that and I found that quite nourishing. I don’t know whether that would generate just the milk and also a sort of porridge made from semolina. So I would bake that and a drink that would help me clear up my stomach too much of gas so those things helped me a lot (Greta).

The importance of food to many Goan rituals and special occasions is emphasised in Flora’s recount of her child’s christening which emphasised the symbolic significance of the Goan connection to the earth through the serving to guests of chickpeas and coconut: Flora’s example highlights how she feels she needs to justify the significance or legitimacy of particular types of food to ‘Kiwis’ or have it legitimated by them. This perhaps represents a sign of her wanting to ‘fit in’. This could also be a way of justifying to white New Zealanders the attachment to things Goan:

Even for a normal party you see all Goan tradition, you must make this food you know, like for an auspicious occasion, like a Christening. Coconut in it, that is a must, you know a christening can’t go without that. The Kiwis, you know wonder what are we serving boiled grams (chickpeas) for on an occasion like this. My aunt was going around to all the Kiwi guests saying you know I’m serving coconut. I didn’t know what was the meaning behind it, but she was explaining you know chickpeas are the food of the soil, and coconut is also a food of the soil (Flora).

Therefore it can be seen that food plays an important role both in the private lives of Goans and the celebrations and life transitions such as parenthood.  One of the many strengths that Goans have is the capacity for celebration and connection with each other through food and song.  The internet and increased numbers in our global communities mean that we can more easily access whatever it means for us to be Goan.

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The Portuguese colonisation of Goa and migration to East Africa

This piece was previously published in the Goanet Reader: May 22nd  2005

We often think of migration as moving between two places, my story is one of many journeys that spans the generations.

I was born in what was then Tanganyika and is now Tanzania, into a Catholic family originating from Goa, India. As a child, I was exposed to multiple heritages and languages; Maragoli, Swahili, Konkani and English. My family’s migration history began with my great-grandfather leaving Goa to work in Burma and both sets of grandparents subsequently migrated to Tanganyika. My parents own double migration took them first to Kenya in 1967 and then to New Zealand in 1975.

Leaving Africa was a result of the unease caused by the expulsion of ‘Asians’ — meaning people from Bangladesh, Pakistan and India — from neighbouring Uganda in 1972. East Africa in the early 1970s saw increasing crime targeted against Indian people, who were the shop owners and business people and our daily lives were being increasingly affected by the process of ‘Kenyanisation’, which privileged Kenyans over all others.

I recall going to sleep frightened and being told to pray for safety. My parents wanted to live away from fear, be able to take advantage of educational opportunities and above all build “a better life” for their children.

In 1975, they decided to emigrate and after some failed attempts to get to the United States we made arrangements to move to New Zealand. Our family knew little about this country; one promotional film and a friend who lived in Wellington. In order to afford the cost of the airfare, we had to sell virtually all our possessions, others were given away, even my parents wedding presents were left behind.

To understand my family history of migration, it is important to put it in context. Goa is located in the middle of an abundant coastal strip on the south west Coast of India which has an area of 3,701 square kilometres and a primarily agrarian economy with, more recently, a tourism and service industry.

The name ‘Goa’ comes from ‘Gomant’ of the Mahabharata and apparently “Goa was reclaimed by Lord Parshuram from the mighty sea by shooting an arrow into it.” (Mahajan, 1978, p.22). This sounds remarkably like the Mori mythology of the discovery of the North island Maui. Goa was renowned as a port as far back as the third century BC, when Buddhism was spreading through India. It was a Portuguese colony from 1510 until 1961, at which time Goa was liberated by the Indian army. On May 31, 1987 Goa became the 25th state in the Republic of India (Newman, 1999).

The arrival of the Portuguese led to Goans becoming a migrating society. The Portuguese came to Goa “to seek Christians and spices” (Albuquerque, 1988, p.25) and Catholicism became entrenched in Goa due to the intense proselytising campaign using “bribery, threat and torture” by the Portuguese (Robinson, 2000, p.2421).

Goa’s inquisition began in 1560 and ended in 1812 (Robinson, 2000). Inquisitions were used by the Portuguese to prevent defection back to other faiths and had far reaching implications. In the laws and prohibitions of the inquisition in 1736, over 42 Hindu practices were prohibited (Newman, 1999). They were implemented through the eradication of indigenous cultural practices such as ceremonies, fasts, the use of the sacred basil or tulsi plant, flowers and leaves for ceremony or ornament and the exchange of betel and areca nuts for occasions such as marriage (Robinson, 2000). Methods such as repressive laws, demolition of temples and mosques, destruction of holy books, fines and the forcible conversion of orphans were used (Mascarenhas-Keyes, 1979).

FAR REACHING

There were other far reaching changes that took place during the occupation by the Portuguese, these included the prohibition of traditional musical instruments and singing of celebratory verses, which were replaced by Western music (Robinson, 2000). People were renamed when they converted and not permitted to use their original Hindu names. Alcohol was introduced and dietary habits changed dramatically so that foods that were once taboo, such as pork and beef, became part of the Goan diet (Mascarenhas-Keyes, 1979). Architecture changed with the Baroque style that was in vogue in Portugal becoming popular. Thus, many customs were suppressed and Goans became ‘Westernised’ to some degree as a Catholic elite who came to see themselves as a “cultivated branch of a global Portuguese civilisation” (Routledge, 2000, p.2649).

During Portuguese rule, the ancient language of Konkani was suppressed and rendered unprivileged by the enforcement of Portuguese (Newman, 1999). The result this linguistic displacement was that Goans did not develop a literature in Konkani nor could the language unite the population as several scripts (including Roman, Devanagari and Kannada) were used to write it (Newman, 1999). Konkani became the lingua de criados (language of the servants) (Routledge, 2000) as Hindu and Catholic elites turned to Marathi and Portuguese respectively. Ironically Konkani is now the ‘cement’ that binds all Goans across caste, religion and class and is affectionately termed ‘Konkani Mai’ (Newman, 1999). In 1987 Konkani was made an official language of Goa.

The Portuguese colonisation of Goa was a catalyst that led many Goans to become a mobile population. Socio-economic factors such as the taxation of land to raise funds for Portuguese expeditions, the appropriation of land from villagers leading to outsider control and the removal of people from their original source of livelihood were powerful forces in the decision to migrate. Yet Newman (1999) claims that what drove Goans to emigrate was that they valued a consumerist, bourgeois-capitalist society in Goa and sought more money, despite the relatively high incomes available at home. Historically, there has been a strong Goan ethos of moving up, caused by the small size of Goa and the inability to divide up communal land (Mascarenhas-Keyes, 1994).

As Goans began migrating, English displaced the dominance of Portuguese in the 1920s as many Goans moved to British India and other British colonies.

This migration began as a result of the declining Goan economy, which under Portuguese rule could not provide adequate employment for Goa’s population whereas new opportunities and economic development were available in British India (Nazareth, 1981). Goans first worked for the British in 1779 at the time of the French Revolution. The naval fleet of the British Indian Government was stationed in Goa and found that Christian Goans were eminently suitable to work for them because of their Western dress, diet and customs. When the fleets withdrew from Goa, many Goans went with them. In the eighteenth century Goan began trading with Mozambique, Zanzibar and East Africa. Indian independence in 1945 exacerbated the flow of migrants of Goan origin who were residing in British India (Mascarenhas-Keyes, 1979).

As English became more significant to Goans, schools began to teach it, giving more Goans the opportunity to migrate to British India. Many Goans also gained English language skills in the process of migrating to British territories, due to the greater emphasis on education and on language, as a method of upward mobility.

Goan migration to Africa was not surprising.  Indians had been traders and later sojourners as far back as three thousand years. The Indian diaspora was a 19th and 20th century development related to the impact of the British indentured labour scheme, which sought to replace slave labour with cheap and reliable labour for plantations (Sowell, 1996), or the building of railways, for example in Uganda (van den Berghe, 1970). This scheme was seen by some as a new system of slavery (Tinker, 1974) and though formally abolished in 1916 it continued until 1922 (Brah, 1996). Indian women were the second largest group transported to colonies after African women and they were subjected to fieldwork and received comparable punishment and gross indignities in the same manner. Smith (1999) suggests that the indentured labour system was as inhumane as the slave trade through the in-humanity of captivity and forced labour for capitalist gains.

Large scale migrations of Indians to Africa began with the construction of the great railway from Mombasa to Lake Victoria in Uganda in the late nineteenth century (Sowell, 1996). The British employed Indians because the Africans who owned land would only work for brief periods.

Fifteen thousand of the sixteen thousand ‘coolies’ who worked on the railroads were Indians. They were renowned for their work ethic and competitiveness, but one quarter of them died or returned disabled (Sowell, 1996). Indians (especially Goans) were recruited to run the railways after they were built (as my grandparents were) and Goans came to dominate the colonial civil services (Sowell, 1996).

Goans made up the only significant number of Christian Indians in East Africa, as it was the Catholic rather than the Hindu Goans that migrated there. Catholic Goans spoke Konkani, English or Portuguese and dressed in more Western clothing. They were further set apart from Hindus and Muslims by virtue of religion and because they ate pork and beef. For Goans, migration to Africa was intended as a way of earning some money for retirement in Goa and putting down permanent roots was not encouraged by colonial authorities (Kuper, 1979).

Asians were excluded from certain professions or from living in areas where Europeans preferred to settle, for example the fertile Kenyan highlands (Kuper, 1979). They operated within a milieu of prejudice, suspicion and disadvantage. Land was unavailable for freehold purchase and education provision was inadequate resulting in children being sent back to India (as my father was). Later on, as communities grew, special schools were established and women and children joined their men (as was the case for my mother’s family).

EVERYTHING CHANGED

Moving forward to our arrival in New Zealand everything I had ever known had changed. The availability of traditional foods, ingredients and so on was limited. The weather was cold and unfriendly, colder than anything we had experienced before. I was dismayed by the lack of wild and colourful animals.

I had also lost my place in the world, moving from a familiar social circle to where everything was now unknown. Settling in New Zealand was difficult financially, socially and emotionally. In Africa there had been a very strong Goan and Indian symbiotic community that provided cultural links. Despite being ‘foreign’ there was a sub-culture in East Africa that was supportive and understood by Africans. As Alibhai (1989, p.31) stated in an account of her life in Uganda:

The Asians had evolved a very strong network, partly because of the needs and fears that inevitably arise when groups migrate and partly because they were non-dominant in countries where they had no political power and a constant sense of being vulnerable.

In New Zealand we were different again, but less well understood. The ensuing years have  become easier and my ambivalence has decreased about whether I belong to Aotearoa.

The increase in members of the Goan and African communities have rejuvenated and inspired me and invigorated the communities I am affiliated with. The increased availability of a range of ingredients and cultural resources have also made connections with food and other cultural icons more accessible.

I prefer the plus model of identity rather than the minus one. I belong to Goa, plus East Africa plus New Zealand and the places I’ve lived and loved in. Although I experienced changes and loss integral to migration and learned first hand of the isolation that migrants can face in New Zealand (which has led me as an adult to be involved in supporting them) there were also positive implications.

The loss of traditional economic, social and familial restraints allowed me to fulfil my potential in a way that I might never have had, had I grown up in Goa or East Africa. Having to scrutinise my identity closely has led me to see the world through many eyes (an important requirement for an educator) as Edward Said states: “The essential privilege of exile is to have, not just one set of eyes but half a dozen, each of them corresponding to the places you have been.” I believe that my migration and travel experiences give me many ways of seeing the world and that the migrants that come to Aotearoa enrich the country with their lives and experiences.

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The Art of Walking Upright Here: Realising a Multicultural Society

Background paper for the Asia:NZ Foundation’s Kiwi India Seminar Series. Auckland and Wellington, October 2004

The title of this paper is drawn from a line in a Glenn Colquhoun poem. He draws inspiration from a poem by Allen Curnow, himself inspired by the site of a skeleton of a long extinct Moa in a museum. Whilst Colquhoun’s words are undoubtedly a profound metaphor for the migrant experience, Curnow’s are, perhaps, a metaphor for our failure to adapt to change, whether as a migrant or a member of the host community:
Not I, some child born in a marvellous year, Will learn the trick of standing upright here (Curnow, 1997, p.220).

Aotearoa/New Zealand has seen a significant increase in new migrants over the last ten years. Drawn here from across the world and facing the challenges of settlement, they face another unique challenge, finding their place within a country that embraces the notion of biculturalism, where Māori are positioned as partners with the Crown. As New Zealand society becomes increasingly multi-cultural, it is still required to negotiate the bi-cultural discourses of Māori which some argue positions migrants from places such as India as outsiders. In this presentation I will introduce myself briefly and outline the challenges facing Indian communities in New Zealand by drawing together the history of migration to New Zealand and outlining some possibilities for the future.

Migrants in Aotearoa/New Zealand
New Zealand is viewed as a nation of immigrants, and immigration has been an important factor in economic growth and social development. One in five New Zealand residents was born overseas and this rises to one in three people in the Auckland region (Statistics New Zealand, 2003). The Treaty of Waitangi/Te Tiriti o Waitangi is the founding document of the nation state, recognising Māori as ‘tangata whenua’ (Roscoe, 1999). Te Tiriti defines “principles of partnership, participation, protection and equity” (Cooney, 1994, p.9). Yet this benign notion of ‘settlerhood’ contrasts sharply with the end result of a process that has led to the traumatic colonisation and dispossession of Māori. Favourable policies resulted in subsequent waves of migrants of European descent, resulting in a dominance of this group such that Māori became the ‘other’ in their own land (Du Plessis & Alice, 1998).
The visibly different migrant, such as Indians, Chinese and Pacific Islanders, became ‘others’ because of their physical appearance, religion or culture but without the status of the indigenous Māori (Du Plessis & Alice, 1998). Most Indians migrated to New Zealand from Gujarat and Punjab then from Fiji and. About 200 came from Uganda as refuges in 1971. One of the first Indians to arrive in New Zealand was thought to be a Goan nicknamed “Black Peter” (Edward Peters) in 1853 (Leckie, 1995). The first Chinese arrived in 1866 (Roscoe, 1999). A fear of the impact of foreigners led to restrictive laws being introduced between 1870 and 1899 and these were only repealed later when new sources of labour were required.

In the last few decades other trends have impacted on migration patterns. The first being an initial increase in migration from the Pacific Islands in the second half of the 1970s and again following the Fiji coup in 1987. Pacific Islands migration decreased in the 1990s with a shrinkage in manufacturing jobs and the closure of factories as tariffs on imported goods were removed. An increase in Asian migration was the second immigration trend and was related to the encouragement of foreign investment in New Zealand. Refugees also arrived from Cambodia and Vietnam and migration from Hong Kong related to the return of the colony to China. The third was the increase in migration from Africa and the Middle East, predominantly from South Africa. The above trends led to an increase in the number of migrants from non-traditional source areas. Compounding these trends, there has been the noticeable increase in tension between Māori and Pākehā, particularly around grievances and claims relating to the Treaty (Pawson et al., 1996) and land issues.

Government Policy
Following World War Two, the notion of assimilation dominated. ‘Invisible’ migrants were seen as desirable and the goal was for migrants to ‘fit in’ rather than change the society they had entered. For many, therefore, change, was one-way. There was a philosophical shift in this policy when Canada and Australia embraced multiculturalism during the 1960s, which held that people had the right to retain their culture and have access to society and services without being disadvantaged (Fletcher, 1999). This transformed the notion of settlement into a two way process whereby change was required by both migrants and the host society. New Zealand policy made a strategic move towards multiculturalism in the 1986 review and subsequent 1987 Immigration Act. This Act eased access into New Zealand from non-traditional source countries and replaced entry criteria based on nationality and culture to one initially based on skills and subsequently through the introduction of a points system (Roscoe, 1999). This policy emphasis on attracting highly qualified immigrants was similar to policy changes in North America and Australia (Pernice, Trlin, Henderson, & North, 2000). The adoption of the points system in 1991 led to immigrants who had experience, skills, qualifications and money being selected for business investment in New Zealand (Ho, Cheung, Bedford, & Leung, 2000).

Implications
Changes in migration policy and the resulting increase in migration have led to much public debate fuelled also by a renaissance in Māori sovereignty, itself related to the global rise in indigenous movements since the 1970s. This has seen the re-positioning of Māori as indigenous to New Zealand and the evolution of a bicultural nationalism (Roscoe, 1999). Many vociferous opponents of increased migration argue that the ideology of multiculturalism is problematic as it negates the primacy of Māori and biculturalism. This, some argue, is problematic because Māori are indigenous, whilst migrants (and refugees) have other places that maintain and preserve their culture. Many argue that because the Treaty has not been honoured, other ethnic groups have had no other option but to relate only to the Crown.

By calling Māori ‘the first immigrants’, it is argued that the rights of Māori as first nation people are negated and their claim for special status as tangata whenua countered (Walker, 1995). The argument continues that the preamble of Te Tiriti o Waitangi allowed immigration to New Zealand from Europe, Australia and the United Kingdom and for any variation to occur, consultation with Māori is required as descendants of the Crown’s treaty partner. Walker concluded that the government consultation process with Māori was flawed because some Māori leaders were not representative and dissenting voices were ignored. Some have also argued that the points system of immigration and active encouragement of migration from non-traditional source countries was
a quick fix for rising unemployment and a stagnant economy driven by the partnership between corporate business interests and the government.

Within this debate between Pākehā and Māori, many visibly different migrants felt marginalised on two levels; firstly as outsiders to Māori and secondly as outsiders and cultural ‘other’ to Pākehā (Jaber, 1998). The process of ‘othering’ of Asian immigrants2 differs from that of Māori. Firstly, Asians are considered to be contributing to the economy even if they are ‘too successful’ by virtue of their skills and working attributes and secondly, elements of Asian culture can be commodified for consumption in the form of food and restaurants (Pawson et al., 1996). In particular this packaging absolves the consumer from caring about “the authenticity of the product, its cultural meaning, its technical sophistication or its historical origin” (Yuan, 2001, p.79). This process of consumption fetishises, foods, clothing and rituals into a decontextualised barren image. Sari material, yoga, ayurvedic medicine and Eastern spirituality have joined the list of consumables that many New Zealanders enjoy without understanding their social, political, cultural and spiritual significance. Despite the consumption of ‘Indianness’, little emphasis has been accorded to visibly different migrants in the debates over citizenship.
Roscoe (1999) sees two ways in which citizenship can be viewed; the first is civic nationalism, underpinning the discourse of multiculturalism, when a national identity is shared equally by citizens regardless of origin. Secondly, citizenship can be viewed as ‘ethnic nationalism,’ when greater standing is given to members of the dominant group.

Far from being the welcoming immigrant nation New Zealand purports to be, the paradigm of ethnic nationalism is more representative of the reality and is based around Pākehā notions of New Zealand. So, there remains a tension between the universalist, egalitarian notion of equal treatment of citizens and the need for recognition of cultural specificity. Docker and Fischer (2000) suggest that there needs to be a recognition of the politics of universalism and the politics of difference and conclude:

Thus, we experience a plethora of overlapping, competing and unresolved contradictions: colonial versus post-colonial, old settlers versus new settlers, indigenous people versus invaders, majority versus innumerable minorities, white against black or coloured, the search for a collective, inclusive or ‘national’ identity…vis-á-vis the search for individual and personal or group identity based on ethnicity, language, country of origin, or religion. All these struggles are played out on the same but rather less-than-level-playing field: social antagonisms, class and gender differences continue to play decisive roles in the game of identity recognition (Docker & Fischer, 2000, p.6).

Critics such as Thakur (1995) argue that the official rhetoric of biculturalism recognises the legitimacy of Māori and Pakeha but excludes migrant cultures that are non-white and non- indigenous. These ‘others’ are excluded from the debate on the identity and future of the country in which they live, leading writers such as Mohanram (1998, p.21) to ask “what place does the visibly different coloured immigrant occupy within the discourse of biculturalism?” This tension exists for many other groups as well, for example Wittman (1998, p.39) has commented “on the exclusionary effect of any others by the ideology of biculturalism” for Jewish people in New Zealand. Many Chinese argue that in New Zealand, a bicultural society, migrant cultures are not even relegated to the margins of society “our place is nowhere” (Yuan, 2001, p.121).

Conclusion
As the global marketplace shrinks, countries compete for people with skills and wealth creating potential. Gone are the days of relying on migrants from the traditional source countries. This transformation in migration means that there is now an urgent need for settlement focussed- resources for new migrants and refugees. New migrants need to be resourced to recognise, understand and value the special position of tangata whenua and to be able to examine their role in relation to the Treaty of Waitangi. Equally, it is necessary for immigration policy and settlement policy to be inclusive of those already here. This means not only Pākehā (represented by government) but also Māori.

Can biculturalism and multiculturalism co-exist or are they mutually exclusive? I would argue that one need not preclude the other. Recognising and celebrating the ethnic diversity of modern day New Zealand need not diminish the rights of Māori. Perhaps we can all work together to create a social and political milieu that is both universal and egalitarian: ironically something many Pakeha New Zealander’s assume already exists. In this model we treat citizens equally, celebrating their diversity but valuing as a central tenet of our society the position of the Treaty of Waitangi and its guiding principles. This ensures a unique position for Māori to be recognised as the guardians of this special land. By doing this we create a dynamic and vibrant society leaving behind a past based on fear (for loss of whiteness), grievance (for abuse of Māori rights) and invisibility (of others arriving in an already formed land).

References
Colquhoun, G. (1999). The art of walking upright. Auckland, NZ: Steele Roberts.

Cooney, C. (1994). A comparative analysis of transcultural nursing and cultural safety. Nursing Praxis in New Zealand, 9(1), 6-12.

Curnow, A. (1997). Early days yet: New and collected poems 1941 – 1997. Auckland: AUP.

Docker, J., & Fischer, G. (2000). Adventures of identity. In J. Docker & G. Fischer (Eds.), Race, Colour and Identity in Australia and New Zealand. Sydney: UNSW Press.

Du Plessis, R., & Alice, L. (Eds.). (1998). Feminist thought in Aotearoa/New Zealand. Auckland: OUP. Fletcher, M. (1999). Migrant settlement; a review of the literature and its relevance to New Zealand.Wellington: New Zealand Immigration Service, Department of Labour.

Ho, E., Cheung, E., Bedford, C., & Leung, P. (2000). Settlement assistance needs of recent migrants (Commissioned by the NZIS). Waikato: University of Waikato.

Jaber, N. (1998). Postcoloniality, identity and the politics of location. In R. D. Plessis & L. Alice (Eds.),Feminist thought in Aotearoa, New Zealand (pp. 37-43). Auckland: Oxford Press.

Leckie, J. (1995). South Asians: Old and new migrations. In S. W. Greif (Ed.), Immigration and national identity in New Zealand (pp. 133-160). Palmerston North: Dunmore Press.

Mohanram, R. (1998). (In)visible bodies? Immigrant bodies and constructions of nationhood in Aotearoa/New Zealand. In R. D. Plessis & L. Alice (Eds.), Feminist thought in Aotearoa, New Zealand (pp. 21-29). Auckland: Oxford Press.

Pawson, E., Bedford, R., Palmer, E., Stokes, E., Friesen, W., Cocklin, C., et al. (1996). Senses of place. In R.L. Heron & E. Pawson (Eds.), Changing places: New Zealand in the nineties. Auckland: Longman

Paul. Pernice, R., Trlin, A., Henderson, A., & North, N. (2000). Employment and mental health of three groups of Immigrants to New Zealand. New Zealand Journal of Psychology, 29(1), 24-29.

Roscoe, J. (1999). Documentary in New Zealand: an immigrant nation. Palmerston North: Dunmore Press.

Statistics New Zealand. (2003). New Zealand in profile 2003. Wellington: Statistics New Zealand, Ministry of Foreign Affairs and Trade, New Zealand Immigration Service.

Thakur, R. (1995). In defence of multiculturalism. In S. W. Greif (Ed.), Immigration and national identity in New Zealand: One people, two peoples, many peoples. Palmerston North: Dunmore Press.

Walker, R. (1995). Immigration policy and the political economy of New Zealand. In S. W. Greif (Ed.), Immigration and national identity in New Zealand: One people, two peoples, many peoples. Palmerston North: Dunmore Press.

Wittman, L. K. (1998). Interactive identities; Jewish women in New Zealand. Palmerston North: Dunmore Press.

Yuan, S. Y. (2001). From Chinese gooseberry to kiwifruit; the construction and reconstruction of Chinesehood in Aotearoa/New Zealand. Unpublished Master of Arts (Sociology) thesis, Massey University, Auckland.

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Motherhood, Migration and Methodology: Giving Voice to the “Other”

DeSouza, R. (2004). Motherhood, migration and methodology: Giving voice to the “other”. The Qualitative Report, 9(3), 463-482.

This paper discusses the need for multi-cultural methodologies that develop knowledge about the maternity experience of migrant women and that are attuned to women’s maternity-related requirements under multi-cultural conditions. Little is known about the transition to parenthood for mothers in a new country, particularly when the country is New Zealand. This paper will challenge the positivist hegemony of previously completed research on migrant women by reflecting on my own experience as a researcher grounded in a broadly–based, pluralistic set of critical epistemologies that allowed me to uncover the issues and contexts that impacted on the experience of migrant women. It concludes by proposing that, where research occurs with minority groups, multiple research strategies are incorporated in order to prevent the reproduction of deficiency discourses.

 

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Migrant Populations

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

The art of walking upright here

Is the art of using both feet.

One is for holding on.

One is for letting go. (Colquhoun, 1999, p.32)

Glenn Colquhoun’s poetry captures the challenge dislocation from home and family. The migrant or refugee has to somehow hold on to their legacy and their heritage whilst simultaneously letting go of those things that cannot be maintained in a new country. They must let go to create new lives, so they can stake a new claim of belonging; a new place to stand.

One in five New Zealanders was born overseas. This rises to one in three in Auckland. For many, migration is seen as a way of obtaining a better life, particular for ones children. Whilst many migrants make informed decisions, this needs to be seen as a continuum between full choice and no choice. This can been viewed as a ‘pull’ effect (migrants are drawn to a new country for the opportunities available) or a ‘push’ effect (the motivation is simply to leave where they are). Migrants can be defined as people who were born in one country and then move to another under an immigration programme. In New Zealand this consists of three main streams:

  •  Skilled/Business: Which relates to attracting migrants with qualifications and skills, or the potential to create business opportunities in New Zealand.
  • Family sponsored: Where New Zealand citizens or permanent residents can sponsor family members to the country.
  • Humanitarian: This includes refugees and allows for family members to be granted residence if there are serious humanitarian concerns.

Refugees that have resettled in New Zealand mostly originate from Africa, the Middle East, South East Asia and Eastern Europe. Refugees differ from voluntary migrants because they were forced to leave their home and have little if any choice in selecting their destination. They are at the extreme end of the ‘push’ effect, often having fled from situations of conflict and human right abuses. This has important implications for the provision of  health care, as they might not have had access to preventative and treatment services. Most refugees arriving in New Zealand will spend six weeks at the Mangere Refugee Reception Centre (MRRC) in South Auckland. There are estimated to be 20.6 million refugees and displaced people in need of protection and help (UNHCR, 2003). Currently New Zealand accepts a United Nations-mandated quota of 750 refugees per year, plus approximately the same number again of asylum seekers. Asylum seekers are people seeking refugee status without legal documentation. They often experience depression, hopelessness and helplessness related to stress and socio-economic deprivation. Even where migration is an informed choice, the result can still be isolation and loss of financial independence. Before migration, one often only considers the positives; it can be difficult to understand the adjustment that is required and to come to terms with the losses of family, friends, culture and familiarity.

In this chapter I present a view of cultural safety and how it is relevant to health from the perspective of a migrant with a view to informing those who will be caring for the needs of migrants and refugees. I will briefly review the history and tensions around migration and migrants. Anecdotes from my clinical experience are woven through the text to present multiple layers to reflect the complexity of the experience and reflective questions are posed to increase self-awareness. I conclude by offering a range of strategies for working with diversity.

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Improving collaboration between nursing professionals and support workers in the New Zealand mental health system– A position paper

In 1998 I began teaching the first mental health support work cohorts in New Zealand at Unitec Institute of Technology. I had the privilege of working with Maori and Pacific mental health workers, peer support workers and consumer providers until 2005. I wrote this position paper for the Australian and New Zealand College of Mental Health Nurses way back in 2003. I have taken it out of the vault in case it is of use. I have listed more up to date references at the end of the document for those who might want to do some further reading.

EXECUTIVE SUMMARY

The Mental Health Commission (1997) states that mental health is the concern of all. Support workers are a reality of today’s mental health system in New Zealand and this paper looks at their relationship with community mental health nurses. This paper is a response to the major changes in mental health care in New Zealand over the last decade, which have dramatically altered the landscape of the mental health workforce. It seems timely to look at a way forward and to develop guidelines for nurses working with support workers in the community. In this paper “support workers” include community support workers and consumers as providers and the term “nurses” refers to community mental health nurses.

No one group can meet the needs of consumers. Together these two groups can provide complimentary services to improve client care but a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. The changes in the socio-political context of mental health care in New Zealand are challenging nurses to re-define their scope of practice. These developments and their implications are summarised and options for the nursing profession are discussed and recommendations given.

ISSUES

Competition for funding

The creation of the Regional Health Authorities (RHA) in 1991 was part of a new system of purchasing health services which replaced Area Health Boards (Yegdich & Quinn, 1996). This new funder /purchaser /provider system encouraged competition between providers and led to many new services entering the health sector. These included non-governmental services who were now able to compete directly with Crown Health Enterprises (CHE), previously there was an obligation for boards to concentrate funding on their own services (Yegdich & Quinn, 1996). In 1996 the new coalition government initiated another review of the health system leading to funding being centralised under the Transitional Health Authority (THA). Competition for central funding begs the question of whether competing services with different philosophies and types of workers can cooperate with each other. When community support services were established in Auckland there was antagonism from nurses as these new services were seen as better resourced, with lower caseloads and were seen to be eroding the role of the professional nurse.

Culturally appropriate parallel services

The changes in funding have also lead to the development of specialised Maori and Pacific Island support work services. In Auckland, the Maori community support work (CSW) service has dramatically reduced the rate of admission and re-admission for Maori . Previous statistics had shown that Maori were entering the mental health system at the same rates as non-Maori but required longer stays and more frequent re-admissions (Te Puni Kokiri, 1993). Increased numbers of immigrants and refugees from Africa, Asia and Eastern Europe have led to the formation of specialised mental health services, for example the Refugees As Survivors (RAS) centre. However, a disadvantage of parallel services is that nurses in main stream services lose the opportunity to develop specialised skills for working with cultures other than their own.

Case management

Case management originated in the United States in the 1980’s in the context of deinstitutionalisation, normalisation and the development of community mental health centres (Sledge, Astrachan, Thompson, Rakfeldt & Leaf, 1995; Willis & Morrow, 1995). It was seen as a way of improving the connections between services and linking both clinical and rehabilitation services together to ensure that “severely mental ill” clients received adequate services (Sledge, et al. 1995). Versions of case management are used in New Zealand although little has been written about the experience locally. Universal agreement has not been achieved regarding the scope of practice of case managers and the level of education required. The assumption that nurses are the most suitable group to provide case management services is being challenged by the emergence of support work services and parallel ethnic mental health teams.

Role change

Yegdich and Quinn (1996) have observed that the role of nurses has extended with the move from institution to community. Needs of clients now include housing, income, employment and social networks. However, an audit of community services in Auckland found that the dominant activity of nurses was crisis intervention (Yegdich & Quinn, 1996). Support work services have evolved in recognition of the gaps in community care provision. This movement to the community has also resulted in an increased emphasis on tertiary prevention, rehabilitation and recovery. New postgraduate training courses in mental health nursing have been developed as a result of a growing dissatisfaction with comprehensive nurse training and what is seen as inadequate preparation for working in this area (Ministry of Health, 1996). This is also important from a case management perspective particularly as broader skills are necessary for this role, for example knowledge of community resources.

Changing relationship with consumers

The consumer movement is influencing the movement of mental health service delivery from a medical to psychosocial rehabilitation model (Worley, 1997). New opportunities have arisen for consumers to interact with policy makers, professionals and others from a position of strength. Consumer operated programmes and initiatives have been developed due to the dissatisfaction with clinical mental health services. Consumers have found consumer-staffed organisations more empathetic, tolerant and understanding because of their own struggles with psychiatric disability (Worley, 1997). Consequently, guidelines have been developed as a result of increased consumer participation in professionally run mental health agencies (Ministry of Health, 1995). This has also led to changes in relationships between consumers and professionals. There is growing recognition on the part of professionals of the value of experiential knowledge and what consumers have to offer other consumers.

Safety and extended roles

  • Assessment by a nurse is required to detect changes in the mental state of a client. Where a support worker is the predominant contact, changes may be missed particularly if they have no clinical experience or assessment skills. In an article about extended roles, Rieu (1994) stated that discussion about accountability (“professional” and “legal”) and competency is needed. Other questions that need to be addressed include:
  • What preparation and training are support workers given?
  • What supervision do they get and how are they regulated?
  • How well are they resourced and supported?
  • Is their scope of practice clearly defined?

ADDRESSING THE ISSUES

Recognising the strengths of support workers

Support workers are seen as filling the gaps in community care, particularly in terms of work with clients with complex needs not met within the reductionist medical model (Davies, Harris, Roberts, Mannion, McCosker & Anderson, 1996). Other advantages include breaking the barrier of client-worker distance, providing a bridge between clients and mainstream staff and providing a role model for clients of similar background (Davies et al., 1996). Studies have shown that support workers are considered more effective than health professionals for several groups with varying mental health needs (Davies et al., 1996; Grant, Ernst, Streissgut, Phipps & Gendler, 1996). These include abused women, who have viewed the health system as sexist, fragmented and professionals as judgemental and insensitive (Davies et al., 1996). Other studies have shown that chronically drug-dependent women have become distrustful of “helping” agencies and in turn many professionals see these women as a hopeless population (Grant et al., 1996). They describe an advocacy model of case management using support workers, who worked intensively with women, who used drugs or alcohol heavily during their pregnancies and were alienated from community services. This alienation increased the risk of delivering children with serious medical, developmental and behavioural problems. It also prevented them from seeking assistance from agencies that were designed to help them. These ‘advocates’ were support workers experienced in social services with high-risk populations, had a variety of life experiences and came from a similar cultural background to their clients. They were seen as positive role models, providing hope and motivation. It was found after one year that clients now engaged with treatment agencies, decreased drug use, increased use of birth control and increased their involvement with supportive and skill building groups, such as parenting classes (Grant, et al., 1996).

Training and education of nurses

Nursing training must incorporate concepts such as recovery and consumer perspectives. Nurses need to be supported to work as case managers and build on their roles as more than adjuncts to the medical model. Mental health nurses working in the community must clarify their current roles and define what pathways they will follow.

Diversity in the workforce to provide culturally appropriate services

Reviews have shown that there are a paucity of culturally safe services for Maori and Pacific people (Ministry of Health, 1997). Furthermore, the provision of resources and devolution of resources have not supported other views of mental illness (Mental Health Commission, 1996). “Moving Forward” (Ministry of Health, 1997) national objectives states more trained mental health workers are needed before culturally appropriate services can be provided by mainstream and kaupapa Maori mental health services. A better partnership is needed between education and health sectors so that training can be specifically targeted to Maori. The Pacific Island objective also recommends that work be done so that mental health services become more responsive to the diverse needs of Pacific peoples. The national objectives recommend educating consumers as providers, community support workers and Maori and Pacific Island workers.

Better cooperation with ethnic support workers

In an Australian article, Fuller (1995) argued that health care practices by professionals continue to be predominantly monocultural despite recognition of the need to be responsive to the culturally diverse population. Fuller added that different ethnic groups practice illness prevention and health promotion differently. Some prefer direct, practical and immediate assistance from the Western care system rather than long term strategies. Fuller argued that nurses could not attain all the necessary cultural knowledge to provide total care to clients without a partnership with cultural intermediaries. According to Fuller, this expectation would result in lists of stereotypical traits being produced rather than an improved understanding of clients individual needs. Fuller added that the values and assumptions of primary nursing with contradictory notions of empowerment and autonomy have resulted in rigid professional boundaries which restrict multi-disciplinary team work, thereby increasing the need for an ethnic support worker.

Alternative structures and models

The Ministry of Health (1997) recommends that mental health promotion and prevention for Maori and Pacific Islanders be strengthened. They suggest using traditional (Pacific and New Zealand) structures to promote mental health including circulating Pacific language descriptions of key western mental illnesses. In addition, the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996) suggested that Maori consumers become integrated into the provider culture of mental health services, so services reflect the wealth of Maori consumer experience. This is in line with the request by Maori consumers to have more Maori community support workers, patient advocates and crisis teams. This leads on to the next area for discussion about who can best provide services for those with mental health needs. Takeuchi, Mokuau & Chun (1992) found that the establishment of parallel services improved mental health for minorities and led to an increase in their use.

Multiskilled, multidisciplinary and comprehensive

According to Øvretveit (1993), it is rare that one profession alone is able to meet the needs of a person with a social or health need. Usually the skills and knowledge of a range of specialists are beneficial and coordination is crucial to prevent costs of duplication and staff frustration. This is echoed by the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996). It suggests that the best way to deliver mental health services to consumers is by having a team of multi-skilled and multi disciplinary workers. This team would be able to address the many facets of care required by sufferers of mental illness and would include community support workers as well as Maori and Pacific Island workers. “Moving Forward’s” National objectives are to increase the Maori and Pacific Island mental health workforce. In addition, a flexible system is required where a case manager might need to spend more time with someone as the nature of mental illness changes rapidly.

A proposed model of cooperation

The mental health of consumers will be maximised if professionals and support workers are able to work in partnership and combine their skills, knowledge, life experience and expertise in a coordinated way. This would ensure that services are respectful, relevant, flexible, responsive and effective and that they are available to consumers to reduce the barriers that prevent them from achieving their full health potential. The framework for community service delivery for people with mental health problems needs to be comprehensive, health promoting and collaborative; a partnership that is committed to client empowerment and the elimination of barriers to access (Association of Ontario Health Centres, 1994).

RECOMMENDATIONS

Several recommendations are proposed:

Liaison

  • Adopt protocols for networking within all services so that inter-agency cooperation is maximised and clients receive a seamless service.
  • Improve the interface between clinical, cultural and psychosocial models to increase understanding and collaboration from both perspectives.

Training 

  • Educate support workers to understand the role of the nurse but not to the extent that traditional healing structures are negated in favour of psychotherapeutic methods.
  • Formalise traditional roles into the mental health system, for example the role of Kaumatua (Street & Walsh, 1996).
  • Train nurses in cultural and psychosocial models.

Role and Scope of practice

  • Develop job descriptions for support workers in cooperation with nurses to prevent role ambiguity, promote job satisfaction and decrease discontent.
  •  Support and safeguard support workers to ensure that their role does not compromise the safety of clients and staff or the role of the nurse.
  • Use nurses appropriately and ensure that they are not substituted by support workers for fiscal or political reasons.
  • Define core competencies for support workers at a national level and ensure on-going monitoring of standards.

Alternatives to the medical model

  • Recognise that the clinical model has limitations and cannot meet the needs of all clients.
  • Increase familiarity with alternative models of mental health amongst nurses, for example recovery and cultural models.
  • Review and clarify the role of nurses working in mental health.

Cultural safety 

  • Acknowledge the importance of spiritual issues, land rights, whanau reconstruction and physical health (Street & Walsh, 1996).
  • Resource nurses appropriately for the cultural component of their work.
  • Involve nurses in developing appropriate policy and healthcare services to Maori and ethnic minorities in New Zealand (Street & Walsh, 1996).
  • Familiarise nurses with the work of ethnic mental health workers and Maori support work services.

Consumer participation/consumer focused

  • Recognise the experiential and personal knowledge of consumers.
  • Ensure that consumers are key players in planning and accountability structures which are linked to outcome measures.

CONCLUSION

This paper has shown how support workers can reach clients who are lost to or fearful of the mental health system, whether this is because of social, ethnic or cultural reasons. In an evolving mental health system moving from institutionalisation to community-based care, these new roles provide a bridge between the clinician and the consumer. No one group can meet all the needs of consumers. Support workers can widen the focus of the mental health system in a way that better meets the needs of clients in the community at large, whatever their background. Friction has existed between nurses and support workers, the former often viewing the latter as eroding their role and of being unskilled. Alternatively support workers have sometimes viewed nurses as part of a system that they see as having failed them. Support workers are seen by some as being a political solution to eroded health care funding. Although there are several issues requiring on-going discussion, not least the legal and ethical requirements for support workers and their regulation, a synergy exists between nurses and support workers and together they can provide complimentary services to improve client care. For this to be successful a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. A guiding framework of principles for working in harmony should be developed.

REFERENCES

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Davies, J; Harris, M; Roberts, G; Mannion, J; McCosker, H & Anderson, D. (1996). Community health workers’ response to violence against women. Australian and New Zealand Journal of Mental Health Nursing,5, 20-31.

Fuller, J. (1995). Challenging old notions of professionalism: how can nurses work with paraprofessional ethnic health workers? Journal of Advanced nursing, 22, 465-472.

Grant, T.M.; Ernst, C.C.; Streissgut, A.P.; Phipps, P.& Gendler, B. (1996).When case management isn’t enough: a model of paraprofessional advocacy for drug and alcohol abusing mothers. Journal of Case Management, 5, 1, , 3-11.

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Ministry of Health (1996). Towards better mental health services: The report of the national working party on mental health workforce development. Wellington: Ministry of Health.

Ministry of Health (1997). Moving forward: The National Mental Health Plan for more and better services. Wellington: Ministry of Health.

Øvretveit, J. (1993). Coordinating community care. Open University press: Buckingham. Rieu, S. (1994). Error and trial: the extended role dilemma. British Journal of Nursing, 3, 4, 168-174.

Street, A & Walsh, C. (1996). Community nursing issues in Maori Mental Health. Australian and New Zealand Journal of Mental Health Nursing, 5, 54-62. Te Puni Kokiri (1993).

Nga Ia O Te Oranga Hinengaro Maori trends in Maori Mental Health: A discussion document. Wellington: Te Puni Kokiri. Worley, N. (1997). Mental health nursing in the community. .Mosby: St Louis.

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Annadale, M., & Instone, A. (2004). Sei Tapu: Evaluation of the National Certificate in Mental Health Support Work. Wellington, New Zealand: Platform.

Barber, K. F. M. (2015). Realising Our Best Intentions: Vision, Values and Voice in Community Non-government Organisations of the Aotearoa$\backslash$ New Zealand Mental Health Sector. University of Waikato. Retrieved from https://waikato.researchgateway.ac.nz/handle/10289/9989

Cheng, R., & Smith, C. (2009). Engaging people with lived experience for better health outcomes: Collaboration with mental health and addiction service users in research, policy, and …. Toronto, Ontario: Minister’s Advisory Group,. Retrieved from https://www.researchgate.net/profile/Christopher_Smith27/publication/260589695_Engaging_People_with_Lived_Experience_for_Better_Health_Outcomes_Collaboration_with_Mental_Health_and_Addiction_Service_Users_in_Research_Policy_and_Treatment/links/0f317531a029393ce7000000.pdf

Hatcher, S., Mouly, S., Rasquinha, D., & Miles, W. (2005). Improving recruitment to the mental health workforce in New Zealand. Of New Zealand. Retrieved from http://www.tepou.co.nz/uploads/files/resource-assets/Improving-Recruitment-to-the-Mental-Health-Workforce-in-New-Zealand-2005.pdf

Hennessy, J. L., Smythe, L., Abbott, M., & Hughes, F. A. (2016). Mental Health Support Workers: An Evolving Workforce. Workforce Development Theory and Practice in the Mental Health Sector, 200.

 

Hennessy, J. L. (2015). The contribution of the mental health support worker to the mental health services in New Zealand: an Appreciative Inquiry approach. Auckland University of Technology. Retrieved from https://aut.researchgateway.ac.nz/handle/10292/9192

McMorland, J., Kukler, B., Murray, L., & Warriner, R. (2008). Partnerships in Development: developments in mental health service provision in New Zealand. A case study. New Zealand Journal of Employment Relations (Online), 33(1), 19.

Morrison, N., & Ronan, K. (2002). Assessment of Core Competency Status and Work Environment of Residential Mental Health Support Workers. The Australian Journal of Rehabilitation Counselling, 8(02), 114–126.

Morrison, N. (2000). Assessment of competency status of residential mental health support workers: a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University. Massey University. Retrieved from http://mro.massey.ac.nz/handle/10179/6018

 

O’Neil, P., Bryson, J., Cutforth, T., & Minogue, G. (2008). Mental health services in Northland. Industrial Relations Centre, Victoria University of Wellington, July, 2–3.

O’Hagan, M. (2001). Recovery Competencies for New Zealand Mental Health Workers. Retrieved from http://eric.ed.gov/?id=ED457512

Pace, B. (2009b). Organisational views of the mental health support worker role and function. Unpublished Paper. Waikato Institute of Technology, New Zealand. Retrieved from http://www.psychosocial.com/IJPR_14/Organizational_Views_Pace.html

Pace, B. (2009a). How New Zealand community mental health support workers perceive their role. Journal of Psychosocial Rehabilitation. Vol 13 (2). 5. Retrieved from http://www.psychosocial.com/IJPR_13/New_Zealand_Comm_Mental_Health_Pace.html

Pace, B. (2010). Exploring support work: Examining the role of mental health support workers in New Zealand (p. 159). Wellington, New Zealand: B. Pace.

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Rangiaho, A. (2003). Te Puawaitanga o Te Oranga Hinengaro-An evaluation of the Natioonal Certificate in Mental Health Support Work from a Maori perspective. Wellington, New Zealand: Mental Health Support Work.

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The ‘small’ things count in caring

Editorial published in Kai Tiaki: Nursing New Zealand 8.10 (Nov 2002): p28(1).

KAI TIAKI Nursing New Zealand has recently carried narratives written by nurses discussing their experiences as recipients of health care, eg “My Journey of Pain” by Glenis McCallum (July 2002, p16). These experiences gave the nurses the opportunity to re-examine their practice and to reclaim their empathy.

Similarly, a personal experience provided the impetus to write this brief piece. I recently had the opportunity to re-evaluate my own beliefs about nursing and the importance of communication and caring when I witnessed my sister receiving care in a hospital maternity setting. What came across was the importance of the “small” things–the caring and the communication, and the importance of compassion and empathy. The sweetness of the person who opened the door to the unit and said “welcome to our world”. The rudeness, almost surliness, of the nurses who forgot to introduce themselves or tell us what was happening.

Rightly, there is much focus on nursing as a profession, yet is it possible that in this debate we have forgotten the small things that really matter to our clients -the things that make people feel safe and cared for?

This personal and professional interest was further piqued by two workshops held in Auckland recently that focused on maternal mental health issues. Both highlighted the important role nurses have to play when caring for women experiencing childbirth.

In the first workshop, organised by the education and support group, Trauma and Birth Stress (TABS), 170 consumers and health professionals gathered to explore post-traumatic stress disorder (PTSD) after childbirth. The group TABS was formed by women who had all experienced stressful and traumatic pregnancies or births that had negatively affected their lives for months or even years after the experience. One of TABS’s aims is to educate health professionals on the distinctions between PTSD and post-natal depression so the chance of misdiagnosis is lessened and correct treatment is started quickly.

Speakers at the workshop included an international nursing researcher from the United States, Cheryl Beck. A number of New Zealand women have shared their stories of PTSD with Beck and have found telling their stories and having someone understand and believe them has been very therapeutic. Other speakers included TABS member Phillida Bunkle and Auckland University of Technolgy midwifery lecturer Nimisha Waller who spoke on how mid wives can assist mothers with PTSD.

In my role at UNITEC Institute of Technology, I organised the second workshop, which also featured Beck. Entitled “Teetering on the edge: Postpartum depression–assessment and best practice”, the workshop attracted around 100 nurses, midwives, GPs and consumers. A professor in the School of Nursing at the University of Connecticut, Beck has for many years focused her efforts on developing a research programme on postpartum depression. Using both qualitative and quantitative research methods, she has extensively researched this devastating mood disorder that affects many new mothers. Based on the findings from her series of qualitative studies, she has developed the postpartum depression screening scale (PDSS). Currently Beck’s research is focused on PTSD after childbirth and she presented her work to date. In September, there were 27 participants in the study, 18 from New Zealand and the rest from the United States.

The themes of her presentation were a reminder of the dramatic negative consequences of occurrences we as health professionals deal with frequently. Emergency situations arise and we all do our job, often without a second thought as to the future impact of our actions (or inactions) on the woman and her family.

Beck also spoke at the TABS work shop. The response to both workshops was really positive. Workshops such as these, where the long-term impacts of the health care experience are discussed, can act as a reminder for anyone working with women at and around the time of childbirth to critically view their practice and that of their colleagues. Themes that feature in the research are around caring, communication and competence–the very things that were absent in my recent experience of the health system. Women in the study felt they were not shown caring, communication from health providers was poor, and they perceived their care as incompetent.

Through her research, Beck poses the question so many mothers ask: “Was it too much to ask to care for me?” As health professionals, we need to ask ourselves every day “how can I care for the needs of this client?”, because nursing is not just a profession, it is a caring profession.

* For further information on TABS http://www.tabs.org.nz/

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Care of the person with Borderline personality disorder in the community

First published online by Ruth DeSouza 1997

Abstract

The development of community-based models of care in New Zealand has led to dramatic changes in the treatment available for people with mental illnesses. However, we appear to be failing to provide comprehensive coordinated and continuous care for clients diagnosed with Borderline Personality Disorder (BPD). One major problem is the stigma and dread that many community mental health nurses equate with the care of people diagnosed with BPD, resulting in the care given being limited and fragmented. This article examines the trauma paradigm for viewing BPD and provides an overview of the knowledge and skills that are required to care for people diagnosed as having a borderline personality disorder within the community .

Introduction

Kaplan and Sadock (1991) define personality as both emotional and behavioural traits that characterise the person and state that personality is stable and predictable to some degree. Thus, a personality disorder is a deviation from the range of character traits that are considered “normal” for most people. When these traits are inflexible and maladaptive and the result is distress and impaired functioning they are considered to be a class of personality disorder. Of the ten different personality disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), one of the most controversial is Borderline Personality Disorder (BPD).

There is much debate around the definition and diagnosis of BPD (Shea, 1991). The term was first used in 1938 to refer to a group of disorders that lie between neuroses and psychoses (Greene and Ugarizza, 1995) but can also be used as a disparaging label for difficult clients (Reiser & Levenson, 1984). Some of the challenges in caring for clients with BPD relate to the symptoms and intense transference and counter-transference in the relationship between client and nurse/therapist (Gallop, 1985). This can result in nurses feeling frustrated, helpless, distant and even denying mental health services (Gabbard, 1991 cited in Greene & Ugarriza, 1995). A person with BPD is often seen as an impostor, who is in control of their behaviour but who chooses to be difficult and manipulative (Nehls & Diamond, 1993). Studies show that 77% of those diagnosed with BPD are women (Widiger & Weissman, 1991).

Aetiology

There are several explanations of the aetiology of BPD.

Biological factors

Greene and Ugarizza (1995) offer two biological explanations for BPD. The first focuses on neurotransmitter activity and systems, where an increase in dopamine action can account for transient psychotic states and decreased serotonin activity can account for irritability and impulsiveness. Lastly, an increase in the cholinergic pathways can lead to depression in clients with BPD. The second explanation puts forward organic brain dysfunction caused by trauma, epilepsy and attention deficit hyperactivity disorder (ADHD) as a cause of the increased impulsiveness, self-mutilation and affective disinhibition seen in BPD. However, Kaplan et al., (1991) argue a genetic link, proposing that people with BPD have more relatives with mood disorders than a control group and often have a mood disorder themselves as well.

Psychoanalytical factors

Another theory of the aetiology of BPD relates to the psychological birth of the human being or process of separation-individuation, which occurs, between birth and three years of age. In this process a sense of self is developed by the child, a permanent sense of significant others (object constancy) and the integration of both good and bad as part of the self concept (Mahler, Pine & Bergman, 1975). Mothering influences the outcome of the separation– individuation process but if this is inconsistent, insensitive or unattuned to a child’s needs then dysfunction occurs (Westen, 1990). If a child’s efforts to be autonomous are punished whilst dependent behaviour is rewarded, differentiation does not occur and responses such as intense anger, mood swings, dichotomous thinking and identity diffusion can result, all of which are seen in a person with BPD.

Childhood abuse/ Trauma

The trauma perspective is gaining increased recognition as studies show strong correlations between sexual or physical abuse in early childhood and the development of BPD (Paris, 1993). Herman (1992) argues that what is labelled BPD is a manifestation of post-traumatic stress disorder (PTSD), called “complex PTSD”, which follows prolonged, repeated trauma resulting in personality changes (most prominently identity and relationship disturbance).

Biosocial factors

Linehan (1993) hypothesises that people diagnosed with BPD have a biological tendency to react more intensely to lower levels of stress than others and to take longer to recover. Linehan adds that often they were raised in invalidating environments and became uncertain of the truth of their own feelings. As adults a failure to master three basic dialectics means they go from one polarity to another.

Cultural issues

There is little literature to indicate that BPD occurs in other than Western cultures, despite the extensive research that has been done on BPD.

Assessment and diagnosis

As seen in the aetiology section above, the accuracy of the diagnosis of BPD is controversial. Most approaches to treatment define BPD according to DSM-IV using a descriptive objective approach (Shea, 1991). Some writers argue that this dominance of DSM-IV in psychiatric settings (as expert authority of behaviours outside the norm) means that a diagnosis pathologises behaviour (Crowe, 1997; Gallop, 1997). In this section the DSM-IV perspective and the trauma perspective are reviewed.

DSM-IV and the medical model

In this paradigm “Borderline personality disorder is described as a pervasive pattern of interpersonal relationships, self-image and affects and marked impulsivity” (Crowe, 1996, p106). It falls under the DSM-IV Axis II diagnostic category, cluster B (dramatic, emotional, erratic) and can be associated with co-morbidity of Axis I and II disorders (American Psychiatric Association, 1994). Diagnosis is problematic because of the fluctuating nature of symptoms and concerns that are presented by the client (Arntz, 1994).

In order to be diagnosed with BPD a person must meet five of nine criteria described in the DSM-IV (1994). These are around abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, recurrent suicidal threats, gestures or behaviours, affective instability, chronic feelings of emptiness, inappropriate intense anger, transient stress-related paranoid ideation or severe dissociative symptoms. Skodol and Oldham (1992) recommended that 2-5 years is the minimum clinical time to indicate a stable personality pattern. Whilst Paris (1993) added that by middle age the majority of clients with BPD had recovered from acute symptoms and no longer met the criteria for BPD (Greene & Ugarriza, 1995).

Complex post traumatic stress disorder (PTSD)

The medical model paradigm of personality disorder is criticised by several researchers (Brown, 1992; Herman, 1992), who see the label as misleading and having negative effects on treatment. Herman warns that trying to fit people into the DSM-IV mould without addressing the underlying trauma or understanding what the problem is, results in fragmented care. Brown (1992 agrees and suggests the distress of abuse resembles responses to experiences of interpersonal trauma rather than core personality pathology. Brown and Walker (1986) argue that a diagnosis that lies between personality disorders and PTSD that is framed situationally is more helpful as it can be changed rather than as personality which can not. This diagnosis acknowledges the effect of multiple exposures to trauma which must be adapted to daily for victims of trauma and interpersonal violence and varies from PTSD, which assumes a single exposure to trauma outside the range of everyday experience.

Gender bias and stigmatisation

Brown (1992) argues that androcentric gender role norms and stereotypes influence judgements of psychopathology, which result in more women than men being diagnosed with BPD and the stigmatisation by mental health professionals of gender role traits that are normative for women. Often the traits and behaviour considered dependent, passive, dysfunctional and pathological are appropriate and skilful ways of accessing some power in a context where more overt and appropriate expressions of power are stigmatised or penalised (Brown). The effects of sexism multiplied by the requirements for survival under abuse require an alternative frame of reference to viewing a person’s symptoms. Further stigmatisation of certain behaviours occurs through having space for Axis II personality traits irrespective of whether they are at a psychopathological level. Brown adds that context and variables such as race, gender, class and experience of abuse or victimisation are not considered either. Brown (1992) and Gallop (1997) propose a feminist perspective for BPD that takes into account the meaning of interpersonal context and relatedness rather than separation and individuation.

Power dynamics

Brown and Gallop (1997) argue that the mental health setting often mirrors the interpersonal power dynamics where abuse occurred. The presence of a powerful other can exacerbate symptoms and vary from how someone presents in a more power-equal situation. Many non-exploitative situations would need to be experienced before patterns of survival were relinquished.

Age trauma occurred

Van der Kolk, Hostetler, Herron & Fisler (1994) suggest that up to a century ago, research showed traumatised people would have their personality development checked at whatever point the trauma occurred after which it could no longer be added to. The authors suggest trauma has different effects at different stages of development. If the trauma is experienced as an adult then it is more likely to become what is known in the DSM-IV as PTSD. However, if trauma is experienced at an earlier age, then different manifestations of developmental arrest will be seen, therefore a person traumatised at a particular age might process intense emotions later in life the way someone at that age would, using earlier developmental accomplishments. The earlier someone is traumatised, the more pervasive their psychological disability.

Ethical and legal issues

There are major ethical and legal issues to consider in caring for people with BPD in the community. An awareness of the Mental Health Act is vital and issues such as splitting and ambivalence can make the area of ethical and legal issues a minefield.

Suicide

People with BPD represent the highest risk of suicide of any of the personality disorders and factors such as “overplaying their hand” or being rescued unexpectedly make suicide risk difficult to ascertain (Stone, 1993). He suggests that the therapist/nurse can become skilled at predicting suicide risk through clinical experience, supervision and by becoming familiar with the literature on suicide risk. The exploration of specific individual techniques for controlling impulses, such as the desire to self-harm, to identify triggers and patterns and increase self-awareness can also be useful. Including such questions as “do you want to slash?”, “Do you want us to help you control slashing?” (Gallop, 1992). Respecting the autonomy of a client with BPD can be difficult if they are presenting with suicidal ideation and there is a requirement to assess the need for compulsory treatment.

Medico-legal issues

Gutheil (1985) makes several points in his article about medico-legal issues that can arise in the treatment of people with BPD. In respect of the Mental Health Act (1992) there can be a legal ignorance of BPD as some people present with excellent functioning whilst others appear too sick to be discharged from compulsory treatment. The effects of borderline psychodynamics such as borderline rage, narcissistic entitlement, psychotic transferences, threats of suicide and impulsivity can also be challenging in relation to the Mental Health Act (1992).

Treatment issues

There are several issues that impact on the treatment of a client with BPD and which are important for nurses to be aware of. These are discussed prior to the exploration of psychotherapeutic and psychopharmacological treatments.

Transference and counter-transference

The therapeutic alliance is the foundation of therapy, which is often difficult to establish and maintain, particularly in the face of disruptive pressures that arise in therapy with a client with BPD (Meissner, 1993). This alliance and transference and countertransference are called “the therapeutic tripod” by Meissner. In the transference, the client relives their relationship with their parents through the nurse and can be very perceptive about who is working with them. This survival skill was learnt through anticipating the needs of their caregivers to prevent victimisation (Van der Kolk et al., 1994). Often an equally strong counter-transference is evoked in the nurse because of the strong emotion and conflict in the transference, which can include helplessness, fury and despair. Nurses can feel a need to rescue or compensate (Van der Kolk et al.,1994). In order to remain therapeutic, it is essential for nurses to know themselves, have safe spaces to review these issues in supervision and ensure they get support from their clinical teams.

Safety

Van der Kolk et al. (1994) suggest that negotiating safety and forming safe attachments are a way in which a client with BPD is able to regulate their internal state. This is especially the case if people with BPD are fixated on the emotional and cognitive level at which they were traumatised and continue to deal with difficulties using the resources at that point in their development . The authors recommend that basic trust and safety are negotiated prior to approaching trauma related material.

Hospitalisation

Gallop (1985) suggests that hospitalisation is an important aspect in the management of acute episodes for people with BPD. Budget and fiscal constraints mean that people with BPD are more commonly admitted for the relief of acute symptoms, usually a shift from chronic suicidality to acute suicidality, rather than for personality restructuring. Gallop reviews the two main clinical approaches for the hospitalised person with BPD. The adaptational approach focuses on preventing regression and encouraging people to take responsibility and has a short-stay emphasis, where staff offer supportive therapy, structure and limit set. In contrast, the long-stay approach allows for regression to take place in the presence of warm and empathic staff who facilitate the process of personality restructuring. The critics of this approach argue that it leads to the exacerbation of borderline symptoms. Gallop proposes an alternative model based on the work of Linehan (1993), but which adapts dialectic behavioural therapy for use in an in-patient setting in order to maximise the current short-stay emphasis and to use the skills of clinicians. Dialectic behavioural therapy will be discussed later in this article.

Dissociation

Research has found dissociation to have a high correlation both with the degree of borderline psychopathology and with the severity of childhood trauma (Van der Kolk et al., 1994). Dissociation is a way of coping with inescapably traumatic situations by allowing the person to detach from the reality of the situation. Often there is a loss of the memory and the relief of pain for the situation, the person can feel numb or spaced out. For some people this becomes a conditioned response to stress even if the situation is not inescapably stressful (Van der Kolk et al., 1994).

Splitting

A defence mechanism seen in clients with BPD is “splitting” (Harney, 1992) which can increase clinical risk if alternate strategies are recommended in the management of suicide risk. This risk can be reduced by ensuring clear communication and management plans across all services. Case management, where one person is responsible for the overall co-ordination of services and meetings with other care providers can also minimise splitting (Nehls & Diamond, 1993).

Psychotherapeutic interventions A systems approach

Nehls and Diamond (1993) state that people with BPD have diverse treatment needs, so treatment should to be based on comprehensive assessment and subsequent individualised treatment planning. This can be difficult for several reasons including: the number and intensity of crises that a person with BPD can have; the theoretical orientation of the clinician and interventions that are made hastily and based on negative reactions to a client or the diagnosis of BPD rather than careful assessment.

Nehls & Diamond propose a systems approach that includes: Individual counselling and psychotherapy; group therapy; medication evaluation and monitoring; drug/alcohol services; psychosocial rehabilitation and crisis intervention services. Planning should also include hospitalisation. Shea (1991) adds that several factors are intrinsic to any of the therapeutic approaches. These include careful attention to the client, skill to address countertransference, flexibility of therapy but also the need for limit setting with the therapist taking an active role.

Psychoanalytical

Shea (1991) suggests two types of psychoanalytic therapy can be helpful. Supportive psychoanalysis focuses on the improvement of adaptive functioning by strengthening defences and avoiding regression and transference by focusing on the present and keeping therapy highly structured. In expressive psychoanalysis, transference and regression are desirable and provide a means for the therapist to gain insight. Behaviour is changed as dissociated aspects are identified and clarified as they appear.

Dialectical behavioural therapy

Linehan ‘s (1993) Dialectical Behavioural Therapy (DBT) emphasises that the person with BPD has inadequate affect regulation related to biological factors and a childhood environment that is characterised by an absence of emotional regulation. DBT focuses on identifying skill deficits in a person’s life and then correcting them. The therapist teaches the client both self and relationship management skills as well as skills of mindfulness, interpersonal effectiveness, distress tolerance and emotional regulation. Therapy takes place individually and in groups and the relationship between therapist and client is paramount in treatment. In a one year trial of DBT, Linehan found that control group subjects remained in treatment longer, parasuicidal behaviour decreased as did the number of days of in-patient hospitalisation (Linehan, 1993).

Cognitive therapy

Cognitive therapy has been modified to treat clients with BPD (Beck, 1990) despite being thought of as most useful in the treatment of Axis I disorders (Shea, 1991). Arntz (1994), an advocate of cognitive therapy, argues that chronic traumatic abuse in childhood leads to fundamental beliefs that include: Others are dangerous and malignant, I am powerless and vulnerable and I am bad and unacceptable. The aim of cognitive therapy is to identify and change these beliefs, so affect and behaviour are normalised. Control over emotions and impulses are increased and identity is strengthened (Shea, 1991; Van der Kolk et al., 1994). Transference reactions provide rich material for uncovering dysfunctional thoughts and assumptions (Shea, 1991). Controlled studies have not been done as to the efficacy of this treatment approach with people with a borderline personality disorder (Shea, 1991).

Group therapy

The advantages of group therapy for the person with BPD include diluting transference and decreasing polarisation because of multiple feedback (Greene and Ugarizza, 1995). Group therapy can decrease demanding behaviour, egocentrism, social isolation and withdrawal and social deviance (Horowitz,1987 cited in Greene and Ugarizza, 1995). Van der Kolk et al., (1994) state group therapy provides both words and actions for expressing emotional states that clients with BPD have difficulty with and can borrow from other group members.

Family therapy

Research has shown a strong link between BPD and pathological families (Clarkin et al., 1991 cited in Greene and Ugarizza, 1995). Family members learn therapeutic interactions so the identified client can begin to form an identity and both the client and family modify their behaviour (Clarkin et al., 1991 cited in Greene and Ugarizza, 1995).

Alternative therapies

Van der Kolk et al., (1994) advocate using psychodrama and drawing to develop language for effective communication as a precursor to effective psychotherapy. The authors’ state that research has shown traumatised children have poor language skills for expressing their internal states. This can result in unmodulated actions, which are acted out in transferences and current relationships.

Psychopharmacology

Van der Kolk et al., (1994) propose that trauma affects a persons ability to self- regulate their emotions and self-soothe. Learning to tolerate affect is a way in which a traumatised person can take part in life. Mood stabilisers such as Lithium and Carbamazepine can help decrease affective lability and impulsive behaviour (Cocarro et al., 1991), whilst antipsychotic medication can help control transient psychotic states and antidepressants help with major depression (Shea & Kocsis, 1991 cited in Greene & Ugarriza, 1995). Linehan & Kehrer (1993) recommend being aware of contraindicated effects of medications, problems with compliance, drug abuse and suicide attempts. However, as long as careful monitoring is in place Linehan & Kehrer argue that pharmacotherapy can be a useful adjunct to psychotherapy.

Conclusion

This article has reviewed ways of viewing BPD. The medical model remains dominant in most psychiatric settings in New Zealand but other paradigms are gaining prominence as the limits of the medical model become more evident, particularly around the management of the client with BPD. The way in which BPD is defined remains contentious and many writers in the field suggest that it is more a response to trauma than core personality pathology. This has implications for how people with BPD are cared for in New Zealand’s mental health system.

As nurses move into the role of case managers in the community, a systems approach incorporating thorough assessment and planning is a good beginning which includes assessing for previous trauma. There is also a need for multiple treatment modalities to include a variety of components such as assistance with daily living needs, pharmacotherapy, dialectical behaviour therapy, cognitive therapy and so forth. Nurses need to disengage themselves from the shadow of the medical model and begin to explore new ways of supporting clients with BPD in the community. In order for community mental health nurses to maintain therapeutic relationships with clients with BPD, they must be proactive and attain supervision, education and self- knowledge.

 

References

American Psychiatric association. (1994). Diagnostic and Statistical Manual of Mental Disorders, (4th Ed.). Washington D.C: Author

Arntz, A. (1994). Treatment of Borderline Personality Disorder: a challenge for cognitive- behavioural therapy. Behavioural Research Therapy, 32, 4, 419-430.

Beck, A.T.& Freeman, A. (1990). Cognitive therapy of personality disorders. Guilford Press: New York.

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