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Submission to the New Zealand Suicide Prevention Strategy 2008

Congratulations on a wonderful job in developing the New Zealand Suicide Prevention Strategy. I am pleased to see an inter-sectoral approach that is both evidence and strengths based. It is also encouraging to see mention of diverse communities and an approach that integrates protection, promotion, early identification, crisis support, attention to families and support in the aftermath of suicide. Thanks for the opportunity to add my rather swiftly developed submission to the New Zealand suicide prevention strategy. I am focussing this submission on Asians and South Asians in particular, but am aware (as per our teleconference on Friday) that these issues pertain to other migrant and refugee groups as well.

My key points are:

  1. Asians are a high risk group for suicide and attempted suicide according to overseas research (especially South Asian young women).
  2. We need better ethnicity data collection practices as data is limited.
  3. There are issues with the umbrella term Asian which disguise differenceswithin groups.
  4. There are significant barriers in accessing services, particularly mental health services.
  5. Further research is needed that is clinical and epidemiological in order to identify prevention and intervention strategies that may vary from other groups.

Asians and statistics

Asians are a growing population in New Zealand. By 2016 they are expected to make up 9% of New Zealand’s and 20% of the Auckland Region’s total population. As such the health and social service needs of Asians must be considered by service providers. As you are aware there is limited research data available in New Zealand, 12 Asian people died by suicide (10 males and two females) in 2002, compared to 20 deaths

in 2001 and 21 deaths in 2000 (Ministry of Health, 2005). In our teleconference we also expressed concern the underreporting of suicide and coronial issues. I am concerned about the category as there is diversity within the people subsumed into the category Asian, with some groups especially at risk and others well protected) and the concept has limited use (Aspinall, 2003; Henare & Ehrhardt, 2004).

High rates of suicide and attempted suicide

Disproportionally high rates of suicide and attempted suicide have been found among South Asians in the diaspora (Batsleer, Chantler, & Burman, 2003; Bhugra & Desai, 2002; Bhugra & Hicks, 2004; Burr, 2002; Hicks & Bhugra, 2003). The highest were in young women of South Asian origin who have rates that are double that of the White population in the United Kingdom of completed suicide and 1.6 times more likely to attempt suicide(Hicks & Bhugra, 2003). Hicks and Bhugra examined perceived causes of suicide attempts in 180 ethnic South Asian women living in the London area. The three factors endorsed most frequently and strongly as causes of suicide attempts in South Asian women were violence by the husband, being trapped in an unhappy family situation, and depression. South Asian women are also two and a half times more likely to attempt suicide that South Asian men.

Barriers to accessing services

Recent New Zealand research has found that barriers for Chinese people accessing services include a lack of English language proficiency leading to communication difficulties and knowledge gaps, for example, being unaware of what services are available; the important role of primary healthy care and General Practitioners in particular as a first point of contact and a lack of awareness of the health and civil rights of citizens in New Zealand (Ruth DeSouza & Garrett, 2005). The research identified regional differences in terms of the place of birth of respondents and, in particularly, it was noted that Chinese-born respondents experienced more communication difficulties than those born in Hong Kong or Taiwan. Some of the strategies recommended in the report which are pertinent here include: encouraging cultural competence in health services (clinical, systemic and organisational), staff training and workforce development, developing partnerships with ethnic communities and community organisations, involving ethnic communities in strategic planning and linguistic competence. The latter involves not only ensuring that resources are available in several languages but also that interpreting and translation services are available.

Accessing mental health services

There are issues in attempting to access mental health services as well which are compounded by stigma within ethnic communities and anxiety from the mental health workforce. Increasingly mental health services are being called on to provide culturally appropriate care, but little is known about what that constitutes. Such a call cannot be answered if mental health professionals are not prepared for working in ways that are culturally competent. Despite the emphasis on cultural safety as part of the curricula of undergraduate health professional preparation, it has largely been concerned with Treaty obligations to Tangata whenua rather than evolving to meet the needs of ethnic communities (R. DeSouza, 2004). Burman, 2003, p.106) found in a research project investigating suicide and self-harm in the United Kingdom among South Asians that staff working with the women were caught in ‘race anxiety’ whereby white staff were hesitant and silent around issues to do with race, gender and mental health and were concerned that their actions were not misinterpreted. Their responses were to pass on issues to their South Asian counterparts or to avoid them. For the South Asian workers there was concern that discussing issues like this would reinforce or add to the existing stereotypes. This culture of silence within mainstream services was viewed as frustrating and annoying.

Ruth DeSouza Centre Co-ordinator/Senior Research Fellow Centre for Asian and Migrant Health Research Faculty of Health & Environmental Science Auckland University of Technology Address: Private Bag 92006, Auckland 1020

Ethnicity data collection

There is a need for improvements in quality ethnicity data collection so as to more clearly ascertain health needs and dispraities (Aspinall, 2003; British Medical Journal, 1996; Klajakovic, 1993; Latimer, 2003; McLeod et al., 2000; Ministry of Health, 2001, 2003, nd-a, nd-b; New Zealand Health Information System, 1996; Pringle & Rothera, 1996; Senior & Bhopal, 1994; Statistics New Zealand, 1996; Thiru, Hassey, & Sullivan, 2003; D. R. Thomas, 2000; S. B. Thomas, 2001). Several reports and research findings confirm that ethnicity data collection is poorly conducted by staff. A Waitemata District Health Board review found that staff were unaware of national guidelines for collecting data, had not received training on why and how ethnicity data was collected and consequently collected it inconsistently (Latimer, 2003). An internal paper for the Ministry of Health based on interviews with key stakeholders and a literature review found that there was inconsistency in the way in which data was collected and that what was collected was inaccurate and incomplete and that the concept of ethnicity was misunderstood (Ministry of Health, nd-a). These factors point to the need for support and training to facilitate accurate data collection. In order that ethnicity data is collected consistently and accurately ethnicity questions need to be aligned with Statistics New Zealand Census question for 2001 so that they are standardised. Variation exists across health providers around the method of ethnicity data collection, ranging from not asking and using previous admission information, to asking verbally to postal or using a show card. Furthermore, in secondary care, staff rely on information from GP’s which has been found to be problematic. A national survey of 1,062 members of the Royal New Zealand College of General Practitioners (RNZCGP) found that only 20% of practices collected ethnicity data. A recent study of 12 South Island practices found ethnicity was recorded for only 5% of patients (McLeod et al., 2000). Other problematic areas include the assumption of ethnicity by a provider.

Recommendations

• Further research and exploration of factors is needed in clinical and epidemiological studies of suicidality in South Asian women which might then contribute to prevention and intervention strategies.

• Better collection of ethnicity data (McKenzie, Serfaty, & Crawford, 2003). • Access to information in commonly used languages. • Encouraging cultural competence in health services (clinical, systemic and

organisational). • Staff training and workforce development. • Developing partnerships with ethnic communities and community

organisations. • Involving ethnic communities in the design of services.

Ruth DeSouza Centre Co-ordinator/Senior Research Fellow Centre for Asian and Migrant Health Research Faculty of Health & Environmental Science Auckland University of Technology Address: Private Bag 92006, Auckland 1020

References

Aspinall, P. J. (2003). Who is Asian? A Category that Remains Contrived in Population and Health Research. Journal of Public Health Medicine, 25(2), 91-97.

Batsleer, J., Chantler, K., & Burman, E. (2003). Responses of health and social care staff top South Asian women who attempt suicide and/or self-harm. Journal of Social Work Practice, 17(1), 103-114.

Bhugra, D., & Desai, M. (2002). Attempted suicide in South Asian women. Adv Psychiatr Treat, 8(6), 418-423.

Bhugra, D., & Hicks, M. H.-R. (2004). Effect of an Educational Pamphlet on Help- Seeking Attitudes for Depression Among British South Asian Women. Psychiatric Services, 55(7), 827-829.

British Medical Journal. (1996). Style Matters: Ethnicity, race, and culture: guidelines for research, audit, and publication. British Medical Journal, 312, 1094. Burr, J. (2002). Cultural stereotypes of women from South Asian communities: mental health care professionals’ explanations for patterns of suicide anddepression. Social Science & Medicine, 55(5), 835-845.

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

DeSouza, R., & Garrett, N. (2005). Access Issues for Chinese People in New Zealand(draft). Auckland: Accident Compensation Corporation.

Henare, K., & Ehrhardt, P. (2004). Support for Maori, Pacific and Asian Family,Whanau, and Significant Others who have been bereaved by suicide: Findings of a literature search. Wellington: Ministry of Youth Development.

Hicks, M. H. R., & Bhugra, D. ( 2003). Perceived Causes of Suicide Attempts by U.K. South Asian Women. American Journal of Orthopsychiatry, 73(4), 455-462.

Klajakovic, M. (1993). Is it easy collecting ethnicity data in general practice? NewZealand Medical Journal, 106, 103-104.

Latimer, S. (2003). Waitemata District Health Board: Ethnicity Data Collection Baseline Review. Auckland: Waitemata District Health Board.

McKenzie, K., Serfaty, M., & Crawford, M. (2003). Suicide in ethnic minoritygroups. British Journal of Psychiatry, 183(2), 100-101.

McLeod, D., Harris, R., Bailey, T., Dowell, A., Robson, B., & Reid, P. (2000). The collection of patient ethnicity data: a challenge for general practice. New Zealand Family Physician, 27(3), 51-57.

Ministry of Health. (2001). Monitoring Ethnic Inequalities in Health. Wellington:

Ministry of Health. Ministry of Health. (2003). Health and disability sector ethnicity data protocols. Wellington:

Ministry of Health. Ministry of Health. (2005). Suicide Facts: Provisional 2002 All-Ages Statistics. Wellington: Ministry of Health. Ministry of Health. (nd-a). Environmental scan: Ethnicity data collection issues.Wellington: Ministry of Health.

Ministry of Health. (nd-b). Submission on the review of the measurement of ethnicity. New Zealand Health Information System. (1996). Recording patient information:Ethnicity. Wellington: New Zealand Health Information System.

Pringle, M., & Rothera, I. (1996). Practicality of recording patient ethnicity in general practice: descriptive intervention study and attitude survey. Retrieved 8th February, 2004, from http://bmj.bmjjournals.com/cgi/content/full/312/7038/1080

Senior, P., & Bhopal, R. (1994). Ethnicity as a variable in epidemiological research. British Medical Journal, 309, 327-330.

Statistics New Zealand. (1996). Ethnicity – Standard Classification 1996. Retrieved 8th February, 2003, from http://www.stats.govt.nz/domino/external/web/carsweb.nsf/Classifications/Ethnicity+-+Standard+Classification+1996

Thiru, K., Hassey, A., & Sullivan, F. (2003). Systematic review of scope and quality of electronic patient record data in primary care. BMJ, 326(7398), 1070-1070.

Thomas, D. R. (2000). Assessing Ethnicity in New Zealand Health Research. New Zealand Medical Journal, 114, 12-14.

Thomas, S. B. (2001). The color line: Race matters in the elimination of health disparities. American Journal of Public Health, 91(7), 1046-1049.

 

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Sailing In A New Direction

First published by: Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet) – www.auseinet.com/journal and then republished in Mindnet Issue 11 – Spring 2007

Abstract

Migrants and refugees make up an increasingly significant number of Aotearoa/New Zealand’s population with one in five New Zealanders being born in another country compared with one in eight people in the United States and one in fifteen in Europe. Increasingly efforts are being made to ensure that settlement services are provided and that mental health service delivery is cognisant of their needs. This paper describes some of the efforts being undertaken in Aotearoa/New Zealand and the implications of such efforts; in particular the mental health of Asians, a growing group, is explored. The author suggests that there is a need to learn from Pacific people’s ventures, to broaden the bicultural dialogue and finally to expand the new focus from Asians, refugees and migrants to also include the needs of long term settled communities and international students.

Keywords

multicultural, bicultural, multicultural mental health, mental health policy, Māori, Pacific peoples, Asian people

Simply by sailing in a new direction You could enlarge the world. (Curnow, 1997, p.226)

A sailing metaphor seems apt as the focus of this paper is on the people who have crossed the ocean to reach Aotearoa/New Zealand. Around 1300 AD the ancestors of Māori used the stars and the winds to sail southward from Hawaiiki in their waka (canoes) to Aotearoa/New Zealand. Thousands of years earlier, the world’s first seafarers had set off from South-East Asia, sailing into the Pacific on rafts. Tasman’s arrival in 1642, followed by Cook in 1769 marked the arrival of Europeans. Organised settlement followed the signing of the Treaty of Waitangi in 1840. Pacific migration increased from a trickle after World War II as manufacturing and service industries grew. Asians too had been coming to New Zealand since the 1800s but their numbers were small until after 1987.

Young Chinese men from Guangdong province travelled to the goldfields of Otago in the 1860s (Ip, 2005) and Indian connections with New Zealand began in the late 1800s with Lascars (Indian seamen) and Sepoys (Indian soldiers) arriving after deserting their British East India Company ships (Swarbrick, 2005). The earliest refugees arrived between 1870-1890 and included Danes, Russian Jews and French Huguenots. Subsequently, refugees from Nazism (1933-39), Poland (1944), Hungary (1956-58), ‘handicapped’ refugees (1959), Chinese (1962-71), Russian Christians from China (1965), Asians from Uganda (1972-73), Chileans, Soviet Jews, Eastern Europeans, people from the Middle East, South-East Asia (Indo-Chinese), Somalia, Zimbabwe, Afghanistan, Bosnia, Ethiopia, Eritrea, Iran and the Sudan have resettled in New Zealand. More recently, Asian foreign fee-paying students have impacted on the education system, becoming important to the national economy and more visible in society (International Division & Data Management and Analysis, 2005).

It’s time to enlarge our world

Migrants to New Zealand are caught between two charged agendas: the colonial ideal of a homogeneous society, replicating Britain, and the desire of Māori for recognition as people of the land, or Tangata whenua, with specific rights. New Zealand’s founding document, The Treaty of Waitangi and the social policy principle of biculturalism have become an explicit template for relationships between indigenous Māori and subsequent migrants. The racialising and othering of migrant groups, along with past migration policy designed to keep the country white (Beaglehole, 2005), have implicitly shaped the treatment of migrants.

Changing migration patterns

The 2001 Census found that Europeans/Pākehā (Māori name for white New Zealanders) made up 79.6% of the population, followed by New Zealand Māori with 14.5%, people from the Pacific Islands 5.6%, and Asians 6.6% (adds to more than 100% because ethnicity is self-defined; people could select more than one ethnicity). Of the Asians, the largest groups are Chinese who make up 2.2% and Indians who make up 1.2% of the total New Zealand population (Statistics New Zealand, 2002b). Asians are the fastest growing ethnic group, increasing by around 140% over the last ten years and predicted to increase by 122% by 2021. In comparison, Pākehā will increase by 1%, Māori 28% and Pacific People 58%. This new diversity is in stark contrast to the previous assimilationist post-1945 migration policy which positioned the ideal migrant as ‘invisible’. Linguistic and religious diversity were also a hallmark of the 2001 Census which noted a 20% increase in the number of multilingual people and an increase in the percentage of people whose religion was non-Christian, including Hindu 56%, Buddhist 48% and Islam 74%.

Policy changes: From monocultural to bicultural to multicultural

Canada and Australia embraced multiculturalism during the 1960s, transforming the notion of settlement into a two way process; change was required by both migrants and the host society. New Zealand policy made this strategic move only as recently as 1986. The 1980s were a pivotal period in discussions of New Zealand identity, featuring biculturalism and its incorporation into social policy in New Zealand (Bartley & Spoonley, 2004). Discussions of multiculturalism began with the arrival of Pacific peoples in the 1970s and required Pākehā to cede the monopoly on power and decision making and the allocation of resources (Bartley & Spoonley, 2004). An attempt to address the bicultural/multicultural relationship came about with proposals that biculturalism should take precedence and subsequent arrivals to Aotearoa needed to negotiate a primary relationship with Māori (Bartley & Spoonley, 2004). Multi-culturalism would then be the outcome of a network of completed bicultural negotiations; however, no process was ever suggested for this to occur (Bartley & Spoonley, 2004). The bicultural/multicultural debate remains un-resolved and problematic (DeSouza, 2004a; Mohanram, 1998; Thakur, 1995; Walker, 1995; Wittman, 1998). However, rather that biculturalism being a barrier to multiculturalism, I believe that it has paved the way for the majority culture to consider cultural issues at large. The Immigration Act 1987 eased access into New Zealand from non-traditional source countries and replaced entry criteria based on nationality and culture with criteria initially based on skills. The policy changes led to unprecedented cultural diversity. In particular, Asians became a sizable majority of migrants, increasing from 18.7% of permanent and long term arrivals in 1987 to 48% in 1993 (Bartley & Spoonley, 2004).

A growing Asian population

‘Asian’ is a term that has differing definitions depending on the geographical context in which it is used. In New Zealand ‘Asian’ tends to refer to people from South East Asia and there are debates about whether an umbrella term such as ‘Asian’ is useful or merely an expedient construct that potentially provides benefits but disguises disparities within groups (Rasanathan, Craig & Perkins, 2004; Workshop Organising Team, 2005). In the 2001 Census, 44% of Asians identified with the Chinese ethnic group, 26% with the Indian ethnic group, 8% Korean, 5% Filipino, 4% Japanese, 3% Sri Lankan, 2% Cambodian, 2% Thai, and 8% with other Asian ethnic groups (note that people could give more than one response; therefore, these percentages do not add to 100) (Statistics New Zealand, 2002a). Asians in New Zealand are a relatively young population and are generally in good health. Most live in the Auckland region and over half are aged between 25 and 65 years, around 20% are aged 15 to 24 years and 20% are aged below 14 years (Asian Public Health Project Team, 2003). This age-distribution is similar to Māori and Pacific people, but Asians are younger (on average) than Europeans. The rapid growth of the Asian population has exposed a lack of policy and structures to evaluate and address their needs (Workshop Organising Team, 2005).

Access issues and underutilisation of mental health services

A survey examining health status in a large representative sample of Asian people (Scragg & Maitra, 2005) found that Asians underutilise health services:

  • Asian people were less likely than other New Zealanders, Māori and Pacific people to have visited a health practitioner (or service) when they were first unwell.
  • Asian people were less likely than Europeans to visit a health practitioner about a chronic disease (doctor, specialist, nurse or complementary healer).
  • Asian women were less likely than other New Zealand women to have had a mammogram or cervical screening test in the last three years.
  • Asians were less likely than all New Zealanders to use any type of telephone helpline in the last 12 months.
  • Asians also only wanted to see their general practitioner for a short term illness or a routine check up rather than visiting for an injury, poisoning, or for mental or emotional health reasons.

Another study found that barriers to accessing services for Chinese people included lack of language proficiency of respondents, lack of knowledge about civil rights and problems accessing general practitioners (DeSouza & Garrett, 2005).

This underutilisation is further reflected in mental health statistics. Of the 87,576 mental health clients seen by District Health Boards in 2002, only 1.9% were Asian despite making up over 6.5% of the population (New Zealand Health Information Service, 2005). This could in part be due to the bias of New Zealand’s migration policy which selects young and healthy migrants but it is clear that Asians underutilise mental health services and this does not necessarily mean that they are keeping well (Ho, Au, Bedford & Cooper, 2002). A study among recent Chinese migrants using the General Health Questionnaire found that 19% reported psychiatric morbidity (Abbott, Wong, Williams et al., 1999). A study of older Chinese migrants aged over 55 found that 26% showed depressive symptoms (Abbott, Wong, Giles et al., 2003). Lower emotional supports, greater number of visits to a doctor, difficulties in accessing health services and low understanding and engagement with New Zealand society increased the risk of developing depression. Interestingly, while participants with depressive symptoms consulted general practitioners more than their counterparts without such symptoms, they reported greater difficulty in accessing health services. Research with Asian migrants, refugees and student sojourners in New Zealand shows that social supports can assist newcomers to cope with the stresses of migration and reduce the risk of emotional disorder (Abbott et al., 1999). Conversely, research shows that language and cultural barriers can limit access to health services (Abbott et al., 1999; DeSouza & Garrett, 2005; Ngai, Latimer & Cheung, 2001).

Need for workforce development

The cultural competence of mental health staff for working with Asian consumers has not been researched. However, a recent project investigating the intercultural experiences of social workers in New Zealand found that contact with migrants, refugees or asylum seekers was infrequent, especially outside of Auckland (Nash & Trlin, 2004), but that the majority of social workers felt competent or better than competent in terms of working interculturally. Respondents recommended that further training in cross-cultural social work, staff training and better support services be available, in tandem with improvements in community services and the education of the host community to see new settlers as valuable additions to society. In another study, psychiatrists were surveyed by Johnstone and Read (2000), who found that out of 247 psychiatrists surveyed, only 40% believed that their training had prepared them to work effectively with Māori. Some of the suggested recommendations for improving how they worked with Māori included needing to understand Māori perspectives of well-being, and increasing the number of Māori professionals and Māori run services. Of psychiatrists who responded to the survey, 70% believed that there was a need to consult with Māori when working with Māori. A training package is being developed by University of Auckland, funded by the Health Research Council, to develop cultural competence in mental health staff working with Asians. Further development in this area is signalled in the next mental health action plan discussed later in this paper.

Omission in health research

Asian ethnic groups have been largely neglected by New Zealand health policies and research, despite their population growth (Duncan, Schofield, Duncan et al., 2004). Duncan et al. cite the example of the 2002 National Children’s Nutrition Survey, where both over-sampling and separate analysis of Māori and Pacific Island children occurred while Asian children were subsumed with New Zealand Europeans. Large-scale studies are needed to determine health risk across all major ethnic groups in New Zealand, which will in turn enable development of ethnic-specific data. Even more critical is the need for data concerning ethnic variation in other areas of health so that effective interventions can be developed and implemented (Duncan et al., 2004). This omission and exclusion is by no means a rare occurrence in national surveys and prevents the development of an understanding of the public health needs of Asian communities in New Zealand, necessary for the development of appropriate preventative health strategies.

Settlement issues

A report commissioned by the New Zealand Immigration service found that migrants had four areas of need: everyday needs, learning English, employment, and supportive connections (Ho, Cheung, Bedford & Leung, 2000). Factors such as unemployment or underemployment, having experienced discrimination in New Zealand, not having close friends, being unemployed and spending most of one’s time with one’s own ethnic group were predictors for poor adjustment among migrant groups (Pernice, Trlin, Henderson & North, 2000). In the last few years, a range of settlement programmes have been funded nationally with the development of an Immigration Settlement Strategy (New Zealand Immigration Service, 2003) for migrants, refugees and their families. The strategy’s six goals provide a broad base for enhancing wellbeing and include appropriate employment; confidence with using English or accessing appropriate language support; accessing appropriate information and responsive services; supportive social networks and sustainable community identity; expressing ethnic identity and acceptance and inclusion of the wider host community; and participation in activities.

Visible but invisible groups

The arrival of primarily Asian fee-paying students has had an impact on the education system, a greater importance to the national economy in terms of providing increased funding to educational institutions, and higher visibility in society in that most of the international students have come from China (International Division & Data Management and Analysis, 2005). Asian enrolment numbers rose by 318% over a five year period (1999-2003) to nearly 119,000, with an estimated economic value NZ$2.2 billion New Zealand dollars and providing 40,101 jobs (Infometrics, 2006). These numbers declined in the 2003-2004 period, leading to concern about the rapid development of the sector and raising the need for better quality assurance systems, which are now implemented through the Code of Practice for the Pastoral Care of Foreign Fee-Paying Students (Section 238H of the Education Act 1989). Levies paid by institutions with international students are used to support activities and projects relating to the export education industry such as promotion, communications, capability development, quality assurance, research and the administration of the Code (Ministry of Education, 2003). However, other than being able to use counselling services within their institutions, most international students are not entitled to access publicly funded (mental) health services while in New Zealand and are liable for the full costs of treatment unless they are sectioned under the Mental Health Act, and then only for the duration of that process. Once they are no longer under the Act, they are charged. Remaining voluntarily on an acute unit can incur a charge of approximately NZ$900 a day. International students are required to have appropriate and current medical and travel insurance while studying in New Zealand as a condition of enrolment (including mental health as long as it is not a pre-existing condition); however, insurance cover is capped at NZ$2,000 so if students need access to in-patient services they must cover their own costs.

The needs of long term settled communities have been brought into focus with the launch of the Asian Health Chart Book (Ministry of Health, 2006a) which demonstrates the need to focus not only on new migrants but also on longer-term settled migrant Asian communities. Major differences in health and health service use between recent migrants and longstanding migrants show that recent or first generation migrants have better health status than longstanding migrants or the New Zealand born, demonstrating the acculturative effects of the dominant culture.

Mental health services: Sailing in a new direction

Mental health services are responding to new migrant populations to varying degrees. Following on from a report on the mental health of Asians in New Zealand (Ho et al., 2002) has been an increased responsiveness to the needs of those communities (Yee, 2003). Research activity, information provision, collaboration and Asian-focused operational activities and policy are some of the strategies that are being used by government agencies (Yee, 2003). Other developments that will assist in meeting this gap include the New Zealand Mental Health Classification and Outcomes study (Gaines, Bower, Buckingham et al., 2003), which includes a small number of Asians, and a planned mental health epidemiological survey which will also assist but is currently limited to the two largest Asian communities, Indian and Chinese. This section briefly reviews national, regional and local developments and initiatives.

Developing visibility and responsiveness in mental health services

Asian researchers (Lim & Walker, 2006; Tse, Bhui, Thapliyal et al., 2005) have outlined the legislative and policy frameworks that support culturally sensitive mental health service provision. These include The Health and Disability Commissioner Act 1995 and the Health and Disability Code of Rights 1996 which require that services acknowledge the needs of people from a range of cultures and provide for these needs while also protecting culturally diverse people from coercion, discrimination and exploitation. A culturally sensitive approach and acknowledgement of the person’s cultural and ethnic identity, language, and religious or ethical beliefs is also advocated in the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the 1999 amendments. In addition, one of the objectives of the New Zealand Public Health and Disability Act 2000 is that health outcomes be improved for Māori and other population groups through the reduction of health disparities. The Human Rights Act 1993 requires that mental health and addiction services do not unlawfully discriminate on the grounds of culture and ethnicity. Lastly, the Health Professional Competency Assurance Act 2003 requires practitioners to demonstrate cultural competence.

National mental health strategy and recovery

Te Tāhuhu – Improving Mental Health 2005-2015: The Second New Zealand Mental Health and Addiction Plan (Ministry of Health, 2005b) builds on the current Mental Health Strategy contained in

* Looking Forward: Strategic Directions for the Mental Health Services (Ministry of Health, 1994); * Moving Forward: The National Mental Health Plan for More and Better Services (Ministry of Health, 1997); and * The Mental Health Commission’s Blueprint for Mental Health Services in New Zealand: How Things Need to Be (Mental Health Commission, 1998).

Te Tāhuhu acknowledges that ‘there is no national strategy or policy to address the mental health issues of the full range of ethnic groups living in New Zealand. Building stronger relationships with people from diverse cultures and ethnic groups will be essential as we work towards developing strategies to address their particular needs’ (Ministry of Health, 2005b, p.37). Te Tāhuhu focuses on developing a comprehensive integrated mental health and addiction system that provides hope for developing a multicultural mental health agenda, compared to the other documents that make specific cultural mention of Māori and Pacific peoples but minimal reference to other groups. Te Tāhuhu emphasises early access to effective primary health care (a key entry point to mental health services for Asians), and an improved range and quality of specialist community based mental health and addiction services built on collaborative relationships (Ministry of Health, 2005b). It covers the spectrum of interventions from promotion/prevention to primary care to specialist services, and in particular the draft action plan (Ministry of Health, 2006b)

* acknowledges the presence not only of Asian peoples but also migrants and refugees, and the need for mental health services to be able to respond to the unique needs of all New Zealanders; * acknowledges the need for responsiveness to Asian peoples and other ethnic communities and refugee and migrant communities; * aims to build a quality mental health and addiction workforce that supports recovery, is person centered, and is culturally capable to deliver services for Asian peoples (that will require new skills and areas of specialised knowledge); * aims to strengthen the cultural capability of workers in mainstream services to work effectively with Asian, refugee and migrant populations through training programmes; * aims to increase the understanding of the mental health and addiction needs of Asian, ethnic, refugee and migrant communities through developing a profile of their mental health, and developing a mental health and addiction research agenda; * aims to implement national and local training for the mental health services workforce to work more effectively with them and use research evidence in service planning and delivery; and * aims to develop culturally responsive problem gambling intervention services for Asian peoples.

In addition, The Mental Health Commission’s Recovery Competencies for Mental Health Workers (O’Hagan, 2001) requires that a competent mental health worker acknowledges the different cultures of Aotearoa/New Zealand and knows how to provide a service in partnership with them. It suggests that every mental health and addiction service worker should demonstrate:

  • knowledge of diversity within Asian cultures;
  • knowledge of Asian culture, for example importance of family, religious traditions, duty, respect for authority, honour, shame and harmony;
  • the ability to articulate Asian views on health;
  • knowledge of traditional Asian treatments;
  • and the ability to involve Asian families, communities and service users in services.

In response to a report on Asian Public Health (Asian Public Health Project Team, 2003) the Mental Health Foundation have also created information sheets written in Chinese as a step towards meeting the mental health needs of Asians. They focus in particular on the mental health needs of Chinese adults and older Korean people. The emphasis on Chinese recognises that they comprise the largest of all Asian ethnic groups and the high number of Chinese international students in New Zealand, particularly in Auckland.

The potential of broader health policy

Developments in population based health policy offer promise in addressing barriers to accessing services by Asian communities. The New Zealand Health Strategy (NZHS) guides the development and provision of new services in the health and disability sector to improve the health of New Zealanders (Ministry of Health, 2000). Administered through District Health Boards (DHBs), the strategy aims to reduce inequalities in health status for Māori, Pacific peoples and people from lower socio-economic groups. It claims to focus on quality of service in order to ensure health outcomes are improved and health disparities reduced. There is scant reference to migrant health in the NZHS, other than a recommendation ‘to assess the health needs of refugees, asylum seekers and Asian immigrants’ (Ministry of Health, 2000, p.47) without any attempt to explain how this might be achieved.

A key strand of the NZHS involves improving responsiveness in the field of primary care. Primary Health Organisations (PHOs) have been established as ‘community-led’ organisations that guide the development of local services and their role defined in the Primary Health Care Strategy (Ministry of Health, 2001). The governance model is intended to involve local people in the planning and delivery of local primary health care services. This promotes the role of health workers as being to reduce health inequalities and address the causes of poor health status. Whilst accessibility, affordability and co-ordination are key, there is no mention of Asian and migrant populations in the strategy, which aligns with the NZHS focus on Māori, Pacific populations and lower socio-economic groups. The needs of Asian communities in New Zealand will need to be proactively considered given their projected population growth and evidence of different health needs to the wider population. Findings from the Asian Health Chart Book (Ministry of Health, 2006a) show that Asian people had positive health outcomes on a range of health indicators compared to the total New Zealand population. Of concern, however, was the lower usage of health services by the Asian population. The report provides a useful baseline on Asian health and it is hoped that it helps in identifying the health needs of Asian peoples in New Zealand and that it will be a tool for Asian communities themselves to advocate for appropriate health services.

Regional developments

The Northern Region Mental Health and Addictions Strategic Direction 2005-2010 (Northern DHB Support Agency & Network North Coalition, 2004) has two foci for its vision. The first is a specific focus on ‘equal opportunity to access quality services delivered in a culturally appropriate manner for refugee and recent Asian migrant clients and families’ and the second is ‘access to professionally trained and qualified interpreting services to meet the needs of migrant and refugees with experience of mental illness and their families’ (p.22). Recently a project was developed for training Asian interpreters and mental health practitioners who provide secondary mental health services for the diverse Asian immigrant population in the Auckland region, focussing on cultural competency and appropriate skills to work together effectively (Lim & Walker, 2006).

Local developments

At a local level, the twenty-one District Health Boards (DHBs) are responsible for deciding on the mix, level and quality of health and disability services to be provided for populations within government-set parameters. Some specialised mental health services, for example the ‘Refugees as Survivors’ (RAS) centres have been established, while others have developed ‘transcultural’ teams with clinicians who have an interest in the area or Asian mental health workers. Asian peer support workers are employed by consumer run organisations such as Mind and Body consultants to support Asian users of Auckland District Health Board Mental Health Services. There are also two Chinese consumers’ self-help groups: Bo Ai She and Yu Ai She. Community Alcohol and Drug services have two Chinese counsellors and non-governmental organisations (NGO) have begun responding to the needs of Asians by employing Chinese staff in community and family support roles such as Action for Mental Health Services, Supporting Families and Affinity. In the Auckland DHB there are two Asian community support workers with a focus on psychiatric rehabilitation. A great many of the developments have been in response to advocacy from ethnic community members and a desire to increase responsiveness to presenting clients.

Learning from the experience of Pacific peoples

There is much that newer migrant groups and mainstream services can learn from the experience of Pacific peoples, who are a diverse group representing over 20 different cultures. The largest group are Samoan making up 50% of Pacific peoples, followed by Cook Islanders (23%), Tongans (16%), Niueans (9%) Fijians (4%) and Tokelauans (2%) (self-identified; more than one response possible) (Mental Health Commission, 2001). A youthful population concentrated in the Auckland region with smaller numbers scattered throughout the country (Ministry of Health, 2005a), Pacific peoples make up 6% of the New Zealand population, which will rise to 12% by the year 2051. Pacific migration to New Zealand after the second world war increased as a result of growing industrialisation and demands for a manufacturing and service industry workforce (Spoonley, 2001). Large numbers of Pacific people migrated to urban areas of New Zealand, accelerating in the 1960s and early 1970s (Spoonley, 2001). The mid-1970s economic downturn led to many Pacific people losing their jobs. Unemployment, low income, poor housing, the breakdown of extended family networks, cultural fragmentation, and rising alcohol and drug problems have had a significant impact on the mental health of Pacific peoples, with rates of mental illness being generally higher among Pacific males and Pacific older people than the rest of the population (Ministry of Health, 2005a). However, Pacific peoples are a little less likely to use mental health services than any other group in New Zealand (Ministry of Health, 2005a).

Innovative health models such as the ‘Fonofale’ created by Fuimaono Karl Pulotu-Endemann (Crawley, Pulotu-Endemann, Stanley-Findlay & New Zealand Ministry of Health, 1995) have promoted holism and continuity. Similar to Durie’s (1994) Te Whare Tapa Wha, the Fonofale model uses the metaphor of a Pacific Island house and incorporates the values and beliefs of various Pacific Island groups. In addition, two key mechanisms have been advanced to improve social and economic outcomes for Pacific peoples. These are to improve ‘the responsiveness and accountability of public sector agencies to Pacific health needs and priorities, and to build the capacity of Pacific peoples, through provider, workforce and professional development, to deliver health and disability services and to develop their own solutions to health issues’ (Mental Health Commission, 2001, p.15). The key agencies in this task are The Ministry of Pacific Island Affairs, the Ministry of Health, District Health Boards and the Mental Health Commission. Other strategies are that services for Pacific peoples should: include Pacific views of mental health and wellbeing (which also includes all other aspects of health); take into account the relatively young Pacific population; acknowledge that there are isolated communities throughout New Zealand; consider the socioeconomic status of Pacific peoples; consider the diverse needs of New Zealand-born versus Island-born people and people of mixed ethnicity; and include the issue of alcohol and other drug use. In parallel, mainstream providers need to incorporate practices that properly address the above issues which will require building networks with Pacific organisations and groups able to advise on culturally acceptable methods of treatment (Mental Health Commission, 2001).

Conclusion: Exploring uncharted waters

Parts of the journey ahead are charted clearly. There are legislative and policy imperatives in place for mental health services to ensure that they are responsive in both policy and practice for ‘migrants, refugees and Asians’. How this is operationalised varies around the country but developments are promising, particularly in Auckland where the population of Asians is 12%. However, there are murky waters ahead that must be navigated. Further discussion is needed about the terms ‘migrants, refugees and Asians’ which are referred to in Te Tāhuhu and are an attempt at inclusion. The diversity contained within labels will have to be disentangled, so that the needs of the diverse people within labels such as ‘migrants, refugees and Asians’ are identified. Consideration must also be given to the needs of long term settled ethnic communities and international students, both of whom are neglected. Diving even deeper, the intersection of ethnicity, religion and socioeconomic status needs exploration. Consideration also needs to be given to how we work with the ‘buzz words’ such as cultural safety, cultural capability, cultural awareness and cultural competence and how they sit together (DeSouza, 2004b, 2006; Wood, Bradley & DeSouza, 2004).

Finally, a more strategic response to New Zealand’s changing demographics is required as until now the majority of developments have been ad hoc, reactive and operational, based on lobbying from ethnic community groups and non-governmental organisations such that responses are geared to our current situation rather than our future. It is necessary to address the place of the Treaty of Waitangi in the context of how multiculturalism is to be accommodated. Some see biculturalism as an obstacle to the acknowledgement of a more diverse society; however, I suggest that multiculturalism through biculturalism remains a possible solution that has been under-explored and under-operationalised. Future developments in Asian, migrant and refugee health need to heed the unique status of Māori and learn from the experiences of Pacific peoples, who have charted these waters already and know the currents and prevailing winds.

References

Abbott, M.W., Wong, S., Williams, M., Au, M.K. & Young, W. (1999). Chinese migrants’ mental health and adjustment to life in New Zealand. Australian and New Zealand Journal of Psychiatry, 33(1), 13-21.

Abbott, M.W., Wong, S., Giles, L.C. Wong, S., Young, W. & Au, M. (2003). Depression in older Chinese migrants to Auckland. Australian and New Zealand Journal of Psychiatry, 37(4), 445-51.

Asian Public Health Project Team (2003). Asian Public Health Project Report. Auckland: Ministry of Health Public Health Directorate.

Bartley, A. & Spoonley, P. (2004). Constructing a workable multiculturalism in a bicultural society. In M. Belgrave, M. Kawharu & D.V. Williams (Eds.), Waitangi Revisited: Perspectives on the Treaty of Waitangi (2nd edition, pp. 136-148). Auckland, N.Z.: Oxford University Press.

Beaglehole, A. (2005, 11 July 2005). Immigration Regulation. Retrieved 8 October 2005, from http://www.teara.govt.nz/NewZealanders/NewZealandPeoples/ImmigrationRegulation/en

Crawley, L., Pulotu-Endemann, F.K., Stanley-Findlay, R.T.U. & New Zealand Ministry of Health. (1995). Strategic Directions for the Mental Health Services for Pacific Islands People. Wellington, N.Z.: Ministry of Health.

Curnow, A. (1997). Early Days Yet: New and Collected Poems 1941 – 1997. Auckland: AUP.

DeSouza, R. (2004a). The art of walking upright here: Realising a multi-cultural society. Paper presented at the Kiwi Indian Seminar Series, Stout Research Centre, Victoria University of Wellington, New Zealand..

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

DeSouza, R. (2006). Pregnant with possibility: Migrant motherhood in New Zealand. MindNet, http://www.mindnet.org.nz/synopsis.php?issueno=6&articleno=100

DeSouza, R. & Garrett, N. (2005). Access Issues for Chinese People in New Zealand. Auckland: Auckland University of Technology and Accident Compensation Corporation.

Duncan, E., Schofield, G., Duncan, S., Kolt, G. & Rush, E. (2004). Ethnicity and body fatness in New Zealanders. New Zealand Medical Journal, 117(1195), U913.

Durie, M. (1994). Whaiora: Maori Health Development. Auckland: Oxford University Press.

Gaines, P., Bower, A., Buckingham, B., Eagar, K., Burgess, P. & Green, J. (2003). New Zealand Mental Health Classification and Outcomes Study: Final report. Auckland: Health Research Council of New Zealand.

Ho, E., Au, S., Bedford, C. & Cooper, J. (2002). Mental Health Issues for Asians in New Zealand: A Literature Review (Commissioned by the Mental Health Commission). Waikato: University of Waikato.

Ho, E., Cheung, E., Bedford, C. & Leung, P. (2000). Settlement Assistance Needs of Recent Migrants (Commissioned by the NZIS). Waikato: University of Waikato.

Infometrics (2006). The Economic Impact of Foreign Fee-Paying Students. Wellington: Ministry of Education.

International Division & Data Management and Analysis (2005). The New Zealand International Education Sector: Trends from 1999 to 2004. Wellington: Ministry of Education,. Ip, M. (2005). Chinese. Retrieved 3 June 2006, from http://www.TeAra.govt.nz/NewZealanders/NewZealandPeoples/Chinese/en

Johnstone, K. & Read, J. (2000). Psychiatrists’ recommendations for improving bicultural training and Maori mental health services: A New Zealand survey. Australian and New Zealand Journal of Psychiatry, 34(1), 135-145.

Lim, S. & Walker, R. (2006). Asian Mental Health Interpreter Workforce Development Project: Report on Curricula & Guidelines Development for Asian Interpreters and Mental Health Practitioners to Work Effectively Together. Auckland: Northern DHB Support Agency.

Mental Health Commission (1998). Blueprint for Mental Health Services in New Zealand: How Things Need to Be. Wellington: Mental Health Commission.

Mental Health Commission (2001). Pacific Mental Health Services and Workforce: Moving on the Blueprint. Wellington: Mental Health Commission.

Ministry of Education (2003). Code of Practice for the Pastoral Care of International Students. Retrieved 19 April 2005, from http://www.minedu.govt.nz/index.cfm?layout=document&documentid=6902&indexid=6666&indexparentid=6663

Ministry of Health (1994). Looking Forward – Strategic Directions for the Mental Health Services. Wellington: Ministry of Health.

Ministry of Health (1997). Moving Forward: The National Mental Health Plan for More and Better Services. Wellington: Ministry of Health.

Ministry of Health (2000). The New Zealand Health Strategy. Wellington: Ministry of Health.

Ministry of Health (2001). The Primary Health Care Strategy. Wellington: Ministry of Health.

Ministry of Health (2005a). Te Orau Ora – Pacific Mental Health Profile, Wellington: Ministry of Health.

Ministry of Health (2005b). Te Tāhuhu: Improving Mental Health 2005-2015: The Second New Zealand Mental Health and Addiction Plan. Wellington: Ministry of Health.

Ministry of Health (2006a). Asian Health Chart Book 2006. Wellington: Ministry of Health.

Ministry of Health (2006b). Draft Action Plan Te Tāhuhu – Improving Mental Health 2005-2015: The Second New Zealand Mental Health and Addiction Plan. Wellington: Ministry Of Health.

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: Connections and Differences (pp. 21-29). Auckland: Oxford University Press.

Nash, M. & Trlin, A. (2004). Social Work with Immigrants, Refugees and Asylum Seekers in New Zealand. Palmerston North: New Settlers Programme, Massey University.

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New Zealand Health Information Service (2005). Mental Health: Service Use in New Zealand 2002. Wellington: Ministry of Health.

Ngai, M.M.Y., Latimer, S. & Cheung, V.Y.M. (2001). Healthcare Needs of Asian People: Surveys of Asian People and Health Professionals in the North and West Auckland. Takapuna: Asian Health Support Service, Waitemata District Health Board.

Northern DHB Support Agency & Network North Coalition (2004). Northern Region Mental Health and Addictions Strategic Direction 2005-2010. Auckland: Northern DHB Support Agency.

O’Hagan, M. (2001). Recovery Competencies for New Zealand Mental Health Workers. Wellington: Mental Health Commission.

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.

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Citation: DeSouza, R. (2006). Sailing in a new direction: Multicultural mental health in New Zealand. Australian e-Journal for the Advancement of Mental Health 5(2) www.auseinet.com/journal/vol5iss2/desouza.pdf

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How is your Central Helping System?

First published in Mindnet Issue 11 – Spring 2007
Recently I’ve come through a series of life changing stresses and learned what true love; friendship and personal strength were about. In particular the words of wise Rabbi Hillel, a Jewish scholar & theologian who lived from 30 BC – 9 AD have been a source of inspiration for a previously uncharted journey: “If I am not for myself, who will be for me? If I am not for others, what am I? And if not now, when?” Dan Baker and Cathy Greenberg suggest using these questions to prompt you on a daily basis. Despite being written so long ago, these words have stood the test of time and got me thinking about how we can maintain good mental health amidst transition and change. Two transitions that have occupied a great deal of my energy and interest have been the transition to parenthood and the transition to living in a new country.

If I am not for myself, who will be for me?

Starting with question one, If I am not for myself, who will be for me? Baker argues that we have to take good care of ourselves and begin by having a good relationship with ourselves and being our own best friend. There are some things that only we can do for ourselves and some things that we can delegate. They recommend asking yourself further questions every day: such as what I have done to take care of my body, mind and spirit today? Both new parents and new migrants experience the loss of otherwise familiar reference points. New mothers face the demands of an unpredictable gamut of demands for a baby whose needs are all-consuming and leave little time or energy for focusing on oneself. For a migrant, the loss of a “village” and familiar things, places and processes often leads to a quest for belonging and clarification of values and purpose. Both transitions offer the potential of transformation provided resources and support are in place, but accessing them can often be difficult.

If I am not for others, what am I?

Question two leads us from taking care of ourselves to taking care of others. If I am not for others, what am I? Research evidence is growing that social support is critical to successful coping through enhancing resilience, buffering the impact of stress and assisting in the maintenance of positive mental health. Social support encompasses four key attributes emotional (e.g. providing empathy, caring, love, and trust), instrumental (e.g. aid in kind, money, labour, time, and modifying environment), informational (e.g. advice, suggestions, directives, and information) and appraisal (e.g. affirmation, feedback (Toljamo & Hentinen, 2001) and results in improved mental health (Finfgeld-Connett, 2005 ). Often support starts with one’s immediate family and then to friendships termed ‘central helping system’ by (Canavan & Dolan 2000 cited in (Pinkerton & Dolan, 2007)) and often it is only when this support is exhausted, weak or unavailable that people approach more formal sources of support.

In terms of my two professional interests, I have found that when people migrate they frequently lose their support networks and when people welcome a new baby into their family they frequently have to develop alternative support networks. Social support is characterised by reciprocity and mutuality and involves the exchange of resources between people that enhance the well-being of both. When we are supported and become part of a network of communication and mutual obligation we can begin to believe that we are cared for, loved and valued (Hupcey, 1998).

If not now, then when?

Question three asks us “if not now, then when?” This is where a focus on the present moment becomes highlighted. For so many of us the focus is on the future. For the new migrant it can be about “when I get the job that recognises my qualifications and worth then I can start enjoying my life in this new country”. For a new parent it might be “when I can sleep through the night I’ll start enjoying being a parent”. How can we feel good in ourselves, when things feel out of control, unresolved and unresolvable? Mindfulness, a Buddhist concept based on becoming aware of the moment and living fully in it regardless of how pleasant or unpleasant it is can lead to transforming that reality and your relationship to it (Kabat-Zinn, 1993). Ultimately there is very little we can do about what has already happened or determine the future, but the likelihood of a wonderful future is enhanced by thoroughly enjoying the present.

Mental health awareness week

Which leads me to the theme of this year’s mental health awareness week, good mental wellbeing can come from:

  • Celebrating our uniqueness
  • Connecting with each other
  • Supporting others in their journey
  • Sharing our stories

So how can we celebrate our uniqueness when there is little to support our identity? How can we connect with each other, when we are isolated? How can we supporting others in their journey, when we ourselves are un-resourced? How can we share our stories if there is no one to listen?

Key points to consider for mental health and health promotion workers and organisations.

There is a need for mental health service providers to both safeguard quality care and ensure continual improvement of the quality of their services by creating an environment where they, their colleagues, their clients and family members can flourish. One of my own favourite strategies is supervision which helps me both with my self-care, self-development and ensuring I get the support that I need. It also helps me develop and increase my knowledge, understanding and skills. Again I’d like to reiterate Rabbi Hillel’s first question. How can we truly care for others if we don’t care for ourselves? Self-care is so under-rated, but if you are a mental health worker ask yourself: How do we I look after myself and cultivate my own wellness? And how can I practice what I preach?

In terms of your own support network. How can you avoid working in isolation? How can you get the support that you need? If you aren’t thinking about this it can be difficult to consider the needs of people and groups that require support to remain socially included. How do you encourage clients/tangata whai ora to use and enhance their own personal support networks? In reflecting on Hillel’s third question, consider how can you be fully present with your mahi. How can you be so fully engaged in your work that it provides a well of energy that is renewable and deeply satisfying so that you don’t get burned out. How can you ensure that your work and efforts are sustainable? For me it goes back to attending to myself regularly, meeting my own needs, considering my own health and well being.

My central helping system undergoes continuous refinement but what I have realised is that it requires me to first have a relationship with myself. Only then can I have an effective relationship with anyone else. Then ensuring that I have a support network in which reciprocity reigns and lastly being fully present with myself (not always easy). Rabbi Hillel’s questions provide a useful starting point for considering our own mental health and of those who are part of our lives personal and professional. Attending to these three questions provides us with accessible resources for mental well being.

REFERENCES

Finfgeld-Connett, D. (2005 ). Clarification of social support. Journal of Nursing Scholarship 37(1 4).

Hupcey, J. E. (1998). Clarifying the social support theory-research linkage. Journal of Advanced Nursing 27(6), 1231.

Kabat-Zinn, J. (1993). Mindfulness meditation: Health benefits of an ancient Buddhist practice. In D. Goleman & J. Gurin (Eds.), Mind, body medicine : how to use your mind for better health (pp. 259–276). Yonkers, N.Y.: Consumer Reports Books.

Pinkerton, J., & Dolan, P. (2007). Family support, social capital, resilience and adolescent coping. Child & Family Social Work, 12(3), 219.

Toljamo, M., & Hentinen, M. (2001). Adherence to self-care and social support. Journal of Clinical Nursing 10(5), 618.

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The ultimate engagement of life: Being mentally healthy

Published in (2007) Asian Magazine, 4.

I came across a wonderful definition of health by Jesse Williams in 1928 the other day in a book that I was reading. Williams defines health as being “the optimal condition of being that allows for the ultimate engagement of life.” To me this is what being healthy is about, being in the best condition to fully take part in life. I have had a long passion in the issue of migration and settlement and in particular the impact on health and specifically mental health. We know that migration is a risky business that also has the potential to transform, so how can we maintain our mental health and go beyond maintenance to optimal health and engaging fully with life? What are the factors that help or hinder being ultimately engaged with life and what can we do about them? In this article I’d like to share my professional, personal and research findings with you from work I did with Goan women living in Auckland some years ago [1].

Migration offers the potential of a new and better life, otherwise why would anyone migrate for a worse life? Yet sometimes this is what unexpectedly happens. We are so focussed on the wonderful future and the leaving, but not so much on the arrival. Without our usual “soft places to fall” as Dr Phil terms it, our support networks, our fulfilling work, migrants can end up with migrant’s remorse!

It was the first time we had been on our own before, in Bombay you’ve always got family to help you and you’ve got everything ready made, so you never know what hardship is until you come here (Flora).

When there is a big gap between our hopes and expectations and the reality the disillusionment can be too much to bear. When the job that is going to be the foundation of the new life doesn’t materialise and the income doesn’t match the sacrifices, it can seem like things are going down hill fast. There is a cumulative impact of all these disappointments that can result in feeling overwhelmed and worn out. So when do ups and downs become something you should pay attention to? In my experience, it is best to ask for help from those around you when you feel like you are not coping and managing as well as you would like to be or know that you usually can. Help-seeking is something that many of us find difficult to do. Whether it is pride or the shame of admitting we cannot manage on our own. What I know for sure though is that when we have exhausted our own resources we should ask for help because things don’t tend to get better by themselves and sometimes they get worse when we do nothing. So start by talking to people that you trust, family or friends and keep talking and asking until you get what you need. If you have a faith community tap into its resources. Talk to your General Practitioner and ask for referral to a counsellor or mental health service. I remember talking to a man with a gambling problem that had become depressed, he said “what is the point of going to talk about my problems, I need financial help!” The answer is that there are a range of things that have contributed to how you feel and equally there are a range of things that will help, from going for a walk to talking to someone to getting budgetary advice. There is not going to be just one magical solution.

So what if you are reading this and thinking, I am fine, I just get down sometimes. Here are four strategies that Goan women used to help them maintain their mental health.

Developing a new support network New Zealand researchers [2] have found that support is one of four important factors for successful settlement. Support makes coping with daily living, acquiring language and employment (the three other factors) easier to acquire. Support also helps you manage stress by reducing how big you see the stress and helping to reduce the severity of your reaction to it [3]. Participants in my research study found that having contact with family, friends and other migrants was crucial and that by volunteering, joining their faith community and having access to support through e-mail the stresses of migration and settlement were minimised. It is important to make sure that you connect with people outside your faith or ethnic group too.

Having a “can do” attitude The term ‘pioneer spirit’ is often used to refer to migrants. The attitude of coping with things in the present because they will get better in the future if you make it work is part of the migrant dream. T some degree pragmatism and philosophical acceptance are necessary for survival and essential:

You just couldn’t pick a flight and go, you’ve resigned your job, you’ve spent half your savings to come here and you know there’s no turning back so you have to make the most of this. So it’s like there’s no turning back, but you think, ‘God what have I done’ (Flora).

As Arisaka says [4] “This almost non-negotiable drive for upward mobility requires diligent assimilation. Self-pity, victim consciousness, and separationist self-consciousness are deadly to the process towards success. Not only are they excessively self-indulgent, but they are also a waste of time and energy, and therefore not allowed”. I think that this can also be a trap and that again it is important to ask for help when you need it. You don’t get extra points at the end of your life for having done it the hard way!

Learning There are two ways of learning that assist with settlement one is the  ‘culture learning approach’ where you adapt  by overcoming every day cross-cultural problems by learning new culture specific skills that assist you to navigate the new cultural environment [5]and the other is by inoculation or anticipatory preparation [6, 7] which helps the transition experience , where a previous visit or some similar kind of preparation where you gain culturally specific knowledge and skills prior to migration can be a great help.

Lastly, maintaining cultural links was used to make sense of the migration and settlement experience and maintaining wellbeing. The loss and separation that can occur with migration can be lessened to some degree by holding on to familiar and trusted values and keeping ties [8]. Keeping a connection with ‘the familiar’ helps lessen the dislocation and challenges that resulted from being in ‘the unfamiliar”. This can be done by attending community events or even going back to the place of origin, for the benefit of children as well:

It’s important not to get carried away by the western thing, to keep taking them back to their roots if you can afford it because I think that priority has really made the difference for us (Sheila).

There are many ways to manage a new life in a new country. Each one of us has to find a combination of ways that are going to work for us. I hope this has give you some ideas about how you can not only survive the transition to life in a new country but thrive as well so that you can be in optimal condition to enjoy your new life fully.

References

  1. DeSouza, R., Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. 2006, Auckland, NZ: Muddy Creek Press.
  2. Ho, E., et al., Settlement assistance needs of recent migrants. 2000, University of Waikato: Waikato.
  3. Kearns, R.A., et al., Social support and psychological distress before and after childbirth. Health and Social Care in the Community, 1997. 5(5): p. 296-308.
  4. Arisaka, Y., Asian women: Invisibility, locations, and claims to philosophy, in Women of color and philosophy: A critical reader, N. Zack, Editor. 2000, Blackwell Publishers: Malden, Mas. p. 219-223.
  5. Ward, C., S. Bochner, and A. Furnham, The psychology of culture shock. Second edition ed. 2001, Hove, East Sussex: Routledge.
  6. Meleis, A.I., et al., Experiencing transitions: an emerging middle-range theory. Advances in Nursing Science, 2000. 23(1): p. 12-28.
  7. Weaver, G., Understanding and coping with cross-cultural adjustment stress, in Culture, communication and conflict: readings in intercultural relations, G. Weaver, Editor. 1994, Gin Press: USA. p. 169-191.
  8. Vasta, E., Gender, class and ethnic relations: the domestic and work experiences of Italian migrant women in Australia, in Intersexions; gender, class, culture, ethnicity, G. Bottomley, M.D. Lepervanche, and J. Martin, Editors. 1991, Allen and Unwin: Sydney.
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Pregnant with possibility: Migrant motherhood in New Zealand

First published in Mindnet  Issue 6 – Winter 2006

When my family arrived in New Zealand in 1975 there were very few people from Goa living here. We quickly got know every Goan in the country and, in hindsight, this connection provided me with an early interest in and focus on both maternal mental health and migrant mental health. Two Goan women we knew developed mental health problems that were devastating for themselves and their families. For one, it led to suicide and for another a lifelong history of mental illness and loss. Hardly good outcomes! This was a time when it was hard to maintain our culture. Thankfully, the more recent shift in focus to encompass settlement rather than just immigration will further enhance the well-being of ethnic communities in New Zealand.

There are still large research, policy and practice gaps in the area of migrant motherhood, which I’d like to address in this article. I’d like to start by highlighting the significance of migrant motherhood, which has potentially long term and wide ranging impacts on members of a family. I’ll then talk about the changing demographics of New Zealand society and suggest that health workers need to broaden their focus for working with New Zealand’s increasing diversity and develop culturally safe ways of working with migrants and their families. Lastly, I’ll share my experiences of research with migrant mothers from different ethno-cultural communities.

When migrants “cross borders they also cross emotional and behavioural boundaries. Becoming a member of a new society stretches the boundaries of what is possible because one’s life and roles change, and with them, identities change as well. Boundaries are crossed when new identities and roles are incorporated into life” (Espín, 1997, p.445). Border crossing can involve trauma related to migration and a psychic split (Mohamed & Smith, 1999).

Migration policies favour women (and families) of childbearing age, so it is no surprise that having a baby is a common aspect of a woman’s settlement experience. Motherhood and migration are both major life events. They present opportunities but incur the risk of mental health problems, more so when they are combined. Many cultures and societies have developed special perinatal customs that can include diet, isolation, rest and household help. But these traditional and specific practices and beliefs that assist in the maintenance of mental health can be lost in migration (Kruckman, 1992). Women are separated from their social networks through migration and must find new ways to recreate these rituals or lose them (DeSouza, 2002). Research suggests that the loss of support, protective rituals and supportive networks compounded by a move to a nuclear family-model can result in isolation and postnatal depression (PND) (Barclay & Kent, 1998; Liamputtong, 1994).

Access to help and support can be impeded if the mother has language and communication problems.

Migrant mothers sometimes face additional cultural and social demands and losses that include the loss of lifestyle, control, sense of self and independence, family and friends, familiar birthing practices and care providers.

Women are more likely to develop emotional problems after childbirth than at any other time in their lives and the life time prevalence of major depression in women is almost twice that of men (Kohen, 2001). According to Lumley et al. (2004), one out of every six women experiences a depressive illness in the first year after giving birth. Thirty per cent of those women will still be depressed when their child is two years old. Of those women, 94% report experiencing a related health problem. Women who experience problems in the early stages of motherhood also report problems with their relationships, their own physical health and well-being. Women report that a lack of support, isolation, and exhaustion are common experiences.

In a study of 119 pregnant immigrant women in Canada, Zelkowitz et al., (2004) found that the transitions associated with migration placed women at higher risk of depression. Forty-two percent of participants scored above the cut-off for depression. Depressive symptoms were associated with poorer functional status and more somatic symptoms. Depressed women reported a lack of social support, more stressful life events and poorer marital adjustment. In Australia, Liamputtong and Naksook (2003) found that Thai women who became mothers in Australia had several main concerns, including social isolation, different childrearing and child disciplinary practices, and the desire to preserve their culture. Findings of isolation, loneliness and negotiating between traditional and Western childbirth rituals are common in these studies and were significant issues in my own New Zealand research (DeSouza, 2006c). This research strongly suggests that migrant mothers, regardless of origin, benefit significantly from effective and familiar social support networks.

Psychiatric illness occurring at this time can have an adverse effect not only on the woman herself but also on her relationships, family, and the future development of her infant. The impact on a child of a mother’s depression can include behavioural problems, relationship problems and cognitive deficits. Research shows that infants who had a mother who was depressed in its first year of life are more likely to develop cognitive deficits and behavioural problems than infants whose mothers were not depressed in that first year (Beck, 1998).
A review by Goodman (2004) of literature from 1980 to 2002 found 20 research studies that included incidence rates of paternal depression during the first year postpartum. During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing postpartum depression. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period.

Changing demographics

Many societies are grappling with issues of citizenship and participation in the context of globalisation, increased migration and increasing diversity. In Europe, one in every fifteen people was born overseas, in the US it rises to one in eight and in New Zealand it is one in five (DeSouza, 2006a). This presents unique challenges and opportunities for service providers to develop skills and competence for working with this diversity, especially as migration is going to be a key source of population increase. Census projections to 2021 suggest that Māori, Pacific and Asian populations will grow at faster rates than the European population but for different reasons. The Asian population is expected to more than double mainly due to net migration gains while Māori and Pacific people’s increases will be due to their higher fertility rates (Statistics New Zealand, 2005).

The Asian community has the highest proportion of women (54%), followed by Māori and Pacific (53% each) and European (52%) (Scragg & Maitra, 2005). Asian women are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups and to some degree this is a reflection of migration policy with Asian women using the opportunity to study or work. It is thought that 23% of New Zealand females were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands (Statistics New Zealand, 2005). The 2001 Census revealed growing numbers of Māori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), despite the dominance of the European/Pākehā who make up 79.6% of the population. In the period between 1991-2001, women originating from the Republic of Korea have increased 23 times from 408 to 9,354, women from China have quadrupled from 4,620 to 20,457 and women from South Asia have doubled in the same time period. Women from Africa (primarily South Africa, Zimbabwe and Somalia) have quadrupled in number (Statistics New Zealand, 2005). This has significant implications for the development and delivery of health services to women.

Cultural competence?

Working on a postnatal ward of a women’s hospital several years ago led me to question whether cultural safety had prepared the nursing and midwifery workforce for working with ethnic diversity1. Cultural safety, which refers to the experiences of the client, and cultural competence, which focuses on the practitioner and their capacity to improve health status by integrating culture into the clinical context, have been gaining prominence, but what do they actually mean?

The introduction of the Health Practitioners Competence Assurance Act 2003 has meant an additional responsibility to ensure the cultural competence of health practitioners. Cultural competence can be defined as “the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural, and linguistic needs (Betancourt, Green, & Carrillo, 2002). Cultural competence includes not only the interpersonal relationship (for example, training and client education) but also the organisational (for example, involving community representatives) and the systemic (for example, providing health information in the appropriate language, collecting ethnicity data).

The New Zealand Medical Council recently consulted its members on cultural competence (The New Zealand Medical Council, 2005). The consultation document includes a proposed framework and says that cross-cultural doctor-patient interactions are common, and doctors need to be competent in dealing with patients whose cultures differ from their own.

It cites the benefits of cultural competence as:

  • Developing a trusting relationship;
  • helping to get more information from patients;
  • improving communication with patients;
  • helping to resolve any differences;
  • increasing concordance with treatment and ensuring better patient outcomes; and
  • improved patient satisfaction.

For cultural competence to occur there is a need for the voices of ethnic communities to be considered in service development, policy and research. Despite the long histories of migration to New Zealand, ethnic communities have been absent from discussions of nation building and health care policy (DeSouza, 2006b). This has in part been due to the relatively small numbers of migrants from non-traditional source countries until the early 1990s, which meant that that the concerns of a relatively homogenous Pākehā people were reflected in policy (Bartley & Spoonley, 2004). This monoculturalism continues to be challenged by the increased prominence of Māori concerns since the 1970’s and increasing attention to biculturalism and health outcomes for Māori. Developments have also occurred with regard to Pacific peoples, largely around health disparities, but this concern has not been extended to ethnic communities despite their increasing visibility in long and short-term migration statistics. This is partly due to an assumption of a ‘health advantage’ of immigrants on the basis of current migration policy, which selects healthy people. However, evidence is growing that this advantage declines with increasing length of residence in a receiving country (Johnstone & Kanitsaki, 2005).

Cultural safety

When Britain assumed governance of its new colony in 1840, it signed a treaty with Māori tribes. Te Tiriti O Waitangi/The Treaty of Waitangi is today recognised as New Zealand’s founding document and its importance is strongly evident in health care and social policy. As an historical accord between the Crown and Māori, the treaty defines the relationship between Māori and Pākehā (non-Māori) and forms the basis for biculturalism.

Durie (1994) suggests that the contemporary application of the Treaty of Waitangi involves the concepts of biculturalism and cultural safety, which are at the forefront of delivery of mental health services. This means incorporating “principles of partnership, participation, protection and equity” (Cooney, 1994, p.9) into the care that is delivered. There is an expectation that mental health staff in New Zealand ensure care is culturally safe for Māori (Mental Health Commission, 2001). Simply put, “unsafe practitioners diminish, demean or disempower those of other cultures, whilst safe practitioners recognise, respect and acknowledge the rights of others” (Cooney, 1994, p.6). The support and strengthening of identity are seen as crucial for recovery for Māori along with ensuring services meet Māori needs and expectations (Mental Health Commission, 2001). Cultural safety goes beyond learning about such things as the dietary or religious needs of different ethnic groups; it also involves engaging with the socio-political context (DeSouza, 2004; McPherson, Harwood, & McNaughton, 2003). However, critics suggest that cultural safety needs to encompass new and growing ethnic communities. Whilst in theory cultural safety has been expanded to apply to any person or group of people who may differ from the health professionals because of socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability (Ramsden, 1997), in practice the focus remains on the relationship between Pākehā and Māori, rather than migrants (DeSouza, 2004) and other communities (Giddings, 2005).

Expanding the bicultural to a multi-cultural framework is necessary without removing the special status of tangata whenua. New Zealand’s reluctance to encompass multiculturalism as a social policy framework has been shaped by two key factors, according to Bartley and Spoonley (2004). The first is the location of historical migration source countries such as the United Kingdom and Ireland, which shaped the development of activities and concerns (as they argue, racist and Anglo centric assumptions of a colonial New Zealand) and, secondly the rise in concerns over indigenous rights and the Treaty of Waitangi, which have precluded discussion around nation and nationality. Thus while countries such as Canada and Australia were developing multicultural policies, New Zealand was debating issues of indigeneity and the relationship with tangata whenua. As a result, New Zealand has yet to develop a locally relevant response to cultural diversity (multiculturalism) that complements or expands on bicultural and Treaty of Waitangi initiatives (Bartley & Spoonley, 2004).

Need for a migrant health agenda

It is, I hope, clear by now that there is a need to develop a migrant mental health agenda, yet much of the previous New Zealand research has omitted the experiences of migrant mothers. The Centre for Asian and Migrant Health Research at AUT University and Plunket have begun a collaborative project with funding from the Families Commission and Plunket volunteers to understand the experiences of migrant mothers from the United Kingdom, the United States, South Africa, Palestine, Iraq, China, India and Korea, which it is hoped will assist in the development of services and policy.

There is a misguided view that migrants do not experience compromises in their health status despite the changes in income and social support and the new stressors they encounter, which can lead to cumulative negative effects and the need to access mental health services. The neo-liberal trajectory that our society has taken has precluded an interest in the wellbeing of migrants who often face culture-related barriers in using mental health care services. Other than a literature review produced by the Mental Health Commission (Mental Health Commission, 2003), which recommended that mental health services become more responsive to Asian people, there has been little in the way of strategic or long term planning with most of the developments in this area coming from the community and voluntary sector.

Conclusion

Migrants face additional stressors that can increase their need for mental health services. Migration can be a traumatic life event. Becoming a mother in an unfamiliar country adds to this already traumatic event, leading migrant mothers to be more at risk of experiencing depression or other mental health issues. Yet, research on the migrant experience in New Zealand is limited and studies on postnatal depression have excluded migrants in the past.

As the number and diversity of migrants increase, their well-being becomes an increasingly important issue for policy makers and health professionals. The time is right to begin a dialogue about how mental health services can work effectively with this diversity. Migrant mothers hold the key to a family’s future well-being and so are an important group for us to understand and support. In the absence of policy there is a need to advocate for migrant mental health service development, building on the many grassroots initiatives that are already occurring. Beyond this, further discussion is needed as to how cultural competency and cultural safety can be applied to migrant populations.

1. ‘Ethnic’ is a term devised by the Department of Ethnic Affairs and refers to people who are neither Pakeha, Maori or Pacific).

References

Barclay, L., & Kent, D. (1998). Recent immigration and the misery of motherhood: a discussion of pertinent issues. Midwifery, 14, 4-9.

Bartley, A., & Spoonley, P. (2004). Constructing a workable multiculturalism in a bicultural society. In M. Belgrave, M. Kawharu & D.V. Williams (Eds.), Waitangi revisited: perspectives on the Treaty of Waitangi (2nd ed., pp. 136-148). Auckland, N.Z.: Oxford University Press.

Beck, C. T. (1998). A checklist to identify women at risk for developing postpartum depression. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27(1), 43-44.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Retrieved 27th April, 2005, from www.cmwf.org/usr_doc/betancourt_culturalcompetence_576.pdf

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

DeSouza, R. (2002). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Massey University, Albany, New Zealand.

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

DeSouza, R. (2006a, May 26th). Cultural Diversity and Context: Responding to the needs of ‘This Child” in “This Family”. Paper presented at the 5th Annual Child Law Conference, Lexis Nexis, Auckland.

DeSouza, R. (2006b). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, In press.

DeSouza, R. (2006c). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Auckland, NZ: Muddy Creek Press.

Durie, M. (1994). Whaiora: Maori health development. Auckland; Oxford: Oxford University Press.

Espin, O. M. (1997). The role of gender and emotion in women’s experience of migration. Innovation: The European Journal of Social Sciences, 10(4), 445-455.

Goodman, J. H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45(1), 2-35.

Johnstone, M.-J., & Kanitsaki, O. (2005). Cultural safety and cultural competence in health care and nursing: An Australian study. Melbourne: RMIT University.

Kohen, D. (2001). Psychiatric services for women. Advances in Psychiatric Treatment, 7, 328-334.

Kruckman, L. D. (1992). Rituals and support: An anthropological view of postpartum depression. In J. A. Hamilton & P. N. Harberger (Eds.), Postpartum psychiatric illness: a picture puzzle (pp. 137-148). Philadelphia: University of Pennsylvania Press.

Liamputtong, P. (1994). Asian mothers, Australian birth: pregnancy, childbirth, and childrearing: the Asian experience in an English-speaking country. Melbourne: Ausmed Publications.

Liamputtong, P., & Naksook, C. (2003). Life as mothers in a new land: The experience of motherhood among Thai women in Australia. Health Care Women International, 24(7), 650-668.

McPherson, K. M., Harwood, M., & McNaughton, H. K. (2003). Ethnicity, equity and quality: Lessons from New Zealand. Quality & Safety in Health Care, 12(4), 237-238.

Mental Health Commission. (2001). Cultural Assessment Processes for Maori – Guidance for Mainstream Health Services. Wellington: Mental health commission.

Mental Health Commission. (2003). Mental Health Issues for Asians in New Zealand: A Literature Review. Wellington: Mental health commission.

Mohamed, C., & Smith, R. (1999). Race in the therapy relationship. In M. Lawrence, M. Maguire & J. Campling (Eds.), Psychotherapy with women: feminist perspectives (pp. 134-159). New York: Routledge.

Ramsden, I. (1997). Cultural Safety: Implementing the concept – The Social Force of Nursing and Midwifery. In P. T. Whaiti, M. McCarthy & A. Durie (Eds.), Mai i rangiatea (pp. 113-125). Auckland, NZ: Auckland University Press and Bridget Williams Books.

Statistics New Zealand. (2005). Focusing on women. Retrieved 25th January, 2005, from www.stats.govt.nz/analytical-reports/children-in-nz/growing-ethnic-diversity.htm

The New Zealand Medical Council. (2005). Assuring Medical Practitioners’ Cultural Competence (draft document for consultation). Retrieved 3rd May, 2005, from www.mcnz.org.nz/portals/1/news/culturalcompetence.pdf

Zelkowitz, P., Schinazi, J., Katofsky, L., Saucier, J. F., Valenzuela, M., Westreich, R., et al. (2004). Factors Associated with Depression in Pregnant Immigrant Women. Transcultural Psychiatry, 41(4), 445-464.

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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.

Mental Health Commission (1997). Discrimination against people with experience of mental illness: Discussion paper for the mental health commission. Wellington: Mental health commission.

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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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More recent references

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.

Pace, B. (2009). A practical guide to mental health support work (p. 94). 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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