Maori Mental Health Services
To place the therapeutic space into context, working as a clinical psychologist at Manawanui Oranga Hinengaro Mental Health Services for Maori in Auckland, New Zealand, raises questions about the cultural-clinical interface. The Treaty of Waitangi of 1840 is the central document that addresses the complex and fraught relationship between Maori people and the crown or the state. Maori mental health services were the result of the principles of the Treaty of Waitangi belatedly being applied in 2000 to the New Zealand Ministry of Health’s delivery of services. The Treaty of Waitangi in relation to Maori health is understood in terms of the three ‘Ps’. Briefly, the Treaty of Waitangi gives Maori the right to ‘Participation’ in the health system both in terms of access and service, ‘Partnership’ in terms of power relations and ‘Protection’ in terms of health and culture (Tapsell and Mellsop 2007).
It has been sufficiently recognized in meta-reviews that Maori in psychiatric services present with different phenomenological profiles at presentation, in the diagnostic patterns, the cost of care, and the therapeutic experiences between Maori and non-Maori New Zealanders (Tapsell and Mellsop 2007). Such differences may be the result of actual differences and/or may reflect inadequacies of diagnosis and treatment by non-Maori clinicians. Maori continue to enter mental health services at a rate that is disproportionately higher than other population groups, twice that of non-Maori and two-and-a-half times that of Pacific peoples with high admission rates (Oakley Browne et al. 2006). Such findings are equally evident amongst indigenous people across the world in regard to higher rates of mental health distress compared to other population groups (King et al. 2009, p. 79). For indigenous people in general, and for Maori specifically, this means that the high number of Maori within such inpatient units requires more effective interventions in order to meet the needs of Maori that ensure better outcomes.
In regard to treatment, similar to other indigenous people across the world, the evidence suggests that tangata whai i te ora and their whanau (families) wish to have choices in how to integrate conventional clinical mental health service assessments and treatments with traditional and complementary cultural practices and healing methods (Lambrecht and Taitimu 2012). This would be in line with an effective recovery approach that allows staff together with tangata whai i te ora to find their unique culturally appropriate healing pathway.
Components of a Maori-dedicated health service would include a Maori workforce with both cultural and clinical competencies, which produce assessments that take into account cultural values, whanau (extended family) participation, the use of Maori language and custom (Durie 2001). Maori mental health services are therefore the result of an awareness of a cultural- political position, that is, support for Maori by Maori in the face of white cultural dominance. This approach to treating indigenous people clinically has good validated support in many other countries (Griner and Smith 2006). This position is a form of political activity to protect Maori tradition, language, and practices, which will ultimately benefit everyone in the country.
Importantly, identity is often fluid, seldom fixed, shifting, and reconstituted. Some Maori may identify with being Christian, as with D, who holds a very specific religious position of the Ratana church, a distinctively Maori pan-tribal denomination. Some Maori identify more strongly with aspects of Western cultures and lifestyles, whilst others feel they are excluded from Western cultural practices, as well as having lost their own indigenous cultural heritage. Music and gang culture become spaces for establishing an identity. In regard to my position as a therapist in a Maori mental health service, I lean towards listening to the gaps of what is unknown, the ruptures, the impasses, the underlying dilemmas of the political, cultural, and personal dynamics, as well as the pain. It is then maybe possible to figure out together with the client what may be helpful. I prefer not to know or assume but rather seek to listen carefully to how they personally respond to the cultural and political landscape of their personal background and to the current struggles of mental distress (Lambrecht 2017). I am more curious as a therapist to listen to where a person comes from, how specific identities and relationships are formed, what patterns occur in specific stories. Such stories quickly lead to cultural, political, and economic entanglements. These are always in some way intertwined with the political and the traumatic histories of the land.
It is often not obvious how to apply this cultural-clinical integration on the ground (Lambrecht and Taitimu 2012). It seems that every cultural context requires its own form of integration, but depends also on the specific needs of the indigenous person. It is important to not turn cultural constructs into absolutes. Individuals are shaped and in turn shape their identity. Some challenges may be worth mentioning. One central issue is idealized cultural countertransference, particularly from white therapists, who may romanticize traditional healing and view it in an uncritical manner. This becomes problematic when considering witchcraft (Lambrecht 2014). People have been killed or their lives traumatically altered by such accusations. Witchcraft is an example of a complex indigenous process that has very destructive aspects which challenge any naive postmodern rhetoric and idealizing view of indigenous constructs.
Another challenge is cultural competency in mental health care (Chowdhury 2012). The Maori mental health services are funded for the top 3% of mental health severity (Oakley et al. 2006), which means they are a secondary mental health service in that referrals arrive from acute inpatient units or from primary health services that cannot manage the severity of the mental health issue. This would include acute psychosis, bipolar and other severe expressions of mood disorders, and personality disorders, to name but a few. To be culturally competent without a significant understanding of mental health is not sufficient. The Ministry of Health document on Maori workforce development (Reanga New Zealand Ltd 2012) has stated that dual competency is required, because in fact it is more complex to work at a culture-specific mental health service. A specialized cultural competency is required to work with complex clinical demands.