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Tungia te ururua kia tupu whakaritorito te tupu o te harakeke

Set fire to the overgrown bush, and the new flax shoots will spring up.

Clear away what you don’t need and the good stuff will grow through.

Key concepts:
  • Recognise that Māori have a high prevalence of mental health problems and an unmet need for receiving treatment
  • Make Māori a priority for identifying mental health problems and providing early intervention
  • Acknowledge that the presentation, definition and treatment goals of mental health problems may differ for Māori
  • Ensure that care is delivered in a culturally appropriate manner
  • Form partnerships with Māori health providers and know who to refer to for treatment that is acceptable to the patient and their whānau

Dispelling myths – what we know about Māori mental health

Until recently, there has been a lack of research and information about the nature and extent of Māori mental health needs, and even less known about how effectively Māori mental health problems and disorders are managed. Key areas of concern include the growing suicide rate among young Māori and the increasing rate of hospitalistion for psychiatric illness.

Over the past decade there have been some important new sources of information that have helped describe the nature and extent of Māori mental health. Te Rau Hinengaro, the New Zealand Mental Health survey, was a key study in providing this insight. This was the first national mental health survey to report on a representative population of Māori adults. The study was undertaken from 2003 to 2004 and included 2595 Māori aged 16 years or over. Results of the survey reinforced some ongoing concerns about Māori mental health.1

Key findings of Te Rau Hinengaro included:1

  • Almost one in three Māori adults (30%) met criteria for at least one mental health disorder in the previous 12 months and just under half of Māori had experienced a mental health disorder during their lifetime
  • Having more than one mental health disorder was common
  • The most common disorders were anxiety disorders (19%), mood disorders (11%) and substance misude disorders (9%)
  • Socioeconomic status was important. Higher prevalence of mental health disorder was associated with low household income and fewer years of education.
  • Mental health disorders were most prevalent among people aged 16–44 years, but much less common among Māori in older age groups, particularly those aged 65 years and over.
  • Māori women had a higher prevalence of mental health disorder (one in three) than Māori men (one in four) in the previous 12 months
  • Contact with health services for Māori with mental health disorders was lower than for non-Māori. Those who did seek treatment most commonly saw a GP.
  • Approximately half of Māori who met criteria for having a serious mental health disorder, had contact with any services.

The findings from Te Rau Hinengaro, along with other important research have helped to challenge some early views about Māori mental health.

Depression and anxiety disorders DO occur in Māori at rates that are as high, or higher, than the total population. A recent study of over 7000 patients in Auckland general practice found that the level of major depression among Māori was at least as high as that in non-Māori and most likely to be higher, particularly for Māori women.2 These results support the findings of Te Rau Hinengaro and other studies. It is noted that when age and socio-economic factors are taken into account, differences between rates of depression among Māori and non-Māori are reduced.

Māori from all regions of New Zealand DO experience similar rates of mental health problems. Results of Te Rau Hinengaro indicated that there was no significant difference in the prevalence of mental health disorders between regions of New Zealand, including both urban and rural areas.1

There is NO evidence that Māori are genetically predisposed to mental disorder. Research highlights social, economic, environmental and other influences as contributing towards disparities in rates of mental health disorders, rather than genetic factors.

There is NO evidence that the high rates of hospitalisation for mental health disorders among Māori are due to poor compliance with medication. No research has been undertaken that proves Māori to be less compliant with medicines than non-Māori.

Although socioeconomic status is an important contributor to mental health problems among Māori, it is NOT the only contributing factor. Te Rau Hinengaro identified that 40% of Māori in the lowest household income quartile had a mental health disorder in the previous twelve months. However one in six Māori in the highest income quartile also experienced a mental health disorder. Socioeconomic determinants do contribute to ethnic differences in mental health disorders, but do not explain all differences. After adjusting for socioeconomic status, the prevalence of substance misuse and other serious mental health disorders was still higher in Māori.1

Eating disorders DO affect Māori. There was a very low prevalence overall for eating disorders in Te Rau Hinengaro. However, the highest prevalence of eating disorders, particularly bulimia, was in Māori.1

Messages for primary care

There is an unmet need for mental health care in Māori. It is of concern that research indicates that half of Māori with a serious mental health disorder had no contact with healthcare services.1 The high rates of suicidal behaviour, among young Māori males in particular,3 indicate the importance of exploring mental health issues with this group.

Mental health problems affect Māori in every region of New Zealand, both rural and urban. Māori experience the same range of mental health problems as all New Zealanders. Mental health problems are often silent, so the challenge is to find ways in which to communicate with Māori patients, be aware of the relationship between physical and mental health, be open to alternative ways of expressing mental health, form partnerships with Māori mental health service providers and support Māori health initiatives.

Practical measures for managing mental health problems in Māori

The Ministry of Health Māori Mental Health and Addiction National Strategic Framework – Te Puāwaiwhero, outlines actions that can be taken to maximise positive outcomes for Māori with mental health problems. Applying this framework to a primary care setting, the following points may be considered:4

  • Implement practice initiatives that recognise and respond to whānau
  • Plan and deliver effective, responsive and culturally relevant care
  • Develop effective partnerships with mental health and addiction services, especially Māori health service providers

The ultimate goal for primary health care providers is effective communication with Māori, in order to identify and provide early intervention for mental health problems.

Recognising mental health disorders in Māori

In most cases, Māori will present with a mental health problem in much the same way as non-Māori, but clinicians should be open to presentations involving more physical and spiritual expressions of distress. There are also several states specific to Māori which may appear on the surface to mimic symptoms of a mental health problem, e.g. experiencing the presence of ancestors. Mainstream health professionals need to be aware of these presentations so they can seek expert advice to clarify the issue and provide appropriate intervention.5

A significant factor in being able to detect a mental health problem is effective communication. Taking the time to build a trusting therapeutic relationship (whānaungatanga) is important. The clinician should introduce themselves and their background and find out about the patient, where they come from, who their whānau is, and try to establish a connection. Time pressures may make this difficult, however it can be the difference between a positive outcome or treatment failure. It is important that the patient is given time to tell their story in their own way and time.6

Understand both patient and whānau views of illness

Ask Māori who present to a consultation alone whether they would like to have whānau present. Whānau not only support the patient, but can also help the clinician and the patient understand each other.

However do not assume that just because the patient is Māori, that whānau support is required or wanted.

Listening to the views of the patient and whānau about the illness will assist in the assessment process and enhance the therapeutic relationship. It may be appropriate to ask the patient and their whānau the following questions:6

  • What do they think is wrong?
  • Is there a name for it?
  • What may have caused it?
  • What, in their view, should be done now?
  • What do they think will be the outcome?

Screen Māori for mental health problems

Target Māori for opportunistic screening for mental health problems, especially those in the 16–44 year age group. Also screen new patients and those who are seen infrequently.7

Consider that mental health disorders commonly co-exist with substance misuse problems and that people may experience more than one mental health problem simultaneously.5

Verbal screening tools

Two to three question verbal screening tools (see below) have been validated for detecting anxiety and depression and have also shown effectiveness in detecting substance misuse7 and addictive behaviour such as gambling.8 These questions have been validated in a New Zealand population, but not specifically for Māori.

If a patient responds positively to screening questions, it may indicate a need to explore the issues more thoroughly. Discussing specific factors may be useful to put the problem in context, however consider that for Māori, roles and responsibilities within the whānau and wider community may be even more important than individual wellbeing. Ask about:7

  • Duration of symptoms
  • Interventions trialled
  • Functional impairment
  • Whānau and personal history of similar issues and how they were managed
  • Precipitating factors (e.g. psychosocial stress – domestic violence, sexual abuse)
  • Perpetuating factors (e.g. feelings of uselessness)
  • Protective factors (e.g. self-insight, whānau support)
  • Specific risk behaviours (e.g. manic episodes, suicidal ideation or attempts)

Examples of verbal screening questions:

Depression
  • During the past month, have you been bothered by feeling down, depressed or hopeless?
  • During the past month, have you been bothered by little interest or pleasure in doing things?
If yes to either question, ask the help question
Anxiety
  • During the past month have you been worrying a lot about everyday problems?
    • If yes, ask the Help question
Alcohol and drug problems
  • Have you used drugs or drunk more than you meant to in the last year?
  • Have you felt that you wanted to cut down on your drinking or drug use in the past year?
If yes to either question, ask the help question
Gambling
  • Have you ever felt the need to bet more and more money?
  • Have you ever had to lie to people important to you about how much you gambled?
If yes to either question, ask the help question
Help question
  • Is this something that you would like help with?

Consider cultural appropriateness of care

  • Practice points for providing culturally appropriate care:5
  • Consider establishing cultural needs of Māori prior to a first consultation, using culturally skilled staff, however do not assume that all Māori will conform to this cultural identity.
  • Obtain advice about appropriate processes, models of health and key issues likely to have an impact on treatment, as early in the process as possible.
  • Ensure a welcoming environment (e.g. waiting room space for whānau, information available in Te Reo Māori)
  • Determine whether it is the patient or another whānau member who is the decision maker and who needs to be involved in each consultation (e.g. whānau, kaumātua)
  • Do not assume it is always appropriate to involve others – always ask
  • Allow culturally appropriate processes where possible (e.g. mihi, karakia and waiata)
  • Ensure language needs are met – use a Te Reo Māori translator or interpreter if required
  • Acknowledge when you are uncertain about cultural processes
  • Know who to contact for support, translation and cultural advice

All practitioners need to be competent in dealing with patients whose culture differs from their own. Simply recognising that people from different cultures might perceive and deal with mental health problems in different ways is an important first step.

Pharmacologic treatment is only one aspect of patient care – spiritual, emotional/intellectual, physical and whānau functioning are other important aspects. Medicine can be viewed as an adjunct to other approaches.

Traditional Māori perspectives challenge some treatment goals, such as the focus on developing individuality and self advocacy. Therapies that focus on the individual may be less relevant and less appropriate for Māori, who may place more emphasis on wider relationships.

Whānau play an important role in the wellbeing of an individual and in the recovery process. Poor dynamics within the whānau and lack of support can contribute to, or worsen, the illness. There can be a lack of understanding and often a stigma associated with mental health problems. Information can be provided to the patient, their whānau, friends, workplace and community.

Kaupapa Māori mental health services

Kaupapa Māori services are specifically designed to reflect the cultural needs of Māori, alongside mainstream medical treatments. It is important to know who the local Kaupapa Māori service providers are and to establish effective working relationships with them. Consider how shared care with Māori providers could work.

Kaupapa Māori providers deliver services within a Maori framework including:10

  • Whānaungatanga (networks, relationships)
  • Whakapapa (genealogy)
  • Cultural assessment
  • Empowerment of tangata whaiora (people seeking wellness, mental health service users) and their whānau
  • Te Reo Māori (Māori language)
  • Tikanga Māori (customs, protocols)
  • Kaumātua (elders) guidance
  • Access to traditional healing
  • Access to mainstream health services
  • Quality performance measures relevant to Māori

Kaupapa Māori mental health services are contracted by district health boards (DHBs) throughout New Zealand and also provide specific services such as residential mental health, child and youth services and alcohol and other drug services.

The availability of specific services differs across regions. DHBs and Primary Health Organisations (PHOs) are a first point of contact for finding out what Kaupapa Māori Mental Health services are available locally.

“My recovery is about my hinengaro (mind), tinana (body), wairua (spirit) and whānau (family), my treatment seems to be only about my tinana with pills and injections.” Tangata whaiora group 9

The definition of wellbeing for Māori

Contemporary health services, including general practice, tend to focus on physical and psychological wellbeing as a measure of treatment progress or cure. For Māori the wairua (spiritual wellbeing) of the individual and whānau, as well as the wider physical and spiritual environment, plays a significant role in the wellbeing of a person. The mauri (life force) of people and of objects, and the strength of cultural identity, are key contributors to health in a Māori world view.11

There are several Māori models for health and wellbeing that incorporate these considerations. These models provide an insight into the definition of wellbeing for Māori. When managing mental health problems, clinicians need to be aware of, and acknowledge, alternative views of health and wellbeing and measures of treatment gains.

Te Whare Tapa Whā and Te Wheke are two commonly used Māori models of health. However other models are used.

Te Whare Tapa Whā

This model, developed by Professor Mason Durie, recognises four components to Māori health. It can be compared to the four sides of a house, all of which need to be healthy for the house to be strong.12

Taha Tinana (physical health)
The physical health of Māori is connected to a person’s spirit, mind and whānau

Taha Wairua (spiritual health)
Wairua encapsulates the mauri around a person and its impact on an individual’s spirit. Wairua requires a consideration of environment, a link to past generations and a connection to higher powers. Traditionally, an examination of an unwell person would include an assessment of the impact that wairua was having on that person’s health. Wairua can impact on both illness and treatment.

Taha Whānau (family health)
Whānau play an important role in the wellbeing of a person. They can contribute to sickness as well as assisting in curing illness. The sense of belonging and strength that whānau provide is one of the key foundations of Māori health.

Taha Hinengaro (mental health)
Thought, feeling and emotions are invariably linked to physical and spiritual wellbeing. Māori acknowledge the vital link that thoughts, feelings and emotions have to overall health.

Adapted from Durie, 199412

Te Wheke

Te wheke (the octopus) is an ancient symbol for many indigenous Pacific peoples. Dr Rose Pere uses this traditional symbol as a way of defining whānau health.13 The head of the octopus represents the whānau, its eyes the waiora (total wellbeing for the individual and family), and each of the eight tentacles define a specific dimension of health. The dimensions are linked and interwoven, stressing the importance of taking a holistic view to Māori health.13

 

Wairuatanga Spirituality
Hinengaro Mind
Taha Tinana Physical wellbeing
Whānaungatanga Extended family
Mauri Life force in people and objects
Mana ake Unique identity of individuals and family
Hā a koro mā, a kui mā Breath of life from forbears
Whatumanawa The open and healthy expression of emotion

Māori concepts relating to health

Adapted from Te Ara Poutama11 and Te Iho14

Some mental and behavioural states experienced by Māori cannot be explained by mainstream medical classifications. Traditional Māori explanations for poor health can be quite different from those based on western beliefs.

Health professionals should be aware that these specific cultural syndromes occur in Māori and be familiar with the terms, but it is important that attempts to treat these conditions are not made. This is the area of expertise of tohunga and kaumātua assisted by kaitakawaenga (Māori cultural workers). It is important to seek expert cultural assistance if these concepts arise when working with Māori.

Mauri ora and mauri mate

Mauri is an energy which is present in all things. However, people (and living or moving things) are also vessels for mauri ora, “life energy”.

“Tīhei mauri ora!” a common beginning of a speech on the marae, literally translates as the “sneeze of life”. This is a call for life energy to be brought into the hui.

Mauri mate is the opposite of mauri ora. It relates to the energies of sickness and death. At a tangi, speeches often start with “Tīhei mauri mate” to acknowledge the “death energy” which is present.

Tapu and noa

Traditionally tapu was the means by which a place, person or thing is set aside from normal everyday use. People in various states such as illness and grief, or while engaged in important work like whakairo (carving) or tāmoko (tattooing), are also considered tapu. Visitors to a marae are considered tapu when they first arrive, as are various parts of the body or the marae itself.

When situations involve something which is tapu, the outcome is uncertain. A positive outcome requires things to be done correctly, following tikanga.

Noa is the opposite of tapu. Water and food are considered noa and have the ability to remove tapu. While tapu is associated with uncertainty and restriction, noa represents certainty and freedom. Things that are noa are clean and safe.

Applying these concepts to health, the process of becoming well involves harmonising the tapu and noa of a person.

Mana

Mana can be described as having two aspects, one relating to authority and the other associated with power.15 The authority in this sense is God-given and the power is dependent on action and performance.

On a personal level, mana is associated with the qualities that an individual is born with. Some people are naturally athletic, some show a tendency toward academic achievement, others are musical.

However, although a person may be born with certain abilities and qualities to enhance their mana, they must also prove their abilities through achievement. Achievement provides them with additional power and authority to exercise that mana, and through their words and actions, influence and lead others. In this way mana is not something a person can claim with their words. It can only be attributed by others. Mana is not about ego or pride.

The wellbeing of a person is directly linked to their mana. Someone who has suffered a substantial loss of mana, or has had few opportunities to develop their mana, may become depressed and unwell. Providing opportunities for people to enhance their mana, by realising their potential, is important in improving health outcomes.

Mate Māori

Mate Māori is a cause of ill health or uncharacteristic behaviour which results from an infringement of tapu or the infliction of an indirect punishment by an outsider (mākutu). It may take several forms, both physical and mental, and various illnesses may be attributed to it. Mate Māori is related to spiritual causes and may require the intervention of a tohunga or priest.

Māori may be reluctant to discuss mate Māori fearing ridicule or pressure to choose between psychiatric and Māori approaches. However, one approach need not exclude the other. Mate Māori does not mean there cannot be a mental disorder. It may be used to explain the cause of the illness rather than the symptoms. Mate Māori remains a serious concept within modern Māori society, and may be more convincing to Māori than complex clinical explanations.

Whakamā

Whakamā is a mental and behavioural response that arises when there is a sense of disadvantage or loss of standing. It can manifest as a pained, worried look, marked slowness of movement, lack of responsiveness to questioning and avoidance of any engagement with the questioner. These signs may be suggestive of depression or even a catatonic state, but the history is different and the onset is usually rapid.

Other concepts

Māori may report seeing deceased relatives or hearing them speak. However, in the absence of other mental health signs or symptoms, this is not a firm basis for diagnosing a serious mental disorder.

Acknowledgement

Thank you to Associate Professor Joanne Baxter, Kāi Tahu, Kāti Mamoe, Waitaha, Ngāti Apa, Associate Dean Māori, Director Hauora Māori, Dunedin School of Medicine, University of Otago for contributing to this article.

Thank you also to Dr Rees Tapsell, Te Arawa, Executive Clinical Director, Midland Regional Forensic Psychiatric Service, Waikato DHB and Associate Professor Amanda Wheeler, Mental Health Pharmacist, Waitemata DHB and School of Nursing, Faculty of Medical and Health Sciences, University of Auckland for expert guidance in developing this article.

References

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