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| Journal of the New Zealand Medical Association,
27-January-2006, Vol 119 No 1228
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Pacific healthcare workers and their treatment interventions
for Pacific clients with alcohol and drug issues in New Zealand
Gail Robinson, Helen Warren, Kathleen Samu, Amanda Wheeler,
Havila Matangi-Karsten, Francis Agnew
Pacific peoples are an
integral part of the New Zealand society with a presence throughout the country.
According to the 2001 Census.18 231,801 people in New Zealand were of Pacific
ethnicity with two-thirds living in Auckland. The majority are Samoan whose
numbers have increased by 34% since the 1991 census, followed by Cook Island
Maori, Tongans, Niueans, Fijians, Tokelauans, and then Tuvaluans.
The median age for
Pacific peoples was 21 years, with an increasing number of New Zealand-born
Pacific peoples. Pacific peoples’ achievements are becoming increasingly
known (particularly in sports) but so are their health-related statistics
including alcohol and other drug (AOD) use.
Changing family and
community structures triggered by migration and modernisation have resulted in
altered patterns of AOD use as well as the population using them. These shifts
are likely to have produced adverse consequences and increasing AOD related
problems. Rapid social changes are clearly linked to these changing patterns and
incidence of AOD use amongst Pacific people. In addition, Pacific peoples living
in New Zealand are exposed to both Western and traditional cultural influences
and problems often arise from the coexistence of these two sets of values.14
The general AOD
literature supports the inclusion of social, psychological, and cultural factors
in the assessment and treatment of AOD-associated problems amongst indigenous
people.19 This is endorsed by New Zealand documents on Pacific issues,10,11,13
which recommend that services designed for Pacific peoples must be responsive to
their needs (based on consultation with Pacific communities) and have
involvement of Pacific staff in the delivery.
There is a paucity of
both quantitative and qualitative research in relation to AOD treatment
interventions with Pacific peoples. Maori models of health and wellness such as
the te whare tapa wha model3
incorporating te taha wairua (spiritual
dimension), taha hinengaro (mental
dimension), te taha tinana (physical
dimension), te taha whanau (family
dimension), are more consistent with the Pacific belief systems and cultural
practices. These models include key concepts that are integral to Pacific
cultures such as the relation/connectedness between the individual, family, and
community; and the holistic links between the mind, body, environment (social
and physical), and spirituality.
The approach to
treatment is often viewed by Pacific people as a collective concept that is
understood not simply as a clinical event but as part of the experience of the
whole ‘family’. For example, for Samoan families, the reciprocity
between the family and the wider Samoan community is the key to maintaining
cohesion and communal ties.7 Also the reciprocity between the family and the
service provider is the key to satisfactory outcomes.4 It emphasises the family
and how it cannot be separated from ‘culture’ and
‘caring’, given that wellness and illness is perceived as a
collective experience within the family.
The primary aim of this
study was to initiate the process of evaluating the effectiveness of alcohol and
drug treatment services for Pacific peoples in New Zealand. It documents and
reports on current treatment interventions for Pacific clients across these
services. This paper reports on information gathered from clinicians regarding
current assessment and treatment models, outcome tools, and processes being
utilised.
MethodsThe method chosen for a particular piece of research
depends on several variables. The first set of considerations concern the
research question. Who or what are you researching? What do you want to find
out? And what do you want to use the information for?
The characteristics of services ‘by
Pacific’ ‘for Pacific’ people20 are intricately tied up with
beliefs about health, family, and community. According to Glaser 6 “the
time has come for a methodology that focuses on the interest of the participants
in favour of that of the researcher”. The ambition of this research is to
document and interpret from the frame of reference of the Pacific people the
nature of treatment interventions for alcohol and drug issues. The researchers
did not begin with a pre-determined hypothesis that would be
‘proved’ or ‘disproved’ within a positivist framework.
The methodology chosen for this research is rooted in
Glaser’s ‘grounded theory;’ 5 and the method:
‘qualitative inquiry’. This in turn is heavily influenced by the
paradigm of symbolic interactionism. Symbolic interactionism gives the tools to
social psychologists to recognise what common set of symbols and understandings
have emerged to give meaning to people’s interactions, and systems theory
asks “how and why does this system function as a whole?”.9
It consists of three basic premises: people act towards
things because of the meanings these things have for them; meanings are produced
via social interaction; and these meanings are modified through an interpretive
process used by people in managing the signs they encounter.9
The research team for this study was largely Pacific in
origin and locate themselves in the role of ‘empathic neutrality’.
This is a term coined by Patton15 who argued that the terms
objectivity and
subjectivity have lost their utility
and he simply asks that the investigator adopt “a stance of
neutrality with regard to the
phenomenon under study”. This means that the investigator has no
pre-determined results to support; no particular perspective to push; and
“does not manipulate data to arrive at predisposed truths.” This
credible qualitative inquiry is based on three elements:...rigorous techniques
and methods at each stage of the research process; the credibility of the
researcher; and a philosophical belief in the phenomenological paradigm.15 Thus,
the research team adopted a discovery-based method, a ‘bottom-up’
approach to research that is developed from participant’s experiences. It
is this function of generating participant-led data that led to its selection as
a method for this project.
Identifying a
sample—31 Pacific staff members from 13 services—registered
with the Alcohol Advisory Council of New Zealand (ALAC) National Directory of
Alcohol and Drug Services for Pacific People—were interviewed. These
included services provided both by District Health Boards (DHBs) and
Non-Government Organisations (NGOs). Care was taken to ensure that differences
within the pan Pacific population in New Zealand were fairly represented. A
‘purposive’ (i.e. not randomly selected) sample of participants were
identified based on their gender, age, ethnicity, Pacific Islands- or New
Zealand-born, language fluency, geographical location of the participants, and
the core business of the service.
Interviewing
processes—Interviews were conducted by Pacific interviewers with
individuals and groups depending on the way participants chose to give their
information. All interviews were face-to-face and organised in a semi-structured
way around the concerns of the participants. Key areas of interest included
assessment, treatment interventions, and outcome measures from a Pacific
perspective.
Data
analysis—Information from the participants was recorded on tape
then transcribed, and analysis began with line by line coding of each interview.
A second round of analysis moved the data from a descriptive level to an
aggregation which was then analysed thematically. This aggregated data was used
to create a set of base-line information of assessment and intervention
practices and outcome measures amongst Pacific providers. As a means of
triangulating the reliability and validity of the data, a second researcher
analysed a range of interviews to compare with that of the primary researcher,
and material was fed back to participants for confirmation.
ResultsParticipantsMore participants were male (61%), with 55% of the
participants being Samoan; within this group, 19% were of mixed Samoan ethnicity
(Samoan/Tongan, Samoan/Palangi
(European), Samoan/Tokelauan, or Samoan/Maori).
Sixty-one percent of the participants were born in the
Pacific Island (PI) nations. The current sample reflects the three main
categories into which Pacific identities are often grouped: those born in the
Islands and immigrated to New Zealand in their adult years; those born in the
Islands and raised in New Zealand from childhood; and those born and raised in
New Zealand.12
Just over half (55%) of the participants were over 40 years
of age. All participants spoke fluent English with 81% fluent in one other
Pacific language; 12% of this group being fluent in two Pacific languages. The
majority reported that they conduct counselling and/or interventions in both
Pacific and English languages. For the 19% who did not speak a Pacific language,
they all reported that they understood much of the language but were unable to
reply. One Samoan author referred to this as ‘tautala New Zealand
born’, a linguistic condition amongst New Zealand-born Samoan where they
understand the Samoan language but are unable to converse in Samoan fluently8.
The majority (77%) of participants were from NGO providers
and 65% of the participants were from Auckland-based services. Most participants
(74%) were from AOD-related services. However, 39% of this sample was
specifically from AOD services (16% of this sample catered for Pacific dual
diagnosis clients), and almost an equal number of participants (35%) were from
AOD combined social services. About a quarter of the participants (26%) worked
in mental health services. The findings differ depending on whether the
participant worked within an AOD specific service, an AOD-related service or a
mental health service.
Participating services were mainly organised into Pacific
teams, with 5 of the 11 AOD services being managed by Samoan staff catering
primarily for Samoan clients. Staff described a range of time spent working
within the AOD field, from 6 months to 12 years with the majority being
full-time employees. Most participants had some form of tertiary education
though not always related to the addictions field.
Official job titles for those employed in AOD services
varied widely despite there being little discernable difference between the
actual work undertaken by ‘counsellors’. More than 50% of staff had
roles specific to working with Pacific youth (who speak English predominantly),
therefore workers capacity to fluently speak a Pacific language was not vital.
Alternatively, fluency is a requirement for working with an ethnic-specific
group.
Some services have ethnic-matched, gender-matched, and/or
age-group-matched roles while the majority of participants have integrated roles
where they cater for a combination of either a particular ethnic group, age
group (youth or adult), or gender. Matching clients and counsellor based on
gender, age group, and ethnicity is important within the Pacific context as male
counsellors have common experiences and understandings that are differentiated
from women and vice versa.
Caseloads for AOD service participants were between 12 and
25 at any one time, but this incorporated interventions with both the individual
and their family.
Mental health services participants estimated 30%–70%
of their current Pacific clients had addiction problems; mainly younger males
under 30 years of age, especially those presenting with psychosis. Discussions
with these participants revealed that whilst there is a stigma associated with
AOD and mental illness, Pacific communities and families appear more accepting
of AOD issues than mental health issues, as addiction is seen to be preventable
and external whereas the cause of mental illness is often attributed to the
family.
AssessmentMany participants perceived that current assessment
practices were ‘foreign concepts’ due to the emphasis on the
‘individual’ and the lack of attention to the process of collecting
this information, such as establishing connection and building trust with the
client within a Pacific context.
“Assessment
is new to many PIs, we have to keep in mind that we’re seen to have power,
you’re a stranger so clients are suspicious and fearful, that’s why
you have to develop trust, without it clients will block things and not tell the
truth”
“We’re
relationship based people, the client will only open up if he thinks he’s
connected with the clinician, this is not a
Palangi
or PI idea, it’s a human thing, we need to relate to the person
we’re talking to if we want them to open up”
All Pacific services adapted assessment forms into Pacific
contexts. Dissatisfaction with the lack of cultural focus led participants to
conduct their own cultural assessments when seeing Pacific clients.
Commonly reported useful frameworks for Pacific clients
included the timeline, genogram/family tree, and the
Fonofale model2 as they take into
account the cultural and family contexts as well as presenting issues.
A typical session was reported to be between 1 to 1½
hours with the assessment process taking one to four sessions to complete.
Participants reported that clients were
often seen where they felt most comfortable not necessarily at the service
itself. Some preferred seeing clients at their home because this allowed them to
assess the physical environment and family dynamics.
Whilst there was variation between services and regions, all
participants reported using a specific format and process for assessment. DHB
services had specific assessment forms and structured routines whereas NGOs were
more flexible in their assessment process, but the requirements for NGOs
appeared to mirror that of DHBs.
Tools predominantly used by DHB services were the Leeds
Dependence Questionnaire (LDQ)16 and Alcohol Use Disorders Identification Test
(AUDIT).17 Concerns about the current AOD assessment forms included difficulties
in adapting Palangi assessment concepts
to Pacific clients; barriers to building rapport; their time-consuming nature;
and the fact that forms were designed mainly for adults and not for youth.
Forms were believed to be useful for agency requirements,
accountability to funders and as guidelines for staff accountability. Despite
the negative opinion, however, all participants agreed that assessment forms
were necessary (particularly as a guideline) although they were unable to
specify alternatives to current recording methods.
Some staff believed that the therapeutic relationship should
have a deeper or ‘spiritual’ connection and not be just a
‘surface’ relationship where the client is connected with the worker
mentally and cognitively. This is supported by Pacific writers who described
spirituality amongst Pacific people as centred on the essential quality of
relationships, and then Pacific therapy can be acknowledged as a spiritual
process.20
Working with families was a more common practice amongst
mental health workers as well as older Pacific workers within NGOs. This was
mainly due to mental health services’ specific expectations of community
support workers and established community roles.
“When
we deal with A&D we deal with family and the home environment, we need to
look at what systems that this person belongs to, it can explain their A&D
behaviour”
Three-quarters of the participants, mostly older Pacific
workers, had commitments within their community and many felt that some roles
were part of their duty (e.g. matai/chief, church, and family roles).
Whilst all younger participants (<30 years) acknowledged
the need to work with families, they also believed they were not well equipped
to deal with older Pacific adults. Recognition of one’s limitations due to
the intergeneration gap is highly regarded, and it establishes that the young
counsellor has knowledge of his or her Pacific culture.
Treatment interventions“The
Pacific way of working means working with the whole person and whatever they
bring to the table and helping them with the confidence to deal with
it”
Treatment intervention was better understood by the majority
of participants as another stage of ‘helping’ the clients and their
families. Whilst participants perceived that some
Palangi interventions can be readily
adapted, all participants felt that treatment interventions with Pacific clients
need to integrate knowledge from both
Palangi and Pacific approaches. This
perception is largely influenced by the obvious factor that Pacific people live
in a Palangi society and are influenced
by modernisation and Palangi systems in
New Zealand. In addition, participants reported that many of their Pacific
clients are either New Zealand-born, in a mixed relationship, or are of mixed
Palangi ethnicity.
Many participants reported that they are either trying to
develop a Pacific framework or have developed their own Pacific models for AOD
interventions, which they trial and adapt to their working environment. The most
commonly reported Pacific model that participants found useful in informing
their approach was the Fonofale model.
Whilst this model was originally developed for the mental health field, it is
simple and captures key Pacific values, relevant to the AOD field.
The Fonofale model
promotes a holistic view of health care. It utilises the metaphor of a house (a
fale) to symbolise the wholeness of a
Pacific person. The ‘physical’, ‘spiritual’,
‘mental’ and ‘other’ parts of a Pacific person make up
the four pillars of the fale, while the
aspects of ‘culture’ and ‘family’ make up the roof and
base of the fale.1
The majority of participants saw working with the client as
a ‘spiritual journey’. Spiritual approaches are not easily measured,
but are seen as a process of ‘inner healing’ for the client.
Participants perceived that an essential aspect of therapeutic conversation
includes discussing dreams, feelings, intuition, Christian principles, or
conducting prayers during sessions. Spiritual approaches may have been expected
more from older Island-born participants, but this was not the case. In fact,
the spiritual approach was just as common amongst young, New Zealand-born, or
Palangi/Pacific mixed
participants.
All participants reported the need for the counsellor to be
transparent and clear about the stages of intervention with the client. The
counsellor needs to explain their role, what counselling means, and why the
client has to see a stranger (counsellor). Roles such as
‘counsellor/therapist’, ‘psychologist’, ‘social
worker’, or ‘community support worker’ are commonly viewed as
Palangi roles and are often
indistinguishable to many Pacific people. All participants acknowledged that
many of their clients are unsure of what therapy is about and often they are
naturally suspicious. This supported their argument for the need to develop
rapport, connection, and trust prior to any meaningful AOD work being
done.
All participants argued that Pacific staff are the most
appropriate people for Pacific clients, based on the belief that a Pacific
worker has in-depth knowledge of Pacific processes and meanings that the client
can identify with or relate to. Whilst the advocacy for Pacific workers was well
emphasised, many participants accept the reality that some Pacific clients may
not want to access a Pacific service, see a Pacific worker, or have the choice
to see a Pacific worker. In this case it was felt consultation by non-Pacific
staff with Pacific workers was crucial.
Both mental health and AOD services identify following-up
the client as a fundamental process in monitoring progress. Mental health
services appear to have more structured follow-up processes partly due to the
nature of mental illness, but also due to the roles of community support workers
who focus on implementing continuing care plans. This process was less
structured for AOD services. Whilst
Palangi systems compartmentalise
assessment, treatment, and follow-up, the majority of participants simply see
this stage as a natural continuation of the counselling sessions.
Overall, an average AOD treatment intervention ranged from 3
to 4 months (about 6–10 sessions) with one to two follow-up sessions
within a month after the last counselling session. On average, clients were
initially seen weekly, reducing to fortnightly if the client was showing good
progress. Clients who do not attend tend to be those mandated by agencies such
as Community Corrections.
NGOs were more flexible to operate in a ‘Pacific
way’, most NGO participants described continuing to do more interventions
than those expected from funders (e.g. working with families and not just
individuals, conducting more sessions than expected). This is mainly due to
their perception that funding does not cover ‘holistic approaches’
and their experience of what works with Pacific clients.
Bilingual workers described that translating between
languages is not only time-consuming but a skill that is not often acknowledged
in the Palangi clinical field. It is
widely recognised that many treatment-related concepts cannot be fully
translated between cultures and often the essence of the meaning is lost when
translated, hence the value of ethnic-specific workers.
Youth were recognised as a group that requires a specific
approach. All participants reported that the involvement of parents or
caregivers is crucial in the intervention process. The approach to youth and
especially New Zealand-born youth was more consistent with the approach to youth
in general. Discussions revealed that New Zealand-born Pacific youth try and
integrate what they perceive as the Pacific culture taught by their parents and
grandparents, but the Pacific culture that they experience is
‘adapted’ to New Zealand culture. Often this can cause conflicts and
difficulties between parents and their children who are highly influenced by the
Palangi culture.
Participants working with Pacific youth commented that
client ‘confidentiality’ is contradictory with the Pacific
expectation of involving significant others. Many acknowledged that session
details were confidential, and that frequently youths did not want their parents
involved but that it was beneficial for the youth in the long term if they
gained the support of their parents. It was seen as a skill of the counsellor to
assess the home environment and family circumstances (e.g. for the youth’s
safety) and engage parents positively from a cultural and educational angle
without revealing session details.
The participants describe education programmes as an
integral part of treatment intervention with Pacific clients, particularly as a
prevention strategy. These programmes targeted not only the clients
(psycho-education), but equally importantly the families and Pacific community
(education programmes) with the aim of raising awareness but also for families
and community to take responsibility by actively managing AOD issues.
Educational programmes are thought to be most effective when
people are in their most ‘natural’ environment such as programmes
delivered in churches, schools, or through Pacific media such as Pacific radio
programmes. A significant number of participants have delivered at least one AOD
programme on Pacific media or are currently running health programmes in their
respective Pacific language on radio.
All participants described that traditional healing
practices are useful for a variety of physical and mental health issues. Many
had either direct or indirect experience with traditional healers, and a few
reported that they practiced traditional healing themselves. The majority of
participants described that using traditional methods to heal AOD issues in
particular was ‘uncommon’ or that they were unaware of clients
utilising healers; however, most participants supported the idea of utilising
traditional healers for mental health issues.
Outcome measuresUnlike the assessment and treatment concepts, the majority
of participants appeared puzzled by the concept of ‘measuring’ the
effects of their treatment intervention with the individual. The idea of
objectively ‘measuring’ the way a worker ‘helps’ an
’individual’ was viewed as foreign. If measured, participants
believed the process is equally important as the actual outcome of intervention.
Many described that measuring the true effectiveness of
their intervention cannot be fully captured during the treatment intervention
period—as change is long term and there are a variety of factors that
could influence change in the client, some which could be attributed to the
treatment intervention. Despite this, participants readily understood the
concept of measuring the worker’s performance to ensure they are effective
with clients, but again the difficulty was in the translation of the
Palangi performance tools and practices
into Pacific contexts within the workplace.
Despite the lack of formal outcome measurements for Pacific
people, all participants described a combination of informal processes that they
utilise to evaluate the effectiveness of their work with clients. Observation
and verbal feedback from the client was the most reported method of gaining
information and was usually conducted at the end of treatment. Given that many
participants work with families, their ongoing feedback was also crucial in
gauging the client’s progress.
Rapport with families from the beginning (assessment stage)
is especially important given that their honest feedback and co-operation is
needed at all stages of treatment. The key client changes that participants
looked for were primarily positive behavioural changes and changes in relation
to the client’s treatment goals. Given that other areas of the
client’s life may be affected, all participants described that it is not
sufficient to simply look at a reduction of AOD use as a measure of progress but
other areas of the client’s life needs to be equally addressed.
With regard to feedback processes, the participants felt
that Pacific people are uncomfortable with, and can feel threatened by, written
materials (questionnaires) because they may have negative connotations and imply
that they too (client) are being evaluated. Despite being told that their
responses are anonymous or confidential, clients may feel obligated and often
record a more favourable response out of respect or shame.
DiscussionThis piece of work represents the first stage of a larger
more comprehensive review of treatment interventions with Pacific clients with
alcohol and drug issues in New Zealand.
AOD workers see evaluation as crucial, and are keen to
improve the content and intervention processes for capturing AOD assessment,
treatment intervention, outcome measures, and service delivery to Pacific
people.
The most effective assessments are those conducted by
skilled Pacific staff with sound knowledge of AOD, Pacific cultures and
processes, and ability to integrate
Palangi and Pacific knowledge in a
manner that would help the client.
The findings imply the
need for clearly defined performance and outcome measures that accurately
reflect Pacific processes and interventions. For instance,
assessment is actually the first phase of
‘helping’ in the treatment intervention and needs to be recognised
as this. The establishment of rapport is vital to the development of ongoing
engagement with the client, and makes the initial stage more than merely
completing an assessment form.
Clients should be encouraged to inform workers about the
meaningfulness of interventions. Alternatives to written questionnaires given to
Pacific clients should be considered, as questionnaires do not always accurately
reflect their true opinions, even if questionnaires are translated to Pacific
languages.
Client progress can be measured at different stages of the
client’s journey especially at the beginning (assessment stage) and at the
end of treatment (after the follow-up period). Client-based outcomes should take
into account social and environmental factors by recording verbal feedback from
the client, families (as identified by clients), referrers and any relevant
others involved with the client. A set of simple tools would be useful to
capture this information.
Funders and other relevant agencies need to recognise and
understand the clinical and cultural needs of Pacific workers in
their approach to Pacific clients and families.
This approach does not focus only on AOD problems and the individual; often
interventions need to be intensive, longer, and incorporate families and
significant others. Steps can be taken to empower Pacific workers to
utilise Pacific processes and interventions that are ‘effective’
with their clients. These issues are not always
included in the current funding contracts but are particularly important
for the development of services and in building Pacific capacity and capability
within the AOD field.
There is clearly an identifiable ‘Pacific’ way
of working with Pacific clients. All participants applied elements of both
Pacific and Palangi understandings of
alcohol and drug issues to their practice. The degree to which this occurred
depended on the age, gender, birthplace, and preferred language of the worker
and the client.
Whilst there appeared to be no significant difference
between Pacific interventions offered by NGO and DHB providers, there were
differences in resourcing and service structure. Reporting and record-keeping
requirements in DHBs were seen to take time away from ‘Pacific
processes’ (in particular ‘rapport’ building) and inclusion of
family in treatment. Any outcome measurement system needs to incorporate Pacific
principles and processes.
There are a wide range of Pacific people who access services
for AOD issues; and in order to provide appropriate interventions, Pacific AOD
workers need to be competent in a variety of skills to meet these various needs.
An effective alcohol and drug worker was described as someone who is of Pacific
ethnicity with sound knowledge of AOD issues and Pacific culture, and has the
skills to integrate this knowledge in the most appropriate way with the
diversity of Pacific people accessing AOD services.
It was acknowledged that
it is not enough to simply be ‘Pacific’ to work with clients. It is
important to also have formal training and skills development. Conversely,
approaching Pacific clients from a purely
Palangi and/or clinical approach is
also ‘not enough’.
Whilst this study has
limitations, it does provide baseline information which will enhance
understanding and may support current intervention practices for Pacific people
with AOD-related issues.
Author
information: Gail Robinson, Co-director and Psychiatrist, Clinical
Research and Resource Centre (CRRC), Waitemata District Health Board and
Department of Social and Community Health, University of Auckland, Auckland;
Helen Warren, Senior Researcher and Lecturer, CRRC, Waitemata District Health
Board and Department of Social and Community Health, University of Auckland,
Auckland; Kathleen Samu, Pacific Researcher, CRRC, Auckland; Amanda Wheeler,
Co-director, CRRC and Department of Pharmacy, University of Auckland, Auckland;
Havila Matangi-Karsten, Clinical Pacific Researcher, CRRC, Auckland; Francis
Agnew, Clinical Director, Pacific Mental Health Alcohol and other Drugs
Services, Waitemata District Health Board, Pacific Mental Health Services,
Auckland District Health Board, Auckland
Acknowledgments:
We thank the Alcohol Advisory Council of New Zealand (ALAC) who funded this
project. (Any findings, conclusions, or opinions are those of the authors and
are not to be attributed to ALAC.) We also thank our Advisory Group for their
support and advice.
Correspondence:
Dr Gail Robinson, Clinical Research and Resource Centre, Pitman House, 50
Carrington Rd, Pt Chevalier, Auckland. Fax: (09) 815 5896; email: gail.robinson@waitematadhb.govt.nz
References:
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