Mahi a Atua: a pathway forward for Māori mental health
Mental health service provision in New Zealand has been controversial in the 2017 year, with the release of the ActionStation People’s Mental Health Report1 in April, the Office of the Auditor-General’s Mental Health: Effectiveness of the planning to discharge people from hospital2 report in May and the New Zealand Herald series on death by suicide called Break the Silence3 in June. In short, these reports and article indicate a mental health service under stress. Indeed, a year ago the Australian Psychology Society apologised to indigenous Australians for the “inappropriate use of assessment techniques and procedures” and treatments that “both implicitly and explicitly, dismissed the importance of culture in understanding and promoting social and emotional wellbeing”.4 This article takes the opportunity presented at this time of challenge and reflection to discuss a kaupapa Māori approach to mental health in primary care that will provide options for both struggling services and for Māori with mental health problems.
Although mental health disorders in New Zealand are reported to be equally prevalent across ethnic groups,5 a larger proportion of Māori present to general practice mentally unwell.6 The literature shows that anxiety, substance abuse and depression are the main problems, particularly for women, who are said to have up to twice the consultation rate of their non-Māori counterparts.7 Furthermore, general practitioners are reported to underdiagnose mental health problems among Māori, particularly depression, and they describe their own communication difficulties alongside feelings of stigma by patients as the reason for this.8 With regard to secondary care, Māori have more acute admissions to mental health facilities than others,9 are readmitted more often after discharge,10 are more likely to be secluded in hospital11 and those with psychotic illness are overly incarcerated in prison foresic units.12 Finally, of those in forensic units with pyschotic illnesses, far fewer Māori have any form of treatment.13
The evidence of a larger burden of illness, underdiagnosis, more frequent admission and readmission to secondary and forensic care indicates that Māori do less well than other New Zealanders with mental health issues. The impact of mental health disorders in the Māori community may relate to the ‘psycho-social adversity’ experienced by those with psychotic illness,14 and where that author discusses this as an effect of migration, I posit it as an effect of colonisation. In addition, it is proposed by some that the very expression of mental distress in Māori is different. For example, schizotypy, a gradation of personality characteristics that range from being rather odd through to psychosis, is far more common in Māori adolescents,15 and in frank psychosis, overactivity and aggression are particularly marked features of Māori patients.16,17
But the capacity and capability of the Mental Health Service in New Zealand is what ActionStation, the Auditor General and the New Zealand Herald have questioned recently, and we all know that deprived minorities do less well in mainstream health service outcomes, more so perhaps where the system is strained. The use of ‘the psychiatric format’, that is, a medical paradigm employing one-on-one interviewing, a DSM-5 diagnosis, a biomedical cause of disease, and a treatment regime involving psychotherapeutics, medication and seclusion eschews any consideration of the relationships, meaning, values, beliefs and cultural practices that are important to Māori. The lack of adequate treatment services and dearth of culturally appropriate options available to whaiora (mentally distressed persons) has been duly noted,18,19 as has the need for appropriate training of, and support for mental health professionals working with Māori.20 Although there has been some promotion of the inclusion of Māori perspectives, and the creation of a cultural base in the provision of the mental health care process,21–23 and even a paradigm-challenging example of a traditional healer-psychiatrist collaboration,24 there is little evidence of systematic change. The “approach to family wellbeing that avoids fragmentation and focuses on positive strength” promoted by Durie25 seems far off. That is, until you get to the East Coast, where a Māori approach to primary mental health care called Mahi a Atua (tracing the ancestral footsteps of the Gods) is being offered under the Ministry of Health’s Mental Health and Addictions Project, “Fit for the Future—a Systems Approach”.
Mahi a Atua is an engagement, an assessment and an intervention based on pūrākau (Maori creation and custom narratives). Creation narratives have for centuries provided a framework on which individuals and communities worldwide can consider ancestral footsteps to better understand and interpret their experience(s) according to their particular cultural mores. The stories help individuals to understand the context in which they find themselves and illustrate acceptable pathways forward. They provide snapshots of ‘mental states of being’ and ‘responses to distress and dis-ease’, which are illustrated by the archetypal characters of the Atua (Gods) who personify the spectrum of family and social dysfunction as well as resilience, resolution and well-being.
Mahi a Atua involves the recitation, by the whaiora, their whānau (family group) and the therapeutic team, of these creation stories. The narratives cover generational conflict, fratricidal struggle, gender adversity, incest, bullying, withdrawal and cold-hearted calculating behaviour. But the Atua also demonstrate a range of responses that include love and nurturing, facing uncertainty with courage, empathy and rage, unbridled curiosity and creativity, and endless endurance alongside, forgiveness, devotion, selflessness and remorse. Eventually the creation stories lead to a re-balancing and a resolution of those problems and they articulate for the whaiora and the whānau, the possibility that they too have a healthy future trajectory.
The recitation of these narratives are guided by Mataora who are psychiatric, social, mental health support, education workers and artists, and who are trained as “change agents specialising in Mahi a Atua”. The whaiora and the whānau also contribute to the pūrākau, as they so often can, in a wānanga (a seeking of knowledge) scenario that includes the Mahi a Atua team and the whaiora and all those who come in support of them. This establishes a whānau-like relationship providing a secure, culturally safe base from which the whaiora might embrace exploration of their situation. It also facilitates a multi-disciplinary lens upon the plight of the whaiora and their whānau. The ‘diagnosis’ and the psychiatric format become somewhat secondary to a process of finding culturally relevant meaning and privileging the Te Ao Māori (the Māori world view) voice. The whānau are introduced to particular Atua within the pūrakau, for example Uru-te-ngārara, the oldest brother who became reclusive (and depressed) after he couldn’t cope with the bullying challenges of his younger brother Whiro. Whaiora and whānau are able to contextualise the pūrakau and its characteristics to their own situation and are able to reflect on feelings (in this case of depression) in a manner that can create a shift in awareness. The participation of the whaiora and their whānau, alongside the health professional team of Mataora, in the assessment of the ‘presenting problem’ and development of an ‘empowering resolution’ embeds the ongoing therapeutic process in the context of the wider community.
Advocates point to the rapid development of therapeutic relationships, identification of the ‘problem’ with a Māori lens, the injection of meaning into the pathway ahead, and the sharing of a common set of understood values, beliefs and practices. The process appears to facilitate whaiora to be ‘on board’ rather than in opposition, therapies that are agreed on rather than enforced, a likely increase in ‘talk therapy’ and decrease in medication, involvement of whānau members, and an appreciation of the complex nexus of relationships that make up real life for the whaiora. It frameworks the ‘road to wellness from a difficult place’ rather than a ‘road to recovery from illness.
Narrative therapy is not new. A Western therapist taking a narrative stance is interested in the stories that shape peoples’ lives in their varied cultural worlds and in the ideas, beliefs, social structures and norms that people live by. Techniques include “collaborative positioning of the therapist, externalising the problem, excavating unique outcomes, thickening the new plot and linking the new plot to the past and the future”26 and these can all be recognised in Mahi a Atua. For mentally distressed Māori, Mahi a Atua stimulates or recreates the trusted cultural narrative, which, standing outside of the profound alienation often experienced by them, provides a ‘way forward’ that is not based on the prevailing psycho-medical model. Rather than seeking to identify internal deficit or dysfunction, a ‘narrative therapist’ will be interested in working with people in defining and then exploring the effects of socio-cultural practices on their lives and relationships and how the person became unwell because problems, as well as answers, are understood to be produced within socio-cultural contexts, rather than to reside within the individual, their family or community.
On the East Coast, Mahi a Atua is now part of the front door to mental healthservices. A new ‘single point of entry’ for those who are struggling with mental distress and who don’t meet the criteria for specialist services has been established. This new Te Kūwatawata service is supported by local primary mental health care providers, the District Health Board and the Ministry of Health. It is named after the particular Atua who provides guidance to those seeking entrance into the Māori spirit world, granting or refusing entrance based on his assessment of the particular presenting situation. Mataora, including psychiatrists, psychiatric nurses, social workers, general practitioners, service managers, artists and researchers meet weekly in a fashion redolent of a Journal Club or a Continuing Professional Development group called the Kurahuna (search for the ‘gems’ within). This group facilitates an active learning of the pūrakau of the Atua Māori, a sharing of stories and an incorporation of Mahi a Atua into their own lives as well their clinical life with whaiora and whānau in distress. The larger goal is efficacy, improving clinical outcomes within a constrained resource.
The Te Kūwatawata service is not restricted to Māori, nor is it imposed upon those feeling uncomfortable within its parameters. Neither is Mahi a Atua practice and training restricted to Māori. It is supported across the Hauora Tairāwhiti District Health Board and is being taken up by social, educational, psychological and psychiatric services searching for a new way of engaging with the seemingly intractable mental health problems that present themselves from within the Māori community. This is an approach whose development will be carefully watched by regional health and other service executives, Ministry of Health policy makers and political leaders as an example of how to provide culturally appropriate (mental health) services to the least fortunate and most alienated part of our modern New Zealand community.