The Mental Health Context BC6232

Culture and Mental Health

Rachel Clarke
With thanks to Dr Sarah Coddington-Lawson

Prerequisites for Health (WHO)

The fundamental conditions and resources for health globally are : peace Consider also: shelter Love, Communities and Social Connectedness education food income . economic resources (and their distribution) sustainable resources and stable ecosystem clean water social justice, basic human rights and equity
Improvement in health requires a secure foundation in these basic prerequisites

Determinants of health

The personal, social, economic and environmental factors which determine the health status of individuals or communities (Wilkinson, 2003) A factor or characteristic that brings about change in health, either for the better or for the worse (Keleher, 2006. P4)

Social determinants of health

Social gradient (ie social class or socio-eco status) Ethnicity Stress (effects on health) Early life Social exclusion (poverty, discrimination and racism) Work Unemployment Popular culture Social support Addiction Peer pressure Materialism Food Transport Colonisation Migration

Health and Social Problems are Worse in More Unequal Countries

Index : Life expectancy Math & Literacy Infant mortality Homicides Imprisonment Teenage births Trust Obesity Mental illness incl. drug & alcohol addiction Social mobility

Source: Wilkinson & Pickett, The Spirit Level (2009)

www.equalitytrust.org.uk

Child Well-being is Better in More Equal Rich Countries

Source: Wilkinson & Pickett, The Spirit Level (2009)

www.equalitytrust.org.uk

Drug Use is More Common in More Unequal Countries

Index of use of: opiates, cocaine, cannabis, ecstasy, amphetamines

Source: Wilkinson & Pickett, The Spirit Level (2009)
www.equalitytrust.org.uk

Influences on mental health Psychological & emotional conflicts

Low self esteem lack of confidence loss of hope Loss of mana

Biochemical & neurological disturbances

Chemical imbalances Synaptic failures Mental disorders

Life-cycle crises
identity diffusion alienation de-culturation poor health

Influences on mental health

Interpersonal relationships
Relationships with family & community Unemployment
School failure Homelessness Risk-taking lifestyles Bankruptcy

Disrupted Bereavement Dysfunctional Threatening

Relationships with society

Loss

of usefulness Loss of role Loss of purpose Loss of engagement

WHAT IS CULTURE?
In short can be referred to as a collective sense of identity and belonging.

What is Culture?

Culture refers to the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a group of people in the course of generations through individual and group striving.

Culture in its broadest sense is cultivated behavior; that is the totality of a person's learned, accumulated experience which is socially transmitted, or more briefly, behavior through social learning.

A culture is a way of life of a group of people--the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next.

Culture is the sum total of the learned behavior of a group of people that are generally considered to be the tradition of that people and are transmitted from generation to generation.

Culture is a collective programming of the mind that distinguishes the members of one group or category of people from another

Acts or thoughts that may be considered abnormal but are actually culturally sanctioned

CULTURALLY SANCTIONED ACTS

Talking of we not I

Arctic Hysteria:Terminally Ill (Ritual public suicide):Epilepsy (Talking to God):Hmong Eskimos

(collective tribal identity): - Maori / Pacific / others

Hearing voices (Ancestral): Maori - tupuna / S. America, African nations

Eskimos

Healing practitioners:Maori - Tohunga

Seizures (Powers):-

Insanity (Incest): Navaho Indians

Adoption of female role: Samoa Fafafines

Insanity as Spirit intrusion:Eskimos

Class (socioeconomic status) Gender (Historical context) Noble Suicide (Harakiri)/

Japan

Borneo

Culture Bound syndromes

DSM-IV: 25 culture bound syndromes e.g.

Brain Fags Old Hag syndrome Amok Bouffee delirante Wild Man syndrome Fan death Koro .

What is cultural assessment?

Cultural assessment is integral to cultural safety and the development of effective treatment plans. It is widely accepted by practitioners working in mental health services that cultural identity plays a significant part in the wellness of individuals and their communities whatever the culture. Cultural assessment acknowledges the link between identity, wellness, treatment and recovery. Cultural assessment refers to the process through which the relevance of culture to mental health is ascertained. Cultural relevance relates to the significance tangata whaiora place on their identity as Mori and how they perceive the role of their cultural heritage in assisting them to achieve wellness. The purpose of cultural assessment is to identify a persons cultural needs and any cultural supports or Mori healing practices needed to strengthen identity and enhance wellness.

The assessment should not only be used to help determine the mental state of tangata whaiora, but also as a tool in planning treatment and rehabilitation programmes. It can determine the significance of cultural factors for the person and enable planning of treatment and rehabilitation processes that address cultural issues.
While cultural assessment processes may vary between service providers it is important to remember that they are complementary to clinical assessment and any diagnostic tool, such as DSM IV. Cultural assessment should support service providers to develop and maintain services that are culturally effective and relevant to tangata whaiora and whanau. The outcome of cultural assessment should be a comprehensive treatment and care plan, which includes cultural supports. The information gained from the cultural assessment should fashion the whole clinical care pathway. Mental Health Commission (2004) Delivery of Culturally Appropriate Assessment for Maori. Wellington: Author (pp 3 4)

Why Culture Matters in Mental Health

Striking disparities in mental health care found for racial and ethnic minorities.

Less access to and availability of mental health services

Less likely to receive needed mental health services

Those in treatment often receive a poorer quality of mental health care

Barriers to care include mistrust and fear of treatment, racism and discrimination, and differences in language and communication.

Culture and Health NZ History

Murphy and Leighton 1965 recognised that cultural variables on illness existed. 1960s Community mental health movement Greater attention given to ethnic and cultural characteristics of community health service delivery 1970s Thomas and Sullen, labelled psychiatry as a vehicle for covered racism Indigenous people worldwide voicing concerns 1980s Maori began presenting an alternative view NZ conceding that its attitudes to health and sickness were biased to Western philosophies and practice 1984 First major Maori health hui at Hoani Waitititi Marae in Auckland discussed action not stats 1986 Recommendation by Department of Health that the implications of the Treaty of Waitangi be seriously considered 1988 Department of Health included statement of corporate intent Accepts biculturalism as a desirable goal Te Puawaitanga (2002) Maori Mental Health National Strategic Framework 1997 (Durie) rate of mental illness for Maori have increased since 1975, although they have decreased for a number of primary health problems

http://www.tepou.co.nz/supporting-workforce/lets-get-real

You can access this through Te Pou and use it as a personal resource for developing your learning

Working with Mori

Essential level learning module

Question:

What are the fundamental conditions and resources necessary for health and wellbeing ? Look in small groups at the policies; organisations and resources that support mental health in the different populations Maori, Pacifica, Asian, Immigrant, Refugee, LGBTT.

Resource Links

Look at Te Pou: http://www.tepou.co.nz/story/2013/11/13/meeting-the-needs-of-gaylesbian-bisexual-and-transgender-people---why-it-matters-and-how-todo-it http://www.leva.co.nz/ http://www.matuaraki.org.nz/ http://www.tepou.co.nz/improving-services/asian-refugee-migrant Look at MOH http://www.health.govt.nz/our-work/populations Maori / Pacific / Refugee / Rural / Asian & Migrant Look at Affinity http://www.affinityservices.co.nz/resources/ Look at the Australian Clearinghouse http://203.32.142.106/clearinghouse/

Pacific Information
http://www.networknorth.org.nz/file/Resources/pacific-model-of-care-lores-copy.pdf

http://unitube.otago.ac.nz/file.do?m=5PLC1cY kw6A&name=Kingi_Te_Kani.pdf

Click on this link if you wish to view this resource

Emerging approaches to Diagnosis

Kaupapa Maori Approaches Pasifika Health and wellbeing approaches Positive Psychology (next class)

Underpinned by Social Determinants of health

Kaupapa Maori Assumptions

Foundations Maori knowledge Maori health perspectives

Engagement Cultural customs with clients Whnau sponsorship

Assessment Cultural profile Relationship map Cultural interevntion plan

Interventions Rongoa Cultural therapies Cultural affirmation Conventional therapies Outcomes Wellbeing (spiritual, mental, physical, family/social)

Clinical Assumptions
Foundations Science Evidence based approaches Engagement Patient consent with clients Professional codes Assessment Diagnosis Risk & level of acuity Treatment plan

Interventions Medication Psycho-social programmes Psychological therapies Outcomes Symptom reduction Functional capacity (SF 36)

The Cultural Clinical Interface

Maori knowledge Maori health perspectives Foundations Science Evidence based approaches

Cultural customs Whnau sponsorship

Engagement Patient consent with clients Professional codes

Diagnosis Risk & level of acuity Treatment plan

Cultural profile Assessment Relationship map Cultural intervention plan Rongoa Cultural therapies Cultural affirmation Conventional therapies Wellbeing (spiritual, mental, physical, social)

Interventions Medication Psycho-social programmes Psychological therapies Outcomes Symptom reduction Functional capacity (SF 36)

THE GOAL

Greater balance

Value of traditional belief systems + Incorporation of Western medical practice

THE MODELS

Te Whare Tapa Wha (Durie 1985) All sides are needed to maintain strength, and ensure shelter

http://www.health.govt.nz/our-work/populations/maori-health/maori-healthmodels/maori-health-models-te-whare-tapa-wha

Te Wheke (Pere 1984) Putangitangi (Davies, Elkington and Winslade 1993)

TE WHARE TAPA WHA

Mason Durie Maori views on health emphasised aspects different to conservative Western views. His model, first presented at hui in Hamilton and Otaki, was received enthusiastically at marae in several parts of the country and was often quoted as the Maori health perspective. The model compares health to the four walls of a meeting house

TE WHARE TAPA WHA

Although each wall might be examined separately, all sides of the house are equally necessary to maintain strength, ensure shelter and give coherence. According to Maori tradition, and giving greater meaning to the model proposed by Durie (1985a), a tribal meeting house often represents an ancestor, and within its structure parts of the body are symbolised.

Each wall was seen to represent a different aspect of health: te Taha Wairua, a spiritual component te Taha Hinengaro, a psychic component te Taha Tinana, a bodily component te Taha Whanau, a family component.

Te Taha Wairua

Whereas there had been an overwhelming Western emphasis on the physical aspects of health and illness (Taha Tinana), Maori emphasis had been at a spiritual level (Taha Wairua), sometimes even at the expense of other aspects. Good health equated with an appreciation of, and an ability to experience, the unspoken influence: of others, the dead, the environment, and links between them. Poor health reflected: an absence of a personal or collective spirit and no degree of physical fitness could compensate for an impoverished soul.

Te Taha Tinana

Bodily health, te Taha Tinana. recognised a physical substrate for health though not in quite the same way that anatomists might.

For one thing, certain parts of the body, and the head in particular, were regarded as special (tapu or sacred). Furthermore, bodily functions such as sleeping, eating, drinking and defecating were imbued with their own significance reflecting various levels of importance and requiring quite different rituals. Eating food, for example, was a leveller which removed any vestige of sacredness or distance (as between people).

Te Taha Tinana
Maori emphasis on clear separation of Tapu and Noa Tapu Head and Genital areas regarded as special of Tapu Sacred and under restriction, beyond ones power Head Housing the brain (hinegaro or think tank) Genital Housing Te Whare Tangata or ability to reproduce and there continuation of whakapapa tribal perpetuation Noa Free from Tapu, ordinary, absent from limitation, within ones power Food removes any vestige of sacredness as does water making one Noa or Whakanoa (to make free from restriction) Thus the need to a group of people to join in a cup of tea immediately after the welcoming ceremony onto a Marae Also the ritual of washing of throwing water over the body immediately after visiting a deceased body lying in state or a burial

Te Taha Hinengaro

Te Taha Hinengaro, (thoughts and feelings) was seen as a second fundamental component of health. Though similar to 'mental health', it was also different in that Maori views did not regard the separation of thoughts and feelings as valid. Equal weight was placed on emotional and verbal communication without an expectation that emotional expression was ultimately only of value if it could be converted into a verbal statement. Similarly, Maori placed greater value on thinking which was integrative and holistic, rather than analytical. Understanding came from being able to locate an event or comment or situation in a wider context. Microscopic explanations held little sway.

Te Taha Whanau

Taha Whanau acknowledged that an individual could not exist, healthily, in isolation, particularly from the extended family.
Independence, to the extent that the group was shunned or even avoided, equated with poor health while a close and reciprocal relationship with the whanau (family) was seen as conducive to good health.

TE WHEKE
Pere (1984)

The octopus, Te Wheke, is used to illustrate the major features of health The eight tentacles of the octopus symbolise a particular dimension of health The body and head represented the whole family unit. The intertwining of the tentacles indicated the close relationships between each dimension.

Te Wheke

Like te Whare Tapa Wha the model includes: wairuatanga (spirituality) taha tinana (the physical side) hinengaro (the mind) whanaungatanga (the extended family, similar to taha whanau).

Pere also promotes the dimensions of:

mana ake, i.e. the uniqueness of the individual and each family, and the positive identity based on those unique qualities mauri, the life-sustaining principle resident in people and objects, including language ha a Koro ma a Kui ma, literally the breath of life that comes from forebears, and an acknowledgment that good health is closely linked to a positive awareness of ancestors and their role in shaping the family whatumanawa, the open and healthy expression of emotion,necessary for healthy human development waiora, total wellbeing for the individual and the family, represented in the mode by the eyes of the octopus.

Putangitangi
The Putangitangi is a colourful duck, which is indigenous to Aoteoroa. Its natural habitat may include four distinct domains: the sky, the sea, the land and the rivers of Aoteoroa. At any one time Putangitangi may inhabit any one of these domains but as a bird it may move with ease from one habitat to another. Its natural characteristics as a species grant it the flexibilty to traverse with comfort the boundaries between sky, sea, land and river. At any one time we may observe Putangitangi and see it busy living out its destiny in one habitat, without conceiving of the whole range of its habitat possiblilites or of how these might fit together in a life. These characteristics make Putangitangi useful as a metaphor of our understanding of Maori worldviews.
Davies, S., Elkington, A., & Winslade, J. (1993). Putangitangi: A model for understanding the implications of Maori intra-cultural differences for helping strategies. New Zealand Association of Counsellors Journal, 15, 2-6.

Effects of Dominant Culture

Strength of Cultural Identity

River Sky Land Sea

Effects of Dominant Culture

Strength of Cultural Identity

Meandering Open for in and out expansion

Grounded

Adrift

Effects of Dominant Culture

Strength of Cultural Identity

Western or Indigenous Models

Western Models
Mixture of Western or Indigenous Models

Indigenous Models

Readings

Durie, M. (2009). Maori Knowledge and Medical Science: The Interface Between Psychiatry and Traditional Healing in New Zealand. In M. Incayawar, R. Wintrob, L. Bouchard & G. Bartocci (Eds.), Psychiatrists and traditional healers: Unwitting partners in global mental health (pp. 238-248): John Wiley & Sons. http://books.google.co.nz/books?id=Su9Zhe3HglsC&pg=PA248&d q=Durie,+M&hl=en&sa=X&ei=QXGIUsb_AarAiQe99oGAAw&ved=0 CDAQ6AEwATgK#v=onepage&q=Durie%2C%20M&f=false http://www.treasury.govt.nz/publications/mediaspeeches/guestlectures/pdfs/tgls-durie.pdf/at_download/file

Pasifika Models

http://www.leva.co.nz/

Fonofale model Samoan holistic model that recognises that Pacific peoples health is best nurtured within the social context. Based on Pacific perspectives it proposes that the mental health of Pacific people is intrinsically bound to the holistic view of health and greater application of Pacific health models is required including establishing and maintaining links between mental health primary health and social services (Mental Health Commission 2001:6).

Samoan Fonofale Model of

Health (Pulotu-Endemann, 1995)

FonoFale Model
Four Pillars of wellbeing supporting Pacific culture.
It is set in the wider context of time and the environment

FonoFale Model
The Roof-represents pacific peoples culture shelter for life Culture-incorporates the philosophical drive and attitudes. It can also include systems of belief that might be limited to traditional methods of healing or the use of Western trained health professionals

FonoFale Model
The Foundation: is the nucleus and extended family which forms the basis of social organisations for Pacific Peoples. The family provides the base that supports the four posts. Spiritual: the sense of wellbeing which stems from a belief system which can include Christianity, traditional spirituality or a combination of both

Four Posts

Physical: the biological wellbeing of the body which can be measured by the absence of illness and pain Psychological/mental: the non-physical aspects of the health of the mind Other: this includes things such as gender, employment, sexuality, age, etc

The cocoon
Environment: relationship and uniqueness of Pacific people in relation to their physical environment (rural or urban). Time: Time in history and how this impacts Pacific people Context: influence of Island-reared identity and NZ-reared identity. Other contexts include politics and socio-economic

PRESENTATIONS OF MAORI

Later presentation for treatment Increased acuity levels Referrals from law enforcement and welfare services (38%) Early intervention is not accessed Cultural identity not being recognised, asked about, etc

Shame/Whakama
Te ao Maori the uniqueness of Maori (As opposed to the socioeconomic disadvantages and disparities equalled with being Maori)

What ethnicities do you identify with? How willing are they/Do they want to discuss cultural issues with you? What is their knowledge of whakapapa, reo, tikanga etc What is their perspective on their presentation/Why are you here? What is their perspective on their beliefs, identity, relationships, AOD use, mental health etc? What is their whanau involvement? What cultural supports do you have? What cultural supports do you want? What do you consider to be treatment options? What would work/wouldnt work for you?

Possible Cultural Screening Questions

Bridging the Cultural-Clinical Divide

Provider experience Hauora Waikato

An integrated approach to care and treatment A personalised recovery model

Essentially the Integrated Personalised Recovery Plan (IPRP) is a: client centred strengths based recovery focussed model Holistic and culturally focussed model.. That ensures all domains including culture are assessed and integrated treatment plans are developed that support resilience, healing and relevant measurable outcomes.

Towards an Integrated Personalised Recovery Plan (IPRP)

There are limitations in a treatment plan based only on diagnosis

There are also limitations in a plan for intervention based only on indigenous paradigms Limitations can also arise if consumer autonomy determines the total approach to treatment and care What is needed is an integrated recovery plan based on a comprehensive formulation

Integrated Personalised Recovery Plan

A plan for treatment and care that:

is unified is able to respond to all dimensions of recovery incorporates recovery principles adopts a positive attitude to long term outcomes

A Framework for Considering an IPRP

Aims Domains of Recovery Recovery principles

IPRP

Domains of Recovery

Clinical domains

Diagnosis & treatment; alleviation of symptoms; syndrome management

Cultural domains - indigeneity

endorsement of world views, safe engagement with services, strengthened identity

Health domains

Improved health status (Mental-physical co-morbidities, obesity, heart disease, primary health care)

Family domains

Family/whnau ongoing care; site for mediation of culture, relationships

Societal domains
greater participation in society education, employment, housing, income, recreation

IPRP
1.

Recovery Principles

Personalised recovery
consumer centred, personal values, culture, indigeneity, the therapeutic relationship

2.

Human potential and resilience over time

Adversity should not mask potential; identification of areas of personal strength and future development

3.

Multiple healing pathways

Choice as to intervention, methods of deliver

4.

Collaborative leadership

Professional e.g. nurse, psychologist, psychiatrist, SW; PHC in future Consumer e.g. Consumer advocate, consumer advisors Community leadership e.g. cultural advisors, kaumatua

5.

Relevant outcomes
Measurable gains & benefits that are meaningful to consumers

Recovery as a Integrated Personalised Process

Broad aims
Optimal health Enhanced wellbeing

Domains of Recovery
Sites of intervention
Clinical Indigenous Health Family Societal

Recovery Principles
Personalised recovery Human potential & resilience Multiple healing pathways Collaborative leadership Relevant outcomes

An Integrated Personalised Recovery Plan

Pre-conditions for Change

A client-centred approach
A shift from a deficit approach towards a model of potential Co-ordination and collaboration across the mental health network of provision (including the primary care sub-sector) A mentor who can work across recovery domains (clinical, indigenous, health, family, societal) Durie,M (2007)

Other Cultures?

CULTURAL INTEGRATION OVERSEAS

Culturally Influenced Perceptions/Barriers

Chinese Native Americans
Associate MHP with other pervasive illnesses (alcoholism) in their community. Believe relapses can occur and a full recovery to be almost impossible. Some distrust of white institution. View MHP through a narrow lens of pressure and performance. Pride, avoidance of shame, and not losing face inhibit many from asking for help and treatment, although many believe that recovery is possible.

African Americans
MHP reflect the inability to cope with lifes challenges. Often too occupied with other priorities, responsibilities, and challenges to dwell on mental health. Years of discrimination have honed a deeprooted pride, that inhibits AAs from admitting to mental issues, which equate to weakness.

Hispanics
Perceive MHP as intrinsic to the acculturation and immigration process. Depression is often seen as a weakness of character.

A visually based recovery tool for The Aboriginal and Islander Mental health initiative AIMHi (see following slides)

Yarning about Indigenous mental health: Translation of a recovery paradigm to practice. Abstract of article Mental health practitioners struggle to translate recovery paradigms into practice. Changing from a focus on remediation of symptoms to a focus on reclaiming life in the community and enhancing protective factors requires a new approach. One new approach that particularly challenges health providers is the equalising of traditional patientservice provider relationships. Given the additional issues of disempowerment and social disadvantage of Indigenous peoples in Australia, equalising relationships and embedding recovery values for Indigenous mental health clients especially require urgent attention. There is also a need to learn more about the meaning of recovery in the Indigenous context and the ways in which it differs from non Indigenous interpretations. The Aboriginal and Islander Mental health initiative (previously the Australian Integrated Mental health initiative) has developed resources and training which seek to address this gap. The resources support a culturally adapted strengths-based approach to assessment and early intervention and are increasing popular in mental health, alcohol and other drug and chronic disease settings. Indigenous people with mental illness are subject to additional complex and toxic combination of social disconnecting factors. Culturally adapted recovery approaches to Indigenous mental illness are thus an important component of closing the gap in Indigenous health. Citation: Tricia Nagel; Rachael Hinton; Carolyn Griffin (2012). Yarning about Indigenous mental health: Translation of a recovery paradigm to practice. Advances in Mental Health: Vol. 10, No. 3, pp. 216-223. doi: 10.5172/jamh.2012.10.3.216

Yarning about mental health with the AIMhi Stay Strong Plan

Discussion/Sharing topic

How can we make our services culturally safe: For clients? For clinicians/counsellors? What open questions might we ask that explore how people are connected to or supported by their whanau or community?

How can your family or community help you with this problem?
Acknowledgement: Pacific Team, HVDHB. A presentation on Pacific health, 2013