Durie (2007) acknowledges that cultural barriers can influence the care provided. Not being able to effectively communicate due to lack of understanding of language or custom is a large contributor towards this. Without an understanding of the cultural dynamics, clinicians can misinterpret spoken and body language. Therefore the importance of cultural competence and safety should not be ignored. This is certainly a worry when reviewing Johnstone & Read’s (2000) research where a survey of psychologists and psychiatrist opinions was taken on Māori mental health. There were 692 respondents, of which 38% of psychiatrists and 28.9% of psychologists believed that they did not have enough knowledge in Taha Māori to work effectively with Māori clients. 49% of psychiatrists and 73.2% of psychologists indicated that their training had not prepared them to work effectively with Māori clients. One should also remember that there is a percentage of the workforce are trained overseas. There were, however, a few racially disappointing comments, one of which articulates a strong racist belief and stereotypical viewpoint:
This questionnaire is worthless! I mean the Māori are always going on about the importance of land etc, so why the hell did they give it away, I feel that they are getting the appropriate services they need, just not using them, medication is the answer – but they just don’t take their pills – if cannabis was prescribed I’d bet they’d bloody take that, my effectiveness as a psychiatrist is not depending on the colour of my skin, my culture, nor my understanding of the bloody Māori culture. (p. 142)
Even though the negative comments came from a very small minority, it indicates and is concerning that individuals with these attitudes are practicing in New Zealand. The majority of respondents understood and could describe reasons why Māori were over-represented in psychiatric institutions. Unfortunately, the minority of respondents who held discriminative stereotypic views of Māori leave a sour taste and concern for tangata whaiora/service users in their care.
Even when using clinical assessment tools, a Barker-Collo (2003) study found that within a New Zealand student sample, cultural identity affected performance on scales. They suggested that on measures of psychopathology, different cultures will perform differently
given the differences in perceived normality. This then can skew results and needs to be factored in when developing treatment or recovery plans. Cherrington (1994) and Sachdev (1989) both found that Māori patients referred to cultural themes and/or beliefs when explaining their symptomology. These were not necessarily considered pathological by tangata whaiora in a cultural context, but from a biomedical view they were aligned to hallucinations and delusions.
The clinician-tangata whaiora relationship is pivotal given that the majority of the New Zealand health workforce are non-Māori. If there is, as Cram, Smith & Johnstone (2003) suggest, a cross culture nature of many Māori patient/Pākehā doctor interactions that sets the platform for miscommunication and negative experiences, then existing disparities will continue and may even widen. Interestingly enough, while there is a small beacon of light around the growth of Māori workforce development capacity, only 3.1% of the medical workforce are Māori doctors (Cram 2010).
Rapport is one of the key facilitators for Māori access to healthcare. While there is currently no set requirements to practice sensitively, there is a need for clinicians to be aware of cultural sensitivity, including the process of care delivery (Tipene Leach 2004; O’Brien, Boddy & Hardy 2007; Ministry of Health 2004).
Ihimaera (2004) undertook a study on a pathway to understand taha wairua (spirituality) in mental health services. She distinguishes between culture and spirituality and the importance for clinicians to understand religion and spirituality beyond the DSM-IV framework. Clinicians, however, can struggle in their understanding of how cultural interventions can assist to improve mental health. Selvarajah's (2006) study involved clinicians working at nine mental health units in the Auckland region. Sevlarajah (p 65) suggested that those 'staff professional status, ethnicity and ability to speak more than one language, may influence the staff member's desire to learn more about counselling across cultures' which synergises with his finding that there is a lack of cross cultural counselling in the Auckland area. Kirmayer, Brass & Tait (2000 p 614) highlight that ‘psychiatric practice must be adapted to local cultural concepts of the person, self, and family that vary across Aboriginal communities’.
It is more than timely that existing tertiary institutions cater and embed dual competencies within their prospectus.
There are an ample range of frameworks designed to enhance cultural competency. Whealin & Ruzek (2008) developed a ten-step framework to enhance cultural competence which
included organisational infrastructure; staff assessment, knowledge and cultural diversity; and service delivery and review. Ihimaera (2004) offers a template of tikanga processes, providing a healing rationale of why tikanga is followed, when it is applicable in a mental health service setting, and the benefits of its application. For example, ‘whakapapa’ acknowledges significant relationships of kin and non-kin persons, it is applicable in all cultural and clinical interactions, and one of the benefits is that it endorses whānau involvement in all aspects of care. It is a baseline template that could be embedded in tertiary institutions across the wider health sector.
The Takarangi Competency Framework is focussed on staff working within the addictions fields and outlines competencies clinicians need to effectively work with Māori46. The framework synergises both cultural and clinical aspects of practice underpinned by 14 essence statements. These statements include aro matawai (assessment and ongoing monitoring), pōwhiri (transactional engagement), mihimihi (structured communication), aroha (empowering action), whakawhanaungatanga (multiple system dynamics), manaaki (honouring and respecting), tātai (effective documentation), tautoko (effective support), ahu whenua (consideration of the use of the environment), ngākau mahaki (unconditional positive regard), te reo (effective communication), karakia (the means by which spiritual pathways are cleared), tuku atu tuku mai (reciprocity), whakawhangahau (celebrating effective transition and service).
Te Pataka Uara47 is under development predominantly for Whānau Ora navigators and practitioners. This has seven core principles as the framework, whānaungatanga, wairuatanga, matakitetanga, manaakitanga, kaitiakitanga, awhinatanga, and rangatiratanga. Let's Get Real48 is the mental health and addictions overall workforce competency framework. One of the ‘seven real skills’ is that every person working in the mental health and addiction field contributes to whānauora for Māori. In this sense, working with Māori requires a range of skills including Te Reo Māori, waiata, karakia, whakawhānaungatanga, Hauora Māori, wairua, tuakiri tangata and manaaki.
Frameworks such as these continue to support the enhancement of providing clinically and culturally responsive services to Māori.
46 http://www.matuaraki.org.nz/library/matuaraki/takarangi-competency-framework-workshop-resources 47 www.matatini.co.nz 48 www.tepou.co.nz