Maea te Toi Ora: Maori Health Transformations

By Huia Publishers

In Maea te Toi Ora: Māori Health Transformations Māori clinicians and researchers explore the relationship between Māori culture and Māori mental health. The six contributing authors in the collection are Simon Bennett, Mason Durie, Hinemoa Elder, Te Kani Kingi, Mark Lawrence and Rees Tapsell and are all well-known in the mental health field. Each discusses aspects of Maori and indigenous health and the importance of culture to diagnosis, patient history, understanding causes, treatment and assessment of outcomes. Along with a discussion of current research into and knowledge about health and culture, the authors provide case studies from their own experiencesof working with Maori to restore well-being.

• Language: English
• Publisher: Huia Publishers
• Release date: Jan 20, 2018
• ISBN: 9781775503460

Book preview

INTRODUCTION

TE KANI KINGI

Research into Māori mental health has been neither extensive nor consistent, and for these reasons, building a comprehensive profile of patterns and trends has always been a challenge. Notwithstanding these difficulties, it is possible to gain an understanding of relevant concerns, highlight major issues and, at least, review the existing research and available evidence.

This introductory chapter carries out that purpose, providing a foundation for the book and a rationale for its focus on Māori mental health. Until recently, data on Māori mental health was at best vague, and it was difficult to determine the extent to which mental health problems affected Māori. While research and enhanced data collections have improved our understanding of contemporary issues and concerns, plotting the history and development of Māori mental health has been far more challenging.

Inconsistent and unreliable data have often prevented accurate trends and patterns from being established. While historical and anthropological accounts provided some early insights, they too lacked robust analysis, were frequently based on anecdotal accounts and were often subject to cultural bias and misunderstanding.¹ The perspectives were too often derived from the impressions of non-Māori: those unfamiliar with Māori society, who were, ultimately, unable to divorce their own cultural bias from clinical assumptions.

The issue of diagnosis and interpretation of illness was a major concern. While afflictions of the body would manifest in tangible forms, diseases of the mind were less audible, less understood and more open to incomplete interpretation and prejudice. Putting aside the complexities of diagnosis, mental health problems can be defined according to a set of parameters that govern the extent to which behaviour is accepted or otherwise classified as abnormal. Often these parameters are founded on notions of normality, which, more often than not, are grounded in cultural bias. What is rational and clear in one system of knowledge may become distorted and misread if it is analysed within the constructs of another.² Normal and/or acceptable behaviour in one culture may be viewed as alternative, different or even psychotic within another. An early description of a Māori haka, for example, was a ‘formal frenzy’ performed by a ‘mob of maniacs, swayed by one insane volition’.³

Illustrations such as this reveal the challenge of interpreting historical descriptions as evidence of mental health or illness. Nonetheless, the earliest impressions of Māori mental health were inevitably informed by the perspectives of non-Māori, however flawed and regardless of their accuracy and intent. A cautious and considered approach is therefore needed when examining what was written, what was said and what was implied.

Putting these issues aside, there are at least two broad conclusions that can be made about Māori mental health. The first is that mental illness (as defined according to Western criteria) is likely to have existed within Māori communities before European contact. This conclusion is simply based on the notion that mental disorders have been known to occur within all cultures and that it is most unlikely that Māori alone could have developed the means, biological or otherwise, by which such conditions (now termed mental disorders) could have been avoided.⁴ Linguistic and literary evidence also suggests the existence of problems specifically related to the mind. Terms such as pōrangi, wairangi, poorewarewa, haurangi and pooteetee are often used by Māori to describe individuals considered to be mad or out of their mind.⁵ Leaving aside the difficulties in equating these words with psychosis or other serious disorders, the words themselves suggest a departure from the norms of the community and at least a recognition of abnormal states of mind.

Within traditional waiata, further examples of mental distress can be found. The Ngāti Whakaue waiata tangi ‘Te Atua Matakore’ was composed as a lament for Te Matapihi o Rehua and recounts a battle between his people of Ngāti Whakaue and Ngāti Tūwharetoa. Concerned that his close friend would be leading the Ngāti Tūwharetoa war party, Te Matapihi o Rehua refused to take part in the battle. His younger brother Te Whanoa then stepped forward and consequently guided Ngāti Whakaue to victory. Feeling he had brought shame to his people, Te Matapihi o Rehua took his own life by drowning himself in lake Rotorua.⁶ Even when accounting for our imperfect understanding of the circumstances that led to this event, it is known that the act of suicide is most typically preceded by significant emotional turmoil (often stress or depression).

In considering how these types of manifestations of the mind might have been perceived by Māori, Sachdev⁷ draws a number of conclusions. He supports the idea that mental illness was unfamiliar to Māori and that issues commonly associated with insanity or psychological disability would have been explained through transgression of sanctity. In essence, these transgressions resulted in a ‘state of mind’ rather than an ‘illness of the mind’. It was therefore these transgressions that were the ultimate cause of the abnormal state.⁸ Beaglehole held a similar opinion:

… the phenomenon of mental disease brings a catch of anxiety and fright to the Maori (as it has to the Pakeha in the past and still does to many Pakeha today) which he tries to understand in terms of a world of obscure spirits interfering for good, but often unknown reasons, with the normal workings of the body and mind. It is natural that the Maori should seek aid from the one person, the curing Tohunga, who claims to understand the workings of these spirits and therefore believes that he can control them.⁹

While both Beaglehole and Sachdev appear to support the idea that mental illness was unfamiliar to Māori, they do not rule out the presence of abnormal states and the use of cultural paradigms to explain them. However, in the end, they favour a Western view and appear to regard the Māori explanation as a proxy for more informed opinion.¹⁰ That is, cultural frames were often used by Māori to explain issues that (in their mind at least) were clearly evidence of mental illness.

The second assumption about Māori mental health leads on from the first and centres on the idea that the current comparatively high rates of Māori mental illness are a recent phenomenon. Again, the available data are scarce and should be interpreted cautiously,¹¹ yet it is sufficiently consistent enough to suggest that mental health problems were not of major concern to Māori in traditional times.

A broad analysis of writings on Māori during the 1800s reveals the emergence of two main themes. The first is that early descriptions of Māori (at least in terms of their health and well-being) were largely positive. Life expectancy was on a par with other parts of the world, and while the population was not immune to illness and disease, the impression was that of a sophisticated society that was healthy, robust and resilient. The second is that by the end of the century an entirely different picture was presented and real concerns were being raised about the ongoing survival of the race – whether or not Māori would be extinct within a generation or two. In 1814, John Liddiard Nicholas, a London iron founder, accompanied Samuel Marsden on a journey of exploration to New Zealand. The expedition was intended to establish a Christian mission, though it also provided an opportunity for Nicholas to observe Māori and to later publish a two-volume book on his observations. An extract is provided below:

I never thought it likely they could be so fine a race of people as I now found them. They generally rose above the middle stature, some were even six feet and upwards, and all their limbs were remarkable for perfect symmetry and great muscular strength. Their appearance … was pleasing and intelligent.¹²

Other observations were even more revealing and provided additional insight into the public health behaviours and nutritional habits of Māori:

So simple a diet accompanied with moderation must be productive of good health, which indeed these people are blessed within a very high degree … I do not remember a single instance of a person distempered in any degree that came under my inspection and among the numbers of them that I have seen naked. I have never seen any eruption on the skin or any signs of one by sores or otherwise. Such health drawn from such sound principles must make physicians almost useless.¹³

While it would be misleading to suggest that Māori were immune to illness and disease or that the stresses and strains of living were not significant, these observations provide useful descriptions of daily life, the values that shaped Māori behaviours and the comparative light in which Māori were viewed.

It was not long, however, until less positive observations of Māori were being reported. As early as 1837, some disturbing trends were beginning to emerge. In a dispatch to his superiors in England, James Busby (the then British Resident) described the ‘miserable’ condition of the native population and the desperate need for active intervention. Failure to do so, he believed, would certainly leave the country ‘destitute of a single aboriginal inhabitant’.¹⁴

In spite of Busby’s dire warnings, the Māori population continued to plummet throughout the 1800s. In an assessment of the Māori predicament, Dr Isaac Featherston commented that the extinction of the Māori race, while regrettable, was scarcely a point for much conjecture:

The Maoris are dying out and nothing can save them. Our plain duty, as good compassionate colonists, is to smooth down their dying pillow. Then history will have nothing to reproach us with.¹⁵

Colenso’s predictions were even more unsympathetic:

Taking all things into consideration, the disappearance of the race is scarcely subject for much regret. They are dying out in a quick, easy way, and are being supplanted by a superior race … The Maori has lost heart and abandoned hope. It [the race] is sick unto death, and is already potentially dead.¹⁶

From an estimated population of 150,000 in 1800, Māori numbered a mere 42,000 by 1896. Māori entry into the twentieth century was both unexpected and unspectacular. The population decline was anticipated to continue. Within a few decades it seemed likely that Māori would only exist as historical curiosities, in anthropological texts or as unique genetic markers within a European population. Yet, the twentieth century was far more sympathetic to Māori. The population began to grow, slowly at first, and eventually a recovery occurred and with it a growing enthusiasm and confidence in the future. In fact, the Māori population is now larger and living longer than at any other time in our history. And, although major health concerns and disparities remain, the threat of extinction no longer exists.¹⁷

These early accounts of health and social and demographic change reveal much about the challenges faced by Māori as well as the predictable consequences of colonisation, conflict, land alienation and introduced diseases. However, they also provide insight into the issues that occupied the minds of writers and those charged with documenting the plight of Māori. Insofar as health concerns were described, they tended to focus on the pernicious effects of introduced diseases, such as influenza, diphtheria, tuberculosis, goitre and measles and observations of morbidity, mortality and malnutrition.

Amidst the various accounts of Māori ill-health, while there is concern, there is an absence of information about Māori mental health or psychological distress. While it would be unreasonable to imply that a lack of information should necessarily equate with an absence of illness, it does suggest that other health concerns were afforded more attention and were of higher concern. If mental health problems were of particular interest, they were certainly not worthy of any special mention – at least they are not seen when reviewing historical texts, transcripts and manuscripts.

In support of this idea, Gluckman observed that the insanity rate for Māori at the turn of last century was about a third that of non-Māori.¹⁸ Beaglehole’s investigations in the mid-1940s further noted the apparent lack of mental disorder within the Māori community and that Māori appeared to be less susceptible to emotional and mental problems:

… the incidence of all types of mental disorder among Maoris was about one third that of the pakeha incidence. An earlier investigation into the relative incidence of the major functional psychotic disorder among the inmates of New Zealand mental health hospitals shows that these disorders occur about half as frequently for Maori as among pakeha inmates. A similar difference exists in the incidence of war neurosis among Maori and pakeha soldiers. According to the report of the New Zealand Rehabilitation Board 14 per cent of the demobilized pakeha returned soldiers are classified as psychiatric cases whereas only 7 per cent of the Maori returned soldiers are so classified.¹⁹

Later investigations produced similar results. In 1951, Blake-Palmer reported that the incidence of Māori admissions to psychiatric hospitals was less than half that of the non-Māori population.²⁰ In 1960, 60 in every 100,000 Māori were admitted for the first time to a psychiatric hospital compared with a non-Māori rate of 119 per 100,000.²¹ In 1962, Foster further noted that for both males and females, lower admission rates for Māori, in all age groups and for most disease categories, could be expected.²² Psychoneurosis, for example, accounted for only 7 per cent of all Māori first admission compared with the corresponding non-Māori rate of 21 per cent. In addition, the rate of psychosis related to old age was much higher for non-Māori. Alcoholism and manic-depression were also lower. Various anecdotal accounts further supported what was being observed:

I worked at Oakley Hospital in the years shortly after the Second World War … There were more than one thousand patients in the hospital … of whom six were Maori.²³

In the end, it is difficult to describe with absolute certainty a definitive historical account of Māori mental health. The information to do so simply does not exist. Yet, there is sufficient support for the two assumptions made previously: while Māori have never been immune to diseases of the mind, until recently, mental ill-health was not a significant concern.

MORE RECENT PATTERNS AND TRENDS

In contrast to the issues raised previously, the past forty years have been characterised by a significant and dramatic increase in the number of Māori accessing mental health facilities. The implications have been considerable and have led, in part, to the development of Māori-specific treatment facilities and an increased emphasis on specific mental health policies for Māori.

Until very recently, much of the data on Māori mental health (in terms of patterns and trends at least) was largely (though not exclusively) based on hospital admissions. As noted, researchers have been reluctant to use this information, or they do so in a very cautious manner. One primary concern is that admissions data simply cover those who access treatment and reveal little about community prevalence. As non-psychotic conditions are often treated in outpatients services, it is also unlikely these people will be consistently included in such data sets.²⁴ Admissions data likewise fails to account for why people use particular services, when they use them and why they choose to use them.²⁵ In the absence of routine data collection, it is also difficult to establish contemporary trends, issues and gains beyond the hospital. Of similar concern is the contention that many Māori who require treatment do not receive it, or only do receive it at a late stage. In this respect, worries about the high numbers of Māori hospital admissions might need to be balanced by the high numbers who warrant hospitalisation but never gain admission.²⁶

Problems and inconsistencies associated with defining ethnicity have further compounded efforts to establish accurate profiles. Several definitions have been used to classify, consider and determine Māori ethnicity, the characteristics of which have changed over time, along with the methods of collection.²⁷ As a result, it has been difficult to compare or to cross-tabulate the data sets from various sources. In spite of the lack of quality data, numerous investigations,²⁸ research reports²⁹ and policy documents³⁰ have highlighted the poor state of Māori mental health. Many of these have relied on admissions data, though some have utilised anecdotal accounts as a supplement.

As touched on previously, one of the more well-considered and documented trends concerns the growth in Māori mental health admissions during the mid-1970s. While historically Māori had been low users of psychiatric facilities, from about 1975 onward it became increasingly clear that the whole pattern of Māori hospitalisation for reasons of mental health was changing. By the mid-1980s the rates of Māori psychiatric admissions were two, and in some categories three, times that of non-Māori. Problems related to alcohol and drug misuse were particularly evident over this period, though additional concerns were linked to the manner in which Māori were accessing psychiatric facilities. Increasingly, large numbers were being admitted under compulsion, through the justice system, rather than through conventional medical referral systems.³¹

Between 1960 and 1990, non-Māori first-time admissions to psychiatric facilities had only slightly increased.³² However, the corresponding Māori rate (over the same period) was more than 200 per cent.³³ Between 1980 and 1991, suicide rates for Māori males had also increased by 162 per cent. Although suicide rates for young Māori and non-Māori were relatively similar, there was some evidence to suggest that the true rates for Māori were likely to have been much higher.³⁴

Māori readmissions were cause for further concern. Readmission rates for Māori males increased by 65 per cent between 1984 and 1994, nearly two times higher than non-Māori male rates and three times higher than corresponding Pacific Island rates. While showing an overall decrease, admissions for drug and alcohol disorders emerged as a major concern for young people, but especially Māori.³⁵ At one time, psychosis and alcohol and drug abuse accounted for almost a third of first-time Māori admissions. Māori readmission rates for affective disorders and psychotic illness (other than schizophrenia or drug or alcohol psychosis) were higher than corresponding non-Māori rates by 36 per cent for women and 75 per cent for men.

Various studies have also revealed that Māori are over-represented in terms of acute psychiatric admissions.³⁶ Other investigations have further suggested that Māori spend on average 40 per cent less time in hospital (for mental health problems) compared with non-Māori, in spite of being admitted for more serious diagnoses.³⁷

In spite of what these statistics reveal, no biological or genetic drivers (linked specifically to Māori) have been found, and, for the most part, these have not been regarded as significant. An ecological approach does not mean that genetic factors can be excluded as irrelevant, but it places greater weight on the external conditions and triggers that lead to changes in health and in particular coping mechanisms. It should also be stressed that mental disorders, the subject of much genetic inquiry, do not account for the total mental health burden and do not arise outside a socio-cultural context.³⁸

Efforts to explain these trends have therefore focused on behavioural issues, environmental factors (including colonisation) and socio-economic stressors. Excessive alcohol and drug consumption continues to be responsible for a large number of admissions to psychiatric facilities, while high rates of unemployment, low income, poor educational achievement and substandard housing are also known predisposing factors of mental ill-health, and ones that disproportionately impact on Māori. Anecdotal evidence suggests that misdiagnosis was also a concern, particularly for Māori, and was at least partly responsible for inflating the admission statistics during the 1970s. The suggestion was that cultural behaviours and nuances were sometimes interpreted as mental disorders. Admission to a psychiatric facility was recommended, regardless of whether or not one actually existed.

Urbanisation has also been linked with social and cultural disorder, which, in turn, provides a catalyst for mental ill-health. During the 1950s, the second great Māori migration occurred though this time it was not from Hawaiki to Aotearoa but from small rural communities to major urban centres. In search of employment, excitement and opportunities, many Māori were enticed into the cities and quite often flourished as jobs were plentiful and opportunities abundant. However, this urban shift and social integration also led to cultural isolation and alienation from many of the traditional structures that in the past had protected and nurtured Māori. While many would have maintained cultural ties, networks, practices and language, distance from traditional lands, marae, cultural institutions, whānau and hapū would have made things difficult. For many, cultural decay was inevitable as was an increased susceptibility to mental health problems.³⁹

An earlier monograph by Ernest and Pearl Beaglehole touches on this issue and provides some support for the idea that Māori mental health was in part linked to social and cultural cohesion. The monograph was also important in that it was perhaps the first piece of scholarly discourse that attempted to understand the mental and psychological perspectives of Māori and examine the potential impact of colonisation and urbanisation. They note:

The fact that there are fewer neurotic and psychotic illnesses among Maori than among Pakehas in New Zealand emphasises among other things the tremendous value to the Maori of possessing a psychological security that comes from tribal and family security.⁴⁰

Somewhat prophetically, they further warned of the dangers of cultural decay and the consequences of increased contact with the Western world; issues that, ironically, were to manifest in later decades.

Judging from experience in other parts of the world, we may hazard a guess that the increasing adjustment of the Maori to the Pakeha way of life with its standards and values, morality and behaviour, will bring a tendency for the Maori