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What are we waiting for? Actualising Mental Health in Whānau Ora

KUA TAE MAI TE WA - THE TIME IS NOW

This paper was written in 2019 by Drs' Diana Kopua, Michelle Levy and Lisa Cherrington.  Trying to get it published became 'hoha'!  So, although unpublished we've decided to just get it out to you!

Abstract
Māori voices in the 2018 Government Inquiry into Mental Health and Addiction demanded transformational paradigm shift, arguing the foundations for such paradigm already existed in Whānau Ora. The government also called for mental health and addiction services to be revolutionised. This viewpoint describes how mental health service delivery and Whānau Ora is actualised in practice. Led out by Te Kurahuna (kaupapa Māori wānanga space delivering a workforce able to explicitly practice at the Whānau Ora mental health interface), Te Kūwatawata (Hauora Tairāwhiti) demonstrates innovative indigenous mental health practice and service delivery firmly embedded and driven by a Whānau Ora paradigm. A revolutionary first, Te Kūwatawata courageously led the way, developing and implementing a Te Ao Māori methodological approach to care within a mainstream mental health service in Aotearoa New Zealand. Fully encapsulating the paradigm shift demanded in the Inquiry, Te Kūwatawata is more than a kaupapa Māori service added to an unchanged mainstream system. Building on the gains made is critical: the impetus for change must not be lost. Government thinking and systems must innovate if they are to catch up with Māori innovation and truly revolutionise and transform outcomes for Māori.

Introduction
Kia mau, kia u, ki ngā kaupapa tika me te tino rangatiratanga o te tangata.
To hold fast to that which is true and to our right as people to self determine.

A new approach to mental health and addiction in Aotearoa New Zealand is needed. This was the overwhelming message provided to the 2018 Government Inquiry into Mental Health and Addiction.(1, 2) Māori voices were clear a radical transformation away from existing bio-medically focused illness models to a wellbeing paradigm founded within Te Ao Māori was critical. Those voices were also clear that such transformation must be underpinned by reorientation, redesign, and the redistribution of resources and the foundations for such transformation already existed: Whānau Ora is our wellbeing paradigm in action.(2) The 2019 government ‘Wellbeing Budget’ allocated significant resources to the mental health and addiction sector; the revolutionising of mental health and addiction service delivery a key aim. This same Wellbeing Budget also invested in its Whānau Ora programme, with whānau ora and whānau-centred service delivery positioned by government as the core pathway forward for Māori.(3)

The obvious question therefore becomes how is the relationship between mental health service delivery and Whānau Ora* actualised in practice? Better understanding ways in which services focused on addressing mental health distress interface with Whānau Ora paradigms is essential if we are to realise both the significant paradigm shift being asked for by Māori, and the mental health and addiction service revolution being sought by government. More importantly better understanding this interface is essential if we are achieve genuine transformation for whānau.

Whānau Ora
Maori voices have been asserting for decades if a difference is to be made for Māori whanau must be at the centre; “start with the unit of most importance to Māori and keep it front and centre”.(4) Whānau Ora rests on a culturally anchored, whānau-centred foundation of realising whānau potential. Collective whānau aspirations are realised by building on the strengths and capabilities already present for whānau.(5) Within this paradigm, not only are whānau seen as holding untapped potential for change, they themselves are the central agents of that change.(6) Emphasising rangatiratanga (self-determination) resides within collectives(6), the broad spectrum of needs and aspirations, from crisis intervention through to aspirational goals are accounted for and addressed within the wider context of whānau.(4) A key distinguishing factor of Whānau Ora is its whānau-centred approach. Genuine whānau-centred practice differs from the typically client-centred approaches in that the client is generally not deliberately positioned within the broader context of whānau, and the wider needs and aspirations specific to that whānau.(4) Whānau-centred practice gives tangible effect to:

Whānau, not individuals, aspiration, needs, and self-determination at the centre;
Transformation, not transaction;
Solutions, not issues;
Effective relationships;
Integrated systems; and
Te Ao Māori and Kaupapa Māori.(6, 7)

Whānau Ora as a government programme has to date been operationalised in a range of ways. These include whanau kaiarahi/navigators working directly with whānau to identify and action needs and aspirations, coordinating access to specialist services, and facilitating access to resourcing and programmes able to grow whānau resilience, capabilities, leadership, and sustainable enterprise. Of vital importance is that the Whānau Ora programme has been underpinned by a funding model (Commissioning) enabling whānau self-determination to be overtly and tangibly supported.(4) The relevance of Whānau Ora to all agencies, services, and institutions who have the potential to impact on whānau wellbeing has long been recognised.(5) Of importance, Whānau Ora underpins He Korowai Oranga: Māori Health Strategy, which all District Health Boards are required to take into account when meeting their statutory objectives and functions for Māori health.(8)

A recent review found the key factors contributing to the success of Whānau Ora included it being culturally anchored, whānau-centred, strengths-based, and flexible in allowing issues of most importance to whānau to be progressed.(4) Relationships founded on cultural connection, community membership, and investment in community success, as opposed to crisis, are a fundamental prerequisite.(4, 9)

Whilst Whānau Ora has been configured into a government programme of action, its origins do not lie within government thinking. Māori communities have been operationalising Whānau Ora for many years, acutely aware that compartmentalised, siloed, individualised approaches do not work. Having accumulated a significant body of knowledge and evidence, demands for Whānau Ora to become entrenched as government policy across sectors, including in mental health and addiction is increasing.(1, 2, 4, 6, 10-12)

Whānau Ora in Specialist Mental Health Services : Te Kūwatawata
The Tairāwhiti District Health Board (Hauora Tairāwhiti) has one of the highest levels of mental health distress in the country, alongside a high proportion of Māori accessing mental health services.(13, 14)  In response, Hauora Tairāwhiti have led the way in designing an ambitious, innovative and ground breaking Te Ao Māori approach to care within a mainstream mental health service in Gisborne. Seeking joint venture service transformation across the primary, secondary, and non-government sectors, and grappling with well documented issues including gaps in primary care, roadblocks in secondary care systems, strict access criteria, long wait times, and escalating demand in the primary sector (15), Te Kūwatawata[1] is a ‘single point of entry’ (SPoE) service for all whānau in the region, irrespective of distress level. Te Kūwatawata is both underpinned and overseen by Te Kurahuna, (storehouse of gems), the community based kaupapa Māori whare wānanga responsible for workforce development and training that nurtures and sustains Māori approaches. All partners in Te Kūwatawata commit to working with Te Kurahuna.

Te Kūwatawata has introduced a way of working with distressed whānau that prioritises whānau voices, participation, and access to care in ways meaningful for whānau. The uniqueness of Te Kūwatawata is that it is:

Whānau led – every person referred to Te Kūwatawata is invited to attend their session with whānau. Whānau, which includes the referred individual, are asked what they are want and need; and

Underpinned by the use of a kaupapa Maori intervention approach, Mahi a Atua.

When the whānau comes in and they’re both in distress; one is referred, the tono, but actually the other member is in distress, like husband and wife. And so we support both, not just one and not the other.(15)

Mahi a Atua (footsteps of the ancestor-gods) is an engagement, assessment and intervention based on pūrākau (Maori creation and custom narratives). Innovative, powerful and gentle, Mahi a Atua moves outside the psycho-medical model, focusing not on identifying internal deficit or dysfunction, but on privileging Māori voice, and offering alternative frames by which meaning can be found in everyday life events, alongside culturally and spiritually acceptable pathways of resolution. There is an emphasis on generating kōrero, the acknowledgement of strengths even in times of distress, tolerance of uncertainty, and collectively promoting change in the whānau.

The recitation of these narratives and the building of relationships with whānau are guided by Mataora. Trained in Te Kurahuna, Mataora are organised into Ue (a party that turns the tide); a specialised multi-disciplinary workforce comprised of psychiatric, social work, mental health support, education workers and artists, all specifically trained as change agents specialising in Mahi a Atua. A wānanga Māori, where the core activity is learning pūrākau and the therapeutic application of these narratives, Te Kurahuna’s independence from the mainstream health institution, medical tradition and psychiatric orthodoxy is important. Wānanga Pākehā also run alongside, exploring technical and professional development aspects of case management.(15)

Wānanga form the basis of therapeutic contact and are deliberately used at every stage of the whānau journey towards wellbeing. A ‘taonga tuku iho’ (gift from ancestors), wānanga emphasises open, responsive relationships which generate kōrero, co-creativity and reflective communication where everyone can be heard and responded to. Within the Te Kūwatawata paradigm, wānanga are a transformative way of engaging narratively with whānau to weave together the many points of view about their distress. Importantly, the wānanga process takes into account that whānau members attending with the person in distress can themselves be distressed, and as such require support.(15)

This was so crucial for me and my family to embrace … we have lost a number of our rangatahi to suicide … in wānanga we had to do pūrākau- an amazing opportunity. At first I thought ‘how is that going to bring healing to our family’? But it was amazing and it did. This weekend will be our ninth wānanga and what it has done is that we have been able to journey down this road as a family. My wife, my nieces and nephews, my cousins - we have had the opportunity of learning pūrākau and it has done amazing things for their lives and moved them forward out of their places of darkness – that’s why wānanga like this are so crucial. (Mataora/Iwi Social Worker)

Through wānanga with whānau, Te Kūwatawata promotes a reinstating of mātauranga Māori and supporting Maori knowledge. As the journey progresses and intensifies, the focus of wānanga develops and grows more meaningful.

I think about 90 percent of whānau healing was done in that one [first] wānanga. It was amazing... I liked that they didn’t work one-on-one. There were always two workers there. And I love the storytelling. I love the whakawhanaungatanga; that was beautiful. Just everything that our whānau had been going through from day one had been validated and heard and that just felt really empowering to us as a whānau.(15)

Conclusion
Māori voices and the government are indeed on the same page when talking about a paradigm shift to wellbeing and revolutionary mental health service provision. However, while 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(16),  there is little evidence of the system-wide paradigmatic change needed. It is clear that revolutionary mental health service provision will not result from more of the same.

Whānau Ora has always been intended as an inclusive approach for all New Zealanders.(17) Te Kūwatawata have had the courage to lead the way, with the development and implementation of a Te Ao Māori methodological approach to care within a mainstream mental health service a revolutionary first in Aotearoa New Zealand. Te Kūwatawata has introduced a way of working with distressed whānau that prioritises whānau voices, participation, and access to care in ways meaningful for whānau. The recent Whānau Ora Review(4) concluded that the significant potential of Whānau Ora resided in shared efforts across Whānau Ora commissioning agencies, partners, providers, and whānau entities. It also recommended the wider embedding of whānau-centred services, concluding a more useful approach to be one in which whānau ora partners, providers and government agencies work together to provide a cohesive and comprehensive spectrum of Whānau Ora support. Specialist mental health services which directly align with the philosophy and practices of Whānau Ora and whānau-centred practice are an essential element of this spectrum.

Enabling movement from crisis to aspiration, Te Kūwatawata occupies a critical space as an indigenised, whānau-centred, and innovative mental health service. Te Kūwatawata has laid a pathway for the achievement of many of the outcomes recommended by the He Ara Oranga, including increased access, shorter waiting times, greater whānau involvement, increased teamwork, a culturally competent mental health workforce and the routine monitoring of outcomes.(15) More than a kaupapa Māori service added to an unchanged mainstream system, Te Kūwatawata fully encapsulates the paradigm shift articulated in the 2018 Mental Health and Addiction Inquiry. Ongoing resistance to Whānau Ora as a paradigm challenging the status quo is an acknowledged reality.(4) Guardianship of mātauranga Māori does not sit with Crown entities. Again, directly supporting Māori voices to the Inquiry, and the Whānau Ora Review, Te Kūwatawata also explicitly focuses on challenging the discrimination, institutional racism and unconscious bias which impact on the achievement of equitable outcomes for Māori.

Interest in Te Kūwatawata as part of an holistic integrated spectrum of whānau-centred wellbeing services is high. Representatives from major regions have visited, keen to implement mana whenua versions in their regions across areas such as mental health, addiction, paediatric, Oranga Tamariki and social housing provision,. Of importance is commitment to a ‘by Māori for all’ approach, with kaupapa Māori only services seen as unsustainable in the long term.(15)

In moving forward, understanding the holistic picture is essential. The success of Te Kūwatawata in delivering whānau-centred service delivery and realising Whānau Ora outcomes lies in the entirety of its components. Selective appropriation of culturally based practices does not work; devolution to those who understand wider tikanga and cultural contexts does.(10) Of critical importance is the fundamental role played by Te Kurahuna in Te Kūwatawata. Recognised as the resilient heart of Te Kūwatawata, Te Kurahuna reached across settings, bringing together workers from across services, cultural experiences and ethnic groups with a dedicated collective commitment to the pursuit of good outcomes for whānau.(15)

That Whānau Ora as a policy direction has survived intact across successive governments is clear testament to the widespread collective acceptance of its validity and legitimacy as a core pathway by which to realise Māori aspirations. All major reviews completed within the term of the current government are vocal in identifying the centrality of Whānau Ora to realising our aspirations as Māori.(1, 4, 10, 11) The kaupapa of Whānau Ora has been through its growth stage and is now at the point where it needs to shape the entire government eco-system.(4) We need those in power to catch up. As Māori, we have always provided the same messages about pathways to holistic wellbeing, and we have always been clear about how to do it and what we need.

Whānau Ora and whānau-centred service provision provides the basis for, and is already revolutionising our approaches to wellbeing for Māori. Te Kurahuna and Te Kūwatawata demonstrate how to truly revolutionise mental health spaces for Māori, in the process providing a working exemplar of how Whānau Ora and whānau-centred practice can realise its full potential across sector and service configurations. Despite being the most difficult element of Te Kūwatawata to upscale, the role of Te Kurahuna, the kaupapa Māori wānanga space responsible for delivering a workforce able to explicitly practice at the Whānau Ora mental health interface, cannot be underestimated. Government thinking and systems must innovate if they are to catch up with Māori innovation. Indeed the real question for us all if we are to truly revolutionise mental health outcomes for Māori within the overall context of a Whānau Ora wellbeing paradigm, is not what can we do, but what are we waiting for? We are ready now.

what if.
we knew we have come too far
kia kore e haere tonu.
what if.
we already know.(18)

References
1.         Government Inquiry into Mental Health and Addiction. Te Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction. Wellington2018.
2.         Russell L, Levy M, Cherrington L. Whakamanawa. Honouring the voices and stories of Māori who submitted to the 2018 Government Inquiry into Mental Health and Addiction in Aotearoa. Unpublished Report.; 2018.

3.         Minister of Whānau Ora. Whānau Ora Minister’s concern over lack of knowledge of services. In: Zealand RN, editor. 2019.

4.         Whānau Ora Review Panel. Whānau Ora Review. Tipu Matoro ki te Ao. Final Report to the Minister of Whānau Ora. Wellington; 2019.

5.         Taskforce on Whanau-Centred Initiatives. Whanau Ora: Report of the Taskforce on Whanau-Centred Initiatives. Wellington; 2009.

6.         Te Puni Kōkiri, The Treasury. An Indigenous Approach to the Living Standards Framework. Wellington: The Treasury; 2019.

7.         Gifford H, Tuaine N, Muir E, Harford R. Whānau Ora: making a difference to New Zealand’s Waistline?  National Centre for Diabetes and Obesity Research; University of Otago2013.

8.         Ministry of Health. He Korowai Oranga: Māori Health Strategy. Wellington: Ministry of Health; 2002.

9.         Rua M, Hidgetts D, Stolte O, Cochrane B, Karapu R, Neha  E, et al. Precariat Māori Households Today (Te Arotahi Series). Auckland: Ngā Pae o te Māramatanga; 2019.

10.       Te Uepū Hāpai i te Ora/ Safe and Effective Justice Advisory Group. He Waka Roimata: Transforming our Criminal Justice System. Wellington: Safe and Effective Justice Advisory Group; 2018.

11.       Welfare Expert Advisory Group. Whakamana Tāngata: Restoring dignity to social security in New Zealand. Wellington: Welfare Expert Advisory Group; 2019.

12.       Te Rau Matatini. Te Hau Mārire: Addiction Workforce Strategic Framework for people working with Māori experiencing addiction-related harm (2015–2025). Wellington: Te Rau Matatini; 2015.

13.       Williment R, Codyre D, Katene K. Report and Recommendations for Tairawhiti Adult Mental Health and Addiction services: A pathway to better mental health 2008. 2008.

14.       Ministry of Health. Mental health, alcohol and drug addiction sector performance monitoring and improvement. 2018.

15.       Tipene-Leach D, Able S, Hiha A, Matthews K. Rangahaua Te Kūwatawata Final Report. Hawkes Bay: Māori & Indigenous Research, Eastern Institute of Technology; 2019.

16.       Durie M. Indigenizing mental health services: New Zealand experience. Transcultural Psychiatry. 2011;48(1):24-36.

17.       Office of Te Minitia mō Whānau Ora. Office of Te Minitia mō Whānau Ora. (2019). Initial response to the Review of Whānau Ora2019. Available from: https://www.tpk.govt.nz/en/a-matou-mohiotanga/cabinet-papers.

18.       Levy M. Exert from What If (Unpublished poem). 2019.

* Whānau Ora is understood as holistically encompassing a philosophy, concept and model of service delivery.

[1] Funding for the contract period, which ran from June 2017 to September 2018, was obtained from the Ministry of Health’s Fit for the Future – a Systems Approach Project and then subsequently extended till June 2019.



 

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