UNDERSTANDING PSYCHOSIS Cultural Paradigms

1. UNDERSTANDING PSYCHOSISCultural Paradigms Mason Durie Massey University Perspectives

2. PERSPECTIVES ON PSYCHOSIS Cannot assume that all cultures or populations will agree that psychosis is a medical condition requiring treatment While accepting that there has been a psychological change, the change may not necessarily be seen as a problem, let alone a medical problem. Demography

3. A Changing Demography • 2001: Mäori comprised 15 % NZ population • 2051: Mäori (about 1 million) comprise 22 % NZ population • 2006: Mäori 25% of school age population • 2051: 33 % of children in NZ will be Mäori Cultural Diversity

4. New Zealand’s Cultural Diversity • Pacific Peoples – immigration, high fertility rates • Migrants from India, China and the Asian Pacific rim • 2050 around half of New Zealand’s population will be non-European • English may not be the preferred language • Cultural understandings may be Polynesian or ‘eastern’ or ‘western’ • the effectiveness of health workers will be challenged by cultural diversity www.com

5. Cultural Impacts on Psychiatry • Reconciling perspectives on health and illness • Understanding the culture of science • Working with people from different world views • Practising at the interface Panel One

6. Panel One Mental health professionals • 2 male psychiatric registrars • 1 female psychiatrist • 2 clinical psychologists Panel Two

7. Panel Two Cultural advisors in mental health services • 3 women, 5 men • Average age 64 years • No formal health qualifications • Close links to te ao Maori The case study

8. The Case Study • Maori male, aged 22 yrs • Increasing isolation over previous 2-4 years; moody, unable to relate to parents • From Northland but living with relatives in PN for past 6 months • Recent change in thinking: • suspicious towards aunty & uncle • several references to himself on TV • able to intercept iwi radio broadcasts • can ‘hear text’ messages • ‘knows’ that PN is an unsafe environment The Questions

9. The questions • What is the problem ? • How should it be managed ? • A single word to sum up the situation ? Problem 1

10. ‘The Problem’ Panel One Responses • ‘Classic’ • Schizophrenia • Paranoid type • Acute, undifferentiated type • Possibly an acute psychotic reaction as a consequence of leaving home • Psychoactive substance abuse possible • But two year prodromal history suggests a process-type schizophrenia with poor prognosis Problem 2

11. ‘The Problem’Panel Two Responses • Alienated from own rohe (tribal homeland) • Listening for ‘voices from home’ • Seeking wider engagement beyond self • Parental dereliction (transferring son) • Unable to handle close relationships • Clash of mana between two iwi (Manawatu, Tai Tokerau) Management 1

12. ‘Management’Panel One Responses • Hospitalisation (50/50) • Cultural assessment • Early intervention team management • Clozapine (negative & positive symptoms) • Risperidone • Family education/support Management 2

13. ‘Management’Panel Two Responses • Hospitalisation (50/50) • Cultural assessment • Whanau assessment • ‘Whakawatea’ to ease Iwi tensions • Tohunga to advise on parental obligations • Tohunga to investigate possible breach of ‘kawa’, committed by parents • Re-align with family of origin Single Word

14. ‘Single Word Summary’ • Panel One SCHIZOPHRENIA • Panel Two WHANAUNGATANGA Scientific world views

15. Perspectives on PsychosisPsychiatric (Scientific) World Views • Illness model to explain ‘the problem’ • Diagnosis ≡ the problem • Search for ‘signs’ (rather than meaning) • Grouping symptoms to identify a syndrome • Psycho-biological-(social) determinants • Chemical solutions • Social supports Māori World Views

16. Perspectives on PsychosisMaori World Views • Fractured relationships • Symptoms have meaning • Explanations lie outside the individual • Short distance causative relationships • whanau and family • Long distance causative relationships • iwi - iwi • ‘Undoing’ necessary for healing world views

17. WORLD VIEWS Two World Views

18. WORLD VIEWS Psychiatric Maori Comparison world views

19. WORLD VIEWS Psychiatric Maori Commonalities

20. Psychosis Commonalities Between World Views • A problem that needs attention • Assumed (but largely unknown) causes • Requires expert management • Represents a ‘breakdown’ • Has implications for family • May need respite until adequately resolved • Resolution requires restoration of equilibrium Barriers to EI

21. Barriers to Early Intervention • Delayed intervention may reflect different perspectives of behaviour • Problem may not be seen as ‘medical’ or even ‘psychological’ • The DSM diagnosis may be an irrelevant irritant to whanau who are trying to ‘understand’ rather than ‘classify’ Facilitating Early Intervention

22. Facilitating Early Intervention • Emphasise the commonalities of different world views • Seek to understand mental phenomena (or at least not dismiss alternate understandings) • Do not equate diagnosis with solving the problem or replacing customised management • Gaining trust requires acknowledging whanau perspectives • Gaining trust also requires winning the confidence of Māori community health and social service providers • Interface workers can negotiate perspectives and mediate across world views The aim

23. Early Intervention - The Aim • Create avenues for engagement at the earliest possible opportuntity • Maori may not choose to seek help within the medical system • Other agencies may have greater contact with whanau Challenges

24. Early Intervention - The Challenges • Build methodologies that transcend different understandings of psychosis • Recognise diverse explanations of abnormal behaviour – resist missionary zeal • Strengthen links with community (non-medical) organisations • Extend the psychiatric comfort zone to encompass parallel approaches to care and management end

25. LIVING (AND WORKING) AT THE INTERFACE Science Indigenous Knowledge THE INTERFACE