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When the dead are as present as the living: psychiatry and the pathologising of culture

Culture, diversity and mutual learning were the key themes of this year’s annual meeting of Australian and New Zealand Psychiatrists, and the program delivered some refreshing insights and challenges to the specialty on the pathologisation of Indigenous knowledge and traditions.

There was a dedicated stream on the topic, and dozens of presenters spread across several days, with sessions featuring work from both sides of the Tasman.

Croakey journalist Marie McInerney was in Cairns covering the RANZCP Congress, #RANZCP2019, for the Croakey Conference News Service, and she reports below.


Marie McInerney writes:

For Dr Allister Bush, there was nothing at medical school that could prepare him for the mental health approaches he now embraces as a Pākehā (non- Māori) child and adolescent psychiatrist in Aotearoa New Zealand.

“This idea that the dead may be as present as the living was a foreign concept in my medical training,” he told a session at the recent Royal Australian and New Zealand College of Psychiatrists (RANCP) congress in Cairns.

And he acknowledges that, from a conventional psychiatry perspective, it is difficult to make sense of some of the experiences that are shared between patients and his close colleague, Wiremu NiaNia, a Maori Tohunga (healer), who is affiliated to Ngāti Tūwharetoa, Tūhoe iwi.

One such patient was an 18-year-old they called Jake (not his real name), who was assessed by Bush and NiaNia at Te Whare Marie, a specialist Māori mental health service near Wellington that combines Tohunga-led spiritual and cultural therapy and clinical methods, and where the two men first began to work together about 15 years ago.

Jake was referred to the service following an incident of impulsive self-harm, after which he admitted he had been hearing voices since he was a young child.

“He was curious but untroubled by the voices, assuming they were spiritual experiences,” NiaNia, Bush and collaborator David Epston wrote this year in an article in Australasian Psychiatry about the case, titled ‘He korowai o ngā tīpuna: Voice hearing and communication from ancestors’.

During their consultation NiaNia reported being able to perceive the same people in the room, and concluded some of the voices were likely to represent Jake’s kaitiaki or guardian spirits.

The trio wrote that this shared experience was a comfort for Jake and made him feel ‘less crazy’, something they see frequently among other young Māori and Pacific Islanders they have worked with.

Jake was ultimately discharged on the basis that he had not been suffering a significant mental health problem and didn’t need further assistance from the service.

The article concludes:

On contacting him two years later, Jake continued to have some experiences of voices, visions, and feelings from time to time, but had no other symptoms that indicated a psychotic disorder. He remained well six years later.”

The case illustrates how cultural experiences can inform clinical decision-making and help address Māori concerns over many years that wairua (spirit) experiences “have often been pathologised” in psychiatric settings, “resulting in unwarranted and potentially harmful psychiatric treatment”, congress delegates heard.

“There’s no confusion about the dead being living and the living being dead,” NiaNia told the RANZCP conference session. “Our job is to tend to the ones who are still here.”

The conference heard similar concerns about the pathologising of cultural or spiritual experiences from Aboriginal and Torres Strait Islander practitioners.

Bush said voices and visions are common for but not confined to Indigenous people.

He recommended the work of Simon McCarthy-Jones, Associate Professor in Clinical Psychology and Neuropsychology at Trinity College Dublin, who has written of a growing Hearing Voices movement that challenges the notion that it is “shorthand for madness“, particularly when many, like Jake, hear voices without distress or impairment.

Croakey reported last year on the mental health consumer advocate award presented to Melbourne mental health peer worker Janet Karagounis for her “inspirational and instrumental” work in the Hearing Voices movement and peer workforce in Victoria. You can watch a Croakey interview with Janet about her work here.

You may also be interested in this Croakey Conference News Service report from TheMHS annual forum in 2017 on ‘two-eyed seeing’, where the biomedical model intersects with Indigenous healing in mental health.

Cultural accountability

NiaNia and Bush talked about their work in a number of sessions at #RANZCP2019, with a strong focus on their unique Māori healing and psychiatry partnership.

“What we’re talking about is finding the best outcomes for the people we work with, regardless of how we might arrive there,” NiaNia said.

It’s a partnership that sparked much discussion at the conference for the way it values and privileges Indigenous knowledge.

In an interview you can watch in full later in this report, Dr Derek Chong, Queensland’s first Indigenous psychiatrist, said it had been fantastic to hear at the session about “psychiatry wrapped around (NiaNia’s) knowledge, rather than him being a complement” to Western medicine.

NiaNia and Bush said they work under a ‘safety first’ principle where, even if they suspect a young person has a cultural problem, if there is any risk they will be sent to hospital first “before we obtain cultural advice”.

There’s a very clear accountability, Bush said.

“As a Pākehā clinician, I’m accountable to Wiremu on the cultural side,” he explained.

“We’re used to thinking about clinical accountability, but we need to be thinking about cultural accountability too,” he said.

 

The pair have written in detail about their partnership in their book, Collaborative and Indigenous Mental Health Therapy, and you can watch a short video below about their work highlighting that Māori have the highest prevalence of mental illness of all ethnic groups in New Zealand, and that “many are diagnosed without the help of a Tohunga“.

 

 

Bush says the extent of his collaboration with NiaNia is still unusual in Aotearoa New Zealand, although it is a long way from the Tohunga Suppression Act 1907 which banned traditional healers and subjected them to British-inspired laws against witchcraft.

While the Act was repealed in the mid-1960s, acclaimed Māori health leader Sir Mason Durie wrote in the foreword to their book that the relationship between traditional healing and medical disciplines, including psychiatry, was characterised by “frank disagreements, mutual ridicule and shared loss of respect each for the other.”

Bush told the congress:

There’s a long history of Māori healing expertise in New Zealand, however in my psychiatric training I didn’t hear any of it.

In fact it’s quite hard to locate written accounts of Māori healing practices, except from the points of view of white settler practitioners.”

He wonders what might have happened in health care if Māori healing methods had been supported and resourced with “just a tiny fraction” of that directed to Western approaches in the 100-plus years since.

The full picture

The risk that Aboriginal and Torres Strait Islander people may be taken down a harmful psychiatric diagnostic path because of lack of cultural understanding was also brought home by Dr Helen Milroy — Australia’s first Indigenous psychiatrist and a former Commissioner with the Royal Commission into institutional child sex abuse — in a Congress session with NiaNia and Bush.

Milroy, who is a descendant of the Palyku people of the Pilbara region, helped found the Wungen Kartup Specialist Aboriginal Mental Health Service in Perth that brings in Elders and traditional healers to participate in clinical cases as part of a “whole of family’ approach.

She laughingly shared one effort to involve acclaimed Ngangkari traditional healers in a South Australian program, where the funding body said they would have to fill out a time sheet and asked how many hours a day they worked on their healing efforts:

The (Ngangkari) said ‘during the day we consult with people and talk about their problems. At night we send our spirit around…so we work 24 hours a day’.

“(The funding body) said ‘That’s too expensive, we’ll just give you a wage’.”

It’s an amusing anecdote, but it underscores the cultural clashes involved in trying to bring traditional Indigenous knowledge into bureaucratic Western health systems.

Difficult as it is, Milroy said it was critical to find ways to involve Elders and healers in the complex world of Indigenous mental health, where many people and communities “have their own explanations for both visual and auditory hallucinations”.

“Something like fatuous affect, how do you judge that cross-culturally?” she asked the session.

“If someone doesn’t give you eye contact, is that poor rapport? Most of the Indigenous mob are not going to look at you,” she said.

These sorts of observations can prematurely steer clinicians down a prescribed track where schizophrenia is the final, but often “spurious”, diagnosis.

“There are still a lot of complexities around disadvantage and racism which complicate the clinical picture in psychiatry, still a lot of difficulty with engagement of services, lots of concerns regarding the validity of assessments and treatments and how we measure outcomes and what therapy is appropriate for our mob,” said Milroy.

“I don’t know how we can do some of this stuff if we don’t engage with Elders and traditional healers and people who have cultural knowledge,” she added.

Milroy walked the session participants through a number of scenarios, asking what they might make of each.

They included:

  • a two-year-old who says to their mum “I know Pop is okay, because he told me so”, even though he died years ago and the child has never seen him
  • an eight-year-old who confides that his brother, who died in a traumatic accident, keeps talking to him and follows him around school
  • a 14-year-old who claims her deceased grandmother looks through the window and calls her name but, disconnected from her Aboriginal family, is told by the Christian family she living with that this is “a vision of the devil”
  • a 25-year-old diagnosed with post-partum psychosis after reporting that her ancestors came at night and did a welcome ceremony for her new baby
  • a 30-year-old who said cockroaches had been sent as a curse.

 

 

“It could be cultural. It could be illness. But you just don’t know and you don’t know till you get the full picture,” said Milroy.

“In a cross-cultural context, that’s the danger in psychiatry, because of lot of it sounds psychotic, a lot of it sounds quite abnormal when a lot of it is completely culturally explainable, or culturally acceptable or culturally informed,” she added.

“Even if it is psychotic, the response to it still has to have a cultural component, to understand why it’s illness and what to do about it.”

Milroy said many Aboriginal and Torres Strait Islander people will experience phenomena like visions and voices, including ancestors and spirits appearing both in human and animal form but it’s not something they will talk about widely.

“They have said to me ‘I wouldn’t tell a doctor, because they’ll think I’m mad’.

“And it’s true, because these experiences are out of the realm of normality for most Western cultures but yet they’re common for our mob,” she said.

In Indigenous cultures, phenomena is not necessarily psychotic, but can be customary, culturally-influenced and culturally-bound, she said.

“If you have someone in hospital away from Country and they get better but then start to get worse – it may not be because of the illness, it may be that they grieving for Country,” she said.

“The solution to that is not longer in hospital or higher medication, it’s going home or having some connection back to home that gives them that sense of wellbeing, connection and safety.”

Like many others at the conference, including Aboriginal and Torres Strait Islander practitioners and community members featured in the interviews below, Milroy said the big challenge for Indigenous mental health is having clinicians and services who understand these fundamental issues.

“My question is: if we don’t perceive the same things and we don’t live in the same sort of world, do we know what we’re doing in assessment and treatment and evaluation and measuring outcomes?”

Other perspectives

Watch our interviews, below, with key Aboriginal and Torres Strait Islander participants at the congress.

The ongoing impact of trauma

Senior registrar Dr Darren Chong, on the need for governments to understand how trauma, “not just colonial but more recently”, has impacted on the mental health of Indigenous people, and how other parts of the world are decades ahead on this.

Weaving culture through clinical practice

Dr Marshall Watson, a Noongar man from Western Australia and now a child and adolescent psychiatrist in South Australia, who presented on how culture impacts on clinical practice.

“I think everyone struggles with Indigenous mental health – not that it’s hard but that it’s complex,” he said.

“There’s a lot of stuff we’re dealing with, complex developmental trauma, substance misuse, overrepresentation in custody – a lot of not just clinical issues but also social and emotional wellbeing issues.”

It can and is being done well, he said, particularly where there is good Indigenous representation in clinical services:

“I think any service can benefit from cultural engagement, but it’s about how you engage and use your Indigenous workforce. When that’s done well, that’s where you see some steps forward.”

Torres Strait Islander psychiatry trainee Dr Jodi Eatt also talks about how trauma is often minimised in practice, and is also an issue for Indigenous people working in mental health.

Community at the table

Three community members of the RANZCP Aboriginal and Torres Strait Islander Mental Health Committee – Elizabeth McEntyre, Sonia Schuh and Diana Jans – on their priorities and the need for community to be “at the table, influencing and bringing the solutions”.

From the Twittersphere

This is the latest in our #RANZCP2019 series: bookmark this link to read our coverage to date, with more to come.


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