UNDERSTANDING PSYCHOSIS Cultural Paradigms

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UNDERSTANDING PSYCHOSISCultural Paradigms

• Mason Durie
• Massey University

Perspectives
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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
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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
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New Zealands Cultural Diversity

• Pacific Peoples immigration, high fertility
  rates
• Migrants from India, China and the Asian Pacific
  rim
• 2050 around half of New Zealands 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
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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
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Panel One

• Mental health professionals
• 2 male psychiatric registrars
• 1 female psychiatrist
• 2 clinical psychologists

Panel Two
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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
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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
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The questions

• What is the problem ?
• How should it be managed ?
• A single word to sum up the situation ?

Problem 1
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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
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The ProblemPanel 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
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ManagementPanel One Responses

• Hospitalisation (50/50)
• Cultural assessment
• Early intervention team management
• Clozapine (negative positive symptoms)
• Risperidone
• Family education/support

Management 2
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ManagementPanel 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
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Single Word Summary

• Panel One
• SCHIZOPHRENIA
• Panel Two
• WHANAUNGATANGA

Scientific world views
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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

Maori World Views
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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
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WORLD VIEWS
Reference frame
Practice Models
Theoretical bias
Assesment
Formulation
Management
Two World Views
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WORLD VIEWS Psychiatric Maori
Reference frame
Practice Models
Theoretical bias
Assesment
Formulation
Management
Comparison world views
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WORLD VIEWS Psychiatric Maori
Reference frame Science Indigenous knowledge
Practice Models Medical Ecological
Theoretical bias Psycho-biology Relationships
Assesment Psychopathology Holistic scope
Formulation Diagnosis Relational map
Management Treatment, recovery Healing
Commonalities
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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
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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
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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 Maori community health and social
  service providers
• Interface workers can negotiate perspectives and
  mediate across world views

The aim
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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
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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
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LIVING (AND WORKING) AT THE INTERFACE
Science
Indigenous Knowledge
THE INTERFACE