1 Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. 2 Te Ara Whakamana: Mana Enhancement Framework in the mahi (work) of New Zealand Psychologists’ A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, Manawatu, New Zealand. Monika Lovelock 2020 3 ACKNOWLEDGEMENTS I would first like to thank my thesis advisor Dr Pikihuia Pomare of the School of Psychology at Massey University and Sarah Goldsbury, clinical neuropsychologist and my mentor. Thank you for supporting me through this process and being so kind, helpful and encouraging. I would also like to express my profound gratitude to my husband and family for providing me with unfailing support and continuous encouragement throughout my years of study and through the process of researching and writing this thesis. This accomplishment would not have been possible without all of you. Finally, I would like to thank all the participants who took part in this study, their honestly and contribution is greatly appreciated. Thank you. 4 TABLE OF CONTENTS Chapter one: Introduction 1.0 Rationale for undertaking the research project ………………………………………………………………………….11 1.1 Mental health and suicide rates in New Zealand…………………………………………………………………………11 1.2 Mental health and suicide rates for Māori population …………………………………………………………….…12 1.3 Tangata whenua/people of the land…………………………………………………………………………………….…….14 1.4 Historical trauma and Te Tiriti o Waitangi/ The Treaty of Waitangi………………………………………….…15 1.5 Te Ara Whakamana: The Mana Enhancement Framework Overview………………………………………….16 Chapter two: Literature Review 2.1 Introduction……………………………………………………………………………………………………………………………….18 2.2 Cultural competence in Aotearoa New Zealand………………………………………………………………………….18 2.3 Māori health models- culturally centred approaches to mental health…………………………………….…20 2.4 Culturally adapted Cognitive Behavioural Therapy (CBT)…………………………………………………………….23 2.5 Conclusion………………………………………………………………………………………………………………………………….27 Chapter three: Methodology 3.1 Introduction……………………………………………………………………………………………………………………………….28 3.2 Aim of research………………………………………………………………………………………………………………………….28 3.3 Ethical considerations…………………………………………………………………………………………………………………29 3.4 Qualitative approach………………………………………………………………………………………………………………....30 3.5 Interview…………………………………………………………………………………………………………………………….……..31 3.6 Sampling and selection……………………………………………………………………………………………………………….32 3.7 Data collection……………………………………………………………………………………………………………………………32 3.8 Data analysis………………………………………………………………………………………………………………………….….33 3.9 Conclusion…………………………………………………………………………………………………………………….……….….34 Chapter four: Findings 4.1 Introduction……………………………………………………………………………………………………………………………….35 4.2 Participants………………………………………………………………………………………………………………………………..36 5 4.3 Rationale for participating in the Te Ara Whakamana: Mana Enhancement training……………………37 4.3.1 Cultural competence…………………………………………………………………………………….…………….38 4.3.2 Structural barriers from the past…………………………………………………………………………………38 4.3.3 Relationship building…………………….…………………………………………………………….………………39 4.3.4 Seeing the presentation on the model……….…………………………………………………………….39 4.4 The feedback on the Te Ara Whakamana: Mana Enhancement training……………………….39 4.4.1 Importance of attendance………………………………….…………………………………………………..….40 4.4.2 Diversity and workshop delivery…………………………………………………………………………………40 4.4.3 Cohesion with other trainings………………………….………………………………………………………….39 4.5 The application of the model……………………………………………………………………….……………………….41 4.5.1 Everyday practise…….…………………………………………………..…………………..……………………..…41 4.5.2 Being creative with the model…..………….……………………………………………………….……………42 4.5.3 For young clients………………………….……………………………….…………………………………….…….43 4.5.4 In complex cases…….…………………….………………………………………..……………….………………….44 4.5.5 The potential……………………………………………………………………..……………………………….………44 4.6 Te Ara Whakamana: Mana Enhancement for Māori clients……………………..………………………………….46 4.6.1 Empowering……………………………..………………………………………………………………………………..47 4.6.2 Structured…………………………………………………………………………………………………………………..47 4.6.3 Applied with cautiousness……………………………………………………………………………….………….48 4.7 Using the model with Pākehā/non-Māori clients………………………………………………….……………………49 4.8 Whānaungatanga-relationship building and therapeutic alliance………………………………………………50 4.8.1 Connecting with Mātauranga Māori and Te Ao Māori………………………………..…………….50 4.8.2 Respect and collaboration………………………………………………………………..………………………..51 4.9 Te Ara Whakamana: Mana Enhancement strengths…………………………………………………………………..52 4.9.1 Collective approach to wellbeing………………………………………………………………..………………52 4.9.2 Wairua/spirituality…………..…………………………………………………………………………………………53 4.9.3 Unique and engaging…………..…………………………………………………………………..…………………53 4.10 Structural issues and possible limitations to utilising Te Ara Whakamana: Mana Enhancement…………………………………………………………………………………………………………………………………..54 4.10.1 Māori models can be seen inferior to Western models……………………………………………54 4.10.2 Collaboration is essential………………………………………………………………………………………….55 4.11 Conclusion……………………………………………………………………………………………………………………………….57 6 Chapter five: Discussion 5.1 Introduction……………………………………………………………………………………………………………………….………58 5.2 Understanding the findings in relation to the research questions……………………………………………….58 5.3 Limitations of the study………………………………………………………………………………………………………………62 5.4 Conclusion………………………………………………………………………………………….……………………………….…....63 Bibliography Appendices 7 GLOSSARY Aotearoa New Zealand (land of long white cloud) Atua Supernatural being Awa River Hapū Subtribe, to be pregnant, conceived in the womb Hauora Health, fit Hinengaro Mind, thought, intellect, consciousness, awareness Iwi Extended kinship group, tribe, nation, people, bone Kaitakawaenga Working in special education Karakia Prayer, chant KaumĀtua Elder(s) Kaupapa Topic, policy, matter for discussion Kaupapa Māori An approach that privileges the perspectives and protocol of Māori Kohanga reo Māori language immersion for preschool children. Concerned primarily with the survival of te reo Māori Mahi Work or activity Mana A supernatural force in a person, place or object; prestige, authority, control, power, influence, status, spiritual power, charisma; mana goes hand in hand with tapu, one affecting the other Māori Indigenous New Zealander, natural Māoritanga (Māoridom) Māori culture, practices and beliefs Marae The complex where whānau and hapū collectives or groups meet, and discuss political and social matters, and host tangi and important events; where Maori lived pre- colonisation Mātauranga Māori Māori epistemology, traditional and contemporary Māori knowledge brought to Aotearoa by Polynesian ancestors of present day Māori Mauri Life principle, vitality, special nature, material symbol of a life principle, source of emotions Mana whenua Māori who have customary authority over a particular land area Oranga Wellbeing Pākehā New Zealander of European descent Papakāinga Original home, home base, village, communal Māori land, ancestral land Papatūānuku (Papa) Earth/ mother of the earth, wife of Ranginui Pepeha A recitation of whakapapa and geographical areas of significance Rangiātea Ancient name strongly associated with Hawaiki, both a physical place and a spiritual realm, literally a clear sky, clear spiritual realm, state of enlightenment, the upmost heaven Ranginui (Rangi) Atua of the sky, husband of Papatūānuku Ruāmoko Atua of earthquakes and volcanoes Tānemahuta Atua of the trees and birdlife also known as Tane-te-toko-o-te- rangi due to his ability to push his father Ranginui into the sky Tangaroa Atua of fish and reptiles Tāngata People, persons, human beings (tangata singular) Tāngata whenua Local people, hosts, Indigenous people of the land- people born of the whenua (of the placenta and the land) Tāwhirimatea Atua of the wind 8 Te ao Māori The Māori world Te ao Pākehā The western world Te ao wairua The spiritual realm Te Whare Tapa Wha The four walls of a house, a Māori model of health care Te Wheke The octopus, a Māori model of health care Tikanga the customary system of values and practices that have developed over time and are deeply embedded in the social context Tinana Physical body Tīpuna/ tūpuna Ancestors, grandparents (tipuna/tupuna singular) Tūmatauenga Atua of war Wāhine Woman, (wahine singular) Wairua Spirit, soul Wairuatanga Spirituality Whakamana To give authority to, give effect to, give prestige to, confirm, enable, authorise, legitimise, empower, validate, enact, grant. Whakapapa Genealogy, lineage, descent, to layer Whakawhānaungatanga Process of establishing and maintaining links and relationships with others, relating well to others Whānau Family and extended family, to be born, to give birth Whānaungatanga Relationship, kinship, sense of family connection Whare House 9 Abstract This study explores Te Ara Whakamana: Mana Enhancement framework, an emotional regulation and behavioural modification tool, which is centred in te ao Māori (the Māori world). This research looks at the experiences of the psychologists who use the model in various work contexts with both Māori and non-Māori clients. This was done by recounting the experiences of psychologists who participated in training for the model and are utilising the framework in practice with clients, have done so in the past, or are planning to do so in the future. Interviews allowed participants to explore how they are using the model, and what are its strengths and potential barriers. Further, this study aims at describing the key ideas that emerged while practitioners were engaging Te Ara Whakamana: Mana Enhancement. A qualitative approach was selected as the research method for this study, utilising eleven semi-structured interviews. The research findings indicate that psychologists value learning about Māori mental health models and are looking for frameworks that can enrich their cultural competence. Psychologists who are using the model found it to be helpful in their practise and those who were unable to use it expressed an interest in returning to the model or using it when their circumstance allow. Structural issues within organisations were identified as some of the possible barriers to the model. 10 ‘Cultural competence requires more than becoming culturally aware or practising tolerance. Rather, it is the ability to identify and challenge one’s own cultural assumptions, values, and beliefs, and to make a commitment to communicating at the cultural interface’ (SNAICC, 2012) 11 Chapter One Introduction The aim of this research is to explore New Zealand psychologists’ experiences using Te Ara Whakamana: Mana Enhancement, an emotional regulation and behavioural modification tool, which is centred in mātauranga Māori/Māori epistemology. The focus of this thesis is how this framework impacts psychologists’ practice with their clients, what are the framework’s strengths and what are the possible barriers and limitations. This chapter will demonstrate the rationale for choosing this research topic; it will also provide an overview of the following chapters by briefly outlining the content of each one. 1.0 Rationale for undertaking the research project 1.2 Mental health and suicide rates in New Zealand Mental health and suicide rates in New Zealand have been strongly criticised by leading global health and human rights organisations such as UNICEF and the World Health Organisation, indicating that current approaches to the issue are failing (Illmer, 2017). Looking at the current statistics and the numbers of referrals from general practitioners to mental health professionals emphasizes the paramount importance of tackling the issue. Obtaining a referral to secondary mental health services is challenging, as it can be hard to meet referral criteria, furthermore, many people refuse to be referred as there is a lack of trust in health services (Dowell, Garrett, Collings, 2009; MaGPIe Research Group, 2009). According to the latest UNICEF report New Zealand has the highest rates of youth suicide in developed countries compared to 41 (OECD) countries and 28 European Union (UE) countries; rates are the highest for New Zealand youth aged between 15 to 16. New Zealand youth are the most likely to experience anxiety or depressive disorders and have the highest rates for suicide compared to other (OECD) nations. Furthermore, it’s estimated that 15.6 out of 10,000 people in New Zealand will become a victim of suicide (Ministry of Health, 2018); which is five times higher than in the UK. Nevertheless, demands for mental health services in New Zealand have increased by up to 70% over the past 20 years. Currently public services such as helplines or youth lines are incapable of meeting the needs of young people seeking support due to high demands and severity of issues (Illmer, 2017). 12 1.3 Mental health and suicide rates for Māori population Māori, the indigenous people of Aotearoa New Zealand comprise 15% of the country’s population and their population grows annually at present by 1.4% (Statistics New Zealand, 2018). However, Māori occupy a vulnerable and disadvantaged position in Aotearoa/New Zealand society with a high level of unmet needs. Especially important in this context is the concept of trauma and the very fact that Māori experience trauma in a distinct way which is related to the process of colonisation, discrimination, and racism as well as ongoing negative stereotyping which further results in unequal rates of poverty, poor health, and violence (Pihama, 2017). Māori are continuously overrepresented in physical and mental health as well as criminal statistics (Department of Corrections, 2018; Ministry of Health, 2018; Oakley-Browne, Wells & Scott, 2006). Statistics indicate poorer health outcomes for Māori than non-Māori. Furthermore, the disparities in Māori mental wellbeing are present across the spectrum of mental disorders (Oakley-Browne, Wells & Scott, 2006). Figure 1. Prison population by ethnicity (Department of Corrections, 2018) 13 Image 1. (Ministry of Health, 2018). For Māori and non-Māori New Zealanders, stigma associated with mental health diagnosis is one of the biggest barriers preventing people from seeking professional help when faced with psychological distress (Chandra & Minkovitz, 2006). Mental health problems and suicide rates are growing rapidly and especially affect young Māori males. As shown by the Ministry of Health statistics there were 31.7 suicides per 100,000 Māori males in 2016 which is 6.1 percent higher than in 2015. This number was the highest in a decade (Ministry of Health, 2018). There is an existing culture of silent suffering in New Zealand, admitting to having psychological distress is often perceived as a weakness in society and as a result, young people are encouraged to ‘harden up’, ‘deal with an issue on their own’, and to ‘grin and bear it’ (Illmer, 2017; White, 2013). Many people do not seek professional help because their concerns are approached using the Western, biomedical model of health that is individualistic and reductionist (Stephens, 2008). This limiting and narrow approach to health issues does not consider factors such as spirituality, cultural identity, historical trauma, or the importance of whānau (family) that is a critical element of wellbeing for many cultures residing in New Zealand (Barnett & Barnes, 2010). The alienation and burden of being diagnosed with mental health issues and being ‘labelled’ without approaching case holistically further leads to many social issues, such as increased crime, addictions, problems at schools and home (Boulton, Tamehana, & Brannelly, 2013). High rates of psychological distress among Māori are often measured at the individual and not collective level, without much regard to the concept of whānau (family), inherent to Māori wellbeing (Te Oranga Hinengaro-Māori Mental Wellbeing, 2018). Māori represent a collectivist culture; thus, emphasis is placed on the individual’s identification with the group. Being a part of the group is the ultimate source of understanding the individual. It creates expectations from the individual to obey and conform to the values and norms of the group (Benet-Martínez & Oishi, 2008). Western models 14 of health offer limited space to include the concept of collectivism that includes family (Royal, 2003). The concept of whānau is a fundamental part of Māori society, it is a key element of connectedness and the source of wellbeing (Boulton, Tamehana, & Brannelly, 2013; King, Young, Li, Rua, & Nikora, 2012). The process of colonisation changed the concept of whānau and therefore limited the way wellbeing can be practised. Māori ancient connectedness to their land was severed due to land confiscation by the Crown and New Zealand Government (Durie, 2003). Being connected to the land and belonging to the distinct territory is a key feature of Māori identity, as well as many other indigenous cultures across the globe. The shared worldview of Māori for whom their land is the source of wellbeing and connectedness to others emphasises that humans are inherently linked to the natural world (Royal, 2003). As pointed out by Ring and Brown, (2003) and Durie, (2003) indigenous people across the globe, who were disconnected from their land as a result of colonisation, experience disparities in their health status as compared to a non-indigenous people in developed countries. 1.3 Tāngata whenua/people of the land Tāngata whenua (people of the land) is the term used by Māori to distinguish their perception of the world from the British or the French, the two main nations that began colonising New Zealand in early 1800s (Orange, 1987). Together with the settlers arrived patriarchal dogmatism that largely differed from a Māori worldview and lifestyle (Mikaere, 1999). In the process of colonisation, Māori land was confiscated, rich in natural resources, followed by their identity, culture, and language also being taken by colonisation (Jackson,1992). The concept of Mana was compromised. Mana is understood as a status, when a person has mana, they are present (Marsden, 1992). Mana can be inherited but also lost or acquired through a person’s actions. In the context of mental health, mana influences the behaviours of individuals and groups. Mana is defended and sought through achievements and successes (Marsden, 1992). It is vital that mana is considered when working with Māori and this means using a mental health framework that will recognise and acknowledge the principals of Māori worldview. Recognising the vital role of mana in the mental health context requires utilising an approach that reaches beyond the Western paradigm and incorporates the unique indigenous perspectives (Mahuika, 2008). Culturally centred approaches can enhance the quality of life for Māori and other indigenous groups by honouring and recognising issues specific to these people and their culture, such as frameworks derived from cultural knowledge systems (Barnes, 2000). 15 When considering Māori wellbeing, we must recognise the holistic makeup of Māori both as individuals and collective members of the community in which aspects of self are intertwined (King et al., 2012). Recreating and rediscovering cultural identity relates to being around whānau/family which helps the person in the processes of defining self and self-construal. ‘All iwi … can recount from their own histories, stories of parents, children or siblings searching for each other and within these stories are located our histories, values and beliefs of what it is to be who we are, Māori.’ (Edwards, 1999 p. 20). 1.4 Historical trauma and Te Tiriti o Waitangi/ The Treaty of Waitangi Western models of mental health and healing are targeting wellbeing mostly at an individual level (Stephens, 2008). It is often assumed that for most clients, trauma is a result of a deeply distressing and disturbing experience at the individual level. From this standpoint the assessment and further diagnosis and interventions take place (Wirihana & Smith, 2014). However, there is a lack of recognition of historical trauma, which is cross-generational, inter-generational, and multi-layered. Such trauma is due to exposure to a chronic, complex, and a long-term collective trauma (Pokhrel & Herzog, 2014; Whitbeck, Adams, Hoyt, & Chen, 2004). Historical trauma is a cumulative psychological and emotional suffering that takes place over lifespans and throughout generations and results in many mental health issues such as depression, anxiety, self-destructive behaviour, anger, or low self- esteem. Historical trauma underlies trauma at an individual level and is a part of social context (Wirihana & Smith, 2014). Assessment, diagnosis, and intervention are all social activities embedded in a social context (Murray, 2014; Lyons & Chamberlain, 2006). Therefore, when a client and their whānau (family) are treated with an approach based on an individualistic view of health, it is not in agreement with social equality and achieving health for all (Prillelltensky & Prillelltensky, 2003). For Māori, individualistic approaches do not adequately address the needs of whānau and collective needs, historical and intergenerational trauma, and does not include Māori models of wellbeing as per te Tiriti o Waitangi/the Treaty of Waitangi: The practice of psychology in Aotearoa /New Zealand reflects paradigms and worldviews of both partners to te Tiriti o Waitangi /the Treaty of Waitangi. Cultural competence requires an awareness of cultural diversity and the ability to function effectively and respectfully when working with people of different cultural backgrounds. (New Zealand Psychologist Board, 2011, p. 7). 16 1.5 Te Ara Whakamana: The Mana Enhancement Framework Overview Te Ara Whakamana: Mana Enhancement model will be explored as a response to the issues just discussed. This model is a culturally centred framework that uses the process of co-construction in identifying and responding to adverse life circumstances. Marshall and Ngawati Osborne (2018) the authors of the framework, point out the process of co-construction enables for strength-based conversations at the individual and whānau level. The mana of the individual and their whānau is the focus point when approaching a case. Te Ara Whakamana: Mana Enhancement is a circular framework that allows clients to use colour, imagery, narrative, and cultural metaphors. These elements are used to help people connect to their mana, their sources of strength, their world and their cultural identity. It is a tool that develops rapport, a fundamental requirement for positive communication: Te Ara Whakamana: Mana Enhancement moves us back to the richness and power of imagery, stories of our origins, of archetypes and superheroes, of amazing adventures, actions and deeds, of individuals overcoming great adversity. Stories passed down to us by our mothers and fathers, our aunts and uncles, our grandparents and from our revered ancestors. Myths and legends, fables and parables, sayings and proverbs have been used through the ages in this way to illustrate instructive lessons or principles for living well on this earth (AKO Solutionz, 2019, p. 7) Each segment of the model uses an inquiry-based approach that promotes self-knowledge and emotional literacy which in turn provides the opportunity for an early intervention and prevention. The segments of the model are designed to develop a plan that can be shared with the whānau, community support workers, and other social services. The model is designed to serve as a reference point that will help client and clinician to set future goals, support self-monitoring, check for progress, and collect and analyse data. The goal is to create a triangular source of data that is in depth and measures outcomes holistically. This dynamic data includes key participants, individuals, whānau, health practitioners, and others with the potential to identify important themes for wellbeing plans, development of strategies, or regulate emotions. The process of collecting data is an 17 intervention in itself, as dynamic interaction occurs which means people share their experiences, discuss their responses, and explore mana enhancing strategies to problems (AKO Solutionz, 2019). Image 2. (AKO Solutionz, 2019) 18 Chapter Two Literature Review 2.1 Introduction The aim of this chapter is to review available literature that contributed to this research study. It will examine the importance of cultural competence, while working in Aotearoa New Zealand. Many limitations still exist for psychologists who aspire to obtain training that will adequately prepare them to work with Māori. Literature canvassing research projects involving existing culturally centred frameworks will be presented. Finally, this chapter will explore culturally adapted Cognitive Behavioural Therapy (CBT) as an example of a culturally centred framework that can effectively meet the needs of Māori. This indicates that Te Ara Whakamana: Mana Enhancement could also be incorporated into empirically validated CBT. 2.2 Cultural competence in Aotearoa New Zealand When it comes to cultural competence there are standards and principals to be adhered to by psychologists working in Aotearoa New Zealand and registered under the Health Practitioners Competence Assurance Act (2003). Cultural competence is defined as: Having the awareness, knowledge, and skills, necessary to perform a myriad of psychological tasks that recognises the diverse worldviews and practices of oneself and of clients from different ethnic/cultural backgrounds. Competence is focused on the understanding of self as a culture bearer; the historical, social and political influences on health, in particular psychological health and wellbeing whether pertaining to individuals, peoples, organizations or communities and the development of relationships that engender trust and respect. Cultural competence includes an informed appreciation of the cultural basis of psychological theories, models and practices and a commitment to modify practice accordingly. (New Zealand Psychologist Board, 2011, p. 4). Although, these guidelines are explicit and psychologists are obliged to act accordingly to ensure that they are culturally competent, inequalities, high dropout rates from treatments, inaccurate diagnosis, and delayed response in Māori mental health are continuously highlighted in the literature (Baxter, Durie, & McGee, 2006; McLeod, King, Stanley, Lacey, & Cunningham, 2017; Kingi, Tapsell, Newton-Howes, Lacey, & Banks, 2014;). Despite high mental health statistics for 19 Aotearoa New Zealand, Māori still make fewer visits to mental health services, as there is an ongoing issue with an access and a lack of culturally appropriate service provision (Baxter, Kokaua, Wells, McGee, & Oakley Browne, 2006). The New Zeland Mental Health Survey (NZMHS), the first New Zealand survey measuring the prevalence of mental disorders in Māori, Pasifika and other ethnic groups of adults, showed Māori had the highest mental health rate followed by Pasifika (Baxter et al., 2006). Baxter et al. (2006) used the standardised diagnostic measures for different ethnic groups to highlight differences, and the researchers ensured sufficient number of Māori and Pasifika participants took part in order to obtain precise estimates. Literature points out Western diagnostic standards lack capacity to meaningfully measure mental disorders in different cultural groups (Karlson, Nazroo, McKenzie, Bhui, & Weich, 2005). McLeod, King, Stanley, Lacey, and Cunningham, (2017) showed Māori had a 39% higher rate of seclusion in inpatient psychiatric units than non-Māori. Rates of seclusion for Māori remained 33% greater even after demographic variables such as age, gender, and admission factors were adjusted. This suggests mental health services are not responding appropriately to Māori needs on multiple levels. Across the globe ethnic minorities exhibit underuse of mental health services and a dropout from psychological treatments (Casar, Vasques, & Ruiz de Esparzo, 2002). In Aotearoa New Zealand, especially rural areas, there is reduced access to mental health services for Māori, Pasifika, and other ethnic groups with serious psychological illnesses, and a lack of practitioners which further impacts communities (Baxter et al. 2006). The current state of affairs raises questions about the high disparities among ethnic groups in terms of seclusion, prevalence, and severity, as well as access to mental health services. Despite the evidence of inequalities in Māori mental health, educational providers still offer limited and varying ways in which psychologists can prepare themselves to work with Māori clients and their whānau. In this context, it is challenging to ensure clinicians are adequately trained and have the ability to reduce the inequality in mental health for Māori and other ethnic groups in New Zealand (Pitama et al., 2017). Johnstone and Read (2000) showed that this is also an issue for psychiatrists, as out of 247 psychiatrists (75 %responding), only 40% believed their training had adequately prepared them to work efficiently with Māori clients. The Code of Ethics for Psychologists Working in Aotearoa New Zealand also encourages psychologists to apply the principles of te Tiriti o Waitangi/the Treaty of Waitangi by seeking advice and further training. This is to ensure mental health practitioners are able to effectively respond to Māori needs and help support Māori to maintain their dignity as documented in the Treaty (New Zealand Psychological Society, 2002). Pitama et al. (2017) point out that in spite of the Health Practitioners Competence Assurance Act (2003) emphasising cultural 20 competencies is critically important when working with Māori and other ethnic minorities, and current reviews of psychology trainings still show that less time is assigned to teaching about Māori mental health. A growing number of studies confirm the critical importance of recognising and honouring a client’s culture, cultural background, and experiences as these impact client-psychologist relationships, therapeutic alliance, treatment selection, and therapy outcomes (Casas, Suzuki, Alexander, & Jackson, 2016; La Roche, 2012; Yeh, Parham, Gallardo, & Trimble, 2011; Vasquez 2007). Therefore, investing in psychologist’s cultural competence is vital with research increasingly reflecting growing awareness of these factors (Tao, Owen, Pace, & Imel, 2011). The use of culturally adapted mental health treatments and frameworks has proved to be an effective way of ensuring cultural competence (Soto, Smith, Griner, Rodriques, & Bernal, 2018). Culturally adapted models and frameworks suggest that therapeutic healing is grounded in cultural context which in turn provides a frame of reference for understanding how people make sense out of their experiences. In other words, human ways, emotions, behaviours, and thoughts are embedded in cultural context (Kleinman, Eisenberg, & Good, 2006; Murray, 2014; Lyons & Chamberlain, 2006, Wampold, 2007). Therefore, culturally adapted interventions can ensure a meaningful alignment with a client’s culture. Moreover, literature shows culturally adaptive interventions are more effective than interventions that are developed by Western Academic Scientific Psychology (WASP) and Western Educated Industrialised Rich Democratic (WEIRD) which are applied to other cultures and cultural groups (Bernal, Saez- Santiago, 2006; La Roche & Lasting, 2013). Still, limited studies evaluating interventions that use culturally adapted models are available. 2.3 Māori health models- culturally centred approaches to mental health As pointed out previously, Māori delay contacting mental health services as a response to a lack of culturally inclusive services, and research suggests this may result in poor provision of appropriate care. The consequence of the above-mentioned issue is that many Māori are seeking help only when the illness has turned into an acute state and the symptoms become severe (Eade, 2014; Ministry of Health, 2006). It is well documented that treating a severe onset of a mental health illness is very difficult. Often the risk of remission is so high, that targeting the control of the optimal symptoms becomes a more realistic goal of the therapy (Rush, Aaronson, & Demyttenaiere, 2018). Therefore, mental health assessment with Māori clients should be comprehensive and consider the specific cultural context in order to avoid inaccurate diagnosis which results in misunderstanding, misdiagnosis, and mistreatment (Pitama et al., 2007). Cultural competence is not always ensured 21 when it comes to Māori admitted as inpatients who are referred by the health services to see any available psychologist in the area. Often it results in ending up being seen by someone who is not adequately prepared to meet Māori needs and therefore not being able to see the holistic make up of Māori wellbeing (Adamson, Sellman, Deering, Robertson, & de Zwart 2006; Pitama et al., 2017; Wheeler, Robinson & Robinson 2005). Accurate identification of needs at the right time can positively impact therapy outcomes and the literature shows inclusion of Māori mental health models can advance the quality of clinical care and increase the use of mental health services (Ihimaera, 2004; Wratten-Stone, 2017). Numbers of Māori health models are now available, however the literature evaluating these frameworks and research on clinical interventions applying them, remains limited, especially regarding models specific to mental health. When reviewing the studies evaluating Māori models of mental health the message is that there is a need to recognize these models as having the capacity of improving mental health services for indigenous populations and ethnic minorities. Some of the models that can be found in the literature include; Te Whare Tapa Whā (Durie, 1984); Raranga, Te Whare Pora (Fletcher, Green, MacDonald & Hoskyns, 2014); Te Wheke (Pere, 1991); Pōwhiri Poutama (Watene & Mataira, 1991); Te Ao Tūtahi Ngā Pou Mana and The (Ihimaera, 2004); and The Meihana Model (Pitama, Huria, & Lacey, 2014). Reviewing all of them is beyond the scope of this thesis. However, the most frequently reviewed Māori model of health, Durie’s (1994) Te Whare Tapa Whā will be discussed to highlight that there is a need for more models of health for Māori especially Māori mental health. Te Whare Tapa Whā compares wellbeing to the four walls of a whare/house, in which all must be in balance in order to achieve good health. These components are taha tinana (physical health), taha wairua (spiritual health), taha hinengaro (thoughts and feelings/mental health) and taha whānau (family health), (Durie, 1994). Durie’s model highlights the need for better understanding of the holistic nature of Māori well-being. The strength of this model is that it can be used for any ethnicity accessing mainstream services (Fletcher, Green, MacDonald, & Hoskyn, 2014). However, McNeill (2009) argues that Te Whare Tapa Wha does not define the uniqueness of te ao Māori, the Māori world, as the model can be applied for any cultural group. McNeill (2009) points, this model is essentially a personality profile which does not consider important variables that have an impact on Māori mental health, such as the socioeconomic position of Māori resulting from colonisation, loss of land, language, and the traditional ways of being (McNeill, 2009). 22 Literature using Māori models of health is very limited, even regarding the more commonly used Te Whare Tapa Whā. Marie, Forsyth, & Miles, (2004) used Te Whare Tapa Wha framework in their non-Māori study, and concluded that there are no essential differences between Māori and non- Māori ways of approaching health problems. Researchers employed 205 participants who were randomly selected from the general and Māori electoral rolls. To judge the differences between Māori and non-Māori participants a vignette methodology was employed, and target stimulus were used to identify the minimum DSM-IV-R criteria for a major depressive disorder. The findings suggested illness perception and treatment preferences were similar for Māori and non-Māori participants. Arguably, this conclusion has several limitations. Te Whare Tapa Wha model is a generic framework that can be used for Māori as well as non-Māori or any cross-cultural evaluations of well-being. This model has a universal application (McNeill, 2009). However, as pointed out by Houkamau and Sibly (2014) research defining Māori identity is a complex and multi facet concept. For example, what exactly distinguishes Taha hinengaro (mental health), or Taha wairua (spiritual health) between someone who is non-Māori or Māori can be influenced by the factors such as self-concept of Māori, spirituality, socio-political consciousness, beliefs, ability to speak te reo Māori, perceived appearance and few more. All these aspects of being Māori, including socio-economic status, lifestyle, and subjective perception of being Māori are linked to Māori wellbeing. Furthermore, Marie et al. (2004) findings are at odds with the well documented theories of cultural identity playing a critical role in mental health (Casar, Vasques, & Ruiz de Esparzo, 2002; Casas, Suzuki, Alexander, & Jackson, 2016; Kleinman, Eisenberg, & Good, 2006La Roche, 2012; Lyons & Chamberlain, 2006;Yeh, Parham, Gallardo, & Trimble, 2011; Vasquez 2007; Tao, Owen, Pace, & Imel, 2011; Soto, Smith, Griner, Rodriques, & Bernal, 2018; Murray, 2014; Wampold, 2007). Nevertheless, the Marie et al. (2004) research is the only study using Te Whare Tapa Wha to compare perceptions of mental health and illness of Māori and Pākehā. Further, it is not a Māori research. Another New Zealand study compared the perceptions of mental health of Māori-diagnosed with schizophrenia, with their non- Māori counterparts’ perceptions, and concluded that there were no significant differences in how mental health was perceived (Sanders, Kydd, Morunga, & Broadbent, 2011). Similar attitudes were found about the causes of the illness, medication, consequences, perceived control over the illness, understanding of the illness and emotional reaction to the illness. Five Māori patients noted spirituality influenced their illness, however that was not considered significant by the researchers. Results showed Māori believed their illness would last a shorter duration than non-Māori did. Some methodological issues with these findings can be pointed out which arise from the fact that only traditional, Western diagnostic criteria were used. Cultural identity and factors that constitute identity, such as beliefs and traditions, were not included. Among them is 23 spiritualty which is a core element of te ao Māori. Spirituality is highly relevant to mental health. It is a factor that structures human experience, influences behaviour, values, and impacts on illness patterns (Turbott, 1996). Spirituality has always played an important role in the form and content of mental illness; however, it is continuously ignored and pathologized by mainstream psychology (Lukoff, 1992, Tse, Lloyd, Petchkovsky, & Manaia, 2005). Taitimu, Read, and McIntoch (2018) argue Māori experiences of psychosis and schizophrenia are subjected to the Western psychiatric theories at both individual and collective level. Further, clinical practice along with the research was done upon indigenous peoples by non-indigenous using the Western paradigms. Taitimu, et al. (2018) research found the predominant explanations for experiences of psychosis or schizophrenia in Māori patients were spiritual and cultural. Rammohan, Roa, and Subbakrshna, (2001) found that spirituality played an important role in patients diagnosed with schizophrenia, even more so for the family members who cared for them. Consequently, this study suggested spirituality and religion should be included in intervention to enhance therapy outcomes. Multiple studies show inclusion of spirituality can have a positive impact on mental health including, reduction of symptom ratings, and being health-enhancing (Durie, 1998; Larson, Sayers & McCullough, 1998; Smith, 1999; Townsend, Kladder, Ayele, & Mulligan, 2002). Another issue in the Sanders, et al. (2011) schizophrenia perception study, is that Māori living in the cities may feel disconnected with their wider whānau and iwi. Participants in this study were predominantly from Auckland, a total of 111 users of mental health services (68 Māori, 43 New Zealand European). Western/colonial health systems were enforced on Māori, therefore it can be argued that there is a need for research that looks at the use of te ao Māori frameworks that account for variables such as culture, historical trauma, effects of colonization, relocation, poverty, language, beliefs, spirituality, and traditions. Moreover, more studies targeting diverse realities and diverse range of Māori are needed. Te Ara Whakamana is a cultural framework which incorporates and considers the above factors. Further, results from Marie et al. (2004) and Sanders et al. (2011) suggest the need for further investigations of the mental health perception between Māori and non-Māori as knowledge about these differences provides an opportunity to create more frameworks designed to ensure effective clinical interventions for Māori. 2.4 Culturally adapted Cognitive Behavioural Therapy (CBT) Te Ara Whakamana: Mana Enhancement framework is a growth model, in other words it is a collaborative model that works alongside existing, well validated and evidence-based models such as 24 Cognitive Behavioural Therapy (Marshall, 2019). CBT was developed to alter and restructure maladaptive thought patterns that cause symptoms of psychological disorders such as depression or anxiety (Beck, 2011). CBT assumption is that cognition facilitates dysfunctional behaviours and symptoms. To help the client, the dysfunctional beliefs are thoughts are restructured and replaced with more realistic ones (Dobson & Dozois, 2001). CBT targets specific problems and applies certain strategies to collaboratively work with a client; is a goal-oriented approach. In CBT the client is taught the key elements of this approach, its gains and how their own thought processes influence their perception of self and their mood; it is an educational model. Different activities are performed with the client and included in the intervention, for example, homework. At the end of the therapy, clients should have developed strategies that will help them become their own therapist. CBT has empirical significance and is time-limited and thus cost-effective (Beck, 2011). The two principal domains in CBT are cognitive restructuring of disordered thoughts and overcoming behavioural deficits responsible for maintaining the symptoms (Beck, 2011). Several studies and meta-analyses support the efficiency of this approach (Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; Parker, Roy, & Eyers, 2003). CBT is also found to be superior to pharmacotherapy and behavioural therapy for the treatment of depression (Gaffan, Tsaousis, & Kemp-Wheeler, 1995). Research demonstrates that the structured and evidence based nature of CBT makes it a very effective approach, however this model can neglect the dynamic relationship between a client and a clinician, which is essential for an effective practice of CBT (Beck, Rush, Shaw, & Emery, 1979). At the heart of effective therapy is a relationship and therapeutic alliance (Hewitt & Coffey, 2005). Understanding the client’s culture is critical for the development of the therapeutic alliance (Soto, et al. 2018). The philosophy and the principles of Te Ara Whakamana: Mana Enhancement may help clinicians develop better relationships with their clients and their families. Antoniades, Mazza, and Brijnath, (2014) point out CBT is a culturally adaptive method, however, there are very limited studies exploring this area, even less so in the context of New Zealand populations and Māori. Bennett, Flett, and Babbage (2014) were the first to investigate the effectiveness of a culturally adapted cognitive behaviour (CBT) therapy for clinically depressed Māori clients. The researchers adapted CBT treatment incorporating processes inherent to Māori mental health approaches including Māori processes of engagement, spirituality, family involvement and metaphor. This study is of significant importance as it is looking at whether CBT is culturally acceptable and efficient for Māori. As a response to these issues a culturally adapted CBT treatment programme from Benett (2018) was developed using culturally relevant literature and CBT research. An advisory panel involved in creating the manual consisted of experienced Māori and non-Māori clinical psychologists. Bennett’s 25 (2018) culturally adapted treatment identified issues within clinical diagnosis of depression that further highlighted the importance of cultural identity as a protective factor in depression and mental illness for Māori. For example, valuing identity has shown psychological benefits (Hirini, 2005). Also, Bennett (2018) pointed out there are limitations to the empirical validity of Western models, from Western cultures applied to non-Western populations. Lastly, Bennett’s (2018) culturally adapted CBT is a response to existing research that offers no direct comparisons between adapted and standard interventions with minority groups. Nevertheless, Bennett, (2018) study showed significant reductions in depressive symptoms and negative cognition in Māori clients as measured by Beck Depression Inventory-II (BDI-II) and Automatic Thought Questionnaire (ATQ). Mean depression scores decreased from a pre-treatment mean 28.69 (S.D. =11.15) to a mean of 10.71 (S.D. = 13.86) post treatment. This reduction was sustained after 6 months. Whilst this is a naturalistic study with no control group, the results provide strong evidence to support the culturally adapted CBT for a Māori population. Another key point highlighted in the research was the importance of whanaungatanga/relationship and connection between professional and the service users. In addition, there has been limited progress in adopting and validating CBT for Māori population and this study is a promising one. Mathieson, Mihaere, Collings, Dowell, and Stanley (2012) adapted guided self-management intervention that was CBT based for Māori in a primary care setting. This was the first brief psychological mental health intervention designed specifically for Māori. Researchers used a collaborative approach in the process of adaptation which included review of the literature, face-to- face and group interviews with primary care clinicians and individual face-to-face interviews. Literature shows a collaborative approach to therapy with adaptations, such as essential aspects of Māori wellbeingand culture being incorporated, can be more easily accepted by Māori (Durie, 1994: Bennett, & Flett, 2001; Hirini, 1997). For the purpose of Mathieson et al. (2012) study, the following were included: Whakawhānaungatanga (the process of forming relationships); whānau (family) and iwi (tribe); te reo (Māori language); as well as spirituality and promotion of cultural identity. K10 scores showed improvement in patients using intention-to-treat rated global psychological distress following intervention. Although, the improvement was not statistically significant, researchers highlighted that the confidence intervals showed that the true mean improvement was likely to be greater than zero. Nevertheless, the strength of this investigation is that it promoted a talking therapy which is highly credible among clinicians and patients. Proponents of Cognitive Behavioural Therapy, Dialectical Therapy, Behavioural Therapy, and Motivational Interviewing all agree that an effective therapeutic relationship is fundamental for positive therapy outcomes (Luborsky et al., 2002; Stiles et al., 2002) and the strength of therapeutic alliance can determine the therapy outcomes (Martin, Garske, & 26 Davis, 2000). Nevertheless, participants and clinicians were in favour of the culturally adapted programme and provided positive feedback in Mathieson et al. (2012) study. Kohn, Oden, Munoz, Robinson, and Leavitt, (2002) compared CBT to a culturally adapted CBT for depressed African American women in US, African American Cognitive Behavioural Therapying AACBT. The intervention was a modification of a manualised CBT group treatment protocol for depression. The key changes applied to the existing CBT were based on theoretical literature, publications of treatment approaches used with African American women, and consultations with clinicians who had experience working and treating African women. This approach is a strength of this study as it allows the identification of possible barriers of the non-adapted treatments (Kohn et al., 2002). An adapted version included changes in the structure and process of CBT and in the content of the material to be covered each week. For example, meditation was added as well as a termination ritual at the end of the 16-week intervention. Some changes in the language were made, for example, the term “homework” was replaced with the term “therapeutic exercise”. This research is an important contribution to the study of culturally adapted models as it compares CBT with culturally adapted CBT. The post-treatment results showed improvement in both CBT and AACBT groups and a drop in symptoms’ intensity as shown in the average BDI II scores in the last week of treatment. The African American group, which used adapted CBT, showed 12.6 points from pre-treatment 34.4 to post-treatment 21.8 as compared to 5.9 points decrease in the CBT group. This research highlighted the initial BDI scores for African American women were higher than scores reported in meta-analytic reviews across 28 studies with similar patients. Therefore, there is some evidence that African American women do not seek professional help until the symptoms are more severe. Improvement scores for AACBT, being twice as high, demonstrates the need for further culturally adapted treatments. More relevant to the Māori population is a study conducted by Whealin at el. (2017) who reported positive results with their culturally adapted mental health intervention for Pacific Island veterans with PTSD and their families. Pacific Islanders are an ethnic group that are often overlooked in the literature (Pole, Gone, Kulkarni, 2008). Researchers in the Whealin at el. (2017) study used the 5-stage Map of the Adaptation Process; assessment, selection, preparation, piloting, and refinement as the framework for guiding the intervention. The core cognitive–behavioural components were integrated and key aspects of cultural values including relationship, family, and spirituality were incorporated. The intervention was called “Koa,” which has various meanings in native Hawaiian languages including: brave, fearless, and hero. The results of the clinical intervention showed participants and their families found all components of the intervention to be highly valid, useful, and 27 relevant. Participants highlighted that the programme was particularly effective as it included “the island way of things”. Some rated the intervention as “excellent” and would refer a friend or a family member. Researchers highlighted that relationship problems are sometimes the result of PTSD (Miller et al., 2013). In this context it is important to note that Pacific Islanders, similarly to Māori represent collectivist culture, with family being integral element of wellbeingand individuals will always place themselves within the family context. Pasifika people often value family before their individual needs and the therapy outcomes for individual will often be influenced by the degree of the support offered by the family (Suaalii-Sauni, Samu, 2005). Koa intervention facilitated connection, trust, and engagement into mental health practise and made a significant difference for both patients and their families. Whealin at el. (2017) highlighted previously used intervention targeting the same population were a mainstream US models which lacked cultural needs of the Pasifika veterans and their families. No other studies of such nature had been found and the high acceptability of such culturally centred framework indicates culturally adaptive models should be developed and made available as a treatment option. Lastly, psychological practice requires use of the multiple models that are indicated at different times, circumstances, and for different cases. Including models that are culturally appropriate and able to meet the clients’ needs (Marshall, 2019). 2.5 Conclusion The primary aim of this chapter was to review the literature relating to cultural competence of psychologists working in Aotearoa New Zealand as well as reviewing the studies contributing to the understanding of the effectiveness of culturally adapted models and indigenous models that integrate aspects of Western models such as CBT, lastly targeting culturally adapted Cognitive Behavioural Therapy (CBT) as an example of culturally centred framework and its potential. This is especially relevant for the context of Aotearoa New Zealand and when working with Māori clients. 28 Chapter Three Methodology 3.1 Introduction The aim of this chapter is to set out the methodological approach undertaken to discover psychologists’ experiences of using Te Ara Whakamana: Mana Enhancement framework with their clients. This chapter will present the aim of this research and the methodological approach adopted. It will present the sample which was selected and set out the method used for data collection along with the process of data analysis. Finally, it will present ethical issues and limitations associated with this study. This research is a part of my academic journey to become a psychologist. I am a non- Māori researcher, who is originally from Poland. I have lived in Te Tairawhiti/Gisborne for ten years now, where the population is 51% Māori. Throughout the completion of my studies, I have developed a strong awareness of the need for my perspective and skills to be culturally inclusive and culturally responsive. I have also developed a passion for learning about Māori models and frameworks within psychology. Cultural competence for psychologists in New Zealand is necessary under Te Tiriti o Waitangi (New Zealand Psychologist Board, 2011). However, if I am to be an effective psychologist in Te Tairawhiti with our population here, cultural competence with Māori is mandatory. This was what brought me to the desire to find out more about Te Ara Whakamana: Mana Enhancement and led me to this research topic. I am extremely grateful that I received the support of Māori psychologists in supervision and mentoring roles. I have had to consider my approach and perspective as a non- Māori researcher conducting Māori research throughout the entire process. 3.2 Aim of research The purpose of this study is to explore the following key research questions: 1. How is Te Ara Whakamana: Mana Enhancement applied by psychologists? 2. How does utilising Te Ara Whakamana: Mana Enhancement impact on psychologists’ practice? 3. What are the possible challenges of incorporating Te Ara Whakamana: Mana Enhancement in psychological practice? 4. How does use of Te Ara Whakamana: Mana Enhancement impact on the relationship between professional and client? 29 3.3 Ethical considerations Several ethical issues and concerns were considered while conducting this research. Any type of research will have an impact on participants and on society as a whole and the researcher must be aware of such possibility at all times and should therefore act accordingly (Kumar,2005). Semi- structured interviews are in-depth interviews that are often subject to enquiry by ethics committees. In depth interviews aim at uncovering details of the interviewee’s experience of the subject being studied. Whereas, in the questionnaire, commonly used in quantitative research, such experiences would be undisclosed (Allmark et al., 2009). Interview based research cannot be completely regarded as low risk and some issues are of particular importance including privacy, informed consent, and identifying possible harms to both participants and researcher (Allmark et al., 2009). A research proposal was submitted to the researcher’s supervisor, and then approval from the conduct of the research was obtained from Massey University Human Ethics Committee prior to commencement of the recruitment. The principles of Māori centred research and Kaupapa Māori theory were explored for this thesis. This was done by exploring and discussing issues that are of high relevance and importance to Māori and by ensuring Māori voice was positioned as central in this research (Tuhiwai-Smith, 2006). The researcher aimed at advancing Māori solutions based on the principals of Kaupapa Māori theory which supported this research processes. By honouring and including Māori knowledge, Māori reality, and epistemological foundation the researcher aimed at exploring a model that can advance and improve Māori wellbeing. A local Māori Cultural Adviser was approached to provide advice on how to ensure adherence to the principles of the Treaty of Waitangi. Voluntary, informed, written consent from the psychologists was obtained prior to commencement of the study. Data was collected and coded, with identification codes stored separately, to ensure privacy (Massey University Human Ethics Committee, 2010). All data is stored in a secure manner and only the author has access to the raw data. Informed consent was ensured from all participants stating that they were willing to participate in the interview while also ensuring their confidentiality and anonymity throughout the process. The issues of privacy and confidentiality were discussed, and participants were aware that there was no obligation to answer questions that they felt uncomfortable with. It was also made clear that their participation was voluntary, and they were free to withdraw from the study at any given time. Prior to the interview, participants received information that this study was being carried out, which also contained the research outline, the type of information that was required, and the aims of 30 the research. The length and the time of the interview was indicated prior to the commencement of each interview and participants were given sufficient time to ask questions before and after the interview. 3.4 Qualitative approach A qualitative research approach was chosen as the research method for this study. All definitions of research suggest that research is a process of investigation that is methodological and aims at gaining new insights and understanding that constitute knowledge about the world (Langdridge, 2014; May, 1997; Stangor, 2015; Weathington, Cunningham, & Pittenger, 2010; Willig, 2019). Psychological research involves gaining knowledge related to human behaviour and experience (Willig, 2019). Qualitative research arrives at its conclusions by involving a systematic series of steps, known as the process of induction. Specifically, qualitative research seeks to provide an understanding of human experiences and how people make sense out of their experiences (Willig, 2019; Hays & Wood, 2011). Willig, (2019) concludes meaning is the aim of most qualitative studies. Qualitative research aspires to describe how peoples’ feelings and thoughts affect their behaviour (Sutton & Austib, 2014). Further, qualitative research postulates that reality, society, and science are phenomena that are shared and/or shared by human lived experiences, reflections, thoughts, interactions, discourse, language, institutions, and storytelling (Hays & Woods, 2011). Qualitative research and specifically thematic analysis was considered most suitable to undertake this research as it allowed in-depth explorations of meanings participants assigned to their experiences of Te Ara Whakamana: Mana Enhancement. As clarified by Clarke and Braun (2018), thematic analysis TA is a term that encompassed not one but many approaches to qualitative analysis. It is best understood as an umbrella term for many approaches that typically share an assumption that TA is a method rather than methodology, and that it is a flexible method in terms of theoretical application. In terms of analytic procedure and philosophy this thesis was based on Clarke and Braun (2006) school of TA which is positioned within the qualitative paradigm. In depth engagement in data enables quality coding and development of themes and subthemes (Clarke and Braun, 2006). Qualitative approach enabled the inclusion of participants beliefs and feelings. Qualitative research methods also help to provide far-reaching details by including participants emotions and viewpoints (Denzin, & Lincoln, 1994; Denscombe, 2010; Minichiello, 1990). The narrative approach 31 provided space for careful consideration of one’s social position, cultural identity, values, and beliefs and how these possibly influenced the way psychologists approach their clients and whānau (Murray & Poland, 2006). Human actions are related to the social context in which they occur, and individual development is largely influenced by the culture in which a person grows up and lives in (Lantolf, 2017). In other words, the mind is mediated by the context in which a person exists. The context is critical in how people make sense of their experiences and it contributes to the development of the higher order functions such as critical thinking, reasoning, or decision making (Lantolf, 2017). Quantitative research on the other hand is more numerically based, broader in scale, and more structured, therefore was considered not suitable for the purpose of this research. 3.5 Interview Semi-structured interviews were selected to carry out this research study as they are flexible and versatile data collection method (DiCicco-Bloom & Crabtree, 2006). They allow reciprocal relationship between researcher and participants, providing space for them to elaborate and give unique and personal answers (Galletta, 2012). Semi-structured interviews allowed topics and areas to be narrowed down thereby reducing the risk of topics and themes being too broad and not closely related to the research questions being explored (Rabionet, 2011). Such a risk can be present when using completely un-structured interviews (Fontana & Frey, 2003). Another advantage of interviewing is its ability to explore complex and often sensitive areas by giving the participants an opportunity to prepare before asking the questions and to explain them in person if need be (Kumar, 2005). Throughout the interviewing process and data collection the researcher aspired to adhere to the values and principles of tikanga Māori, which ensured ‘right ways of doing things with Māori’ (Tuhiwai-Smith, 2006). The principles of tikanga Māori helped the researcher to endure respectful collaboration, and it allowed participants to define their own space. Interviews were conducted in a cautious, safe and reflective way including protection of the mana and dignity of the participants (Tuhiwai-Smith, 2006). Interviews allowed psychologists working in Aotearoa New Zealand to include their social context and provided the space to embrace their own social structure in which they live. The process of narration can unlock and communicate human qualities such as love, anguish, disappointment, or conflict (Cortazzi, 2001). Psychologists, like most of us, change their perspective on their experiences as they engage in dialogue with other people and gain new experiences (Heikkinen, 2002). Stories are not isolated abstractions, they are rooted in cultural context (Bruner, 1984) and therefore knowledge and human identities are continuously constructed and modified (Heikkinen, 2002). 32 While the interview process has many benefits there are also some disadvantages. Similarly, to quantitative survey research, semi-structured interviews rely on the participants ability to provide honest and adequate recollections of the issues that they are being asked about (Esterberg, 2002). The interview process can also prove to be time intensive, costly, and emotionally taxing (Kumar, 2005). Data can be affected by the skills, experience and commitment of the researcher. Lastly there are risks associated with a small sample which can affect the reliability of the data as well as researcher bias (Kumar, 2005). 3.6 Sampling and selection As pointed out previously exploring the topic in depth is a primary strength of the qualitative research approach (Carlsen & Glenton, 2011). Information gathering and methods of analysis will influence selection of participants and when the sampling should stop (Cleary, Horsfall, & Hayter, 2014). Purposive sampling method was chosen in selecting participants. Qualitative research methods are commonly described as purposive because the selection of participants should have a clear justification and specifically correspond to the research questions (Collingridge & Gantt 2008). The inclusion criterion was based on participants who are registered and practicing psychologists in Aotearoa New Zealand and who have received training in Te Ara Whakamana: Mana Enhancement framework and have used it or intend to use it with their clients. In undertaking this study, the researcher chose to interview individuals. Individual interviews have the ability to generate a large breath of items ( Aldag &Tinsley, 1994; Coenen, Stamm, Stucki, & Cieza, 2012; Guest, Namey, Taylor, Eley & McKenna, 2017.) The majority of empirical research is consistent with the findings that in terms of data collection, focus groups and individual interviews can both generate unique information. However, focus groups require more time, resources, and 6-10 times more participants per data collection than individual interviews. Focus groups are also difficult to schedule and can require more than one researcher to collect and transcribe data. Participants were sought through personal contacts of the researcher. Eleven participants were recruited to be interviewed and all of them participated in the research. 3.7 Data collection Data collection took place in July, August, and September 2019. The author of this thesis aimed at working with participants in a collaborative dialogic relationship. A dictaphone was used to record the interviews and all interviews were fully transcribed verbatim. Data gathering and analysing was conducted concurrently, which adds to the depth and quality of data analysis (Chamberlain, Camic, & Yardley, 2004). Three of the eleven participants were acquaintances of the researcher; the other eight https://onlinelibrary-wiley-com.ezproxy.massey.ac.nz/doi/full/10.1111/jan.12163#jan12163-bib-0003 33 were recruited through third parties known to the researcher and word of mouth. All participants were contacted through email and received the participants information sheet containing details of the research along with informed consent. The interviews took place in Gisborne and two interviews were conducted via emails. The researcher studied the research topic in advance as interview questions should be based on previous knowledge (Wengraf 2001; Kelly 2010). The interview schedule was prepared covering the main topics of the study in the general form of the interview with series of questions. Such format provides focused structure for the discussion during the interviews but the sequence of questions can be varied and the schedule does not have to be followed strictly (Holloway & Wheeler 2010). The interview schedule guides participants on what to talk about. It enables probing and exploring additional questions and has freedom to investigate the research area by gathering similar information from each participant. At the same time semi-structured interviews have capacity to allow for rapport and empathy to develop between the researcher and the participants (Holloway & Wheeler 2010). Each participant was presented with a similar set of questions relating to their overall experiences of Te Ara Whakamana: Mana Enhancement framework. An example of an open- ended question included in the interview schedule is ‘What are the main challenges you face in your work with the models you are currently using with Māori (tamariki/whānau/adults)? And others who are not Māori? Are there any models you used in the past that you stopped using and why? What are the models you find effective for your practise?’ 3.8 Data analysis First and for most analysing and managing the data needs to be true to the participants (Sutton & Austin, 2015). The researcher kept in mind that conducting qualitative research is about the world from the perspective of the participants and putting oneself in their shoes. The main goal of this data analysis was to hear and capture the voice of the participant so that their experiences could be interpreted and reported on for others to read and learn. Once data was gathered and recorded the author immersed herself in the data to obtain a sense of the whole by reading and rereading (Polit & Beck, 2003). The data was then transcribed, coded, analysed, interpreted and verified. Repetitive listening and reading helped the researcher gain better understanding of the subjects as well as correct any spelling or other errors. Once all the data was fully transcribed and checked the coding process took place. ‘Coding refers to the identification of topics, issues, similarities, and differences that are revealed through the participants narratives and interpreted by the researcher’ (Sutton & Austin, p. 228, 2015). Coding helps the researcher understand the world from each subject’s perspective (Sutton & Austin, 2015). 34 The data was then analysed, categorised, and organised into themes and further sub-themes which emerged through the coding process. The themes which were identified were assigned a specific code accordingly. The next stage involved interpreting the data by identifying any reoccurring themes throughout and highlighting any similarities and differences in the data. The final stage involved data verification, this process involves checking validity of understanding by rechecking the transcripts and codes again, thus allowing the researcher to verify or modify hypotheses already arrived at previously (Sarantakos, 1998) 3.9 Conclusion This chapter discussed the methodological approach undertaken in the research. It outlined the research questions, the method employed for data collection, the sampling methods, and how the data was analysed along with ethical considerations and the limitations of the study. 35 Chapter Four Findings 4.1 Introduction This chapter presents the main themes and findings from the interview process and data analysis. The demographic overview of the psychologists is presented. The key themes identified following data analysis were; psychologists wanted to grow their knowledge and skills around culturally inclusive models, Te Ara Whakamana: Mana Enhancement was used by most of the psychologists, and they reported the model is effective, and it positively influenced their practise; almost all psychologists identified structural and organisational barriers to train in the model and facilitate the model; this model is effective for both Māori and non-Māori clients and has a potential to be used more with adult clients. All of the themes are interconnected. Table 1. Themes and Subthemes Themes Subthemes 4.3 Rationale for participating in Te Ara Whakamana: Mana Enhancement training 4.3.1 Cultural competence 4.3.2 Structural barriers from the past 4.3.3 Relationship building 4.3.4 Presentation on the model 4.4 The feedback on the training 4.4.1 Importance of attendance 4.4.2 Diversity and workshop delivery 4.4.3 Cohesion with other trainings 4.5 The application of the model 4.5.1 In everyday practise 4.5.2 Being creative with the model 4.5.3 For young clients 4.5.4 In complex cases 4.5.5 The potential 36 4.6.4 Te Ara Whakamana: Mana Enhancement for Māori clients 4.6.1 Empowering 4.6.2 Structured 4.6.3 Applied with cautiousness 4.7 Using the model with Pākehā clients/non- Māori clients. 4.8 Whānaungatanga-relationship building and therapeutic alliance 4.8.1 Connecting with Mātauranga Māori and Te Ao Māori 4.8.2 Respect and collaboration 4.9 Te Ara Whakamana: Mana Enhancement strengths 4.9.1 Collective approach to wellbeing 4.9.2 Wairua/spirituality 4.9.3 Unique and engaging 4.10 Structural issues and possible limitations to utilising Te Ara Whakamana: Mana Enhancement 4.10.1 Māori models can be seen inferior to Western models 4.10.2 Collaboration is essential 4.2 Participants Eleven participants took part in this study. Ten psychologists were female, and one was male. Four of the participants are Māori and four were trained abroad. All participants are currently registered in New Zealand, ten are working in New Zealand, and one is abroad at present. The majority are working in the Te Tairāwhiti/Gisborne region. One was an intern psychologist who successfully completed her internship before this study was completed. One psychologist and two clinical psychologists were trained overseas. With an exception of the intern psychologist, the experience in working within the field of psychology ranged from 6 years to 21 years. The areas of employment for participants varied from Ministry of Education, ACC, Courts, CAMHS and private practice. All participants had participated in Te Ara Whakamana training. 37 4.3 Rationale for participating in the Te Ara Whakamana: Mana Enhancement training Almost all participants took part in the training because they were interested in gaining more knowledge and understanding about models that are culturally inclusive and culturally grounded. Most decided to participate in a Te Ara Whakamana: Mana Enhancement two-day workshop as they believed they needed more culturally appropriate tools to offer in their practise. Some believed they had limited resources to offer when working with Māori clients. 4.3.1 Cultural competence One of the participants was trained as a clinical psychologist abroad and she acknowledged she needed to upskill in order to work meaningfully with the New Zealand population: I was looking for sort of culturally approachable tool to use in New Zealand and to build my own knowledge base to work with people from different cultures. (Participant 2). Some of the participants moved to New Zealand from overseas and found it challenging to ensure their work was meaningful, so they were open to gain more confidence as psychologists practising within diverse New Zealand populations. One participant felt the need to be more culturally grounded with people. She had learned some Māori customs like Pepeha and Karakia as a way of showing her clients that she is making an effort. However, she felt that she needed something more that would enhance her relationships with clients and result from collaboration, while not being affected by her background: With the accent that I have and who I am I don’t want people feel that they are in the outs. I want to be able to build a therapeutic alliance as quickly as we can. Being someone who is not from New Zealand I wanted to find ways to practise in something that is more culturally grounded. (Participant 3). Another participant who emigrated from abroad felt similar: My main challenge is that I am from the UK so everything was new to me – I have found that the students I have used the model with have enjoyed being able to teach me about the Creation Stories and the Māori Ātua and correcting my pronunciation. (Participant 6). 38 Participant one sought to attend the training because of their positive impression of how Te Ara Whakamana: Mana Enhancement was implemented by one of the schools she works with, and the way the school applied cultural elements of the model to everyday life of the students. For example, the school implemented new strategies, tools, and changes to their environment. She also highlighted that the school talked a lot about Te Ara Whakamana: Mana Enhancement: I liked their approach. I liked the Atua garden, the zen table, and how they had their kind of restorative questions that they did with the young people and they talked a lot about Te Ara Whakamana: Mana Enhancement model. I guess I am passionate about the things that are culturally inclusive, and I wanted an opportunity to be able to use it in my practise. I wanted a tool that I can use with students to find out the solutions and then to support the teachers to understand that. (Participant 1). One participant wanted to use a culturally grounded model to find new ways of interacting with children. A model that was engaging and would: Broaden their culture that also make them proud of their culture in a way. (Participant 3). Another participant wanted to use Te Ara Whakamana: Mana Enhancement model as a therapeutic framework to ensure cultural sensitivity and to integrate other approaches into her practise. Some of the participants took the training because they heard positive feedback about Te Ara Whakamana: Mana Enhancement from their colleagues and the importance of participating in the training in person. 4.3.2 Structural barriers from the past Interestingly five of the participants had known about the model for some time and wanted to be trained in the past, however due to structural issues within their previous jobs they were unable to: Since I graduated, so almost 10 years ago, I’ve been aware of Mana Enhancement and have wanted to be trained however MOE was not keen on using the framework. I still can’t understand the rationale there. So, I had to wait 10 years and having left MOE to actually do the training. (Participant 7). I learned about the model in 2014. A number of our RTLBs were trained in the model and were using it. I was coworking with them and I was very impressed by what I saw. So, we tried to persuade our service to train in it and our big manager said we were not allowed to because it 39 was not evidence based even though our Kaitakawaenga found it effective and most of us found it effective. So, I went and trained in my own time, and have been using it since 2014. (Participant 11) 4.3.3 Relationship building Some participants pointed out how important the first session with a client is and how being able to facilitate the model could support the process of relationship building: I also wanted to know how to facilitate Mana Enhancement and how to bring it into that one- on-one place when you are gathering the data from the student. There really is quite a therapeutic nature to that interaction to that interview. And I wanted to see how Te Ara Whakamana went about that process. (Participant 7). 4.3.4 Seeing the presentation on the model For some of the participants the rationale to undertake the training was seeing the presentation on the model by the creators of it: I had seen a presentation by the creators and loved what this offered. (Participant 8). One participant undertook the training after being told by his colleague that this model would be particularly helpful in their work. They had no expectations of the training and were just curious about it. 4.4 The feedback on the Te Ara Whakamana: Mana Enhancement training All participants spoke positively about the two-day training/workshop and described it as ‘very good, ‘interesting’, ‘helpful’, ‘meet expectations’, or ‘even better than I thought’. Two of the clinicians highlighted how they particularly valued the break between day 1 and day 2 of the workshops: It was good. I liked the gap actually. I liked doing the training in the model one day and having the chance to practise it and then coming back to talk about struggles that we had. Consolidating that learning. I felt like I applied it more in that way and made adjustments that you wouldn’t have done doing two days back to back. (Participant 3). 40 I like that it was done over two days and that the second day there was quite a lot of time in between. I found that really helpful. I thought it was a good, hands on, practical training. I left the workshop confident that I can use the tool. (Participant 2). 4.4.1 Importance of attendance Some of the participants spoke about the importance of participating in the training in person, and how participation changes the understanding of the model, rather than learning it from others or trying to train oneself by using resources such as manuals: I found the training even better than I thought I would, because I purchased a manual and read it before I even went to the training, so, I was very familiar with the material that I was using. But one of the things about the Te Ara Whakamana: Mana Enhancement is part of the wairua aspect of it; actually, being in the room with workshop trainers and talking about it and acknowledging the wairua. That made a real difference to me than just get the book and read about it. (Participant 11). 4.4.2 Diversity and workshop delivery Other participants spoke a lot about the diversity of the people participating in the training and the number of people attending: We had really good diverse bunch. We had people from all over the country. I realised people coming up from Rotorua from Wanganui from Palmerston North and I thought my goodness this really is popular. But it was also a really, really good bunch of people. Lots of different backgrounds. (Participant 8). Another participant valued how the workshop was delivered: It was a wonderful mix of intellectual challenge, cultural relevance, and sensitivity. And to be learning all of that in relation to how essentially assist kids in changing behaviour… I really liked the presentation I saw. (Participant 7). 41 4.4.3 Cohesion with other trainings Some participants noticed that Te Ara Whakamana: Mana Enhancement training fitted easily and complemented the other trainings they take part in. Participant one noted: The training was really good. I like the concept, and I like how it lines in. I am one of the key facilitators for the Understanding Behaviour Responding Safely and that’s the one day training we do in Ministry of Education. And Mana Enhancement dovetails really beautifully. That training is given to all the teachers. (Participant 1). 4.5 The application of the model 4.5.1 Everyday practise Six of the participants used the model in their everyday practise as one of the tools offered to their clients. Participant seven is currently working abroad and therefore unable to use the model. Three of the participants are not currently using the model themselves due to the nature of their work responsibilities but are recommending it to others when appropriate and continue to support the wider use of it. Participant four intended to use the model as a part of their professional development in supervision. The majority of the participants completed the initial sessions as homework including practising the framework with someone they knew to gain more confidence before using it with clients. The practise sessions were completed with family members, friends, or work colleagues. The homework was then brought back for the second day of the training to review and discuss. I have used it as side try with my whānau first. It was interesting seeing how my boy responded. That was really cool, and I actually learned something about him. So that was great. (Participant 1). Participant one noted even though the model is a part of her daily practice it is not for all of her clients: I am using this model in everyday mahi. It’s just a part of the practice. It’s not for all my kids that I work with but it’s definitely for some of them. The ones that I think get a lot out of it. (Participant 1). 42 Participant eight used the model regularly in her previous job but at the time of the interview she has just changed jobs and was adjusting to the new workplace and tasks. She was planning to return to the model and use it as her everyday tool: I found that it worked with a lot of kids. After using it with that boy I realised I can use it with that kid and that kid. At the time I was working in (XYZ) it was my everyday thing. (Participant 8). 4.5.2 Being creative with the model Participant one spoke about using additional visual resources when applying the model and how being creative in utilising the model helps clients get more out of it: I got a YouTube video clip that I play, with music and amazing graphics and it tells the creation story so, I played that as well and we discuss it before we get to the model, before we start. It’s really cool with kids with challenging behaviour. So even that first boy that initially struggled with the model, we then did it with his mum and I had heaps done and I use it with the teacher as part of our planning for him as he is returning to the mainstream school. (Participant 1). A few of the psychologists created their own visual templates to help their clients complete the sessions. They pointed out this was especially helpful for clients who struggled with writing and speaking: I have done like an extended Mana enhancement plan template and shared it with a school staff as they were all happy to share it because it is easier to share the information that way. (Participant 2). A few participants spoke about using the model in a flexible way with individuals but also in a family setting: By the end of it he actually did complete the model as a whānau, and we came up with some strategies around what he could do. (Participant 1). Participant two spoke about how she challenged herself in applying the model with the family and highlighted a case when she completed the model with a dad and a son at the same time. I did it with a dad and son sort of simultaneously and we did it over an extended period over eight sessions. We completed a little component and reflect on that and did goals setting around 43 when we were completing the bottom half- the Papatūānuku, talking about the places you feel safe and the people. The dad, and the family had a really good relationship and we explored what is it that creates those good connections? How do you facilitate them as a relationship that you want to repair and then we did sort of repair relationship, and maintaining them. (Participant 2). She also noted that she had the best results when taking the time to complete the model: The most effective way I ever used the tool is not rushing it. (Participant 2). Another way a participant applied the model was in a group setting with five students from a Kura Kaupapa Māori (Māori immersion school) who all completed their own Mana Enhancement plans and then as a group went through the concepts to explore them in different ways. The group explored together each of the different Atua, identifying their strengths and what are the things they need to be aware of and linked it back to their own characteristics. Participant one collaborated with another professional to use the model with a boy who had a significant trauma background and struggled to describe certain things when going through the model. She collaborated with a speech therapist to design visual reminders to assist him: What I did is I spoke to speech language therapist, a friend of mine, and there is strategy they use where they use a whole lot of visuals (…). So, what we came up with was the speech therapist came up with different categories which is about thinking about each section. So, when we hit each section, we are going to give visual reminders of who could be in there. (Participant 1). 4.5.3 For young clients A few participants used the model mainly with young clients. One participant described using Te Ara Whakamana: Mana Enhancement mainly with young male clients but she made it clear that this model is also suitable for adults. She particularly liked seeing parents being very involved in the sessions, assisting their children in the room, and helping the children complete the sessions. I had one mum who we did Te Ara Whakamana: Mana Enhancement with and she really liked Rūamoko and really identified with this idea of volcano around anger, so we drew up a volcano leading on from that and described anger that is something very explosive. She came back the next session, she taken photos of what we’ve done, and she had shared it with her sister whose an adult as well and she really got it too. She really got it. So, it was really interesting to see the mum grasp that but then shared the principals with another adult. 44 (Participant 3). I think it would be hugely effective with adults. I personally believe that every CAMHS service and every mental health and drug and addiction service in the country should be offered training in the model, so it is a tool they have in their kete. I also believe in the justice system should have it too. It is very diverse model that can be used in many different ways. (Participant 11). 4.5.4 In complex cases Some participants who work with disability noted that when working with a disability caused by brain damage, it is important to adapt the environment around the client and hence necessitates the presence of family or caregivers. She believed the application of Te Ara Whakamana: Mana Enhancement could support these processes: With the kids with Fetal Alcohol Spectrum Disorder (FASD) they really need their whānau or their caregiver to be involved. Because first of all we need to understand where their brain injury is, because they might struggle with their verbal memory or their attention. So, we have to be scaffolding. And when we have their family or caregiver with them it’s really important that the caregivers are on board and to take charge of implementing it. Because those kids are not going to individually implement it, but they need someone else to take responsibility to do it for them. (Participant 11). One participant asked the creator of the model to interview and create a plant for a client: I had a young man who was on my case for a couple of years and he ended up having a diagnosis of autism. He was really hard to talk to about stuff because he didn’t have insight into his own thoughts and feelings. We got Sue to do a Mana Enhancement plan with him and honestly, I’ve known this kid for 2 years and knew 10 times more about him after that hour. (Participant 11). 4.5.5 The potential Participant eleven spoke about the potential of the model that is yet to be explored: Being a psychologist is not just going into a room and using the model. It is about the whole part of how we hold ourselves, and how we manage the emotions in the room and everything that is going on. There is a whole level how Te Ara Whakamana could be utilised therapeutically that is barely even been touched because there are not enough psychologists that are using it and are aware of that. Because it has been developed with schools in mind it is mainly being used with young clients. (Participant 11). 45 Interestingly participant four found a unique way of applying the model as part of their professional development. As a psychologist we are required to do continuous competency practise called CCP. And one of the goals that I have made myself for this until March next year is to offer some pair supportive reflective supervision /protocol with one of my colleagues, that is doing similar work to me. We both going to go on a journey with it me as supervisor and him being supervisee. See whether it’s a workable framework to offer reflective practise. So, offering supervision as a psychologist is a part of my practise and that’s how I am going to use Te Ara Whakamana: Mana Enhancement. (Participant 4). Participant eleven has been using the model since 2014 and from her experience she was able to point out what are the best ways of using the model: Te Ara Whakamana: Mana Enhancement and what it allows us to do as psychologists is it provides an easy framework to talk about thoughts and feelings and helps us to help the clients put things into words that are really hard to put into words (…). I think this model makes it easier for people to look at Rongo-mā-Tāne, look at Ruaumoko, and apply that to themselves. In each of the cases I spoke about, Te Ara Whakamana: Mana Enhancement framework would be part of helping the person to explore their thoughts, and feelings, and behaviours and put this into practise. (Participant 11) She also pointed out that with adults there is a lot of valuable verbal information that arises during the session which you can then put aside and explore it later. One participant spoke about her role in the field of clinical neuropsychology within the high courts and how it involves working with some of the most dangerous young offenders in the country, such as those who have killed. She believed Te Ara Whakamana: Mana Enhancement can be effectively applied in her complex cases: We talk about the multitude of problems over many generations and you know severe trauma. With this kid I am not just sticking a plaster on gangrene. You need to go in and think about much more, and it’s not just chose a symptom with one technique. You need to get to the root of the problem. I am not saying Te Ara Whakamana: Mana Enhancement will, as there is so much to the problem, but at least it would be a start (…). So, I am not saying that Te Ara Whakamana on its own will solve the problem, nothing on its own wil