Mental Health and Polynesian Clients

Originally published in The GM Resource & Referral Directory 2000, 258-259.
By Cabrini Makasiale, with Philip Culbertson

People indigenous to Oceania and the South Pacific are either Melanesians (Fiji, Vanuatu, Solomon Islands, Papua New Guinea) or Polynesians (Samoa, Tonga, Rarotonga, Niue, Aotearoa). There is a great similarity when we talk about doing counselling and psychotherapy with people of these various cultures, and yet each culture has its unique history, traditions, and values. In order to be responsible, since no Melanesian therapist contributed to this article, the remarks herein are limited to the stressors and needs of Polynesian clients.

Culture

Five major issues define Polynesian identity: hierarchy, obedience, family, land, and spirituality. Polynesian cultures are all hierarchical, though there is some difference among them in the way that power is distributed and moderated. All Polynesian cultures require obedience from inferior to superior in a complicated vertical structure of authority. "Family" is a large category in Polynesian societies, and most often resembles what Pakeha would call "a widely-extended" family. Land, too, is a primary source of identity: all Polynesians can recite easily the name of the village or geographical area to which their family belongs and something of the family's history there. Personal names often relate to family history, or geography of origin, or the achievements of an outstanding ancestor, or the family's hopes for the bearer. Names, like traditions of greeting and welcoming, are a critical factor in establishing a therapeutic alliance with Polynesian clients. Conversely, incorrectly pronouncing a client's name or dismissing the expectations of cultural protocols, can quickly damage that alliance.

Culture Specific Stresses

It is very difficult for Polynesians to separate culture from self, or family from self. A child is born into "a group belonging." From day one, the child goes to the group - on the mother's lap, the sister's lap, the auntie's lap - and sleeps with a group when the group sleeps, and is carried everywhere and participates in everything. For this reason, many Polynesians are unskilled at making decisions independently, without seeking family advice and consensus. Therefore, an "externally-referenced" personality emerges. Pakeha culture presumes an independent core identity of separation, individuation, and individualism; Polynesian culture presumes a situational identity, dictated most often by cultural expectations, family desires, and tradition as interpreted by elders. Exposure to Pakeha ways of being and thinking undermines this identity structure, and can create significant stress and even neurosis or other psychopathology.

Caught between two worlds, Polynesian clients are forced to make adaptations, sometimes successful and sometimes less so. Each client needs to be assessed for his or her unique developmental stage in the process of learning to "live in two worlds." Often clients are torn between several cultures: the culture of life back in the islands, the culture of the Polynesian diaspora in New Zealand, and the cosmopolitan culture of urbanity. Middle-aged women in particular are often held responsible for keeping the intergenerational family together, trying under great stress to hold together the life experiences and needs of three or more generations, each one step further removed from the island culture of origin. Help is needed to open up some new ways of looking at the world, and of making some meaning and order out of it in a way that is achievable and appropriate.

Communally-oriented cultures presume an element of proximity and cohesion. As the family is spread further and further apart geographically, isolation can lead to confusion about what to do, guilt about making a wrong or an independent decision, and fear of loss of identity as one moves further outside family and hierarchical control. In more extreme instances, the individual may find the secure cocoon of cultural identity stripped away, producing feelings of abandonment and insecurity. Clients need fairly directive psycho-education to enable them to choose between the several old and new options available, and to be held securely as they allow a new identity to emerge which combines the best of both worlds: the one they have come from, and the one they are now engaging.

Coping Strategies

Culture and family, while indispensable parts of Polynesian identity, can also become camouflages behind which clients attempt to hide. Clients may defend their culture as flawless, or their family as being without problem. In the same way, in order to maintain a sense of cultural and family unity, and to avoid revealing the faults of culture and family to "outsiders" such as mental health workers, the Polynesian client may have been enculturated to deeply repress feelings and individual needs. Both feelings and individual needs can be understood as threatening the cohesion of group identity.

Due to the power of hierarchical authority, Polynesians are accustomed to first taking their problems to family members, and then to tribal or community elders, and then to church ministers, very few of whom have mental health training. Last on the list, then, are trained mental health workers, due again to factors such as family cohesion and shame. For this reason, Pacific Islanders often seek help from the Pakeha system only when it is too late to be of much assistance.

Symptom Presentations

Somatisation is common among Polynesians. As a result of socialization, they feel readily and quickly, so they will feel things like headaches, or body tightness. They can readily name that, and if asked "do you think this is linked to ..." will straight away find a narrative which connects to the physical symptom. They can link the psyche and the soma easily, if a prior trust relationship has been established with the mental health worker. Somatisation can easily lead to absenteeism-from work, from church, or from an appointment with a mental health worker. In this sense, absenteeism is a socially-conditioned solution, but also one which indicates that the client is not coping well at all.

Social and economic displacement, and the injustices of racism endemic in Pakeha culture, mean that an increasing number of Polynesians are showing signs of urban dis-ease and cultural stress. These can take the form of alcoholism and other addictions, petty offenses produced by intergenerational conflict, and breakdown in family communication. Family communications are further complicated by the cultural tendency toward overcompensating attempts at control, particularly between parents or grandparents and the youngest generation, who are most deeply affected by contact with other cultures, and who are most critical of the "traditional" ways of doing things.

Psychological Approaches To The Treatment

The most effective modalities of treatment with Polynesian clients include family systems work, narrative counseling, object relations theory, and psycho-educational or behavioral modification methods. The primary use of psychodynamics should be via narratives of how early childhood has affected their present life. Otherwise, many Polynesians are not accustomed to think reflectively or self-critically in ways that are normative to Pakeha culture, and so the counselor working cross-culturally must exercise patience with the client.

With Polynesians, the family is always present, even when it is invisible (the family within). At times, it may be appropriate to have other family members present in the treatment rooms. At other times, the "internal family" needs to be made visible through externalization. Only then can choices be made about when to be connected and when to be separate. Polynesian clients may be reluctant to make decisions or behavioral changes without checking with the extended family first. I say to my client, "Yes, you may go check with your family, and there's something else I would like to put before you to have a look at and see whether you would be interested in another way of looking at it - after you have come back from your family." Eventually they will tire of functioning as a go-between between the therapist and the family, and begin to find a sense of self, to make decisions on their own.

The mental health worker's knowledge of the client's culture, effective observation of expected protocols, and a secure therapeutic alliance of trust all serve as doorways to allow new ideas to be introduced. Among the most productive counseling techniques is re-framing, in which the content or intent of traditional ways of doing things is honored, but the outward expression of the tradition is altered to accommodate the client's new situation, or needs for personal expression toward future goals.

For Further Reading:

Becker, Anne. 1995. Body, Self and Society: The View from Fiji. Philadelphia: University of Pennsylvania Press.
Culbertson, Philip. 1997. Counselling Issues in South Pacific Communities. Auckland: Accent Books.
Culbertson, Philip. 1999. "Listening Differently to Maori and Polynesian Clients," Forum: The Journal of the New Zealand Association of Psychotherapists 5, 64-82.
Epati, A'e'au Semi. 1998. "Multi-Cultural Issues in Everyday Practice: Samoan Culture." Auckland: Auckland District Law Society.
Finnegan, Ruth and Margaret Orbell (eds). 1995. South Pacific Oral Traditions. Bloomington: Indiana University Press.
Foster, RoseMarie Perez, Michael Moskowitz, and Rafael Art. Javier (eds). 1996. Reading Across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Northvale: Jason Aronson.
Ihimaera, Witi, ed. 1998. Growing Up Maori. Auckland: Tandem.
Mageo, Jeannette Marie. 1998. Theorizing Self in Samoa: Emotions, Genders, and Sexualities. Ann Arbor: University of Michigan.
Morton, Helen. 1996. Becoming Tongan: An Ethnography of Childhood. Honolulu: University of Hawaii Press.
Tuilotolava, Mary. 1998. "Multi-Cultural Issues in Everyday Practice: Tongan Culture." Auckland: Auckland District Law Society.