The experience of colonial contact for Māori in Aotearoa, New Zealand has been associated with loss of culture, dislocation, and deprivation [1]. Like other Indigenous Peoples, Māori continues to fare poorly on many social indices, including employment, education, housing, and health [2]. Mental health remains one of the greatest reported health risks to Māori [3–7].

The Ministry of Health, Aotearoa (2015) reported that Māori adults were more likely than non-Māori to be hospitalized (over three times as likely) or die (over two and half times as likely) as victims of violence. The Ministry of Health [2] further stated that with regard to mental health, that Māori adults were more likely than non-Māori (one-and-a-half times as likely) to score high to very high probability of having an anxiety or depressive disorder. This disparity was found to be larger in males; the rate at which Māori males scored high to very high probability was double the rate of non-Māori.

It is our belief that the involvement of whānau (family) is essential to address the difficulties these rising statistics reveal. Whānau involvement in decision-making processes as well as improving access to both a clinically and culturally capable workforce is seminal to addressing mental health disorders [5, 8].

Whānau remains the foundation of Māori society. It is central to the well-being of Māori both individually and collectively and a principal source of security and identity [9, 10]. Traditionally, whānau are those who are bound together as an extended family based on common descent and shared reciprocity, obligations, responsibilities, and aspirations [10, 11].

A contemporary term, kaupapa whānau, describes whānau as not necessarily linked by whakapapa (genealogy) but as a social system and or collective associate for a commonly valued purpose that also reflects traditional whānau responsibilities and obligations [10]. 

Whānau Ora

In Aotearoa, the Ministry of Health [12] plan, Rising to the Challenge the National Mental Health and Addiction Service Development Plan 2012–2017 (SDP), requires that a Whānau Ora approach be undertaken when working with Māori. The SDP also states that Whānau Ora initiatives require priority action to help cement and build on gains in resilience and recovery for Māori [12]. Thus, whānau ora is a strategic direction, an outcome, a policy imperative, and a way of working. Whether it is a direction or a way, the focus is on Māori mana motuhake (autonomy), collaborative working (partnership), and taking a systems approach where the collective is the prime focus not the individual.

This innovative development plan supports realizing whānau potential, the collective aspirations of the whānau, and building on the strengths and capabilities present within whānau [13]. Whānau Ora as a strategic direction and as a way of working explicitly recognizes that:

• Whānau is a collective entity.
• Whānau has a capacity for self-determination.
• Whānau is affected by intergenerational dynamics including colonization and historical trauma.
• Māori cultural values, principles, and experiences are to be prioritized.
• There are positive roles for whānau within society.
• The approach can be operationalized across a wide range of health, social, and economic sectors.

A Whānau Ora capable workforce, that is, a workforce able to work with the whānau, is located in a range of disciplines and contexts, including community work, social work, nursing, public health (including health promotion), and youth justice. It means irrespective of role and context we are working collectively to contribute to improving shared outcomes for Māori [9]. A Whānau Ora capable workforce goes beyond crisis intervention and symptom relief to building skills and strategies that contribute to maximizing positive outcomes, in other words, well-being. [9]. Special skills are required that include:

• ascertaining whānau aspirations;
• mediating whānau tensions; and
• brokering opportunities for whānau to ensure whānau have access to the best possible services and resources [9].

In order to collectively contribute to positive outcomes for whānau, it is important for mental health and addiction services to establish reciprocal relationships with kaupapa Māori services (services that are governed by Māori, delivered predominantly to Māori, and use Māori knowledge and skills in the delivery of their service), providers dedicated to Whānau Ora, and agencies where whānau present, for example, government health and social services. Currently, many service providers and commissioners of services operate in a siloed approach; therefore, taking a collaborative approach with others from different services and sectors to contribute to a shared outcome, that is, a Whānau Ora approach, can be daunting. 

Pātaka Uara: Whānau Ora in Action

Pātaka Uara is an example of a Whānau Ora practitioner model based on te reo me ona tikanga (language, values, beliefs, principles, and practices). Some of the principles included within this model, and detailed in the example1 below, include whakapapa (genealogy), whanaungatanga (building relationships with whānau), manaakitanga (care and support), ūkaipōtanga (secure sense of identity), kaitiakitanga (stewardship), kotahitanga (solidarity), wairuatanga (spirituality), and rangatiratanga (self-determination) [14]. 

Working with the Whole Whānau

A Māori family of four (mother, father, and two sons under 11 years of age) residing in Tauranga, a city on the East Coast of the North Island of New Zealand, accessed a local Whānau Ora service. The father came from a tribe further down the East Coast of the North Island (Ngāti Porou) and the mother came from a tribe located in the far north of the North Island (Te Rarawa). While this family lived in a region they did not whakapapa to, they still maintained strong links to their tūrangawaewae (place of belonging), particularly the tribal region of Ngāti Porou. They regularly participated in events which were Māori-centered, and Māori culture and protocols were demonstrated. The whānau accessed a Whānau Ora service in Tauranga because it was based in the city they lived. They wanted the service to assist them with their sons’ anger issues, as well as to support their whānau. This matched with a Whānau Ora approach, which works with the whole whānau instead of only with the boys in isolation from their parents.

Whanaungatanga: Making Connections

In line with Māori cultural practices, the Whānau Ora service first established a good rapport and engagement with the whānau (a process of whakawhanaunga). As the supporting case manager was from the same tribe as one of the parents, it meant there was a connection between the whānau and services, a shared tribal history, that preceded their meeting. This assisted to make the establishment of trust and whanaungatanga (a sense of connection) with the whole whānau easier. 

Ūkaipōtanga: Security and Stability

The Whānau Ora services learned from the whānau that when the boys were younger, their mother had been too ill to care for them and their father became her carer. At that time the boys were placed in the care of a trusted family elder—their maternal grandmother. While the boys received good care at their grandmother’s and appeared to be coping well, their preference was to be with their mother, who they missed. When their mother’s health improved, the boys returned to the care of their parents. In the 2 years before the whānau meeting with the Whānau Ora service, the boys developed issues with anger. A link was made between the boys’ behavior and their mother’s absence from home because of study commitments as well as their resentment from being away from their parents when they were younger. The boys questioned why they had not lived with their mother at that time. 

Manaakitanga: Supportive Care

The mother of this family self-referred her whānau to this kaupapa Māori service in order to gain assistance and support. The staff at this service were able to use manaaki to build rapport and trust with this whānau, and ultimately help them. During this time all of the whānau members were physically well and the parents were engaged in either full-time work (father) or full-time study (mother). 

Kotahitanga: Reconnecting

Resolution was made possible through mediation and support. The supporting case managers helped the sons to discuss and understand why they were separated from their parents in the past and what was currently happening. This process included facilitated discussions between the boys and their parents, their mother in particular. Talking things through and getting support was healing for the boys, who were able to gain a sense kotahitanga. 

Wairuatanga: Spirituality

The Māori cultural practice of opening and closing each hui with karakia (reciting prayers, a spiritual process which manages and uses the taha wairua/Māori spiritual dimension) was a normal part of interactions between the whānau and the services. The karakia were often led by the boys, who can speak te reo fluently. 

Rangatiratanga: Autonomy

This family was supported by this Whānau Ora service for 9 months. By the end of their time with the service, the family identified that they no longer needed help; the boys were doing well at school and fully active in sport again and were content at home.

Māori practitioners, whether involved clinically or in support roles, have endorsed the Whānau Ora process, as described in this study at Pātaka Uara, saying they are more likely to build respectful and trustworthy relationships with whānau that ensures quality engagement and ultimately contributes to better health outcomes [15]. 

Young People and their Whānau

Improving the delivery of mental health services to young Māori and their whānau has been identified as a priority in several studies [6, 16]. Parental involvement in the assessment and treatment processes is thought to be essential to this development [5, 8]. Positive contact for parents with Child and Adolescent Mental Health Services (CAMHS) is more likely to influence ongoing dealings with the service that leads to better mental health outcomes for their children [17, 18].

Studies with Māori parents and young people who accessed CAMHS identified that they desired a Māori workforce with cultural capacity and capability [5, 8]. Whānau and young Māori valued information about options for both cultural and clinical pathways for support, as they saw this helping with better engagement and participation. They felt Māori working in this space would work to enhance the quality of the relationship between whānau and CAMHS [5, 19].

Furthermore, parents wanted CAMHS to factor in the appropriate time and space for real communication, one that valued partnership, relationships, responsibility, and reciprocity with whānau. They viewed this as essential to ensuring that positive engagement and participation that would influence better health outcomes [5].

McClintock et al. [5] found that having a workforce appropriate to the Aotearoa context, with te reo me ona tikanga and culturally competent health professionals, was an important aspect to ensuring improved health outcomes for Māori who access CAMHS. Likewise, they found that correct and timely information regarding medication and its benefits were further viewed as seminal to assist understanding and therefore compliance with medication regimes offered by CAMHS [5]. Successful access, engagement, and participation of Māori with CAMHS were also deemed more likely to occur when whānau involvement was encouraged and valued. A process of engagement and participation, founded on cultural respect, partnership, reciprocity, and commitment is therefore valued [5, 8].

Although this framework of service improvement has been offered to services to champion whānau aspirations, sadly, implementation continues to be minimal as services prefer to stay focused on a clinical approach. Managers within CAMHS have reported being pressured by their service to meet key performance indicators that place little value on whānau culture. Improving outcomes for Māori who access CAMHS will remain a challenge if it continues to ignore the relevancy of culture.

Mental Health Outcome Measurement: Hua Oranga

A number of national health policies in Aotearoa have endorsed the planning and delivery of effective and culturally relevant treatment practices that promote cultural and clinical competency in the delivery of services for Māori. These directives also include the use of culturally relevant assessment tools and outcome measures [20–22]. Outcome measures are critical to the development of quality mental health services and to their continuous improvement [23]. Assessment and outcome information collected, if fully utilized, can inform the construction and delivery of effective care and treatment plans thus ensuring high-quality services that contribute to better health outcomes [23].

Hua Oranga is a Māori mental health outcome measure for use with Māori that incorporates a holistic method of outcome assessment founded on an existing framework of health and well-being, the whare tapa whā. This framework encompasses four dimensions: taha wairua (spiritual), taha hinengaro (cognitive and emotional), taha tinana (physical), and taha whānau (family and relationships) [24]. From a Māori perspective, constructing a measurement around the model involves assessment of these four dimensions and taking account of the perspectives of three key stakeholders: the tangata whaiora (consumer), whānau, and the clinician [24]. 

Participation in the Hua Oranga

The administration of the Hua Oranga outcomes tool encourages a partnership approach between clinicians, tangata whaiora, and whānau. In this partnership approach, goals are negotiated using the results from the completed individual Hua Oranga schedules (see Appendix). Clinicians see discussing strengths essential to this process: first, so that the tangata whaiora does not feel whakamā (ashamed) and, more important, to build on positive experiences and skills of the tangata whaiora [19]. The clinicians are adamant that respect for the tangata whaiora is essential for a successful partnership leading to improved health outcomes [19]. 

Benefits of the Hua Oranga

The Hua Oranga provides support and a starting point for developing Māori tikanga (values and beliefs) treatment plans based on kawa (protocols), and including wairua (spiritual dimensions), te reo Māori (Māori language), and karakia (prayers). Clinicians, tangata whaiora, and whānau also view the Hua Oranga as support designed to identify needs and areas of improvement. Engagement with tangata whaiora and whānau is deemed essential to ensuring a collaborative partnership approach to developing care plans [19].

A review of the plan is recommended at 6 weeks, 3 months, or both, depending on the needs identified as part of the collective treatment plan. Assessments are expected to show progress toward a desired outcome, as a result of the collaboration and partnership. Reviews also allow an opportunity to celebrate achievement and to set new goals [19]. 

Hua Oranga Case Study (See Footnote 1)

This example has been provided by MOKO Māori Mental Health Services (MHS), Whitiki Maurea, the Mental Health and Addiction Services of the Waitemata District Health Board (DHB). 

Referral History

At the beginning of 2014, a man (BG) experiencing first-time psychosis presented to the Waitemata DHB MHS. Reasons for BG’s psychosis included increased drug use (cannabis), discord with his partner, and increased paranoia—specifically that his neighbors wanted his cannabis plants. BG’s whānau was initially resistant to the involvement of MHS; BG’s wife thought he had transgressed tapu (restricted protocols concerned with preserving life). Before coming into contact with MHS, BG had tried seeking help through a kaumatua (Elder), who had carried out a whānau blessing in an attempt to rectify the transgression.

When BG was first admitted to MHS, it was informally into the acute unit. His stay lasted 4 days, after which he discharged himself. He also turned down the medication he was prescribed. Once discharged, BG was followed up by community MHS. Eventually, against his strong wishes and under the Mental Health Act, BG was involuntarily committed to mandatory assessment and treatment. At that time, for the first time, BG was introduced to MOKO Māori MHS.

A service cultural assessment tool was used with his consent to determine his knowledge of his whakapapa (genealogy). Through this process, MOKO Māori learned that that BG was trying to find out ko wai ahau? (Who am I? Where am I from?) to learn who he was and connect to his cultural heritage. BG’s mistrust of MHS was evidenced by his anxiety; MHS could take away his autonomy and liberty. BG was more willing to seek help from a Māori MHS like MOKO services because he felt they listened to him and were more understanding than mainstream MHS of his situation. 

Whānau

Through discussion with BG, Moko MHS learned that he was a tamaiti whāngai (adopted child) who did not have a relationship with his birth family. The only information he knew of his whānau was his mother’s name from his birth certificate. Recently BG had learned he was born in a home for mothers with unwanted pregnancies. BG also shared that while he had lived in multiple foster homes growing up, he felt the strongest affinity to an area he had worked in as a farmhand—Kaipara, in the far north of the North Island of New Zealand.

Not knowing his family or where he was from made BG feel incomplete and insufficient. He said “I have no legacy Māori to give my tamariki (children), although my wife is Māori” ([14], p. 17–18). BG was a father of two and his wife was a member of a tribe located in the north of the North Island of New Zealand (Ngāti Whātua) and another from the Midlands region (Ngāti Maniapoto). 

MOKO Services

Moko services followed up with BG, both culturally and clinically. As part of his work with Moko services, BG agreed to participate in the Hōtaka Hauora Māori program. This program is based on the whare tapa whā model and uses basic te reo (language). As is usual for Moko services, BG, with his wife, was welcomed into the program in a traditional Māori welcome (pōhiri, or powhiri). A powhiri is a timeless Māori approach to engagement which is based on tikanga Māori such as tika (to be correct), pono (honesty), and aroha (love). A karakia (prayer) was said to open the hui, which solidified the understanding of a shared kaupapa (purpose) and journey between BG, his whānau, and Moko services. 

Hua Oranga

BG enjoyed the powhiri and, while sharing his life story, he was comfortable enough to tangi (crying release of sorrow). BG’s wife shared the positive changes she had seen in him, and that his life was better for coming to MOKO services. While with MOKO services, BG, his whānau, and his clinical team at MOKO services carried out a Hua Oranga interview. Hua Oranga involves gaining the perspectives of tangata whaiora, their whānau, and the treatment team as part of the assessment process. It promotes collaboration and shared views going forward.

Everyone agreed to support BG to learn more about his whakapapa, his wish not to take medication, to contest his mandatory treatment under the Mental Health Act, and work on reducing his cannabis use. With the start of this journey of self-discovery, BG said he was able to stop his cannabis use.

To review BG’s progress, 7 weeks later, Hua Oranga was carried out again. Many positive changes had occurred for BG. He was able to be discharged from the Mental Health Act, as he was assessed by the clinical team as free of psychosis and no longer manic. With the support of his whānau, BG continued to participate in the MOKO services program, attended his first Hōtaka Hauora reo, and was working with a taurawhiri (cultural adviser) to help him reconnect with his birth family.

“Tawhiti rawa tou haerenga ake te kore haere tonu.
He nui rawa ou mahi te kore mahi tonu

You have come too far not to journey further.
You have done too much not to do more!

—Sir James Henare” (as cited in Te Rau Ora, 2014, p. 18)

Although Māori clinicians have embraced the fundamentals as well as the depth of the Hua Oranga, non-Māori clinicians’ understanding of the Hua Oranga, especially the taha wairua, presents an ongoing challenge. The test is even greater for clinicians who lack an understanding of Māori spirituality. Mental health and addiction services must however provide an approach that culturally resonates with Māori who access their services if they are to contribute to improved Māori well-being. 

The Addiction Workforce

In this section, we specifically examine the development of a clinical and cultural capable workforce that contributes to the minimization of addiction-related harm experienced by Māori. Early snapshots of the alcohol and other drug (AOD) 

treatment sector consistently found the proportion of the workforce who identified as Māori was substantially lower than the proportion of Māori presenting as clients. A similar trend was noticed in the problem gambling workforce. In the 10 years from 1998 to 2008, the proportion of Māori in the AOD workforce appeared to decrease from 25% to 15% [25].

The most recent surveys [26, 27] found Māori make up about 23% of the addiction workforce, 35% of the ICAMHS workforce, 15% of those employed in DHB addiction services, and nearly 32% of practitioners in NGO AOD services. Māori clients accounted for nearly 33% of AOD service provision. Problem gambling services reported that 24% of the workforce was Māori compared to 31% of those presenting at services.

Although there appear to be increasing numbers of Māori identified as working in the addiction treatment sector, there is no indication as to their capacity or competency to operate from a mātauranga Māori (knowledge) space or deliver culturally located models, frameworks, and practice.

The addiction workforce, both Māori and non-Māori, continues to call for and require skills and knowledge to work in Māori-responsive ways thus the development of competency frameworks and development programs such as the Takarangi Framework and Huarahi Whakatū.

The most common professional affiliations in the addiction workforce are reported as addiction practitioners/counselors, nurses, and social workers [25, 28]. The “More than Numbers” survey of the mental health and addiction workforce [27] indicates that more than half (62%) of the kaupapa Māori addiction workforce had roles in the allied health group, with support workers and nurses comprising only 14% and 6%, respectively.

Tami Cave et al. [29] reported the average age of the Māori addiction workforce was 47 years, with equal representation of male and female workers. The workforce is an aging one and most are employed in NGOs [28, 30, 31]. Moreover, many in the addiction workforce have lived experience from their own addiction issues or those of their whānau. 

Competent practitioners can contribute to whānau ora (well-being) by integrating cultural and clinical elements within their practices. Eileen Britt et al. [32] emphasize that linking mātauranga Māori with other theoretical models is possible when the goal is hope, well-being, and transformation. Using resources such as He Puna Whakaata [33, 34] and opportunities such as the inclusion of manaaki (care, thoughtfulness) in the new Substance Addiction Compulsory Assessment and Treatment Act 2017 [35] is a good beginning. Groups like Te Rau Ora can encourage shifts in practice that will support the realization of whānau potential, aspirations, and well-being.

An example of shifts in practice is He Puna Whakaata. This resource offers activities that use mātauranga Māori and the wisdom and experience of the tīpuna as part of a transformative process of healing. The activities draw on motivational interviewing and encourage practitioners to be more aware of and use cultural symbolism, processes, and metaphor to help whānau navigate their own path to sustained well-being. 

The Whai Tikanga card sort, described in He Puna Whakaata, is similar to the Value Cards Sort used to help people see the differences between their values and their behavior. Whai Tikanga uses values and whakataukī (proverbs or sayings) centered in Te Ao Māori. Whakataukī are the handed-down “voices” of tīpuna and they reinforce the “values” drawn out in the activity.

Traditionally, sayings, proverbs, and various customs were educational devices highlighting and illustrating morals, principles, models, and behaviors to be applied in everyday life—and they were part of the process of enculturation. Many today no longer know, understand, or live the basic values of these traditional values, practices, and experiences. Increasingly some are disconnected or have been excluded from opportunities to grow and develop as Māori. This disconnection and the compromise of these traditional values and knowledge is one explanation for a range of health and social harms.

During the first 6 months of 2017, more than 130 practitioners in a range of AOD, problem gambling, mental health, and social service agencies across the country received the He Puna Whakaata resource, which included a pack of Whai Tikanga cards. Evaluations from the workshops showed that knowledge transfer occurred during the training and the practitioners were grateful for the opportunity to be able to integrate mātauranga Māori into their practice. Feedback after the workshops indicated that there were benefits for the practitioners as well as for the individuals, groups, and whānau they worked with.

Respondents also noted that sustaining the shifts in practice promoted in He Puna Whakaata requires cultural competence and ongoing reflective practice. Others noted that activities such as the Whai Tikanga cards tended to lead practitioners from concentrating on deficits and problems to aspirational and strength-based approaches. They also enabled the use of Māori-oriented narratives and talking therapies, the exploration of mātauranga Māori, and the development of a greater sense of self as Māori. Further evaluation will determine the degree to which skill transfer occurs post-workshop and how to sustain this change in practice. 

Conclusion

In this chapter, we have reported on a range of strategies and initiatives to support the Indigenous population of Aotearoa. These initiatives were created to ensure better health outcomes for Māori, and to help them reach their potential through the delivery of effective culturally and clinically appropriate mental health and addiction services. In sharing the intentions and the associated progress of these programs to date, we look for a future that will continue to focus on providing Māori approaches that resonate with the aspirations of Māori.