Occasional Paper – No. 3
By Beven Yee
by Jan Dowland
The Mental Health Commission is pleased to publish this occasional paper, which is the second Asian-focused piece of work that the Commission has undertaken.
The response to our first publication “Mental Health Issues for Asian in New Zealand: A Literature Review” has been encouraging. Asian communities, government organisations and the media have welcomed the report.
This occasional paper presents a developing Asian view of recovery and identifies ways to make recovery more relevant to Asian people. Reading the paper, one is struck by the many similarities between Asian, Pacific and Maori perspectives of the world. Clearly, there is a lot that can be shared between these communities when it comes to mental health initiatives.
The government-funded Like Minds Like Mine anti-discrimination initiative has also taken on board Asian issues in its new strategic plan. Asians with experience of mental illness in New Zealand face a stigma double whammy – first because they are Asians and second because of their mental illness.
Asian mental health is well and truly on the Mental Health Commission’s agenda. We will continue to adapt our work programme to incorporate Asian issues and perspectives – in our anti-stigma work, our sector monitoring and our workforce projects.
I welcome your feedback on this report and how the Commission can promote recovery from mental illness for Asian people.
In May 2003, the Mental Health Commission (MHC) launched its first Asian-focused publication entitled Mental Health Issues for Asians in New Zealand: A Literature Review (‘the report’) written by Dr Elsie Ho, Sybil Au, Charlotte Bedford and Jenine Cooper. Publicly endorsed by the Prime Minister, Rt Hon Helen Clark and the Minister of Health, Hon Annette King, the report is set to become the grounding document in the area of Asian mental health in New Zealand. This paper is a follow-up to that report and analyses government initiatives and Asian community responses to Dr Ho’s recommendations. An Asian cultural perspective on recovery is introduced, and used as an analytical framework in parts of the paper, which is in three sections.
The first section provides background information, to locate the significance of Dr Ho’s work for the New Zealand mental health sector. This is followed in section two by discussion of ‘recovery’ using sociological and anthropological theories on Asian cultural perspectives. Here, an Asian understanding of ‘recovery’ is tentatively developed. In the final section the responses of various government agencies and Asian communities are presented and analysed using the Asian recovery approach developed in section two. The conclusion provides some general comments on what may be required to ensure Asian mental well-being in New Zealand.
Asian peoples make up the fastest-growing ethnic community in New Zealand. Approximately 6.4% of the total population are Asian, equating to almost 240,000 people. This expansive growth sees its roots in the immigration policy changes initiated in 1987, which saw the removal of preferential treatment to ‘traditional’ source countries (for example, the United Kingdom) and the introduction of immigration criteria based on objective measures. It was also a product of New Zealand’s reorientation towards Asia as its major trading bloc.
With large numbers of Asian peoples settling in New Zealand, it was only a matter of time before social issues for this population, aside from immigration itself, came to the attention of government. Mental health issues for Asian peoples can be the product of migration experiences that leave people dislocated from support networks, isolated from the host community and unable to cope in a foreign cultural environment. These issues are the result of adaptation problems, such as:
disruption of family and social support networks, including separation from family
acculturation attitudes (acculturation refers to changes in behaviour, attitudes, values and identity that occur when individuals from one cultural group are in continuous contact with people from another cultural group)
lack of friendly reception by surrounding host population
traumatic experiences prior to migration – this can include severe trauma and torture
drop in personal socio-economic status following migration.
Although ‘official’ data on the mental health status of Asian peoples in New Zealand is not yet available, the data that is available suggests that prevalence rates are similar to the general population in both severity and scope. US studies suggest that Asian peoples tend not to use mental health services but, if they do, they tend to be more acutely unwell by the time they present (Tse, in press).
These circumstances create significant challenges for government agencies and Asian communities alike. The key point is not necessarily that government and communities respond to these challenges, but rather, ‘how’ they respond. Measures that address Asian mental health concerns should be more than just culturally sensitive; to be effective they need to integrate the values, morals and philosophies of ethnic communities. The former approach is akin to tokenism and can be interpreted as superficial. The latter approach questions the dominant cultural values of the host society and, where appropriate, such values are usurped by the core understandings of the ethnic culture. To explore these ideas further and make them useful we need to examine Asian cultural perspectives in relation to the concept of ‘recovery’.
ASIAN CULTURAL PERSPECTIVES AND RECOVERY
2.1 What is recovery?
The recovery approach to mental ill health has international beginnings, is the driving philosophy behind the MHC and has been adopted via the Blueprint (Mental Health Commission, 1998) as government policy. Tse suggests,
...[recovery] has grown from both positive and negative roots: The failure of mental health institutions to meet the needs of people with psychiatric disabilities; distrust of mental health professionals; and on the positive side, reduction of stigma about mental illness; and [the] promotion of community care...
Recovery can be defined as ‘the ability to live well in the presence or absence of one’s mental illness’ (Mental Health Commission, 1998:1). It involves the development of meaning and purpose in life, and emphasises Tse’s ‘concepts such as hope, information, knowledge and skills, sense of control, empowerment, self-determination, personal responsibility, [and] spirituality’.
2.2 How can we apply recovery to Asian peoples?
In order to understand the meaning of recovery for Asian peoples, we must first understand the underlying cultural values, morals and philosophies of ‘Asians’. This is a complex exercise in itself, as New Zealand’s Asian population is extremely diverse. We run the risk of over-simplifying. However, ideal Asian understandings of the world can be identified and these understandings can be seen as different from ideal Pakeha/European understandings of the world. The work of Francis Hsu, a Chinese-American anthropologist, may prove useful here.
Hsu (1971) argues that the cultural values of Asian peoples (Chinese in particular) can be differentiated from ‘Western Man’ by understandings of individualism and collectivism. For Hsu (ibid: p34), ‘Western Man’ holds the ‘individual human animal as the center with the rest of the world around him’, while Asian peoples define the ‘human individual as part of a set of relationships with no assured starring role [for the individual]’. Hence the maintenance of immediate and extended family ties are given central importance in many Asian cultures and are reflected in notions of filial piety. Figure 1 graphically represents Hsu’s understanding of ‘Western’ and ‘Asian’ peoples.
Figure 1: ‘Asian’ and ‘Western’ conceptions of the individual
The concentric circles (figure 1a) depict Asian interconnectedness with immediate and extended family, community and wider society. From this understanding, Asian peoples are embedded in layers of social relations that are seamless and clearly ordered. Everybody has a place and the maintenance of that place is what creates social harmony.1
The molecule depiction (figure 1b) of ‘Western’ society reflects an organisational structure that is more fragmented yet still interconnected, though not seamless. Hierarchies in Western society are often challenged, relationships with family and friends can be reconfigured, fragmented or completely severed with not too much social disapproval. New relationships can be formed that can replace severed relationships and these can take on greater importance than immediate family or community.
These generalisations can be taken one step further in order to explain the differences between Asian and Western understandings of the world. Hsu (ibid) argues that the maintenance of mental wellbeing is inherently connected to morals, values and ideals embedded in culture. He introduces the concept of ‘psychosocial homeostasis’, which is an understanding that people need to maintain a satisfactory level of psychic and interpersonal equilibrium, ‘in the same sense that every physical organism tends to maintain a uniform and beneficial physiological stability within and between parts’ (ibid p:28), in order to maintain their mental wellness.
What this means is that if Asian peoples maintain cultural values that uphold family connectedness, filial piety, obligation to community and social harmony then it is these things that will maintain mental wellbeing. To be mentally healthy, therefore, is to be connected to family, to be obligated to family and community and to maintain social harmony. Likewise, if Western society values independence, volition, and exclusivity then this is what is required to ensure mental wellbeing in ‘Western Man’. Thus the ability to make choices that determine one’s life path, the maintenance of responsibility and the achievement of status beyond the immediate family are of critical importance.
If we use these ideas to construct an ‘Asian’ understanding of recovery, we immediately see a Western bias in the recovery approach. Notions of individual ‘self-determination’, ‘sense of control’ and ‘personal responsibility’, which Tse suggests are core components of a recovery approach, do not fit easily into an ‘Asian’ value set. Other aspects of recovery fit rather nicely, such as ‘spirituality’, ‘hope’ and ‘knowledge and skills’, which are reasonably neutral concepts.
2.3 Asian recovery - an emergent conceptual framework
Assuming the cultural generalisations made in this paper are valid, then what does this say about ‘how’ we should respond to Asian mental health concerns? Figure 2 depicts a series of concentric circles representing the scope of possible responses. The Asian service user is not separated from family but exists in the same concentric zone. The ethnic community is represented in the next outward layer followed by the inter-community layer, where ethnic community interacts with the host community. Mental health services (specifically hospital services) and general society are represented in the outer layers.
To be culturally integrative of Asian values, an appropriate response to Asian mental health concerns would focus attention on the family and community layers. This may translate into support for grassroots activity such as support groups for service user and family; destigmatisation work focusing on families and specific ethnic communities; and mental health information made available that takes account of Asian cultural perspectives. At the inter-community layer, it would mean the promotion of acceptance from the immediate host community of ethnic difference, not at a ‘culturally sensitive’ level, but at a ‘culturally integrative’ level. Cultural sensitivity involves a degree of respect for cultural difference but not necessarily a profound understanding of it; a cultural integrative approach involves paradigm shifting - an attempt to see the world from another cultural viewpoint. For hospital mental health services, an Asian recovery approach would mean additional attention being paid to ‘family connectedness’ and ‘spirituality’, and less emphasis on ‘independence’ and ‘personal responsibility’.
Figure 2: The scope of possible
responses to Asian recovery
Focusing on family and community is also important because, for many Asian peoples, the migration experience has dislocated and isolated them from their traditional social supports. The communities they are part of are still developing, and thus it would be ideal to tap into this development, especially with destigmatisation programmes. So how do government and Asian community responses fit within this emergent Asian recovery paradigm?
3.1 GOVERNMENT RESPONSES TO THE REPORT
Given the holistic approach to mental health inherent in the recovery approach, the MHC asked a wide range of government agencies to respond to the report. How the ongoing and planned activities of these agencies fit into an emergent ‘Asian’ recovery paradigm is examined here (see Appendix A for a list of agencies and their responses).
Research activity, both ongoing and planned, formed a significant portion of the work within government agencies when it came to Asian peoples. The aim of this research was very pragmatic, assessing current policy stances, strategic directions and operational efficacy. This emphasis on research should be not unexpected as there is much to learn about New Zealand’s Asian population, and developing appropriate policy responses requires significant thinking and assessment time. Some examples of research activity include: a) The Department of Labour’s ‘Migrants in New Zealand: An Analysis of Labour Market Outcomes for Working Aged Migrants’ project, which compared migrants with local-born people of working age to assess characteristics that impact on labour market outcomes; and b) ‘The Longitudinal Immigration Survey’, which aims to capture migrant experiences and assess the outcomes of immigration policies.
Information provision was another key area on which many government agencies focused. This includes interpreting services, such as the pilot telephone service co-ordinated by Ethnic Affairs; pamphlets that translate various codes and regulatory requirements, such as the Code of Health and Disability Services Consumers’ Rights, and Customs regulations; and booklets, which aim to inform people about New Zealand, such as those provided by the Department of Labour - the Settlement Kit for instance, which covers housing, education, government, health, work, and so on, available in English and Chinese.
Collaboration is another response, where government agencies either establish cultural exchanges between New Zealand and Asia or establish intersectoral activity within government to better tackle the needs of Asian peoples. The Ministry of Education has been particularly focused on these types of activities; they have, for example: a) Professional Development Programmes where school principals, international managers and Boards of Trustees members are financially assisted to develop policy and programmes for international students; b) Cultural Awareness Initiatives such as the International Education Visits Fund, which is accessed by teachers and students; c) Special Education Group - a proposed joint sector initiative to provide services for refugees and migrants. The Ministry of Health’s funding support of the Asian Network is another example of collaboration, in this instance focusing at the grass roots level.
Operational activities and policy that cater for the direct and immediate needs of Asian people is another response from government agencies. The Ministry of Education’s funding support of ESOL (English for Speakers of Other Languages) programmes is one such example; others are the Code of Practice for the Pastoral Care of International Students and the proposed Guardian Visa, which would allow young international students to be accompanied by their parents.
In all of this work two key underlying approaches can be identified. First, we can identify a verbatim translation approach, which is the literal translation of documents into an Asian language (eg, the Code of Health and Disability Services Consumers’ Rights by the Health and Disability Commission) that does not necessarily take account of cultural differences in values, morals or philosophies. Second, we can identify a cultural translation approach, which involves deep immersion within an alternate cultural sphere in order to understand the inner workings of a cultural group. Exchange programmes are of this nature and so is the Ministry of Education’s ‘Professional Development Study Programme in China’ for New Zealand teachers to learn about Chinese culture, the Chinese education system, learning styles and pedagogy.
These two approaches are significant for they enable us to interpret the approaches of government agencies from our emergent ‘Asian’ recovery paradigm. Verbatim translation, as an approach, can be seen as less useful for Asian recovery as this does not take account of Asian cultural values. This approach can be seen as culturally sensitive, in that people literate in other languages can at least read government documents. Often regulatory agencies, which have prescriptive roles enacted in statute, will adopt this method of translation.
The cultural translation approach is far more useful and integrative of an Asian recovery approach as it requires a shift in mindset; a level of deep immersion in a world of different values, morals and philosophies. The Immigration Service’s ‘Guardian Visa’ proposal, whether inadvertent or intended, can be seen as cultural translation. Notions of family connectedness, obligation and filial piety are accounted for. Parents can watch over their children to ensure they attend school and get the support required, and they get a sense of community status2 for attending to their children’s needs.
3.2 ASIAN COMMUNITY RESPONSES TO THE REPORT
The MHC actively sought responses from various Asian communities with consultation meetings held in Wellington and Auckland in late 2002. A summary of these responses is contained in Appendix B. In the final section of this paper, feedback from Asian communities will be summarised and assessed against our emergent Asian recovery paradigm. The emergence of some Asian community initiatives will also be assessed.
3.2.1 Feedback on the report
The diversity of the Asian population was emphasised in consultation meetings, with differences in language, culture and migration status evident. This does not detract from our Asian recovery paradigm, which is extremely general. It does, however, suggest that recovery approaches for Asian service users requires a degree of individualisation, while still taking account of key Asian concepts such as family connectedness, filial piety and social harmony.
The small size of many Asian communities in New Zealand places great emphasis on social status within these communities. So the consequences of stigma associated with mental illness becomes compounded. Somatisation becomes the normative mode of presenting mental illness. It is a way of disguising and avoiding stigma within the community and stigma directed from outside the immediate community both towards mental illness and Asians peoples generally. This re-emphasises the need for destigmatisation work focusing on communities, thus enabling a community that can assist in a person’s recovery from mental ill health. The Like Minds campaign against mental health stigma has addressed Asian needs in its latest strategic plan.
In terms of government agency responses to Asian needs, many people noted the lack of co-ordination between and across organisations. This fragmentation has been noted by many agencies who are now responding (eg, The Auckland Regional Migrant Resource Centre in Three Kings involves the New Zealand Immigration Service, Work and Income New Zealand, Housing New Zealand Corporation, Citizens Advice Bureaux and others; and Waitemata District Health Board’s (DHB’s) Asian Health Office, which provides an integrated service for its Asian clients).
Other points raised related to policy initiatives that did not take account of the importance of family to Asian peoples and to the lack of information on services. Both of these issues have been noted by government agencies, who are now more aware of Asian cultural needs and are providing translated documentation for communities.
3.2.2 Community-focused initiatives
Two types of community-focused initiative are worth mentioning: grass roots initiatives, and those held within government agencies. Auckland has a number of recovery-oriented services at the grass roots level, including Yan Oi Sei for Chinese carers and family members for people with experiences of mental illness, supported by SF Auckland and Challenge Trust. Pao Oi Sei is another group specifically for Chinese recovering from mental illness.
Waitemata DHB’s Asian Health Office is an example of community work on a larger scale and was initiated in response to threefold growth in the Asian population within its catchment area. It employs an iCare Programme, which provides: a) information on the New Zealand health system, b) call centre access for language assistance and for booking GP visits, c) advocacy, d) representation for migrants and refugees, and e) education programmes on the New Zealand health system.
Yan Oi Sei and Pao Oi Sei are examples of a cultural translation approach, where ‘Asian’ cultural values are embedded in the philosophies of the organisation. Waitemata’s Asian Health Office is an example of a verbatim translation approach, where existing services are translated at an operational level, but not so much at a deep cultural level. Both approaches are valid, although from an Asian recovery perspective, the former option may be preferable.