When Hearing Voices is Not Schizophrenia: A cross-cultural experience with the Maori of New Zealand

Aoraki, Mount Cook National Park, NZ

It was a chilly summer day on the South Island of New Zealand, and we were headed to a rural town.  It was my fourth year of medical school, and I was doing a month long rotation working with the CAF-Rural (Children, Adolescent and Family), service.²   Because our clinic that morning was some distance from Christchurch, one of the doctors working with the service had reserved one of the off-site cars and met the three of us working in the clinic that day along the way.  She and one of the social workers with the service were chatting happily in the front, and the service’s new Pukenga Atawhai and I were doing likewise in the back.  Pukenga Atawhai are Maori mental health care workers who work in multidisciplinary care teams throughout the mental health care system of New Zealand, but whose primary placement is with the Te Korowai Atawhai (Maori Mental Health Service). ⁵   The Te Korowai Atawhai is seen as the modern day fulfillment of the Treaty of Waitangi (Tiriti o Waitangi) and their guiding philosophy is to “improve the delivery and quality of health service to tangata whaiora (Maori consumers of mental health services)” through a framework of culturally sensitive care.^3,4,5

My placement at CAF-Rural was not by chance, but rather a position deliberately chosen to give me the greatest possible exposure to models of disease and wellness that differed from my own culturally-ingrained beliefs and those inherent in my training as a US-based physician; so I was particularly pleased that day to have the opportunity to chat with our new Pukenga Atawhai about her work. As a medical student, I had always been fascinated by how differently similar disease processes are experienced and perceived by different patients and their families.  This is all the more striking in the realm of psychiatric disease where centuries of stigmatization can turn what may seem to a psychiatric practitioner as a common and mild disorder into a crippling and shameful disease.  It had thus far been my experience that without understanding the cultural context and narrative through which a patient experiences a psychiatric illness it is not only difficult, but perhaps quite impossible, to deliver sensitive and effective psychiatric care. 

So, as we drove to our clinic site that morning, I plied our Pukenga Atawhai with questions, which she graciously and patiently answered.  For Maori, the conception of health is much broader than the western conception, which focuses almost exclusively on the physical body and objective observations of disease manifestations.  In the Maori Health Model (Te Whare Tapa Wha), health is comprised of four pillars: Taha Tinana (physical health), Taha Wairua (spiritual health), Taha Whanau (family health), and Taha Hinengaro (Mental health).¹  This model is often visualized as a house (Wharenui) with each of the four major components of health viewed as pillars holding up the roof, symbolizing overall wellness, of the house. ¹ Should any of the pillars be deficient, the roof becomes crooked and can no longer function until these four elements are brought into balance. ¹ Consequently, these four pillars are not seen as distinct and independent, but intertwined and seamlessly connected.  The role of the Pukenga Atawhai is largely to help the patient or Tangata Whaiora (seeker of health) to evaluate these four dimensions and identify deficiencies.^3,5  In order to fully evaluate these dimensions and perform a full cultural assessment, the Pukenga Atawhai usually interviews a patient for hours, systematically going through each of the dimensions.  By identifying deficiency or dysfunction in one of the four pillars of Te Whare Tapa Wa, the Pukenga Atawhai can then design a plan with the patient intended to correct the underlying issue and bring them back into balance. ^3,5

As we approached the clinic site our conversation moved from the general to the specific, and we began discussing one of the Maori patients we were scheduled to see that morning.  This seeker of health was a young Maori who had been hearing voices for several years and was initially quite alarmed by these voices. During the cultural assessment, our Pukenga Atawhai had discovered that when visiting his ancestral burial grounds, he and his family had not ritually cleansed themselves, a practice believed to prevent one’s ancestors from clinging to oneself when leaving. Being able to communicate with one’s ancestors is a fundamental component of Maori spirituality, but such communication usually happens in a structured time and place.⁶  Every Thursday all of the Pukenga Atawhai come together as one and meet under Te Korowai Atawhai.  During the previous Thursday's meeting our Pukenga Atawhai had brought up this patient’s presentation and there was widespread consensus that the oversight in the cleansing ritual and an ancestral tapu (spirit) who had accompanied the boy from the site was likely the source of the voices.  Many of the Pukenga Atawhai offered advice on how she might help her patient to cleanse himself, and one of the Matua (respected elder) offered to perform a ritual cleansing.  She was excited to meet the patient again and see how he had fared since their last meeting, as well as offer him advice on steps he might take to cleanse himself and rebalance his Wharenui.  I was excited to meet the patient too, but my training made me wary that our young male patient who had just begun hearing voices might be developing a psychotic disorder.

When the time came to finally meet our Maori patient that day, he proved to be a young man with a keen intellect and a ready smile.  He was at first quite shy discussing his experiences, especially with a new face in the room, but as the conversation progressed he appeared to visibly relax.  He and our Pukenga Atawhai discussed the cleansing options discussed at Te Korowai Atawhai and the significance of the voices.  It was clear as the discussion progressed that since his last session, he had become more comfortable with the voices.  He related several instances when he had heard the voices either while awake or asleep and they had served as a warning before a dangerous or unfortunate event befell one of his friends or family.  He no longer found the voices intrusive, and he had begun to view them as protectors and allies.  He further related how he was now able to listen to them at appropriate times and otherwise set them out of his conscious awareness.  In discussions with his family, they had agreed with the initial cultural assessment: the voices likely represented ancestral communication, and they had even identified which tapu was the likely source of the primary voice. I was struck throughout the interview by the lack of negative repercussions he had experienced both in the response of his community to his revelation that he was hearing voices, but also in his ability to function without impairment. This was clearly not a patient experiencing psychosis.

Punakaiki, NZ

As one progresses through medical school, one gains layer upon layer of medical knowledge, first understanding how the body works in health and then understanding how the body works in illness, and finally how to treat illness returning the body to health.  Along with this knowledge, one develops innate medical pattern recognition to help quickly jump to a correct diagnosis.  These are essentially little scripts of how patients present.  Things like: An elderly patient presents with a low hemoglobin and hematocrit, an elevated BUN, and no obvious sources of bleeding.  This is a script that is most suggestive of an occult GI bleed, and you gear your treatments and workup to this most likely diagnosis.  While psychiatric illnesses are extremely complex and the presentations vary enormously, in essence you do largely the same thing.  The patient presents complaining of hearing voices, seems internally preoccupied, has disorganized thinking and appears emotionally withdrawn with a flattened affect; this is the script for schizophrenia. 

Our patient, though he heard voices, wasn’t fulfilling the rest of the script.  He didn’t appear to be internally preoccupied, and he wasn’t experiencing functional difficulties in his relationships because of emotional flattening or disorganized thinking.  In fact, he appeared in every way to be a completely happy and normal, well-adjusted adolescent except for the fact that he heard voices.  In the end, the decision was made that he would work with our Pukenga Atawhai to continue to conceptualize the voices in a culturally appropriate way and that he would represent to the psychiatry service if he developed new or impairing symptoms. 

On the car ride back to Christchurch, I was able to discuss my impressions and also my diagnostic hesitancy.  While the patient wasn't fulfilling my classic schizophrenia script, I worried that this could in fact be early or atypical schizophrenia.  However, the doctor working with our service was able to offer me a particularly valuable insight by comparing our patient’s presentation with that of a girl we had previously seen together, who had fulfilled the classic schizophrenia script.  This comparison as well as the fact that our patient’s symptoms had persisted over years with no apparent deficits in day-to-day functioning allayed my lingering concerns.  This was clearly not schizophrenia.  While I struggled to find diagnostic certainty within the framework I was most familiar, US-based medical practice, our Pukenga Atawhai, was already working successfully with the patient and his family to interpret his experience in a culturally normative way and offer him support and guidance.  This intervention seemed to have thus far provided the patient with a returned sense of self-efficacy and control, and the cultural explanation appeared to satisfy both the patient and his family.

I traveled to New Zealand with the dual goals of increasing my understanding of cross-cultural health care beliefs and practices as well as to gain familiarity with another health care system.  In my brief time in New Zealand, I feel like I was able to accomplish both of those goals and quite a bit more.  I learned that I have reached a point in my career where I have to start expanding my innate medical scripts, a point where I have to start considering not only the most likely medical diagnoses, but the wide complexity of human experiences; and when something doesn’t fit any of my innate scripts, I have to step back and dwell in diagnostic uncertainty for a minute.  After all, at the end of the day, successfully helping a patient to make sense of their symptoms and regain a sense of control and wellbeing is the real goal.

Elizabeth Fenstermacher MS4, Washington University in St. Louis

References:

1.New Zealand Ministry of Health. 2014. “Maori Health Models” Retrieved 8 April 2014. (http://www.health.govt.nz/our-work/populations/maori-health/maori-health-models)

2.Canterbury District Health Board.”CAF Rural Service” Retrieved 8, April, 2014. (https://www.cdhb.health.nz/Hospitals-Services/Mental-Health/Child-Adolescent-Family-Service/CAF-Rural-Service/Pages/default.aspx)

3.Canterbury Distict Health Board. 2014. “Te Korowhai Atawhai (Maori Mental Health Service” Retrieved 23, March, 2014 (https://www.cdhb.health.nz/Hospitals-Services/Mental-Health/Maori-Mental-Health/Pages/default.aspx)

4. Kingi, T. R. (2007). The Treaty of Waitangi: A framework for Māori health development. New Zealand Journal of Occupational Therapy, 54 (1), 4-10. Retrieved March 23, 2014. (http://www.nzaot.com/downloads/contribute/TheTreatyofWaitangiAFrameworkforMaoriHealth.pdf )

5.MHERC (mental health education and resource centre) 2014. “Te Korowai Atawhai (Maori Mental Health Service) Retrieved 23, March 2014. (http://mherc.org.nz/directory/maori-mental-health-services/te-korowhai-atawhai)

6. McNeill, Hinematau. (2009). Maori Models of Mental Wellness. In Te Kaharoa, vol 2 (pp  96-114). Retrieved April 22, 2014. (http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=13&ved=0CDcQFjACOAo&url=http%3A%2F%2Fwww.tekaharoa.com%2Findex.php%2Ftekaharoa%2Farticle%2Fdownload%2F47%2F19&ei=fd9WU4b0GpCFyQHqzYGoCQ&usg=AFQjCNF1QrcgbEuPNnxgU8vYgYvDN-guNA&sig2=_sCuRGJlLJTBliRc2UkRvg&bvm=bv.65177938,d.aWc)