Becoming informed health care consumers: Asian migrant mothers in NZ

Presented at the Prevention, protection and promotion. Second International Asian Health and Wellbeing Conference, November 11,2006.

Cite as: DeSouza, R. (2006). Becoming informed health care consumers: Asian migrant mothers in New Zealand. In S. Tse, M.E. Hoque, K. Rasanathan, M. Chatterji, R. Wee, S. Garg, & Y. Ratnasabapathy (Eds.), Prevention, protection and promotion. Proceedings of the Second International Asian Health and Wellbeing Conference, November 11, 13-14, (pp. 196-207). Auckland, New Zealand: University of Auckland.

Abstract
A central tenet of New Zealand’s midwifery and maternity services is the emphasis on a partnership between two equals namely the midwife and the woman. However, such a partnership rests on the notion of an informed consumer who is independent. When the consumer is a migrant who has experienced social upheaval, lost their knowledge resources and is experiencing isolation and language barriers, they may take up a more dependent role rather than the autonomous and self-determining consumer that midwives are prepared for. This imbalance can mean that health professionals are challenged to take up less facilitative and more authoritative positions and in turn migrant mothers and their partners are challenged to develop more proactive roles. This paper presents partial and preliminary findings from a qualitative study of Asian mothers in New Zealand with regard to their information needs.

Introduction
The notion of a partnership between the midwife and the woman underpins New Zealand midwifery models, where both parties are equal and make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. However, for women become equal partners, they need to make informed decisions about their health and this in turn depends on having access to relevant and timely information. For mothers, biological knowledge about the pregnancy, birth and labour is only one form of knowledge. In addition, social knowledge and institutional knowledge are important (Lazarus, 1994). While biological knowledge can be obtained from authoritative sources like experts and electronic resources, social and institutional knowledge are more difficult to access for migrant women. AS access to these forms of knowledge is dependent on context and social networks which migrant mothers often lose in the social upheaval of migration. For many women who migrate, the separation from family and peers leads to ‘breaks in knowledge’ (Fitzgerald et al., 1998) and the loss of these knowledge resources which help prepare the mother for the processes of pregnancy, childbirth and parenting, creates what Liem (1999, p.157) calls a “vacuum of knowledge”. The vacuum of knowledge needs to be filled and most often this role falls heavily on health professionals (DeSouza, 2005).

This paper begins with a description of the dramatic population changes in New Zealand with a particular focus on Asian women. A discussion about receiving accurate and timely information follows suggesting that the quality of communication between women and their carers is critical for feeling safe and satisfied with care. An outline of research conducted in Auckland New Zealand follows and the findings are presented through the transition to parenthood. Strategies for managing the transition to parenthood and becoming an informed consumer are discussed with the paper concluding with practice, policy and research recommendations.

Literature Review
The following section contextualises the study by reviewing the changing demographics in New Zealand society with a focus on Asian women. This is followed by a discussion about the link between information and communication and satisfaction with care for migrants.

An increasingly diverse New Zealand
Service providers need to develop skills and competence for working effectively with diverse members of New Zealand society. International trends show that people of diverse racial, ethno-cultural and language backgrounds are underserved by health and social services, experience unequal burdens of disease, experience cultural and language barriers to accessing appropriate health care, and receive a lower quality of care when they do access health care services in comparison with members of the population (Johnstone & Kanitsaki, 2005). The 2001 Census revealed growing numbers of M␣ori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), in addition to European/Pakeha who make up 79.6% of the population. There has been a 20% increase in the number of multilingual people and an increase in people whose religion was non-Christian. People who practice Hinduism increased by 56%, there was a 48% increase in Buddhists and a 74% of people practising Islam.

Asians are the fastest growing ethnic group; increasing by around 140% over the last ten years and predicted to increase by 122% by 2021 due to net migration gains rather than high fertility rates (Statistics New Zealand, 2005). The Asian community has the highest proportion of women (54%), (Scragg & Maitra, 2005) who are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups, a reflection of a skills focused migration policy. 23% of New Zealand women were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands. Some of the most dramatic demographic changes are evident in the Asian community, for example in the period between 1991 and 2001, the number of women originating from the Republic of Korea increased 23 times from 408 to 9,354, numbers of women from China quadrupled from 4,620 to 20,457 and women from South Asia doubled in the same time period (Statistics New Zealand, 2005). Such diversity has been unprecedented and present both unique challenges and opportunities to health and social service providers and policy makers.

Communication, caring and safety
Migration often results in the loss of reference points in the form of family networks, peer support and familiarity with health services. Such a loss amplifies the necessity for receiving accurate and timely information. Davies and Bath (2001) suggest that information provision during pregnancy and childbirth is critical for both supporting choices that are made but also in preparing women to manage uncertain outcomes. Citing a study by Kirkham (1989), Davies and Bath argue that women’s satisfaction with maternity services in secondary care is primarily dependent on the quality of communication between the women and their carers. Little is known about the health care experiences of migrant women, however, they are thought to report more acute concerns about communication and sensitivity of care than the population in general (Davies & Bath, 2001). Furthermore, language barriers can exacerbate isolation and promote dependency on health workers rather than enhancing self- determination, a dominant midwifery discourse. Small, Rice, Yelland, & Lumley (1999) found that Vietnamese, Turkish and Filipino women in Melbourne who were not fluent English speakers experienced problems in communicating with their caregivers and this made experiences of care less positive. Of more importance than knowledge about cultural practices, was care experienced as unkind, rushed, and unsupportive. Another Australian study found that migrant patients (and their families) did not feel safe when in hospital. Safety was undermined when effective communication with caregivers was compromised through being unable to access qualified health interpreters or being unable to have family members around to advocate and participate in decision-making (Johnstone & Kanitsaki, 2005).

The study
Migrants tend to maintain better health than the local population initially so often have little to do with hospitals (McDonald & Kennedy, 2004), but motherhood is a common aspect of migration requiring contact with the health system. The study took place in Auckland, New Zealand among White migrants (from South Africa, United Kingdom and the United States of America), Muslim Arab migrants (from Iraq and Palestine) and Asian women from three ethnic communities (Korean, Chinese and Indian) as part of a larger Families Commission funded study. Ethics approval was obtained from the Auckland University of Technology Ethics Committee and the Plunket Ethics Committee. Participants for the migrant mothers’ focus group were recruited though Plunket nurses who invited women to participate, selection criteria limited participation to migrant women who had become mothers within the last 12 months in New Zealand. Informed consent was obtained from all participants and consent forms were translated into Arabic, Korean and Chinese. Data collection involved focus groups using semi-structured interviews conducted in English, Chinese and Korean. The groups were facilitated by interviewers proficient in English and the language spoken by the women. These interviews were recorded and transcribed, translated into English if necessary and verified by an independent translator. The interview transcripts were then coded and analysed. The codes were clustered according to similarity and reduced. Similar phenomena were grouped into categories and named. The process was one of constant comparison, iteratively classifying and grouping the material to identify preliminary categories and sub- categories. This paper reports on a sub-theme about information needs and the findings focus on Asian women.

Findings
Midwives caring for migrant Asian parents are challenged to reconfigure their model of partnership and in turn migrant Asian parents experience a shift from birth being a social event to more of an individual responsibility. This shift requires a more proactive and self- sufficient role for women and their husbands, who become more involved than they might have been in their country of origin. In addition, language and communication drive experiences of care. This separation from knowledge resources places greater responsibility onto midwives to assume a more central role in information provision and support. In particular migrant mothers require detailed, individualised, stage specific information in order to take up the role of informed consumer.

Antenatal period
Not only are migrant mothers confronted with changing bodies and roles when they become pregnant, they also have to deal with an unfamiliar health system in the absence of a support network and knowledge resources they might have had in their countries of origin. In this study, Asian migrant women had to make decisions that required access to information in order to ascertain the choice of maternity carer and access to ante-natal classes. At this time women who were not fluent or confident English speakers had to contend with linguistic and cultural barriers to accessing services.

The loss of traditional sources of knowledge meant that pregnancy in a new country moved from being a social event and responsibility to being an individual one (DeSouza, 2005). This required the participants to become more involved and proactive in seeking out detailed, timely and specific information about the stages of their pregnancy. This allowed them to become more involved in the pregnancy than if they had been in their country of origin where this responsibility would have been shared. Husbands also became more involved in the processes of pregnancy, than they might have been in their countries of origin. Knowing where to begin the process was difficult:

I had no idea at all about the system here. It was through the pregnancy test kit that I found out I was pregnant, but did not know what the next step was. I wondered whether I had to show my test result to my GP. I had no knowledge of how to get the necessary information [Korean participant].

Obtaining language specific and precise information was important for many Korean women. Being given broad encouragement was not a substitute for specific information and was perceived as a laissez-fare attitude to their wellbeing.

I was given some information, but I didn’t read it, as it was not in Korean. I always felt that I was one step behind. It was not only the midwife who did not give enough information or necessary support. Everyone kept saying, “It is okay, you are doing well” but gave few information or specific support [Korean participant].

Pregnancy in a new country raised the need to develop active decision making strategies and to choose a health care provider. Many of the women were proactive about finding out about the New Zealand health system and turned to authoritative sources for information:

Luckily, I was attending school and the assignment from school was to complete a project. I chose ‘New Zealand’s maternity system’ and that was how I got some ideas about my situation [Korean participant].

For some women the absence of family members and the access to information meant that they could monitor themselves through the stages of pregnancy and this led to developing increased knowledge and greater self-sufficiency:

I have to take care of my own self. I found this good thing in New Zealand that you should take care of the baby and you should be aware of foods and what is going on each and every month, each and every week, what really is important [Indian participant].

One Indian woman found that she was more engaged in her pregnancy because her previous pregnancy was a joint responsibility with other family members while this time round she had to take more personal responsibility:

Why didn’t I get the feelings the first time? Time passed with families, mother in law, sisters, brothers and time passed like anything but here we are alone,  thinking about the baby early and so every moment for me was a first time moment, even though I’m a second time mother [Indian participant].

Many husbands become more involved during the pregnancy and were more in tune with what was happening to their partner’s bodies:

We used to wake up and the first thing we used to do was take a book and read ‘Okay, so now our baby’s doing that’ and he will pat me on my tummy saying ‘Oh my little one’ you know? So I doubt whether the same feeling would have come if my pregnancy was in India [Indian participant].

Language dictated the choice of LMC for many Chinese women and they, more than any other cohort, relied on their networks to find a care provider with Chinese newspapers also being a useful knowledge resource.

She speaks English and can speak Chinese. After I met her, I had a good impression of her. So I decided to have her as my midwife. My midwife has a partner who is also a Chinese (Malaysian Chinese). When I gave birth to my child, her partner delivered my child. The whole process was quite smooth [Chinese participant].

Antenatal classes
Antenatal classes were a pivotal mechanism for acquiring knowledge:

When you know something it’s better than just going without knowledge and you’re worried. , Yeah and as a first time mother I didn’t really know what was going to happen or what to expect and then yeah, I learnt a lot from that [Indian participant].

And for gaining confidence about what was to come by having some broad knowledge about what was to come:

I felt it was not so relevant to my delivery. But I felt more at ease and more confident during delivery. There are Chinese people in the class. The midwife was also careful when teaching us. We could understand her. My husband’s English is very good. He escorted me to the class. It was about some basic ideas. I didn’t find it useful for my delivery. During delivery, you follow the instructions of your midwife and have no time to reflect on what was taught in the class. But you feel relieved and less anxious. You roughly know what is going to happen and what is what [Chinese participant].

But language barriers made classes inaccessible for some:

I felt frustrated because I could not understand everything [Korean participant].

Both my husband and I have poor English so only attended once [Korean participant].

This section highlighted the importance of receiving detailed and specific information in one’s own language and how this influences the choice of LMC or attendance at ante-natal classes. Knowing where to start can be difficult. For women and their husbands who want to take up an informed consumer role there are resources available which lead women and their husbands to be more self-sufficient, proactive and engaged in the process.

Labour and delivery
Labour and delivery was also a time when information, support and cultural needs were highlighted. Women wanted information that was specific to their stage of labour and that was individualised (some felt they had too much and others too little information to feel that they could make the best choice for themselves). The value of specific stage by stage information was supported by a Korean participant rather than broad encouragement:

In Korea mums are given lots of warning and feedback of what is happening during labour, and told by Dr’s what to do regularly. This was missing in NZ. It would be good to be given feedback of our progress of labour and how many cm we are at each stage after the vaginal examinations. I was not told this. Not enough explanation and only told that “You are doing well” [Korean participant].

The need for not only specific information but also to be told the best option or given enough information to make the best choice was also voiced. The facilitative role of health providers was called into question with some participants wanting a more authoritative role. The partnership between the midwife and the woman underpins the midwifery model in New Zealand maternity services and is based on equity and the acknowledgement that both parties make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. Midwives have moved from authoritative sources of knowledge to models of partnership and collaboration in a bid to empower women and distinguish themselves from the more hierarchical professional models of medical, nursing and obstetric practise (Tully, Daellenbach, & Guilliland, 1998). However, this is predicated on the notion of the informed consumer:

In NZ different delivery options are given to mums and we are asked to choose by ourselves but unable to choose the best options for ourselves due to lack of sufficient knowledge. Want more advice and guidance and even want to be told which better option for us is. So in the end we have limited options due to not enough knowledge of all the pros and cons of delivery methods [Korean participant].

Information does need to be individualised, one participant who felt that she was given too much information:

During the labour the ladies said that I need an epidural because I can’t go through the pain anymore, the anaesthetist comes in the room and says out of 150 million there are 10% of cases with risk all that information beforehand [Indian Participant].

This section has highlighted the importance of detailed and specific information and the need for information to be individualised. The midwifery model of care which emphasises facilitative rather than authoritative relationships was challenged.

Post-partum
The postnatal period is a critical time for women but it is also a time when their needs are often not met (Baker, Choi, Henshaw, & Tree, 2005). In the postpartum, information needs were an issue, women needed to know how to handle an unpredictable and unknown baby, there were issues around feeding from a cultural point of view and what to feed and when, the amount and type of information became important too:

We need more information. Iron deficiency for example. We don’t know what to feed our babies for this. And solid feeding too. We don’t know how to begin solid feeding with Korean food. The information is only on Kiwi way of feeding [Korean participant].
I didn’t even know how to care for her after delivering baby. No knowledge. Had to cook and clean and do everything after delivering baby , had no one to help. Breastfeeding was hard, received no help. Got sore bones and joints. No Korean appropriate services available, so often missed out altogether on information and the right kind of help [Korean participant].

However, not everyone wanted to be an informed consumer:

Yeah, you just want to get out of that place and these people are giving you like the advantages and disadvantages of various things, you don’t want to hear all these things [Indian participant].

The post-partum period highlights the need for the expansion of the information agenda from New Zealand models of infant feeding to incorporating other cultural models and the need for language specific information about breastfeeding. Some women contested the pressure to be informed consumers. The following section provides some discussion and recommendations.

Discussion

This section focuses on five key areas where further exploration and consideration by both migrant mothers and health professionals would be beneficial, namely:

  • Providing detailed and individualised information;
  • Language support;
  • Preparing women for new discourses of maternity;
  • Developing fluency; and
    Developing health literacy.

Providing detailed and individualised information

Health-care providers have a responsibility to make available, accessible and up-to-date information. However this is not as easy as it sounds, when facilitating informed choice. Midwives and other health professionals are caught in a difficult position and have to strike other balances, such as between giving enough information for the woman to make a choice but not giving too much information and frightening her (Levy, 2006). They also have to delicately meet the needs of women and to appear neutral in their advice, when they might have strong feelings regarding certain issues. In this study, migrant mothers looked to health professionals to fill the vacuum of knowledge by being authoritative rather than facilitative. Increasingly research shows that information is more effective when it is tailored to the individual and their needs (Rapport et al., 2006) and relevant to the women’s current stage of pregnancy (Benn, Budge, & White, 1999). In addition detailed information rather than ‘big picture’ was valued. Therefore highlighting the need for individualised and detailed information when planning for the provision of maternity information (Soltani & Dickinson, 2005). Information that is available in ones own language or written information is important. While translated information is available about childbirth in New Zealand from the Maternity Services Consumer Council of New Zealand it is not clear how well this information is distributed or whether LMCs are aware of its existence.

Language support
Communication as a part of information support can be improved through implementing a two pronged strategy. First, health professionals and systems can become more skilful at information provision through linguistic competence and secondly through identifying and assisting in the extension of sources of information. Health providers can assist new migrants to identify information sources and encourage women to develop information seeking skills. Developing linguistic and cultural competence can be achieved by:

  • Providing bilingual /bicultural staff;
  • Providing foreign language interpreting services; Having link workers/advocates; and     Having materials developed and tested for specific cultural, ethnic, and linguistic
    groups;
  • Having translation services including those of:Legally binding documents (for example, consent forms); Hospital signage; Health education materials; and Public awareness materials and campaigns, including ethnic media in languages other than English. Examples include television, radio, internet, newspapers and periodicals (Szczepura, 2005).

In the USA, health care organisations are required to both offer and provide language services such as bilingual staff and interpreter servicesat no extra cost to clients who require it. It is recommended that information about services is provided both in writing and in a timely manner with credentialed interpreters and bilingual workers available (U.S. Dept. of Health and Human Services, 2003).

Lastly, research is needed to assess the level of unmet information needs among new migrant women in greater depth. To borrow from a recommendation from a recent study:
Research is needed on cross-cultural and intercultural communication in particular on the nature and impact on Culturally and Linguistically Diverse (CALD) people not being able to communicate with service providers; not being able to get information and explanations about ‘what is going on’; not being able to get information in a timely manner; not being given information in a culturally appropriate manner; not being given any information at all; being given too much information; being given unwanted information (Johnstone & Kanitsaki, 2005, p.15).

Preparing women for new discourses of maternity
The study findings highlight the need for health providers to assist women socialise into new discourses in particular the discourse of partnership and the informed consumer. A useful mechanism for socialising women into an informed consumer discourse is to provide multi- lingual antenatal classes. Many women in this study felt the need for specific and detailed information in order to make the best choice but some women also wanted to be told the best option. The facilitative role of health providers was called into question with some participants wanting their LMC to have a more authoritative style. The partnership model underpinning midwifery in New Zealand maternity services assumes that midwives bring their knowledge, skills and experience and women brings their knowledge of themselves and their families to the relationship. This is intended to be a collaborative and empowering relationship but it requires that the woman wants the responsibility of being an informed consumer. It appears that the notion of partnership cannot contain women who don’t want the equal responsibility that is required. In addition, one needs to be information literate in order to take this role on (Henwood, Wyatt, Hart, & Smith, 2003).

Developing fluency
Lack of English language proficiency impacts on access to health care, employment prospects, income levels and other factors which determine health status (Asian Public Health Project Team, 2003).The link between language and accessing health care is further strengthened by the findings of a New Zealand study where self-rated fair or poor health was found to be associated with Chinese-only reading knowledge, residency of more than five years and regretting having come to New Zealand (Abbott, Wong, Williams, Au, & Young, 2000). While a study of Chinese American women which found that lack of English language ability was a major barrier to access (Liang, Yuan, Mandelblatt, & Pasick, 2004). Ensuring that migrants are aware of Language line and encouraging them to take up their English for Migrants language courses, as proficiency is a key settlement enhancer. The migrant levy that migrants pay when coming to New Zealand entitles migrants to take up English language classes (English for Migrants). The Tertiary Education Commission pays for English language tuition on behalf of migrants to New Zealand who have pre-paid for their training, recent news reports indicate that few migrants take up these classes.

Developing health literacy
The development of health literacy among health care recipients is gaining prominence as a health promotion strategy. Health literacy is defined by the World Health Organisation as “ the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” (World Health Organization, 1998, p.10). Health literacy is a stronger predictor of health status than socio-economic status, age, or ethnic background (Speros, 2005). Speros claims that the lack of health literacy can act as a barrier to navigating the system and functioning successfully as a consumer, presumably then the combination of socio-economic status, ethnic background and low health literacy compound the issues of access. Speros cites a large study by Williams et al. (1995) which found that one-third of English -speaking patients at two public hospitals in the USA could not read and understand basic health-related materials. Sixty per cent could not understand a routine consent form, 26% could not understand information written on an appointment slip, and 42% failed to comprehend directions for taking medications. While little is known about health literacy is known in New Zealand, overseas research suggests that being culturally and linguistically different magnifies the problem.

Conclusion
This study highlights the importance of information provision for health care consumers, in particular migrant mothers. The study shows that migrant women frequently experience a vacuum of knowledge that needs to be filled. Factors such as poor English language proficiency, limited networks and unresponsive health providers can all increase the likelihood of migrant mothers experiencing a problematic birth experience and poor outcomes. This research suggests that improving the quality and range of information for migrant mothers and the inter-cultural resources for health providers could improve outcomes.

Further research is needed into how maternity information is provided and it is suggested that more attention is paid to the information needs of migrant mothers and migrants in general. Language proficiency is vital not only with regard to access to services but also for being empowered and prepared for the dual transition of parenthood in a new country. The study highlights the need for further exploration of changing demographics on dominant health care discourses in New Zealand such as partnership and whether there is space for new discourses. There are several aspects that contribute to a satisfying experience of health care for migrant mothers and these appear to be the ability to access a service, being able to obtain relevant information and having a supportive relationship between themselves and providers. These appear to be mutually dependent factors.

Acknowledgements

Funding for this research was provided by grants from The Families Commission and the Plunket Society volunteers in Central Auckland. The following people are gratefully acknowledged for their contributions: The mothers, Elaine Macfarlane, Sheryl Orton, Michele Hucker, Dr Wanzhen Gao, Rose Joudi, Paula Foreman, Rezwana Nazir, Lorna Wong, Jane Vernon, Zahra Maleki, Nagiba Mohamed, Hyeeun Kim, Catherine Hong and Stephanie Shennan.

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Pregnant with possibility: Migrant motherhood in New Zealand

First published in Mindnet  Issue 6 – Winter 2006

When my family arrived in New Zealand in 1975 there were very few people from Goa living here. We quickly got know every Goan in the country and, in hindsight, this connection provided me with an early interest in and focus on both maternal mental health and migrant mental health. Two Goan women we knew developed mental health problems that were devastating for themselves and their families. For one, it led to suicide and for another a lifelong history of mental illness and loss. Hardly good outcomes! This was a time when it was hard to maintain our culture. Thankfully, the more recent shift in focus to encompass settlement rather than just immigration will further enhance the well-being of ethnic communities in New Zealand.

There are still large research, policy and practice gaps in the area of migrant motherhood, which I’d like to address in this article. I’d like to start by highlighting the significance of migrant motherhood, which has potentially long term and wide ranging impacts on members of a family. I’ll then talk about the changing demographics of New Zealand society and suggest that health workers need to broaden their focus for working with New Zealand’s increasing diversity and develop culturally safe ways of working with migrants and their families. Lastly, I’ll share my experiences of research with migrant mothers from different ethno-cultural communities.

When migrants “cross borders they also cross emotional and behavioural boundaries. Becoming a member of a new society stretches the boundaries of what is possible because one’s life and roles change, and with them, identities change as well. Boundaries are crossed when new identities and roles are incorporated into life” (Espín, 1997, p.445). Border crossing can involve trauma related to migration and a psychic split (Mohamed & Smith, 1999).

Migration policies favour women (and families) of childbearing age, so it is no surprise that having a baby is a common aspect of a woman’s settlement experience. Motherhood and migration are both major life events. They present opportunities but incur the risk of mental health problems, more so when they are combined. Many cultures and societies have developed special perinatal customs that can include diet, isolation, rest and household help. But these traditional and specific practices and beliefs that assist in the maintenance of mental health can be lost in migration (Kruckman, 1992). Women are separated from their social networks through migration and must find new ways to recreate these rituals or lose them (DeSouza, 2002). Research suggests that the loss of support, protective rituals and supportive networks compounded by a move to a nuclear family-model can result in isolation and postnatal depression (PND) (Barclay & Kent, 1998; Liamputtong, 1994).

Access to help and support can be impeded if the mother has language and communication problems.

Migrant mothers sometimes face additional cultural and social demands and losses that include the loss of lifestyle, control, sense of self and independence, family and friends, familiar birthing practices and care providers.

Women are more likely to develop emotional problems after childbirth than at any other time in their lives and the life time prevalence of major depression in women is almost twice that of men (Kohen, 2001). According to Lumley et al. (2004), one out of every six women experiences a depressive illness in the first year after giving birth. Thirty per cent of those women will still be depressed when their child is two years old. Of those women, 94% report experiencing a related health problem. Women who experience problems in the early stages of motherhood also report problems with their relationships, their own physical health and well-being. Women report that a lack of support, isolation, and exhaustion are common experiences.

In a study of 119 pregnant immigrant women in Canada, Zelkowitz et al., (2004) found that the transitions associated with migration placed women at higher risk of depression. Forty-two percent of participants scored above the cut-off for depression. Depressive symptoms were associated with poorer functional status and more somatic symptoms. Depressed women reported a lack of social support, more stressful life events and poorer marital adjustment. In Australia, Liamputtong and Naksook (2003) found that Thai women who became mothers in Australia had several main concerns, including social isolation, different childrearing and child disciplinary practices, and the desire to preserve their culture. Findings of isolation, loneliness and negotiating between traditional and Western childbirth rituals are common in these studies and were significant issues in my own New Zealand research (DeSouza, 2006c). This research strongly suggests that migrant mothers, regardless of origin, benefit significantly from effective and familiar social support networks.

Psychiatric illness occurring at this time can have an adverse effect not only on the woman herself but also on her relationships, family, and the future development of her infant. The impact on a child of a mother’s depression can include behavioural problems, relationship problems and cognitive deficits. Research shows that infants who had a mother who was depressed in its first year of life are more likely to develop cognitive deficits and behavioural problems than infants whose mothers were not depressed in that first year (Beck, 1998).
A review by Goodman (2004) of literature from 1980 to 2002 found 20 research studies that included incidence rates of paternal depression during the first year postpartum. During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing postpartum depression. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period.

Changing demographics

Many societies are grappling with issues of citizenship and participation in the context of globalisation, increased migration and increasing diversity. In Europe, one in every fifteen people was born overseas, in the US it rises to one in eight and in New Zealand it is one in five (DeSouza, 2006a). This presents unique challenges and opportunities for service providers to develop skills and competence for working with this diversity, especially as migration is going to be a key source of population increase. Census projections to 2021 suggest that Māori, Pacific and Asian populations will grow at faster rates than the European population but for different reasons. The Asian population is expected to more than double mainly due to net migration gains while Māori and Pacific people’s increases will be due to their higher fertility rates (Statistics New Zealand, 2005).

The Asian community has the highest proportion of women (54%), followed by Māori and Pacific (53% each) and European (52%) (Scragg & Maitra, 2005). Asian women are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups and to some degree this is a reflection of migration policy with Asian women using the opportunity to study or work. It is thought that 23% of New Zealand females were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands (Statistics New Zealand, 2005). The 2001 Census revealed growing numbers of Māori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), despite the dominance of the European/Pākehā who make up 79.6% of the population. In the period between 1991-2001, women originating from the Republic of Korea have increased 23 times from 408 to 9,354, women from China have quadrupled from 4,620 to 20,457 and women from South Asia have doubled in the same time period. Women from Africa (primarily South Africa, Zimbabwe and Somalia) have quadrupled in number (Statistics New Zealand, 2005). This has significant implications for the development and delivery of health services to women.

Cultural competence?

Working on a postnatal ward of a women’s hospital several years ago led me to question whether cultural safety had prepared the nursing and midwifery workforce for working with ethnic diversity1. Cultural safety, which refers to the experiences of the client, and cultural competence, which focuses on the practitioner and their capacity to improve health status by integrating culture into the clinical context, have been gaining prominence, but what do they actually mean?

The introduction of the Health Practitioners Competence Assurance Act 2003 has meant an additional responsibility to ensure the cultural competence of health practitioners. Cultural competence can be defined as “the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural, and linguistic needs (Betancourt, Green, & Carrillo, 2002). Cultural competence includes not only the interpersonal relationship (for example, training and client education) but also the organisational (for example, involving community representatives) and the systemic (for example, providing health information in the appropriate language, collecting ethnicity data).

The New Zealand Medical Council recently consulted its members on cultural competence (The New Zealand Medical Council, 2005). The consultation document includes a proposed framework and says that cross-cultural doctor-patient interactions are common, and doctors need to be competent in dealing with patients whose cultures differ from their own.

It cites the benefits of cultural competence as:

  • Developing a trusting relationship;
  • helping to get more information from patients;
  • improving communication with patients;
  • helping to resolve any differences;
  • increasing concordance with treatment and ensuring better patient outcomes; and
  • improved patient satisfaction.

For cultural competence to occur there is a need for the voices of ethnic communities to be considered in service development, policy and research. Despite the long histories of migration to New Zealand, ethnic communities have been absent from discussions of nation building and health care policy (DeSouza, 2006b). This has in part been due to the relatively small numbers of migrants from non-traditional source countries until the early 1990s, which meant that that the concerns of a relatively homogenous Pākehā people were reflected in policy (Bartley & Spoonley, 2004). This monoculturalism continues to be challenged by the increased prominence of Māori concerns since the 1970’s and increasing attention to biculturalism and health outcomes for Māori. Developments have also occurred with regard to Pacific peoples, largely around health disparities, but this concern has not been extended to ethnic communities despite their increasing visibility in long and short-term migration statistics. This is partly due to an assumption of a ‘health advantage’ of immigrants on the basis of current migration policy, which selects healthy people. However, evidence is growing that this advantage declines with increasing length of residence in a receiving country (Johnstone & Kanitsaki, 2005).

Cultural safety

When Britain assumed governance of its new colony in 1840, it signed a treaty with Māori tribes. Te Tiriti O Waitangi/The Treaty of Waitangi is today recognised as New Zealand’s founding document and its importance is strongly evident in health care and social policy. As an historical accord between the Crown and Māori, the treaty defines the relationship between Māori and Pākehā (non-Māori) and forms the basis for biculturalism.

Durie (1994) suggests that the contemporary application of the Treaty of Waitangi involves the concepts of biculturalism and cultural safety, which are at the forefront of delivery of mental health services. This means incorporating “principles of partnership, participation, protection and equity” (Cooney, 1994, p.9) into the care that is delivered. There is an expectation that mental health staff in New Zealand ensure care is culturally safe for Māori (Mental Health Commission, 2001). Simply put, “unsafe practitioners diminish, demean or disempower those of other cultures, whilst safe practitioners recognise, respect and acknowledge the rights of others” (Cooney, 1994, p.6). The support and strengthening of identity are seen as crucial for recovery for Māori along with ensuring services meet Māori needs and expectations (Mental Health Commission, 2001). Cultural safety goes beyond learning about such things as the dietary or religious needs of different ethnic groups; it also involves engaging with the socio-political context (DeSouza, 2004; McPherson, Harwood, & McNaughton, 2003). However, critics suggest that cultural safety needs to encompass new and growing ethnic communities. Whilst in theory cultural safety has been expanded to apply to any person or group of people who may differ from the health professionals because of socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability (Ramsden, 1997), in practice the focus remains on the relationship between Pākehā and Māori, rather than migrants (DeSouza, 2004) and other communities (Giddings, 2005).

Expanding the bicultural to a multi-cultural framework is necessary without removing the special status of tangata whenua. New Zealand’s reluctance to encompass multiculturalism as a social policy framework has been shaped by two key factors, according to Bartley and Spoonley (2004). The first is the location of historical migration source countries such as the United Kingdom and Ireland, which shaped the development of activities and concerns (as they argue, racist and Anglo centric assumptions of a colonial New Zealand) and, secondly the rise in concerns over indigenous rights and the Treaty of Waitangi, which have precluded discussion around nation and nationality. Thus while countries such as Canada and Australia were developing multicultural policies, New Zealand was debating issues of indigeneity and the relationship with tangata whenua. As a result, New Zealand has yet to develop a locally relevant response to cultural diversity (multiculturalism) that complements or expands on bicultural and Treaty of Waitangi initiatives (Bartley & Spoonley, 2004).

Need for a migrant health agenda

It is, I hope, clear by now that there is a need to develop a migrant mental health agenda, yet much of the previous New Zealand research has omitted the experiences of migrant mothers. The Centre for Asian and Migrant Health Research at AUT University and Plunket have begun a collaborative project with funding from the Families Commission and Plunket volunteers to understand the experiences of migrant mothers from the United Kingdom, the United States, South Africa, Palestine, Iraq, China, India and Korea, which it is hoped will assist in the development of services and policy.

There is a misguided view that migrants do not experience compromises in their health status despite the changes in income and social support and the new stressors they encounter, which can lead to cumulative negative effects and the need to access mental health services. The neo-liberal trajectory that our society has taken has precluded an interest in the wellbeing of migrants who often face culture-related barriers in using mental health care services. Other than a literature review produced by the Mental Health Commission (Mental Health Commission, 2003), which recommended that mental health services become more responsive to Asian people, there has been little in the way of strategic or long term planning with most of the developments in this area coming from the community and voluntary sector.

Conclusion

Migrants face additional stressors that can increase their need for mental health services. Migration can be a traumatic life event. Becoming a mother in an unfamiliar country adds to this already traumatic event, leading migrant mothers to be more at risk of experiencing depression or other mental health issues. Yet, research on the migrant experience in New Zealand is limited and studies on postnatal depression have excluded migrants in the past.

As the number and diversity of migrants increase, their well-being becomes an increasingly important issue for policy makers and health professionals. The time is right to begin a dialogue about how mental health services can work effectively with this diversity. Migrant mothers hold the key to a family’s future well-being and so are an important group for us to understand and support. In the absence of policy there is a need to advocate for migrant mental health service development, building on the many grassroots initiatives that are already occurring. Beyond this, further discussion is needed as to how cultural competency and cultural safety can be applied to migrant populations.

1. ‘Ethnic’ is a term devised by the Department of Ethnic Affairs and refers to people who are neither Pakeha, Maori or Pacific).

References

Barclay, L., & Kent, D. (1998). Recent immigration and the misery of motherhood: a discussion of pertinent issues. Midwifery, 14, 4-9.

Bartley, A., & Spoonley, P. (2004). Constructing a workable multiculturalism in a bicultural society. In M. Belgrave, M. Kawharu & D.V. Williams (Eds.), Waitangi revisited: perspectives on the Treaty of Waitangi (2nd ed., pp. 136-148). Auckland, N.Z.: Oxford University Press.

Beck, C. T. (1998). A checklist to identify women at risk for developing postpartum depression. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27(1), 43-44.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Retrieved 27th April, 2005, from www.cmwf.org/usr_doc/betancourt_culturalcompetence_576.pdf

Cooney, C. (1994). A comparative analysis of transcultural nursing and cultural safety. Nursing Praxis in New Zealand, 9(1), 6-12.

DeSouza, R. (2002). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Massey University, Albany, New Zealand.

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

DeSouza, R. (2006a, May 26th). Cultural Diversity and Context: Responding to the needs of ‘This Child” in “This Family”. Paper presented at the 5th Annual Child Law Conference, Lexis Nexis, Auckland.

DeSouza, R. (2006b). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, In press.

DeSouza, R. (2006c). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Auckland, NZ: Muddy Creek Press.

Durie, M. (1994). Whaiora: Maori health development. Auckland; Oxford: Oxford University Press.

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Goodman, J. H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45(1), 2-35.

Johnstone, M.-J., & Kanitsaki, O. (2005). Cultural safety and cultural competence in health care and nursing: An Australian study. Melbourne: RMIT University.

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Liamputtong, P. (1994). Asian mothers, Australian birth: pregnancy, childbirth, and childrearing: the Asian experience in an English-speaking country. Melbourne: Ausmed Publications.

Liamputtong, P., & Naksook, C. (2003). Life as mothers in a new land: The experience of motherhood among Thai women in Australia. Health Care Women International, 24(7), 650-668.

McPherson, K. M., Harwood, M., & McNaughton, H. K. (2003). Ethnicity, equity and quality: Lessons from New Zealand. Quality & Safety in Health Care, 12(4), 237-238.

Mental Health Commission. (2001). Cultural Assessment Processes for Maori – Guidance for Mainstream Health Services. Wellington: Mental health commission.

Mental Health Commission. (2003). Mental Health Issues for Asians in New Zealand: A Literature Review. Wellington: Mental health commission.

Mohamed, C., & Smith, R. (1999). Race in the therapy relationship. In M. Lawrence, M. Maguire & J. Campling (Eds.), Psychotherapy with women: feminist perspectives (pp. 134-159). New York: Routledge.

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Mutual sustenance: Goan women and the Catholic church in New Zealand

First published in Goanet Reader Sun, 30 Apr 2006 and also published in the Indian Catholic May 21,2006

On December 3 2005, Catholic Goans in Auckland, New Zealand celebrated the Feast of St Francis Xavier with a mass in Konkani, the first time such an event had been held in New Zealand. For those who don’t know, Francis Xavier was actually born in the Spanish kingdom of Navarre. He arrived in Goa in May 1542 and went on from there to Cape Comorin in the south of India, spending three years working among the pearl-fishers, or Paravas, of the Fishery Coast. His journey took him to the East Indies, to Malacca and the Moluccas, and, finally, in 1549 to Japan. He died on December 3rd, 1552, as he attempted to enter China and was buried. Within a few weeks his body was recovered and found to be perfectly preserved. It was brought to Goa and received there with devotion and enthusiasm leading to his beatification by Pope Paul V in 1619 and later his canonization by Pope Gregory XV, on March 12th, 1622. He is now the patron Saint of Goa. This event led me to wonder about the significance of religion and faith among Goans and how this sustained them during their migration and settlement in other countries.

In terms of  the New Zealand population, there is growing cultural, linguistic and religious diversity. Three trends are apparent: first, that religious participation by White or Pakeha New Zealanders is declining while changes in immigration policy have resulted in the introduction and growth of both diasporic religious traditions (such as Islam, Hinduism, Buddhism and so on) and an invigoration of Christian denominations. The 2001 Census noted that more than half the New Zealand population identified with a Christian religion (Anglican, Catholic and Presbyterian dominating) and the largest non-Christian religions were Buddhism, Hinduism, Islam and Spiritualism and New Age religions.

In my research among Goan women in New Zealand, what became apparent to me is that while Goan women have become detached from their homeland (all participants were born outside of Goa) they continue to have a link with the homeland while surviving in, and engaging, a foreign culture. Also religion and cultural identity are tightly inter-connected. There is academic debate about whether religion is a core attribute of culture or whether it functions within it, is more prominent than culture or in the background. I found many women in describing their identity, forgot that there are Hindu and Muslim Goans.

My description would be Goan Roman Catholic. Primarily being Goan is being Catholic because all the Catholics normally came from Goa, which was one of the Catholic states of India (Lorna).

As I grew up you grow out of church and praying and you go the other way kind of thing, but that was very strong, I think the Catholic faith, which stayed throughout. I mean even now you just link up being Goan and Catholic together (Rowena).

Crossing borders as migrants do involves not only physical borders but also emotional and behavioural boundaries. Becoming a member of a new society stretches the boundaries of what is possible because one’s life and roles change, and with them, identities change as well. This involves trauma and then incorporating new identities and roles becomes necessary for survival.

For many Goans in Auckland, the Catholic religion and church provided a mechanism for coming to grips with a new environment and assisted the transition to living in New Zealand. They could mix with other ethnic communities while at the same time maintain their culture and faith, that is it provided a bridge connects Goans to other Catholics while who shared similar religious beliefs and values even if they were culturally different.

Thus Churches provide a vehicle for helping Goans participate in New Zealand life rather than isolating them. In the case of the Catholic Church Goan migrants were already familiar with the rituals and structure and the church provided a supportive and welcoming space for them as immigrants. As someone who grew up in New Zealand, our youth group provided a wonderful source of friendship and fellowship for me and my two sisters.

Churches provide not only institutional spiritual comfort but also practical support. For example when we first came to New Zealand, our family was able to buy what is now called ‘retro’ or ‘vintage’ through the recycling process of the mini-market where you could buy other parishioners unwanted clothes.

Churches have also responded to new migrants by attending to and incorporating religious practices that are culturally significant for immigrants; for Goans this includes celebration of the Feast of St Francis Xavier, the patron Saint of Goa. Thus immigrants have infused change and a rich range of experiences in the churches they have joined within their receiving communities. I also remember with delight the Samoan choir who would sing in Samoan and English elevating our services to celestial heights once a month.

Integration into New Zealand is made so much easier by belonging to a ‘mainstream’ faith, providing entry into New Zealand society and enhancing integration and acceptance for participants into the dominant society in a way that people from minority faiths don’t have access to. Because Catholicism can be accessed within mainstream society, it can mean that not as much energy is required to maintain the faith. I remember at a Muslim women’s Hui I attended last year the major efforts Muslims went through to obtain halal food, such as going to farms and butchering their own animals.

Furthermore, faith, prayer and networks from the church also provide the support to aspire and do well in New Zealand. Flora felt strongly that her transition and survival in New Zealand was due to her faith and the help of the church.

You know the help came from God, you know through the Church (Flora).

There is a risk of complacency in extending ourselves beyond our own faith and ethnic communities once we grow in size as a community. As ethnic communities increase in size they move from being multi-ethnic religious communities and later establish themselves into ethnically-specific religious institutions. Rowena developed a new network of support through her church, which went beyond Goans and was a lifeline:

I started going to a mothers group there and I met a lot of other Malaysian and Indonesian and Filipino women and we would go and have coffee together and that kind of thing and my social life. I got quite involved with the Parish and doing work for the Church because I mean I really didn’t know many other people. I did meet a lot of elderly parishioners they were wonderful they would come and give me flowers, chocolates and really spoil me because they knew I was on my own and they were wonderful (Rowena).

For many early Goan migrants the lack of a community meant that her faith took on great importance and in particular prayer:

Like prayer did help me it honestly did, because you are alone, you are alone a lot of the time. Even though there are lots of people, you can still be alone you know (Sheila).

Therefore it can be seen that religious institutions provide spiritual resources that offer sustenance through the tasks of adjusting to living in a new country. The recognition of faith is well recognised in the United Kingdom where it is recognised that “faith groups are part of the ‘glue’ that binds strong communities and we value the experience, skills and diversity they bring to wider society.”

In considering the New Zealand Immigration Settlement Strategy for migrants, refugees and their families it can be seen that Churches often provide many of the settlement resources and are linked with the strategy’s six goals for migrants and refugees. They are for migrants and refugees to:

  • Obtain employment appropriate to their qualifications and skills;
  • Are confident using English in a New Zealand setting, or can access appropriate language support to bridge the gap;
  • Are able to access appropriate information and responsive services that are available to the wider community (for example housing, education, and services for children);
  • Form supportive social networks and establish a sustainable community identity; Feel safe expressing their ethnic identity and are accepted by, and are part of, the wider host community.

This brief piece paper provides some new information about the place of religion among Goans in the diaspora by focussing on Goans who have settled in Auckland, New Zealand.

The Catholic Church has been a mechanism of integration, offering a two way exchange of support and energy through social support, spiritual and secular activities. The Church provides a mechanism for facilitating cultural continuity while simultaneously easing immigrants’ transitions into New Zealand. The Church has supported Goan migrants and in turn the presence of Goans has I am sure enriched the church itself (certainly in numbers, if not energy and dynamism. This paper demonstrates the enduring nature of religion as a social institution which plays a part in sustaining Goans through the settlement process, providing both spiritual resources (such as prayer, connections with other migrants and receiving community members) and practical help for managing both the psychological effects of migration and enduring the hardship of migration and settlement in a new country.

Care of the person with Borderline personality disorder in the community

First published online by Ruth DeSouza 1997

Abstract

The development of community-based models of care in New Zealand has led to dramatic changes in the treatment available for people with mental illnesses. However, we appear to be failing to provide comprehensive coordinated and continuous care for clients diagnosed with Borderline Personality Disorder (BPD). One major problem is the stigma and dread that many community mental health nurses equate with the care of people diagnosed with BPD, resulting in the care given being limited and fragmented. This article examines the trauma paradigm for viewing BPD and provides an overview of the knowledge and skills that are required to care for people diagnosed as having a borderline personality disorder within the community .

Introduction

Kaplan and Sadock (1991) define personality as both emotional and behavioural traits that characterise the person and state that personality is stable and predictable to some degree. Thus, a personality disorder is a deviation from the range of character traits that are considered “normal” for most people. When these traits are inflexible and maladaptive and the result is distress and impaired functioning they are considered to be a class of personality disorder. Of the ten different personality disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), one of the most controversial is Borderline Personality Disorder (BPD).

There is much debate around the definition and diagnosis of BPD (Shea, 1991). The term was first used in 1938 to refer to a group of disorders that lie between neuroses and psychoses (Greene and Ugarizza, 1995) but can also be used as a disparaging label for difficult clients (Reiser & Levenson, 1984). Some of the challenges in caring for clients with BPD relate to the symptoms and intense transference and counter-transference in the relationship between client and nurse/therapist (Gallop, 1985). This can result in nurses feeling frustrated, helpless, distant and even denying mental health services (Gabbard, 1991 cited in Greene & Ugarriza, 1995). A person with BPD is often seen as an impostor, who is in control of their behaviour but who chooses to be difficult and manipulative (Nehls & Diamond, 1993). Studies show that 77% of those diagnosed with BPD are women (Widiger & Weissman, 1991).

Aetiology

There are several explanations of the aetiology of BPD.

Biological factors

Greene and Ugarizza (1995) offer two biological explanations for BPD. The first focuses on neurotransmitter activity and systems, where an increase in dopamine action can account for transient psychotic states and decreased serotonin activity can account for irritability and impulsiveness. Lastly, an increase in the cholinergic pathways can lead to depression in clients with BPD. The second explanation puts forward organic brain dysfunction caused by trauma, epilepsy and attention deficit hyperactivity disorder (ADHD) as a cause of the increased impulsiveness, self-mutilation and affective disinhibition seen in BPD. However, Kaplan et al., (1991) argue a genetic link, proposing that people with BPD have more relatives with mood disorders than a control group and often have a mood disorder themselves as well.

Psychoanalytical factors

Another theory of the aetiology of BPD relates to the psychological birth of the human being or process of separation-individuation, which occurs, between birth and three years of age. In this process a sense of self is developed by the child, a permanent sense of significant others (object constancy) and the integration of both good and bad as part of the self concept (Mahler, Pine & Bergman, 1975). Mothering influences the outcome of the separation– individuation process but if this is inconsistent, insensitive or unattuned to a child’s needs then dysfunction occurs (Westen, 1990). If a child’s efforts to be autonomous are punished whilst dependent behaviour is rewarded, differentiation does not occur and responses such as intense anger, mood swings, dichotomous thinking and identity diffusion can result, all of which are seen in a person with BPD.

Childhood abuse/ Trauma

The trauma perspective is gaining increased recognition as studies show strong correlations between sexual or physical abuse in early childhood and the development of BPD (Paris, 1993). Herman (1992) argues that what is labelled BPD is a manifestation of post-traumatic stress disorder (PTSD), called “complex PTSD”, which follows prolonged, repeated trauma resulting in personality changes (most prominently identity and relationship disturbance).

Biosocial factors

Linehan (1993) hypothesises that people diagnosed with BPD have a biological tendency to react more intensely to lower levels of stress than others and to take longer to recover. Linehan adds that often they were raised in invalidating environments and became uncertain of the truth of their own feelings. As adults a failure to master three basic dialectics means they go from one polarity to another.

Cultural issues

There is little literature to indicate that BPD occurs in other than Western cultures, despite the extensive research that has been done on BPD.

Assessment and diagnosis

As seen in the aetiology section above, the accuracy of the diagnosis of BPD is controversial. Most approaches to treatment define BPD according to DSM-IV using a descriptive objective approach (Shea, 1991). Some writers argue that this dominance of DSM-IV in psychiatric settings (as expert authority of behaviours outside the norm) means that a diagnosis pathologises behaviour (Crowe, 1997; Gallop, 1997). In this section the DSM-IV perspective and the trauma perspective are reviewed.

DSM-IV and the medical model

In this paradigm “Borderline personality disorder is described as a pervasive pattern of interpersonal relationships, self-image and affects and marked impulsivity” (Crowe, 1996, p106). It falls under the DSM-IV Axis II diagnostic category, cluster B (dramatic, emotional, erratic) and can be associated with co-morbidity of Axis I and II disorders (American Psychiatric Association, 1994). Diagnosis is problematic because of the fluctuating nature of symptoms and concerns that are presented by the client (Arntz, 1994).

In order to be diagnosed with BPD a person must meet five of nine criteria described in the DSM-IV (1994). These are around abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, recurrent suicidal threats, gestures or behaviours, affective instability, chronic feelings of emptiness, inappropriate intense anger, transient stress-related paranoid ideation or severe dissociative symptoms. Skodol and Oldham (1992) recommended that 2-5 years is the minimum clinical time to indicate a stable personality pattern. Whilst Paris (1993) added that by middle age the majority of clients with BPD had recovered from acute symptoms and no longer met the criteria for BPD (Greene & Ugarriza, 1995).

Complex post traumatic stress disorder (PTSD)

The medical model paradigm of personality disorder is criticised by several researchers (Brown, 1992; Herman, 1992), who see the label as misleading and having negative effects on treatment. Herman warns that trying to fit people into the DSM-IV mould without addressing the underlying trauma or understanding what the problem is, results in fragmented care. Brown (1992 agrees and suggests the distress of abuse resembles responses to experiences of interpersonal trauma rather than core personality pathology. Brown and Walker (1986) argue that a diagnosis that lies between personality disorders and PTSD that is framed situationally is more helpful as it can be changed rather than as personality which can not. This diagnosis acknowledges the effect of multiple exposures to trauma which must be adapted to daily for victims of trauma and interpersonal violence and varies from PTSD, which assumes a single exposure to trauma outside the range of everyday experience.

Gender bias and stigmatisation

Brown (1992) argues that androcentric gender role norms and stereotypes influence judgements of psychopathology, which result in more women than men being diagnosed with BPD and the stigmatisation by mental health professionals of gender role traits that are normative for women. Often the traits and behaviour considered dependent, passive, dysfunctional and pathological are appropriate and skilful ways of accessing some power in a context where more overt and appropriate expressions of power are stigmatised or penalised (Brown). The effects of sexism multiplied by the requirements for survival under abuse require an alternative frame of reference to viewing a person’s symptoms. Further stigmatisation of certain behaviours occurs through having space for Axis II personality traits irrespective of whether they are at a psychopathological level. Brown adds that context and variables such as race, gender, class and experience of abuse or victimisation are not considered either. Brown (1992) and Gallop (1997) propose a feminist perspective for BPD that takes into account the meaning of interpersonal context and relatedness rather than separation and individuation.

Power dynamics

Brown and Gallop (1997) argue that the mental health setting often mirrors the interpersonal power dynamics where abuse occurred. The presence of a powerful other can exacerbate symptoms and vary from how someone presents in a more power-equal situation. Many non-exploitative situations would need to be experienced before patterns of survival were relinquished.

Age trauma occurred

Van der Kolk, Hostetler, Herron & Fisler (1994) suggest that up to a century ago, research showed traumatised people would have their personality development checked at whatever point the trauma occurred after which it could no longer be added to. The authors suggest trauma has different effects at different stages of development. If the trauma is experienced as an adult then it is more likely to become what is known in the DSM-IV as PTSD. However, if trauma is experienced at an earlier age, then different manifestations of developmental arrest will be seen, therefore a person traumatised at a particular age might process intense emotions later in life the way someone at that age would, using earlier developmental accomplishments. The earlier someone is traumatised, the more pervasive their psychological disability.

Ethical and legal issues

There are major ethical and legal issues to consider in caring for people with BPD in the community. An awareness of the Mental Health Act is vital and issues such as splitting and ambivalence can make the area of ethical and legal issues a minefield.

Suicide

People with BPD represent the highest risk of suicide of any of the personality disorders and factors such as “overplaying their hand” or being rescued unexpectedly make suicide risk difficult to ascertain (Stone, 1993). He suggests that the therapist/nurse can become skilled at predicting suicide risk through clinical experience, supervision and by becoming familiar with the literature on suicide risk. The exploration of specific individual techniques for controlling impulses, such as the desire to self-harm, to identify triggers and patterns and increase self-awareness can also be useful. Including such questions as “do you want to slash?”, “Do you want us to help you control slashing?” (Gallop, 1992). Respecting the autonomy of a client with BPD can be difficult if they are presenting with suicidal ideation and there is a requirement to assess the need for compulsory treatment.

Medico-legal issues

Gutheil (1985) makes several points in his article about medico-legal issues that can arise in the treatment of people with BPD. In respect of the Mental Health Act (1992) there can be a legal ignorance of BPD as some people present with excellent functioning whilst others appear too sick to be discharged from compulsory treatment. The effects of borderline psychodynamics such as borderline rage, narcissistic entitlement, psychotic transferences, threats of suicide and impulsivity can also be challenging in relation to the Mental Health Act (1992).

Treatment issues

There are several issues that impact on the treatment of a client with BPD and which are important for nurses to be aware of. These are discussed prior to the exploration of psychotherapeutic and psychopharmacological treatments.

Transference and counter-transference

The therapeutic alliance is the foundation of therapy, which is often difficult to establish and maintain, particularly in the face of disruptive pressures that arise in therapy with a client with BPD (Meissner, 1993). This alliance and transference and countertransference are called “the therapeutic tripod” by Meissner. In the transference, the client relives their relationship with their parents through the nurse and can be very perceptive about who is working with them. This survival skill was learnt through anticipating the needs of their caregivers to prevent victimisation (Van der Kolk et al., 1994). Often an equally strong counter-transference is evoked in the nurse because of the strong emotion and conflict in the transference, which can include helplessness, fury and despair. Nurses can feel a need to rescue or compensate (Van der Kolk et al.,1994). In order to remain therapeutic, it is essential for nurses to know themselves, have safe spaces to review these issues in supervision and ensure they get support from their clinical teams.

Safety

Van der Kolk et al. (1994) suggest that negotiating safety and forming safe attachments are a way in which a client with BPD is able to regulate their internal state. This is especially the case if people with BPD are fixated on the emotional and cognitive level at which they were traumatised and continue to deal with difficulties using the resources at that point in their development . The authors recommend that basic trust and safety are negotiated prior to approaching trauma related material.

Hospitalisation

Gallop (1985) suggests that hospitalisation is an important aspect in the management of acute episodes for people with BPD. Budget and fiscal constraints mean that people with BPD are more commonly admitted for the relief of acute symptoms, usually a shift from chronic suicidality to acute suicidality, rather than for personality restructuring. Gallop reviews the two main clinical approaches for the hospitalised person with BPD. The adaptational approach focuses on preventing regression and encouraging people to take responsibility and has a short-stay emphasis, where staff offer supportive therapy, structure and limit set. In contrast, the long-stay approach allows for regression to take place in the presence of warm and empathic staff who facilitate the process of personality restructuring. The critics of this approach argue that it leads to the exacerbation of borderline symptoms. Gallop proposes an alternative model based on the work of Linehan (1993), but which adapts dialectic behavioural therapy for use in an in-patient setting in order to maximise the current short-stay emphasis and to use the skills of clinicians. Dialectic behavioural therapy will be discussed later in this article.

Dissociation

Research has found dissociation to have a high correlation both with the degree of borderline psychopathology and with the severity of childhood trauma (Van der Kolk et al., 1994). Dissociation is a way of coping with inescapably traumatic situations by allowing the person to detach from the reality of the situation. Often there is a loss of the memory and the relief of pain for the situation, the person can feel numb or spaced out. For some people this becomes a conditioned response to stress even if the situation is not inescapably stressful (Van der Kolk et al., 1994).

Splitting

A defence mechanism seen in clients with BPD is “splitting” (Harney, 1992) which can increase clinical risk if alternate strategies are recommended in the management of suicide risk. This risk can be reduced by ensuring clear communication and management plans across all services. Case management, where one person is responsible for the overall co-ordination of services and meetings with other care providers can also minimise splitting (Nehls & Diamond, 1993).

Psychotherapeutic interventions A systems approach

Nehls and Diamond (1993) state that people with BPD have diverse treatment needs, so treatment should to be based on comprehensive assessment and subsequent individualised treatment planning. This can be difficult for several reasons including: the number and intensity of crises that a person with BPD can have; the theoretical orientation of the clinician and interventions that are made hastily and based on negative reactions to a client or the diagnosis of BPD rather than careful assessment.

Nehls & Diamond propose a systems approach that includes: Individual counselling and psychotherapy; group therapy; medication evaluation and monitoring; drug/alcohol services; psychosocial rehabilitation and crisis intervention services. Planning should also include hospitalisation. Shea (1991) adds that several factors are intrinsic to any of the therapeutic approaches. These include careful attention to the client, skill to address countertransference, flexibility of therapy but also the need for limit setting with the therapist taking an active role.

Psychoanalytical

Shea (1991) suggests two types of psychoanalytic therapy can be helpful. Supportive psychoanalysis focuses on the improvement of adaptive functioning by strengthening defences and avoiding regression and transference by focusing on the present and keeping therapy highly structured. In expressive psychoanalysis, transference and regression are desirable and provide a means for the therapist to gain insight. Behaviour is changed as dissociated aspects are identified and clarified as they appear.

Dialectical behavioural therapy

Linehan ‘s (1993) Dialectical Behavioural Therapy (DBT) emphasises that the person with BPD has inadequate affect regulation related to biological factors and a childhood environment that is characterised by an absence of emotional regulation. DBT focuses on identifying skill deficits in a person’s life and then correcting them. The therapist teaches the client both self and relationship management skills as well as skills of mindfulness, interpersonal effectiveness, distress tolerance and emotional regulation. Therapy takes place individually and in groups and the relationship between therapist and client is paramount in treatment. In a one year trial of DBT, Linehan found that control group subjects remained in treatment longer, parasuicidal behaviour decreased as did the number of days of in-patient hospitalisation (Linehan, 1993).

Cognitive therapy

Cognitive therapy has been modified to treat clients with BPD (Beck, 1990) despite being thought of as most useful in the treatment of Axis I disorders (Shea, 1991). Arntz (1994), an advocate of cognitive therapy, argues that chronic traumatic abuse in childhood leads to fundamental beliefs that include: Others are dangerous and malignant, I am powerless and vulnerable and I am bad and unacceptable. The aim of cognitive therapy is to identify and change these beliefs, so affect and behaviour are normalised. Control over emotions and impulses are increased and identity is strengthened (Shea, 1991; Van der Kolk et al., 1994). Transference reactions provide rich material for uncovering dysfunctional thoughts and assumptions (Shea, 1991). Controlled studies have not been done as to the efficacy of this treatment approach with people with a borderline personality disorder (Shea, 1991).

Group therapy

The advantages of group therapy for the person with BPD include diluting transference and decreasing polarisation because of multiple feedback (Greene and Ugarizza, 1995). Group therapy can decrease demanding behaviour, egocentrism, social isolation and withdrawal and social deviance (Horowitz,1987 cited in Greene and Ugarizza, 1995). Van der Kolk et al., (1994) state group therapy provides both words and actions for expressing emotional states that clients with BPD have difficulty with and can borrow from other group members.

Family therapy

Research has shown a strong link between BPD and pathological families (Clarkin et al., 1991 cited in Greene and Ugarizza, 1995). Family members learn therapeutic interactions so the identified client can begin to form an identity and both the client and family modify their behaviour (Clarkin et al., 1991 cited in Greene and Ugarizza, 1995).

Alternative therapies

Van der Kolk et al., (1994) advocate using psychodrama and drawing to develop language for effective communication as a precursor to effective psychotherapy. The authors’ state that research has shown traumatised children have poor language skills for expressing their internal states. This can result in unmodulated actions, which are acted out in transferences and current relationships.

Psychopharmacology

Van der Kolk et al., (1994) propose that trauma affects a persons ability to self- regulate their emotions and self-soothe. Learning to tolerate affect is a way in which a traumatised person can take part in life. Mood stabilisers such as Lithium and Carbamazepine can help decrease affective lability and impulsive behaviour (Cocarro et al., 1991), whilst antipsychotic medication can help control transient psychotic states and antidepressants help with major depression (Shea & Kocsis, 1991 cited in Greene & Ugarriza, 1995). Linehan & Kehrer (1993) recommend being aware of contraindicated effects of medications, problems with compliance, drug abuse and suicide attempts. However, as long as careful monitoring is in place Linehan & Kehrer argue that pharmacotherapy can be a useful adjunct to psychotherapy.

Conclusion

This article has reviewed ways of viewing BPD. The medical model remains dominant in most psychiatric settings in New Zealand but other paradigms are gaining prominence as the limits of the medical model become more evident, particularly around the management of the client with BPD. The way in which BPD is defined remains contentious and many writers in the field suggest that it is more a response to trauma than core personality pathology. This has implications for how people with BPD are cared for in New Zealand’s mental health system.

As nurses move into the role of case managers in the community, a systems approach incorporating thorough assessment and planning is a good beginning which includes assessing for previous trauma. There is also a need for multiple treatment modalities to include a variety of components such as assistance with daily living needs, pharmacotherapy, dialectical behaviour therapy, cognitive therapy and so forth. Nurses need to disengage themselves from the shadow of the medical model and begin to explore new ways of supporting clients with BPD in the community. In order for community mental health nurses to maintain therapeutic relationships with clients with BPD, they must be proactive and attain supervision, education and self- knowledge.

 

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