Positive Horizons, Well Health PHO's primary mental health programme, has three initiatives that really set it apart when it comes to delivering culturally responsive services.

  1. The Pacific Project has succeeded in presenting its messages in ways that connect and engage with the Pacific community.
  2. Partnership with the Wellington Refugees as Survivors Trust (RAS) provides massage alongside counselling and therapy, which has aided recovery for those traumatised by their refugee experiences.
  3. Regular community huis offer an opportunity for various cultural groups and service providers to interact.

Taking time and creating space to engage in meaningful conversations has been a key factor in establishing connections in Positive Horizons' multicultural community, which includes a high proportion of Pacific peoples and refugees.

Well Health serves Wellington’s South East, City and Porirua areas. Positive Horizons also offers packages of care including counselling, psychology and social assistance.

The Pacific Project

Positive Horizons primary mental health coordinator Margaret Donald says the PHO, which includes four Wellington-based practices – Newtown Union Health Services, Evolve Youth Service, Pacific Health Service and Te Aro Health Centre – has a Pacific population of about 33 per cent. "We were not getting many referrals (of Pacific peoples) and we knew we weren’t getting to the Pacific population, partly because they were not comfortable with the concepts of counselling or mental health and other words we use," Margaret explains. "That is why we wanted to look at how we could address the issue of working alongside Pacific people and began the work in progress that is the Pacific Project." The Pacific Project aims to get primary mental health services out to Pacific communities and communicate with Pacific peoples in ways they are familiar with and feel comfortable to respond to.

Miriama Tolo, primary mental health coordinator (Pacific), says that conversations are a big part of her role. "Pacific people have to be approached in a different way," she explains. "There has to be a lot of talking around sensitive issues to do with mental health. I talk about what counsellors do and what clinicians do - that tends to demystify it. It means people have the knowledge to be able to make informed choices about coming to use a service like this." This process is called 'talanoa', where using an indirect and a 'round-about' approach is often more effective for Pacific peoples.

Emphasising the collective rather than addressing an individual is important when talking with a Pacific person, Miriama says. Rather than suggesting that a person is experiencing anger, talk about how that anger could be affecting the person’s family. "Every culture has a different approach and as long as people are aware of that and are respectful they should be able to get their message across."

Translated written resources can be useful for Pacific peoples. However, Miriama has found that those who contact Positive Horizons, especially if they are recent migrants to New Zealand or English is a second language, prefer a more personal approach.

Miriama is in the process of developing a 'talking resource' which contains information on CDs using Pacific voices, presenting a range of messages about mental health issues in three-minute slots. The topics include anxiety, depression, grief, loss, gambling and alcohol addiction. One of the translators is an 80+ year old mother, grandmother and great grandmother who speaks in Tokelauan. The CDs are a good opening for conversation. The segment about anxiety, for example, talks about panic attacks which can make one hold their breath causing lightheadedness. The CDs have important information about the services available, telephone numbers and directions to get there. They use common words that any community can relate to. The CD’s messages will be broadcast on Access Radio. If you would like more information contact Positive Horizons directly.

"The voices on the CDs are community voices, the people who are doing the translating are community people who understand." - Miriama Tolo, Primary mental health coordinator (Pacific)

Using a holistic approach is helpful when working with Pacific peoples. Pacific models of care such as Fonofale, Seitapu, Te Whare Tapa Wha and Te Wheke are good examples of working holistically. Te Pou’s Talking Therapies for Pasifika Peoples discusses this further. Another useful resource is Real Skills plus Seitapu, a Pacific cultural competency framework developed by Le Va.

In addition, Positive Horizons have been able to offer packages of care which include massage and gym membership. Pacific communities have always used their own unique ways of healing, for example, Fofo, Fotafota or Romiromi, Miriama says. "One lovely client that had used our service had for some time suffered from headaches. After four massage sessions she contacted me and said ‘…headaches have gone and I am now smiling’."

Another initiative within the Pacific Project that Miriama facilitated was the programme called 'Incredible Years', a 14-week parenting course which was adapted for the Pacific community and has been well received in Wellington. The curriculum is family-centred as well as focusing on parents. Limit setting, household rules and increasing positive behaviour with praise/rewards are some of the topics. Another important topic is the use of prayer as "most Pacific families value lotu and prayer". "It is an important way of bringing family together," Miriama explains.

Feedback to Positive Horizons from the Pacific community shows that verbal communication is the preferred medium. Pacific people like to have conversations (talanoa). "Pacific people can sense when there is genuine rapport and compassion, even when a firm message is communicated," says Miriama.

Partnership with the Wellington Refugees as Survivors Trust (RAS)

Ranka Margetic-Sosa.

Pictured: Ranka Margetic-Sosa.

Positive Horizons formed a partnership with RAS because general practitioners refer a high number of refugees to the primary mental health service. "We were finding that a lot of people were holding their stress in their body and it came out looking like a medical condition," Margaret says. RAS approached Positive Horizons for support to provide massage therapy alongside counselling after seeing good results from other PHOs offering a similar service.

RAS clinical manager Ranka Margetic-Sosa is a Bosnian-trained psychologist and New Zealand registered psychotherapist who has worked with war victims in former Yugoslavia. She came to New Zealand in 1994 and is a foundation member of the Wellington Refugees as Survivors Trust, having started in May 1997. She says refugees were referred to RAS from GPs with symptoms such as headaches, back pain, joint pain and chest pain as somatic representation of psychological pain and trauma. "We wanted to have something that is free and easy to access and that meets the needs of our clients, while also fitting with our philosophy of an integrated approach to treatment for torture and trauma survivors," she says. "GPs are always looking for something that is culturally appropriate."

The project went from March to November 2010 and included between 5-10 sessions, varying between 30-60 minutes, once per week. RAS is currently seeking funding to continue offering massages. Some of the population groups to receive massage therapy alongside counselling included Sudanese, Ethiopian, Somalian, Afghani, Iraqi, Iranian, Burmese and Colombian. Many had experienced civil war; psychological, emotional and physical abuse; deprivation of food, water, healthcare or shelter; and for some, severe torture.

Before experiencing a massage, refugees see a counsellor and the massage process is explained to them. During the appointment the body therapist seeks permission before touching the person who has full control over what happens to them. "Often former refugees would experience complicated grief and with the massage they would relax and would access a deeper pain and deeper trauma and need to talk that through," Ranka says.

"Sometimes they feel a bit stuck and don’t have the words to say or explain what is happening for them, but with a massage they show some ability to express themselves and gain more insights about what is happening." - Ranka Margetic-Sosa, Refugees as Survivors clinical manager

The refugees were also finding other emotional benefits from physical touch. "Many refugees don’t have friends or family members around them and they don’t have many opportunities to have physical touch like a good hug that you get in families or communities," Ranka says. "A caring touch that is safe makes a difference."

RAS’s talking therapies range from cognitive to humanistic, including cognitive behaviour therapy (CBT), psychodynamic approaches to therapy, eye movement desensitisation and reprogramming (EMDR), family therapy, interactive drawing therapy, motivational interviewing, gestalt, narrative therapy, emotional focus therapy and working with small figures. Using these therapies alongside massage as a co-therapy, refugees have reported improved sleep and more relaxation. They say their headaches or back pains have disappeared or are not as strong as they used to be, their quality of life has improved and depression has lifted. "People have said they feel human again while previously they lived like an animal. Although that is metaphorical, it is a strong way of saying that they have human senses again," Ranka says.

Community hui

Positive Horizons primary mental health coordinator Margaret Donald said the PHO started the community hui in 2006 as a way to engage and exchange ideas with the community, including health professionals, counsellors, community health organisations and service users. It was also a contracted requirement from the Ministry of Health primary mental health initiative pilot to undertake provider training and service development. The hui provides an opportunity to deliver on both of these requirements.

Since it started, 28 hui have been held. Topics include parenting, sexual ethics, anxiety, self-hypnosis, sexuality in women during mental illness, suicide prevention, depression initiative, spirituality in health promotion, and working alongside youth with addiction issues.

A recent Pacific series was well received. Guest speakers for the first hui Mercy Drummond and Marina Pouesi spoke about the 'Incredible Years' parenting programme. Karlo Mila-Schaaf, poet, academic, writer and columnist, spoke at the second hui. She reflected on her own personal journey and what she had learned through her own healing, recovery and staying well. The last of the Pacific series was presented by a dynamic group of seven Wellington–based Pacific counsellors. They offered an Experiential Journey – where deep insights from their extensive counselling work were shared. The original presentation was given at the ACA/NZAC (Australian Counselling Association and New Zealand Counselling Association) Conference in Auckland, October 2010.

The Somali Council presented at the last hui. The Wellington region is home to about 1500 Somalis who all have a refugee background. Established in 2003 by Somali community leaders, the chairperson Faduma Moallin was elected in October 2010. The council aims to support community integration and achievement. Some of its services include a homework centre for refugee students at high school or college level, social soccer nights, a Somali radio programme and a Somali social work service.
Between 25 and 80 people attend the huis, which are held at the Trinity Union Church, Hall Ave, Newtown, on the first Tuesday of the month from February to November from 12-1.30pm. Two weeks' notice is sent to various networks, health providers and practitioners.

The community hui is a great example of cross-agency collaboration. Not only has Positive Horizons strengthened its relationships in the community through the hui, but it has also brought together counsellors, nurses, doctors, non-government organisations (NGOs) and service users for a common purpose. "Lots of NGOs have brought their clients along," Margaret says.

"The first half hour of the hui is networking time and I think people really value that." - Margaret Donald, Positive Horizons primary mental health coordinator

The high caliber of speakers has also been a draw card. She says the fact that people keep coming back is evidence it is working.

The result

The Positive Horizons Pacific project, partnership with RAS and the community hui are excellent examples of culturally responsive services. By making it a priority to talk and connect with people and tailor their approach accordingly, Positive Horizons has found that their culturally diverse community is ready to meaningfully engage with the service.