Being in Relationship - Reimagining our addiction sector

An inquiry into the mental health and addiction sector has recently been announced, and conversations about how these services might look in the future are now urgent. Fundamental to this will be how we might meet our obligations under Te Tiriti o Waitangi and, in doing so, meet the needs of Māori communities. 

Kura Rutherford talked with people who offer and receive help with addictions and asked them about their experiences. Woven together, these stories highlight diverse aspects of tikanga and te ao Māori and envision a future approach that will place identity, connectedness and partnership firmly at the core of the healthcare system in Aotearoa New Zealand.

Crying out loud – Francine (Ngāpuhi)

First it was Valium, then Rohypnol, nitrazepam and pinkies. It was Wellington and the world of drag queens, Cuba Street nightclubs and getting high.

Francine was taken to another world when she discovered drugs.

“These things gave me a voice, landed me back in my skin, so I felt grown up and connected to others,” she says.

And they also helped disguise feelings of disassociation that began during a hospital visit as a two-year-old.

“I remember sobbing for hours [in hospital] wanting to be held or heard but no one came … Somewhere in my child-size mind and brain, I felt completely abandoned and unlovable.”

But life got hard. Really hard. After several suicide attempts, hospital stays and severed relationships, Francine was desperate for help.

A core part this came from the kaupapa Māori elements of the addiction services she found at Lifewise in Rotorua, at Higher Ground and at Narcotics Anonymous.

“Te reo, pepeha, waiata, spiritual dimensions – [they were] collective, holistic and whānau-oriented. That was the element that healed my spirit. Karakia keeps me connected to spirit and allows me to let things go and trust in the process of things. Today I have the peace of mind I’ve searched for my whole life.”

“I started my journey towards whakapapa, and I sang again after a voiceless 10 years.”

Having public figures like Rob Mokaraka being brave and speaking out about mental illness also helped. Rob advocates being vulnerable, talking, letting people in – reminding her “crying is better than dying”.

“I learned I am worthy of love through the kindness of those who have stood by me. When I wanted to quit or give up, someone would share their story, and I felt understood, that I was not alone and I would make it through that day without picking up.”

Moko power – Pipi Rutherford

Pipi Rutherford was a young Kiwi hippy in Paris when he first smoked cannabis-laced cigarettes. It was the least of the drugs he had been experimenting with, but the habit stuck and he kept up the combination for the next 45 years.

Back in New Zealand, Pipi, his then partner and some friends set up a hippy commune in the hills behind Opononi, Hokianga. It was isolated, tucked away from mainstream New Zealand – just what he was looking for.

Though the commune is long gone, he still lives in the board and batten house he built for his family 34 years ago. People like to visit Pipi for a cup of tea on his front step. He’s articulate and deeply switched on to politics and the state of the world.

But he doesn’t travel further than Opononi to get the paper or to the little village of Waimamaku to visit the local doctor’s clinic for check-ups – he has chronic obstructive pulmonary disease (COPD).

Two years ago, when he was out working in the garden, his lung collapsed. His trip to Whangärei hospital (a two-and-a-half hour drive) by ambulance was hell.

Pipi’s admission to hospital was a crisis point. In the shared ward of the busy Northland hospital, he quit smoking.

“You want to stop. There’s like 30 percent of you wants to stop all the time, but the 70 percent is stronger.”

But this time it was 100 percent that wanted to stop, and he did.

Pipi didn’t feel up to reaching out to health services. He couldn’t shake the feeling of being judged, and he was scared. But his family gathered around, staying in a motel nearby while he was in hospital.

“I had a new moko, Maioha. He was six months old then, and when I was in the hospital, he spent most of the time on the bed beside me. That helped a lot.”

The family drove him home and kept close during those early days of withdrawal. And every time the urge to roll a cigarette got strong, he hopped in his car and drove over the hill to take Maioha for a walk around the garden.

For Pipi, hospital visits were critical moments. Ten years earlier, he had been admitted to hospital – that was when he found out he had COPD. He tried to stop smoking then, but it was too hard.

“It’s OK in hospital. It’s at home where you’ve got the problem. You go back, and you’re faced with it again. I had a grubby house, a big empty house. I had no family living nearby. I was kinda up against it.”

He is certain that if someone – a community worker or district nurse – had knocked on his door after his first visit to hospital, it would have helped. Someone who said, “No pressure, but make us a cup of tea and let’s talk.” Someone who could have helped him work out his triggers and take those first steps to community services.

If this had happened early it’s likely he would have arrived at a positive place 10 years sooner.

Taking your toolkit to the job – Pam Kupa-Sheeran

Ko Tākitimu te waka
Ko Ngāti Kahungunu te iwi
Ko Kauahehei te maunga
Ko Tukituki te awa
Ko Whatuiapiti te marae
Ko Whatuiapiti te hapū

For Pam Kupa-Sheeran, it’s not just what you do in your job that’s important, it’s also about the kete you bring with you – your toolkit of life experience.

Pam is a drug and addiction clinician at Hawke’s Bay District Health Board, working with clients with moderate to severe mental health and addictions in both Waipukurau and Hastings.

For her, life experience is a vital part of being an effective counsellor. Pam’s experience includes study, connections and a diverse career path.

“You’ve got to be good at researching what’s gone on, you’ve got be good at engagement, you’ve got to be good at lots of things … connection, you’ve got to be good at connection,” she says

“If you miss the boat on what it is [your client] connects to, you probably won’t get good engagement. It’s maybe talking about whakapapa – and sometimes not. You’ve got to be quite sensitive around that.”

You can hear Pam’s passion in her voice. It would be hard not to be buoyed by her optimism.

“You want to make people feel like it’s possible, and you want to create hope. That’s what we are trying to do – create hope that things can be different, things can be better and things can change.”

Part of working holistically, Pam believes, is calling in resources and networks.

“I really think that, as a collective, you get better results, and I mean networking, and I mean family and whoever it is you need in that package of care.

“You’re kind of looking for people [your client] might connect with. It might be an opportunity to bring in whānau. It can be a powerful tool having the family there. It is often also about finding links within the wider community.

“If you don’t have networks, you are not doing your clients a service. It’s balancing out all your links and networks and wrapping around a model of care that is quite holistic.”

These networks might include group services, home care, financial care, housing, work and training.

When bringing families of clients into the therapeutic process, Pam’s focus is not just on support but also on education.

“Where I find we have the most success is when the family is educated as well … We’re not around for ever and a day, but whānau are. They need to know the support networks and what to look out for if their loved one needs more help. So, if you educate someone they can carry that on.”

Pam believes more addiction education is sorely needed.

“I don’t think addiction is really understood by a lot of people … We need to talk to people generally about addiction. It needs to happen more, because it’s so much part of our lives now.”

And if that education was able to be extended out into education packages in schools, Pam believes we would be seeing massive changes.

“If I had a magic wand, I would ask every school to educate our children about addiction and emotional regulation. Honestly, I don’t mean to sound simplistic, but I do kind of think it’s as basic as that.”

Being in relationship – Steve Hughes

Relationships are a critical part of every dimension of Steve Hughes’s work – the relationship between him and his clients, the relationship between his clients with each other and their families, the crucial professional collaboration needed to provide effective client care and also the relationship society has with addiction.

Steve has been an addiction counsellor for the last 10 years at Hawke’s Bay District Health Board. He works out of the modern, bustling premises of Napier Health, doing specialised opioid substitution treatment (OST) work under the broader umbrella of the mental health team. He’s the kind of person you would want on your side in a crisis. He’s approachable, solid, not fazed by much.

The first meeting Steve has with his clients is defining.

“Quite often when someone does present, that’s the window – the moment – when there’s been a coalescing of factors that has led them to come through the door. My ultimate aim is that they come back again. They kinda have a window of time for us to meet them, to get them engaged.”

Catching people in time, Steve believes, should be a key consideration in future planning in the mental health and addiction sector.

“The more someone has to wait, the more that can go wrong. People become entrenched in behaviour that makes it hard to come through the door again. It’s about hope, and waiting for too long diminishes hope.”

And easy access to good resources is also essential.

“When we are supporting someone’s identity ... whatever it takes, we will consider it. [At Hawke’s Bay District Health Board], we have access to really good kaupapa Māori resources, team members who know what we do [in opioid substitution]. We can call on them, and they will support directly with clients, with the whānau of the client, with Māori medicine, working alongside us.”

Steve believes taking time to foster family relationships is something that adds significantly to the success of the OST programme. But it’s not always an easy road.

“Family can be a very fraught thing. One of the big effects of addiction – be it alcohol, whatever – is the lowering of your self-esteem and feeling that you are worthless in the eyes of the people you care about … and actually ending up doing the wrong things by them. Addiction is very powerful, it sort of defies self-preservation.”

But family can sometimes be the thing that makes all the difference.

“Sometimes it’s the critical factor that gets them onto a programme – that support from family or wanting to do well by their kids. We are social creatures, aren’t we?”

Outside of the ‘traditional’ family unit, Steve sees another really strong tight-knit community who support the treatment process – the community that has formed around their addiction. Many of his clients have long allegiances. These relationships can be complex and at times unproductive, but there are often also whānau principles at work.

“They do help each other out – getting on the programme, getting to the pharmacy, getting jobs. There’s some empathy there. They are part of something ... and they know what it is to be hanging out.”

Community support coming from other quarters, especially in response to the rising levels of methamphetamine use, is something Steve would like to see more of.

“A lot of what has actually happened is self-help as a response to an epidemic – parents, grandmothers, people who see what’s going on – trying to address it. We need to give support to those who are stepping up, who are under-resourced. It needs proactive things, and working with young people, [providing] information.”

Steve sees a lot of complexities in his work – things like poly-drug use, high rates of hepatitis C and unmet dental needs (a biggie that he would love to see addressed with funding). But the biggest obstacle he sees is all about relationships – society’s relationship to drug use.

“The whole public perception thing gets in the way. Quite a lot of people want to get back into employment or studies. Some of them have criminal records, which makes it hard. Being on methadone, there is a stigma attached.”

When the lights go on – Tipene Pickett

Nga ngaru a te Huki te maunga
Waihua te awa
Kahungunu te iwi
Kurahikakawa te hapū
Waihua te marae

Tipene Pickett brings two world views to the work he does – the clinical skills he is trained in and a knowledge of tikanga that informs his work. Like many in the sector, he juggles multiple roles. He is a trainer, group facilitator and a clinician at Waitemata Health’s Whitiki Maurea, Te Atea Marino alcohol and drug services and MOKO mental health services.

From his kete, Tipene draws on motivational interviewing – the practice of “helping people talk themselves into change” – alongside wisdoms gleaned from Māori wellness models, such as Pöwhiri Poutama, Te Whare Tapa Whä, the Rangi Matrix and the Pütangitangi model.

When meeting clients, Tipene has “an overarching process that guides the whole thing”, and it is proving to be a successful approach.

He starts with a cup of tea, a karakia and a mihimihi to acknowledge their mana and tapu, their inherent right to be here, the influence they have in their world. Then he acknowledges any goals they’ve had, what’s brought them in the door.

“I always acknowledge their journey. There’s an affirmation that goes on, it’s a process of affirmation.”

And next is whanaungatanga.

“I would introduce me and give them a sense of me, so they have an idea of the container they are going to place their trust into.”

And woven into all that would be an exploration of whakapapa and tikanga, and if the client wants, the whole process can all be conducted in te reo Māori.

“You just see the lights go on, see them having their awakening moments and the motivation for change just … moves from maybe a sense of feeling pressured from the outside, from feeling like their partner or other services are pressuring them to change, to moving to an internal state of motivation where they feel thirsty for more … change just tends to follow on from that. They feel much more connected to themselves culturally with that knowledge … boom, you’re away.”

Tipene is seeing amazing results for Māori and non-Māori alike, so it’s no big surprise that, when asked what a future service might look like, his answers were not about process. Rather, they point to ways we need to think about recentring our services.

“Rather than being asked at the point of entry by someone who is not Māori would they like a cultural service, [I would like to see Mäori clients] automatically go to the cultural service … that would change the outcomes.”

Tipene would also like to see services being located alongside other services, such as education.

“There is real value in considering co-location of resources – Māori services literally on site within education services so that pathway becomes a whole lot easier.”

But there are two crucial things that affect all the communities Tipene serves – poverty and the traumatisation of colonisation that goes unrecognised.

”When people have had childhood trauma, what’s often forgotten is that it’s an experience they’re born into, so they are doubly traumatised and poverty is the result. That’s the biggest, biggest block I come up against.

“Lack of cultural connection, lack of finances at times, disconnection from cultural identity and how that manifests – it manifests in all the behaviours that Māori are well over-represented in.”

All in this together – Simon Waigth

Ko Matawhaura te maunga
Ko Rotoehu te roto
Ko Waitaha me Ohau ngā awa
Ko Ngāti Makino me Ngāti Pikiao ngā iwi
Ko Te Arawa te waka

The day Simon Waigth handed in his doctorate thesis was a celebration for him and his whānau. But even if people working in addiction weren’t entirely aware of it, it was also a significant day for the sector.

Simon’s research, Mä te whānau, ka Ora ai te Tangata: Māori Experiences in Recovery from Addiction, completed through the University of Auckland, is the first PhD research to focus on the recovery process in Māori addiction services.

The research followed a group of clients who had been part of the whānau group at the Higher Ground treatment centre in Auckland and were reintegrating into the community.

One of the most wide-ranging and evident findings from Simon’s research was the importance of helping Māori work through any identity issues they had in treatment and post-treatment.

“It was extremely validating for a lot of people to be able to address their Māori identity. The number of ways they were able to do that was huge, there were just so many unique experiences of that. [Within the research], there was a common experience of being distanced in some way from their Māori identity,” Simon says.

Within the Higher Ground treatment process itself, he saw participants reconnecting to their whakapapa, learning more about te ao Māori, tikanga, kaupapa, developing routines, benefiting from tuakana/teina relationships, all in the safety of a whānau group environment.

What happened out in the community afterwards was significant.

“The way the facilitators of the whānau group intentionally help the whaiora [clients] carry over into the community, the things they had learned from treatment – it’s pretty unique to them and what they do, but they put a lot of effort into maintaining the whānau group more broadly in their own time. They’ve set up their house as a sort of half-way home between treatment and full independence.

“The facilitators organised activities like hängï fundraisers, parents’ nights, parenting advice sessions and music nights. It was really an organic process, quite natural for Māori, but it was so pronounced … that level of ongoing connection would be hard to come by.

“I am hearing a lot more people talking about community reintegration, and this is what that is, but in a Māori context – Māori principles and tikanga. These people didn’t have the funding, they didn’t have any extra resourcing to do this. It’s just something they did because they believed in it … and it really helped in the recovery process.”

Simon believes what is needed in planning for future addiction programmes is funding for the recovery aspect of treatment.

“It seems to be such a gap. It’s understandable there’s a gap, it’s expensive … [but] funding is a consequence of priority.”

He also believes an ideal model would include significant resourcing to support community participation in after-care initiatives.

“It needs to be more than just previous addicts participating in the reintegration. It needs to be people from all walks of life.”

The hidden benefit to this would be an opportunity to disrupt the stigma and prejudice surrounding addiction.

Simon references the work of Peter Adams – a University of Auckland professor who also works for the Kina Foundation – who saw successful groups being run in Italy.

“There were community groups, a lot like AA support groups but more, because they included people from the community who hadn’t been through addiction issues helping people with addiction issues.”

And part of that picture is to have more research, like Simon’s, that focuses on the addiction field.

“We don’t have any research in New Zealand showing the outcomes of treatment. There’s a complete absence of it. We need a huge focus on evidence-based practice for an Aotearoa New Zealand population that absolutely includes Māori models of working with Māori and non-Māori.”

Finding the way forward – Boyd Broughton

Ko Ngātokimatawhaorua te waka
Ko Ramaroa te maunga
Ko Whirinaki te awa, te whenua tapu hoki
Ko Te Hikutū te hapū
Ko Mātai Ara Nui te marae

As programme manager for Action on Smoking and Health, Boyd Broughton is no stranger to thinking about societal perceptions of addiction, the shifts that stem from policies and health initiatives and how these impact a population.

In his work, he has come to see the need for a fundamental shift in the way we perceive addiction.

“We need to move away from the idea that people are broken and focus on the individual, with all their trauma and all the gifts they have. A te ao Māori point of view of mental health for working with people who are hearing voices is saying, ‘This is what’s happening with you, we recognise that, it’s actually a gift and this is how you can manage it.’”

“Tohunga were renowned for eating different leaves to put them in a state so they could come to a place to be able to manage their voices. Hearing voices for some people was considered normal – there wasn’t negative stigma.

“When you apply that to addiction services, people who take drugs because they’re feeling stress and feeling sad, [it’s about saying] ‘Sadness is normal, feeling unhappy is normal, and this is how we can manage it,’ so you can operate in all the other spheres of life. That is the key conversation that needs to happen.”

In relation to smoking tobacco, “While there have been some gains, there’s a stigma about smoking tobacco that we really didn’t want to happen. We have sidelined a whole lot of people. We wanted to make smoking not cool, but we’ve also made the person smoking it feel not cool.”

However, Boyd points to some positive shifts that have occurred in the way communities interact with alcohol and drugs, and he puts these changes down to a concerted effort a decade ago “where the focus was on sharing information about the use of drugs, the harms and pros and cons. That’s been as a result of some really good information and a change in the workforce not to condemn the person.”

That initiative, Boyd believes, has led to changes in behaviour and attitude – people smoking outside away from children, not smoking in the car, not drinking on the sidelines of sports games.

“All that sort of behaviour, while it hasn’t been legislated, there’s been massive change. It’s happening among whānau, among community groups, sports groups, sports teams … I’ve had beer bottles thrown when I was playing – that doesn’t happen any more.

“whānau are openly talking about – without condemning – the use of marijuana. The conversation isn’t about ‘You’re naughty for smoking dope.’ The conversation is that their brain is still developing … and adding marijuana to the mix can stunt that growth.”

Both policy and health initiatives clearly have a massive part to play in all realms of society. So, what is the path forward in policy development for the addiction sector?

“First of all, there needs to be a plan for all those different areas – for mental health, tobacco control, addiction, suicide – all those services our people need help with. It needs to have realistic timeframes, and the main thing is that the government needs to be accountable in terms of timing, realistic targets and evidence-based strategies.”

And within that planning, there needs to be room to hear the people who, up until now, haven’t had a voice.

“[Some lesser-recognised] services do have the researchers. They say, ‘This is the evidence, and this is what needs to happen based on the evidence to get good inroads,’ but they don’t get as listened to because they either don’t have the right voice, don’t have the right language or just don’t look right.”

To Boyd’s mind, these discussions will need to place the individual and their complex group of needs, not the addiction, at the forefront. The discussions will need to consider where and how services are provided to best meet the needs of communities – things like working outside 9am–5pm hours and visiting people in their own homes are just some of the ideas he has – and they will need to place more trust in the people doing the work on the ground.

But essentially, the planning needs to be about taking action.

“There are always going to be disagreements on paths forward. The focus needs to be on what is agreed … then we’ll have to have intelligent discussion, research and evidence on what we don’t agree on to come to a sensible conclusion.”

Dreaming big

All these conversations identify different facets of a wide-ranging topic, but when seen as a whole, they remind us that many of the answers are already evident, deep within our communities, within tikanga practices and models of health and within te ao Māori.

It is a critical time to listen to those doing the groundwork, to resource the initiatives that are already successful, to analyse the dynamics that underpin our services and to reimagine a healthcare system that firmly puts identity, relationships, community and Te Tiriti o Waitangi at the centre. This is time to reflect, plan and dream big.