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. 2022 Jul 24;31(6):1438–1445. doi: 10.1111/inm.13044

The effectiveness of ūloa as a model supporting Tongan people experiencing mental distress

Sione Vaka 1, Helen Paris Hamer 2,✉, Anau Mesui‐Henry 1
PMCID: PMC9796273  PMID: 35872607

Abstract

This article is based on a larger research project, which investigates the effectiveness of a culturally appropriate model, namely ūloa, when working with Tongan people. Ūloa is a communal method of fishing in Tonga, which includes all members of the community. A previous paper described the three phases of ūloa: presenting the concept to health providers and community groups; phase two amended the model based on phase one. This paper reports on phase three and findings related to the increased awareness of ūloa model within the mental health services and to raise awareness of how to work with Pacific people and adjust the health service to suit the needs of this population to test its effectiveness. Using reflexive thematic analysis, results highlighted a number of patterns both across the groups, described as napanapangamālie (harmony, balance), ngāue fakataha (working together/oneness), and toutai (fisher). These findings continue to support that the conventional biomedical approach employed in the mental health services overlooks elements of Tongan constructions of mental illness and the intersections between Tongan and biopsychosocial themes. Care that is based only on the ‘medicine’ rather than bringing the spiritual aspect into care planning (fake leaves) will not serve the needs of the Tongan community.

Keywords: biomedical approach, indigenous, spirituality, Tongan mental health, ūloa

BACKGROUND

Tangata (people) o le Moana (Pacific ocean) refers to people of Polynesian origin who first stepped foot in New Zealand over 800 years ago. This population group has a higher prevalence of mental illness at 25% compared with the 20% of the non‐Polynesian (general) population in New Zealand and have also been found to be the group with the highest level of suicidal ideation, attempts, and plans (Oakley‐Browne et al. 2006). Further, accessing mental health services has been identified as of concern, with only 25% of Pacific people accessing mental health services compared with 58% of the general population within a 12 month period (Oakley‐Browne et al. 2006). Additionally, Pacific children and adults were less likely to get help for mental health issues (Ministry of Health 2020). Rates of mental illness have been increasing (Ataera‐Minster & Trowland 2018; Oakley‐Browne et al. 2006; Vaka 2014), and management of mental illness has largely focused on designing appropriate Pacific cultural tools to inform health services about working effectively with Pacific people (Fotu & Tafa, 2009; Samu & SuaaliiSauni, 2009).

These numbers confirm the higher number of Pacific people with mental distress, with lower access to mental health and addiction services. Though current health services are using culturally appropriate tools when working with Pacific people, there is concern that staff fail to question Pacific people in their levels of understanding and interpretation of their illness due to their experience of mental health services being ‘hostile, coercive, culturally incompetent, individualistic, cold and clinical’ (p 41) (New Zealand Government 2018). In order to, in part, address this failure, the researchers set out to explore how mental health clinicians could adjust health care to suit the needs of Pacific people at the ethnic level, and to clarify and recommend systems changes. Hence, this phase three of the larger research project trialled the ūloa model in both the mental health services and the Tongan community in an Auckland metropolitan health board, to test the increased awareness and effectiveness of this culturally appropriate ūloa Tongan model.

Ūloa is a communal method of fishing in Tonga, which includes all members of the community. Ūloa is usually done in a community setting like villages or churches; Vaka (2014, 2016), further asserts that ūloa involves all ages and genders whereby everyone goes down to the sea to join in with one another. Using coconut leaves, the people move together in a symmetrical manner toward a collection basket; all the fish caught are distributed evenly to all villagers. Importantly, it is challenging to achieve symmetrical movements as they are largely affected by contexts, climate, environment, the sea tides, availability of coconut leaves, and numbers of people.

METHOD

The methodology used is talanoa, which is largely used with Pacific people (Vaioleti 2006; Vaka 2014; Vaka et al. 2016). Talanoa captures Pacific ways of knowing and doing and provides a platform for tala (conversation/talking) and ability to reach into people's noa (hearts, souls) (Vaka, Holroyd, et al. 2020, Vaka, Neville, et al. 2020).

Sampling

Purposive sampling was used to identify participants from mental health service providers who had implemented and trialled ūloa in their area of practice. All were recruited through an intermediary person who invited them to the talanoa and acted as the contact liaison person to alleviate cultural pressures.

All participants were Tongan, and one participant was employed as a cultural worker; however, it is important to note that all participants are cultural experts in their own culture. Participant interviews included staff at the local district health board, non‐government organizations, traditional healers, and also importantly, to hear perspectives from service users. The data were collected in both English and Tongan language and were digitally recorded. There were four individual talanoa and one talanoa with two participants as follows:

The first talanoa was with a female community support worker from a non‐government organization, second was with a traditional healer who practices Tongan traditional treatment, third was a person experiencing mental distress and uses mental health services, and the fourth individual talanoa was with a psychiatrist from the district health board. The group talanoa was with a social worker and cultural workers from the district health board.

Ethics

This study gained ethics approval from the national Health and Disability Ethics Committee (reference number 19/STH/83) in 2019. Pseudonyms were used to protect participants' identity. Approval was also confirmed by the ethics committee at the district health board.

Analysis

Reflexive thematic analysis (Braun & Clarke 2021), (TA), was used based on the methodological alignment and philosophical aspect of talanoa, and its use in counselling and psychotherapy research to create meaningful knowledge production. Further, by following these guidelines, the researchers were assured that they could replicate the analysis in previous phases of the larger study. TA had been used extensively in qualitative research and mental health as it allows researchers to analyse their data independent from methodology. TA also addresses cultures effectively (Trevino et al. 2021). Each talanoa group interview was conducted in Tongan and then transcribed, coded, and thematically analysed to identify patterns across the data and alignment with the talanoa approach and Braun and Clarke (2021). Upon reading the data, it was evident that each talanoa told a different story. However, the analysis identified a number of patterns both across the groups and within each talanoa. Three themes were identified, napanapangamālie (harmony, balance), ngāue fakataha (working together/oneness), and toutai (fisher). Each theme will be presented with data from the participants in the following section.

Rigour

The talanoa allowed the authentic voices of Tongan participants to be heard and provided a context where participants were able to talk openly and the opportunity to confirm participants' viewpoints, which gave validity to the findings. Authenticity was tested throughout the talanoa process (McGrath & Ka'ili 2010; Vaioleti 2006) with an academic and an expert on Tongan culture. These experts were involved in analysing the data and the translation of Tongan language interview data into English.

RESULTS

Theme 1

Napanapangamālie (harmony, balance)

Ūloa involves movement with the aim of arriving at the collection basket in a balanced and symmetrical manner. Napanapangamālie is when this movement in the ūloa is successfully achieved. Tongan people usually talk metaphorically; saying one thing but meaning another. Tongan concept like napanapangamālie was useful in terms of applying to everyday practice. This theme captures Tongan concepts that were useful in terms of collectively moving towards the same directions, in harmony and balance, to achieve napanapangamālie. The psychiatrist noted their deeper understanding of napanapangamālie:

So, over the last month you know…when I think back to when you explained the concept to me… I understand more deeply now the role that metaphor plays in the way that Tongans communicate.

The psychiatrist explained that they had been functioning within the dominant medical model; however, opportunity to use ūloa and Tongan concepts strengthened their understanding of the role of metaphor in practice.

Tongan concepts such as loto refers to inside/heart/soul. The cultural advisor discussed loto and further highlighted other Tongan concepts like ‘atamai, ‘uto, and ongo.

Loto is the unseen part … one of the problems we have is trying to dissect unseen things. Ongo are feelings, and we all know that they come from one place, the soul. 'Atamai (brain) comes from the same place … mind is different from the brain. Brain is 'uto, some secular people refer to the brain as 'atamai. No, the mind is the unseen part, and I like how we talk about the heart, the mafu is the heart and loto is the soul.

It is important to understand these Tongan concepts and incorporate them into the metaphor of moving towards the collection of the fish with the basket to achieve napanapangamālie.

The NGO representative discussed the relationships between loto and the mind and thinking, explaining that ‘When you have a sad loto… that will affect your thinking’. They further added how it is important to know where you are at, and that the services acknowledge that too, however, suggesting there is a lack of knowledge and awareness from Tongan people:

There are many people who do not know the services that they should go to. Especially, our Tongan people, they are not clear where to get help in this area

For one service user, they reported that they do not feel accepted in their own home or experience a sense of harmony and balance

I do not usually go to our living room. When I go there, we (family) talanoa (talk) but I don't think that's my space of acceptance.

This participant highlighted the importance of harmony at home and importantly how the mental health workers can play a larger role to support both the individual and their family's need to work closely together. Phases 1 and 2 of the research reported earlier that by bringing everyone together to the same level through a shared understanding of what services can provide will promote a feeling of acceptance and harmony, leading to our next theme, which is about working together.

Theme 2

Ngāue fakataha (working together/oneness)

This theme discussed the importance of working together in terms of incorporating both Tongan and broader worldviews. It is important to note the Tongan word for together is fakataha, which also means oneness focusing on the word, taha, one. These include language, different interpretations of mental distress, treatments, and the challenges of individualism and collectivism. The traditional healer highlighted the importance of working together in ūloa and the relationship to Tongan worldviews of collective family:

Remember, ūloa is about working together … for the collectives' benefit … if you think of suicide … as indigenous Tongan, you are not ‘you’, you are ‘us’… If you can understand that and want to commit suicide, what about your father, mother, sisters, and everyone? It gives you a sense of belonging, you are more than yourself.

The cultural worker supports this idea and explains the importance of incorporating Tongan treatments into care:

The effectiveness of ūloa depend on the loto … and we need to work together … I remember when I went and got a [traditional healer] and they used traditional medicine and there are improvements in the client's mental state

The psychiatrist discussed relationship from a Tongan perspective, and how they are important in terms of mental health:

When you talk to a young person and their families, the number one thing that it comes down to is that [mental illness] is a break down in the relationship … what we call vā (relationship) and tauhi vā (maintaining relationship). Without thinking about it, everything we do is about tauhi vā (maintaining relationship). You know, even the introduction before we started this conversation.

This emphasizes the importance of relationships between Tongan healers and the medical team.

Theme 3

Toutai (fisher)

Toutai is the main person who makes the decisions in ūloa. In the earlier phases of this larger study participants, including traditional healers, staff, NGOs, service users, strongly argued that they each should be the toutai. After implementing ūloa, all participants in this phase three compromised and regarded toutai as a shared role:

You want to use your expertise to strengthen the individual to the point where they manage all the important decisions in their lives well. That the issues that cause them to experience mental illness are gone. And using the metaphor, then they can be that person that makes those decisions, [toutai]. Not just for themselves, but for the collective (Psychiatrist)

When asked, ‘Who do you think should make the decision for you when you are unwell?’ The service user replied:

Me, because I am the person who knows myself and I should make the decision … if I get bad, then call the hospital

A social worker reported their view of toutai

The role of practitioners is to direct … but we must also be flexible so that we are able to achieve ūloa. Pacific practitioners are kind to Pacific people when [we] fulfil our duties. We just feel the ocean as we move, so we know their movements and directions

DISCUSSION

This study set out to further develop the ūloa model, a Tongan model of care based on a communal fishing technique, and how service providers in mental health practice can implement the ūloa model to deliver successful treatment outcomes for Tongan service users.

Phase 1 of this study was the consultation with the Tongan community and mental health providers, Phase 2 was amending the model according to the findings from Phase 1. The findings from Phases 1 and 2 emphasized the need for working together, effective communication and the importance of using a Tongan tool, like ūloa. This article has reported findings from Phase 3 to further inform and modify ūloa and then followed by a trial of this novel approach in the mental health services. Three main themes were derived from the data: napanapangamālie, ngaue faka‐taha and the central role of the service user as the toutai and key person in ūloa; these are discussed below.

Napanapangamālie

The participants reported that the understanding of the Tongan worldview is vital for culturally informed care. Though a bio‐psycho‐social approach to care is often cited as a focus in clinical practice, there is still a reliance and dominance of the biomedical explanations of mental distress and can unwittingly exclude notions of loto, or soul, ongo, or emotional context of people's experience and ‘atamai, the mind, and the service user's interpretation of the experience.

Inclusion of these concepts would expand the spiritual connections between service user and the clinician, reduce stigma, and support a shared understanding of the experiences of the person's distress that can also be shared and understood by their family. For example, similar to the Tongan view, it is not uncommon for many cultures to ascribe their source of distress to the notion of ‘transgression’ or ‘wrongdoing’ in the eyes of the deities. Not only is sensitivity required in working with cultural expressions of mental distress, often understood through the western view of mental illness, it also requires the services to be more informed and confident in embracing these spiritual concepts.

Carter and Palmer (2017), suggest that transgression itself is a metaphor for further re‐imagining of experiences, in this study, we argue further that such a disruption of the spatial, emotional, and ethical boundaries within traditional psychiatry will shape a more responsive, respectful interpretation of the world in terms of human values and experiences held by the service user. Further, Bracken and Thomas (2013), take a post‐psychiatry approach asserting that contemporary psychiatry is required to value community development and safe spaces whereby different understandings and responses to madness and distress within minority ethnic communities can be articulated by dissecting the unseen. Ūloa is about trust – that the collective action of fishing will feed the village – therefore to be truly culturally competent as a health professional, placing one's trust in models that propose such communication and community action, such as the ūloa model is central for Tufunga faka‐Tonga – Tongan constructions of mental health.

Ngaue faka‐taha

Ūloa offers the safety‐net of Ngaue faka‐taha that supports collaborative, and collective action, based on relationships that create the Va, literally the space within a relationship that connects sacredness and inclusion with harmony and balance, underpinned by mutual respect (Te Pou 2010). Forms of communication and the use of language were reported as being central to ūloa and further supported by the participants. Tongan culture is replete with metaphors – as images and symbols that require minimal explanation yet consist of collective understandings of distress that normalize the service user's experience. Paying attention to metaphors provides a way forward for the health professional and systems to actively collaborate as a collective, rather than the western, individualistic approach, to safely bring resolution to the distress of the whole person and their family.

Ūloa brings to the fore the ‘net’ to capture the essence of the service user and to also provide a collective approach in care planning, hence reducing the risk of stigma, minority stress (Velez et al. 2017), and cultural alienation (Taonui 2010). In Aotearoa, metaphors of integrating and collaborating are also evident in the future direction of integrated mental health services. For example, ‘long‐lining’ is a fishing metaphor cited by the Health and Disability Review report (New Zealand Government 2020), which signifies the future whereby service providers are ‘hooked on and in’ care planning to maintain a seamless connection and strengthening of the service users care across the specialist and primary care sector.

Both the metaphors of ‘long‐lining’, and the ‘net’ in ūloa, symbolize a collective safe ‘holding’ of the person on the care pathway to meet the needs of the service user at that time, rather than services perpetuating an individualistic and fragmented approach. Health professionals will also need to work effectively, rather than being in one corner of the net resulting in care that is disjointed. Finding a common language to join each world together into the net is important particularly as the older and younger generation hold different understanding of mental distress and illness. Ūloa therefore can offer provision of the cultural needs in one care pathway, and like other cultural models, such as Fonefale (Pulotu‐Endemann 2009), and Te Whare Tapa Wha (Durie 1994), provides health professionals with a shared understanding across a range of cultural expressions of distress; ūloa is well suited to join this broad church of alternative and culturally relevant approaches to mental distress (Pulotu‐Endemann & Faleafa 2017).

The Toutai

The role of the service user at the centre of their care and recovery is the concept that has been part of mental health service delivery for several decades (Mental Health Commission 2001). Participants reported that the notion of toutai is regarded as a key concept in ūloa; the status of toutai is interchangeable, as is the person who holds the net to secure the catch, while others assist in bringing the weight of the fish to shore. Following the symbolism of ūloa, the service user may not immediately be the toutai, as there is a journey to be undertaken to gain understanding of their mental distress, continue their recovery, and regain their power. Though the aim is for the service user to be toutai, significant others may support them to regain this role. For example, the role of aiga or extended family, traditional healers, church leaders, and health professionals will be interchangeable, and like the notion of ‘long‐lining’, the right people and relevant resources ‘hook’ on or off the care journey with the best interests and cultural needs of the person at the forefront of care.

Vaka described the concept of hē (lost) for people with experience of mental illness as ‘the mind is lost’ and needing support to steer their journey through the distress. Likewise, the original work of R. D. Laing is also replete with metaphors such as navigation, mental maps, territory, and lost, whereby the role of the helper is to support the person as a ‘traveler who's been lost in a land where no one speaks his language… he feels completely lost… and sharing the problem with someone means…. you don't feel hopeless anymore’ (Laing 1990, p. 165).

However, the concept of the service user as toutai may not currently ‘fit’ with the historical and paternalistic notions of ‘doctor knows best’. According to Kanaan (2009), the discipline of psychiatry has long been viewed as paternalistic and underpinned with the notion of ‘insight’, which perpetuates the impression that service users lack the capacity to make their own decisions (Cavelti et al. 2012; Hamilton & Roper 2006). Therefore, heightening concerns about risk to self and others by the person if current palagi (western) protocols and care pathways are not followed.

For example, one health professional participant described how they encountered a person who did not take their advice to consult with the mental health services because their voices suggested that the ‘staff want to kill you, so run away from them’. From a biomedical view, this would indicate that the person is at great risk to self/others due to a command hallucination, thus increasing the professional need to address the safety and risk aspects of care. Whereas a cultural‐ and spiritual‐based view of hearing voices would make sense once explained through an anthropological lens (Larøi et al. 2014). Balancing risk versus safety is imperative to support the person's informed consent processes to increase both choice of, and shared power in collaborative care planning; however, care that is collaborative relies upon talanoa (story) being shared. Unfortunately, restrictive mental health legislation, stigmatizing attitudes, and helping responses inherent in institutional racism may regard non‐medical involvement, such as traditional healers, to be involved later rather than sooner in care planning.

Harris et al. (2019) argue that forms of institutional racism are higher among Māori, Pacific, and Asian groups compared with Europeans, acting as a barrier to, and influence on the quality of healthcare. Racism is also present in policy development and in the contracting of services to effectively meet the needs of these populations (Came et al. 2020). Systems that bring a cultural approach to care can reduce the restrictive practices and increase the collaborative negotiation on care planning. Partnerships between health professionals and Tongan traditional healers is vital for cultural care planning (Incawayar et al. 2009), more socially accepting of distressing experiences and often more accessible for service users and their family (Ibrahim Awaad et al. 2020).

Similar to the inclusion of the peer workforce over time (Vandewalle et al. 2018), the increased engagement of traditional healers as peers alongside health professionals will ensure an authentic and meaningful contribution to the cultural care of the person and possibly liberating professionals from their restrictive roles and patterns of care that perpetuate stigma and racism inherent in our institutions (Came et al. 2020).

The power of metaphors within a new practice of ūloa breaks from traditional approaches and consideration needs to be given to how novel, symbolic, and metaphorical language will impact on health professionals' clinical reasoning and formulation to determine the current, western, diagnostic criteria (American Psychiatric Association 2013). As (Vaka et al. 2020, p. 4), argue, from a Tongan spiritual perspective, the person is regarded as a whole and ‘perfect form’, who is now broken or damaged, therefore the finding in this study suggest that healing requires a cultural perspective to be embedded into the practice of health workers to and the cultural humility to recognize their role in healing.

However, participants in the Tongan health professionals group felt conflicted in working between the traditional Tongan healing approach versus the medical model, thus closing their options to explore how ūloa could be practiced. Conversely, if too many health professionals are involved, then the Tongan worker ‘backs out’. We suggest that mental health nurses can demonstrate cross‐cultural leadership in the implementation of ūloa and thus challenging the task‐oriented approach. As one participant stated in the previous study, we need to refocus on the ‘ripples in the water, rather than the focus only on the pebble’ as the source of continuing distress for service users.

Hence, the role of the toutai ca also be ascribed to leading culturally informed collaborative care so that health workers gain the trust and respect as through demonstrating cultural humility in their key position with the Tongan community. However, this requires health workers to defer leadership in care planning to the service user, their traditional healer, and family as a collaborative unit to ‘bringing everyone in as village’.

Though safety and risk will always be present in dynamic health systems, options for respite facilities where the healer lives with the person/family and brings the rituals such as kava for healing is likely to reduce risk, restrictive use of the mental health act, and ultimately reduce discrimination and stigma, including self‐stigma by the person. As argued earlier, Cavelti et al. (2012), assert that self‐stigma has a detrimental effect on a person's insight arguing that self‐stigma needs to be addressed with interventions that increase self‐concept to reduce dysfunctional, or troubling, beliefs related to mental distress. Ūloa and the role of the traditional healers have a vital role to play to achieve this outcome.

CONCLUSION

The importance of health professionals understanding how the Tongan model of ūloa can inform their practice will provide a framework to strengthen their skills in safely navigating their way through the Tongan relationships. Both Pangopango malie has described the person's worldview within the Pacifica culture of voyaging and fishing the oceans; therefore, the use of the metaphor of ‘navigation’ is central to collaborative care. The incorporation of ngaue faka‐taha – effective and culturally informed communication, underpinned by the va, will support the practice of health professionals. Like the fishing net, ūloa supports practice that attends to the whole task, increases awareness of all the cultural connections in treatment planning, and promotes restoration of the toutai role to service users – and to teach them how to fish.

RELEVANCE FOR CLINICAL PRACTICE

Given some limitations experienced by the researchers, such as the challenges of working with two languages, this was handled carefully between the researcher translating data followed by discussion with two peer Tongan researchers and expert translators for validation. The findings continue to support that the conventional biomedical approach used in the mental health services has been found to overlook elements of Tongan constructions of mental illness and the intersections between Tongan and biopsychosocial themes. The notion of care based on ūloa creates an opportunity to critique the dichotomy between the biomedical and the psychosocial‐spiritual approach to current mental health and addiction approaches. The findings support that care based only on the ‘medicine’ rather than bringing the spiritual aspect into care planning will not serve the needs of the Tongan community.

ETHICS APPROVAL

This study gained ethics approval from the Health and Disability Ethics Committee (reference number 19/STH/83) and Counties Manukau Health (reference number 17/STH/141/AMO1) in 2019. Pseudonyms were used to protect participants' identity. Approval was also confirmed by the ethics committee at the district health board.

ACKNOWLEDGEMENTS

This was part of a doctorate study to examine the Tongan constructions and interpretations of mental distress that was funded by the Health Research Council of New Zealand. Author 1 was involved in the conceptualization, planning, and led the interviews; author 3 transcribed the qualitative interviews; authors 1 and 3 completed analysis of data; author 2 reviewed the analysis and findings, wrote discussion, and prepared the manuscript for publication. Open access publishing facilitated by Auckland University of Technology, as part of the Wiley ‐ Auckland University of Technology agreement via the Council of Australian University Librarians.

Declaration of conflict of interest: We declare that there is no conflict of interest for any of the authors listed above.

Authorship statement: All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors and have read and agreed with the manuscript.

DATA AVAILABILITY STATEMENT

Research data are not shared.

REFERENCES

  1. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Vol. DSM‐V). Washington, DC: Author. [Google Scholar]
  2. Ataera‐Minster, J. & Trowland, H. (2018). Te kaveinga: Mental health and wellbeing of pacific peoples. In: Le V. A. (Ed). Results from the New Zealand Mental Health Monitor & Health and Lifestyles Survey (pp. 1–52). Wellington, New Zealand: Health promotion agency. [Google Scholar]
  3. Bracken, P. & Thomas, P. (2013). Postpsychiatry: Mental Health in a Postmodern World. Oxford University Press. 10.1093/med/9780198526094.001.0001 [DOI] [Google Scholar]
  4. Braun, V. & Clarke, V. (2021). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology, 18 (3), 328–352. [Google Scholar]
  5. Came, H. , O'Sullivan, D. & McCreanor, T. (2020). Introducing critical Tiriti policy analysis through a retrospective review of the New Zealand primary health care strategy. Ethnicities, 20 (3), 434–456. [Google Scholar]
  6. Carter, J. & Palmer, J. (2017). Dilemmas of transgression: Ethical responses in a more‐than‐human world. Cultural Geographies, 24 (2), 213–229. [Google Scholar]
  7. Cavelti, M. , Kvrgic, S. , Beck, E.‐M. , Rusch, N. & Vauth, R. (2012). Self‐stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Comprehensive Psychiatry, 53 (5), 468–479. 10.1016/j.comppsych.2011.08.001 [DOI] [PubMed] [Google Scholar]
  8. Durie, M. (1994). Whaiora, Maori Health Development. Auckland, New Zealand: Oxford University Press. [Google Scholar]
  9. Fotu, M. & Tafa, T. (2009). The Papao model: A Pacific recovery and strengths concept in mental health. Pacific Health Dialog, 15(1), 164–170. [PubMed] [Google Scholar]
  10. Hamilton, B. & Roper, C. (2006). Troubling ‘insight’: Power and possibilities in mental health care. Journal of Psychiatric and Mental Health Nursing, 13 (4), 416–422. [DOI] [PubMed] [Google Scholar]
  11. Harris, R. B. , Cormack, D. M. & Stanley, J. (2019). Experience of racism and associations with unmet need and healthcare satisfaction: The 2011/12 adult New Zealand health survey. Australian and New Zealand Journal of Public Health, 43 (1), 75–80. [DOI] [PubMed] [Google Scholar]
  12. Ibrahim Awaad, M. , Mohsen Ibrahim, N. , Naguib, R. M. , Khalil, S. A. , Elhabiby, M. & Khaled Mohamed, Z. (2020). Role of traditional healers in the pathway to care of patients with schizophrenia in Egypt. International Journal of Social Psychiatry, 66 (4), 382–388. [DOI] [PubMed] [Google Scholar]
  13. Incawayar, M. , Wintrob, R. , Bouchard, L. & Bartocci, G. (2009). Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health. Oxford, England: Wiley. [Google Scholar]
  14. Kanaan, R. A. A. (2009). Truth‐telling in psychiatry. Psychiatry, 8 (12), 471–472. [Google Scholar]
  15. Laing, R. D. (1990). The Divided Self. London, England: Penguin Books. [Google Scholar]
  16. Larøi, F. , Luhrmann, T. M. , Bell, V. et al. (2014). Culture and hallucinations: Overview and future directions. Schizophrenia Bulletin, 40 (Suppl_4), S213–S220. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. McGrath, B. B. & Ka'ili, T. O. (2010). Creating project talanoa: A culturally based community health program for U.S. Pacific islander adolescents. Public Health Nursing, 27 (1), 17–24. [DOI] [PubMed] [Google Scholar]
  18. Mental Health Commission . (2001). The recovery competencies for mental health workers in New Zealand . [Accessed 15 September 2021]. Available from: URL: http://www.hdc.org.nz/publications/other‐publications‐from‐hdc/mental‐health‐resources/recovery‐competencies‐for‐new‐zealand‐mental‐health‐workers
  19. Ministry of Health (2020). Mental Health 2016/2017: New Zealand Health Survey. Wellington, New Zealand: Ministry of Health. [Retrieved 24 November 2021, Accessed 25 March 2020]. Available from: URL:. https://minhealthnz.shinyapps.io/nz‐health‐survey‐2016‐17‐mental‐health‐explorer [Google Scholar]
  20. New Zealand Government . (2018). He Ara Oranga: Report of the Government inquiry into mental health and addiction . [Accessed 20 April 2021]. Available from: URL: www.mentalhealth.inquiry.govt.nz/inquiry‐report
  21. New Zealand Government . (2020). Health and disablity system review . [Accessed 10 March 2021]. Available from: URL: https://systemreview.health.govt.nz
  22. Oakley‐Browne, M. A. , Wells, J. E. & Scott, K. M. (2006). Te Rau hinengaro: The New Zealand mental health survey. Australian and New Zealand Journal of Psychiatry, 40 (10), 865–874. [DOI] [PubMed] [Google Scholar]
  23. Pou, T. (2010). Talking therapies for Pasifika peoples; best and promising practice guide for mental health and addiction services . [Accessed 15 May 2019]. Available from: URL: https://www.tepou.co.nz/resources/talking‐therapies‐for‐pasifika‐peoples
  24. Pulotu‐Endemann, K. (2009). Fonofale model. Auckland, New Zealand: Massey University. [Accessed 14 December 2018]. Available from: URL:. http://www.hauora.co.nz/resources/Fonofalemodel.pdf [Google Scholar]
  25. Pulotu‐Endemann, K. & Faleafa, M. (2017). Developing a culturally competent workforce that meets the needs of pacific people living in New Zealand. In: Smith M. & Jury A. F. (Eds). Workforce Development Theory and Practice in the Mental Health Sector. Hershey, PA: IGI Global. [Google Scholar]
  26. Samu, K. S. & Suaalii‐Sauni, T. (2009). Exploring the ‘cultural’ in cultural competencies in Pacific mental health. Pacific Health Dialog, 15 (1), 120–130. [PubMed] [Google Scholar]
  27. Taonui, R. (2010). Mana tamariki: Cultural alienation: Māori child homicide and abuse. AlterNative: An, Mana Tamariki: Cultural Alienation International Journal of Indigenous Peoples, 6 (3), 187–202. [Google Scholar]
  28. Trevino, A. Y. , Tao, K. W. & Van Epps, J. J. (2021). Windows of cultural opportunity: A thematic analysis of how cultural conversations occur in psychotherapy. Psychotherapy, 58 (2), 263–274. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Vaioleti, T. M. (2006). Talanoa research methodology: A developing position on Pacific research. Waikato Journal of Education, 12, 21–34. [Google Scholar]
  30. Vaka, S. L. (2014). A Tongan Talanoa about Conceptualisations, Constructions and Understandings of Mental Illness (Ph.D. thesis). Auckland, New Zealand: Massey University. [Google Scholar]
  31. Vaka, S. (2016). Ūloa: A model of practice for working with Tongan people experiencing mental distress. New Zealand Sociology, 31 (2), 123–148. [Google Scholar]
  32. Vaka, S. , Brannelly, T. & Huntington, A. (2016). Getting to the heart of the story: Using talanoa to explore pacific mental health. Issues in Mental Health Nursing, 37 (8), 537–544. [DOI] [PubMed] [Google Scholar]
  33. Vaka, S. , Holroyd, E. , Neville, S. & Cammock, R. (2020). Comparing and contrasting Tongan youth and service users' interpretations of mental distress. Journal of Mental Health, 29, 1–6. [DOI] [PubMed] [Google Scholar]
  34. Vaka, S. , Neville, S. & Holroyd, E. (2020). An ethnic interpretation of mental distress from the perspective of Tongan men and community leaders. International Journal of Mental Health Nursing, 29 (5), 953–961. [DOI] [PubMed] [Google Scholar]
  35. Vandewalle, J. , Debyser, B. , Beeckman, D. et al. (2018). Constructing a positive identity: A qualitative study of the driving forces of peer workers in mental health‐care systems. International Journal of Mental Health Nursing, 27 (1), 378–389. [DOI] [PubMed] [Google Scholar]
  36. Velez, B. L. , Watson, L. B. , Cox, R., Jr. & Flores, M. J. (2017). Minority stress and racial or ethnic minority status: A test of the greater risk perspective. Psychology of Sexual Orientation and Gender Diversity, 4 (3), 257–271. [Google Scholar]

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