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In conversation with Dr Hinemoa Elder – Atlas

In conversation with Dr Hinemoa Elder

Helen Ker

Dr. Hinemoa Elder is a Māori child and adolescent psychiatrist specialising in youth forensics and the neuropsychiatry of traumatic brain injury. Helen Ker sat down with her to talk about her work and why cultural identity matters in medical practice.

Hi Hinemoa, tell me a bit about your day to day work.

E mihi kau ana ki a koe, i tō karanga e pā ana tēnei take whakahirahira
Ko wai au?
He uri tēnei nō Waimirirangi.
Ko Parengarenga te moana,
Ko Awapoka te awa,
Ko Te Aupouri, ko Ngāti Kuri, ko Te Rarawa, ko Ngāpuhi nui tonu ōku iwi.
Ko Hinemoa Elder tōku ingoa.
Kia ora, nice to meet you Helen. My name is Hinemoa, I come from the far North and I’m a child and adolescent psychiatrist. So you want to know about my daily routine?

Yes, please.

Well I don’t actually have a daily routine. My days are very varied because I work in private practice and I do a range of different things. That’s just how I like it at this stage of my life. In my clinical practice I take referrals from the Ministry of Justice to write court reports for the youth and family court. These can be around care and protection issues, questions of fitness or a comprehensive assessment and formulation of what’s going on for young children, tamariki Māori usually and their whānau. And then I have gone on to specialise in an area called neuropsychiatry, and in particular, the neuropsychiatry of traumatic brain injury (TBI). I’ve been working with whanau with TBI for about 10 years and it became clear to me pretty early on that the whole Māori world was not available to these whānau despite knowing family are an integral part of the healing journey. So I wondered how could I help our whānau who were going through these experiences. Because unfortunately we also know that we (Māori) are much more likely to have brain injuries. So long story short I have developed a validated cultural needs assessment tool for people who have experienced a brain injury to help inform the kind of interventions that should occur, and to monitor the impact of those.

We refer to Māori as one homogenous group but I imagine Māori culture varies regionally/locally. Am I right in thinking that or is that a bit of a misnomer?

I think there is a reason to talk about Māori as an overarching group and within that there are also reasons to think about our heterogeneity. One of the interesting things I found in my PhD where I used a marae-based method both in cities and rural environments was that actually the feedback was very homogeneous — surprisingly so, and to me that suggests that while we might have all sorts of different expressions and experiences of being Māori, under certain circumstances and when we think about certain things, we respond in a more homogeneous way. And that finding doesn’t necessarily sit on its own. There is information from Statistics New Zealand and reports done by Te Puni Kōkiri and the Ministry of Culture and Heritage that have found that the majority of Māori value Māori activities, and so there are certain things about being Māori that most of us do. Which to me is really powerful because I think there is this other discourse that goes on that suggests that we are all really disenfranchised from our culture, and suffering because of that. I think to some extent that is the case, but in actual fact there is this other more resilient story about our connectedness.

That story is sadly not often shown.

Well, I think that’s what happens when you write about people by way of the pathology of the statistics. Māori scholars within public health have been highlighting this for many many years: that when you write, ‘only 40% of Māori high school students come out of high school with a qualification’, or whatever the stat might be, you’re reminding us that we have a lot of problems. Whereas you can turn those stats around, you can write about those things in different ways. So that whole victim blaming way of writing about people is problematic, at the same time we need to find a way to talk about how complex and significant the issues are in order to advocate for them to change. So we’ve got to do both.

That’s what I want to talk about a little bit because it’s hard to ignore the statistics of a huge inequity. Particularly alarming is the high suicide rate in young Māori males. It’s a huge question and I’m sure there’s no one answer, but why does this problem exist?

It exists as an ongoing manifestation of colonisation — where you systematically create laws and attitudes and conventions whereby one group of people have everything that is culturally nurturing such as land and language, everything that helps people to reflect on their identity and continue to pass that on to their descendants, systematically removed — often forcibly through violence. Then you have the modern, some would say perhaps more subtle, forms of that same process, which occur in health systems as much as anywhere else. We know for example that if a young Māori person commits the same crime as a young Pākehā person they have a different experience and at all the decision points along that journey, different discretionary decisions are made, so that’s the same process of colonisation that happened 150 years ago, happening now.

And have you seen any progress made on the public health or wider governmental scales to reduce this?

I think it’s a pretty continuous story, I think there are some pockets where people have carved out a different way of doing things and are showing some pretty positive outcomes. For example we have a marae-based Rangatahi court system now with 12 marae-based courts and it would appear that these have a better outcome in terms of reducing recidivism for young Māori offenders, another example is a large mental health and addiction service called Hauora Waikato which is based in Hamilton. They are an iwi-owned and run organisation which over the last 15 years has taken over DHB contracts, and in fact does a better job often. So the way that the services are organised can make a significant difference.

As a Pākehā, cultural identity hasn’t always been a strong concept for me, I guess in part because I am part of the dominant culture in New Zealand and have access to that in every way possible. How do you define and understand the concept of cultural identity?

That’s a really good question. I suppose it is a way of thinking of oneself and the people that one feels closest to across a range of domains. These include the language you choose to speak, the way in which you have had knowledge passed down to you, the roles that you experience, gender issues, the role of people at different generational stages in life, the expectations from an ancestral perspective, the role of ancestors, the food you want to eat and the places you want to go.

Do you think knowing your own personal and family history is a crucial part of that, or can cultural identity exist without that?

I think of course people can have a cultural identity without knowing too much about their intergenerational history and I suppose that’s part of the problem, isn’t it, because we don’t teach NZ history in school. And I think for all NZ citizens that creates a profound disease and vulnerability, if we all knew the stories and histories better, if we could all speak Te Reo Māori this would be a much healthier country.

How do we change the norms to make it feel more inviting or to feel more normal for all people living in NZ to speak Māori?

I think changing people’s attitudes and behaviours has a lot to do with how they feel about things. So in my experience and in my reading of the literature, most New Zealanders have a profound relationship with the land here — the beaches, the ocean, some sort of place where they grew up, a farm, a river, a lake, and I think that’s a potential inroad. One of the things I use a lot is the whole idea of pepeha, so at the beginning when I introduced myself I did that in the formal Māori way, which is to say: this is my mountain, my river, my marae, this is my people and my name comes at the end. And this is something we get the young people at the marae court to do. It’s the most important thing they learn and they can take it anywhere they go. You see them over weeks getting more and more confident in themselves, you can see their identity strengthening, because the judge says, ‘well, next week I want to see you do it without the piece of paper. I want to see you stand and proudly deliver that pepeha’. So I think that that is an activity that all New Zealanders could embrace as a simple way of opening the door.

We had to do that every morning at my primary school and it did make me a lot more interested in places and gave me something to feel proud of.

Because when you learn the names of the places you think well why is it called that, who called it that, and what is the story of that person and when did they live there and who came before and who came after them and suddenly this whole history unfolds. And when you’re standing there and doing yours and I’m doing mine I’m thinking, ‘Oh my God, right, she grew up there and that’s her mountain, well, my people went there and did something’. So then you get into whakawhanaungatanga and you draw linkages and think about relationships in the stories that are embedded in the land and the people. So I think the pepeha is up there for me in terms of just starting to shift people’s consciousness.

Do you think that these important connections to whenua/maunga/awa are missed in a typical Western medical psychiatric consult?

Well, I would argue that we try very hard in the College of Psychiatry to teach this. We have an indigenous training module for all of our registrars, many of us have advocated for years that these are things that need to be done by anyone who is seeing a Māori person and their whānau for a mental health assessment. I published a paper about this in 2008, where the Māori psychiatrists I interviewed said that, look, we are trained to be opaque, in psychodynamic psychiatry at least, you are not supposed to talk about who you are because the other person is supposed to project onto you all their stuff. But actually nobody practises that kind of psychiatry any more but we still have this hangover from the previous time. So what the people in my study were saying was that actually we do have to share about who we are (a little bit) and that helps whānau to feel respected and to know, ‘ah, now I can place you, now I know who you are’ and if you don’t get that cultural bit right first you actually never get to the clinical bit.

Working with children and adolescents must be interesting because they are still in the process of developing their own personal identity let alone cultural identity. Do the two develop together?

There are lots of theories around this. I think cultural identity is a part of your overarching identity, which is evolving throughout your entire life. I don’t think it occurs in distinct periods and then stops evolving, and there are different times when it can come up against some different stressors  when it’s not cool to be Māori, and people might not mention it. There are these layers of cultural identity for Māori that are different, because we live in a racist environment, with microaggressions that occur all the time, as well as lateral violence. I don’t know if you’ve come across that term, that’s essentially where a dominant culture gets the people within the minority culture to beat each other up psychologically.

And you’d see a lot of consequences of that in your work in child protection.

Definitely. Because we also know from education that Māori students are not given the same opportunity as non-Māori students. Teachers do not have the same expectations for them – ‘you can do the barrister course, you’re going to be digging the roads, you’re not going to be doing science, you’re not going to do law’. So when you’ve been told that overtly often as well as covertly, then who are you? — you’re a useless person, you’re going to be some sort of drain on society, you’ve been told that you have no contribution to make, it’s a community-level learnt helplessness, it’s a Durkheimian concept of anomie on a massive scale, why would you even try?

Who has the power to change that deeply entrenched story?

We all do, we all have to play a part. It’s not only Māori, all citizens need to play a part, and that’s why I think educating us about the history of NZ is critical.

It must be hard working at an individual level as a psychiatrist when many of these issues are so large and systemic. What actions do work at that individual level?

Okay, so before I get into that can I just say one of the things I advocate for is that doctors need to learn how to take a better family and community history. In medicine we have these traditions of taking a family history, a developmental history, a psychiatric history etc etc and what I’m advocating for is that we actually broaden this concept of family history into a community history. Let’s say that we actually get to know much more about the communities in which people grow up, and the history of those communities. So if you take a community in South Auckland like Manurewa for example, it’s the most culturally diverse community in Aotearoa right now. Back in the day it was a Māori area — Tainui and then the colonial army and government basically gave an ultimatum in 1863: if you don’t stand up for the queen here then you’re going to have to leave your homes and get south of the Maungatautari River, otherwise you’re going to get killed. So that history is lying dormant there. We as doctors need to get to know those histories and how those histories of the battles; Hinahina, Gate Pā, Ōrakau, are affecting our patients right now. Often our patients might not know them and say, ‘why are you asking me this!?’ Because we’ve trained them iatrogenically to think that it’s not important information, but actually we know that it is very important information and from that come opportunities and potential for change: ‘wow, did you realise this has been affecting your whānau over these generations, you got kicked off your land, and then these other things happened, and here you are today. We need to heal all of those losses and all of that grief and all of those seemingly incremental, little things that happened out of your control, so you can discover your oranga, for you and your whānau’. It’s about seating the individual amongst the interdependent issues.