Introduction
Pasifika[1] people are a heterogenous group and are the fourth largest ethnic population in New Zealand (NZ), comprising 8% of the total population (Ministry for Pacific Peoples, 2020). Pasifika people are a migrant population in NZ, comprising people from a number of different island nations in Polynesia, Melanesia and Micronesia (Ataera-Minster & Trowland, 2018). In NZ, the four largest Pasifika populations are Samoan, Cook Island Māori, Tongan and Niuean; however, Census classifications indicate there are over 17 Pasifika cultures in total (Statistics New Zealand, 2018).
A recent report, Te Kaveinga, found that Pasifika people reported higher psychological distress on average than other ethnic groups (Ataera-Minster & Trowland, 2018). There is also a growing divergence between Pacific-born and NZ-born generations of Pasifika people with regard to cultural values, identity and beliefs about well-being (Anae, 2001; Ministry of Health, 2008). Many Pasifika people have to navigate defining their own ethnic identity (Manuela & Sibley, 2013) and many of the challenges to mental health and well-being may differ between NZ-born and island-born Pasifika. Te Kaveinga also reported that Pasifika people were likely to seek support from a family member or friend if they were having mental health difficulties (Ataera-Minster & Trowland, 2018). The disparity between Pasifika and Western understanding/knowledge around mental health is a potential contributing factor to the low engagement of Pasifika people in the NZ mental health system (Gunther, 2011).
Mental health services that are better designed to support Pasifika would be characterised by a holistic view of well-being that focuses on the collective and relational aspects of the Pasifika worldview (Kingi-Ulu’ave et al., 2016). This holistic view places family as central to Pasifika cultures, but also values spiritual, physical and mental well-being as well as any other aspects of life that connect family and culture (Manuela & Sibley, 2013). Pasifika people from Aotearoa NZ recently expressed that the current health system was not working for them (New Zealand Government, 2018). Emphasis was placed on the importance of having Pasifika healthcare workers at the frontline (New Zealand Government, 2018). Some international literature showed that ethnic minorities may feel that white/non-minority therapists cannot understand important aspects of their experiences, and subsequently avoid discussing racial, ethnic or cultural issues (Chang & Yoon, 2011). In 2021, 4266 out of 4385 psychologists did not select Polynesian, Pasifika or Māori as their first ethnicity option when renewing their registration (G. Giannios, personal communication, May 11, 2021). Research has emphasised that a key factor for reducing health inequality globally is to develop the presence of underrepresented ethnic minorities in the health workforce (Pulotu-Endemann & Faleafa, 2017). Given the current low numbers of Pasifika psychologists, this highlights the need for all psychologists in NZ to be culturally competent.
Methods
The lead researcher for the present study is a NZ-born Pākehā person of Spanish, English, Scottish and Irish decent. As a Pākehā person with both experience working with Pasifika people in a mental health setting and an interest in training as a psychologist, the researcher was personally motivated to learn about the kind of experience, understanding, training and competence non-Polynesian psychologists working with Pasifika communities had. The researcher acknowledges that this research looks at Pasifika communities through both a Pākehā researcher lens and through a focus on the experiences and understanding of non-Pasifika participants. The researcher engaged in regular supervision/discussion with the corresponding researcher to consider and explore the biases that could occur when researching a community from a different worldview.
This study used a qualitative methodological approach from a critical realist perspective to acknowledge the way participants make meaning and the broader social context that influences this meaning, while keeping understanding rooted within the limits of reality (Braun & Clarke, 2006). Ethics approval was obtained from the Massey University Human Ethics Committee (Ethics Notification Number: 4000023979). Data were mainly collected through semi-structured interviews that were held online because of COVID-19 conditions (Mann, 2016) (See Appendix). Participants who were current and registered non-Pasifika psychologists, with 3 or more years of experience working with Pasifika communities, were purposefully recruited through the networks of the researcher and research supervisor, as well as via snowball sampling (Goodwin & Goodwin, 2017). Six participants were recruited (five females and one male). Half of the participants were born in NZ, and the other half were born overseas. Most participants were trained in NZ.
Data were analysed using an inductive thematic analysis (TA) approach (Braun et al., 2019; Braun & Clarke, 2006). The analysis was conducted using the step-by-step guide to TA developed by Braun and Clarke (2006). This involved the lead researcher becoming familiar with the data through transcribing, re-reading and taking preliminary notes from the interviews. The inductive TA approach involved coding in a data-lead way, with reference to the broader research questions. Initial codes were then collated, analysed and sorted into categories of broader themes and subthemes. Themes were then reviewed and refined to fit within a ‘thematic map’, which involved re-reading and re-coding the data to ensure that all aspects reflected the broader themes of the dataset. Concise but accurate names were attributed to each theme, and some themes were merged because of similarity. Miscellaneous codes were grouped together and either attributed to a relevant theme or left out, as appropriate. Finally, the results were produced as follows. To ensure participants’ anonymity, quotes are identified using codes (e.g. P1, P2…).
Results
Who are Pasifika?
Theme 1: Diversity and history. Participants identified the importance of understanding who Pasifika communities were with regards to their diverse cultures and history, both in NZ and their origin countries. Many participants felt that it was important to acknowledge and understand that Pasifika is a term that encapsulates a number of different cultures.
I guess my understanding that it’s not homogeneous, homogeneous, it’s not just Pasifika doesn’t just describe one community to multitude of different communities, maybe from the same, similar geographical area in the Pacific, but each community has their own, you know, worldviews, culture, history, identity. (P5)
Many participants noted that diversity was important to hold in one’s mind alongside recognition of the several generations of people who had migrated from the Pacific as well as those who were recent migrants.
Yes, it’s very diverse, and it’s also worth looking at historically because people who’ve been here three generations are different in that they don’t have the same experiences as somebody who’s just arrived. (P3)
All participants noted the importance of history when it came to understanding who Pasifika communities were. They discussed history in terms of colonisation in NZ, migration, acculturation and individual Pacific nation histories and political structure.
I think knowing about their migration to New Zealand and about how they were mistreated and treated. (P4)
Well, I think the multiple effects of colonisation are the biggest challenge if you want to put it in a frame, in that, you know, Pasifika communities, Māori communities, Indigenous communities, have got no real reason to trust the Western worldview. (P1)
Theme 2: Family and spirituality. Participants identified family and spirituality as being pivotal to their understanding of Pasifika communities.
I guess being very aware of the importance of spirituality and beliefs, and the importance of family obviously, kind of, you know the two sort of fundamental sort of elements that drive my knowledge around Pasifika culture. (P2)
When it came to the importance of spirituality, participants discussed the importance of the church.
I think one of the things for me is just being, constantly holding in mind how important the church is, perhaps more so than in general for European, for Pākehā or for Palagi. (P6)
Working with Pasifika Communities
Theme 3: Relationship—genuine connection and interest. Key relational aspects included being respectful, kind, open and always listening and learning from Pasifika clients
…it’s my responsibility to send that message that all of you are welcome in this space and I am interested and curious about all of you. (P2)
Some participants suggested looking for where their own identity and values may align with a client as a way creating a genuine connection.
…reflecting on how might we be able to relate and also connect and be with them in a way that’s meaningful for them. (P4)
Participants also discussed connecting through aspects of Pasifika culture, such as correct pronunciation of names, learning the language and learning key concepts/customs that may be important to clients.
…He [the client] was just so ecstatic I’d talk like that, and I thought I should have done that from the start! but I guess that was me being shy (laughs). So I guess it’s not being a-, yeah, not being afraid to…use the language to make someone feel comfortable. (P5)
Theme 4: The client as the ‘expert’. Participants indicated that valuing their client’s expertise was a key aspect, and something they considered to be highly important in their engagement with Pasifika.
The clients are the expert in their lives, that’s because, you know, they’re living their current life where the problems will be, but they’re also going to be living their life in the future life like you know we are not going to be there… (P1)
In addition, having the client as the expert also meant being aware of one’s own limitations, accepting those limitations and not making any assumptions about clients.
I don’t assume to know…much, I don’t assume to know a lot, I assume to know little. (P4)
I think that I’m very aware of how much I don’t know. So I tend to let people teach me what is important to them…(P3)
Participants also outlined that viewing their client as the expert meant being flexible and meeting them in the clients’ environment or wherever the client wanted to meet.
You know, [I’m] happy to come to church, I’m happy to come your home, I’m happy to come to your early childhood education centre, you can come to my office, you can come on your own, you can come with anybody else you want to bring. (P1)
Theme 5: Cultural competency and training. There was some inconsistency in participants’ responses around being culturally competent to work with Pasifika. Some participants felt you could not claim to be culturally competent unless you were Pasifika yourself. For example, '…it’s impossible to be culturally competent unless you are Pasifika’ (P6). Another participant felt that you could not be culturally competent with all Pasifika cultures because of their multitude/diversity.
Yeah, it’s a very diverse group of people so I don’t know that we can be competent with all of them. (P3)
Other participants tended to view cultural competence in a client-focused way.
Well, I think it depends on what they think it means really, you know. I think in general, I’m sure, not always, but I think in general, the experience that people have of someone in the room is where they decide whether the person is competent or not. (P1)
Participants’ reported that they had received minimal formal training to work with Pasifika communities and there was no monitoring arm to review their cultural competence.
I know, no one actually checks on you whether you actually are [culturally competent]. (P5)
I sought information (myself), I’ve done as much reading as I possibly can. (P3)
Some participants felt that experience was important for improving a psychologist’s competence working with Pasifika communities, but many felt they did not have the resources, supervision and training opportunities needed to work effectively with Pasifika. Oen participant suggested a support/advisory service for psychologists to access cultural advice/guidance.
…if we could set up some sort of, or if somebody, might be like the Ministry of Health could have a line for people to call in terms of ‘hey, I’m a psychologist, I need advice on a Niuean family’. (P3)
Another participant advocated the importance of having more Pasifika people working in the mental health professions.
…Just, doing whatever we can to have more and more people in the professions who themselves are Pasifika. Cause I think that’s…Yeah but in the meantime it’s kind of like, we do our best, and, but always holding, and open to learning and while we can do our best it’s never the same… (P6)
Discussion
Who are Pasifika?
Previous literature outlined the importance of acknowledging diversity in Pasifika communities, and not compromising on knowledge regarding these diverse cultures (Fonua-Faeamani, 2017; New Zealand Government, 2018). Participants in this study felt it was important to acknowledge the differences between NZ- and Island-born people and how this may impact their Pasifika identity. This finding was congruent with previous findings indicating the importance of considering generational differences when working with Pasifika communities (Oakley Brown et al., 2006). Gaining an understanding of the history of migration was considered important when working with Pasifika. It was important to be aware of the history of Pasifika communities in NZ and the history or political structure of their origin countries. Participants identified these things as historical context, which may contribute to why many Pasifika people distrust or are disengaged from Western healthcare systems and non-Pasifika practitioners (Fa’alogo-Lilo & Cartwright, 2021). It is also important to consider how awareness of the history of Pasifika people in NZ may provide understanding as to how structural oppression has resulted in socioeconomic disadvantage for Pasifika, and the subsequent impacts on access to health services (Fonua-Faeamani, 2017).
Family is fundamental to who Pasifika communities are (Ioane, 2017). Participants emphasised the importance of family as not just being the nuclear family but also extended family and community. It is well validated in the literature that Pasifika communities have a collectivist culture, and that family is central to well-being (Ioane & Tudor, 2017; Kingi-'Ulu’ave et al., 2012; Ministry of Health, 1995; Mulder et al., 2016). Participants identified spirituality as another shared feature of importance when it comes to who Pasifika communities were. This was consistent with previous research that suggested the centrality of religion to the ethnic and cultural identity of many Pasifika people (Manuela & Sibley, 2013). Both the present study and previous literature indicated that spiritual understanding may not fit within clinical understanding, and that psychologists need to seek advice where needed to navigate this space (Kingi-Ulu’ave et al., 2016; New Zealand Government, 2018). The importance of spirituality should be incorporated into treatment/intervention (Ministry of Health, 1995; Suaalii-Sauni et al., 2009; Tamasese et al., 2005).
Despite these important aspects being acknowledged by participants in the present study, Pasifika service users reported feeling a disconnection with non-Pasifika practitioners as they did not understand the importance of collectivism and spirituality (Fa’alogo-Lilo & Cartwright, 2021; New Zealand Government, 2018). Working within a Western-centric service framework may be a barrier for psychologists to sufficiently demonstrate their understanding of these core values through their therapeutic interventions (Fa’alogo-Lilo & Cartwright, 2021).
Working with Pasifika Communities
Participants discussed connecting with their clients in meaningful ways, by finding points of mutual connection (e.g. self-disclosure, initiating conversations about culture, demonstrating genuine interest and engagement with Pasifika culture). Previous literature supported this, whereby conversations were initiated particularly around culture and background with clients (Gurpinar-Morgan et al., 2014). Demonstrating a genuine interest in engaging with Pasifika culture was emphasised as being important in the development of this relationship (Ioane, 2017; Ioane & Tudor, 2017; Suaalii-Sauni et al., 2009). The findings of this study also implied that clinicians working effectively with Pasifika did so by building a genuine, caring and open therapeutic relationship. Furthermore, they advocated for a person-centred, reciprocal and respectful approach when working with Pasifika communities (Ioane & Tudor, 2017; Le Va, 2014; Mila-Schaaf & Hudson, 2008).
Participants found that connecting with the community beyond just individual sessions/clients was also an effective way of demonstrating their genuine interest in the culture/people, creating trust/familiarity, building rapport with the community as a collective and being accessible to people. This was consistent with Berger and Hwang’s (2014) findings that counsellors who were culturally skilled tended to engage with minority individuals outside of the therapeutic context.
The importance of viewing the client (rather than the clinician) as the expert was described as being fundamental to how participants worked with Pasifika communities. An important aspect of this was not making any assumptions about the best approach to treatment, and considering how a non-Pasifika person may experience limitations in seeing things from a Pasifika client’s perspective. Notably, humility and respect are well-known cultural values of Pasifika communities (Fa’alogo-Lilo & Cartwright, 2021; Ioane & Tudor, 2017; Te Pou o Te Whakaaro Nui et al., 2010). Demonstrating humility has been identified as an important aspect of developing positive therapeutic relationships with Pasifika service users (Fa’alogo-Lilo & Cartwright, 2021). This finding was consistent with the concept of cultural humility, which describes the ability to take an ‘other-oriented’ approach to cultural identity (Hook et al., 2013). An important aspect of cultural humility is the therapist being able to demonstrate their respect and lack of superiority, which contributes to strong therapeutic alliance (Hook et al., 2013). Cultural humility also aligns with the idea that it is important to develop an awareness of one’s own cultural worldview/perspective and its difference (or not) from that of one’s clients (Black & Huygens, 2016).
In this theme, participants also discussed the importance of being open and flexible about conducting treatment in ways that were appropriate and comfortable for their Pasifika clients. This supported findings reported by Fa’alogo-Lilo and Cartwright (2021), which indicated that offering a home visit or encouraging family involvement were important ways of prioritising Pasifika knowledge and worldviews in treatment. This was further validated in work with Pasifika youth to include the family and support them to guide the process (Ioane, 2017).
Cultural competence is a well-known concept in psychology training and practice, but participants’ responses around what this meant for working with Pasifika communities were mixed. Cultural competence is defined by the NZ Psychologists Board (2018) as ‘having the awareness, knowledge, and skill, necessary to perform a myriad of psychological tasks that recognises the diverse worldviews and practices of oneself and of clients from different ethnic/cultural backgrounds’ (New Zealand Psychologists Board, 2018). It would follow from this definition that it is possible for a non-Pasifika clinician to be culturally competent to work with Pasifika communities; however, some participants did not feel this was the case. Participants gave varied responses regarding whether it was possible to be culturally competent to work with Pasifika, and if so what this would entail. It is possible that the participants who did not feel it was possible to be culturally competent were speaking to the idea of being ‘completely’ culturally competent. Several of the responses also reflected the idea that cultural competence is relative to what it means in each context (e.g. what it means in relation to each Pasifika culture/ethnicity, or what it means to that particular client). The latter indicates a client-centred approach, which could result from a sense of humility, and ties into the earlier theme of the client as the expert. Regardless of the reasons for this variation, the discrepancy in responses indicated that the concept of Pasifika cultural competency may not be universally recognised/defined. Growing importance is being placed on cultural competence for healthcare professionals, including psychologists, and its pertinence to working effectively in a multicultural country such as NZ (New Zealand Government, 2018; Tiatia, 2008). This is important, as having a clear idea of what it means to be culturally competent to work with Pasifika and how to build this competence is likely to improve non-Pasifika psychologists’ ability to work effectively with Pasifika communities (Pulotu-Endemann & Faleafa, 2017; Tiatia, 2008).
A lack of formal training to work with Pasifika communities was highlighted by all participants in this study. The present findings supported the idea that although experience is valuable, formal training is important in providing foundational knowledge for new psychologists around Pasifika culture and values, as well as cultural safety more generally. Psychologists should be able to reflect on their own culture and its impact on their practice as well as the origins, assumptions and limitations of psychological practices when working with Pasifika communities (NZPB, 2018).
Most participants noted the importance of cultural supervision or access to a cultural advisor, to ask questions and to learn by working alongside Pasifika colleagues, even if these colleagues were not psychologists. However, some participants noted that not only was there a shortage of Pasifika psychologists but there was also strain on/shortage of cultural advisory services generally (Health Quality & Safety Commission, 2021). This leads back to Pasifika people being underrepresented in our health/mental health services (Fa’alogo-Lilo & Cartwright, 2021; Pulotu-Endemann & Faleafa, 2017). Not only will having more Pasifika people in these roles benefit Pasifika clients/service users, but it may also increase the confidence and effectiveness of non-Pasifika practitioners working in this space through increased opportunities for cultural support and supervision and to work alongside/learn from Pasifika colleagues.
Conclusion
Although having cultural supervision/advisory and formal training will strengthen the practice of non-Pasifika psychologists, they will also need to acquire confidence in themselves that they have the knowledge and abilities to work effectively with Pasifika in their own right, along with an awareness of their limitations. All of the participants in the present study were able to provide examples of how they had made meaningful connections with their Pasifika clients using the knowledge and skills they had gained. They were able to reflect on challenges they had experienced and ways that they could mitigate some of these issues.
The present study indicates that individual learning and authentic lived engagement with Pasifika culture and community, beyond what is prescribed through mandatory training, is likely to improve working with Pasifika people. Non-Pasifika psychologists should take advantage of any opportunities to upskill through training, co-work, supervision and cultural advice, but a simple and practical response could also be to engage with Pasifika communities in their natural settings (e.g. Pasifika community events, shopping centres) to observe and participate in an environment that is predominantly Pasifika (Ioane & Tudor, 2017). It is up to individual psychologists to take their cultural awareness/learning into their own hands, seek information and seize any opportunity to learn more about Pasifika communities. It is through our own openness and willingness to learn and grow that non-Pasifika psychologists can continue to improve their confidence and efficacy working with Pasifika communities in NZ.