Recovery in New Zealand: An evolving concept?

Abstract

Recovery was first officially promoted in New Zealand in 1998 and it became a key concept in mental health service development. Since the mid 2000s however, recovery has been on the wane in New Zealand, but the fundamental concepts within the term live on in two more recently adopted terms: whanau ora and well-being.

He Korowai Oranga (Maori Health Strategy) defines whanau ora as families being supported to achieve health and well-being. The extended family is recognized as a source of strength, identity, security and support. Whanau ora is underpinned by Te Whare Tapa Wha, a well-being model that focuses on health being a balance between Taha Wairua (spiritual health), Taha Tinana (physical health), Taha Hinengaro (psychological health) and Taha Whānau (family health).

New Zealanders are also using the term well-being, not just for the whole population but for people diagnosed with mental illness. The advantages of placing recovery into the larger well-being agenda are reduced discrimination and segregation of people with a diagnosis into a distinct population group, reduced association with medical and deficits approaches that can counter the recovery approach, and bypassing the dilution of the recovery approach that has occurred in traditional services.

Recovery in New Zealand

Recovery can take place when a person with a diagnosis of mental illness has the personal resources, services, supports, opportunities and rights to achieve the lives they choose. Services using a recovery approach therefore, need to emphasize hope, self-determination, a broad choice of services and equal participation in society.

At the national policy level New Zealand was an early adopter of the recovery approach in mental health services. The Mental Health Commission's Blueprint for Mental Health Services in New Zealand (1998) heralded the recovery approach. It was followed over the next few years by national policy documents in other English-speaking countries such as England, Australia and the USA (Australian Health Ministers, 2003; DoH, 2001; New Freedom Commission on Mental Health, 2003).

In 1998 the New Zealand mental health sector was ripe for innovation. By 2000, 30% of the country's mental health budget was spent on community-based non-government support services, enabled by the closure of all New Zealand's psychiatric hospitals in the 1990s and the introduction of a funder–provider split in health in 1993, where statutory specialist services were no longer the monopoly provider. The mid 1990s however, saw a crisis in confidence in the underfunded and under-developed deinstitutionalized services, and in response the government announced a national anti-discrimination campaign and a new Mental Health Commission with a systemic monitoring role. As a result of the crisis and the Commission's Blueprint, the government allocated additional funding for new services. Mental health became a government priority. Alongside these developments a Maori renaissance beginning in the 1970s advocated a holistic, family-centred, community-based approach to mental health and a range of Maori-led services were established. A national user/survivor movement which appeared in the 1980s also influenced the system towards a recovery orientation.

Against this background there was reasonably wide acceptance of recovery and opportunities to embed it in New Zealand's mental health sector over the next decade. However, recovery had been a point of discussion in New Zealand in the years preceding the Blueprint. Service users had semantic reservations about the word and its medical associations, some stating that recovery takes people back but their experience had transformed them, or others that they had no illness to recover from, and still others who believed that they had an illness from which they would never recover. Some professionals had their own concerns, that recovery was esoteric nonsense and lacked an evidence base (O’Hagan, 2004).

Some people, especially people with lived experience of mental distress and Maori, had other concerns about recovery that went deeper than semantics or uninformed criticism. The American literature from the 1980s and 1990s was strong on the individual process of recovery, especially the view that people with major mental distress have reason for hope, and that recovery is the service user's own unique, self-determined journey (Anthony, 1993; Deegan, 1988). But there were gaps in this literature, which paid little attention to the social, economic and political processes that also enable recovery. New Zealand is a slightly less individualistic country than the USA, and Maori have a very collectivist worldview; this threw the spotlight more clearly on the role of social justice, citizenship and countering discrimination as integral to recovery. New Zealand is also one of the few western countries to have made a systemic attempt to right the wrongs of the colonization of indigenous people. The American recovery literature through to the late 1990s was very mono-cultural, and New Zealand needed to acknowledge cultural diversity and a connection to one's own culture as a key to recovery. At the time much of the American recovery literature, coming from a psychiatric rehabilitation perspective, did not place a great deal of emphasis on challenging the veracity or the dominance of the biomedical and other deficits models in mental health services, or questioning compulsory treatment or professional power throughout the mental health system (Spaniol et al., 1997). These issues were core to the service user movement (Chamberlin, 1978).

The Blueprint reflected New Zealand's early thinking about recovery but it did begin to address some of the gaps in the recovery literature at the time. The Blueprint loosely defined recovery as ‘living well in the presence or absence of one's mental illness’ (p. 1). It mentioned the importance of hope and of social as well as personal responsibility. It stated that families, communities and people with mental health problems themselves need to be as actively involved in recovery as mental health services. The Blueprint also asserted that discrimination is the biggest barrier to recovery.

After the publication of the Blueprint the Mental Health Commission went on to lead the development of recovery and to define it more fully with a New Zealand flavour. At the same time literature from other parts of the world started to emphasize the social and human rights dimensions of recovery (Jacobsen & Greenley, 2001; Onken et al., 2002).

The first major publication after the Blueprint was the Recovery Competencies for New Zealand Mental Health Workers (Mental Health Commission, 2001). These competencies fell into ten major categories that are elaborated on in the text. A competent mental health worker understands recovery principles and experiences, supports service users’ personal resourcefulness, accommodates diverse views on mental health issues, has self-awareness and respectful communication skills, protects service users’ rights, understands discrimination and how to reduce it, can work with diverse cultures, understands and supports the user/survivor movement, and understands and supports family perspectives.

The Commission also published a research report, Kia Mauri Tau! (Lapsley et al., 2002), a thematic analysis of 20 Maori and 20 non-Maori people's narratives of recovery from disabling mental health problems. The research described people's journeys: mental illness shattered lives, and so recovery involved not just overcoming symptoms, but also developing personal resourcefulness and receiving support from others. Recovery processes were similar across cultures, but some contributors to recovery were identified that were uniquely Maori. As a result of mental illness and recovery, people said they had changed profoundly, knowing and liking themselves better, empathizing with others, and appreciating the important things in life.

Over the next few years the Mental Health Commission continued to publish documents that helped to articulate and define recovery for New Zealand (Mental Health Commission, 2004, 2006) and the Ministry of Health made recovery the centrepiece of its 10-year mental health and addictions strategy (Ministry of Health, 2005). New Zealand's Mental Health Advocacy Coalition (2008) went on to develop a vision for a recovery-based system entitled Destination Recovery. New Zealand remains a long way from the vision in Destination Recovery of zero discrimination, a service culture that fosters hope, self-determination, choice and social inclusion, a broad range of integrated services, the whole-government promotion of well-being for all, and a system that is genuinely accountable to the people that use it. The translation of recovery from policy to practice has remained extremely patchy. Although there are some examples of recovery-based funding, service development and practice, these tend to be the exception (Mental Health Commission, 2007). Like other similar countries over the decade, clinical services were increasingly driven by pressures to contain risk through locked wards, compulsory treatment orders and defensive practices (Undrill, 2007). This trend continues. While many statutory and non-government organization (NGO) services began to adopt recovery rhetoric, some recovery proponents believed that these services diluted the recovery concept to fit the status quo (Wallcraft, 2009).

From the mid 2000s national leadership for recovery began to wane in New Zealand. The Mental Health Commission published No Force Advocacy in 2006 which raised questions about the use of compulsory treatment in a recovery-based system; this received negative responses from some psychiatrists, family members and even the mental health legal fraternity. Some advocates for reform and recovery left key national positions. In 2008 the Director of Mental Health at the Ministry of Health wrote a paper cautioning services not to abdicate their responsibility to meet community expectations for safety in the name of recovery (Chaplow, 2008). At the end of 2008 a new government was elected which took mental health off the health priority list, cut funding in response to the global financial crisis and sought to give doctors and nurses more say in the health system. Energy for recovery and innovation dissipated. The Ministry of Health's mental health staff has been drastically cut and the Mental Health Commission, due to close in 2015, will now be closing in 2012.

New Zealand's closure of its psychiatric hospitals, the development of its non-government support services, the influence of Maori and service users, and its early adoption of a recovery approach earned it an international reputation. At a structural level, the ratio of funding for institutional and clinical services over community-based support services has remained quite stable over the last decade. But at a service culture level, the priority given to recovery and service user leadership has weakened as services struggle to survive and meet other government priorities. Current government workforce and service development documents still mention recovery as a clinical outcome or a personal process, but no longer highlight it as a core philosophy driving services (Mental Health and Addiction Service, 2011; Ministry of Health, 2011).

All is not lost, however. A few statutory services and more NGOs continue to try and innovate despite the current climate, and sometimes because of it. The waning of recovery as a driving philosophy does not necessarily mean a lurch to the past because other concepts are filling the gap and, some would argue, taking us beyond recovery. These concepts are whanau ora and other related Maori concepts, and well-being.

Whanau ora and Maori notions of recovery

Within New Zealand, Maori, the Indigenous people of the country, have a significant role in the way that mental health recovery is evolving. Maori make up approximately 15% of the overall population of over four million, with the median age for Maori being young at 22. By 2031, close to one third of all New Zealand school-age children will be Maori (Taskforce on Whanau Ora, 2010, p. 13).

The Treaty of Waitangi, signed by the British Crown and Maori chiefs in New Zealand, is regarded as key to the development of Maori health initiatives. Although signed in 1840, the document is considered a cornerstone of the ways that hapu (sub-tribes) develop a relationship with the Crown and its delegated authorities. The Treaty of Waitangi outlines a unique relationship between Maori and non-Maori that guarantees the well-being of Maori. Like all founding documents, the relevance of the Treaty has been debated between particular groups in the country, but since the 1980s numerous laws have included the Treaty and Treaty rights.

The most comprehensive survey completed on mental health in the country has been Te Rau Hinengaro: The New Zealand Mental Health Survey (Oakley Browne et al., 2006). It revealed a bleak picture for Maori, showing that over half of Maori had experienced a mental disorder in their lifetime and just under a third within the previous 12 months. It also showed that despite the high needs of Maori, contact with health services was low. When it came to hospitalization for mental disorder, Maori rates were 80% higher than those of non-Maori. Suicide rates among Maori youth were twice the rate of non-Maori, and one and half times as high for Maori up to the age of 44. Research has explained the disproportionately poor outcomes for Maori through poverty indicators, access to health provision issues, disconnection from cultural identity, racial inequalities and environmental factors, all of which are contributors to poor Maori health outcomes. New research in the country is now looking at intergenerational and historical trauma as a factor that has collective mental health outcomes (Health Research Council, 2011).

Whanau Ora

Since the 1980s New Zealand has seen the development of a wide range of Maori-led initiatives and services that have supported Maori language, culture, and Maori ways of delivering services. Today it is now possible for Maori to be educated in the Maori language, to access Maori health providers, to use Maori language in courts, to listen to Maori radio, and to watch Maori language television. This has largely happened through the flourishing of Maori community initiatives, changes in policy, and also increasing numbers of Maori working in health, justice and social services.

We are currently undergoing a radical shift in thinking about service delivery in the country. There is also an examination of where power should lie when it comes to health and svocial service delivery. Whanau Ora is a shift away from working with individuals to working with whanau, or extended family. In 2002 the policy direction for Maori health was outlined in He Korowai Oranga: Maori Health Strategy (Ministry of Health, 2002). Whanau or extended family became the new Maori health policy focus. He Korowai Oranga outlined a responsibility for the public sector to support the needs of whanau and to support whanau in ‘achieving their maximum health and well-being’. It focused on the need to proactively work with iwi (tribes), with Maori providers, with Maori communities and whanau themselves to improve health and reduce disparities. This was an important step forward, as for years Maori community workers had worked alongside whanau and had taken a ‘whole-of-whanau’ approach to their work, but this was not reflected in policy or mainstream service delivery (Rangihau, 1988). For Maori, the extended family is regarded as a source of strength, support, wisdom and identity. What was also important in He Korowai Oranga was that recognition was given to Maori views of health and well-being. Maori models of health and well-being had begun to be developed from the early 1980s with Professor Sir Mason Durie developing a model that included four dimensions of health that underpin Maori well-being, which includes: taha wairua (spiritual health), taha tinana (physical health), taha hinengaro (psychological health) and taha whanau (family health) (Durie, 1994).

In 2009 the Taskforce on Whanau Ora was established to progress the implementation of Whanau Ora policy. They emphasized the centrality of whanau as being the centre of the health picture with services needing to become more integrated, with the need to increase collaboration across state service agencies to reduce the ‘silo mentality’ of current service provision (Taskforce on Whanau Ora, 2010). The Taskforce emphasized the need for whanau to identify their own strengths, needs and priorities. When the Taskforce met with Maori throughout the country, whanau indicated that they were keen to be self-determining, economically secure and healthy.

What has also been emphasized in Whanau Ora is the rebuilding of relationships among generations. The unique relationships that exist within whanau, between the old and the young is crucial to the strength, dynamism and unique composition of whanau (Taskforce on Whanau Ora, 2010). Tariana Turia, the Minister for Whanau Ora, stated that her greatest role was one of strengthening cultural resilience in her grandchildren and great grandchildren by nurturing them in the lessons handed down through generations by elders (Turia, 2011). She also noted the risk factors for Maori that had an impact on mental health and well-being, including cultural alienation, institutional racism and the influence of historical, social and political processes. She commented that it is through drawing on Maori cultural resources such as language, culture and people, that these impacts can be mediated. (Turia, 2011).

Maori notions of recovery

Maori notions of ‘recovery’ and ‘well-being’ are located within a specific cultural, social and economic context. To understand Maori notions of recovery and well-being, a brief explanation follows of how the philosophical basis of Maori well-being differs from western notions. These principles include whakapapa (map of existence/genealogy), mauri (life force/essence) and hauora (health and well-being).

Whakapapa

Whakapapa is the core of understanding of any Maori framework. Whakapapa can be likened to a map of existence. All relationships of the world, the universe, and human existence can be located on the map. The directions or instructions contained within whakapapa are where Maori can draw knowledge and social responsibility.

Maori well-being is connected to whakapapa and being people of the land (Hawira, 2007). The importance of balance between Ranginui (Sky Father) and Papatuanuku (Earth Mother) is critical for a Maori view of well-being. This imbalance has become more pronounced with numbers of Maori becoming dispossessed of land and having no identity or standing in either the Maori or non-Maori worlds. This description gives a Maori explanation for the impacts of colonization and the dispossession from land, from cultural connections, from language, which results in unhealthy states of being.

Mauri

A key concept for well-being and vibrant health that is understood through whakapapa is mauri or life force. A common proverb said by Maori talks about how when the life force (mauri) of a person is strong, they have good health; but if the life force sickens, they could become ill or die. The state of a person's mauri therefore is a critical indicator for health and well-being. Pania Waaka (2008, p. 89) likens mauri to rivers of energy that pass through all of existence. She notes that Maori see everything as being related, but it is the quality of the relationship that is mediated by mauri.

Mauri therefore is important for assessing well-being of people and all aspects of creation. If we are to look at the health and well-being of whanau then we would say that whanau also have mauri. Pohatu and Pohatu (2004) state that particular actions will strengthen mauri, and other actions, events or traumas will weaken it. There are a number of things that can affect the mauri of whanau, including disconnection and fragmentation from land and each other, imbalance of relationships and roles with regard to each other, self-harm and harm to others, and disrespectful behaviour. All of the factors above can impact on the well-being of a family.

Hauora

Health, in a mainstream service provision sense, is usually talked about in relation to individuals and is generally talked about as an individual right. Maori, however, emphasize the health and well-being of the family. Hauora is a common term which is translated as health. However, within Maori thinking the origins of the term hauora came from Maori creation stories, where it refers to the gods breathing life into humans, and therefore animating human life and health (Waaka, 2008, p. 94). So implicit within the term are human responsibilities and obligations. Waaka (2008) says that in creation it is only with hauora, the breath of life, that shape, form, time and space then came to be.

Kepa and Reynolds (2005) use the term ‘genealogical nets’ to describe one of the critical factors for whanau resiliency when it comes to hauora of the elderly. At the heart of hauora they argue are cultural protocols – whanau, whanaungatanga (familial relations and relations of care) and kanohi kitea (being present and with family), which are key social relationships within Maoridom. These form intergenerational safety nets:

These genealogical nets or intergenerational families join elderly parents, sons and daughters and grandchildren to Maori health providers in provincial towns and rural centres in relations of access, utilization and culturally appropriate beliefs of sacredness and good heart, and practices of reciprocity or shared responsibility of care. (Kepa & Reynolds, 2005).

Maori and recovery

Recovery for Maori needs to be seen within the context of the strength of a person's identity within their whanau and hapu. It also recognizes the importance of reconnection with the natural world and a person's origins or whakapapa. Recovery recognizes a person nested within the generations, responsible for those younger ones and being mentored and guided by elders. This also means that respect for the place a person holds in whanau is important. Recovery also recognizes that healing is supported by the love of children and the presence of elders. Recovery therefore recognizes a web of relationships and support that derive from a person's extended family and tribe. When these important relationships are missing then this will have a significant impact on recovery.

Recovery recognizes the spiritual realms within which we are located and acknowledges that particular ceremonies can mediate the effects of spiritual harm. An example of this was when Maori Vietnam veterans returned from the war, they felt that without undergoing Maori ceremony to remove the ‘cloak of war’ they would still remain in a state of war and therefore in a weakened state (Te Atawhai o te Ao, 2010). Like many cultures, prayer is often daily communal practice among Maori. Prayers are reminders of our place in creation, where Maori epistemologies place humans as descendants of creation. Prayers remind us of the reverence and awe of the physical world such as water, mountains, lakes, seas, as well as the creation and existence of people in the world.

One of the best examples of how mental health recovery for Maori involves reconnection to identity is depicted in the film Awa Hikoi made in 2004 (Marbrook, 2004). The film documents the three-day canoe journey made by a group of mental health patients on the Whanganui River, situated in the central North Island of New Zealand. As the group travels down the river in regions where there are no roads, they visit the early living sites of their ancestors and learn about themselves and their culture. The film documents how those on the journey reconnect to their extended families and tribe, as well as strengthening their understanding of their own culture and spiritual beliefs. Those who participated in the journey talked of the powerful reconnections they made as they journeyed, how the journey with its challenges gave them renewed strength, and provided them with a new understanding of health and recovery.

Well-being

Another concept that has evolved alongside recovery in New Zealand and elsewhere is well-being. Recovery can be described as mental health or well-being promotion for people with mental distress. In the last decade or two there has been a burgeoning of new thinking and evidence about increasing the well-being of the whole population, sometimes addressed in terms such as positive psychology, happiness and social capital (Government Office for Science, 2008; Layard, 2005; Marmot, 2004; New Economics Foundation, 2004, 2008; Seligman, 2002; WHO & the Commission on Social Determinants of Health, 2008; Wilkinson, 2005; Wilkinson & Pickett, 2009). This work has improved our knowledge of well-being and loss of well-being – their determinants, consequences and the interventions needed for population well-being.

Although this work is as relevant for people with mental distress as it is for the rest of the population, the traditional continuum approaches to mental health and mental illness (Mrazek & Haggarty, 1994) segregate people with a diagnosis into treatment and services while those without a diagnosis are the target for prevention and promotion interventions. The recovery approach collapses this polarization because it focuses on increasing whole-life well-being, instead of primarily on treating people. There is also demographic evidence that well-being and mental illness are best viewed as two intersecting continua because some people with loss of well-being (languishing) have no diagnosable mental illness, whereas some people with a mental illness diagnosis have optimal well-being (flourishing) (Keyes, 2002, 2007).

Added to this, is evidence that the determinants, consequences and effective interventions for people with loss of well-being and a diagnosable mental illness are similar. The social determinants include trauma and inequality (Government Office for Science, 2008; Keyes, 2007; WHO & the Commission on Social Determinants of Health, 2008; Wilkinson, 2005; Wilkinson & Pickett, 2009). The consequences for both groups include less psychological resilience, poorer relationships, poorer productivity, poorer physical health and a shorter lifespan than for those with optimal well-being and no mental illness (Government Office for Science, 2008; Keyes, 2007; WHO & the Commission on Social Determinants of Health, 2008;Wilkinson, 2005; Wilkinson & Pickett, 2009).

There is an emerging evidence base for government interventions designed to increase the well-being of the population. These include wealth redistribution through taxation, sufficient income for all, stable healthy housing, support and coaching for parents, a broad education curriculum, lifelong access to education, stimulating the demand for skills, and fair employment laws. (Government Office for Science, 2008; Keyes, 2007; Layard, 2005; McDaid et al., 2007; New Economics Foundation, 2004, 2008; WHO & the Commission on Social Determinants of Health, 2008; Wilkinson, 2005; Wilkinson & Pickett, 2009). All these interventions are important for the recovery of people with a diagnosable mental illness. In addition to this some people with mental illness will need further interventions, such as therapeutic services, support for employment, housing, day-to-day living and in crisis, and programmes to reduce stigma and discrimination.

In New Zealand, well-being is beginning to be used alongside or instead of recovery in mental health circles. Although the current government has no explicit focus on well-being, the Mental Health Foundation, a major national NGO, has put its ‘focus on flourishing’ in its strategic direction (Mental Health Foundation, 2010). The foundation has developed well-being resources for New Zealanders and is investigating ways the government can measure well-being in the population.

Well-being work in New Zealand is also being generated out of the development of Maori models of well-being which show that notions of well-being can be culturally defined and understood. This is a critical understanding for working successfully with Maori and for developing interventions that will work for Maori.

Lessons

As this paper has stated, New Zealand made a contribution to the conceptual evolution of recovery but has a long way to go to fully embed a recovery approach in its mental health services. At this point recovery has not survived as the guiding principle for the development of services. The reasons for this are complex but they include a loss of leadership, dissipated stakeholder support and a failure to press the right systemic levers to realign service structures, processes and responses.

Moves in other countries to establish recovery-based systems may have more long-lasting success (Slade, this issue, Editorial). These include the use of recovery measures in the USA (Adams, this issue) and Scotland (Bradstreet, this issue), taking advantage of recovery-friendly trends in health such as personal health budgets in England (Perkins, this issue), supporting organizational transformation in England, the development of the peer workforce in Australia (Oades, this issue), Scotland, Canada (Piat, this issue) and the USA; programmes to reduce discrimination in Scotland, England and New Zealand; and programmes to eliminate seclusion and restraints and introduce trauma-informed care in the USA.

Future transformation efforts in New Zealand's mental health sector may not use the term recovery as the guiding principle but there are comparable terms we can use such as well-being, whanau ora, and other related Maori concepts. This may not be a bad thing. These concepts, used alongside or instead of recovery, may open the door to more innovation and fairer distribution of power and resources.

Whanau ora is causing an ideological shift in the country and pushing a focus on recovery being whole-family led rather than individually focused. It is also causing new conversations and collaborations, new ways of thinking about service delivery to meet the needs of individuals within extended family. Because of the community-based focus of whanau ora, government services are having to think outside their offices and their usual ways of doing business to respond to the needs of extended families.

Combining recovery with whole-population well-being may weaken the medical and deficits dominance within the mental health system if concepts, policies and service delivery for both groups are much more integrated. Moving recovery into the whole-population well-being agenda also has the potential to erode stigma and discrimination because people with a diagnosis of mental illness are no longer ‘other’; they share many experiences and attributes with anyone in the community who struggles with well-being. Finally, the combining of recovery and well-being could mean that more resources are made available to people with a diagnosable mental illness, because well-being is a whole-government responsibility, whereas recovery on its own has stayed largely a mental health sector responsibility.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.