Lisa Cherrington

“See me as a whole
I am more than my cancer”
Te Whare Tapa Wha: A holistic model
of well-being
Lisa Cherrington, Clinical Psychologist/ Scriptwriter
This workshop was orgiinally presented in 2012 in conjunction with
CNN Equity Manger, Carol Wrathall, Pauline Wharerau (Maori
Cancer co-ordinator – Whakapai Hauora) Lorraine Searanke
(Kaiawhina for Ward 23, Te Whare Rapuora) and Lizzy Kent, Cancer
Psychology Service
Overview
What is Te Whare Tapa Wha (TWTW)?
What is Hua Oranga?
Practical application: Case study
Using Te Whare Tapa Wha as a stocktake, plan and
reflection when working with Maori clients and
whanau
WHAT IS TE WHARE TAPA WHA (TWTW)?
• A Maori model of
health/ well-being
developed by Mason
Durie in 1980’s
• Holistic view of wellbeing that states in order
to be at one’s optimal
health, all area’s need to
be in balance and
working order
• Each dimension is
integrated, intertwined
TE WHARE TAPA WHA
Te Taha Hinengaro
The capacity to communicate,
to think and to feel (Durie,
1998)
Te Taha Hinengaro
Mind and body are inseparable
Cultural/ clinical issues:
•Use of te reo to communicate
•Beliefs about cancer, what’s causing it?
•Understanding/ comprehension about medical
treatment process
•Feelings of isolation/ disconnection in medical
system
•Beliefs about tikanga, tapu/ noa, wairua
•Whakama
•Pouri
•Lack of motivation to engage in treatment process
Te Taha Tinana (physical
health and environment)
The capacity for physical growth
and development (Durie, 1998)
Good physical health is necessary for optimal
development (Durie, 1998)
Sacredness of the body - Tapu and noa emphasis
Taha tinana is turning to nature for herbal
compassion, utilising rituals for physical
appeasement, keeping the soul and body intact
(Te Roopu Awhina Tautoko, 1987)
Practical issues – income, housing, food
Te Taha Tinana
Cultural/ clinical issues
Western medicines AND rongoa/ karakia
Sense of tapu about own body parts
Hospital environment – eating, washing,
toileting in same place
Shelter and food are priorities?
Accessing medical system at a very late stage
Urban vs rural/ turangawaewae
Te Taha Whanau (family and
relationships)
The capacity to belong, to care
and to share (Durie, 1998)
Te Taha Whanau
Refers to family, extended family and sense of
belonging and connection with
The capacity to belong, to care and to share (Durie,
1998)
•Individuals are part of wider social systems (Durie,
1998)
•Identity/ whakapapa/ connection
•Interdependence a strength
TE TAHA WHANAU
Clinical/ cultural issues
• Identity as a Maori
• Tuakana/ teina
• Kuia/ kaumatua
• Obligations to whanau
• Whakapapa
• Whanau, hapu, iwi connections
• Whakawhanaungatanga – sense of connection with
family AND medical staff
• Whanau beliefs about cancer
• Support from whanau – Is it appropriate?
• Expectations of whanau, ability of whanau to
communicate with clinician’s
• Involvement with other groups/ associates (gangs,
sports, church, Maori)
Te taha wairua (spirituality)
The capacity for faith and wider
communion (Durie, 1998)
Te taha wairua (spirituality)
Te taha wairua is probably the most difficult area to define,
assess and understand – yet it is the most important
area and intertwined with every other taha
-
Refers to spiritual well-being, not just religion
- Beliefs in a non-physical dimension or force (Kingi,
2002)
-
Health is related to unseen and unspoken energies
(Durie, 1998)
-
A relationship also with the environment and ancestors
- Intuition (which is also connected to hinengaro)
Taha Wairua is…
the unforgettable cry of birth
the magical moment of natural death…
…Taha wairua makes the intolerable, tolerable
the biased, objective;
despair, hopeful
and man kind, God like
It is the seed for world peace, the power for brotherly
and sisterly love and the crucial element for the maturity
of mankind…(Te Roopu Awhina o Tokonui, 1987)
Wairua
Na Heather Delamere Thomson
“Koro, what is wairua?” the child asked, eyes wide
“Wairua, my moko is what gives us life
Handed down to us from a time past
At the moment of your beginning
You shared with me the wairua of your tipuna:
For I am your link with the past
And you are my link to the future
The aroha of the whanau has wairua
And their words, their laughter, their tears
The marae, tangi, waiata and whakapapa
Have a wairua that strengthens us, gives us pride
So too the sunrise and sunset
The soft summer rain, the raging storm,
The song of the birds in the trees,
The waves on the beach
The mist rising from the bush
The moonlight on the water
And the embracing darkness of the night
To sit quietly in the wharenui or the urupa
And feel the presence of your tipuna is to feel wairua
Your arms around my neck, your breath on my cheek,
Fills me with a special wairua
For there is wairua in all things that give meaning to life
To love, to the future
So moko, open your mind,
Let your heart love
Your eyes see
Your ears hear
Your hands feel
Give of yourself, my moko
For in giving, you receive
And the wairua grows.”
Na Heather Delamere Thomson
Te taha wairua
Clinical/ cultural issues
Beliefs and connection with spirituality and
/or religion
Tapu and noa
Makutu, mate Maori – what’s causing cancer?
Use of and beliefs in tohunga, rongoa,
karakia, moemoea, purakau, taonga, tohu
Tangihanga
Life’s purpose
Connecting with spirituality – how do they
do this?
What makes them feel centred, uplifted in
some way (ie listening to music, going to the
ocean, laughing with their children)
Rona’s story:
26 year old Maori woman on Ward 29 who had just had her stomach
removed as she had recently been diagnosed with stomach cancer and
family had been identified as having stomach mutation gene.
Other family members were being tested for the gene and cancer.
Rona’s mother had been diagnosed with stomach cancer. Rona had
been living in Fiji with her 4 year old daughter and partner, but had
come back to New Zealand with her daughter to be with her mother.
Family members noticed that Rona had lost a significant amount of
weight and Rona had reported stomach pains. Rona had been
informed by her mother’s own GP that her symptoms were ‘all in her
head’ and ‘learned behaviour.’ However, family members advocated
for Rona to be tested because of the mother’s own cancer.
On the day that Rona’s mother died, Rona had been informed that
her own stomach cancer was not terminal. However, she would need
to have her stomach removed.
A family member who knew about the Cancer Psychology
Service made the initial referral. The aunty was concerned
for Rona’s psychological well-being as Rona had a previous
history of self-harm and bipolar disorder.
In meeting with Rona on Ward 29, she identified frustration
at only being able to eat small amounts of food and did not
like that she was continuing to loose weight. “I don’t do
skinny. I want my baby rolls back. I want to feel like a
woman.”
She was trying to organise for family to bring her daughter up
to hospital to see her and finding money to do so as her
daughter was in Himatangi with whanau. Her partner in Fiji
had broken up with her, telling her that he could not handle it
anymore. Rona’s focus at the initial meeting was on ‘all that
I have lost.’
See me as a whole,
I am more than
my cancer
Using Te Whare
Tapa Wha form,
‘stocktake’ – what
are the pumanawa
(strengths)
and kia ata titiro
(area’s of
attention)
What else would
we want to learn
about Rona?
How do we honour each taha when
working with Maori diagnosed with
cancer?
Hua Oranga (Maori Mental Health Outcomes Measure)
(Kingi, 2002)
Developed a Maori mental health outcomes measure
based on Te Whare Tapa Wha
Through consultation/ hui with key stakeholders
identified components within each taha as a way to
evaluate outcomes of interventions
Clinician, whanau and tangata whaiora forms
Useful questions to ask ourselves when working with
Maori cancer patients
As a result of this intervention do you/ does your
patient/ whanau member feel…
Te taha hinengaro:
Capacity to communicate, think and feel
*Motivation – As a result of the intervention are you more
able to set goals for yourself?
•adherence to treatment regime
•engaging in healthy life style behaviours (exercising,
food)
•disengaging in unhealthy life style behaviours (addictions)
*Cognition and behaviour – As a result of this intervention
are you more able to think, feel and act in a positive
manner
- reaction to a cancer diagnosis, distress
- sense of control over what is happening
- behaviours/ attitudes/ communication with clinicians
-attendance at appointments
*(Kingi,2002)
Te taha hinengaro
The capacity to communicate, think and feel
*As a result of this intervention are you more able
to manage your thoughts and feelings
•ways of expressing distress – verbal, physical,
anger, sadness
•whakama – not asking questions or not wanting
to be different
* As a result of this intervention do you have a
better knowledge and understanding of the
problem?
•cultural beliefs around cause of cancer
•understanding of medical system – treatment
options, statistics
Te Taha Tinana
Capacity for physical growth and development
* Mobility and pain- ability to move around without pain
and distress
- need for 24hr nursing care
-home environment
* Opportunity for enhanced health- commitment to good
physical health
- accessibility of services
- sense of control over cancer process
- commitment to improving physical health – diet,
exercise, adherence to tx regime, life style factors
Te Taha Whanau
The capacity to belong, to care and to share
*Communication – ability to communicate
With medical staff
about cancer process with whanau
death and dying issues, tangihanga
*Relationships – confidence
- state of relationships with whanau, staff, clinicians
*Mutuality
- whanau obligations
- mai and atu
- change in status – from well to sick
* social participation
- participation in other groups within community – Maori
organisations, gangs, cancer community
Te Taha Wairua
The capacity for faith and wider communion
DIGNITY AND RESPECT – feeling valued as a
person
As a result of this intervention do you feel more
valued as a person?
- treatment process
CULTURAL IDENTITY – strong as a Maori person
As a result of this intervention do you feel
stronger in yourself as a Maori person?
-
Te taha wairua
The capacity for faith and wider communion
* Personal contentment
As a result of this intervention do you feel
more content within yourself?
-identifying what might assist with feeling more
content, more at peace
* Spirituality
As a result of this intervention do you feel
healthier from a spiritual viewpoint?
- spiritual practises
- karakia, prayers, rituals of significance for client,
church
- creative processes – singing, drawing, writing,
building
Get into groups according to your professional background
(4 groups)
Using Te Whare Tapa Wha what pathways / plan would you
recommend for this case?
Feedback to whole group.
Are there any similarities or differences?
Does the plan/ recommended pathways:
1.
2.
3.
4.
Enhance her capacity to communicate, think and feel?
Enhance her capacity for physical health and development?
Enhance her capacity to belong, to care and to share?
Enhance her capacity for faith and wider communion? In
particular:
• Does she feel more valued as a person?
• Is she stronger in herself as a Maori person?
• Is she more content within herself?
• Healthier from a spiritual view point?
We connected
We shared stories
We laughed a lot when the time was right
We gave each other a hard time
We talked about rituals
We talked about being in te po
And that te ao marama will come
We talked about strength and where hers came from
We talked a lot about whanau
We cried.
Te Taha Whanau –Relationships
with Maori health professionals
Who are our Maori health professionals working specifically with Maori
cancer patients and whanau?
Maori cancer co-ordinators:
Polly Marsters (Te Runanga o Raukawa – Levin/Otaki)
Doris Peeti (Te Kete Hauora – Dannevirke)
Chrissy Paul (Te Wakahuia, PN)
Kathkeen Hollaway-Smith (Best Care Whakapai Hauora, PN)
Te Whare Rapuora – PN Hospital:
Lorraine Searanke (Kaiawhina for Ward 23, Te Whare Rapuora)
HOW DO WE
HONOUR TE
WHARE TAPA
WHA WHEN
WORKING WITH
MAORI CLIENTS
DIANGOSED WITH
CANCER?
1)Think holistically – See me as a whole
2)Reflect using Te Whare Tapa Wha
3) Ask yourself the four outcome
questions:
Will this enhance his/her/their:
• capacity to communicate, think and
feel?
• capacity for physical health and
development?
• capacity to belong, to care and to
share?
• capacity for faith and wider
communion?
I’m a solo Mum
Rona:
I’m a good parent
I’m a solo Mum
I’m a part time care
assistant for the elderly
I’m the tuakana
I’m part of a whanau who
has this gene
I’m a beneficiary
I’m a Maori woman
I’m a pain sufferer
I’m a good mate
I’m a listener to my Mum
and Grandma
I’m an advocate (so give
me a job )
I’m more than my cancer