Substance Use & Misuse

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Aug 31, 2001 - P. J. Robertson (Kai Tahu), M.A. (Hons), Dip. Clin. Psych.,*. A. Futterman-Collier, Ph.D., J. D. Sellman, M.B.Ch.B.,. Ph.D., S. J. Adamson, M.Sc.
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Substance Use & Misuse

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CLINICIAN BELIEFS AND PRACTICES RELATED TO INCREASING RESPONSIVITY TO THE NEEDS OF MĀORI WITH ALCOHOL AND DRUG PROBLEMS

P. J. Robertson ab; A. Futterman-Collier b; J. D. Sellman b; S. J. Adamson b; F. C. Todd b; D. E. Deering b; T. Huriwai b a Department of Psychological Medicine, National Center for Treatment Development, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand b National Center for Treatment Development, (Alcohol, Drugs & Addiction), Christchurch, New Zealand Online Publication Date: 31 August 2001 To cite this Article: Robertson, P. J., Futterman-Collier, A., Sellman, J. D., Adamson, S. J., Todd, F. C., Deering, D. E. and Huriwai, T. (2001) 'CLINICIAN BELIEFS AND PRACTICES RELATED TO INCREASING RESPONSIVITY TO THE NEEDS OF MĀORI WITH ALCOHOL AND DRUG PROBLEMS', Substance Use & Misuse, 36:8, 1015 - 1032 To link to this article: DOI: 10.1081/JA-100104487 URL: http://dx.doi.org/10.1081/JA-100104487

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SUBSTANCE USE & MISUSE, 36(8), 1015–1032 (2001)

CULTURALLY RESPONSIVE TREATMENT

CLINICIAN BELIEFS AND PRACTICES RELATED TO INCREASING RESPONSIVITY  ORI WITH TO THE NEEDS OF MA ALCOHOL AND DRUG PROBLEMS P. J. Robertson (Kai Tahu), M.A. (Hons), Dip. Clin. Psych.,* A. Futterman-Collier, Ph.D., J. D. Sellman, M.B.Ch.B., Ph.D., S. J. Adamson, M.Sc. (Dist.), Dip. Clin. Psych., F. C. Todd, M.B.Ch.B., D. E. Deering, M. Heal.Sc. (Dist.), and T. Huriwai, Dip. MHS (Te Arawa/Ngati Porou) National Centre for Treatment Development, (Alcohol, Drugs & Addiction), Christchurch, New Zealand

ABSTRACT Culturally responsive treatments are often cited as essential for successfully addressing substance use-associated problems in indigenous and other ethnic groups. However, there has been little investigation of the support for this assertion among alcohol and drug-user treatment workers, or how it might translate into clinical practice. The current paper reports on the results of a survey of the New Zealand alcohol and drug-user treatment field, which canvassed these issues.

* Corresponding author. National Center for Treatment Development, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand. E-mail: [email protected] 1015 Copyright & 2001 by Marcel Dekker, Inc.

www.dekker.com

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Eighty-six percent of respondents advocated adjustment of clinical practice when working with Maori. Two key strategies were referral to specialist Maori groups or individuals and/or contacting/meeting with wh anau (family). Comparisons were made between respondents who referred clients on and those who provided intervention themselves. Implications of results, limitations and future research are discussed. Key Words: Cultural responsivity; Treatment; Workforce; Survey.

Indigenous;

Maori;

INTRODUCTION There has been much discussion in recent times about the need to adapt health services and clinical practice to be more responsive to the needs of indigenous peoples and other ethnic groups, including Maori in New Zealand.1,2 Maori are the indigenous people of New Zealand, comprising approximately 15% of the total population. This discussion has been prompted in large part by continued disproportionately high representation of Maori in a range of negative health and social statistics.3,4 This over-representation is similar to that of other indigenous people, for example, in North America.5,6,7 Similarly these groups have parallel disproportionate representation in the criminal justice system.8,9,10 An area of primary concern in New Zealand is the high number of Maori with alcohol and drug-use related problems.11,12 The continued disproportionate representation of Maori and other indigenous people in negative health statistics is suggested by many Maori to be evidence that conventional approaches to addressing indigenous health issues, including substance use problems, have not been effective.2,8 Over the past decade the need to address cultural issues in relation to substance use and other health problems has increasingly been promoted internationally13,14,15,16 and in New Zealand.2,17,18 This has taken place in a socio-political climate, both locally and globally, in which the aspirations and needs of indigenous people have been increasingly to the fore.19 Increased understanding of the impact of cultural variables on health and wellbeing has developed and contributed to a cultural renaissance for many indigenous and other ethnic groups. In this context, Maori, as the indigenous people of Aotearoa/New Zealand, have increasingly demanded control over processes that influence their health and economic status. The Treaty of Waitangi established the parameters for relations between Maori and the Crown and, despite vigorous debate about its place

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in New Zealand today, has underpinned much of the progress made in developing more culturally responsive services for Maori. The Treaty was initiated in the early part of the 19th century by representatives of the Queen of England, as a prerequisite for establishment of English common law in New Zealand. Representatives of a significant number of Maori tribes, in part seeking to bring seamen, escaped convicts, and other settlers under control, co-signed the Treaty in 1840. Central principles of this Treaty include tino rangatiratanga (self-determination), maintenance of taonga (treasures), including health, and equity of access by Maori to the rights and privileges available to all New Zealanders. Attempts to address cultural factors in the area of health have seen progression from relatively rudimentary ‘‘cultural clip-on’’ in mainstream services, to attempts to develop bicultural programmes and dedicated services operating under a Maori kaupapa (principles).20 This progress has paralleled international development promoting relatively more sophisticated approaches to meeting the needs of ethnic groups in a range of health-related areas.13,16,21 Despite development of Maori focused services, many Maori continue to access so called ‘‘mainstream’’ services, such that non-Maori clinicians continue to have an impact on the progress of Maori in treatment. Recognition of this influence has contributed to development of more systematic approaches to ensuring that health workers have an increased awareness of the impact of cultural variables in clinical settings. ‘‘Cultural safety’’ programs put in place as part of nursing training in New Zealand22 represent one of the more far reaching efforts to develop greater cultural responsivity. There have been other attempts to meet the needs of Maori in a range of settings, including criminal justice,23 education,2 general mental health1 and in the treatment of alcohol and drug problems.18 There is emerging evidence, both in New Zealand and internationally, that attention to cultural issues increases client satisfaction and retention in treatment.24,25,26 In the alcohol and drug-user treatment field in New Zealand there has been considerable development in terms of establishing dedicated Maori services and to a lesser degree increasing responsivity of conventional service providers to cultural issues. However, to date there has been little systematic investigation into the nature or efficacy of these services. Further, there has been no comprehensive investigation of the level of support among clinicians for working with Maori clients in a way that is different from working with non-Maori clients. There has also been limited investigation of how being more responsive to the cultural needs of Maori might translate into clinical practice. Finally, there has been no substantive evaluation of how culturally responsive adaptation of clinical practice, general or specific, might contribute to more positive treatment outcomes.

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The current study represents a first step in the process of evaluating the relevance of addressing cultural variables in treatment, by investigating the degree of support for responding to the needs of Maori in a way that is different from working with non-Maori. It also represents a first attempt to identify specific ways in which alcohol and drug-user treatment workers currently adapt their practice in order to be more responsive to the needs of Maori.

METHOD Data for the current paper was gathered as part of a telephone survey of 90 alcohol- and drug-user treatment services in New Zealand undertaken by the National Centre for Treatment Development (Alcohol, Drugs & Addiction) in 1998. After gaining unanimous support for the survey from service managers, a random sample of 288 alcohol- and drug-user treatment workers was selected from the 527 potential participants. Of the final group of 223 potential participants who were contacted, 217 clinicians (97.3%) agreed to participate in the survey. The mean age of respondents was 42 and the majority were female (60%). Seventy percent identified ethnically as New Zealand European/ Pakeha, a quarter as Maori and the remainder with other ethnic groups, notably those from Pacific Islands. Participants reported on average six years experience in the alcohol- and drug-user treatment field with over half identifying as a counsellor/therapists and just under half identifying with one of four major professional groups (nursing, social work, psychology, medicine). Nearly three-quarters of participants were in full-time employment, with the majority working in the public health system, in outpatient services. A fuller description and discussion of participant characteristics and the methodology of the survey is outlined elsewhere.27

Questionnaire Four senior clinical psychology students were trained to apply the questionnaire, which was designed to be administered over the telephone in approximately 30 minutes. On contacting potential respondents, interviewers introduced themselves and reiterated the purpose of the survey, which had already been explained to services by managers and through written information. Anonymity of the individual and their service was assured, as was confidentiality. The questionnaire contained items on demographic and other personal information, including work site, age,

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qualifications and occupational group and geographic location. In addition, questions were asked to assess general alcohol and drug knowledge, clinical practice, attitudes about alcohol- and drug-user treatment and opinions on patient rights. Questions on issues related to the treatment of Maori with substance use problems provided the data for the current paper. Analyses of other aspects of the survey have been presented elsewhere.28,29

Questions Related to Working with Maori Participants were first asked a primary question: ‘‘In general, do you think people of Ma ori descent with alcohol and drug problems should be treated any differently to people not of Maori descent with alcohol and drug problems’’. If a participant responded in the affirmative they were asked to identify how they had adjusted their practice to be more responsive to the treatment needs of Maori clients. Specifically they were asked in what way the treatment they gave to their Maori clients over the previous month was different from the treatment they gave to their non-Maori clients. A range of response options (Table 1) was provided to guide interviewers’ recording, but no prompts were given to respondents. The list of response options was based on knowledge of practices commonly used when working with Maori clients. Definitions were purposely kept broad in order to capture and accommodate as wide a range of practice as possible and to provide a ‘‘broad brushstroke’’ picture. The main aim was the identification of any aspect of practice that had been adjusted in order to be more responsive to the needs of Maori clients.

Table 1. Response Categories Defining How Respondents Treated Maori Differently in Their Clinical Practice Referred to Maori health service or worker Contacted and/or met wha nau (family) Whakawhanaungatanga (making links/establishing common ground) Referred to Maori support group Cultural assessment (please specify) Said Karakia (prayer, incantation, chant) Offered cup of tea/kai (food) Waiata (song, chant, music) Mihi (‘‘structured’’ relatively formal greeting) Provided rongoa (Maori medicine) Other

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Statistical Analysis Response frequencies by groups for the primary question were obtained. Chi-square analyses were then performed on key grouping variables to compare positive and negative responses. The primary grouping variables considered included: gender, ethnicity (Maori, Pakeha/European, Pacific Island, Other), geographical location (rural/provincial vs metropolitan; South Island vs North Island – The majority of the population of New Zealand (3.5 million) live on two main islands, the South Island (approximately 25%) and the North Island (approximately 75%).) and work site (Government health organization vs non-Government organization; residential vs non-residential). Chi-square analysis was also performed to compare clinicians that adjusted their practice only by referring the client on and those who attempted some sort of ‘‘cultural intervention’’ themselves. As a result of the large number of grouping variables analyzed, only p values of .005 or less are reported as significant.

RESULTS Eighty-six percent of all respondents stated that clients of Maori descent should be treated differently to those not of Maori descent. Of this group, 77% identified at least one way in which they adapted their practice when working with clients of Maori descent. There were no significant differences related to gender, clinician ethnicity, work site, geographic location or age. The most common responses as to how participants treated Maori differently related to: referral on to a Maori health worker, service, or support group (70%); contacting and/or meeting with whanau (family/extended family) (40%); and whakawhanaungatanga (broadly defined as establishing common links) (25%). See Table 2 for the percentage endorsement for each item. A number of respondents also reported undertaking ‘‘cultural assessment’’, which primarily focused on issues of clients’ cultural identity, iwi (tribe) and ethnic affiliation and/or spirituality. Only small numbers of respondents identified other practices, but it is noted that participants could and did identify more than one practice. Comparison of respondents who only adapted their practice by referring Maori clients on with those who undertook some type of ‘‘cultural intervention’’ themselves revealed significant differences for the main grouping variables (Table 3). Maori and Pacific peoples were significantly more likely to undertake cultural intervention themselves compared to the Pakeha (New Zealanders of European ancestry) group. Those working in outpatient settings were more likely to provide ‘‘cultural intervention’’ themselves

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Table 2. Percentage of ‘‘Cultural Interventions’’ Reported by Respondents (N ¼ 144) Intervention

%

Refer to Maori health service or worker Contact and/or meet whanau (family) Whakawhanaungatanga (making links/establishing common ground) Refer to Maori support group Cultural assessment (please specify)* Say Karakia (prayer, incantation, chant) Offer cup of tea/kai (food) Waiata (song, chant, music) Mihi (‘‘structured’’ relatively formal greeting) Provide rongoa (Maori medicine)

46 40 25 24 13 7 3 3 1 1

*Cultural assessment primarily related to issues of identity, iwi and ethnic affiliations and spirituality. An ‘‘Other’’ option was also provided, with responses including: attending to spiritual issues, language, physical environment, process, epidemiological information, and socio-historic and political issues, as well as ‘‘taking a holistic approach’’. Respondents could and often did report that they applied more than one ‘‘cultural practice’’ when working with M aori clients.

compared with workers in residential settings. The same was true for respondents working in rural and provincial areas of the North Island compared with respondents from the South Island and those working in North Island metropolitan areas. However, analysis revealed no significant differences in terms of age, gender, professional group, education level, years in the field, alcohol and drug knowledge level, or level of respondent alcohol/nicotine use. Despite the significant differences that were found for several of the main grouping variables, it was notable that across the sample a high percentage of individual respondents provided some ‘‘cultural intervention’’ themselves for their Maori clients. A large number of Pakeha/European participants (61%), as well as those respondents working in residential settings (61%), and in metropolitan (64%) or South Island rural/provincial (57%) areas, undertook some intervention themselves, even though the main results indicated that as a group they did this significantly less than comparison groups.

DISCUSSION The results of the current study are consistent with increasing recognition internationally of the need to attend to cultural variables when devel-

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Table 3. Comparison of Respondents Who Only Referred on M aori Clients vs Respondents Who Provided Some Intervention Themselves (N = 144 )

Clinician ethnicity Maori Pakeha/European Pacific Island Work site Residential Outpatient Geographical location South Island Rural/Provincial Metropolitan North Island Rural/Provincial Metropolitan

Referred on only

Clinician intervened*

5% 39%

95% 61% 100%

39% 24%

61% 76%

p .000

.05

.003 43% 36%

57% 64%

5% 35%

95% 65%

*In some cases people in this group also referred their M aori clients on to someone else for further assistance.

oping treatments for indigenous people and other ethnic minorities.13,16,30,31 Strong support by the New Zealand alcohol- and drug-user treatment field for attending to cultural factors when working with Maori, particularly in relation to the process of engagement, is indicated by the results of the current survey. The fact that the majority of respondents, both Maori and non-Maori, affirmed the need to treat Maori clients differently to non-Maori clients may be seen as indicative of a high level of motivation to continue development of culturally responsive interventions. It is significant that a positive response to differential treatment was consistent across a range of variables, including gender, age, work site and geographic location. It is interesting to note however, that while some participants reported thinking it was important to treat Maori differently, they did not report actually doing anything to adapt their practice. There are likely to be numerous reasons why this endorsement was not translated into action, which unfortunately we are unable to deduce from the current data. However, we can speculate that some workers may be more willing and/or able to develop culturally responsive practice than others. Thus, the above response may be a result of paying ‘‘lip service’’ to cultural responsivity for some, while for others it may reflect a nervousness about practice in an area they feel uncomfortable in and/or lack knowledge of. Whatever the reasons for

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this discrepancy, the results of the current and previous studies suggest that many clinicians have some commitment to being more culturally responsive, but may be hampered by limited knowledge and/or lack opportunities to develop skills.32,33,34 The above notwithstanding, the current study indicates that alcoholand drug-user treatment workers in New Zealand are actively trying to adjust their clinical practice in order to be more culturally responsive. This frequently manifested in clinicians referring Maori clients on to Maori agencies or workers, which could reflect an unsophisticated or even tokenistic approach. This would not be surprising, given that there has been some resistance in New Zealand and internationally to addressing cultural issues as part of standard clinical practice.22 Additionally, consideration of cultural issues in the treatment of mental health problems is only a relatively recent phenomenon and to date culturally responsive treatment has frequently been of an elementary nature.20 Whilst it is not possible to definitively interpret these results, given the current study’s design, there are a number of factors that may have contributed to the tendency for respondents to refer Maori clients on to Maori services or individuals. In the New Zealand context non-Maori clinicians are frequently encouraged by Maori colleagues and/or service policy to refer Maori clients to dedicated Maori services or involve Maori health workers when working with Maori clients. The current results may in fact be indicative of heightened awareness of the limitations of conventional clinical training and models. Thus, referring on may actually reflect progress toward developing more culturally aware and responsive clinicians. The reported high rates of referral on to specialist Maori individuals or services may also be indicative of ‘‘mainstream’’ providers endeavouring to develop closer relationships with Maori service providers. It was not surprising to find that significantly more Maori than Pakeha respondents provided ‘‘cultural intervention’’ themselves, rather than just referring on. Even Maori clinicians with limited clinical training are likely to be able to offer ‘‘cultural intervention’’ at the level specified in the current study, if only by virtue of sharing broadly similar values, beliefs and experiences with many of their Maori clients. That is not to suggest that being Maori alone is sufficient to provide specialist, culturally focused treatment. Indeed, it is likely that the referring on reported by some Maori clinicians reflects awareness of their limitations dealing with certain issues and recognition of the need for even more specialised intervention. It was also notable that a relatively high number of Pakeha participants reported that they attempted to provide ‘‘cultural intervention’’. It is likely however, that there were important differences between the interventions of Pakeha and Maori respondents, given the generally greater

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familiarity of the latter with ‘‘things Maori ’’. This would be particularly apparent in dedicated Maori services or for people specifically identified as Maori workers. However, it is important to remember that there will be significant within group variance for both Maori and Pakeha in terms of the level of sophistication of the interventions provided. The current survey also highlighted differences in terms of geographic and service location (i.e. inpatient vs outpatient). The significantly higher clinician intervention recorded for North Island rural/provincial workers is not surprising, given the high number of Maori working in those areas and the limited availability of resources. Other differences, for example between residential and outpatient services, are more difficult to interpret without additional data.

Limits of the Current Study and Future Directions A number of results raised concerns about the potential for misinterpretation of questionnaire items related to what workers do and why they do it. With regard to the primary question related to ‘‘treating Maori differently’’, some Maori clinicians may have considered that they treated everyone the same, but in a ‘‘Maori way’’. Thus they may be working in what could be considered a culturally responsive way, but in responding to the survey failed to affirm such an approach. Conversely, some Maori respondents may have been wary of endorsing differential treatment given past experience of inferior differential treatment.35 While the current study sought to identify ‘‘cultural interventions’’ undertaken by respondents, the focus on macro level data precluded elucidation of the exact nature of these interventions. Interviewers’ limited knowledge combined with broad response categories for ‘‘cultural interventions’’, is likely to have constrained their ability to fully understand responses and clarify queries. An indication of this was the number of Maori who failed to identify mihi (‘‘structured’’ relatively formal greeting) as a way of treating Maori differently. Basic understanding of Maori protocol would lead one to expect that most Maori clinicians mihi when working with clients as a matter of course. This option may not have been reported by some Maori respondents as a result of their failing to identify this process as ‘‘different’’. More detailed comparison of the nature of the interventions provided by Maori and non-Maori would also be useful, as would clarification of the level of knowledge and expertise of those providing them. It is likely that different respondents who identified the same ‘‘cultural intervention’’ actually provided very different interventions. Identification of the use of

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whanaungatanga (making links/identifying ‘‘common ground’’) provided an example of this. It is likely that Maori would base their connecting on whakapapa (genealogy), while non-Maori would be more likely to base it on shared experience.36 The nature of the connection made could have significant implications for engagement and retention of clients, for example whakapapa would be likely to provide the basis for a stronger and more durable link. The results of the current study indicated that further research is needed to gain a more in-depth and detailed understanding of clinicians’ attitudes and approaches to working with Maori clients. Such research will require a narrower focus to allow evaluation of the level of understanding of the practices being implemented and expertise of those applying them, for example in relation to undertaking of ‘‘cultural assessments’’. Employment of Maori interviewers with a thorough understanding of the concepts being investigated and ability to clarify questions, especially for Maori respondents, would also strengthen future research. This would also be likely to alleviate a general wariness of research evidenced by many Maori.35 Finally, ensuring inclusion of smaller Maori alcohol- and drug-user intervention services and Maori general health agencies is essential if a more thorough understanding of the needs of Maori is to be developed.

CONCLUSION The data from the current survey, the first systematic investigation of the New Zealand alcohol- and drug-user treatment field, suggests that there is strong support by workers for consideration of the specific needs of Maori and adjustment of clinical practice when working with this client group. The results indicate that a broad range of people in this field are making efforts to be more responsive to the needs of Maori clients. In spite of some limitations, the current study provides answers to general questions about what workers do to be more culturally responsive, and facilitates comparison with international developments. While the results cannot provide more than a basic understanding of the nature of the interventions applied or the people applying them, the current study is an important first step in gathering broad baseline information about attempts to be more culturally responsive. In addition, the current study gives some direction for future research, in particular, in relation to workforce and service development. This will ultimately contribute to more detailed and systematic evaluation of the efficacy of alcohol- and drug-user treatments being undertaken with Maori in New Zealand. The results of such studies will obviously have implications internationally for other indigenous and ethnic groups.

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ACKNOWLEDGMENTS The authors particularly want to thank the busy clinicians who gave their time to answer the survey. We also wish to acknowledge the assistance of Cristina Fon, Rachel Lawson, Catherine Schulte and Jo Mulligan who collected the data, financial backing from the Alcohol Advisory Council of New Zealand and the support of the 90 contributing alcohol- and drug-user treatment services in New Zealand. Thanks also to Alison Pickering and Michelle Anngow for their assistance in the preparation of this paper.

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26. Huriwai, T.T.; Sellman, J.D.; Sullivan, P.; Potiki, T.L. Optimal Treatment for Maori with Alcohol and Drug Use Related Problems: An Investigation of Cultural Factors in Treatment. Substance Use Misuse 2000, 35(3), 281–300. 27. Sellman, J.D.; Futterman-Collier, A.; Adamson, S.; Huriwai, T.T.; Deering, D.; Todd, F.; Robertson, P.J. A National Telephone Survey of the Alcohol and Drug Treatment Field in New Zealand Part 1: Methodology and Demographic, Knowledge and Attitudinal Profile of the Workforce. Paper presented at Cutting Edge: Annual Alcohol and Drug Treatment Conference, August 1998, Wellington, New Zealand. 28. Adamson, S.J.; Sellman, J.D.; Futterman-Collier, A.; Huriwai, T.T.; Deering, D.E.; Todd, F.C; Robertson, P.J. A profile of alcohol and drug clients in New Zealand: Results from the 1998 national telephone survey. New Zealand Medical Journal, 2000,113, 414–416 29. Cowan, L.; Deering, D.; Crowe, M. Alcohol and Drug Treatment for Women: Clinicians’ Beliefs and Practices. Paper presented at Cutting Edge: Annual Alcohol and Drug Treatment Conference, August 1998, Wellington, New Zealand. 30. French, L. Native American Alcoholism: A Transcultural Counselling Perspective. Counselling Psychol. Quart. 1998, 2(2), 153–166. 31. Terrell, M.D. Ethnocultural Factors and Substance Abuse: Toward Culturally Sensitive Treatment Models. Psychol. Addictive Behav. 1993, 7(3), 162–167. 32. Abbott, M.; Durie, M.H. A Whiter Shade of Pale: Taha Maori and Professional Psychology Training. N. Z. J. Psychol. 1987, 16, 58–71. 33. Gilgen, M. Evaluation of Psychological Services Understanding of Tikanga Maori and Service Delivery to Maori Questionnaire. Paper presented at: New Zealand Psychological Services Division Annual Conference, March, 1994, Rotorua, New Zealand. 34. Sawrey, R. A Survey of Psychologists’ Opinions and Behaviour on Aspects of Ma ori Mental Health. Paper presented at the Annual Conference of the New Zealand Psychological Society, August, 1991, Wellington, New Zealand. 35. Stewart, T. Historical interfaces between Maori and psychology. In Mai I Rangiatea: Ma ori Wellbeing and Development; Te Whaiti, P.; McCarthy, M.; Durie, A.; Eds.; Auckland University Press: Auckland, 1997. 36. Metge, J. New Growth from Old. Victoria University Press: Wellington, 1995.

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RESUMEN Tratamientos de sensibilizacio´n cultural se citan frecuentemente como primordiales para abordar de manera eficaz los problemas de utilizacio´n de substancias en grupos indı´ genas ası´ como de otros grupos e´tnicos. Sin embargo existe muy poca investigacio´n que respalde este postulado entre trabajadores sociales en el a´rea del alcohol y del tratamiento de drogas, o co´mo podrı´ a implementarse a los medios clı´ nicos pra´cticos. Se reporta en los estudios actuales de una encuesta en Nueva Zelanda en el campo del tratamiento de alcohol y drogas en donde se investigaron estos problemas. Ochenta y seis por ciento de los entrevistados fueron partidarios de ajustes en la pra´ctica clı´ nica al trabajar con Maorı´ es. Dos estrategias claves fueron el remitir a los pacientes con grupos Maorı´ es y ası´ mismo organizar encuentros con la familia del paciente. Se realizaron comparaciones entre los entrevistados quienes remitieron pacientes ası´ como aquellos que proporcionaron una solucio´n. Las implicaciones de los resultados, limitaciones e investigacio´n a futuro son discutidas.

RE´ SUME´ Les traitements a` re´ponse culturelle sont souvent cite´s comme une approche positive essentielle aux proble`mes lie´s a` l’utilisation de la drogue ou de l’alcool chez les groupes ethniques indige`nes. Toutefois, tre`s peu de recherches ont e´te´ mene´es qui permettent d’affirmer cette assertion par ceux qui travaillent dans ce domaine, ou de meˆme la fac¸on dont cette approche pourrait eˆtre traduite dans la pratique me´dicale. Cet article expose le compterendu d’une enqueˆte re´alise´e dans le domaine Ne´o-Ze´landais du traitement des proble`mes lie´s a` la drogue et l’alcool, cette enqueˆte tente de sonder ce proble`me. Quatre-vingt-six pour cent des re´pondants ont recommande´ un adjustement de la pratique clinique lorsqu’ils travaillent avec les Maoris. Deux strate´gies clefs ont e´te´ la consultation de spe´cialistes Maoris en groupes ou individuals et/ou le contact/recontre de la whanau (la famille). Des comparaisons ont e´te´ e´tablies entre les re´pondants qui ont renvoye´ les clients a` cette approche et ceux qui ont fourni eux-meˆmes ce type d’intervention. Les implications des re´sultats, ses limitations et les recherches futures sont aussi discute´s dans cet article.

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THE AUTHORS Paul J. Robertson, M.A. (Hons), Dip. Clin. Psych., is of Ngai Tahu and Celtic descent. He is a lecturer at the National Centre for Treatment Development (Alcohol, Drugs & Addiction) (NCTD), Dept of Psychological Medicine at the Christchurch School of Medicine. His research interests and publications to date relate mainly to developing culturally responsive and effective treatments for Maori. His primary current research is a qualitative investigation of Maori men’s experience of treatment and recovery. Other areas of interest include gambling, coexisting disorders, psychological aspects of addiction and forensic issues. He is co-coordinator of ‘‘Addictions and Addictive Behaviour’’ and contributes to a number of other postgraduate papers. He also currently works as a clinical psychologist at the Christchurch Community Alcohol and Drug Service and has worked in the area of forensic psychology for a number of years. He is Chairperson of He Waka Tapu Trust which works with Maori men with violence related problems and is involved with several Maori alcohol and drug-user treatment services in a variety of capacities.

Dr. Ann Futterman-Collier was on faculty as Senior Lecturer and Co-Director at the National Centre for Treatment Development (Alcohol, Drugs & Addiction) (NCTD), Dept. of Psychological Medicine, Christchurch School of Medicine, at the time of this study. She received her B.S. (Psychology), M.A. (Clinical Psychology), and Ph.D. (Clinical Psychology) from the University of California, Los Angeles, and then went on to complete a post- doctoral fellowship is psychoimmunology and psycho-oncology at Memorial Sloan-Kettering Hosptial in New York. From 1991 to 1995, Dr. Futterman-Collier was an Assistant Professor in the Department of Psychiatry at the University of Colorado Health Sciences

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Center, conducting research and clinical work in the area of psychosocial oncology. From 1995 to 1997 Dr. Futterman-Collier worked in the Republic of Palau (Micronesia) as Chief Clinical Psychologist and developed and taught a countrywide substance abuse training and certification program. Dr. Futterman-Collier has taught coursework on alcohol and drugs to both undergraduate and graduate students, and is currently interested in research on domestic violence, child abuse, and treatment and recovery issues with indigenous peoples. She is currently on maternity leave. Doug Sellman, M.B.Ch.B., Ph.D., graduated M.B.Ch.B. from the University of Otago in 1980 and then completed postgraduate training in psychiatry in Christchurch, New Zealand, gaining his FRANZCP in 1987 and then his Ph.D. in 1997 on the topic of ‘‘Alcoholic Relapse.’’ He was the inaugural Director of the National Centre for Treatment Development (Alcohol, Drugs & Addiction) and was promoted to Associate Professor within the University of Otago in 1999. He is principal investigator of two currently funded projects, is collaborating with colleagues in several others, supervises a number of Ph.D. and Masters students and contributes to a range of undergraduate and postgraduate teaching programmes in the area of alcohol and drug and mental health. His clinical work since 1994 has been as consultant to the alcohol and drug stream of the Youth Specialty Service in Christchurch, a specialist mental health service for people aged 13–18 years. Simon Adamson, M.Sc. (Dist), Dip.Clin.Psych., graduated with Distinction from the University of Canterbury in 1997, having completed a Masters Thesis entitled ‘‘Drug Use and Crime in a Christchurch sample of Opioid Depen-dent Drug Users’’. He currently works as a clinical psychologist at the Community Alcohol and Drug Service, Christchurch, where he has been employed since 1996. Simon was appointed to the National Centre for Treatment Development (Alcohol, Drugs & Addiction) (NCTD) as Lecturer in 1997. Simon is currently involved in a number of projects within the NCTD. These include: being Principal Investigator for the National Treatment Outcome Project (NTOP) and being a co-investigator in several other studies. He is also involved in a full range of teaching responsibilities in the addictions field. Simon is currently studying for his

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Ph.D. examining psychological predictors of treatment outcome in alcohol and drug disorders. Fraser Todd, M.B.Ch.B., graduated M.B.Ch.B. from the University of Otago in 1985 and completed psychiatric training in Christchurch, receiving his FRANZCP 1997. He is a Senior Lecturer in the National Centre for Treatment Development (Alcohol Drugs & Addiction) (NCTD), part of the Department of Psychological Medicine, Christchurch School of Medicine. He also works clinically as a Consultant Psychiatrist working in an acute psychiatric inpatient unit and has research interests in the areas of cannabis and co-existing substance use and mental health disorders. Daryle Deering, M.Heal.Sci. (Dist.), is a lecturer at the National Centre for Treatment Development (Alcohol, Drugs & Addiction) (NCTD), Department of Psychological Medicine at the Christchurch School of Medicine. Her current research interests relate to the area of youth and alcohol and drug misuse and her Ph.D. topic is related to the evaluation of treatment for opioid dependence. Other areas of interest include the role of nurses in alcohol and drug service delivery, treatment for women, psychosocial interventions and working with families. She co-coordinates a postgraduate paper on therapeutic case management and contributes to a number of other papers. Her clinical and management roles have been within adult alcohol and drug outpatient treatment services and youth mental health, including alcohol and drug.

Terry Huriwai, Dip. MHS, is a Maori of Te Arawa and Ngati Porou descent. A Probation Officer by profession, he has also worked as Manager for Te Rito Arahi Maori Alcohol and Drug Resource Centre (a dedicated Maori non-residential alcohol and drug service. He is currently employed part time as a research and educator at the National Centre for Treatment Development (Alcohol, Drugs & Addiction) (NCTD), Dept of Psychological Medicine at the Christchurch School of Medicine. His research interests and publications to date relate mainly to advancing culturally safe and responsive interventions for Maori.

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