New spaces and possibilities: The adjustment to parenthood for new migrant mothers

DeSouza, R. (2006). New spaces and possibilities: The adjustment to parenthood for new migrant mothers. Wellington, New Zealand.

I recently completed a report for the Families Commission about migrant maternity, based on interviews with new mothers in Auckland and with the help of Plunket and many colleagues (see the acknowledgements in the report).

Parenthood and migration are both major life events which, while stressful, can be mediated effectively with appropriate support. International research indicates that parenting in a new country without support, networks or access to information creates additional stressors.

There is a paucity of research about the transition to parenthood in New Zealand for migrant families and this research project explores the maternity experiences of women from five different migrant backgrounds. It is a starting point for further research about migrant families and the development of a migrant family life-cycle research agenda.

Forty migrant women were interviewed about their experiences of the adjustment to parenthood in a new country in order to ascertain their support needs. Early motherhood was chosen as a focus because migration policy selects healthy women and therefore the maternity experience is often when many migrant women are first initiated into the New Zealand health system. In consultation with Plunket, five groups were chosen for the study; three were from the largest Asian communities, Chinese, Indian and Korean (Chinese make up 44 percent of all Asians, Indians 26 percent and Koreans 8 percent). Two other new migrant groups were also selected for inclusion for different reasons. European migrant women were chosen because they are the largest migrant group yet little is known about their needs. These are assumed to be similar to those of other Pa-keha- because of their familiarity with language and systems. Arab Muslim women were chosen because their faith and cultural needs are not well understood. One focus group was undertaken for each group. AUT University’s Centre for Asian and Migrant Health Research and the Royal New Zealand Plunket Society conducted the research together in March 2006.

KEY FINDINGS

It is hoped that the research findings will inform policy, the development of appropriate resources and other research in this area, and will assist both health professionals and migrant communities in New Zealand. The key findings of the research were that:

  • migrant women lose access to information resources, such as family and friends, in the process of migrating and come to depend on their husbands, health professionals and other authoritative sources. Importantly, the expectations from their country of origin come to inform their experiences of pregnancy, labour and delivery in a new country
  • migration has an impact on women’s and their partners’ roles in relation to childbirth and parenting. The loss of supportive networks incurred in migration results in husbands and partners taking more active roles in the perinatal period
  • coming to a new country can result in the loss of knowledge resources, peer and family support and protective rituals. These losses can lead to isolation for many women.

RECOMMENDATIONS

The findings of the research suggest that:

  • support services for women who have a baby in a new country need to be developed and services also need to be ‘father-friendly’
  • the information needs of migrant women from all backgrounds need to be considered in planning service delivery (including European migrant women)
  • services need to develop linguistic competence to better support migrant mothers, for example by providing written information in their own language
  • those developing antenatal resources must consider the needs of migrant mothers; for example, by having antenatal classes available in a number of common languages, eg Korean
  • workforce development occurs among health professionals to expand existing cultural safety training to incorporate cultural competence
  • health and social services staff must become better informed as to the resources that are available if they are to provide effective support for migrant mothers.

FUTURE RESEARCH

Further research is required to:

  • explore the experiences of New Zealand-born women to identify whether the issues raised in this report are peculiar to migrant women or to women in general
  • explore the information needs of migrant parents through the family life-cycle
  • identify the factors that support breastfeeding in the absence of social support
  • understand the experiences of migrant father
  • understand the needs of additional migrant groups, including African, Middle-Eastern and Latin American communities
  • review the effectiveness of cultural safety for migrant women by focusing on outcomes.

Advice to a student nurse

My response to  a student nurse who was haunted by questions about becoming a nurse. Published in Kai Tiaki: Nursing New Zealand 13.1 (Feb 2007): p4(1).

I was pleased to see [x} letter, Questions haunt nursing student, in the December/ January 2006/2007 issue of Kai Tiaki Nursing New Zealand (p4). The questions she has reflected on indicate she is going to be an amazing nurse.

I believe nursing is both an art and a science, and our biggest tools are our heart and who we are as human beings. I was moved by her letter and thought I’d share my thoughts. The questions she posed were important because the minute we stop asking them, we risk losing what makes us compassionate and caring human beings.

Let me try to give my responses to some of the questions Lisa raised–I’ve been reflecting on them my whole career and continue to do so.

1) Can a nurse “care” too much?

Yes, when we use caring for others as a way of ignoring our own “issues”. No, when we are fully present in the moment when we are with a client.

2) Don’t patients deserve everything I can give them?

They deserve the best of your skills, compassion and knowledge. Sometimes we can’t give everything because of what is happening in our own lives, but we can do our best and remember we are part of a team, and collaborate and develop synergy with others, so we are resourced and can give our best.

3) How do I protect myself and still engage on a deeper level with the patient?

I think we have to look after our energy and maintain a balance in our personal lives, so we can do our work weft. We also need healthy boundaries so we can have therapeutic communication.

4) How do I avoid burnout?

Pace yourself, get your needs met outside work, have good colleagues and friends, find mentors who have walked the same road to support you. I’ve had breaks from nursing so I could replenish myself.

5) Why can’t I push practice boundaries, when I see there could be room for adjustment or improvement?

I think you can and should, but always find allies and justification for doing something. Sometimes you have to be a squeaky wheel

6) Isn’t it okay to feet emotionally connected to the patient?

Yes, it is okay to feel emotionally connected to the patient, but we also have to remember that this is a job and our feelings need transmutation into the ones we live with daily.

7) Don’t I need to continually ask questions, if nursing is to change, or will that just get me fired?

Yes, you do have to ask questions but it is a risky business. Things don’t change if we don’t have pioneers and change makers.

8) Finally, am I just being a laughable year-one student with hopes and dreams, and in need of a reality check?

No, your wisdom and promise are shining through already and we want more people like you. Kia Kaha!

Becoming informed health care consumers: Asian migrant mothers in NZ

Presented at the Prevention, protection and promotion. Second International Asian Health and Wellbeing Conference, November 11,2006.

Cite as: DeSouza, R. (2006). Becoming informed health care consumers: Asian migrant mothers in New Zealand. In S. Tse, M.E. Hoque, K. Rasanathan, M. Chatterji, R. Wee, S. Garg, & Y. Ratnasabapathy (Eds.), Prevention, protection and promotion. Proceedings of the Second International Asian Health and Wellbeing Conference, November 11, 13-14, (pp. 196-207). Auckland, New Zealand: University of Auckland.

Abstract
A central tenet of New Zealand’s midwifery and maternity services is the emphasis on a partnership between two equals namely the midwife and the woman. However, such a partnership rests on the notion of an informed consumer who is independent. When the consumer is a migrant who has experienced social upheaval, lost their knowledge resources and is experiencing isolation and language barriers, they may take up a more dependent role rather than the autonomous and self-determining consumer that midwives are prepared for. This imbalance can mean that health professionals are challenged to take up less facilitative and more authoritative positions and in turn migrant mothers and their partners are challenged to develop more proactive roles. This paper presents partial and preliminary findings from a qualitative study of Asian mothers in New Zealand with regard to their information needs.

Introduction
The notion of a partnership between the midwife and the woman underpins New Zealand midwifery models, where both parties are equal and make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. However, for women become equal partners, they need to make informed decisions about their health and this in turn depends on having access to relevant and timely information. For mothers, biological knowledge about the pregnancy, birth and labour is only one form of knowledge. In addition, social knowledge and institutional knowledge are important (Lazarus, 1994). While biological knowledge can be obtained from authoritative sources like experts and electronic resources, social and institutional knowledge are more difficult to access for migrant women. AS access to these forms of knowledge is dependent on context and social networks which migrant mothers often lose in the social upheaval of migration. For many women who migrate, the separation from family and peers leads to ‘breaks in knowledge’ (Fitzgerald et al., 1998) and the loss of these knowledge resources which help prepare the mother for the processes of pregnancy, childbirth and parenting, creates what Liem (1999, p.157) calls a “vacuum of knowledge”. The vacuum of knowledge needs to be filled and most often this role falls heavily on health professionals (DeSouza, 2005).

This paper begins with a description of the dramatic population changes in New Zealand with a particular focus on Asian women. A discussion about receiving accurate and timely information follows suggesting that the quality of communication between women and their carers is critical for feeling safe and satisfied with care. An outline of research conducted in Auckland New Zealand follows and the findings are presented through the transition to parenthood. Strategies for managing the transition to parenthood and becoming an informed consumer are discussed with the paper concluding with practice, policy and research recommendations.

Literature Review
The following section contextualises the study by reviewing the changing demographics in New Zealand society with a focus on Asian women. This is followed by a discussion about the link between information and communication and satisfaction with care for migrants.

An increasingly diverse New Zealand
Service providers need to develop skills and competence for working effectively with diverse members of New Zealand society. International trends show that people of diverse racial, ethno-cultural and language backgrounds are underserved by health and social services, experience unequal burdens of disease, experience cultural and language barriers to accessing appropriate health care, and receive a lower quality of care when they do access health care services in comparison with members of the population (Johnstone & Kanitsaki, 2005). The 2001 Census revealed growing numbers of M␣ori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), in addition to European/Pakeha who make up 79.6% of the population. There has been a 20% increase in the number of multilingual people and an increase in people whose religion was non-Christian. People who practice Hinduism increased by 56%, there was a 48% increase in Buddhists and a 74% of people practising Islam.

Asians are the fastest growing ethnic group; increasing by around 140% over the last ten years and predicted to increase by 122% by 2021 due to net migration gains rather than high fertility rates (Statistics New Zealand, 2005). The Asian community has the highest proportion of women (54%), (Scragg & Maitra, 2005) who are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups, a reflection of a skills focused migration policy. 23% of New Zealand women were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands. Some of the most dramatic demographic changes are evident in the Asian community, for example in the period between 1991 and 2001, the number of women originating from the Republic of Korea increased 23 times from 408 to 9,354, numbers of women from China quadrupled from 4,620 to 20,457 and women from South Asia doubled in the same time period (Statistics New Zealand, 2005). Such diversity has been unprecedented and present both unique challenges and opportunities to health and social service providers and policy makers.

Communication, caring and safety
Migration often results in the loss of reference points in the form of family networks, peer support and familiarity with health services. Such a loss amplifies the necessity for receiving accurate and timely information. Davies and Bath (2001) suggest that information provision during pregnancy and childbirth is critical for both supporting choices that are made but also in preparing women to manage uncertain outcomes. Citing a study by Kirkham (1989), Davies and Bath argue that women’s satisfaction with maternity services in secondary care is primarily dependent on the quality of communication between the women and their carers. Little is known about the health care experiences of migrant women, however, they are thought to report more acute concerns about communication and sensitivity of care than the population in general (Davies & Bath, 2001). Furthermore, language barriers can exacerbate isolation and promote dependency on health workers rather than enhancing self- determination, a dominant midwifery discourse. Small, Rice, Yelland, & Lumley (1999) found that Vietnamese, Turkish and Filipino women in Melbourne who were not fluent English speakers experienced problems in communicating with their caregivers and this made experiences of care less positive. Of more importance than knowledge about cultural practices, was care experienced as unkind, rushed, and unsupportive. Another Australian study found that migrant patients (and their families) did not feel safe when in hospital. Safety was undermined when effective communication with caregivers was compromised through being unable to access qualified health interpreters or being unable to have family members around to advocate and participate in decision-making (Johnstone & Kanitsaki, 2005).

The study
Migrants tend to maintain better health than the local population initially so often have little to do with hospitals (McDonald & Kennedy, 2004), but motherhood is a common aspect of migration requiring contact with the health system. The study took place in Auckland, New Zealand among White migrants (from South Africa, United Kingdom and the United States of America), Muslim Arab migrants (from Iraq and Palestine) and Asian women from three ethnic communities (Korean, Chinese and Indian) as part of a larger Families Commission funded study. Ethics approval was obtained from the Auckland University of Technology Ethics Committee and the Plunket Ethics Committee. Participants for the migrant mothers’ focus group were recruited though Plunket nurses who invited women to participate, selection criteria limited participation to migrant women who had become mothers within the last 12 months in New Zealand. Informed consent was obtained from all participants and consent forms were translated into Arabic, Korean and Chinese. Data collection involved focus groups using semi-structured interviews conducted in English, Chinese and Korean. The groups were facilitated by interviewers proficient in English and the language spoken by the women. These interviews were recorded and transcribed, translated into English if necessary and verified by an independent translator. The interview transcripts were then coded and analysed. The codes were clustered according to similarity and reduced. Similar phenomena were grouped into categories and named. The process was one of constant comparison, iteratively classifying and grouping the material to identify preliminary categories and sub- categories. This paper reports on a sub-theme about information needs and the findings focus on Asian women.

Findings
Midwives caring for migrant Asian parents are challenged to reconfigure their model of partnership and in turn migrant Asian parents experience a shift from birth being a social event to more of an individual responsibility. This shift requires a more proactive and self- sufficient role for women and their husbands, who become more involved than they might have been in their country of origin. In addition, language and communication drive experiences of care. This separation from knowledge resources places greater responsibility onto midwives to assume a more central role in information provision and support. In particular migrant mothers require detailed, individualised, stage specific information in order to take up the role of informed consumer.

Antenatal period
Not only are migrant mothers confronted with changing bodies and roles when they become pregnant, they also have to deal with an unfamiliar health system in the absence of a support network and knowledge resources they might have had in their countries of origin. In this study, Asian migrant women had to make decisions that required access to information in order to ascertain the choice of maternity carer and access to ante-natal classes. At this time women who were not fluent or confident English speakers had to contend with linguistic and cultural barriers to accessing services.

The loss of traditional sources of knowledge meant that pregnancy in a new country moved from being a social event and responsibility to being an individual one (DeSouza, 2005). This required the participants to become more involved and proactive in seeking out detailed, timely and specific information about the stages of their pregnancy. This allowed them to become more involved in the pregnancy than if they had been in their country of origin where this responsibility would have been shared. Husbands also became more involved in the processes of pregnancy, than they might have been in their countries of origin. Knowing where to begin the process was difficult:

I had no idea at all about the system here. It was through the pregnancy test kit that I found out I was pregnant, but did not know what the next step was. I wondered whether I had to show my test result to my GP. I had no knowledge of how to get the necessary information [Korean participant].

Obtaining language specific and precise information was important for many Korean women. Being given broad encouragement was not a substitute for specific information and was perceived as a laissez-fare attitude to their wellbeing.

I was given some information, but I didn’t read it, as it was not in Korean. I always felt that I was one step behind. It was not only the midwife who did not give enough information or necessary support. Everyone kept saying, “It is okay, you are doing well” but gave few information or specific support [Korean participant].

Pregnancy in a new country raised the need to develop active decision making strategies and to choose a health care provider. Many of the women were proactive about finding out about the New Zealand health system and turned to authoritative sources for information:

Luckily, I was attending school and the assignment from school was to complete a project. I chose ‘New Zealand’s maternity system’ and that was how I got some ideas about my situation [Korean participant].

For some women the absence of family members and the access to information meant that they could monitor themselves through the stages of pregnancy and this led to developing increased knowledge and greater self-sufficiency:

I have to take care of my own self. I found this good thing in New Zealand that you should take care of the baby and you should be aware of foods and what is going on each and every month, each and every week, what really is important [Indian participant].

One Indian woman found that she was more engaged in her pregnancy because her previous pregnancy was a joint responsibility with other family members while this time round she had to take more personal responsibility:

Why didn’t I get the feelings the first time? Time passed with families, mother in law, sisters, brothers and time passed like anything but here we are alone,  thinking about the baby early and so every moment for me was a first time moment, even though I’m a second time mother [Indian participant].

Many husbands become more involved during the pregnancy and were more in tune with what was happening to their partner’s bodies:

We used to wake up and the first thing we used to do was take a book and read ‘Okay, so now our baby’s doing that’ and he will pat me on my tummy saying ‘Oh my little one’ you know? So I doubt whether the same feeling would have come if my pregnancy was in India [Indian participant].

Language dictated the choice of LMC for many Chinese women and they, more than any other cohort, relied on their networks to find a care provider with Chinese newspapers also being a useful knowledge resource.

She speaks English and can speak Chinese. After I met her, I had a good impression of her. So I decided to have her as my midwife. My midwife has a partner who is also a Chinese (Malaysian Chinese). When I gave birth to my child, her partner delivered my child. The whole process was quite smooth [Chinese participant].

Antenatal classes
Antenatal classes were a pivotal mechanism for acquiring knowledge:

When you know something it’s better than just going without knowledge and you’re worried. , Yeah and as a first time mother I didn’t really know what was going to happen or what to expect and then yeah, I learnt a lot from that [Indian participant].

And for gaining confidence about what was to come by having some broad knowledge about what was to come:

I felt it was not so relevant to my delivery. But I felt more at ease and more confident during delivery. There are Chinese people in the class. The midwife was also careful when teaching us. We could understand her. My husband’s English is very good. He escorted me to the class. It was about some basic ideas. I didn’t find it useful for my delivery. During delivery, you follow the instructions of your midwife and have no time to reflect on what was taught in the class. But you feel relieved and less anxious. You roughly know what is going to happen and what is what [Chinese participant].

But language barriers made classes inaccessible for some:

I felt frustrated because I could not understand everything [Korean participant].

Both my husband and I have poor English so only attended once [Korean participant].

This section highlighted the importance of receiving detailed and specific information in one’s own language and how this influences the choice of LMC or attendance at ante-natal classes. Knowing where to start can be difficult. For women and their husbands who want to take up an informed consumer role there are resources available which lead women and their husbands to be more self-sufficient, proactive and engaged in the process.

Labour and delivery
Labour and delivery was also a time when information, support and cultural needs were highlighted. Women wanted information that was specific to their stage of labour and that was individualised (some felt they had too much and others too little information to feel that they could make the best choice for themselves). The value of specific stage by stage information was supported by a Korean participant rather than broad encouragement:

In Korea mums are given lots of warning and feedback of what is happening during labour, and told by Dr’s what to do regularly. This was missing in NZ. It would be good to be given feedback of our progress of labour and how many cm we are at each stage after the vaginal examinations. I was not told this. Not enough explanation and only told that “You are doing well” [Korean participant].

The need for not only specific information but also to be told the best option or given enough information to make the best choice was also voiced. The facilitative role of health providers was called into question with some participants wanting a more authoritative role. The partnership between the midwife and the woman underpins the midwifery model in New Zealand maternity services and is based on equity and the acknowledgement that both parties make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. Midwives have moved from authoritative sources of knowledge to models of partnership and collaboration in a bid to empower women and distinguish themselves from the more hierarchical professional models of medical, nursing and obstetric practise (Tully, Daellenbach, & Guilliland, 1998). However, this is predicated on the notion of the informed consumer:

In NZ different delivery options are given to mums and we are asked to choose by ourselves but unable to choose the best options for ourselves due to lack of sufficient knowledge. Want more advice and guidance and even want to be told which better option for us is. So in the end we have limited options due to not enough knowledge of all the pros and cons of delivery methods [Korean participant].

Information does need to be individualised, one participant who felt that she was given too much information:

During the labour the ladies said that I need an epidural because I can’t go through the pain anymore, the anaesthetist comes in the room and says out of 150 million there are 10% of cases with risk all that information beforehand [Indian Participant].

This section has highlighted the importance of detailed and specific information and the need for information to be individualised. The midwifery model of care which emphasises facilitative rather than authoritative relationships was challenged.

Post-partum
The postnatal period is a critical time for women but it is also a time when their needs are often not met (Baker, Choi, Henshaw, & Tree, 2005). In the postpartum, information needs were an issue, women needed to know how to handle an unpredictable and unknown baby, there were issues around feeding from a cultural point of view and what to feed and when, the amount and type of information became important too:

We need more information. Iron deficiency for example. We don’t know what to feed our babies for this. And solid feeding too. We don’t know how to begin solid feeding with Korean food. The information is only on Kiwi way of feeding [Korean participant].
I didn’t even know how to care for her after delivering baby. No knowledge. Had to cook and clean and do everything after delivering baby , had no one to help. Breastfeeding was hard, received no help. Got sore bones and joints. No Korean appropriate services available, so often missed out altogether on information and the right kind of help [Korean participant].

However, not everyone wanted to be an informed consumer:

Yeah, you just want to get out of that place and these people are giving you like the advantages and disadvantages of various things, you don’t want to hear all these things [Indian participant].

The post-partum period highlights the need for the expansion of the information agenda from New Zealand models of infant feeding to incorporating other cultural models and the need for language specific information about breastfeeding. Some women contested the pressure to be informed consumers. The following section provides some discussion and recommendations.

Discussion

This section focuses on five key areas where further exploration and consideration by both migrant mothers and health professionals would be beneficial, namely:

  • Providing detailed and individualised information;
  • Language support;
  • Preparing women for new discourses of maternity;
  • Developing fluency; and
    Developing health literacy.

Providing detailed and individualised information

Health-care providers have a responsibility to make available, accessible and up-to-date information. However this is not as easy as it sounds, when facilitating informed choice. Midwives and other health professionals are caught in a difficult position and have to strike other balances, such as between giving enough information for the woman to make a choice but not giving too much information and frightening her (Levy, 2006). They also have to delicately meet the needs of women and to appear neutral in their advice, when they might have strong feelings regarding certain issues. In this study, migrant mothers looked to health professionals to fill the vacuum of knowledge by being authoritative rather than facilitative. Increasingly research shows that information is more effective when it is tailored to the individual and their needs (Rapport et al., 2006) and relevant to the women’s current stage of pregnancy (Benn, Budge, & White, 1999). In addition detailed information rather than ‘big picture’ was valued. Therefore highlighting the need for individualised and detailed information when planning for the provision of maternity information (Soltani & Dickinson, 2005). Information that is available in ones own language or written information is important. While translated information is available about childbirth in New Zealand from the Maternity Services Consumer Council of New Zealand it is not clear how well this information is distributed or whether LMCs are aware of its existence.

Language support
Communication as a part of information support can be improved through implementing a two pronged strategy. First, health professionals and systems can become more skilful at information provision through linguistic competence and secondly through identifying and assisting in the extension of sources of information. Health providers can assist new migrants to identify information sources and encourage women to develop information seeking skills. Developing linguistic and cultural competence can be achieved by:

  • Providing bilingual /bicultural staff;
  • Providing foreign language interpreting services; Having link workers/advocates; and     Having materials developed and tested for specific cultural, ethnic, and linguistic
    groups;
  • Having translation services including those of:Legally binding documents (for example, consent forms); Hospital signage; Health education materials; and Public awareness materials and campaigns, including ethnic media in languages other than English. Examples include television, radio, internet, newspapers and periodicals (Szczepura, 2005).

In the USA, health care organisations are required to both offer and provide language services such as bilingual staff and interpreter servicesat no extra cost to clients who require it. It is recommended that information about services is provided both in writing and in a timely manner with credentialed interpreters and bilingual workers available (U.S. Dept. of Health and Human Services, 2003).

Lastly, research is needed to assess the level of unmet information needs among new migrant women in greater depth. To borrow from a recommendation from a recent study:
Research is needed on cross-cultural and intercultural communication in particular on the nature and impact on Culturally and Linguistically Diverse (CALD) people not being able to communicate with service providers; not being able to get information and explanations about ‘what is going on’; not being able to get information in a timely manner; not being given information in a culturally appropriate manner; not being given any information at all; being given too much information; being given unwanted information (Johnstone & Kanitsaki, 2005, p.15).

Preparing women for new discourses of maternity
The study findings highlight the need for health providers to assist women socialise into new discourses in particular the discourse of partnership and the informed consumer. A useful mechanism for socialising women into an informed consumer discourse is to provide multi- lingual antenatal classes. Many women in this study felt the need for specific and detailed information in order to make the best choice but some women also wanted to be told the best option. The facilitative role of health providers was called into question with some participants wanting their LMC to have a more authoritative style. The partnership model underpinning midwifery in New Zealand maternity services assumes that midwives bring their knowledge, skills and experience and women brings their knowledge of themselves and their families to the relationship. This is intended to be a collaborative and empowering relationship but it requires that the woman wants the responsibility of being an informed consumer. It appears that the notion of partnership cannot contain women who don’t want the equal responsibility that is required. In addition, one needs to be information literate in order to take this role on (Henwood, Wyatt, Hart, & Smith, 2003).

Developing fluency
Lack of English language proficiency impacts on access to health care, employment prospects, income levels and other factors which determine health status (Asian Public Health Project Team, 2003).The link between language and accessing health care is further strengthened by the findings of a New Zealand study where self-rated fair or poor health was found to be associated with Chinese-only reading knowledge, residency of more than five years and regretting having come to New Zealand (Abbott, Wong, Williams, Au, & Young, 2000). While a study of Chinese American women which found that lack of English language ability was a major barrier to access (Liang, Yuan, Mandelblatt, & Pasick, 2004). Ensuring that migrants are aware of Language line and encouraging them to take up their English for Migrants language courses, as proficiency is a key settlement enhancer. The migrant levy that migrants pay when coming to New Zealand entitles migrants to take up English language classes (English for Migrants). The Tertiary Education Commission pays for English language tuition on behalf of migrants to New Zealand who have pre-paid for their training, recent news reports indicate that few migrants take up these classes.

Developing health literacy
The development of health literacy among health care recipients is gaining prominence as a health promotion strategy. Health literacy is defined by the World Health Organisation as “ the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” (World Health Organization, 1998, p.10). Health literacy is a stronger predictor of health status than socio-economic status, age, or ethnic background (Speros, 2005). Speros claims that the lack of health literacy can act as a barrier to navigating the system and functioning successfully as a consumer, presumably then the combination of socio-economic status, ethnic background and low health literacy compound the issues of access. Speros cites a large study by Williams et al. (1995) which found that one-third of English -speaking patients at two public hospitals in the USA could not read and understand basic health-related materials. Sixty per cent could not understand a routine consent form, 26% could not understand information written on an appointment slip, and 42% failed to comprehend directions for taking medications. While little is known about health literacy is known in New Zealand, overseas research suggests that being culturally and linguistically different magnifies the problem.

Conclusion
This study highlights the importance of information provision for health care consumers, in particular migrant mothers. The study shows that migrant women frequently experience a vacuum of knowledge that needs to be filled. Factors such as poor English language proficiency, limited networks and unresponsive health providers can all increase the likelihood of migrant mothers experiencing a problematic birth experience and poor outcomes. This research suggests that improving the quality and range of information for migrant mothers and the inter-cultural resources for health providers could improve outcomes.

Further research is needed into how maternity information is provided and it is suggested that more attention is paid to the information needs of migrant mothers and migrants in general. Language proficiency is vital not only with regard to access to services but also for being empowered and prepared for the dual transition of parenthood in a new country. The study highlights the need for further exploration of changing demographics on dominant health care discourses in New Zealand such as partnership and whether there is space for new discourses. There are several aspects that contribute to a satisfying experience of health care for migrant mothers and these appear to be the ability to access a service, being able to obtain relevant information and having a supportive relationship between themselves and providers. These appear to be mutually dependent factors.

Acknowledgements

Funding for this research was provided by grants from The Families Commission and the Plunket Society volunteers in Central Auckland. The following people are gratefully acknowledged for their contributions: The mothers, Elaine Macfarlane, Sheryl Orton, Michele Hucker, Dr Wanzhen Gao, Rose Joudi, Paula Foreman, Rezwana Nazir, Lorna Wong, Jane Vernon, Zahra Maleki, Nagiba Mohamed, Hyeeun Kim, Catherine Hong and Stephanie Shennan.

References

  1. Abbott, M. W., Wong, S., Williams, M., Au, M. K., & Young, W. (2000). Recent Chinese migrants’ health, adjustment to life in New Zealand and primary health care utilization. Disability & Rehabilitation, 22(1/2), 43-57.
  2. Asian Public Health Project Team. (2003). Asian Public Health Project Report. Auckland: Ministry of Health Public Health Directorate.
  3. Baker, S., Choi, P. Y. L., Henshaw, C., & Tree, J. (2005). I felt as though I’d been in jail’: Women’s experiences of maternity care during labour, delivery and the immediate postpartum. Feminism & Psychology, 15(3), 315-342.
  4. Benn, C., Budge, R. C., & White, G. E. (1999). Women planning and experiencing pregnancy and childbirth: Information needs and sources. Nursing Praxis in New Zealand, 14(3), 4-15.
  5. Davies, M. M., & Bath, P. A. (2001). The maternity information concerns of Somali women in the United Kingdom. Journal of Advanced Nursing, 36(2), 237-245.
  6. DeSouza, R. (2005). Transforming possibilities of care: Goan migrant motherhood in New Zealand. Contemporary Nurse, 20(1), 87 – 101.
  7. Fitzgerald, M., Ing, V., Heang Ya, T., Heang Hay, S., Yang, T., Duong, H., et al. (1998). Hear our voices: trauma, birthing and mental health among Cambodian women. Paramatta: Ausmed.
  8. Henwood, F., Wyatt, S., Hart, A., & Smith, J. (2003). ‘Ignorance is bliss sometimes’: constraints on the emergence of the ‘informed patient’ in the changing landscapes of health information.Sociology of Health and Illness, 25(6), 589-607.
  9. Johnstone, M.-J., & Kanitsaki, O. (2005). Cultural safety and cultural competence in health care and nursing: An Australian study. Melbourne: RMIT University.
  10. Lazarus, E. S. (1994). What do women want?: Issues of choice, control, and class in pregnancy and childbirth. Medical Anthropology Quarterly(8), 25-26.
  11. Levy, V. (2006). Protective steering: a grounded theory study of the processes by which midwives facilitate informed choices during pregnancy Journal of Advanced Nursing, 53(1), 114-122.
  12. Liang, W., Yuan, E., Mandelblatt, J. S., & Pasick, R. J. (2004). How do older Chinese women view health and cancer screening? Results from focus groups and implications for interventions. Ethnicity & Health Issue, 9(3), 283-305.
  13. Liem, I. I. L. (1999). The challenges of migrant motherhood: The childrearing practises of Chinese first-time mothers in Australia. In P. L. Rice (Ed.), Asian mothers western birth (pp. 135-160). Australia: Ausmed.
  14. McDonald, J. T., & Kennedy, S. (2004). Insights into the ‘healthy immigrant effect’: Health status and health service use of immigrants to Canada. Social Science and Medicine, 59(8), 1613-1627.
  15. Pairman, S. (2001). International trends and partnerships in midwifery education. New Zealand College of Midwives(24), 7-10.
  16. Rapport, F., Iredale, R., Jones, W., Sivell, S., Edwards, A., Gray, J., et al. (2006). Decision aids for familial breast cancer: Exploring women’s views using focus groups. Health Expectations, 9(3), 232-244.
  17. Small, R., Rice, P. L., Yelland, J., & Lumley, J. (1999). Mothers in a new country: The role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia. Women Health, 28(3), 77-101.
  18. Soltani, H., & Dickinson, F. M. (2005). Exploring women’s views on information provided during pregnancy. British Journal of Midwifery, 13(10), 633 – 636.
  19. Speros, C. (2005). Health literacy: Concept analysis. Journal of Advanced Nursing, 50(6), 633-640. Statistics New Zealand. (2005). Focusing on women. Retrieved January 25, 2005, from
  20. http://www.stats.govt.nz/analytical-reports/children-in-nz/growing-ethnic-diversity.htm
  21. Szczepura, A. (2005). Access to health care for ethnic minority populations. Postgrad Med J, 81(953), 141-147.
  22. Tully, L., Daellenbach, R., & Guilliland, K. (1998). Feminism, partnership and midwifery. In R. Du Plessis & L. Alice (Eds.), Feminist thought in Aotearoa/New Zealand (pp. 245-255). Auckland: OUP .
  23. U.S. Dept. of Health and Human Services, (2003). Training culturally competent primary care professionals to provide high quality healthcare for all Americans : the essential role of Title VII, Section 747, in the elimination of healthcare disparities : third annual report to the Secretary of the U.S. Department of Health and Human Services and to Congress. Washington, D.C.: U.S. Dept. of Health and Human Services, Health Resources and Services Administration.
  24. World Health Organization. (1998). Health promotion glossary. Geneva: Division of Health Promotion, Education and Communications Health Education and Health Promotion Unit, World Health Organization.

Researching the Health Needs of Elderly Indian Migrants to New Zealand

DeSouza, R. (2006). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, 20 (1&2), 159-170.

The older adult population in New Zealand is increasing and becoming more ethnically diverse. With this change comes a requirement for health and social service professionals to become more knowledgeable about the cultural needs of their clients and to provide care that is cognisant of language, culture and religion. Indians have a long history of settlement in New Zealand; however this has not been reflected in policy or service provision. The reasons for this include a focus on the bicultural relationship with indigenous Mâori and a relatively small Indian population. The Immigration Act 1987 has led to an increase in the cultural diversity of migrants and the number of Indians. Policy has not kept pace with demographic changes and there is a need to develop the health sector to work with Indians and other migrants. This article begins by tracing the changing demographics of age and ethnicity in New Zealand and the relationship with migration policy. Indian history, settlement and health in New Zealand are explored then a brief overview of existing research is presented along with the identification of gaps and recommendations for an expansion of current health research and practice agendas such as cultural safety and ethnicity data collection.

Keywords: Indians, health, settlement, Asian, older adults, New Zealand

Migrant Populations

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

The art of walking upright here

Is the art of using both feet.

One is for holding on.

One is for letting go. (Colquhoun, 1999, p.32)

Glenn Colquhoun’s poetry captures the challenge dislocation from home and family. The migrant or refugee has to somehow hold on to their legacy and their heritage whilst simultaneously letting go of those things that cannot be maintained in a new country. They must let go to create new lives, so they can stake a new claim of belonging; a new place to stand.

One in five New Zealanders was born overseas. This rises to one in three in Auckland. For many, migration is seen as a way of obtaining a better life, particular for ones children. Whilst many migrants make informed decisions, this needs to be seen as a continuum between full choice and no choice. This can been viewed as a ‘pull’ effect (migrants are drawn to a new country for the opportunities available) or a ‘push’ effect (the motivation is simply to leave where they are). Migrants can be defined as people who were born in one country and then move to another under an immigration programme. In New Zealand this consists of three main streams:

  •  Skilled/Business: Which relates to attracting migrants with qualifications and skills, or the potential to create business opportunities in New Zealand.
  • Family sponsored: Where New Zealand citizens or permanent residents can sponsor family members to the country.
  • Humanitarian: This includes refugees and allows for family members to be granted residence if there are serious humanitarian concerns.

Refugees that have resettled in New Zealand mostly originate from Africa, the Middle East, South East Asia and Eastern Europe. Refugees differ from voluntary migrants because they were forced to leave their home and have little if any choice in selecting their destination. They are at the extreme end of the ‘push’ effect, often having fled from situations of conflict and human right abuses. This has important implications for the provision of  health care, as they might not have had access to preventative and treatment services. Most refugees arriving in New Zealand will spend six weeks at the Mangere Refugee Reception Centre (MRRC) in South Auckland. There are estimated to be 20.6 million refugees and displaced people in need of protection and help (UNHCR, 2003). Currently New Zealand accepts a United Nations-mandated quota of 750 refugees per year, plus approximately the same number again of asylum seekers. Asylum seekers are people seeking refugee status without legal documentation. They often experience depression, hopelessness and helplessness related to stress and socio-economic deprivation. Even where migration is an informed choice, the result can still be isolation and loss of financial independence. Before migration, one often only considers the positives; it can be difficult to understand the adjustment that is required and to come to terms with the losses of family, friends, culture and familiarity.

In this chapter I present a view of cultural safety and how it is relevant to health from the perspective of a migrant with a view to informing those who will be caring for the needs of migrants and refugees. I will briefly review the history and tensions around migration and migrants. Anecdotes from my clinical experience are woven through the text to present multiple layers to reflect the complexity of the experience and reflective questions are posed to increase self-awareness. I conclude by offering a range of strategies for working with diversity.

The ‘small’ things count in caring

Editorial published in Kai Tiaki: Nursing New Zealand 8.10 (Nov 2002): p28(1).

KAI TIAKI Nursing New Zealand has recently carried narratives written by nurses discussing their experiences as recipients of health care, eg “My Journey of Pain” by Glenis McCallum (July 2002, p16). These experiences gave the nurses the opportunity to re-examine their practice and to reclaim their empathy.

Similarly, a personal experience provided the impetus to write this brief piece. I recently had the opportunity to re-evaluate my own beliefs about nursing and the importance of communication and caring when I witnessed my sister receiving care in a hospital maternity setting. What came across was the importance of the “small” things–the caring and the communication, and the importance of compassion and empathy. The sweetness of the person who opened the door to the unit and said “welcome to our world”. The rudeness, almost surliness, of the nurses who forgot to introduce themselves or tell us what was happening.

Rightly, there is much focus on nursing as a profession, yet is it possible that in this debate we have forgotten the small things that really matter to our clients -the things that make people feel safe and cared for?

This personal and professional interest was further piqued by two workshops held in Auckland recently that focused on maternal mental health issues. Both highlighted the important role nurses have to play when caring for women experiencing childbirth.

In the first workshop, organised by the education and support group, Trauma and Birth Stress (TABS), 170 consumers and health professionals gathered to explore post-traumatic stress disorder (PTSD) after childbirth. The group TABS was formed by women who had all experienced stressful and traumatic pregnancies or births that had negatively affected their lives for months or even years after the experience. One of TABS’s aims is to educate health professionals on the distinctions between PTSD and post-natal depression so the chance of misdiagnosis is lessened and correct treatment is started quickly.

Speakers at the workshop included an international nursing researcher from the United States, Cheryl Beck. A number of New Zealand women have shared their stories of PTSD with Beck and have found telling their stories and having someone understand and believe them has been very therapeutic. Other speakers included TABS member Phillida Bunkle and Auckland University of Technolgy midwifery lecturer Nimisha Waller who spoke on how mid wives can assist mothers with PTSD.

In my role at UNITEC Institute of Technology, I organised the second workshop, which also featured Beck. Entitled “Teetering on the edge: Postpartum depression–assessment and best practice”, the workshop attracted around 100 nurses, midwives, GPs and consumers. A professor in the School of Nursing at the University of Connecticut, Beck has for many years focused her efforts on developing a research programme on postpartum depression. Using both qualitative and quantitative research methods, she has extensively researched this devastating mood disorder that affects many new mothers. Based on the findings from her series of qualitative studies, she has developed the postpartum depression screening scale (PDSS). Currently Beck’s research is focused on PTSD after childbirth and she presented her work to date. In September, there were 27 participants in the study, 18 from New Zealand and the rest from the United States.

The themes of her presentation were a reminder of the dramatic negative consequences of occurrences we as health professionals deal with frequently. Emergency situations arise and we all do our job, often without a second thought as to the future impact of our actions (or inactions) on the woman and her family.

Beck also spoke at the TABS work shop. The response to both workshops was really positive. Workshops such as these, where the long-term impacts of the health care experience are discussed, can act as a reminder for anyone working with women at and around the time of childbirth to critically view their practice and that of their colleagues. Themes that feature in the research are around caring, communication and competence–the very things that were absent in my recent experience of the health system. Women in the study felt they were not shown caring, communication from health providers was poor, and they perceived their care as incompetent.

Through her research, Beck poses the question so many mothers ask: “Was it too much to ask to care for me?” As health professionals, we need to ask ourselves every day “how can I care for the needs of this client?”, because nursing is not just a profession, it is a caring profession.

* For further information on TABS http://www.tabs.org.nz/

Care of the person with Borderline personality disorder in the community

First published online by Ruth DeSouza 1997

Abstract

The development of community-based models of care in New Zealand has led to dramatic changes in the treatment available for people with mental illnesses. However, we appear to be failing to provide comprehensive coordinated and continuous care for clients diagnosed with Borderline Personality Disorder (BPD). One major problem is the stigma and dread that many community mental health nurses equate with the care of people diagnosed with BPD, resulting in the care given being limited and fragmented. This article examines the trauma paradigm for viewing BPD and provides an overview of the knowledge and skills that are required to care for people diagnosed as having a borderline personality disorder within the community .

Introduction

Kaplan and Sadock (1991) define personality as both emotional and behavioural traits that characterise the person and state that personality is stable and predictable to some degree. Thus, a personality disorder is a deviation from the range of character traits that are considered “normal” for most people. When these traits are inflexible and maladaptive and the result is distress and impaired functioning they are considered to be a class of personality disorder. Of the ten different personality disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), one of the most controversial is Borderline Personality Disorder (BPD).

There is much debate around the definition and diagnosis of BPD (Shea, 1991). The term was first used in 1938 to refer to a group of disorders that lie between neuroses and psychoses (Greene and Ugarizza, 1995) but can also be used as a disparaging label for difficult clients (Reiser & Levenson, 1984). Some of the challenges in caring for clients with BPD relate to the symptoms and intense transference and counter-transference in the relationship between client and nurse/therapist (Gallop, 1985). This can result in nurses feeling frustrated, helpless, distant and even denying mental health services (Gabbard, 1991 cited in Greene & Ugarriza, 1995). A person with BPD is often seen as an impostor, who is in control of their behaviour but who chooses to be difficult and manipulative (Nehls & Diamond, 1993). Studies show that 77% of those diagnosed with BPD are women (Widiger & Weissman, 1991).

Aetiology

There are several explanations of the aetiology of BPD.

Biological factors

Greene and Ugarizza (1995) offer two biological explanations for BPD. The first focuses on neurotransmitter activity and systems, where an increase in dopamine action can account for transient psychotic states and decreased serotonin activity can account for irritability and impulsiveness. Lastly, an increase in the cholinergic pathways can lead to depression in clients with BPD. The second explanation puts forward organic brain dysfunction caused by trauma, epilepsy and attention deficit hyperactivity disorder (ADHD) as a cause of the increased impulsiveness, self-mutilation and affective disinhibition seen in BPD. However, Kaplan et al., (1991) argue a genetic link, proposing that people with BPD have more relatives with mood disorders than a control group and often have a mood disorder themselves as well.

Psychoanalytical factors

Another theory of the aetiology of BPD relates to the psychological birth of the human being or process of separation-individuation, which occurs, between birth and three years of age. In this process a sense of self is developed by the child, a permanent sense of significant others (object constancy) and the integration of both good and bad as part of the self concept (Mahler, Pine & Bergman, 1975). Mothering influences the outcome of the separation– individuation process but if this is inconsistent, insensitive or unattuned to a child’s needs then dysfunction occurs (Westen, 1990). If a child’s efforts to be autonomous are punished whilst dependent behaviour is rewarded, differentiation does not occur and responses such as intense anger, mood swings, dichotomous thinking and identity diffusion can result, all of which are seen in a person with BPD.

Childhood abuse/ Trauma

The trauma perspective is gaining increased recognition as studies show strong correlations between sexual or physical abuse in early childhood and the development of BPD (Paris, 1993). Herman (1992) argues that what is labelled BPD is a manifestation of post-traumatic stress disorder (PTSD), called “complex PTSD”, which follows prolonged, repeated trauma resulting in personality changes (most prominently identity and relationship disturbance).

Biosocial factors

Linehan (1993) hypothesises that people diagnosed with BPD have a biological tendency to react more intensely to lower levels of stress than others and to take longer to recover. Linehan adds that often they were raised in invalidating environments and became uncertain of the truth of their own feelings. As adults a failure to master three basic dialectics means they go from one polarity to another.

Cultural issues

There is little literature to indicate that BPD occurs in other than Western cultures, despite the extensive research that has been done on BPD.

Assessment and diagnosis

As seen in the aetiology section above, the accuracy of the diagnosis of BPD is controversial. Most approaches to treatment define BPD according to DSM-IV using a descriptive objective approach (Shea, 1991). Some writers argue that this dominance of DSM-IV in psychiatric settings (as expert authority of behaviours outside the norm) means that a diagnosis pathologises behaviour (Crowe, 1997; Gallop, 1997). In this section the DSM-IV perspective and the trauma perspective are reviewed.

DSM-IV and the medical model

In this paradigm “Borderline personality disorder is described as a pervasive pattern of interpersonal relationships, self-image and affects and marked impulsivity” (Crowe, 1996, p106). It falls under the DSM-IV Axis II diagnostic category, cluster B (dramatic, emotional, erratic) and can be associated with co-morbidity of Axis I and II disorders (American Psychiatric Association, 1994). Diagnosis is problematic because of the fluctuating nature of symptoms and concerns that are presented by the client (Arntz, 1994).

In order to be diagnosed with BPD a person must meet five of nine criteria described in the DSM-IV (1994). These are around abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, recurrent suicidal threats, gestures or behaviours, affective instability, chronic feelings of emptiness, inappropriate intense anger, transient stress-related paranoid ideation or severe dissociative symptoms. Skodol and Oldham (1992) recommended that 2-5 years is the minimum clinical time to indicate a stable personality pattern. Whilst Paris (1993) added that by middle age the majority of clients with BPD had recovered from acute symptoms and no longer met the criteria for BPD (Greene & Ugarriza, 1995).

Complex post traumatic stress disorder (PTSD)

The medical model paradigm of personality disorder is criticised by several researchers (Brown, 1992; Herman, 1992), who see the label as misleading and having negative effects on treatment. Herman warns that trying to fit people into the DSM-IV mould without addressing the underlying trauma or understanding what the problem is, results in fragmented care. Brown (1992 agrees and suggests the distress of abuse resembles responses to experiences of interpersonal trauma rather than core personality pathology. Brown and Walker (1986) argue that a diagnosis that lies between personality disorders and PTSD that is framed situationally is more helpful as it can be changed rather than as personality which can not. This diagnosis acknowledges the effect of multiple exposures to trauma which must be adapted to daily for victims of trauma and interpersonal violence and varies from PTSD, which assumes a single exposure to trauma outside the range of everyday experience.

Gender bias and stigmatisation

Brown (1992) argues that androcentric gender role norms and stereotypes influence judgements of psychopathology, which result in more women than men being diagnosed with BPD and the stigmatisation by mental health professionals of gender role traits that are normative for women. Often the traits and behaviour considered dependent, passive, dysfunctional and pathological are appropriate and skilful ways of accessing some power in a context where more overt and appropriate expressions of power are stigmatised or penalised (Brown). The effects of sexism multiplied by the requirements for survival under abuse require an alternative frame of reference to viewing a person’s symptoms. Further stigmatisation of certain behaviours occurs through having space for Axis II personality traits irrespective of whether they are at a psychopathological level. Brown adds that context and variables such as race, gender, class and experience of abuse or victimisation are not considered either. Brown (1992) and Gallop (1997) propose a feminist perspective for BPD that takes into account the meaning of interpersonal context and relatedness rather than separation and individuation.

Power dynamics

Brown and Gallop (1997) argue that the mental health setting often mirrors the interpersonal power dynamics where abuse occurred. The presence of a powerful other can exacerbate symptoms and vary from how someone presents in a more power-equal situation. Many non-exploitative situations would need to be experienced before patterns of survival were relinquished.

Age trauma occurred

Van der Kolk, Hostetler, Herron & Fisler (1994) suggest that up to a century ago, research showed traumatised people would have their personality development checked at whatever point the trauma occurred after which it could no longer be added to. The authors suggest trauma has different effects at different stages of development. If the trauma is experienced as an adult then it is more likely to become what is known in the DSM-IV as PTSD. However, if trauma is experienced at an earlier age, then different manifestations of developmental arrest will be seen, therefore a person traumatised at a particular age might process intense emotions later in life the way someone at that age would, using earlier developmental accomplishments. The earlier someone is traumatised, the more pervasive their psychological disability.

Ethical and legal issues

There are major ethical and legal issues to consider in caring for people with BPD in the community. An awareness of the Mental Health Act is vital and issues such as splitting and ambivalence can make the area of ethical and legal issues a minefield.

Suicide

People with BPD represent the highest risk of suicide of any of the personality disorders and factors such as “overplaying their hand” or being rescued unexpectedly make suicide risk difficult to ascertain (Stone, 1993). He suggests that the therapist/nurse can become skilled at predicting suicide risk through clinical experience, supervision and by becoming familiar with the literature on suicide risk. The exploration of specific individual techniques for controlling impulses, such as the desire to self-harm, to identify triggers and patterns and increase self-awareness can also be useful. Including such questions as “do you want to slash?”, “Do you want us to help you control slashing?” (Gallop, 1992). Respecting the autonomy of a client with BPD can be difficult if they are presenting with suicidal ideation and there is a requirement to assess the need for compulsory treatment.

Medico-legal issues

Gutheil (1985) makes several points in his article about medico-legal issues that can arise in the treatment of people with BPD. In respect of the Mental Health Act (1992) there can be a legal ignorance of BPD as some people present with excellent functioning whilst others appear too sick to be discharged from compulsory treatment. The effects of borderline psychodynamics such as borderline rage, narcissistic entitlement, psychotic transferences, threats of suicide and impulsivity can also be challenging in relation to the Mental Health Act (1992).

Treatment issues

There are several issues that impact on the treatment of a client with BPD and which are important for nurses to be aware of. These are discussed prior to the exploration of psychotherapeutic and psychopharmacological treatments.

Transference and counter-transference

The therapeutic alliance is the foundation of therapy, which is often difficult to establish and maintain, particularly in the face of disruptive pressures that arise in therapy with a client with BPD (Meissner, 1993). This alliance and transference and countertransference are called “the therapeutic tripod” by Meissner. In the transference, the client relives their relationship with their parents through the nurse and can be very perceptive about who is working with them. This survival skill was learnt through anticipating the needs of their caregivers to prevent victimisation (Van der Kolk et al., 1994). Often an equally strong counter-transference is evoked in the nurse because of the strong emotion and conflict in the transference, which can include helplessness, fury and despair. Nurses can feel a need to rescue or compensate (Van der Kolk et al.,1994). In order to remain therapeutic, it is essential for nurses to know themselves, have safe spaces to review these issues in supervision and ensure they get support from their clinical teams.

Safety

Van der Kolk et al. (1994) suggest that negotiating safety and forming safe attachments are a way in which a client with BPD is able to regulate their internal state. This is especially the case if people with BPD are fixated on the emotional and cognitive level at which they were traumatised and continue to deal with difficulties using the resources at that point in their development . The authors recommend that basic trust and safety are negotiated prior to approaching trauma related material.

Hospitalisation

Gallop (1985) suggests that hospitalisation is an important aspect in the management of acute episodes for people with BPD. Budget and fiscal constraints mean that people with BPD are more commonly admitted for the relief of acute symptoms, usually a shift from chronic suicidality to acute suicidality, rather than for personality restructuring. Gallop reviews the two main clinical approaches for the hospitalised person with BPD. The adaptational approach focuses on preventing regression and encouraging people to take responsibility and has a short-stay emphasis, where staff offer supportive therapy, structure and limit set. In contrast, the long-stay approach allows for regression to take place in the presence of warm and empathic staff who facilitate the process of personality restructuring. The critics of this approach argue that it leads to the exacerbation of borderline symptoms. Gallop proposes an alternative model based on the work of Linehan (1993), but which adapts dialectic behavioural therapy for use in an in-patient setting in order to maximise the current short-stay emphasis and to use the skills of clinicians. Dialectic behavioural therapy will be discussed later in this article.

Dissociation

Research has found dissociation to have a high correlation both with the degree of borderline psychopathology and with the severity of childhood trauma (Van der Kolk et al., 1994). Dissociation is a way of coping with inescapably traumatic situations by allowing the person to detach from the reality of the situation. Often there is a loss of the memory and the relief of pain for the situation, the person can feel numb or spaced out. For some people this becomes a conditioned response to stress even if the situation is not inescapably stressful (Van der Kolk et al., 1994).

Splitting

A defence mechanism seen in clients with BPD is “splitting” (Harney, 1992) which can increase clinical risk if alternate strategies are recommended in the management of suicide risk. This risk can be reduced by ensuring clear communication and management plans across all services. Case management, where one person is responsible for the overall co-ordination of services and meetings with other care providers can also minimise splitting (Nehls & Diamond, 1993).

Psychotherapeutic interventions A systems approach

Nehls and Diamond (1993) state that people with BPD have diverse treatment needs, so treatment should to be based on comprehensive assessment and subsequent individualised treatment planning. This can be difficult for several reasons including: the number and intensity of crises that a person with BPD can have; the theoretical orientation of the clinician and interventions that are made hastily and based on negative reactions to a client or the diagnosis of BPD rather than careful assessment.

Nehls & Diamond propose a systems approach that includes: Individual counselling and psychotherapy; group therapy; medication evaluation and monitoring; drug/alcohol services; psychosocial rehabilitation and crisis intervention services. Planning should also include hospitalisation. Shea (1991) adds that several factors are intrinsic to any of the therapeutic approaches. These include careful attention to the client, skill to address countertransference, flexibility of therapy but also the need for limit setting with the therapist taking an active role.

Psychoanalytical

Shea (1991) suggests two types of psychoanalytic therapy can be helpful. Supportive psychoanalysis focuses on the improvement of adaptive functioning by strengthening defences and avoiding regression and transference by focusing on the present and keeping therapy highly structured. In expressive psychoanalysis, transference and regression are desirable and provide a means for the therapist to gain insight. Behaviour is changed as dissociated aspects are identified and clarified as they appear.

Dialectical behavioural therapy

Linehan ‘s (1993) Dialectical Behavioural Therapy (DBT) emphasises that the person with BPD has inadequate affect regulation related to biological factors and a childhood environment that is characterised by an absence of emotional regulation. DBT focuses on identifying skill deficits in a person’s life and then correcting them. The therapist teaches the client both self and relationship management skills as well as skills of mindfulness, interpersonal effectiveness, distress tolerance and emotional regulation. Therapy takes place individually and in groups and the relationship between therapist and client is paramount in treatment. In a one year trial of DBT, Linehan found that control group subjects remained in treatment longer, parasuicidal behaviour decreased as did the number of days of in-patient hospitalisation (Linehan, 1993).

Cognitive therapy

Cognitive therapy has been modified to treat clients with BPD (Beck, 1990) despite being thought of as most useful in the treatment of Axis I disorders (Shea, 1991). Arntz (1994), an advocate of cognitive therapy, argues that chronic traumatic abuse in childhood leads to fundamental beliefs that include: Others are dangerous and malignant, I am powerless and vulnerable and I am bad and unacceptable. The aim of cognitive therapy is to identify and change these beliefs, so affect and behaviour are normalised. Control over emotions and impulses are increased and identity is strengthened (Shea, 1991; Van der Kolk et al., 1994). Transference reactions provide rich material for uncovering dysfunctional thoughts and assumptions (Shea, 1991). Controlled studies have not been done as to the efficacy of this treatment approach with people with a borderline personality disorder (Shea, 1991).

Group therapy

The advantages of group therapy for the person with BPD include diluting transference and decreasing polarisation because of multiple feedback (Greene and Ugarizza, 1995). Group therapy can decrease demanding behaviour, egocentrism, social isolation and withdrawal and social deviance (Horowitz,1987 cited in Greene and Ugarizza, 1995). Van der Kolk et al., (1994) state group therapy provides both words and actions for expressing emotional states that clients with BPD have difficulty with and can borrow from other group members.

Family therapy

Research has shown a strong link between BPD and pathological families (Clarkin et al., 1991 cited in Greene and Ugarizza, 1995). Family members learn therapeutic interactions so the identified client can begin to form an identity and both the client and family modify their behaviour (Clarkin et al., 1991 cited in Greene and Ugarizza, 1995).

Alternative therapies

Van der Kolk et al., (1994) advocate using psychodrama and drawing to develop language for effective communication as a precursor to effective psychotherapy. The authors’ state that research has shown traumatised children have poor language skills for expressing their internal states. This can result in unmodulated actions, which are acted out in transferences and current relationships.

Psychopharmacology

Van der Kolk et al., (1994) propose that trauma affects a persons ability to self- regulate their emotions and self-soothe. Learning to tolerate affect is a way in which a traumatised person can take part in life. Mood stabilisers such as Lithium and Carbamazepine can help decrease affective lability and impulsive behaviour (Cocarro et al., 1991), whilst antipsychotic medication can help control transient psychotic states and antidepressants help with major depression (Shea & Kocsis, 1991 cited in Greene & Ugarriza, 1995). Linehan & Kehrer (1993) recommend being aware of contraindicated effects of medications, problems with compliance, drug abuse and suicide attempts. However, as long as careful monitoring is in place Linehan & Kehrer argue that pharmacotherapy can be a useful adjunct to psychotherapy.

Conclusion

This article has reviewed ways of viewing BPD. The medical model remains dominant in most psychiatric settings in New Zealand but other paradigms are gaining prominence as the limits of the medical model become more evident, particularly around the management of the client with BPD. The way in which BPD is defined remains contentious and many writers in the field suggest that it is more a response to trauma than core personality pathology. This has implications for how people with BPD are cared for in New Zealand’s mental health system.

As nurses move into the role of case managers in the community, a systems approach incorporating thorough assessment and planning is a good beginning which includes assessing for previous trauma. There is also a need for multiple treatment modalities to include a variety of components such as assistance with daily living needs, pharmacotherapy, dialectical behaviour therapy, cognitive therapy and so forth. Nurses need to disengage themselves from the shadow of the medical model and begin to explore new ways of supporting clients with BPD in the community. In order for community mental health nurses to maintain therapeutic relationships with clients with BPD, they must be proactive and attain supervision, education and self- knowledge.

 

References

American Psychiatric association. (1994). Diagnostic and Statistical Manual of Mental Disorders, (4th Ed.). Washington D.C: Author

Arntz, A. (1994). Treatment of Borderline Personality Disorder: a challenge for cognitive- behavioural therapy. Behavioural Research Therapy, 32, 4, 419-430.

Beck, A.T.& Freeman, A. (1990). Cognitive therapy of personality disorders. Guilford Press: New York.

Brown, L.S. (1992). A feminist critique of the personality disorders. In L.S. Brown & M. Ballou (Eds), Personality and psychopathology, feminist reappraisals, (pp 206-228), New York: Guilford Press.

Crowe, M. (1996). Cutting up: Signifying the unspeakable. Australian and New Zealand Journal of Mental Health Nursing, 5, 103-111.

Gallop, R. (1985). The patient is splitting: everyone knows and nothing changes. Journal of Psychosocial Nursing,23, 6-10.

Gallop, R. (1992). Self destructive and impulsive behaviour in the patient with borderline personality disorder. Archives of Psychiatric Nursing, 6, 3, 178-182.

Gallop, R. (1997). Caring about the client. In S. Tilley (Ed), The Mental Health Nurse, (pp28-42), Oxford: Blackwell Science.

Greene, H& Ugarizza, D.N. (1995). The ‘stably unstable’ Borderline personality disorder: History, theory and nursing intervention. Journal of Psychosocial Nursing, 33, 12, 26-30.

Gutheil, T.G. (1985). Medicolegal pitfalls in the treatment of borderline patients. American Journal of Psychiatry, 142, 1, 9-14.

Harney, P. (1992). The role of incest in developmental theory and treatment of women diagnosed with borderline personality disorder. Women and Therapy, 12, 1⁄2, 39-57.

Herman, J.(1994).Trauma and recovery. Harper Collins: London.

Kaplan, H.I & Sadock, B.J. (1991). Synopsis of psychiatry, behavioural science, clinical psychiatry. Williams & Wilkins: Baltimore.

Ruth De Souza 4 October 1998 Page 13 of 13

Care of the person with Borderline personality disorder in the community

Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York:Guilford Press.

Linehan, M.& Kehrer, A. (1993). Borderline personality disorder. In D.H Barlow (Ed), Clinical handbook of psychological disorders (2nd ed.). New York: Guildford Press, 396-411.

Mahler, M.S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. New York: Basic books.

Meissner, W.W. (1993). Treatment of patients in the borderline spectrum: An overview. American journal of psychotherapy, 47, 2, 184-193.

Nehls, N. & Diamond, R.J. (1993). Developing a systems approach to caring for persons with a borderline personality disorder. Community Mental Health Journal, 29, 2, 161-171.

Shea, M.T. (1991). Standardised approaches to individual psychotherapy of patients with borderline personality disorder. Hospital and Community Psychiatry, 42, 1034-1037.

Skodol, E. & Oldham, J.M. (1991). Assessment and diagnosis of borderline personality disorder. Hospital and community psychiatry, 42, 1021-1028.

Stone, M.H. (1993). Paradoxes in the management of suicidality in Borderline Patients. American Journal of Psychotherapy,47, 2, 255-271.

Van der Kolk, B.A., Hostetler, A., Herron, N & Fisler, R.E. (1994). Trauma and the development of borderline personality disorder. Psychiatric Clinics of North America, 17, 4, 715-731.

Widiger, T.A. & Weissman, M.M. (1991). Epidemiology of borderline personality disorder. Hospital and community psychiatry, 42, 1015-1020.