Complementing cognitive behavioral therapy (CBT) for Pacific peoples in New Zealand

Abstract

This study aimed to determine the efficacy of cognitive behavioral therapy (CBT) delivery to Pacific peoples by exploring Pacific psychologists’ perspectives. The research was qualitative in its approach, using the Pacific methodology of “talanoa.” The study carried out two face-to-face focus-group interviews using the talanoa method. Initially, nine participants expressed their interest in the study. However, five participants did not attend the interviews. Three participants participated in the first focus group discussion, and one participant participated in the second focus group, which resulted in an individual interview. All four participants were clinically trained psychologists, with an average of 14 years of clinical experience. These participants worked continuously with Pacific service users in various mental health settings and private practice. The need to enhance the compatibility of CBT with the culture of Pacific peoples was highlighted throughout the study. From the psychologists’ perspectives, there were significant challenges regarding the delivery of CBT among Pacific peoples. These included: accessibility barriers due to socioeconomic and financial stressors; funding constraints and the availability and affordability of therapy sessions; the appropriateness of treatment that needed to be tailored to suit Pacific peoples; and the lack of spiritual and cultural aspects of treatment. The results of the study provide preliminary validation for the efficacy of CBT among Pacific peoples. There is an increasing awareness that delivering culturally relevant and appropriate care to Pacific peoples living in New Zealand requires a deeper understanding of valuing the realities and unique experiences they bring both collectively and individually. Ultimately, the findings provide significant insight into the barriers to the efficacy of CBT and strategies to overcome these.

Keywords

mental health cognitive behavioral therapy cultural competence Pacific research Pacific mental health indigenous worldview ethnic minority

Introduction

Cognitive behavioral therapy (CBT) was developed in the 1960s by psychoanalyst Aaron Beck (Beck, 2011). CBT was designed as a “structured, short-term, present-oriented psychotherapy for depression, specifically aiming at modifying dysfunctional thinking and behaviour” (Beck, 2011, p. 2). There has been extensive research on the effectiveness of CBT as a form of psychological treatment to manage mental health disorders globally (Currell et al., 2016; Kaufman et al., 2005; Keller et al., 2000; Ladouceur et al., 2000), and in New Zealand (Bennett et al., 2008; Hirini, 1997; Merry et al., 2012). CBT has had some proven efficacy with ethnic minorities, with mental health professionals modifying elements and concepts of CBT to tailor to the needs of such groups (Hays & Iwamasa, 2006). These ethnic groups include Hispanics (Interian et al., 2008; Pineros-Leano et al., 2017), Chinese (Dai et al., 1999; Hwang et al., 2015; Sobowale et al., 2013; Williams et al., 2006), African-American (Miranda et al., 2003; Nicolas et al., 2009; Rathod et al., 2013), and Māori (Bennett et al., 2014; Hirini, 1997; Lucassen et al., 2015). According to Te Pou (2010), NZ-born Pacific peoples who have used CBT with some cultural modifications have reported a few positive outcomes. Visually seeing the five-part model written down was practical and well understood for the Pacific person. The need to incorporate spirituality was paramount when delivering CBT. The evidence proves that the effective use of the CBT model among Pacific service users is determined by the practitioner's clinical experience and training and their cultural knowledge and competence (Te Pou, 2010). Therapists that have used various talking therapies (including CBT) have reported the benefits. However, they have pointed out the need to continuously adapt and modify the model to meet the needs of Pacific peoples with a more flexible, cultural, and holistic approach (Paterson et al., 2018; Te Pou, 2010).

Recent research suggests that Pacific peoples prefer services that support a holistic approach, aligning therapies with their cultural values (Paterson et al., 2018). For instance, delivering treatment in Pacific settings, such as churches, homes, and Pacific community centers, is fundamental in ensuring that cultural principles are applicable and embedded within the treatment. While there is substantially a wide range of evidence-based research on the effectiveness of psychological treatment for mental disorders, there is a dearth of published research nationally and internationally on psychological interventions for Pacific peoples (Ataera-Minster & Trowland, 2018; Te Pou, 2010).

In New Zealand, a recent study by Tiatia-Seath (2018) outlined the urgent need for Pacific cultural competence in healthcare, as it is part of the responsibilities of the health workforce to reduce health inequalities and inequities in New Zealand. The lack of culturally appropriate healthcare models and understanding of the Pacific worldview concepts of mental health is overlooked and are contended to be barriers to accessing care that need to be addressed (Ataera-Minster & Trowland, 2018).

Taua’i et al. (2018) understand the significance of upholding cultural factors (emphasizing a sense of identity and belonging and speaking fluently in their language) in achieving positive health outcomes among Pacific peoples. Imperative variables to consider when conveying appropriate care and treatment to Pacific peoples emphasize language and culture and the holistic view of the individual through the Pacific lens of what constitutes one's health and well-being. Overall, the findings from this research will provide essential knowledge and insight from the perspectives of Pacific psychologists, with the overall aim of contributing to the health and well-being of Pacific peoples.

Background

Pacific peoples suffer more significantly from mental disorders than other New Zealand populations (Ataera-Minster & Trowland, 2018). Ataera-Minster & Trowland (2018) reported that Pacific peoples score significantly higher in psychological distress than other groups in New Zealand. Furthermore, the Te Rau Hinegaro report (Wells et al., 2006) confirmed the rate of mental illness among Pacific peoples to be 25%, as opposed to 20.7% for the rest of the New Zealand population. Research indicates that those with significant mental health issues are considerably linked to those from lower socioeconomic areas (Howden-Chapman & Tobias, 2000). Poverty, lack of education, and unemployment generate vulnerability and significantly place those at higher risk of developing mental health and addiction problems (Mental Health Commission, 2012, p. 16). Consequently, the burdens on a person, and expectations to meet obligations such as financial security, can cause harm and distress to mental health.

Pacific peoples are much less likely to access any professional health service for mental health problems (Ataera-Minster & Trowland, 2018; Suaalii-Sauni et al., 2009). Recent research shows that inadequate health literacy contributes hugely to this outcome of poor access to health services (Ministry of Health, 2012). According to Parker et al. (1999), health literacy is defined as the ability to process and comprehend health information to make better health decisions. Consequently, poor health literacy affects a person's health, impacting treatment and health outcomes (Kickbusch et al., 2005). In the Tupu Ola Moui (Ministry of Health, 2012), 90% of Pacific men and women (15 years and over) proved to have poor health literacy compared to 55% of non-Pacific men and women in New Zealand. In other words, their health literacy was scored at Level 1 or 2, signifying their inability to understand and cope sufficiently to meet the complex demands of everyday life and work. Simich (2010) summarizes health literacy: “the greater a person’s ability to learn about health, the better that person's health” (p. 17). However, the literature suggests that health literacy depends not only on one's ability to obtain and understand information. Instead, it requires a much more complex development of a health workforce that reflects the needs of the specified population, strengthening cultural and communication competencies, and forming effective therapeutic relationships with service users (Kickbusch et al., 2005; Ministry of Health, 2010, 2012; Parker et al., 1999; Simich, 2010).

Pacific peoples have expressed their desire to access services that have incorporated a holistic and culturally responsive approach. A 2012 survey by the Ministry of Health indicated common themes Pacific women reported concerning access to healthcare services and included such statements as: “more comfortable talking to someone who understands my culture, and also the services that were the closest and cheaper” (Ministry of Health, 2012, p. 51). As seen in the results of the 2012 survey (Ministry of Health, 2012), the emphasis on developing a mental health service that encompasses the ability to understand the culture, language, and level of education of patients is paramount.

The Pacific concept of wellness is based on having a balance of three elements to support and sustain health and well-being: God (spirituality), people (family), and land (environment). Pacific views are founded on a collective approach, meaning family and community are essential (Te Pou, 2010). This view of health aligns with the World Health Organization's holistic definition of health: “a state of complete physical, mental, and social well-being and not merely the absence of a disease” (Larson, 1999, p. 125). However, there is an added element of spirituality in the Pacific view. Pacific perspectives on mental illness oppose the Westernized idea of mental illness, claiming that having a mental illness is caused by a spiritual curse that only traditional healers can treat or heal (Te Pou, 2010). However, in the Westernized view, mental illness is caused by a “chemical imbalance” in the brain (Te Pou, 2010). It is vital to deliver a holistic care approach to the Pacific people by understanding and incorporating the Pacific views of health and wellness.

The importance of culture and indigenous knowledge must be at the forefront in psychology when considering research and clinical practice for Pacific peoples. In Samoa, Tamasese et al. (2005) describes a worldview as one's sense of sacredness and wholeness, derived from one's place of connectedness within the family, village, genealogy, language, and culture. To disregard this concept when delivering care to a Samoan patient generates a disconnection from their sense of self, family, community, and culture. For Fijians, the importance of incorporating and understanding cultural protocols is utterly crucial for one's mental well-being (Otsuka, 2006). For New Zealand-born Cook Islanders, maintaining family and social support connections is critical in achieving positive mental well-being (Puna & Tiatia-Seath, 2017). Lastly, Niuean people highly value their language and associate it with a sense of identity and belonging (Tukimata, 2018).

The CBT model encompasses elements of one's cognition, behavior, physiology, and the individual's environment and situational experience. These five elements are also known as the “five-part model.” All five elements are interrelated and assists in understanding life experiences in therapy (Greenberger & Padesky, 2015). There is a strong emphasis on recognizing the thought processes that commonly influence and challenge one's belief system, resulting in a behavioral and emotional response (Chen & Davenport, 2005). Enhancing and nurturing the therapeutic alliance between the therapist and the client is fundamental within CBT. Allowing the client to express their vulnerability is determined by the partnership between the therapist and the client. Raue and Goldfried (1994) reinforced that a solid therapeutic alliance results in a client's progress and improvement within a treatment.

According to Te Pou (2010), therapists have raised awareness of their approach in delivering psychological interventions (talking therapies) with Pacific peoples. They recognized the rigidity and inflexibility of some of the “manualized” type approaches and discovered that they were modifying and adapting these models continuously in practice for Pacific service users (Te Pou, 2010). For Māori, a study by Bennett et al. (2014) used two case vignettes to illustrate the effectiveness of applying a culturally adapted CBT approach. The therapists incorporated whānau involvement and described using whakawhanaungatanga as the process of establishing family relationships. For instance, the therapist disclosed personal information about themselves, including tribal affiliation, working history, and family background. The element of self-disclosure is discouraged in a generic CBT approach because it is seen to be inappropriate and suggests a boundary issue in clinical contact (Westbrook et al., 2011). However, a growing body of literature promotes an environment where the therapist can share their family connections, as it is culturally acceptable in most ethnic groups. It has been proven to enhance the therapeutic alliance (Hays, 2001).

Cultural adaption is defined as the “systematic modification of evidence-based treatment to account for language, culture and context in a way that corresponds with the client's cultural patterns, meanings and values” (Bernal et al., 2009, p. 362). Developing relationships is exceptionally important for Pacific people, requiring a deep interpersonal connection (Farrelly & Nabobo-Baba, 2014; Morrison, & Vaioleti, 2008). For instance, tapu or sa describe the sacredness in relationships between one person and another. A relationship between the matai (chief), siblings, and parents are defined as tapu and etiquette prescribed by culture (Tamasese et al., 2005). Such relationships are central to Sāmoan identity, as they enlighten every aspect of Samoan life (Tamasese et al., 2005).

However, the generic CBT model highlights the autonomy of the individual. The fact that central to the successful use of CBT is developing an individualized concept that helps the therapist understand and explain a client's problem (Westbrook et al., 2011). Rathod et al. (2015) emphasize the importance of considering a client from a collectivist culture (having communal values) and ensuring that the therapist perceives them as a collectivist and not as an individual. Moreover, the client's belief system is influenced by their own and their family's perspectives and cultural influences. A therapist must understand this to avoid disengagement and distrust on the part of the client.

A further study by Interian and Diaz-Martinez (2007) showed that Hispanic participants found it challenging to grasp specific CBT techniques due to their inability to understand CBT concepts. Interian and Diaz-Martinez (2007) recommended that utilizing a cultural intervention in treatment should include the following: “ease of access, strategies chosen based on Hispanic culture and an adaptation of traditional treatment approaches” (p. 85). Bennett et al. (2008); Chen and Davenport (2005); González-Prendes, Hindo and Pardo (2011); Hwang et al. (2015); Interian et al. (2008); and Pineros-Leano et al. (2017) all reported positive and significant changes in critical areas of treatment outcome after implementing a CBT method culturally adapted for that specific minority group.

There is limited research conducted on the perspective and attitudes of ethnic service users and therapists on using CBT, highlighting the purpose of this research. Ethnic-particular studies and data are constrained in New Zealand (Wells et al., 2006). The researcher aimed to grasp a better understanding of the delivery of CBT within a Pacific context. This consisted of exploring CBT principles, concepts, structures, and therapeutic approaches from a psychologist's perspective on Pacific peoples. Based on this discussion, the researcher hoped to draw attention to the efficacy and challenges of delivering CBT to Pacific service users, bringing about an awareness of ways to improve and promote mental well-being.

Considering the lack of research on Pacific mental health, the findings of this study will provide helpful information for mental health professionals about delivering a practical CBT approach to Pacific peoples. Investigating and determining the views of psychologists is a significant first step.

Methods

According to Leavy (2014), qualitative research explores social reality; this research sought an in-depth understanding, aiming to explore and explain the meanings of the participants’ views and experiences using CBT. From a Western perspective, an interpretivist research paradigm was the most appropriate and relevant for this study. The researcher aimed to explore and understand individuals from their worldview by making sense of their realities, experiences, and how they interpret and give meaning to life and social situations (O’Donoghue, p. 132). The interpretivist paradigm was used in this research to encapsulate the notion of a person's perspective. O’Donoghue (2006, p. 8) emphasizes that a “paradigm shift involves a new way of looking at the world and hence new ways of working, new ways of doing.” In agreement with this notion of a paradigm shift, the findings from this research were significant. They generated a more accurate interpretation and understanding of participants’ shared realities and experiences regarding the use of CBT with Pacific peoples.

This research was conducted using a qualitative design by encompassing aspects of the qualitative Pasifika (Pacific) research method of talanoa (communicating) (Halapua, 2007; Vaioleti, 2006). This method was the most suitable for exploring the perceptions of Pacific psychologists conducting CBT among Pacific peoples.

The talanoa method is a well-known qualitative research approach among Pacific researchers, as it embraces the importance of conversing in a culturally appropriate and authentic manner. A positive feature of this approach is that it enabled the researcher to contextualize and have a deeper understanding of the views and experiences expressed by Pacific psychologists. Using the talanoa method allowed the Pacific culture and heritage to be restored, cherished, and protected within a sacred space or vā tapuia. The word talanoa is recognized and applicable to all diverse nations in the Pacific Islands: Sāmoa, Fiji, Tonga, Cook Islands, Niue, Hawai’i, and the Solomon Islands (Vaioleti, 2006). The founders of the talanoa method define tala as “telling stories or talking and noa meaning zero or without concealment” (Halapua, 2007; Vaioleti, 2006). In a Pacific context, talanoa is a traditional way of “reciprocating interaction that is founded on common interest, regard for respectfulness and is conducted mainly face to face” (Morrison & Vaioleti, 2008, p. 11). The literature suggests that the talanoa method allows researchers to make sense of both worldviews (Pacific and Western), thus generating valuable knowledge in Pacific research.

Concerning the Pacific worldview of health, Tamasese et al. (2005) discuss three crucial elements in the way Pacific peoples seek harmony: in their relationship with God (Atua), people (Tagata), and environment (laufanua). It is essential to understand that the talanoa method provides a safe environment for Pacific participants to discuss personal matters. Therefore, to implement the talanoa method successfully, the researcher aimed to establish relationships that connect Pacific peoples with Atua, Tagata, and laufanua. Tamasese et al. (2005) explain that the stories shared are valuable knowledge and experience threaded together to create a collective experience. Furthermore, Vaka (2014) affirms that talanoa targets the loto (heart), which generates tapu (sacred) knowledge. Therefore, protecting the cultural integrity of participants is utterly imperative.

The commonality that Pacific people are accustomed to before and after a talanoa meeting is the acknowledgement given to God in the form of a prayer. Much of the literature supports the implementation of spiritual activities in research depending on participants’ preferences (Bush et al., 2009; Tukimata, 2018). Thus, spirituality within a therapeutic context is crucial. Seiuli (2013) eloquently discussed the significance of the spiritual connection and described it as a “safe covering during sessions” (p. 48). Praying before an interview is not only aimed at maintaining a “safe covering of the sacred space,” as described by Seiuli (2013), but it acts as guidance and opportunity for both the researcher and participant to express themselves freely in the talanoa process. Therefore, recognizing cultural practices and beliefs is advised when engaging with Pacific people.

The data were collected in the form of face-to-face, focus-group discussions, using the talanoa method, consulting with one or more participants via in-depth and open-ended questions. Within the Pacific culture, talanoa is also emphasized communally or collectively (Te Pou, 2010). It enables participants to provide meaningful connections to their cultural heritage and beliefs, which goes beyond a traditional, structural way of collecting data. Therefore, facilitating a focus group is culturally appropriate and relevant.

The researcher recruited participants through an email invitation sent to Pacific psychologists located in Auckland. As a qualitative study method was used, the primary source of collected data was through focus-group interviews. A consent form was given to participants that outlined the purpose of the research, the interview process, confidentiality measures, and disseminating findings. The researcher reassured the Pacific participants that their identity would remain confidential in the study.

The method used for recruitment was known as “snowball sampling” (also called chain-referral sampling) (Robinson, 2014). After one of the psychologists was notified via email about the research, she sent out an email invitation to other colleagues. Three participants attended the first focus group, and two were unavailable. In the second focus group, one participant attended, and two participants contacted the researcher (during the interview), stating they were unavailable and did not attend. Each focus group was recorded using a digital audio recorder, with the participants’ consent, and then transcribed by the researcher.

Initially, nine participants expressed their interest in the study. Among the nine, most were of Samoan descent, and the others were of Tongan and Cook Island ethnicity. However, five participants did not attend the interviews. Three participants participated in the first focus-group discussion, and one participant participated in the second focus group, which resulted in an individual interview. All four participants were clinically trained psychologists with an average of 14 years of clinical experience. Three participants were of Samoan descent, and one participant was from Indonesia. The participant from Indonesia expressed an interest in the study and wanted to contribute as they currently practice CBT daily in a Pacific mental health and addiction service and also expressed similarities of Indonesian and the Pacific culture. The participants that did not attend were of other Pacific ethnicities. The researcher was mindful that this might potentially impact the results due to the lack of different Pacific ethnic groups represented in the research.

Clearly, the participants in this research worked closely with Pacific service users. They had all worked in various mental health settings and were highly experienced in delivering CBT and other psychological therapies with Pacific peoples. The participants had a wealth of knowledge and expertise with Pacific service users as they actively worked in Pacific communities. All participants were female. One male expressed an interest in this research but reported that he was not a clinical psychologist, thus did not participate in the study. To protect the privacy of participants’ identity, names and specific workplaces have been anonymized throughout the study (Table 1).

Table 1.

Outlines the participants’ demographics

Participant	Gender	Ethnicity	Years of training	Area of expertise
Participant 1	F	Indonesian	14	Pacific mental health & additions adults, Private practice
Participant 2	F	Samoan/European	11	Various contracts with Public services, Pacific mental health & addictions, private practice, corrections
Participant 3	F	Samoan	14	Pacific mental health & addictions, PHO, Child & adolescents, GP, private practice, offenders program, supervision
Participant 4	F	Samoan	10	PHO, GP, Child & adolescents, private practice, Pacific mental health & addiction

Conducting the interview at a church hall in Central Auckland, and opening the talanoa with a prayer, represented an essential connection to participants’ cultural values and beliefs. According to the Ministry of Health (2008), the importance of acknowledging the church setting provides value and meaningful connections for the Pacific community. The relevance of church settings in New Zealand is connected to their beliefs, values, and Pacific ways of being. Therefore, allowing Pacific individual to express themselves freely within the vā (sacred relational space) generated a much more rich and authentic talanoa. In support of this notion, the Ministry of Health states that the “Pacific church setting has replaced the village setting, it helps one feel supported by meeting their spiritual needs and maintains Pacific languages and elements of traditional culture” (2008, p. 22).

Providing food during the focus groups was also symbolically important as it created a sense of gathering collaboratively. The value of having food, as Vaioleti (2006) describes it, is the opportunity to “observe behaviour and enrich the talanoa” (2006, p. 30).

In summary, incorporating the talanoa method during this interview process was paramount. Recognizing cultural practices and beliefs allowed the participants to engage effectively and converse freely in the vā tapuia (sacred space). The researcher needed to be mindful of such practices, incorporating prayer, physical space, and food to establish a respectful, trusting therapeutic relationship during the interviews.

Analysis

Thematic analysis was utilized to examine and analyze the data. Braun and Clarke (2006, p. 79) explained that this method “minimally organises and describes research data in rich detail.” The information was grouped into themes based on the transcript data, drawing mainly on the study's principles and interpretation (Braun & Clarke, 2006). Coding and analysis of the data highlighted critical factors of the implications of CBT and understanding the perception and the effectiveness of this tool for Pacific peoples. To be culturally appropriate, a matua or cultural advisor was consulted to ensure that cultural conceptions were acknowledged, capturing the data's complete essence and exact value. Once the interviews were completed, the researcher transcribed the data. Once the transcripts were coded, the data extracted were sorted and grouped into themes. The thematic analysis was used to define and organize themes and subthemes, which were evolved by exploring the participants’ views and experiences of this treatment.

Overall, thematic analysis is a substantially flexible and well-structured method that provided an in-depth richness of insightful data. The talanoa approach was helpful, as the participants were open during the talanoa meeting, which generated rich, authentic data. Conducting the interview at a church hall, and opening the talanoa with a prayer, placed great importance on and connected to the participants’ cultural values and beliefs. Providing food was also of symbolic significance as it created a sense of communal gathering.

Fa’avae et al. (2016) pointed out that researchers need to incorporate core Pacific values, such as respect, love, humility and generosity, to provide meaningful engagements with participants. Neglecting these connections will result in poor-quality data (Fa’avae et al., 2016). It is crucial to teu le vā (maintain the relationship), as it removes the distance and barrier between the researcher and participants to create enriched and authentic research.

Results

Enhancing the cultural implications of CBT for Pacific peoples is one of the main themes discussed. The format of the discussions provided the opportunity for an open, enriched, authentic talanoa about ways of maintaining and upholding the cultural elements with Pacific peoples. Three subthemes encompass and outline this significance.

Subtheme 1: Knowledge and expectations

The participants' opinions on the knowledge and expectations of CBT among some Pacific service users led to the development of this subtheme. The fundamentals of therapy for Pacific people are having the capacity to relate to and connect with them while considering their worldviews and values. Therefore, it is crucial to clarify psychological ideas and give concrete examples in a way that resonates with Pacific people and enables them to contextualize and understand these concepts on their own:

For Pacific, I see the foundation as relationships. And so … when I do the psychoeducation, and you know talk about the relationships between the thinking, our emotions and how we behave, I also kind of relate that to how we are in our relationships. So, you know whether … first of all, our relationship with our self. How do we see ourselves? How do we think and feel?

Participant 2 explained that using analogies was essential to seeing self-worth and having “worth” to create a link to their Pacific clients’ interpretations of how they viewed themselves and others. Psychologists used analogies to frame CBT elements as they assisted with bridging the gap between the Westernized language of CBT and the cultural language of the minority:

So, you know the analogies, feeding ourselves, well … aye … you know through our senses. So, I come from that and talk about how our experiences over time … we do interpret … sometimes negative things about how people treat us. And so, that forms the beliefs about ourselves, about not being good enough, not belonging, useless, worthless. So, kind of spending a lot of time on that explanation.

Using visuals was explicitly addressed during the talanoa. For instance, laminating the five-part model allows the individual to write on the model with a whiteboard marker. As participant 4 explained,

I have laminated the five-part model and said, “Tell me about the situation.” So, I am writing … and so I’m asking, “How did you feel, what did you think? What did you feel in your body? What did you do?” and then they go, “Oh!” And so, once they notice that, they wipe (pointing to the laminated paper), and then they will write. They tend to respond to that quite well.

Participant 3 agreed and stated,

They don’t usually do the thought column stuff. Even though it is the same, but visually! They like that [pointing to the five-part model] seeing it … so they have a visual thing about their story. So, the introductory stuff and assessment stuff is important because they helps with the assessment. You get to see which relationships—there's a disconnect.

The four participants frequently used behavioral interventions with Pacific peoples. Participant 1 explained a specific technique she used in practice:

In terms of the techniques, like I think activity scheduling … is … I mean I use that with everyone. And I’ve seen studies even in Africa where they made kids who have been exposed to trauma do activity scheduling and found that … with the control group, they actually did better. You know, particularly for our Pacific peoples they like to do things. So, I think that's really important. Cause when they stop doing things, like isolate themselves … I’m thinking of the 45-year-old Samoan woman that I’m working with at the moment, just getting her to do something every day … took us a few weeks you know … but as soon as she started doing it she … reported feeling her mood was so much better.

Furthermore, the service user's responded well to the “doing part” in therapy as evaluating and challenging their cognition was not so simple, as participant 3 explained:

They like the “doing” in CBT, but when they start teasing out their thoughts, they struggle. But the doing part is that they feel a sense of achievement in that … It's the odd person that says they feel things. They find it hard to identify the thoughts … “I don’t know what I’m thinking, I just feel it …”

The “doing part” (behavioral interventions) suggested to be a good place in exploring and changing their way of thinking and feeling:

The importance of just doing the basics; getting up, having something to eat, having a shower, getting dressed, making your bed. So, at least, anything more, you’ve done five things. So, getting them to document what they’re doing but also actually planning what they can do. Not focusing on what they’re not doing but what they can do. Rather than, always looking at what they didn’t achieve, just what they can do. (Participant 2)

Others explained the importance of using relaxation and mindfulness methods. These techniques were also the most frequently used among Pacific service users. Participant 2 stated,

The use of relaxation, and I include mindfulness as part of that as well. Again, has been massive for most of Pacific clients as well, I remember doing mindfulness in a group and you know with Pacific I was thinking, “Oh I don’t know if this will … ” you know, or mindfulness with the violent offenders group and you think, “Oh I don’t know if this will be acceptable to them … ” but THEY LOVED IT.

As participant 3 explained,

I use mindfulness a lot. Because when we explain about time travelling or drifting, bringing themselves to the now … “Where am I? What am I doing?” Just to give them the skill … In their heads, [is] a hell of a lot. It's amazing, and I didn’t think mindfulness was something that Pacific would get. But we get it! We get it! I was surprised. Cause you think its Western … but they get it.

Subtheme 2: Therapeutic relationships and connections

Therapeutic relationships and connection were accentuated throughout the whole talanoa. The participants in this study also shared their experiences on attendance and dropout rates among Pacific service users of CBT, explaining they all had good attendance and low dropout rates. The participants reflected on their answers and explained it was imperative to develop those therapeutic relationships early on in therapy. For instance, participant 2 expressed her thoughts on appropriate disclosure in therapeutic relationships:

I’ve noticed working in the cultural service, different to the mainstream, is how much appropriate disclosure in the Pasifika setting really does enhance and bring together the therapeutic relationship, where I didn’t even think about that … but that's where the fluidness as it were of working with Pasifika … they so appreciate sitting alongside, of course they already by default respect us, being in authority, but also the understanding that they are a person and they might have had something similar that they had to deal with, so that appropriate disclosure is invaluable in building … but then, of course, something that new players need to be careful around making sure … because you still have to maintain the boundary.

The importance of connectedness was emphasized by participant 3:

I found when I first started as a contracted psychologist at a Pacific service, my first client who was an older woman, her first question to me was where was my village, and I was gobsmacked … you know, and I kind of sat there … oh … but if I think about “whakawhanaungatanga” like in the Māori sense and introducing yourself and where you are from … I think I have incorporated much more with my Pacific clients around where they come from so you can kind of locate each other … you know, and making meaning and make sense of. So, I think that is pretty different.

“Family is everything”

The involvement of family was also stressed throughout the talanoa. All participants expressed that most service users opt to have their families included within therapy:

It's an ongoing conversation … I think if the family knows the triggers, early warning signs and things like that, they can help support their family … then, again, you can’t force it on the client. Maybe talking about the pros and cons, but at the end of the day, it's up to them. Most of the time they are keen on having their family on board. (Participant 3)

The question was raised “What about the role of the family? How do you incorporate family in therapy?” Participant 2 brought up a good point about viewing this situation from a different angle. There is an emphasis on providing ongoing opportunities to have this talanoa with the service users, weighing up the pros and cons of their family involvement so they may feel supported.

I mean we all understand the course of their distress, sometimes it may be their family … then they’re not going to want their family to be there. And it takes some skill and experience to be able to figure out how you could convince your clients that they will be safe. In doing that, just how that will benefit them, and that you will take responsibility for making sure that there's going to be no harm, which is a big thing. So, I guess it's opening those kinds of conversations, barring sexual abuse where we don’t want them in the same room to protect them … So, it's an ongoing conversation I guess what I do in my individual therapy is, “would you like your family to come” “you’ve come such a long way … ” “who would you like to support you?” I don’t just ask once or twice. I keep at it, to encourage them.

All four participants have expressed that establishing a sense of connectedness and the Pacific ways of knowing and doing is fundamental when delivering CBT

Conflicts with confidentiality

Some participants outlined issues of confidentiality and defining such boundaries within therapy:

I was just going to make a point about confidentiality and how that's really, really important with our people. And I keep saying to non-Pacific, you know that's vitally important. But especially in the Pacific service where you do know people, you know our community is quite small, we know each other. I found, where I go and work in the Cooks … I get a lot of people who want to see me cause I’m not from there. Because everybody knows everybody. Because it's such a small community. (Participant 2)

Participant 2 also reiterated the importance of upholding confidentiality:

Sometimes people don’t want you to know, where they’re from, and they become a little bit suspicious … yeah, so I think again it depends on … yeah … it can be a way of opening … for example, recently, I was assessing a client and found out that they were from the same village possibly family connections. So, yeah there was kind of like a shutdown sort of thing. And that's where you kind of have to reinforce that confidentiality.

Subtheme 3: Culture and spirituality

The findings from this research have recognized the crucial roles of maintaining and embracing a sense of connectedness as well as upholding the language, values, and beliefs of the Pacific culture. The participants all shared similar views. As participant 4 explained,

Keeping it simple and giving examples. Even if you use Pacific terminology. I am definitely not fluent in Samoan. But for some of the older women or men who are more comfortable speaking, they’ll speak, and at least they can communicate. My understanding is a lot better than my talking.

The notion of incorporating cultural proverbs and metaphors to provide meaning to their stories was fundamental among most Pacific service users. Participant 3 stated that

… because I do focus a lot on relationships, so things like our spirituality … So, if they raise that with me, in terms of faith or their relationships, then that's something we will explore. There needs to be … the metaphors we use, more cultural. I have a book with even … alagaupu [Samoan proverbs] or whether they’re Tongan, just so that they can have some to guide because they’re not … cause the metaphors we use are “light under the tunnel,” and they don’t understand … So, things they can actually get meaning for themselves because they’re going to remember that stuff and if they give their own meaning to it, then that's going to stay … .Using the metaphor of the fanua [land] … just their own beliefs … checking those out … their own stories of where they’ve come from.

Participant 4 agreed that culture and spirituality are very much a part of who they are as Pacific peoples:

I think the effectiveness for Pacific peoples regarding the talanoa in CBT is the use of their stories and linking it with what they know of the Bible.

All participants expressed their thoughts of adapting the techniques and concepts to enhance CBT delivery in a culturally appropriate manner. The use of Pacific analogies, storytelling, and talanoa were frequently used:

I use a lot of analogies; I use vignettes to describe, I paint word pictures even though … you know there's always going to be that cultural mismatch always but I’m Indonesian and that … There is a common thread with the Indonesian culture and a lot of the Pasifika of being able to identify who they are, I could really use that to enhance this kind of learning. You know whether it's the concept of extended family, or spirituality or whatever. This means that often these sessions are fuller, could be longer, but those changes have been necessary. So, there's a lot of adapting! (Participant 1)

Participant 2 agreed:

I use proverbs a lot; you know, Pacific proverbs, particularly Samoan proverbs with my Samoan clients. And again, I think that connects with them, and they get it, and it also builds their sense of identity. So, I think it's got these unintended consequences as well, that's greater than CBT.

Incorporating talanoa during therapy

Talanoa in the Pacific worldview is shaped and influenced by Pacific core values as mentioned earlier. All the more, understanding cultural protocols is imperative. Bearing this in mind, this highlights the need to teu le va (maintain the relationship) and incorporate Pacific core values while acknowledging and learning how to navigate through the power imbalances between clinicians and service users.

I think that's where the talanoa comes in … Because when I think about talanoa because in a therapeutic setting, there's always that sort of power imbalance. And I think with the talanoa it reduces the power [im]balance a bit … Also, I think it uses the concepts or the roles that we have. I’m just thinking around the fa’asamoa [Samoan culture, a way of life] as well, you know … sort of like aunty or those kinds of connections, whereas in a Palagi setting, it might be seen as like crossing boundaries. (Participant 4)

Participants 1, 2, and 3 agreed, emphasizing establishing a solid therapeutic relationship, interweaving Pacific values and culture as the foundation:

I think using those Pacific structures can really help [create] trust [in] a therapeutic relationship, and I think clients really want to know that you care. You know it's not just an intellectual exercise, it's an emotional, spiritual sort of relationship as well. (Participant 3)

The participants discussed some challenges with delivering a rigid, Western structure of CBT. They reported that at times they would need to take fuller sessions to explain specific concepts and techniques. The significance of adapting techniques and ideas was fundamental, allowing room for flexibility. Participants saw the use of analogies, metaphors, stories, spirituality, and talanoa as immensely practical with Pacific peoples:

I use a lot of metaphors … I have a book with even … alagaupu [Samoan proverbs]. They can actually get meaning for themselves because they’re going to remember that stuff, and if they give their own meaning to it, then that's going to stay. (Participant 4)

Participant 3 pointed out that understanding the richness of the Pacific culture is not solely based on the written recording, but in “a narrative form.” Flexibility is paramount:

… you know … the older people, their culture, their histories are held in the narrative form, and memories and things like that … this is not just what you do for the Pasifika, this is actually really useful for non-Pasifika people as well and could enhance the outcomes, because Palagi people … there are variations in how they deal, and perceive and interpret things and what a wonderful thing to be able to perhaps look at them as like individuals and offer them a different way of dealing with their difficulties rather than just … ok, this is how you write … write it down. What about if they were artistic and wanted to sing it?

The rigidity of the CBT Westernized model was clarified and the need to incorporate Pacific concepts was paramount:

An unhelpful way for Pacific people is sticking to a strict CBT structure … I think … my experience working with our people is the flexibility. I think if you’re too rigid in any sort of approach that can be problematic. (Participant 2)

Furthermore, participant 4 pointed out an interesting perspective using the expression “complemented” as opposed to being “modified,” stating,

I’m sort of more eclectic in my practice. As opposed to being modified, I think complemented perhaps with other things. So, I think like the spiritual context is very important. You know, like the holistic comes, the Fonofale model. So, addressing those as part of CBT approach. The values and purpose. Because I still think CBT … to me it's very intellectual dry kind of approach … it just almost needs to be fleshed out.

There was also an emphasis on assessing the Pacific service users’ knowledge and expectations of therapy. The participants mentioned how vital connectedness and relationships were in treatment and the incorporation of whānau or aiga (family) to ensure meaningful connections in treatment.

Discussion

This was the first research to explore Pacific psychologists’ perspectives on CBT among Pacific peoples in New Zealand. The results provided preliminary validation for the usefulness of CBT among Pacific peoples. Furthermore, the findings have revealed the need to enhance the compatibility of CBT with the culture of Pacific peoples.

Engaging and forming therapeutic relationships within therapy was crucial. The participants explained that it was imperative to develop a sense of solid therapeutic relationships early on in treatment, which resulted in low dropout rates and good attendance in therapy. In the same way, establishing a connection with the client is fundamental, for example, through self-disclosure, exploration of ancestry, and engagement with family (Bennett, 2009). The Te Kaveinga (Ataera-Minster & Trowland, 2018) report emphasized that Pacific peoples in New Zealand felt strongly connected to their culture and have recognized the significance of this connection.

Furthermore, the findings have highlighted that encompassing cultural values and beliefs is part of developing solid therapeutic relationships within therapy. Factors such as family connections, language, and boundaries were emphasized throughout treatment. The participants related “boundaries” to understanding the vā or the sacred, relational space within the talanoa. For instance, one participant described the significance of talanoa: “I think with the talanoa it reduces the power [im]balance a bit.” Research shows that when there is a connection in therapy, this provides a “safe space” for the individual and generates appropriate disclosure (Amituanai-Toloa, 2006; Fa’avae et al., 2016). Also, in agreement with the findings, Taua’i et al. (2018) examined the associations between experiences of mental illness, migration status, and languages that are spoken among Pacific adults living in New Zealand, finding that embracing cultural characteristics such as the Pacific language and a sense of belonging was crucial to producing positive health outcomes among Pacific peoples.

The participants in this study spoke about the importance of building a trusting relationship with Pacific service users and “understanding” their Pacific worldview. To some degree, the Pacific psychologists linked this notion of “understanding” to their low dropout rates. They stressed how vital it was to understand the service user's worldview, which provided meaningful connections in the therapeutic relationship. Hays and Iwamasa (2006, p. 107) supported this finding, stating that “once a therapist recognizes the reality of an African American's life, it will help maintain a good relationship, which in return prevents dropout rates in therapy.” Conversely, Naeem et al. (2015) pointed out that high dropout rates in CBT were linked to the lack of engagement between the therapist and the patient.

This research found that delivering a rigid structure of CBT was at times ineffective. The importance of flexibility was vital for Pacific service users. When asked about some of their suggestions on the delivery of homework, the participants explained that this depended on their assessment regarding the individual‘s capabilities. The participants emphasized and framed homework, with Pacific service users, as the “doing part” in therapy. According to a few studies, homework was one of the significant obstacles patients found challenging in treatment due to the lack of education and literacy problems among ethnic groups (Naeem et al., 2010; Parker et al., 1999; Pineros-Leano et al., 2017).

There were numerous modifications to CBT that the participants used with Pacific people during therapy. Most reported that they were “always adapting” with Pacific service users. The participants explained that CBT treatment is delivered using talanoa, narratives or stories, analogies, Pacific proverbs, and vignettes. Some participants expressed the importance of the use of talanoa in therapy. In any given Pacific context, the value of using talanoa allowed the Pacific culture and heritage to be restored, cherished, and protected within a sacred space, or vā tapuia. The incorporation of metaphors and Pacific proverbs was critical, as it provided meaningful connections back to their ancestors, Pacific culture, traditions, and identities. Similarly, in Pakistan, the use of the Urdu language in explaining concepts of CBT meant involving the family in therapy for support and allowing the client to express their stories freely in a cultural context (“folk stories”) to provide an active engagement (Naeem et al., 2015).

The use of proverbs and metaphors in CBT has also been effective for culturally adapting a CBT program for Māori with depression (Bennett, 2009). McRobie and Agee (2017) discussed the importance of integrating proverbs counselling Pacific clients. Proverbs are incorporated to help people express their stories through narrative within therapy. They are essential for most Pacific people because they enable them to contextualize and connect to their ancestors, traditions, and cultural identity. Interian and Diaz-Martinez (2007) found that Hispanic people had trouble grasping concepts of CBT. Therefore, clinicians incorporated a culturally adapted CBT approach and implemented dichos (proverbs or sayings) to provide a meaningful expression for the client.

The findings indicated that holistically assessing a client's presentation was imperative. Specifically, for Pacific peoples, this involved determining a client's cognitive and literacy abilities, socioeconomic status, spirituality, family, and cultural considerations. One participant referred to the “adaptations” as “complementing” CBT treatment, incorporating “spirituality, values, culture” by viewing Pacific individuals holistically and relating their view of health to the Fonofale model (Pulotu-Endemann, 2009). In agreement with the findings, and similarly to Pacific peoples, Nicolas et al. (2009, p. 379) found that Haitian immigrants upheld their worldview, which influenced their understanding and experience of mental illness, therefore impacting treatment outcomes. Similarly, the Pacific worldview of health is defined by three relationships through which Pacific peoples interpret and seek harmony: God, people, and land (Tamasese et al., 2005). The participants agreed and discussed the importance of connecting these elements in therapy to “adapting” CBT treatment. The majority of participants made it clear that they were still practicing CBT, even with those adaptations.

The incorporation of family within therapy was also an essential factor mentioned by all the participants. They explained that involving family was crucial for Pacific clients, though only if they were willing to engage. Interian and Diaz-Martinez (2007) pointed out that familismo (family) is understood to be a substantial value of Hispanic culture. As Ataera-Minster and Trowland (2018, p. 24) encapsulated, the “aiga, kaiga, magafoa, Tangata, famili” or family is the essence of maintaining healthy well-being for the individual.

This research has enhanced an understanding of the impact of using a Westernized approach with Pacific people, from a psychologist's perspective. Based on the findings of this research, there is a need to address the accessibility of mental health services among Pacific people. The cost of accessing psychological treatment is one of the many challenges that Pacific people face, collectively contributing to socioeconomic, psychosocial, and cultural dynamics. Having a cultural understanding and valuing the realities and experiences of Pacific individuals is critical in treatment delivery, which in turn affects the outcomes. With the valuable knowledge and skills gained from this research, this research aimed to understand those perspectives better. Paterson et al. (2018) confirmed that therapies need to be widely available and prioritized in NZ, with “suitable adaptations to different cultural and delivery contexts” (p. 112). Therefore, future studies should examine the incorporation of cultural adaptations or modifications to tailor to the needs of Pacific people using CBT. A further recommendation of exploring the impact of CBT from a Pacific service user perspective will help health professionals deliver the appropriate care. Due to this being a qualitative study, quantitative research could examine the number of Pacific people using CBT in the Auckland region, across different mental health settings, whether in private practice, GP services, community, or inpatient locations. A further quantitative study could also examine the dropout and attendance rates of Pacific people using CBT. This may aim to assess and explore issues regarding CBT treatment among this population. Furthermore, Tiatia-Seath (2018, p. 9) addresses the need for “advancing the capabilities and capacity of Pacific health professionals, researchers, educators not as a preference, but as a necessity.” A recommendation to explore the integration of Pacific and Westernized approaches is a requirement in fulfilling the responsibilities of the health workforce to help improve health outcomes and reduce health inequities among Pacific people in NZ (Tiatia-Seath, 2018).

Limitations

A significant limitation in this study was the sample size. Although the sample size in this study was appropriate for qualitative research, and data saturation was sufficient, there was still room to explore other perspectives to provide an improved analysis. The snowball sampling method also contributed to the small sample size. It was out of the researcher's control to follow up participants excessively due to ethical issues of possibly oversampling and manipulation of bias sampling. The small size of the groups limited the depth and range of experiences and perspectives discussed, which may have potentially impacted the quality of the collated data.

Second, this study was initially designed to explore perspectives, from a Pacific service user’s point of view, on the use of CBT to gain a greater understanding of how to deliver Westernized treatment models to Pacific peoples safely. Initially, the primary health organizations explained that it was difficult to extract data and recruit participants as there were very few Pacific individuals who completed the entire CBT course. There were many challenges in identifying and recruiting participants, and, as a result, this approach was not possible. Therefore, still focusing on the same area of interest, the researcher aimed to explore a Pacific psychologist's perspective on CBT delivery.

A third limitation was that there was a lack of diversity of Pacific ethnicities, despite this study being a Pacific study exploring Pacific perspectives. There were three participants of Samoan descent and one from Indonesia. It would have been beneficial and insightful to gain perspectives from other ethnic backgrounds, such as Tongans, Cook Islanders, Fijians, Niueans, and so on. Understanding different perspectives would also have generated more valuable data. According to Te Pou (2010), there is a shortage of Pacific therapists trained to deliver approaches (such as CBT) to service users. Also, a lack of research regarding the effectiveness of these treatments among Pacific people was another vital factor to consider. Hence, this research aims to address the need to explore these perspectives further to enhance the appropriateness of care for Pacific people. Therefore, it was challenging to recruit a variety of psychologists from different ethnic groups. The researcher sent an email invitation to psychologists from different ethnic backgrounds. However, some responded and stated that they did not practice CBT. Two Tongan psychologists responded to the email and were willing to participate. However, they were unavailable to attend on the interview day. The participant from Bali took an interest due to her actively practicing CBT within a Pacific mental health service.

Conclusion

The findings from this study have provided empowering and meaningful information for enhancing and improving the mental well-being of Pacific peoples in New Zealand. Exploring the participants’ perspective on the use of CBT was pivotal in this research, as it raised awareness, understanding, and—most importantly—knowledge on this topic. The study found that understanding the client’s worldview, language, and culture was the pinnacle of delivering an effective and appropriate CBT treatment among Pacific peoples. The findings intend to help other psychologists gain insights into the need to complement CBT to accommodate cultural practices and how this can be done, which could have implications for different ethnic groups.

This research gathered valuable knowledge on the significance of adapting CBT and having a more profound understanding of the cultural implications of conducting CBT with Pacific peoples. The data will provide understanding for mental health research and help inform clinical practice and encourage future psychological interventions. Not only does this study have value as the first of its kind in New Zealand, but it aims to enhance the accessibility of therapy that can lead to improving mental health. Given that Māori and Pacific peoples have an increased risk of developing mental disorders, the findings emphasize the need to explore the cultural compatibility and relevance of mental health treatment methods as a key priority in improving the mental well-being of different groups.

These findings will contribute to current Pacific mental health research and enlighten and provide authentic, valuable knowledge to health professionals. Upholding the Pacific worldview, language, and culture is paramount in the successful delivery of CBT to Pacific peoples. As a final point, the true essence of this research is summarized in a statement by Ataera-Minster and Trowland (2018, p. 48):

We need to strengthen the Pacific workforce and culturally appropriate models of care so that Pacific peoples felt safe and understood when using the mental health services available to them.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Taulaga Auva’a-Alatimu

Correction (May 2023):

The address under “Corresponding author” has been updated.

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