The Experience of Depression in the Tokelauan Culture in Two North Island Communities

Abstract

Background and Aims: The Tokelauan language lacks a word that corresponds to the western term ‘depression’. Furthermore, there is no research on the experience of depression in Tokelauans, and yet doctors continue to apply a western biomedical model of depression to Tokelauan patients and those from other Pacific cultures. This research aims to describe the experience of depression in Tokelauans and provide insight into its management. Better awareness of the symptoms and signs of depression as experienced by Pacific Islanders will enhance diagnosis and treatment of the illness by general practitioners. Method: Following extensive consultation with the Tokelauan community in Taupo, and using purposive stratified sampling, ten respondents contributed to this study. Semi-structured in depth interviews were performed and recorded verbatim. The transcripts of the interviews were thematically analysed using an immersion crystallisation technique, with further analysis to detect sub themes. Results: There is no specific word for depression in the Tokelauan language but an illness involving extraordinary sadness does exist. Ordinary sadness is regarded as just ‘part of life’ but extraordinary sadness can be classified as “unwellness” or “a burden". Tokelauans use several indicators to recognise someone with extraordinary sadness. The main indicator is isolation and withdrawal from family and community activities as well as absence from work and church. Tokelauan men are more likely to hold their feelings in and may indicate their unwellness with increased alcohol use or violent tendencies. For Tokelauans, privacy and pride are important cultural characteristics and these may be barriers to recognising sadness. The shame and loss of status associated with displaying sadness may also cause a person to hide his or her feelings. Often the smiling Tokelauan face becomes the mask that hides sadness. The main causes of extraordinary sadness are the changes caused by western influences on the Tokelauan culture and the stress of poverty and unemployment. The family, community and church are all important avenues for caring and for counselling the Tokelauan with extraordinary sadness. Discussion: This research documents some of the features of depression experienced by Tokelauans that are different from those that doctors may be trained to detect and manage using a western biomedical model. This research demonstrates the complexity of relationships between the patient, their illness and their culture that impacts on how the illness manifests. Similarly, this research indicates that therapy must have a holistic approach that includes the family, the community and that accounts for the patient’s spiritual beliefs. Te Vaka Atafaga is a metaphor for Tokelauan wellbeing involving a canoe. Its structure is representative of different components of health, and it provides a holistic model for the general practitioner involved in assessing and treating Tokelau Islanders with a possible depressive illness. The model does not exclude the use of western medical approaches, but it emphasises the need for social disharmony to be corrected to allow healing. Conclusion: The presentation and management of depression in Tokelauans may differ from that of other patients in a general practice setting. The Te Vaka Atafaga model provides the general practitioner with a tool to assess the different components that comprise health in the Tokelauan. A holistic approach involving the family, spirituality and correction of social factors along with palagi medicine is then necessary for treatment.