Siale ‘Alo Foliaki has been at the frontline of mental health services in South Auckland for more than 20 years — as one of a too-small number of Pacific psychiatrists in this country.
Here he talks to Dale about his life and his work — how he became a psychiatrist, the importance of a cultural perspective in mental health, and why we need to do more to address the bigger forces that shape our children’s lives.
Mālō e lelei, Siale. At e-Tangata, we're big on connections, so if you would be so kind as to share some of yours and tell us about your names, your mum and dad, maybe your grandparents and your village, that sort of kōrero.
I was born in Tonga in 1967, and in Tongan custom, your father's eldest sister gets naming rights. The arrival of a new child is seen as part of a continuum — and so, often, children are given the names of some of the people that you love who have passed on.
With me it happened a bit differently. There was a dream involved. A mentor of my father — a medical doctor — and his wife were childless, and the wife of this doctor had a dream that the child my mum was carrying would grow up and be a doctor.
So she asked my mum whether my family would consider naming this child after her husband, which is not the done thing in our culture. Nevertheless, these sorts of dreams are powerful in Polynesian culture, so my mum talked it over with my dad and they agreed that my middle name should be ‘Alo. My full name is ‘Alo-ki-hakau, which means “to paddle to the reef.”
The reef is a place where a lot of Pacific people lose their life, because it's quite a dangerous place, and my understanding of the name is that it has something to do with not being scared to live your life where the dangerous waters are.
That story was told to me when I was still a child and you can't help but carry the burden of that. I always felt I had to live up to that woman's dream.
Sometimes Tongan culture can also be cunning, Dale. I don't know to what extent I believe the story, but it sent me on a trajectory towards a pathway that maybe I wouldn't have gone down without it.
As early as I can remember, that sort of mythology was part of my upbringing. And I think it's part of a lot of Polynesian households.
My dad (Leopino) was a doctor himself, and he was from a small village near Nuku‘alofa. My mum (Seini) grew up in a neighbouring village. She's got an interesting history because one of her great-grandparents was involved in the mutiny of the Bounty. The sailors took some women from Tahiti with them, and one of those Tahitian women was my great-great-grandmother.
I'm the youngest of seven. My father sent my mum and me here to New Zealand in 1967 so I could get an education. Education was always designed to provide something of value to our community.
Thanks, Siale. Did the wāhine who dreamed about you live to see you graduate?
She did, but her husband didn't. I only met them one time. Because we grew up in New Zealand and they were in Tonga, and international travel was so expensive, once you migrated away you saw the important people of your family maybe once in your lifetime. But yes, she lived to know that I graduated and that her dream had come to fruition.
What a beautiful story, Siale. Who else had an influence on your life?
My grandmother. I only saw her once, actually, when she came to New Zealand for a visit. I think I was still at primary school. She couldn't speak English and the only way I could communicate with her was by recapturing some of my lost language, and that helped me to find the joy there is in being bilingual.
She had spinal scoliosis, which means she couldn't walk straight. You know that famous photo of Whina Cooper and her walking stick, walking along a dusty road bent over? That was like my grandmother going to church. She wanted to go to church every morning and it was my duty to take her there. If I broke into a sprint it took me under a minute to get there from our home, but she would take somewhere between 15 and 20 minutes.
The funny thing about my grandmother is she made me slow down, and she used to talk to me in ways that made me understand something about the nature of what it means to be Tongan, to be Polynesian. There was a stillness in her that was quite at odds with the chaotic environment of 1970s industrial Penrose.
Tell us about your schooling. Was it that situation we hear often that teachers don't have high expectations of Māori and Pasifika kids. Were there those who were supportive and believed that you had the potential to go further, or were you lumped in with the attitude that affected other Māori and Pasifika kids of that time?
I was certainly dumped into that category. There's no doubt about that. But one of the things I would say is that, even though educators might have had that view, in our Pasifika families there was a very high expectation on us that we were going to do well in life and meet the community’s expectations and be of value to our community.
But that high expectation didn’t come with a lot of support.
So you would come home from school, and home was chaotic because your relatives from the islands were staying with you. You had these little overcrowded homes, and it was good fun, but the chaos was not conducive to doing well educationally.
I remember in the fourth form, the science teacher going around the room at the beginning of the year and asking everybody what they wanted to do. I said I wanted to go to medical school, and everybody laughed and the teacher laughed, and it was one of the most humiliating moments of my life.
Then and there I made a promise to myself that I would never tell anybody again that I wanted to go to medical school, because the reaction was just so invalidating. From then on, I kept it to myself.
But, on the other hand, it was the single most motivating moment in my life. There's nothing like a group of your peers and somebody in authority giving you the message that “you can forget about that, mate, you're kidding yourself”. Sometimes those moments can be quite inspirational. It goes one of two ways, doesn't it? It can break you and you can think, shit, if these people don't believe in me I’ve got no chance — or it can do the opposite. I think that’s a common experience amongst our people.
You ended up at Otago medical school, but bucked the trend in living arrangements, because most Tongan guys don't leave home till they're at least 27!
I needed to get out of my house because it was chaos. So many cousins were coming out from the islands to get an education, and my parents supported them. We had a downstairs rumpus room, and at one point there were 14 males in that space. If you arrived home late at night, you didn't get a bed, you slept on the floor.
You'd get up in the morning and one of your cousins would have taken your school shoes, and you can't turn up to school without your pair of black shoes, so you just skip school that day.
Ah, Dale, the 1970s in New Zealand was a funny time.
It sure was, but obviously you were able to make it work for you. Who would you acknowledge as someone who encouraged you to go to Otago University, and what were some of your feelings about the university experience?
One thing stands out. By the time I went to university, I had Europeanised my name, because nobody could pronounce it, and it was embarrassing to hear my name pronounced incorrectly — because if you said the “a” the way most Pākehā say it, it means “shit”.
Anyway, there was a Professor Eru Pomare who took a lot of the Māori and Pacific students under his wing, and I remember introducing myself to Eru, and he told me never to introduce myself like that again. I didn't know him then — and I thought, who's this bloke to talk to me like that?
I didn't take his advice that day, but it stuck with me all these years. And what he was trying to say was that I shouldn't accommodate myself to the wider culture but be proud of who I am. He's passed away now, but he was one of my allies and he believed in me.
You studied psychiatry. Was that always your intention, or did that decision come later?
The doctor that I was named after was a surgeon. He was Tonga's first surgeon. And there were so many similarities between us that I just naturally assumed that I was going to be a surgeon.
But life took a different turn. My first son, Daniel, was born with spina bifida, which means that he was paralysed from the waist down. I needed to spend a lot of time with him while he was being treated, and that meant taking a lot of time off my surgery programme.
I remember having a conversation with one of the surgeons who was taking an interest in my career, and he said maybe I should reconsider whether surgery was for me, given my commitment to my son and family. I found that conversation really hard, but he was right. Being a surgeon requires a commitment from you that it’s surgery first, everything else second. And for me, family had to come first.
So I did general practice for three years and helped set up a community clinic that was free for non-English-speaking Tongans, something I'm really proud of.
But during those three years, I realised that general practice wasn't for me, and when I thought deeply about who I was as a person and what my strengths and weaknesses are, I realised that with psychiatry you get a chance to spend time with people to an extent that you deeply understand them, and you can make a contribution to their lives through that relationship.
The stereotype we have about psychiatry is the shrink and the couch, but there are wonderful cultural dimensions to mental health, many of them advanced by Mason Durie. How pleasing was it to you that he developed a model that factored in our indigeneity?
Mason has had a profound influence on all of us doctors who are Māori and Pacific. He's been a pioneer in giving us the confidence that there are cultural dimensions that are valid and important in relation to understanding who an individual is, and what it is that they're going through.
When you use those traditional frameworks to help that person, there's enormous joy in that. It's meant that I can practise from a far deeper place and feel confident that that's okay. Mason opened that door and allowed the rest of us to follow him through.
How useful has this model been in looking at the mental health of our own people?
There are two aspects to our work. There's an aspect where we apply the dominant clinical paradigm that explains what people are going through when they're having difficulty psychologically. If we Māori and Pacific doctors practise too remotely from that paradigm, we're in danger of having our legitimacy challenged.
Defending that legitimacy is wasted energy, so most of us choose to walk the fine line between acknowledging the dominant paradigm, but also practising from a place of intimacy with our patients and their families that mainstream psychiatry might consider is too enmeshed in our client’s world, and not being objective enough.
But without that intimacy and trust, our patients are unable to talk to us about the things that really paralyse them — and a lot of that is historical trauma, stuff they're not solely to blame for. Intimacy allows people to really talk about some of the profoundly disturbing stuff that we just really don't want anybody to see, or even admit to ourselves.
Being able to allow my Polynesian-ness to coexist with my clinical knowledge enables my clients and me to occupy that space together.
A lot of people hear the term “historical trauma,” and think: “Get over it, we’re one New Zealand now, we've all got the same opportunities.” So I'm pleased that you remind us that, no, that trauma is real, and mental illness is not all the individual’s fault.
I had an interesting experience that I'd love to share with you. A few years ago, I visited the only Tongan at that time on death row in the United States. I had to write a report on his mental state that would go before the justices of the US Supreme Court Justices, and help them decide if he was mentally disordered at the time that he committed his crime — and on that basis whether or not he could be executed.
Such a report is basically an autobiography of the person’s life, because although you’re required to make an assessment as to why he did what he did at that time, you’re aware that that moment was filled with all the things that came before it, and all the forces in his life.
I remember talking to his family in Tonga, and learning how distressed he was at the age of three, when his mother left to go to the United States, and the father wasn't even in the picture, and his life starts to unravel.
And one of the things I learned through that process was: “there but for the grace of God,” man. You know, the forces at work in his life — if those forces were active in my life and vice versa, it could've been him sitting there interviewing me. I truly believe that.
As I get older, I’m much more conscious of the forces at work that shape our children’s lives, and a lot of those forces are way beyond the control of any individual mother or father or family. And I know that however long I've got left on this planet, I need to address those forces.
You know, I love my work. I will finish this interview with you, and people will come in here at Otāhuhu, where all those Tongan league fans were running around with their flags just a few weeks ago, and I will confront yet again the forces at work in their lives that are far beyond their ability to manage.
We can help them in a small way to address the current crisis that's going on in their lives, but I know that if we really want to shape a generation of people, we have to address the bigger forces at work.
I'm very moved by your observations and willingness to share this kōrero. Can we address the suicide situation, in which the stats for both Māori and Pasifika are appalling?
That's a tough topic, but it's not a topic that we should shy away from.
If you think about the forces that lead to a young person taking their life, and go backwards in time to when that child entered the world, we know from good quality research that the mother's emotional wellbeing at the time that she got pregnant is critically important.
If she was stressed or depressed, then that child has a different trajectory — just as we know that, after birth, if the mother suffers from post-natal depression, psychosis, or some serious drug and alcohol-related issues, that child will start to demonstrate abnormal behaviours by around the age of three.
If you follow those children over a long period of time, there's good research that show that they will have what’s called an “insecure attachment,” causing all manner of other problems. This tells me that there's something about that formative period in the making and growing of a child that is profound.
If you compare Māori and Pacific women, they have much higher rates of maternal psychopathology — which we would describe as being psychologically distressed — compared to non-Māori, non-Pacific women.
And if you look at the factors that are involved in being distressed when you're carrying a child, the big-ticket items that stand out are poverty, domestic violence, substance abuse. And then the other major factor is the quality of maternal support.
Suicide is one of those issues that we all want to address but often don't quite know how, and despite our willingness to get involved, the situation surfaces time and time again. What do you read into this, and how can we help?
I think we've got to not be afraid of talking about suicide to our children — particularly the attempted suicides that we see all the time at the emergency department of Middlemore Hospital.
You know, this coming Friday and Saturday, we will see 10 to 15 times as many kids presenting with self-harm as are actually committing suicide.
The size of the problem is enormous, and it's got to a point where we've got to help our own community engage and have conversations with their children about how they're feeling, and about whether or not they’re having suicidal thoughts. Because there's really good evidence to show that if you have those conversations, and somebody that you care about says, yes, they’re having those thoughts, then that young person can get the help they need from people who know how to help them with their distress.
By doing that, we can save lives.
My advice to families and communities is to start talking, and wherever possible, government agencies need to support how to have those conversations safely with young people.
As we conclude our conversation, can I ask how young Daniel is getting on?
Daniel is completely wheelchair bound, and for him to get to university from where we live, he has to catch a ferry, then a bus, then navigate suburban streets to get to the old teachers training college in Epsom, where he's doing a degree in human services.
Daniel does really well if he has a small volume of work, but if you give him too much volume he goes from doing really well to failing everything, and I think there's a message in that for our community: there are some kids that can do well academically, but they can only handle a certain volume of work. Those kids could do a lot better if we could align their capacity for learning with how much we expect them to be able to do.
What’s in store for you, Siale?
I’ve been trying to get a group of youngsters, Pacific and Māori, into psychiatry. It’s still not a preferred profession — they tend to want to choose surgery and general practice and pediatrics, so we’re struggling to get young Pacific doctors into training. We need more of them coming through and doing the frontline work that I’ve been doing.
I want to move into more of a community service role, where we can start to mobilise our community to support young people in a way that’s more effective than what we’re doing right now.
Dr Siale ‘Alo Foliaki is a consultant psychiatrist with Counties Manukau District Health Board, based at Middlemore Hospital in Otāhuhu. He chairs the Tongan youth suicide prevention group, Toko Collaboration, and is a director of Vaka Tautua, a charitable trust providing health services and support to older people, people with disabilities, and those needing support with mental health.
Siale was the lead psychiatrist for the development and national rollout of the of the crisis mental health services project with the Ministry of Health. He’s a Fellow of the Australian and New Zealand College of Psychiatrists, and is unique in having dual fellowship — in both adult, and child and adolescent psychiatry.
As well as his clinical work, Siale has undertaken extensive research projects, the most significant being his involvement in the New Zealand Mental Health Survey Te Rau Hinengaro. He’s had significant involvement in policy level roles with the Ministry of Health and the Mental Health Commission and had a key role in writing the cultural competency guidelines for Pacific people for the New Zealand Medical Council.