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West Indian Medical Journal

Print version ISSN 0043-3144

West Indian med. j. vol.61 no.4 Mona July 2012

 

SHORT COMMENTARY

 

Caribbean contributions to contemporary psychiatric psychopathology

 

Contribuciones caribeñas a la psicopatología psiquiátrica contemporánea

 

 

FW HicklingI; G HutchinsonII

ICaribbean Institute of Mental Health and Substance Abuse (CARIMENSA), The University of the West Indies, Kingston 7, Jamaica
IIDepartment of Medicine, The University of the West Indies, St Augustine, Trinidad and Tobago

Correspondence to

 

 


ABSTRACT

The intellectual exploration of phenomenological and psychiatric discovery that has flowered in the Caribbean in the period of political independence from British colonization is a reflection of the scholarship that has emerged from the academic nurturance by The University of the West Indies. Burgeoning migration of Caribbean people to England in the twentieth century has resulted in high reported rates of psychosis for this migrant population. Caribbean research into this condition has revealed that there exist hostile racial and environmental challenges in Britain that have had a profound pathological effect on the mental health of African Caribbean migrants. These findings have significantly shifted the pendulum of understanding of the aetiology of this condition from a genetic to a biopsychosocial position. Research has also revealed longstanding psychopathological effects of slavery and colonialism in the Caribbean that have had significantly negative long term effects on the mental health of many within the Caribbean population. Current research suggests that there is a need to nurture protective strategies to enhance resilience and social capital, which would ensure the wellness and continued survival of Caribbean people in spite of the many challenges they face.

Keywords: Aetiology of psychosis in Caribbean migrants, resilience, social capital, wellness


RESUMEN

La exploración intelectual del descubrimiento fenomenológico y psiquiátrico que ha florecido en el Caribe en el periodo de independencia política de la colonización británica, es un reflejo de la erudición surgida del cultivo académico de la Universidad de West Indies. La pujante migración de personas del Caribe a Inglaterra en el siglo 20, ha traído como consecuencia reportes de altas tasas de psicosis en relación con esta población de emigrantes. La investigación caribeña de esta condición ha revelado la existencia de retos producidos por la hostilidad racial y ambiental en Gran Bretaña, que han tenido un profundo efecto en la salud mental de los emigrantes afrocaribeños. Estos resultados han desplazado significativamente el péndulo de la comprensión de la etiología de esta condición, desde una posición genética a una posición biopsicosocial. La investigación también ha revelado la presencia de efectos psicopatológicos pertinaces provenientes de la esclavitud y el colonialismo en el Caribe. Se trata de efectos significativamente negativos y a largo plazo, sobre la salud mental de muchos dentro de la población caribeña. La investigación actual sugiere que hay una necesidad de fomentar estrategias de protección a fin de mejorar la resiliencia y el capital social, que asegurarían el bienestar y la continuación de la supervivencia de las personas del Caribe, a pesar de los muchos desafíos a que se enfrentan.

Palabras claves: etiología de la psicosis en los emigrantes del Caribe, resiliencia, capital social, bienestar


 

 

INTRODUCTION

The development of a training curriculum in psychiatry at The University of the West Indies (UWI) in 1965 heralded the advance of influential research in the epistemology and epidemiology of mental illness in Caribbean people, which has had a significant impact on contemporary international psychopathology. It introduced the concept that treatment and the development of mental health services can occur contiguously with training of mental health professionals. With the burgeoning rates of migration of people of Caribbean origin to North America and Europe, the mental health issues of African Caribbean people have taken prominence in international psychiatry as these countries grapple with mental health service delivery in multicultural settings. Psychiatric graduates of the UWI have played a decisive role in the unfolding of many of these mental health challenges in African Caribbean people, and the findings of the research emanating from the UWI and her graduates have had a significant role in the clarification of the aetiology and epidemiology of international psychopathological research. This review of the literature on this topic will be mainly restricted to the reports of the psychopathology and epidemiology of mental illness in the Caribbean, and will focus on the critical issues of regional and international importance.

Migration and Mental Illness

Two major epidemiological studies have been reported on the range of mental illness in the Anglophone Caribbean (1, 2). There have been several studies in recent decades suggesting that the risk ratio for schizophrenia was six to eighteen times higher for African Caribbeans in the United Kingdom (UK) than for Caucasians (2), with British psychiatrists strongly suggesting that the migrants brought this condition with them from the Caribbean and that the aetiology of this condition was predominantly genetic. However, early studies in Jamaica (3, 4) reported that the admission rates for schizophrenia were similar to those of Caucasians in the UK. A further study (5) demonstrated that African Caribbean returning migrants to Jamaica had five times more schizophrenia than the native Jamaican population and that the returning migrants had experienced a step down in social class when they migrated to the UK. These early findings questioned a primarily genetic aetiology of schizophrenia. A watershed incidence study of first contact schizophrenia in Jamaica (6) settled the aetiologic controversy by establishing that the incidence of 2.09 per 10 000 for schizophrenia in Jamaica was significantly less that that reported for Caucasians in the UK, and that the reportedly high risk ratios for schizophrenia in African Caribbeans in the UK was likely to be a product of the host environment. The first-contact incidence rates that were established in Jamaica were replicated in Barbados (7) and in Trinidad and Tobago (8), confirming that the high rates of schizophrenia reported for African Caribbeans in the UK was a product of environmental factors in the host migrant country of England. This Caribbean based research thus helped to swing the aetiologic pendulum in psychiatry essentially away from a limited genetic focus to a broader biopsychosocial framework. Further work by Hutchinson and his colleagues (9, 10) supported the ideas that genetic and perinatal factors were much less important aetiologic factors in the high incidence rates of schizophrenia reported for African Caribbeans in the UK, and that potent psycho-social environmental factors were instead more likely to be the cause of these findings.

The study by Hickling and Hutchinson (11) and the review by Hickling (2) also provided strong evidence that the misdiagnosis of schizophrenia in African Caribbeans in the UK may play an important role in the high risk-ratios of schizophrenia reported from England. Whaley and Geller (12) reported that 'clinician bias' and 'cultural relativity' factors caused an over-diagnosis of schizophrenia in African Americans in the United States of America (USA), and suggested that similar factors could obtain for African Caribbeans in Europe. A case-report narrative study (13) con-cluded that such clinical biases and cultural relativity factors may cause some British clinicians to confuse illness and wellness in some African Caribbean people; this in turn could significantly skew epidemiological risk ratio studies in that country, with false positive results. However, the presence of large numbers of people of African Caribbean and African origin in mental hospitals and prisons, compared to their population percentage suggests that there are societal problems that result in these outcomes (14).

Racism and Mental Illness

In a study of Caucasian migrants to Jamaica, Hickling (15) demonstrated that Caucasian migrants had a much lower rate of schizophrenia in Jamaica compared to Jamaican controls, and were also privileged to significant elevation in social class in the Black host country. All previous migration studies worldwide had been conducted on White and Black migrants to White first world countries and Cochrane and Bal (16) concluded that a doubling of the rate of schizophrenia was the only reportedly consistent mental illness to be a consequence of these migrations. Hickling (15) suggested that the political, economic and social systems in Black post-colonial countries like Jamaica seem to protect White people from the development of schizophrenia. Conversely, the political, economic and social systems in White first world countries like the UK seem to facilitate the development of schizophrenia and downward social class mobility in African Caribbean migrants. In a subsequent article, Hickling (17) suggests that in the Caribbean Diaspora, European colonial rule resulted in a culture with differential effects on the native socio-economically deprived and white immigrants.

". . . It is suggested that the political/economic system in post-colonial countries of the Caribbean engenders severe mental illness in the poorest native-born socio-economic classes but protects White immigrants from the social stress of migration . . . the political structure of White 'first world' countries seems to create psy-chosocial stress factors that predispose to the development of schizophrenia in Caribbean migrants. . . " (17)

Marley (18) in a review of these hypotheses from Hickling's article suggests that they ". . . offer potentially important insights into the prevention and treatment of psychosis . . . and also make potential cultural contributions to psychosis quite concrete with racial factors figuring prominently. . . ." Caribbean psychiatrists have long been suggesting that the main cause of mental illness in African Caribbeans in the UK is racism and hostile social environments (19). A report in the British Medical Journal suggested that racism and other hostile aetiological challenges in the UK might be a significant cause of the high rates of mental illness for African Caribbeans in Britain (20).

Marley (18) also asks the question ". . . to what extent do historical events contribute to the development of contemporary culturally induced psychoses and social mobility? Can history be playing such a role in events today and if so does this manifest through a retrovicarious trauma. . ." The Caribbean psychiatrists of the past three decades have indeed been posing these challenging questions that are now beginning to be addressed. Smith (21) in attempting to speak to these questions suggests:

". . . The colonies and peoples of the British West Indies shared a common set of experiences that differentiated them from the rest of the empire. . . . The effects of slavery were profound, even incalculable, not only on the psychological states of enslaved peoples, but also on those of the slaveholders. . . . The consequences of abolition were also profound...the social and economic legacy of slavery and abolition permeated every aspect and stratum of West Indian society . . . ." (21).

Hickling and Hutchinson (11) attempted to tackle these questions ". . . to highlight that psychopathology in formerly colonized and oppressed peoples can take a form that reflects continuing problems with their identity arising out of the ambivalence and anomie fostered in their collective and personal history. . . ." Their investigation of the nature of psychotic symptoms of African Caribbeans challenged the historical relationship between Britain and the Caribbean as it applies to definitions of normality and acceptance. They described patients who initially displayed behaviour of being 'functionally White' as having a 'roast breadfruit syndrome', that is, black on the outside and white on the inside; named after the cooked version of the breadfruit (Artocarpus altilis) which has a green skin that becomes charcoal-black when roasted while the inner flesh remains white in colour. They described the characteristic features:

". . . include an overwhelming desire for acceptance by European society, being ashamed of one's indigenous culture with exaggerated rejection in language and manners, and attempts to alter skin colour to appear more white. This can be exacerbated to psychosis by experience of social difficulties because of racism, and/or experiencing abuse because of an inability to succeed on European terms. The psychotic symptoms themselves defy easy categorization and have a significant affective component as well as psychotic phenomenology encompassing self and identity" (11).

Martiniquan psychiatrist Frantz Fanon (22) identified the phenomenon whereby Black colonials could become and believe themselves to be 'White' by the integration of the colonizers language and culture into their own psyche. Such individuals would usually be insightless to this process and would also negate or reject their own indigenous culture as inferior or primitive. Hickling and Hutchinson (23) suggested that this syndrome is one of the sequelae to European colonization in the Caribbean, and that the 'roast breadfruit psychosis' is a potential consequence of this abnormal personality identity formation combined with the stress of social racism.

Redefining Personality Disorder

The anthropological work of Madeline Kerr (24) on personality and conflict in Jamaica suggested: ". . . most of the Jamaican psychological and sociological problems arise out of two culture patterns with ideologies which conflict in certain important aspects leaving the individual bewildered and insecure . . . . In the individual, the cultural dilemma is reflected in personality difficulties and in some cases it exercises a partial inhibition of the development of psy-chological maturity . . ." Kerr's work suggests that it is very difficult for Jamaicans to assimilate the idea of cooperation with a group without spectacular leadership and that this can be correlated to the lack of male leadership in the Jamaican family. She suggests five contributory aetiological situations, which include: a split in constructions of parental roles, lack of patterned and culturally relevant learning in child-hood, difficulties regarding skin colour, dichotomy in religious versus magical beliefs and the pervasive and persisting impact of the slavery tradition

Jamaican political sociologist Carl Stone (25) asserted that British colonization and the plantation economy created a warped authority system that engendered personality disorder seen in present day Jamaica. According to Stone, the tensions experienced by the Jamaican people in dealing with issues of authority and power have been muddled since the colonial British Empire and these tensions are compounded by ongoing political struggles in which power struggles of competing ideologies, values and norms have resulted in a disequilibrium of power that has weakened authority in all domains of social space (26). This longstanding struggle for power and authority within the Jamaican culture, combined with high levels of verbal and physical aggression, has been associated with "serious personality disorders in our culture" (26).

In a case-control study of Jamaican patients seen in a private Jamaican psychiatric practice, Hickling and Paisley (27) assessed the phenomenological factor structure of 351 patients with DSM-IV (28) Axis II diagnosis of personality disorder, and a control group of patients matched for gender, age, and social class diagnosed with DSM-IV Axis I disorders, who did not have a diagnosis of personality disorder. Disaggregating the phenomenology, the conventional DSM-IV Axis II personality disorder diagnoses disappeared. Factor analysis revealed that the 38 clinical phenomena clustered into three major themes: power management disorders, dependency problems and psychosexual dysfunction, suggesting a clinical triad that should be situated as a possible Axis I diagnostic disorder of inter and intra-personal power management. Positing a need for redefining the conventional European concept of personality disorder, the term shakatani from the Swahili words 'shaka' (problem) and 'tani' (power) was the name proposed for this revealed unitary condition based on the clinical triad revealed in this study. The work of Kerr and Stone from the latter decades of the twentieth century underlines conclusion that these problems have existed in Jamaica for centuries and are reflected in the personality problems, the institutional disorders and abnormal behaviours that are present in contemporary Jamaica.

Resilience and Social Capital

In a study of risk and resilience factors in African Caribbean people in the UK and in Jamaica, Robertson-Hickling and Hickling (29) concluded that psychiatric research internationally has placed too much emphasis on risk and not enough study on resilience. Davydov et al (30) suggest that ". . . the relationship between disease and good health has received relatively little attention in mental health. Resilience can be viewed as a defence mechanism, which enables people to thrive in the face of adversity and improving resilience may be an important target for treatment and prophylaxis. . ." Robertson-Hickling and Hickling (29) in agreement, suggest that the mechanisms of resilience and the formation of social capital have ensured the wellness and continued survival of Caribbean people through dire circumstances of slavery and colonialism and has enabled them to thrive and to overcome a range of adversities and to excel in all walks of life, nationally and internationally. They noted that Jamaica produces a phenomenal number of people of world-class athletes, scholars, reggae musicians and music, out of proportion to the fewer than three million souls inha-biting that island. This also applies to the rest of the Carib-bean with three Nobel Laureates, two of whom were closely associated with the UWI and several leading academics, writers and sportsmen impacting on world affairs. Robert-son-Hickling and Hickling (29) opine that resilience is a significant factor in the healing of the mental pathology that exists in the African Caribbean population. This resilience is as a result of the efforts in the Black community itself in the struggle to overcome the travails and situations of great hardships that have arisen from the colonial past.

 

CONCLUSION

The University of the West Indies is acknowledged as a leader of Black education worldwide and has made a profound contribution to psychiatric research in the English-speaking Caribbean in the past sixty years. The intellectual exploration of phenomenological and psychiatric discovery that has flowered in the Caribbean in the period of political independence from British colonization is a reflection of this scholarship that has emerged from the academic nurturance by the University. Burgeoning migration of Caribbean people to England in the twentieth century has resulted in high reported rates of schizophrenia for this migrant population. Caribbean research into this condition has revealed that there exist hostile racial and environmental challenges in Britain that has had a profound pathological effect on the mental health of African Caribbean migrants. Research has also revealed longstanding psychopathological effects of slavery and colonialism in the Caribbean that have had significantly negative long term effects on the mental health and behaviour of many of the Caribbean population. Current research suggests the existence of defence mechanisms of resilience and social capital, which have ensured the wellness and continued survival of the majority of Caribbean people in spite of the demonstrated traumatizing effects of colonialism. These resilience factors have facilitated the survival of Caribbean people in spite of dire political, economic and social circumstances, and suggest that a formula for healing exists that has facilitated the survival and remedial growth of the psyche of Caribbean people in the aftermath of centuries of systematic colonial exploitation and oppression.

 

REFERENCES

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2. Hickling FW. The epidemiology of common mental disorders in the English-speaking Caribbean. Rev Panam Salud Publica 2005; 18: 256 - 61.

3. Royes K. The incidence and features of psychosis in a Caribbean community. Proceedings of the Third World Congress of Psychiatry. Montreal: University of Toronto Press and McGill University Press; 1962: 1121 - 5.

4. Hickling FW. Psychiatric hospital admission rates in Jamaica 1971 and 1988. Br J Psychiatry 1991; 159: 817 - 21.

5. Hickling FW. Double jeopardy: psychopathology of black mentally ill migrants and returned migrants to Jamaica. Int J Soc Psychiatry 1991; 37: 80 - 9.

6. Hickling FW, Rodgers-Johnson P. The incidence of first onset schizophrenia in Jamaica. Br J Psychiatry 1995; 167: 193 - 6.

7. Mahy GE, Mallett R, Leff J, Bhugra D. First-contact incidence rate of schizophrenia on Barbados. Br J Psychiatry 1999; 175: 28 - 33.

8. Bhugra D, Hilwig M, Hossein B, Marceau H, Neehal J, Leff J et al. First contact incidence rates of schizophrenia in Trinidad and one year follow up. Br J Psychiatry 1996; 169: 587 - 92.

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11. Hickling FW, Hutchinson G. The roast breadfruit psychosis - disturbed racial identification in African Caribbeans. Psychiatr Bull 1999; 23: 1 - 3.

12. Whaley AL, Geller PA. Toward a cognitive process model of ethnic/ racial biases in clinical judgment. Rev Gen Psychol 2007; 11: 75 - 96.

13. Hickling FW. Understanding patients in multicultural settings: a personal reflection on ethnicity and culture in clinical practice. Ethnicity and Health 2012; 17: 203 - 16.

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15. Hickling FW. Psychopathology of white mentally ill immigrants to Jamaica. 1996; 28: 261 - 7.

16. Cochrane R, Bal S. Migration and schizophrenia: an examination of five hypotheses. Soc Psychiatry 1987; 22: 181 - 91.

17. Hickling FW. The high cost of poverty: mental health perspectives from the Caribbean Diaspora. Int Psychiatry 2009; 6: 29 - 30.

18. Marley J. Review: Mental health perspectives from the Caribbean Diaspora [Internet]. The Amazing World of Psychiatry: A Psychiatry Blog; [published 2009 April 8]. Available from: http://theamazing worldofpsychiatry.wordpress.com/2009/04/08/

19. Burke A. Racism and psychological disturbance among West Indians in Britain. Int J Soc Psychiatry 1984; 30: 50 - 68.

20. Hickling FW. Racism - An afro-Jamaican perspective. BMJ 1992; 305: 1102.

21. Smith L. Caribbean bedlam: the development of the lunatic asylum system in Britain's West Indian colonies, 1838 - 1914. J Carib Hist 2010; 44: 1 - 47.

22. Fanon F. The wretched of the earth. New York: Grove Press; 1968.

23. Hickling FW, Hutchinson G. Post-colonialism and mental health: understanding the roast breadfruit. Psychiatrist 2000; 24: 94 - 5.

24. Kerr M. Personality and conflict in Jamaica. London: Collins/ Sangster's; 1963.

25. Stone C. The anatomy of aggression. Jamaica Gleaner. 1992 Oct 21.

26. Stone C. Values, norms and personality development in Jamaica. Paper presented at the National Consultation on Values and Attitudes, University of the West Indies, Kingston, Jamaica [Internet]. 1992 Mar 23 [cited 2011 Aug 31]. Available from: http://gtuwi.tripod.com/stonearticle.htm

27. Hickling FW, Paisley V. Redefining personality disorder in Jamaica. Rev Panam Salud Publica. 2011; 30: 255 - 61.

28. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.

29. Robertson-Hickling H, Hickling FW. Risk and resilience in African Caribbean migration to the UK. In: Thomas Hope E, ed. Freedom and constraint in Caribbean migration and Diaspora. Kingston, Jamaica: Ian Randle Publishers; 2008.

30. Davydov DM, Stewart R, Ritchie K, Chaudieu I. Resilience and mental health. Clin Psychol Rev 2010; 30: 479 - 95.

 

 

Correspondence to:
Professor FW Hickling
Caribbean Institute of Mental Health and Substance Abuse (CARIMENSA)
The University of the West Indies
Kingston 7, Jamaica
E-mail: frederick.hickling@uwimona.edu.jm