Issues of clinical and cultural competence in Caribbean migrants

Abstract

The level of out-migration from the Caribbean is very high, with migration of tertiary-level educated populations from Caribbean countries being the highest in the world. Many clinicians in receiving countries have had limited diagnostic and therapeutic experience with Caribbean migrants, resulting in diagnostic and therapeutic controversies. There is an urgent need for better understanding of these cultural differences. The paper explores issues of clinical and cultural competence relevant to assessing, diagnosing, and treating Caribbean migrants with a focus on three areas: cultural influences on illness phenomenology; the role of language differences in clinical misunderstandings; and the complexities of culture and migration. Clinical issues are illustrated with case studies culled from four decades of clinical experience of the first author, an African Jamaican psychiatrist who has worked in the Caribbean, North America, Europe, and New Zealand.

Keywords

clinical competence cultural competence Caribbean migrants

The level of migration in the Caribbean is very high, with migration of tertiary-level educated populations from Caribbean countries being the highest in the world (Mishra, 2006). A number of mental health issues affecting people of Caribbean origin living in Western societies (mainly Britain, Europe, and North America) have emerged during the past 40 years: Caribbean Black minorities are more often diagnosed with schizophrenia than are members of the White majority community; in the United Kingdom (UK) Caribbean Black minorities are more often compulsorily detained under The Mental Health Act (1983), admitted to hospital as “offender patients,” and held by the police under Section 136 of the Mental Health Act that authorizes a police officer to remove from a public place someone thought to be mentally ill; Black and ethnic minorities in the UK are also more often transferred to locked wards from open wards of mental hospitals, not referred for psychotherapy, given high doses of medication, and sent to psychiatrists by courts. The factors underlying these findings have been extensively discussed (Canter-Graae & Selten, 2005; Cochrane & Sashidharan, 1996; Fernando, Ndegwa, & Wilson, 1998). However in spite of the large numbers of Black Caribbean clients in mental health services in Britain, Europe, and North America, there is as yet no conclusive explanation of these disparities.

In the United States, ethnic minority Americans currently comprise 27.6% of the population and are expected to comprise more than 40% of the population by 2035 and 47% by 2050 (U.S. Bureau of the Census, 1996, 2010). Ensuring that the health care provided to this diverse population takes account of their linguistic and cultural needs constitutes a major challenge for health systems and policy makers (Brach & Fraserirector, 2000). This is further complicated by the influence that cultural factors have on the health-related beliefs, behaviors, and values of patients as well as their diagnosis, treatment, and care (Kleinman & Benson, 2006). As such, there has been worldwide recognition of the necessity of cultural competence in health services.

Cultural competence was first defined over two decades ago by mental health researchers as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or amongst professionals and enables that system, agency or those professionals to work effectively in cross-cultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989, p. 7). This definition has however been modified over the years for greater specificity in the attitudes, knowledge, and skills of the health professional in

understanding the importance of social and cultural influences on patients’ health beliefs and behaviors; considering how these factors interact at multiple levels of the health care delivery system (e.g., at the level of structural processes of care or clinical decision-making); and, finally, devising interventions that take these issues into account to assure quality health care delivery to diverse patient populations. (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003, p. 297)

The idea of cultural competency and its systematic training then is an explicit statement that one-size-fits-all health care cannot meet the needs of increasingly diverse populations. Instead, cultural competency demands much more of clinicians, going beyond cultural awareness or sensitivity (Brach & Fraserirector, 2000). It includes not only possession of cultural knowledge and respect for different cultural perspectives but also requires having skills and the ability to use them effectively in cross-cultural situations (Cross et al., 1989; Orlandi, 1995; S. Sue, 1998; Tirado, 1996). A leading advocate of cultural competence in North America, Kirmayer (2008), identified its necessity:

Cultural competence begins with the clinician’s self knowledge, and an appreciation of how historical circumstances situate the encounter with the patient. The history of colonialism, slavery, racism, and discrimination precede the clinical encounter and give each word and gesture added meaning. Culturally competent clinicians consider the potential impact of these larger social and political contexts on their own feelings and those of their patients and employ a set of strategies for monitoring and managing the subsequent interaction. But the language of competence implies a kind of mastery and control that belies the vulnerability and uncertainty of the clinical encounter in which empathy must sometimes fail. (Kirmayer, 2008, p. 469)

Migration has been a fundamental feature of the Caribbean for centuries, with Caribbean people leaving their home countries and moving to higher income countries such as Canada, the United States, and the United Kingdom for voluntary and economic reasons (Ferguson, 2003; Pienkos, 2006). It is not surprising then that the present rate of net migration from the Caribbean is one of the highest in the world, with almost all the Caribbean nations among the top 20 countries in the world with the highest tertiary-educated migration rates. For instance, there has been a reduction of as much as 89% of the Jamaican and Guyanese tertiary-level labor force (Massiah & Lorde, 2011; Mishra, 2006). In some cases migrants may have difficulties in adapting to changes in language, values, customs, climate, food, availability of social support, and other factors. The receiving environment has not always been hospitable and welcoming for these migrants. Thus, these migratory processes have created a burgeoning psychopathological conundrum worldwide. Few mental health professionals in receiving countries have had much diagnostic and therapeutic experience working with Caribbean people with psychopathology, and relatively little has been written on cultural competence in this ethno-cultural group. Diagnostic and therapeutic mental health controversies in Caribbean migrants, especially to higher income countries have triggered an urgent need for an understanding of and training in these cultural differences.

This paper seeks to highlight issues in competently assessing, diagnosing, and treating Caribbean migrants through the discussion of cases that illustrate three important areas: phenomenology and cultural competence; culture and linguistics in clinical misunderstandings; and the complexities of culture and migration. These case studies have been culled from the four-decade clinical experience of the first author, an African Jamaican psychiatrist who has worked in the Caribbean, North America, Europe, and New Zealand. Identifying details have been modified to maintain patient confidentiality.

Phenomenology and cultural competence

The move to standardize diagnostic systems and practices worldwide by the use of phenomenology has been an important step towards addressing the issues of cultural competence. Mullen (2007) suggested that phenomenological approaches share the aim of systematically considering and studying human experience and behavior in a way that does not start from prior theories and assumptions, but which focuses instead on recording the experience in its entirety, without attempts to explain or quantify. Phenomenology was defined by Jaspers (1923/1963) as the subjective and objective experiences of human psychic life:

The term phenomenology was used by Hegel for the whole field of mental phenomena as revealed in consciousness, history and conceptual thought. We use it only for the much narrower field of individual psychic experience … Phenomenology is for us purely an empirical method of enquiry maintained solely by the fact of the patient’s communications. [emphasis added] (Jaspers, 1923/1963, p. 55)

Mullen (2007) suggests that it is the final employment of the phenomenological descriptions to inform and direct subsequent examinations of psychopathology and to lay the basis for subsequent classification, which then seeks its reflection in the science of systematic enquiry. This is what S. Sue (1998) refers to as “scientific mindedness”: competent clinicians form and test clinical inferences about culturally different patients, particularly when they are uncertain about the cultural meaning of the symptoms presented. At the core of cultural competence in clinical care, then, is the clinician’s ability to consider social and cultural contexts and correct for their possible distorting effects on communication (Kleinman & Benson, 2006). However, the problems currently encountered in the cross-cultural clinical experience seem to reflect clinicians’ weakness in accurate phenomenological identification, poor conduct of the mental state examination, poor communication skills, and the pervasive effects of stereotypes in the comprehension of patients. The following case studies illustrate these diagnostic dilemmas.

Case Study 1: Low pressure hydrocephalus and depression

A 33 year-old black man was brought to see the first author (FWH) in the mid 1980’s in Jamaica, having returned from living in the United States for a period of 5 years. He had been a very successful journalist in Jamaica and had fled to the USA following a very violent election campaign in Jamaica. The patient had feared possible repercussions about the vitriolic articles that he had published about the right wing party when they were in opposition and of some of its leaders who had won political power. He was not able to find work in the USA, that he thought befitting his skills. For two years he remained unemployed, being supported by his relatives in the USA. His relatives provided the history that he had been arrested for throwing stones at a skyscraper in the U.S. city in which he lived. His incoherence and aggressive behavior towards the police triggered his involuntary admission to the acute ward of a mental hospital where he was diagnosed with schizophrenia. His deteriorating clinical condition forced his transfer to a State Mental Hospital where he was treated with large doses of various neuroleptics over the next two years. His relatives reported that his condition continued to deteriorate until finally he was diagnosed as having low-pressure hydrocephalus and received the surgical operation of a ventriculo-spinal shunt. When his family received the information that the doctors were planning to perform a frontal lobotomy on their relative, they arranged for his discharge from hospital and brought him home to Jamaica where they first sought the assistance of many Obeah (spiritualism) men. Despite the interventions of the Obeah men his condition had not improved and then he was brought to see the first author. When examined he could speak only with difficulty, and his writing had become almost unintelligible. The anti-psychotic medications that he had been prescribed in the United States were discontinued, and a diagnosis of a profound major depression was made. He was started on antidepressants (trimipramine) and weekly psychotherapy, and after a few months of treatment he returned to complete normality and gradually recovered his ability to work. (Hickling, 2007, p. 185)

The case described suggests the diagnostic errors that can be made in cross-cultural clinical encounters, and the devastating effects this can have on the patient’s mental health status. It seems likely that the ineffective and inappropriate treatment of this patient would likely have continued had his family not insisted on his discharge, brought him back to Jamaica first for obeah spiritualism treatment and then culturally appropriate psychiatry and psychotherapy. This Jamaican man developed a major depression in the USA that was completely misdiagnosed and mishandled. He recovered once he returned home and received the appropriate empathic diagnostic and therapeutic understanding.

Case Study 2: Phenomenological symptom confusion

A 38-year-old Black woman was brought to the Psychiatric Outpatient Clinic at the University Hospital of the West Indies, by her cousin, who described that the patient was a resident of a large city in Canada, but had been sent home to Jamaica two weeks previously by her husband, to seek psychiatric assessment and care. Born in Jamaica, the patient had migrated to Canada at 19, and had been working in that country since that time. Her relative said that the patient’s husband had reported that she had been behaving strangely in Canada for nearly two years and had been seen by her General Practitioner on a number of occasions and treated with antacids without improvement. The Canadian GP had been informed of the patient’s deteriorating mental health at home and at her church, but had insisted that the patient did not have a mental illness, and had continued to prescribe antacids for her. Her mental deterioration had caused her husband to send her to her family in Jamaica to seek psychiatric assessment and treatment. On entering the examination room, the patient exhibited a loud guttural sound that sounded like a coarse belch. The sound was repeated several times and on occasion sounded like a sharp dog’s bark. This was the patient’s main method of communication, as apart from the belch-like sound, she was almost mute. The patient was observed to hold her head down without making eye contact, and on very close examination she was observed to be moving her lips as if talking to someone. There were no audible words, and the lip movement was almost imperceptible. She appeared frozen, almost catatonic. After a period of gentle confrontation and coaxing the psychiatrist (FWH) was able to persuade the patient to admit almost inaudibly that she was indeed talking to unseen persons in the room whom she thought were evil spirits who were provoking and attacking her. Mental state examination revealed that this woman was exhibiting auditory, visual and olfactory hallucinations, paranoid delusions, and severe thought disorder, which she had been experiencing for the previous two years. She admitted that the belching sound that she emitted at regular intervals, for which the Canadian GP had prescribed antacids, was her attempt to “rebuke the demons” that she perceived surrounding her. A diagnosis of schizophrenia was made. She was treated with antipsychotic medication and made an excellent recovery within a few weeks, before returning home to Canada. There was no evidence that she had ever had symptoms of dyspepsia.

This case illustrates the need for careful clinical observation in diagnosis. The clinical differential diagnosis was between a dyspeptic symptom and a psychotic illness manifested in the patients’ speaking aloud to unseen persons or spirits. The sound made by the patient resembled a belch, however, close observation revealed that the patient was mouthing words as she emitted the sound. From these close observations, it was evident that the patient was speaking to unseen persons but only after a lengthy interview was it ascertained that the patient was rebuking demons. This rebuking was not an indication of the patient’s cultural self-treatment as she did not think that she was ill. Instead, her rebuke of the perceived demons was related to her spiritual belief system, which was confirmed by her relatives who indicated that she believed her home and world were infested by demons, and that she had a spiritual responsibility to “rebuke” these demons. Without the clinical insight of the psychiatrist, an accurate understanding of the patient’s illness would not have been achieved.

Culturally competent evaluation requires a phenomenologically oriented approach, as described by Mullen (2007), in which clinicians do not simply seek to confirm or refute diagnoses through careful inquiry, but attempt to elicit an understanding of the symptoms and their meaning in individual experience. The phenomenological approach requires a thorough examination which not only includes the patient’s account of symptoms, but also careful consideration of cues in demeanor that may indicate dysfunction that is psychopathological rather than physiological. The ability to distinguish between the “belch” as a dyspeptic symptom and the “belch” as a conversation with a hallucinated spirit reflects a detailed mental state examination that is part of basic clinical competence. Added to this is the clinician’s cultural knowledge that led him to suspect that this patient might be prone to interpret auditory and visual hallucinations as evidence of demonic manifestations. Knowledge of the cultural beliefs held within the patient’s heritage is an issue of cultural competence that works in synergy with the phenomenological approach to the mental status examination.

Case Study 3: Sickle cell painful crisis and schizophrenia

A 32-year-old male seen in a psychiatric clinic in Kingston complained of having severe pain in his feet, legs, and arms for four years. He reported that these pains had started quite suddenly after he had visited the market to purchase a pair of shoes. He observed that the shoe salesman had taken him into a special room away from the general market place and had selected a specific pair of shoes for him. He noticed that the vendor had held his fingers and gestured in a particular way over the pair of shoes, before giving it to him. The patient suggested that with this gesture the shoe salesman had put some bad chemical in the shoes, thus working obeah spiritualism on him. The pain in his feet had started immediately after he had worn these shoes. He was sure that the gesture of the vendor was the cause of his pain, and he proceeded to wash the shoes repeatedly and used various methods to cleanse the shoes from that moment on. That did not help him however, as he continued to feel these pains whenever he wore these shoes. The pain extended from his feet to his legs and then to his arms. From that time on he began experiencing other strange experiences including seeing and hearing and smelling spiritual beings (auditory, visual and olfactory hallucinations) around him. Sometimes the spirits would hold him down and have sex with him in his anus (sexual delusions). He would hear a voice in his ears taunting him saying “don’t come in here; we no want no Satan in here.” He felt that these spirits would “mess up his head” and command him to do wicked things like hurting and killing other people, and to have sex with animals (command hallucinations). He was sure that people were looking at him in a special way and wanted to hurt him, and that they could read his mind (paranoid delusions). He indicated that his friends and family told him that he was paranoid. A diagnosis of paranoid schizophrenia was made based on the phenomenology, and he was treated with antipsychotic medication (olanzapine). His symptoms of auditory, visual, olfactory hallucinations, delusional perceptions, and paranoid and sexual delusions all disappeared within a few weeks. His symptom of pain also diminished. This latter symptom was of particular importance as he had been treated for years before at the medical clinic of the hospital for sickle cell disease and his pain had been interpreted as resulting from the painful crises of sickle cell anemia.

There are two phenomenological components being described here. The first was the patient’s immediate interpretation that the salesman’s gesture represented a deliberately harmful act towards the patient. This was the delusional perception. The belief that the obeah could harm and affect him continuously from that moment onward, and be the cause of his feet pain was the ongoing delusion. This case thus demonstrates the difference between a delusional perception, which was immediate, sudden, and transforming, and the obeah delusion, which was all pervasive and continuous. Karl Jaspers describes the difference clearly: “[Delusional perceptions] may range from an experience of some vague meaning to clear delusional observation and express delusions of reference. Suddenly, things seem to mean something quite different” (Jaspers, 1923/1963, p. 99). A very clear distinction between the two phenomena is made in an article by Fuchs (2005):

In the initial stages of schizophrenia, the environment as perceived by the patient changes into a puzzling, mysterious and stage-like scenery. At the same time, objects or persons may gain an overwhelming physiognomic expression and may even fuse with the patient’s body … the alteration of schizophrenic perception in delusional mood may be described as a paralysis of intentionality, or of the “gnostic” component of perception … On the other hand as a result of the disturbance of intentional perception, physiognomic and expressive properties are set free within the perceptual field. The “pathic” component of perception becomes independent. Thus, the intersubjective constitution of reality is replaced by idiosyncratic meanings and qualities of perception, leading finally into delusional perception. (Fuchs, 2005, p. 133)

Case Study 3 illustrates the phenomenological manifestations of abnormal perceptions, hallucinations and delusions that are identified during a mental state examination, and also indicates that a differential diagnosis of pain in the limbs can include the psychiatric condition of schizophrenia. Furthermore, the case highlights the important difference between obeah as a spiritual belief system and obeah as a symptom of psychosis. Although the patient was from a very religious Pentecostal faith, his obeah spiritual beliefs about the demons that were affecting him far exceeded the orthodox beliefs and practices held by his church brethren and his family members. As such, it became clear to the patient’s closest family and church associates that something was mentally wrong with him when he started voicing these delusion-ridden beliefs.

The patient suffered from sickle cell disease all his life and had been attending the sickle cell clinic since he was a teenager. But it was only after his delusional perception experience four years prior to his psychiatric referral that he began to attribute the pain in his feet and legs to obeah spiritualism and consequently his psychiatric illness became apparent. It is very unlikely that the development of schizophrenia in a 28-year-old man was the result of the sickle cell disease. In a Jamaican study on the psychiatric complications of sickle cell disease, psychotic illnesses were found to be no more common in patients with sickle cell disease than in individuals in the matched control groups (Hilton, Osborn, Knight, Singhal, & Serjeant, 1997). Thus, the lessons to be learned from this third case include the recognition that delusional symptoms of demonic manifestations can be distinguished from obeah belief systems. The following case study (4) elucidates this point further. In this case, obeah spiritualism played a major role in the life of the mother of the patient and was therefore the explanatory and treatment model for her daughter’s plight.

Case Study 4: “Duppy-Lik”: The devil in the detail

A 19 year-old Black female Jamaican university student was admitted to the psychiatric ward with an acute psychosis. She had led a sheltered middle-class upbringing in urban Jamaica with a good academic career in a leading school. The acute psychosis was heralded by the unusual behavior of her not returning home after class and being seduced by a man who had lured her into the inner city. She was admitted to hospital a few days later and treated for an acute schizophreniform disorder, with good recovery. Follow-up in the first author’s private clinic resulted in an engagement with the patient and her mother in family therapy (the parents had divorced in the patients’ early childhood). A major, seemingly irresolvable conflict emerged, with the mother suggesting that her daughter was not mentally ill but had experienced a “duppy-lik” (a spiritual blow by a demon). Her mother also suggested that the family of the patient’s biological father had “red eye” (obeah based) jealously and that the “duppy-lik” was as a result of their “bad-mind” (evil-eye hex) that they had put on her daughter. The patient strongly objected to this obeah spiritual formulation, and complained that her mother attacked her with this daily. The patient reported that her mother refused to allow her to wear a new garment that the patient’s aunt (her father’s sister) had sent for her from the USA, claiming that it had been “treated” to harm the patient. The mother took the garment to an obeah healer for the “hex” to be removed. Paradoxically the mother continued to pay the fee for her treatment with anti-psychotic medication, at the same time taking her daughter to a “Bush doctor” (obeah man) for parallel treatment. In the ensuing family therapy this seeming irresolvable contradiction was engaged psychotherapeutically, with the daughter stoutly resisting the obeah spiritual pronouncements, and complying with the anti-psychotic medication that had helped her to recovery. Questions were raised in family therapy as to whether the mother too was mentally ill.

The constructs of “red eye” and “bad mind” (envy and wishing ill of others) (Hickling & James, 2008) are cultural experiences that are extremely common in Caribbean migrants, particularly those from countries, such as Jamaica and Haiti, in which obeah/black magic is customarily practiced. In these societies, obeah is a method used to put a curse on people who are envied or despised (Abel, 2004; Bilby & Handler, 2004). These concepts are poorly understood and handled even in the Caribbean, let alone in countries outside the Caribbean, as they are embedded in local religious/spiritual culture that at times makes it difficult to distinguish between religious/spiritual beliefs and delusions or hallucinations. Making this type of diagnostic distinction is a major challenge worldwide, demanding empathy, insight, and cultural competence. The cultural beliefs, customs, and linguistic differences presented have sculpted phenomenological nuances not well articulated or understood outside of the Caribbean.

Although obeah has been publicly denounced as superstition and a form of sorcery, many people in the Caribbean still continue to use it privately (Bilby & Handler, 2004). The spectrum of belief in obeah ranges from the very mild to the very intense, can occur in all classes and genders, and varies even within families. At the mild level, people may deny a belief in obeah spirits but at the same time be influenced by obeah predictions and accusations. At the very intense level, individuals’ experiences can border on the psychotic. In some instances, individuals are recognized as being a “Warner”—a person who publicly predicts future events and “warns individuals and societies” of spiritual and social transgression. “Warners” publically preach predictions of the future, while otherwise leading healthy, remarkably “normal” lives.

The Warner or other devout believer in obeah spiritualism is culturally recognizable and distinguishable from the individual with schizophrenia who has fixed false delusional beliefs in the effects of obeah and is usually recognized by others and labeled culturally as being “mad.” However, there can be significant conflict within families where the belief systems can range from the very mild to the very intense. In Case 4, it is possible that the psychotic illness of the daughter, who denied belief in obeah, was influenced by the rigid, strict and demanding spiritualist upbringing of the mother who possessed a very intense obeah belief systems, but was not psychotic herself. Interestingly, although the mother insisted to the psychiatrist that her daughter was not “mad,” but was the subject of a “duppy-lik,” she accepted the diagnosis of schizophrenia and the treatment of her daughter with antipsychotic medication. She was even prepared to pay for a second diagnostic opinion and treatment from another psychiatrist with atypical antipsychotics. More research is needed to unpack the complexities of these issues and their relationship to the teaching of cultural competence.

The role of culture and language in clinical misunderstandings

Caribbean cultural identity is created by an amalgamation of geographical location, shared language, and shared history (Munroe, 2009). As part of the oral traditions of the Caribbean, common experiences are shared through cultural lore and folktale storytelling, which utilize wordplay and linguistic inventions that often result in semantic confusion particularly for listeners from different cultural origins. In the clinical context, intercultural misunderstanding of Caribbean language and idioms may result in bizarre and sometimes dangerous diagnostic interpretations that label culturally different behaviors as illness, or misinterpret cultural expressions in ways that result in misdiagnosis. Following the historical tradition, people of Caribbean origin and many of African origin often use sayings and idioms to illustrate their conversations. Discussing issues of intercultural empathic understanding of psychopathology, Kirmayer (2008) suggested that “it may be that the non-narrative organization and intensity of metaphor and imagery of lyric poetry provides a better vehicle for communicating the texture of the experience” (2008, p. 464). However, it is this very mode of expression that is likely to lead to a grave misinterpretation of the Caribbean migrants’ description of symptomatology in the clinical setting.

Added to the complexity of linguistic inventions in the oral tradition is the use of patois or Creole. Patois is the Creole language that is spoken commonly by people within the Caribbean, each Caribbean country having its own version. For instance, Jamaican patois, is an English-based Creole language with Western African influences that is very difficult to understand for mental health professionals not versed in this dialect. This has significant implications for clinical work that involves the treatment of Jamaicans who speak only this Creole. Such barriers in communication may at times lead to misunderstandings of patient concerns, needs, and behaviors and result in incorrect diagnosis and treatment. These barriers can, however, be circumvented by the inclusion of a cotherapist, interpreter, or culture broker who is able to assist both the therapist and patient. Case 5, illustrates this strategy.

Case Study 5: “De teet doan fit”

The Jamaican psychiatrist was asked to intervene in an ongoing conflict between a 58-year-old African Jamaican male and an Irish consultant psychiatrist on a moderate secure Forensic Psychiatric Unit in the UK. At a ward meeting, the patient, who had been detained on a section for violent abusive behavior, took his seat quietly but was talking loudly and rapidly, and appeared angry and hostile. The Jamaican psychiatrist asked the patient to restrain himself, to speak slowly, and to explain what his concerns were. The patient became calmer, but still in an angry tone complained that the White ward staff and in particular the forensic psychiatrist were racist and had been abusing him. The Jamaican psychiatrist asked him to explain why he thought that the forensic psychiatrist was racist. The Jamaican man replied “Look yah nuh sah, de teet wey dem man gi mi doan fit an jus roll roun ina mi mout, an me caan nyam food, an mi aks dem fi a new teet, an dem nah lisen; all mi aks dem fa is a new teet an den all a dem hole mi dung an jook jook up mi batty wid medicine dat nock mi out.” The Irish forensic psychiatrist and the other White staff members were perplexed by what seemed to be another unintelligible hostile outburst from this Jamaican man. The staff asked the Jamaican psychiatrist to translate what the patient had said. The translation was: “Look Sir; the set of dentures that was given to me [by the National Health Service dentists] do not fit, just roll around in my mouth and therefore I am unable to eat properly. I asked the forensic psychiatrist and staff for a new set of dentures, and their response was to hold me down, and inject my bottom with medication that made me fall asleep.” The upshot of the translation of the outburst was immediate comprehension by the forensic psychiatrist, who promised the patient a new set of dentures. At a ward meeting attended by the Jamaican psychiatrist some weeks later, the patient had been fitted with new dentures and he and the forensic psychiatrist and staff were communicating in a calm and friendly manner.

The complexities of culture and migration

Mental health professionals in receiving countries often have difficulties in understanding fully the challenges of the Caribbean migrants’ experience. The complexities of the pressure from the push-and-pull factors that precede the migratory process are often inadequately described or understood (e.g., Lashley, 2000). There are specific issues related to cultural identity that may inform the onset of psychosis in some people of African Caribbean origin. The personal and social confrontation of the reality of being Black may be in contradiction with the White perception of self in the racially threatening communities of North America and Europe. This predicament could precipitate a psychotic illness in which the behavioral manifestations of the psychosis reflect the patient’s racial confusion. If this is the case, the resolution of the problem, and thereby healing, might be fostered when these racial identity issues are addressed in culturally specific psychotherapy.

Racialized identities clearly influence the clinical presentation, course, and treatment of migrants from the Caribbean. This suggests the potential value of not only a culturally sensitive approach but also a culturally specific form of therapy. The confrontation of social identity in a White society where skin color is the greatest signifier in daily life, and which determines the degree of social acceptance, is in itself a considerable stressor. When color is intimately associated with social disadvantage, dangerousness, and inferiority, the stress only increases. This combination of color and culture is not unique to Caribbean people, but is especially relevant to them because of their history of being transplanted from Africa involuntarily. Their engagement with European culture was therefore forced and unavoidable, and their definitions of social and cultural norms affected as a result. This may mean that these processes also frame their presentations of psychological distress, particularly when confronted with the ambivalence of ambiguous identity. The consequences for psychiatry are evident in the recurrent presentation of Black Caribbean migrants in mental health services and may be resolved only by approaches to diagnosis and treatment that include much greater awareness of sociocultural issues.

Case Study 6: Migration and identity confusion

A 19 year-old black Jamaican woman presented to the mental health services in Germany and was seen at the request of her parents, who had been divorced for a number of years. She had attended an exclusive secondary school in Jamaica, and then had spent a year in Switzerland as an exchange student. On her return to Jamaica she violently rejected her parents’ lifestyle, which she condemned as being too materialistic, and also began using cannabis. Within a few months she left for Germany and married a German gypsy whom she had met in Jamaica. After living for two years in Germany where she was confronted with her blackness, she began to embrace the Rastafarian philosophy and grew her hair in dreadlocks. She presented to the psychiatric service with what was described as a manic psychosis. The contact had been precipitated by her burning her hair and her scalp in an attempt to remove the dreadlocks. There was no previous or family history of mental illness. On discharge, she discontinued her medication and became aggressive and violent to the family with whom she was staying and was then readmitted to hospital, this time to a locked ward. Her manic psychosis returned with greater intensity. The diagnosis remained manic psychosis, but when she continued to deteriorate it was thought necessary to involve a Jamaican psychiatrist. When interviewed, she declared she was not crazy, but that she had discovered that her early upbringing was false, that the value system of her parents and her friends in Jamaica was too material. She was declaring her blackness by growing her hair in dreadlocks as a symbol of her identity, although she denied being a Rastafarian. She had burnt off her dreadlocks because she had wanted to die for her beliefs. At the time she was disinhibited and demonstrated pressure of speech and flight of ideas. She was also irritable and had paranoid ideas of reference. It became evident that her psychosis had developed at the time when she was trying to work through her white cultural identification in a racially hostile German environment. The burning of her dreadlocks was a further indication of her identity crisis and racial confusion. She recovered from her acute psychosis and returned to Jamaica where she underwent cultural therapy, which focused on the ambivalence of her cultural references. After treatment, the patient was asymptotic, employed and remained well on minimal atypical antipsychotic medication. (Hickling, 2008, p. 49)

This case highlights the premorbid state that has been hypothesized as affecting Black people whose racial and cultural identity was of being “functionally White,” who may face heightened identity conflict on returning to the Caribbean from abroad in what has been termed the “roast breadfruit syndrome” (Hickling & Hutchinson, 1999).

The family difficulties of Caribbean migrants are quite complex. Issues arise in the relationships between children and their parents or guardians that are the result of a complex blend of practices and experiences mainly within rurally located households, in Jamaica for example, and migration. The sexual complexities of migrants from the Caribbean, especially women, are therefore often ill understood. Female patients often experience major problems with sexual engagements in the host country, which they would not easily divulge. These would include sexual power manipulations central to survival in the host country, which are patterns of behavior learned from the typical Caribbean experience between men and women. For instance, there are gender-differentiated roles in the Caribbean, in which men generally ascribe to the double standard that women are to be loyal and subordinate and men are dominant and open to seeking outside sexual relationships (Roopnarine & Brown, 1997 as cited in Roopnarine & Shin, 2003). Further complications are created by the family pathology and child abuse, which is frighteningly common, whereby children are reared in a hostile dehumanizing environment by reluctant family members or foster parents. This horrifying reality takes many forms; two of the most common practices are elucidated in Cases 7 and 8.

Case Study 7: Complex intra- and extrafamilial sexual relationships

A 16 year-old black girl born in a rural farming parish to peasant parents, was seen at the Bellevue Mental hospital. Mother and father were never married nor cohabited. Both parents migrated from their rural district, the mother to the United States of America, and father to the nearby city in search of work. The patient was raised by her maternal grandmother, and, after her death when the patient was age 6, by a paternal aunt. She attended primary school in her district, and by her early teens she was having severe conflicts with her aunt. A confrontation arose when the aunt’s common-law partner attempted to have sexual relations with the patient. When she refused to comply they both threw her out of the house with nowhere to go. She then proceeded to make her way to the capital city Kingston where she lived from the garbage on the streets for three weeks. Malnourished and exhausted, she was picked up by a man who took her to his home and had sexual relations with her and threw her out on the streets again. After wandering around the streets for a further week, she was picked up by the police and brought to the state mental hospital dirty, disheveled with an acute psychotic illness, which responded very quickly to treatment which included: chlorpromazine and benztropine for some weeks; along with occupational therapy, cultural therapy, and a therapeutic community program. (Hickling, 2008, p. 41)

It is well documented that migration can have devastating psychological effects on children who are left behind and those who have been included in the migratory process. For those left behind, the children become vulnerable to several psychosocial problems such as feelings of abandonment and rejection, loss, anger, depression, violence, risks of abuse (sexual, physical, and emotional), “parentification,” and reduced academic performance (Bakker, Elings-Pels, & Reis, 2009; D’Emilio et al., 2007). For children who migrate with their parents/guardians, moving to a foreign country may result in feelings of alienation by members of the host country, experiences of xenophobia, insecurity, and depression. These complex issues need to be the subject of further research. For example, the range of child-rearing and sexual beliefs that occur in many Caribbean families can lead to behaviors that in many receiving countries might be regarded as psychopathological. The first author has a number of case studies of African Caribbean patients for whom such practices brought them into significant conflict with the social work and legal system in the UK.

There is an extensive literature on the effects of slavery and family dysfunction in the Caribbean (Barrow, 2001). However the recent publication of the life of the English plantation owner and slave master Thomas Thistlewood in the mid-18th century recorded in his own diaries (Hall, 1999) has brought into sharp focus the effects of social engineering by British slavery on the Caribbean family and sexual dysfunction in Caribbean people. In the first 100 years of slavery, there was wholesale destruction of the African slave family. Families were separated, marriage between African slaves was forbidden and breeding and rearing of children was discouraged. In the next 100 years, as the cost of purchasing new slaves increased, plantation slavery relaxed the draconian stranglehold on the African Caribbean family, and visiting relationships between slaves were sanctioned and encouraged. The breeding and rearing of children by women was allowed, although marriage between male and female slaves was discouraged. With the abolition of slavery and the inception of colonial rule, Christian marriage became acceptable for African Caribbean men and women, but by that time the legacy of serial monogamy had become entrenched in lower socioeconomic families. Case Studies 7 and 8 illustrate the range of family and sexual dysfunction that had become entrenched in Jamaican families of all social classes with the resultant mental health challenges. Sexual exploitation based on economic dependency had become commonplace in Jamaican society. The implications of this reality for cultural competence are profound, as psychiatrists in migrant host countries may be unfamiliar with the genesis of such Caribbean kinship patterns and practices, and may make erroneous evaluations of and conclusions about patients who present to them with mental health issues deriving from these historically rooted types of dysfunction.

Case Study 8: The lover and father

A 28-year-old Jamaican housewife (upper class) presented at the author’s private practice in Kingston, Jamaica with symptoms of a major depression. She was born in an urban Kingston community and was the eldest of 13 children for her parents. Her father died following a political fight when she was age 14. Soon after her father’s death her mother was admitted to the mental hospital and at that time the patient became the “mother of the house.” A man 20 years her senior started visiting her home and providing food for the family. Their relationship started when she was age 14 and she moved into his house. “It wasn’t a love relationship; I was grateful; he give me money to help the family.” It was always a relationship of convenience and dependence, not of love. “He is like my father … I grew up with that man … he bring me up his way … I never had a teenage life, I was always a mother and a wife” she said. They were married when she was age 19 and became pregnant. She has taken care of his home, mothered their 11-year-old son, and her husband’s 8-year-old daughter with another woman. Her husband always had many “outside women” and treated her with contempt. He would physically and sexually abuse her, and would not allow her to work or to attend school. She described herself as always having been a very lonely person who would live in a fantasy world of denial about her relationship and living condition. Her symptoms of major depression had started three years previously when her husband established a relationship with another woman in the USA. He had bought this new woman a house and a car in America and would spend all of his spare time with her in that country. The patient had thought on a number of occasions of taking her own life, and could see no future for herself beyond being a housewife and a mother to his children, living always at his mercy.

Unfortunately, the situation described in this case is not unfamiliar to Jamaicans and has been reported locally in the media: “Many Jamaican women, for years, have been content with the understanding that their teenaged daughters are sexually involved with mature men, old enough to be their fathers, in exchange for taking care of the family” (Hyatt, 2001). The behaviors exhibited in the case studies often create major difficulty for inexperienced psychiatrists, who may completely misread these complex communications and hence fail to grasp the patient’s plight. This difficulty in communication is further impacted by the naivety of Caribbean migrants with the host-countries systems that often place them at a severe disadvantage in navigating the society, and which may reach a crescendo in the interaction with psychiatric services. Without knowledge of the sexual power struggles common to people of Caribbean origin, practitioners in foreign countries may have difficulties in understanding the root of dysfunctional sexual behaviors.

Case Study 9: Complications of migration

A 28-year-old Black woman born in England to first-generation migrant Jamaican parents, presented in the UK with a 10-year history of depression and escalating features of psychosis and social disintegration. She was the youngest of 10 siblings, with her siblings living across America, the UK and Jamaica. Her mother died at the age of 49 when the patient was 16 years old. She did not have a good relationship with her 67-year-old father who was then remarried and living in Jamaica. She did not think of him as a father as he did not care for her when she was growing up. She and three of her sisters went to live in Jamaica when she was 3 years old. She returned to England with her mother when she was 7 years old. She did not want to leave Jamaica, and thought that they were only going for a short trip. Her initial experiences in England were “strange at first”; everything looked different, and the weather was cold. She was unhappy and missed the sunshine and the food in Jamaica. She left school at age 16 to attend college and dropped out of college when she became pregnant. The child’s father was a schoolmate of hers. The patient’s father did not approve of her having the baby, but her mother stood by her. She gave birth to a healthy son after going through normal labor. Within a few months of the baby’s birth, her mother, who had been her main support, died. “It made me feel sad when she died. I felt alone. People die. I think about her a lot. I wish I could have helped her more. Her death was sudden. I just had the baby. After she died I had nobody to help me.” She developed a major depression with psychotic features after the birth of her baby, when she was clearly grieving the sudden death of her mother, and the breakup of her relationship with the baby’s father. She recovered without treatment and she got on with her life, looking after her son. Her psychotic symptoms returned and became progressively more intense. At this point she was diagnosed as having schizophrenia as her clinical situation deteriorated. Within two years her son was received into foster care. She started a relationship with another man and they had a good relationship for about two years until she became pregnant. She had two daughters with him but they eventually drifted apart. In a further episode of sadness and depression, she agreed to put her daughters into care. She describes the effects of these continued social stresses on her already beleaguered mental health. The patient was reported walking naked in the streets and not looking after her children properly. She was arrested by the police, and assessed as having a schizophrenic psychosis. After spending a period in a state mental hospital she entered a cultural therapy program run by FWH, where a number of her cultural contradictions and conflicts were identified and addressed. Her psychiatric condition progressively improved, and she was attempting to reestablish contact and a stable relationship with her children.

The patient described had major depression initially, which progressed to a major depression with psychotic features. She had then been misdiagnosed as having schizophrenia, following which she spent a considerable period on a locked ward of a state mental hospital. Her recovery began when she was placed in an appropriate cultural therapy program in a culturally safe environment. Our experience with programs such as these suggests that severe psychopathological morbidity in Caribbean patients can be reduced or avoided with culturally informed interventions.

Discussion

It is important to recognize that many of the concepts and theories of behavior that underlie psychiatric theory and practice have been developed within Western European contexts, and liberally applied to the understanding of human behavior of other cultures. However, it is increasingly acknowledged that such theories may be limited in their application in culturally diverse settings. This is based on the insight that the interpretations of reality and perspectives on the nature of people, meanings of behavior, sources of dysfunction, and ideas of normality versus abnormality, are different for each cultural or racialized group (D. W. Sue, 2001).

Despite this recognition, it is clear that Black Caribbean people, particularly those considered “other,” continue to have difficulty with the mental health systems of foreign countries, Westernized countries in particular. As Black Caribbean people struggle to explode the mythical concepts of “otherness” generated by European racism, which are linked to attributions of inferiority and dangerousness, our experiences of the mental health systems designed by Europeans will continue to be draconian. Addressing the mental health of Black Caribbean people therefore involves a struggle against mental enslavement and social relegation, and a continued struggle for Black and African liberation. The insistence of training on multiculturalism and in cultural competence without appropriate resources and overstanding (insight) begs the question as to whether these practices will indeed help to alleviate the stereotypic images and the inappropriate diagnostic and therapeutic practices of the dominant European cultures in these countries. In these contexts, behaviors and cultural expressions of Caribbean perceptions of the world, which have been designated as symptoms of illness, may not in fact be illness, or in some cases may be illness but misinterpreted as evidence of more serious dysfunction.

The case studies presented in this paper illustrate some of the cultural issues that are inherent to understanding the Caribbean migrant. Such issues are deep-rooted in a history that dates back to slavery, and that continues to impact people of Caribbean heritage. It is hoped that the case studies offer insight into the ways in which the Caribbean migrants should be understood and how dysfunction may develop and present clinically. The cases highlight the importance of marrying cultural and clinical competence grounded in phenomenology and in an understanding of social, historical, and political contexts in order to have thorough and unbiased approaches to history-taking, conceptualization, and treatment of patients hailed from culturally diverse backgrounds.

Conclusion

Based on the commentary and the cases discussed in this paper, the following guidelines are suggested for mental health practitioners working with Caribbean migrant clients: The clinician must have the professional humility to recognize that even the most experienced clinician can make mistakes and may have certain personal and professional biases, especially in relation to cross-cultural matters, and therefore use the value judgment to review and revise their diagnostic impression. It is important that clinicians engage in careful, active listening to the patient’s narrative. Clinicians need to make careful phenomenological assessments of the patient’s symptoms and behaviors. In situations where the clinician has a doubt or might be unclear about the meaning of the patients’ linguistic expressions and/or cultural identity he or she should request the assistance of a trained interpreter or culture broker. As far as possible, the clinician should corroborate events and phenomena described by the patient with the patient’s family members. The clinician should triangulate the patient’s narrative and the family members’ narrative, with his/her own understanding and interpretation of the narrative. Finally, the clinician must always be open to acknowledging that his/her interpretation of the patient’s narrative may be culturally out of sync with the reality of that patient and/or the family.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Frederick W. Hickling, BSC (Anat.), MBBS, DM, FRCPsych(UK), FRSM, DLFAPA, was born in Jamaica and educated in medicine and psychiatry at the University of the West Indies, Mona. He received specialist training in anatomy at St. Thomas’ Hospital Medical School, University of London, and postgraduate training in psychiatry at the Royal Edinburgh Hospital, University of Edinburgh. Professor Hickling helped to establish a unique community psychiatric service and to pioneer cultural therapy in Jamaica in the 1970s. In the 1980s he established a private psychiatric research and clinical service in Kingston, and in the 1990s he was instrumental in helping to shape policy for African Caribbean mental health in the United Kingdom. With wide international experience in the Caribbean, North America, the UK, and New Zealand, he was Head, Section of Psychiatry at the University of the West Indies Mona, from 2000 to 2006, and is presently Professor of Psychiatry at the same university, and Executive Director of the UWI Caribbean Institute of Mental Health and Substance Abuse (CARIMENSA). His research interests are in African Caribbean mental health, schizophrenia, personality disorder, community psychiatry, psychotherapy, political psychology, and cultural therapy. He has more than 100 articles and book chapters in peer-reviewed journals and books. He is the author and editor of five books. He was elected a Distinguished Fellow of the American Psychiatric Association in 2008, a Fellow of the Royal College of Psychiatrists UK in 2011, and Emeritus Professor of Psychiatry at the University of the West Indies in 2011. He was awarded the Black Psychiatrists of America Andrea Delgado Award for Excellence in November 2010. Email: frederick.hickling@uwimona.edu.jm

Vanessa Paisley, MSc, was born in Kingston, Jamaica. Her training includes a Master’s degree in Clinical Psychology and a certificate from McGill University in Cultural Psychiatry and Working with Culture. Since graduating she has worked for 2 years in a private psychological practice as a clinical assistant working mainly in assessment and research on children and adolescent populations. She has also worked with the Ministry of Education’s PASS programme, assisting in the programme development, development of the interventions, programme management, and provision of group, individual, and family counselling. Since 2008 she has been a clinical associate at Psychotherapy Associates Limited, focusing on project development and bidding, project management, intervention design and implementation, individual and group therapy, and research. In 2009 to present, she has also been working with the Caribbean Institute of Mental Health and Substance Abuse, the University of the West Indies, Mona, as an Assistant Lecturer, Project Coordinator and Research Supervisor. Her work has focused on research in cultural therapy with children from an inner city community, assessment of adults from inner city communities in Kingston and Montego Bay, and executing workshops with at-risk populations. She has also presented at local and international conferences in: Jamaica, at the UNICEF Caribbean Child Research Conference and the 3rd Annual National Conference on ADHD; Montreal, Canada at the Advanced Study Institute, McGill University in 2009 and 2011; the Advanced Study Institute, McGill University in association with the Society for the Study of Psychiatry and Culture, in 2010; and Seattle, Washington at the Society for the Study of Psychiatry and Culture, in 2011. Her conference presentations have focused primarily on conduct disorder, attention deficit/hyperactivity disorder and risk reduction in children, and personality disorder in adults. Research interests include child mental health, cultural therapy, cultural competence, personality disorder, and community mental health.

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