To Di World: Jamaican soccer, poiesis and post-colonial transformation.

This article presents a case study of an innovative culturally based therapeutic approach using collective poiesis to improve the functioning of a youth sports team in Jamaica. In recent decades, Jamaica has endured high levels of violence and corruption, and has been ranked among the top four countries in the world in terms of murder rate per capita. We conjecture that a high prevalence of personality disorder linked to the legacy of slavery and colonialism often impedes Jamaicans from achieving success in diverse fields, including sports. Psychological interventions in the preparation of football teams are a novelty, and have been used mainly to enhance global team performance or individual player skill. The use of psychological interventions to address personality disorder psychopathology on the soccer pitch has not been reported. Psychohistoriographic cultural therapy (PCT) integrates psychological perspectives with a dialectic method of historical analysis and uses collective poiesis as a vehicle to translate insights through an embodied cognitive restructuring process. Two workshops were carried out with a high school football team using PCT techniques. The process of dialectic reasoning engaged their collective ideas and insights to establish a psychic centrality that was expressed in poetic form to illustrate the pathologies of the group in an emotionally safe and psychologically acceptable narrative. This poetic narrative of the group's psychic centrality counters the personality disorder psychopathology caused by the lingering intergenerational wounds of slavery, colonial oppression and collective trauma.

Community Engagement Mental Health Model for Home Treatment of Psychosis in Jamaica.

Economic constraints in low- and middle-income countries like Jamaica challenge health care services to identify efficient methods of mental health care. This column describes the community engagement mental health (CEMH) model in Kingston, Jamaica, for patients with mental disorders, including psychosis. The CEMH uses a task sharing methodology to deliver acute psychiatric treatment within a community setting. Preliminary results suggest high service user and provider satisfaction and good clinical outcomes. The authors discuss challenges and benefits of the CEMH in terms of its potential as a cost-effective service innovation.

Owning our madness: Contributions of Jamaican psychiatry to decolonizing Global Mental Health.

The contentious debate on evidence-based Global Mental Health care is challenged by the primary mental health program of Jamaica. Political independence in 1962 ushered in the postcolonial Jamaican Government and the deinstitutionalization of the country's only mental hospital along with a plethora of mental health public policy innovations. The training locally of mental health professionals catalyzed institutional change. The mental health challenge for descendants of African people enslaved in Jamaica is to reverse the psychological impact of 500 years of European racism and colonial oppression and create a blueprint for the decolonization of GMH. The core innovations were the gradual downsizing and dismantling of the colonial mental hospital and the establishment of a novel community mental health initiative. The successful management of acute psychosis in open medical wards of general hospitals and a Diversion at the Point of Arrest Programme (DAPA) resulted in the reduction of stigma and the assimilation of mental health care into medicine in Jamaica. Successful decentralization has led to unmasking underlying social psychopathology and the subsequent development of primary prevention therapeutic programs based on psychohistoriographic cultural therapy and the Dream-A-World Cultural Therapy interventions. The Jamaican experience suggests that diversity in GMH must be approached not simply as a demographic fact but with postcolonial strategies that counter the historical legacy of structural violence.

Current research on transcultural psychiatry in the Anglophone Caribbean: epistemological, public policy, and epidemiological challenges.

In this article, we review recent research on mental health in the Caribbean. Three major themes emerge: (a) the effects of colonialism on the Caribbean psyche; (b) decolonization of psychiatric public policy, including innovative treatment approaches, deinstitutionalization, and community and policy responses to mental health issues; and (c) the nature and epidemiology of psychiatric pathology among contemporary Caribbean people, with particular focus on migration, genetic versus social causation of psychosis and personality disorders, and mechanisms of resilience and social capital. Caribbean transcultural psychiatry illustrates the principles of equipoise unique to developing countries that protect the wellness and continued survival of postcolonial Caribbean people.

Promoting Resilience in High-risk Children in Jamaica: A Pilot Study of a Multimodal Intervention.

OBJECTIVE: To assess the effectiveness of a multimodal afterschool and summer intervention called the Dream-A-World (DAW) Project for a cohort of school-aged Jamaican children from an impoverished, disadvantaged inner-city community in Kingston, Jamaica. Children were selected by their teachers based on severe disruptive disorders and academic underachievement and compared with a matched control group. The pilot was a child focused therapeutic modality without parental intervention for disruptive conduct and academic failure. METHOD: A group psychotherapeutic intervention of creative arts therapies and remedial academic support adapted for the Jamaican context was implemented with 30 children from an inner-city primary school. The intervention was implemented over 2½ years spanning grade three to six with evaluation of outcomes using the ASEBA Teacher Report Form (TRF) and end of term grades for the intervention group versus matched controls who were offered usual school supports. RESULTS: The intervention group made significant improvements in school social and behavior adjustment measured by the TRF, with more successful outcome amongst boys for behavioral gains. No significant improvements were made by the girls. Limitations of cohort size, lack of parent data and questions of gender disparities in outcome were unresolved interpretative issues. CONCLUSION: This multi-modal mental health and academic intervention for high-risk children living in an impoverished, violent neighbourhood, improved global functioning of boys more than girls, and raised questions for design of further preventive planning.

OBJECTIF: Évaluer l'efficacité d'une intervention multimodale parascolaire en été, nommée Projet Dream-A-World (DAW, rêver un monde), pour une cohorte d'enfants d'âge scolaire jamaïcains issus d'une communauté pauvre défavorisée du centre-ville de Kingston, en Jamaïque. Les enfants ont été choisis par leurs enseignants en fonction de graves troubles perturbateurs et d'un mauvais rendement scolaire, et comparés avec un groupe témoin apparié. Le pilote était une modalité thérapeutique axée sur les enfants sans intervention parentale pour les conduites perturbatrices et l'échec scolaire. MÉTHODE: Une intervention psychothérapeutique de groupe basée sur des thérapies d'activités créatrices et un soutien de redressement scolaire, adaptée au contexte jamaïcain, a été mise en œuvre auprès de 30 enfants d'une école primaire du centre-ville. L'intervention a duré plus de 2,5 ans et a été appliquée de la 3e à la 6e année. Les résultats ont été évalués à l'aide du formulaire d'évaluation des enseignants (FEE) ASEBA et des notes de fin de session pour le groupe de l'intervention contre les groupes témoins appariés à qui des soutiens scolaires usuels ont été offerts. RÉSULTATS: Le groupe de l'intervention s'est amélioré significativement en ce qui concerne le redressement scolaire social et comportemental mesuré par le FEE, les résultats étant plus réussis chez les garçons pour ce qui est des améliorations du comportement. Aucune amélioration significative n'a été observée chez les filles. Les limitations de la taille de cohorte, l'absence de données des parents et les questions de disparité des résultats selon le sexe sont demeurées des questions interprétatives non résolues. CONCLUSION: Cette intervention multimodale et théorique en santé mentale, destinée aux enfants à risque élevé vivant dans un quartier défavorisé violent, améliorait le fonctionnement général davantage chez les garçons que chez les filles, et soulevait des questions quant à la méthode de futures planifications préventives.

Issues of clinical and cultural competence in Caribbean migrants.

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.

Understanding patients in multicultural settings: a personal reflection on ethnicity and culture in clinical practice.

OBJECTIVE: To identify and discourse on the complexities of ethnicity and culture, their role in the social and psychological functioning of patients and their potential impact on clinical assessment and treatment of these patients in diverse cultural contexts. DESIGN: Description of aspects of the cultural competence required by clinicians in mental health service provisions in therapeutic interactions involving the therapist and patient and also in the encounter between practitioners. RESULTS: The four-decade clinical experience of the author, an African Jamaican psychiatrist, encompasses clinical experience in the Caribbean, North America, Europe and New Zealand. From this wealth of multicultural clinical practice the author uses personal examples of four experiences with patients and professionals of African Caribbean, British and Maori ethnicities to discuss issues of ethnicity, ethnic identity and stereotyping, culture, cultural competency and alterity in the exchanges between the therapist and patient, and between therapists and the difficulties encountered in effective assessment and treatment of patients in multicultural settings. The author highlights the importance of historical experience in the psychological constitution of patients, which is the basis of a novel analytic model called psychohistoriography. This insight-oriented individual or group-focused intervention was created with the intention of attempting to heal the wounds of history; an aim that is absent from existing psychoanalytic treatment modalities. CONCLUSION: Psychohistoriography may be a viable therapeutic option in the negotiation of cross-cultural clinical interactions.

Redefining personality disorder: a Jamaican perspective.

OBJECTIVE: To characterize and assess the factor structure of phenomenological features of DSM-IV personality disorder diagnosis in Jamaican patients and determine any similarities with those of traditional criteria, associations with disorder severity, and/or significant relationships between variables to inform the current debate on the relevance of established personality disorder diagnostics. METHODS: This was a case-control study. All the patients included were seen by one private psychiatric practice from 1974 to 2007. The study sample group (n = 351) were patients diagnosed as having a personality disorder (DSM-IV Axis II). The control group was composed of patients with DSM-IV Axis I clinical disorders, who had not been diagnosed with a personality disorder, and matched exactly on gender, and closely on age, as well as socioeconomic variables. RESULTS: Of the 351 individuals in the study sample group, 166 (47.3%) were male and 185 (53.7%) were female; 50 (14.2%) were white and 301 (85.8%) were black; 293 (83.5%) were born and raised in Jamaica; and 202 (57.6%) were from socioeconomic classes I and II. Mean age was 33.92 (standard deviation 10.236). Disaggregating the phenomenology, the conventional DSM-IV personality disorder diagnoses disappeared. Factor analysis of 38 clinical phenomena identified five components: psychosis, major depression, power management problems, psychosexual issues, and physiological dependency. Independent t-tests revealed patients without personality disorder had significantly higher mean scores for psychosis; both groups scored equally for depression; and those with personality disorder had significantly higher mean scores on the remaining factors. Analysis of variance indicated these factors differed significantly for three levels of severity (mild, moderate, and severe). CONCLUSIONS: The phenomenology clustering into three major groups suggested an Axis I (clinical) diagnostic disorder of impulse control and authority and conflict management.

Redefining personality disorder: a Jamaican perspective / Redefinición del trastorno de la personalidad desde una perspectiva de Jamaica

OBJECTIVE: To characterize and assess the factor structure of phenomenological features of DSM-IV personality disorder diagnosis in Jamaican patients and determine any similarities with those of traditional criteria, associations with disorder severity, and/or significant relationships between variables to inform the current debate on the relevance of established personality disorder diagnostics. METHODS: This was a case-control study. All the patients included were seen by one private psychiatric practice from 1974 to 2007. The study sample group (n = 351) were patients diag nosed as having a personality disorder (DSM-IV Axis II). The control group was composed of patients with DSM-IV Axis I clinical disorders, who had not been diagnosed with a personality disorder, and matched exactly on gender, and closely on age, as well as socioeconomic variables. RESULTS: Of the 351 individuals in the study sample group, 166 (47.3 percent) were male and 185 (53.7 percent) were female; 50 (14.2 percent) were white and 301 (85.8 percent) were black; 293 (83.5 percent) were born and raised in Jamaica; and 202 (57.6 percent) were from socioeconomic classes I and II. Mean age was 33.92 (standard deviation 10.236). Disaggregating the phenomenology, the conventional DSM-IV personality disorder diagnoses disappeared. Factor analysis of 38 clinical phenomena identified five components: psychosis, major depression, power management problems, psychosexual issues, and physiological dependency. Independent t-tests revealed patients without personality disorder had significantly higher mean scores for psychosis; both groups scored equally for depression; and those with personality disorder had significantly higher mean scores on the remaining factors. Analysis of variance indicated these factors differed significantly for three levels of severity (mild, moderate, and severe). CONCLUSIONS: The phenomenology clustering into three major groups suggested an Axis I (clinical) diagnostic disorder of impulse control and authority and conflict management.

OBJETIVO: Caracterizar y evaluar la estructura factorial de las características fenomenológicas del diagnóstico de trastorno de la personalidad según el DSM-IV en pacientes jamaiquinos, y determinar sus semejanzas con las de los criterios tradicionales, la asociación con la gravedad del trastorno o las relaciones significativas entre las variables con objeto de aportar información al debate actual sobre la relevancia de los diagnósticos establecidos de trastorno de la personalidad. MÉTODOS: Estudio de casos y controles, donde todos los sujetos fueron atendidos en una práctica psiquiátrica privada de 1974 a 2007. Los casos (n = 351) correspondieron a pacientes diagnosticados con un trastorno de la personalidad, (Eje II del Manual Diagnóstico y Estadístico de los Trastornos Mentales [DSM-IV, por su sigla en inglés]). El grupo de control estuvo integrado por pacientes con trastornos clínicos del Eje I del DSM-IV, sin diagnóstico de un trastorno de la personalidad, emparejados exactamente en cuanto al sexo y estrechamente en cuanto a la edad y a variables socioeconómicas (n = 351). RESULTADOS: De los 351 individuos del grupo de la muestra del estudio, 166 (47,3 por cento) eran varones y 185 (53,7 por cento) mujeres; 50 (14,2 por cento) eran de raza blanca y 301 (85,8 por cento) de raza negra; 293 (83,5 por cento) habían nacido y crecido en Jamaica; y 202 (57,6 por cento) pertenecían a las clases socioeconómicas I y II. La media de la edad era de 33,92 (desviación estándar 10,236). Cuando se desagregaron las características fenomenológicas, no concordaban con los diagnósticos convencionales de trastorno de la personalidad según el DSM-IV. El análisis factorial de 38 fenómenos clínicos permitió determinar cinco componentes: psicosis, depresión mayor, problemas de manejo del poder, trastornos psicosexuales y dependencia fisiológica. Las pruebas de la t independientes revelaron que los pacientes sin un trastorno de la personalidad obtuvieron puntuaciones medias significativamente mayores para la psicosis; ambos grupos obtuvieron las mismas puntuaciones para la depresión; y los que padecían un trastorno de la personalidad obtuvieron puntuaciones medias significativamente mayores para los factores restantes. El análisis de la varianza indicó que estos factores diferían significativamente según el nivel de gravedad (leve, moderado o grave). CONCLUSIONES: El agrupamiento de las características fenomenológicas en tres grupos principales sugirió un diagnóstico (clínico), correspondiente al Eje I, de trastorno del control de los impulsos y del manejo de la autoridad y los conflictos.

Deinstitutionalization and attitudes toward mental illness in Jamaica: a qualitative study.

OBJECTIVE: To consider whether or not deinstitutionalization and the integration of community mental health care with primary health care services have reduced stigma toward mental illness in Jamaica. METHODS: A qualitative study of 20 focus groups, with a total of 159 participants grouped by shared sociodemographic traits. Results were analyzed using ATLAS.ti software. RESULTS: Participant narratives showed that stigma had transitioned from negative to positive, from avoidance and fear of violent behavior during the period of deinstitutionalization to feelings of compassion and kindness as community mental health services were integrated with Jamaica's primary health care system. The Bellevue Mental Hospital and homelessness were identified as major causes of stigma. CONCLUSIONS: Attitudes toward the mentally ill have improved and stigma has decreased since the increase of community involvement with the mentally ill. This reduction in stigma seems to be a result of the rigorous deinstitutionalization process and the development of a robust community mental health service in Jamaica.

Deinstitutionalization and attitudes toward mental illness in Jamaica: a qualitative study / Externamiento psiquiátrico y actitudes hacia las enfermedades mentales en Jamaica: estudio cualitativo

OBJECTIVE: To consider whether or not deinstitutionalization and the integration of community mental health care with primary health care services have reduced stigma toward mental illness in Jamaica. METHODS: A qualitative study of 20 focus groups, with a total of 159 participants grouped by shared sociodemographic traits. Results were analyzed using ATLAS.ti software. RESULTS: Participant narratives showed that stigma had transitioned from negative to positive, from avoidance and fear of violent behavior during the period of deinstitutionalization to feelings of compassion and kindness as community mental health services were integrated with Jamaica's primary health care system. The Bellevue Mental Hospital and homelessness were identified as major causes of stigma. CONCLUSIONS: Attitudes toward the mentally ill have improved and stigma has decreased since the increase of community involvement with the mentally ill. This reduction in stigma seems to be a result of the rigorous deinstitutionalization process and the development of a robust community mental health service in Jamaica.

OBJETIVO. Evaluar si el externamiento psiquiátrico y la integración de los servicios comunitarios de salud mental con los servicios de atención primaria de salud han reducido el estigma respecto de las enfermedades mentales en Jamaica. MÉTODOS. Estudio cualitativo de 20 grupos de opinión con un total de 159 participantes agrupados según sus características sociodemográficas. Se analizaron los resultados con el software ATLAS.ti. RESULTADOS: Los relatos de los participantes revelaron que, cuando los servicios comunitarios de salud mental se integraron con el sistema de atención primaria de salud de Jamaica, el estigma había pasado de negativo a positivo y de la evitación y el temor a un comportamiento violento durante el período de externamiento a sentimientos de compasión y amabilidad. Las principales causas de estigma identificadas fueron el modelo de atención del hospital mental Bellevue y vivir en las calles. CONCLUSIONES: Las actitudes hacia los enfermos mentales han mejorado y el estigma ha disminuido desde que aumentó la relación de la comunidad con los pacientes. Esta reducción del estigma parece deberse al proceso riguroso de externamiento psiquiátrico y al desarrollo de un servicio comunitario de salud mental sólido en Jamaica.

"Mad, sick, head nuh good": mental illness stigma in Jamaican communities.

Stigma may be an important factor in mental health service seeking and utilization. However, little work on stigma has been conducted in developing nations in the Caribbean, including Jamaica. We explored mental illness stigma in Jamaica by conducting focus groups with 16 community samples. Four overarching conceptual themes are discussed: (1) community members' definitions of stigma; (2) emotional responses towards those with mental illness, such as fear and love; (3) behavioral responses towards those with mental illness, including avoidance and cautious approach; and (4) perceptions of and beliefs about mental illness, including a distinction between "madness" and "mental illness."

Psychic centrality: reflections on two psychohistoriographic cultural therapy workshops in Montreal.

The use of psychohistoriographic cultural therapy (PCT) developed in Jamaica is described in the context of two workshops in Montreal. PCT is a form of group intervention that seeks to elicit and clarify the "psychic centrality" of a group. Psychic centrality refers to a sense of psychological containment or organization of diverse individual points of view through creating a historical map of collective experience. In PCT, this collective map is constructed and techniques borrowed from creative arts therapies are used to develop a performance. This performance provides additional containment and fosters a group process that can contain collective conflicts. The performance can also be used to engage an audience, working to contain conflict while representing diverse perspectives within the group. Factors that may contribute to the effectiveness of PCT and those that may derail the process are identified through the systematic comparison of the two workshops. PCT was demonstrated to cross successfully from a Third to a First World culture, and established potential as a method to facilitate group conflict resolution and for the promotion of pluralistic civil societies.

Psychiatry in Jamaica.

The intense historical relationship linking Jamaica and Britain to 300 years of the transatlantic slave trade and 200 years of colonialism has left 2.7 million souls living in Jamaica, 80% of African origin, 15% of mixed Creole background and 5% of Asian Indian, Chinese and European ancestry. With a per capita gross domestic product of US$4104 in 2007, one-third of the population is impoverished, the majority struggling for economic survival. The prevailing religion is Protestant, although the presence of African retentions such as Obeah and Pocomania are still widely and profoundly experienced, and the powerful Rastafarian movement emerged as a countercultural religious force after 1930. The paradox and contradictions of five centuries of Jamaican resistance to slavery and colonial oppression have spawned a tiny, resilient, creative, multicultural island people, who have achieved a worldwide philosophical, political and religious impact, phenomenal sporting prowess, astonishing musical and performing creativity, and a criminal underworld that has stunned by its propensity for violence.

Fostering resilience in children at risk through a cultural therapy intervention in Kingston, Jamaica.

This report explores an initiative in Kingston, Jamaica to foster resilience in children in an inner-city community plagued by violence and other social problems. This initiative was undertaken by CARIMENSA, the Caribbean Institute for Mental Health and Substance Abuse.

A public health and suicide risk in Jamaica from 2002 to 2006.

BACKGROUND: Globally, suicide is the third leading cause of mortality among persons aged 15-44 years. However in Jamaica it is not among the leading cause of mortality; but its importance cannot be ignored because of this fact. AIMS: This study seeks to 1) update the prevalence of suicide in Jamaica, 2) make comparisons with international data, 3) provide an understanding of age-sex composition of those who are committing suicides, and 4) provide public health practitioners with valuable information which will be used to inform policy decisions. MATERIALS AND METHODS: Secondary data published by the Jamaica Constabulary Force was used for this study. Data were summarized using percentages and associations were examined by Kruskal-Wallis or Analysis of Variance. RESULTS: The suicide rate averaged 2.26 per 100,000 over the last six years. In 2006, the suicide rate for males was 9 times higher than that of females. The group of 65-74 age, among the male population, recorded the highest suicide rate (11.3 per 100,000) and the 5-14 age group recorded the lowest (0.3 per 100,000). The highest rate for the female population (3.4 per 100,000) was recorded in the 65-74 age group. The 30-39 age group showed an overall higher rate of suicide over the study period, this was followed by the 40-49 age group. CONCLUSIONS: Jamaica's suicide rate is among the lowest in the world and in spite of this, there is a need to formulate a suicide policy for the nation in particular males and young adults.