Afro Caribbean Experiences of Psychosis Explored

Addressing the racial and ethnic disparities in mental health continues to be a significant issue within political debates, academic research, and advocacy efforts. In the United Kingdom, successive governments have launched various initiatives aimed at promoting race equality in mental health services. Notable among these initiatives are Delivering Race Equality in Mental Health (Department of Health 2005), referred to as “DRE,” and the current Patient and Carers Race Equality Framework (PCREF) initiated by NHS England in 2023. These frameworks seek to tackle long-standing inequalities, yet tangible outcomes remain elusive.

Despite numerous reports generated by local services outlining necessary actions to address these disparities, many of these reports remain unaddressed and gather dust. Research studies and academic literature have attempted to identify the factors contributing to the disproportionate use of mental health services by various racialized groups. However, a meta-analysis by Barnet et al. (2019) indicates a significant gap in primary research exploring the fundamental causes of these disparities. This lack of exploration exacerbates the issue, leaving many questions unanswered about the systemic factors at play.

Citation bias in academic literature often leads to a situation where newer papers reference previous studies and their proposed causative hypotheses as if they were established facts. Consequently, while there is extensive discussion around the dominant narratives that attribute racial disparities to factors like elevated rates of involuntary admissions, the underlying causes lack rigorous scientific validation. Moreover, there is a pronounced absence of patient representation and collaborative research that includes insights from those directly affected by these disparities, making it even more challenging to fully understand the nuances involved.

The term ‘racial disparities’ can inadvertently homogenize experiences, obscuring the profound variations among different population groups. To illustrate this point, consider the stark differences in psychosis diagnosis rates: 3.2% for Black men, 0.3% for White men, and 1.3% for Asian men (McManus et al. 2016). These figures highlight not only the disparities in diagnosis but also the urgent need for tailored approaches to mental health care that acknowledge these differences.

The recent study conducted by Knight and Jarvis (2024) significantly enriches our understanding of this field by providing a comprehensive scoping review of the literature. Their research specifically focuses on the experiences of English-speaking Afro-Caribbean individuals dealing with psychosis in both North America and the United Kingdom, thereby shining a light on this often-overlooked demographic.

Research Methods: Understanding Psychosis Through Lived Experiences

The research conducted aimed to delve deeply into the attitudes and beliefs of the target demographic concerning their personal experiences with psychosis. By amplifying the voices of these individuals, the study seeks to inform and improve mental health services to better align with their unique needs. Although this study was not explicitly comparative, the findings do reference large-scale population studies such as Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) in the UK and the European Network of National Schizophrenia Networks Studying Gene–Environment Interactions (EU-GEI) across Europe, along with the National Survey of American Life (NSAL) in the USA. These references highlight the inadequacies of mental health services in catering to the Afro-Caribbean populations in both North America and the UK.

Notably, the research uncovered several significant challenges faced by the Afro-Caribbean community in accessing and utilizing mental health services effectively. These challenges include:

• Reduced involvement from familial caregivers,
• Stigma associated with mental health issues and a general distrust of services,
• Increased exposure to poverty and social disadvantages,
• Experiences of societal discrimination, threats, hostility, and violence,
• Discrimination in accessing healthcare services,
• Diagnostic errors stemming from cultural biases within mental healthcare,
• Recent studies have explicitly linked these challenges to racism in healthcare.

To gain a more in-depth understanding of these challenges, the researchers performed a focused keyword search across databases like Medline, PsychINFO, and Scopus, resulting in the identification of 296 articles that span various research methodologies concerning English-speaking Afro-Caribbean populations. Additionally, a grey literature search was conducted to “identify and integrate Afro-Caribbean attitudes and beliefs that may not be highlighted in mainstream sources or found through traditional peer-reviewed research”.

However, articles that exclusively evaluated Haitians (French-Creole), Dominicans (Spanish), or groups outside the Afro-Caribbean cultural or linguistic spheres were excluded from this analysis. Ultimately, only English-language full-text articles were included, leading to a final evidence base comprising 220 studies.

The thematic analysis that followed incorporated sub-thematic analysis, coding the information from each article to reveal emergent attitudes and views held by English-speaking Afro-Caribbean individuals in both North America and the United Kingdom.

Key Findings: Themes Emerging from the Analysis

Through the thematic analysis, five significant themes emerged:

• Colonisation: This theme encompasses both historical and contemporary administrative structures, reflecting on the legacies of colonialism that persist today. It addresses notions of cultural superiority and inferiority, alongside the material inequalities arising from the exploitation that accompanied colonial endeavors.
• Adaptation: This theme highlights the unique challenges that migrants face while assimilating into new cultures and societies. Factors such as language barriers, cultural norms, dietary adjustments, and differing values create hurdles. The analysis depicts experiences of feeling unwelcome in new environments and the personal struggles that come with this adaptation, often leading to a sense of being “black on the outside but effectively white” in terms of behaviors and values.
• Cultural mistrust: This theme delves into the ongoing social mistrust arising from historical breaches of trust, particularly in the U.S. context. A prominent example cited is the unethical Tuskegee experiments, during which African American men were denied treatment options to study the progression of syphilis.
• Collectivism: This theme examines the cultural norms of the communities involved in the study, which often emphasize group identity and collectivism. However, the experience of migration tends to disrupt these collective identities, leading to specific challenges, including strained familial relationships, such as between mothers and grandmothers. Larger disruptions to sociocultural values, including connections to ancestors, may also be misinterpreted in clinical assessments.
• Religion and Spirituality: This theme addresses the powerful cultural values and traditions present within these communities. A wide range of belief systems is acknowledged, including Christianity, Rastafarianism, and various African heritage beliefs such as Obeah and voodoo.

The authors of the study also emphasized their own positionality, identifying with racialized communities, which adds a layer of understanding to the research’s findings.

Each identified theme is discussed in relation to its potential influence on individuals’ relationships with clinical staff and the diagnostic process for psychosis. Verbatim accounts from participants enrich the textual data, providing a context for presentations that may be framed medically as psychosis, with experiences ranging from feeling “nervous” to possessing religious or supernatural beliefs of being “possessed” or “cursed.”

The discussion section connects the views and attitudes of the study group, namely English-speaking Afro-Caribbean individuals in North America and the United Kingdom, to potential developments in service approaches and design. This includes advocating for a greater recognition of the impact of historical colonialism and its legacy, as well as the need to decolonize mental health practices and incorporate Caribbean sociocultural and collectivist influences in understanding psychosis.

Furthermore, the authors stress the importance of mental health professionals actively validating the experiences of racism reported by individuals from marginalized communities. They advocate for increased cultural competence by utilizing cultural formulations and being mindful of language and meanings.

Insights and Implications: Understanding Afro-Caribbean Experiences in Mental Health

The authors acknowledge the diversity within Caribbean societies in the Northern Hemisphere, while also emphasizing the shared experiences of colonialism and social discrimination, which have profound implications for those seeking mental health services.

The experiences of English-speaking Afro-Caribbean individuals in North America and the United Kingdom must be understood within the broader context of historical and contemporary discrimination. The authors clarify that the challenges faced by the study group are not merely a result of omissions in practice; they are also reflections of societal discrimination that manifests in clinical practices and the frameworks used for treatment and care.

Assessing Strengths and Limitations of the Study

This scoping review offers valuable insights into the beliefs and attitudes of the research participants, facilitating a focused thematic analysis of their lived experiences. It also highlights the disparities between these experiences and the prevailing assumptions within psychiatric and psychological frameworks. While the authors do not provide a specific toolkit for practical application, they do offer tangible examples that can enhance practice.

Crucially, the authors successfully avoid framing the research solely around cultural understanding. They highlight the detrimental effects of individual racism and systemic discrimination. However, a notable limitation of the study is the absence of a comparator group, which makes it challenging to ascertain whether the emerging themes were causally linked to racial inequalities.

Additionally, the paper mentions misdiagnosis as a potential consequence of the divergence between the attitudes, beliefs, and perspectives of service users and providers. It would have been beneficial for the authors to identify specific domains where improvements could be made, such as enhancing service user experiences and designing culturally sensitive outcome measures that contextualize psychosis diagnosis rates.

While the paper briefly references intergenerational trauma, it does not explicitly frame this concept within theoretical constructs. The work of Carter and Pieterse (2020) on ‘race-based traumatic stress’ emphasizes the importance of understanding intergenerational trauma’s role in such stress. Given the emergence of themes related to collectivism and disruptions within familial relationships, the authors may have strengthened their analysis by incorporating an intergenerational trauma framework. Considering the increasing focus on trauma-informed approaches in psychiatry, this perspective could provide valuable insights for developing inclusive clinical practices in the future.

Practical Implications: Transforming Mental Health Services for Racialized Communities

This innovative study underscores that neglecting the broader context of racialized lives is not merely an oversight; it has harmful consequences at the practical level through invalidation.

Critical works such as Suman Fernando’s Institutional Racism in Psychiatry and Clinical Psychology (2017) present a perspective on reassessing the evolution of disciplines that often perpetuate racism through coercive care practices. Knight and Jarvis (2024) reinforce this notion, asserting that striving to be non-discriminatory while employing processes that yield racist outcomes is not a benign goal.

This paper reflects the ongoing challenges in dismantling established approaches, despite the diversity of individual experiences documented in research on mental disorders. It is crucial to recognize that the process of ‘professionalization’ can create personal investment and identification with a particular framework, which may hinder self-critique, making any critique feel personal.

Therefore, at the practice level, fostering cultural humility and effectively engaging in cross-cultural practices is vital. Effective mental health practice requires collective action to address and dismantle systemic discrimination within professions dedicated to serving vulnerable communities. Additionally, it is essential to be open to co-producing changes with both current and potential service users.

Declaration of Interests

None.

Key References for Further Reading

Primary Research Article

Knight, S., Yang, X.Q., & Jarvis, G.E. (2024). “Dem sey mi mad”: A scoping review of the attitudes and beliefs of English-speaking Afro-Caribbeans about psychosis. Frontiers in Psychiatry, 15, 1385525. https://doi.org/10.3389/fpsyt.2024.1385525

Additional References

Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) Study, United Kingdom

Barnett P, Mackay E, Matthews H, Gate R, Greenwood H, Ariyo K, Bhui K, Halvorsrud K, Pilling S, Smith S. (2019) Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. Lancet Psychiatry. 2019 Apr;6(4):305-317. Open Access Published: March 04, 2019 DOI: https://doi.org/10.1016/S2215-0366(19)30027-6

Carter, R & Pieterse, A. (2020) Measuring the Effects of Racism: Guidelines for the Assessment and Treatment of Race-Based Traumatic Stress Injury. New York. Columbia University Press

Department of Health (2005) Delivering Race Equality in Mental Health Care. Crown: London

European Network of National Schizophrenia Networks Studying Gene–Environment Interactions (EU-GEI), Europe

Fernando, S. (2017) Institutional Racism in Psychiatry and Clinical Psychology. London: Palgrave.

McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

NHS England (2023) Patient and Career Race Equality Framework https://www.england.nhs.uk/long-read/patient-and-carer-race-equality-framework/ (last accessed 3 February 2025)

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