The Jamaican LMIC Challenge to the Biopsychosocial Global Mental Health Model of Western Psychiatry
The mental health challenge for descendants of Africans enslaved in Jamaica and the New World is described. The urgent need to negate the psychology of five hundred years of racism and colonial oppression and to create a psychosocial decolonization blueprint of GMH suitable for LMIC’s is outlined. The colonial history of the exploitation of the Caribbean, as part of the European appetite for conquest and settlement, and the ruthless, socially engineered, European imposition of African slavery in the New World set in place the pathologizing of freedom. A novel historical and political methodology of psychological analysis called psychohistoriography is described here, which identifies complex trauma: physical abuse, long standing sexual abuse, domestic violence, and enslavement, occurring over a long period of time, as the progenitors of contemporary mental illness in Caribbean people. The gradual deinstitutionalization of the colonial British lunatic asylums in Jamaica is then chronicled, along with the development of novel community engagement modalities. Primary, secondary, and tertiary prevention strategies that have metamorphosed Jamaican psychiatry and revolutionized treatment and outcomes for psychosis are discussed. The Psychohistoriographic Dream-A-World Cultural Therapy, a means to reduce dysfunctional behavior and academic underachievement in primary schools, is then explored. The challenge to the Jamaican people to overcome the epigenetic effects of slavery by owning our madness is summarized. Current outcome data on primary prevention mental health programs in Jamaica continues to buttress the efficacy of the Jamaican challenge to the biopsychosocial Global Mental health model.
Forced custodialization in lunatic asylums driven by cruel physical torture in LMIC’s like Jamaica and other Caribbean territories has been the creation and sequelae of European’s five hundred years of genocidal invasion of the New World, African slavery in exploitative plantation systems, and a prolonged colonial period of European Imperial rule (Smith 2010). Common histories of colonialism and slavery in the New World pose the question of whether there is a living legacy derived from European colonialism and transatlantic African slavery. Christopher Columbus was the father of the Atlantic Slave Trade (Thomas 1997, p. 89). He encountered Jamaica on his second voyage to the West Indies on May 5, 1494, and reported the peacefulness of the original Tiano people in his first letter to the Spanish king and queen (Gilder Lehrman Institute). Las Casas (1999) accounts of Columbus’s murderous genocidal brutality explains the Caribbean being at the forefront of the colonial invasions of Europe before the eighteenth century (Williams 1970; Carew 2006). Lunatic asylums in the New World emerged to house descendants of enslaved Africans who had grown with distorted concepts of self and a warped concept of freedom following emancipation, manumission, and colonial independence. The European urge to own and dominate the rest of the world has arguably been the single largest causative factor of mental pathology in human history (Hickling 2005). Evidence from the Spanish, Dutch, French, and British Caribbean colonies shows that status inconsistencies and social prejudices were especially brutal (Walvin 1992; Thomas 1997). Cheung-Judge (1988) has suggested that the descendants of Africans enslaved in the New World have remained at the bottom of the social order, subject to physical and verbal abuse. Gaining their political freedom had a substantial impact on their self-perceptions, identity structure, interpersonal relations and their social and communal life.
Following worldwide progression towards emancipation from lunatic asylums (Caudill et al. 1952; Stanton and Schwartz 1954; Goffman 1961) that accompanied the striving for political freedom (Scull 1979), the physical shackling in asylums has gradually been replaced by the chemical straitjacketing of the biomedical reductionist approach (Ghaemi 2015). The paradigm shift to the biopsychosocial (BPS) approach followed as an “enlightened” imposition of contemporary Western psychiatry (Engel 1977; Lane 2014). Regarded as one of the most important developments in medicine and psychiatry in the late twentieth century (Babalola et al. 2017), the BPS systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. It engenders “client-centered” approaches and a renewed emphasis on the importance of the doctor-client relationship (Smith et al. 2013). However, BPS has been criticized as being both time-consuming and expensive which are pressing issues in resource-poor settings (Truglio et al. 2012), and a luxury many health care systems in LMICs cannot afford. Babalola et al. (2017) also highlight a need to extend the BPS approach to include a specific acknowledgement of the central role that cultural beliefs and practices can play in understanding mental health difficulties. Growing skepticism of the BPS approach also includes “an eclectic freedom bordering on anarchy” (Alonso 2004) and ambiguity in relevance to guiding clinical practice and alleviating disease (White and Sashidharan 2014).
Increasingly, Global Mental Health (GMH) initiatives (Saraceno and Saxeno 2004; Patel and Prince 2012) have been undertaken worldwide in the hope of improving mental health inequities and inequalities and closing the “treatment gap” that exists between those that need mental health services through the “scaling-up” of evidence-based treatments. A consortium of researchers, advocates, and clinicians applied the Delphi method to announce comprehensive research priorities for improving the lives of people with mental illness around the world (Collins et al. 2011). This comprehensive proposal was challenged (Bemme and D’souza 2012) as being the new mental health face of Western Imperialism. This chapter presents the mental health challenge for descendants of Africans enslaved in Jamaica as the urgent need to negate the psychology of five hundred years of racism and colonial oppression, by attempting to document the mental health effects of African-Caribbean enslavement and to describe the LMIC psychosocial blueprint of GMH based on six decades of postcolonial experience of Jamaica since 1962.
The Effects of African Enslavement
The Caribbean Challenge to the Pathological Psycho-Sociological Concepts of Freedom
In the popular Western imagination, there are pathological forms of freedom, formed by systems of power and economic exchange, which legitimate the neglect, exploitation, and domination of “the others,” validating, to varying degrees, war, slavery, colonialism, and the appropriation of “others” collective common property (Nelson 2012, p. 64), as “a freedom to dominate and exploit others” (Harvey 2000, p. 173). The first Caribbean psychiatrist to challenge the pathological psycho-sociological concepts of freedom of descendants of Africans enslaved in the New World was Martinique-born psychiatrist Frantz Fanon (Fanon 1967). Describing the concept of mental illness in descendants of Africans enslaved in the New World as an extreme form of freedom, Fanon described mental illness as a product of European colonialism and emancipation he suggested that this mental illness emerged from the social creations of those who want to impose their presence on the world, who want to absorb and exclude others according to their own standard of freedom (Fanon 1967, p. 200). Quoting German philosopher Günther Anders who described this process as the “pathology of freedom” as a domination and the will to fill the world with oneself and make it conform to one’s own identity (Anders 1936/37, pp. 22–54; 2009, pp. 278–310). Fanon (1959) suggested that mental illness is a true pathology of freedom, which situates the mentally ill in a world where his freedom, his will, his desires are constantly broken by obsessions, inhibitions, counter-orders and anxieties.
In a challenge to the Episteme of the European classical age that was the center of knowledge and the principle of order in Jamaica, Hickling (2007/2012, p. 26) opined:
…It is our responsibility…we have to use our knowledge in the challenge of the episteme in shaping tomorrow’s professionals … who are going out there to transform our society … to look at social history as treatment… it cannot be anybody else’s responsibility; we have to deal with it.
Effects of Slavery on the Jamaican Population
There is extensive documentation of the colonial history of exploitation of the Caribbean as part of European colonialism and the imposition of African slavery in the New World (Thomas 1997). A comprehensive study of the effects of this imposition on the inhabitants of Caribbean territories began to emerge in the mid-twentieth century. While working with the West Indian Social Survey in Jamaica (1947–1949), British social psychologist Madeline Kerr (1963) conducted a seminal anthropological study of conflict and personality development in Jamaica, encapsulating historical perspectives of cultural tensions stemming from the paradoxical juxtaposition between African heritage and values, and the imposition of Western (British) attitudes and values that arose during slavery. She identified that these two conflicting cultural ideologies left Jamaicans “bewildered and insecure” with this dilemma reflecting “personality difficulties and in some cases, it exercises a partial inhibition of the development of psychological maturity” (p. 165). Kerr’s work must be seen as a foundation for the later contemporary exploration of transcultural psychiatric issues in the Caribbean. The deep-seated rage, anger, violence, and hostility originating from the soul murder of abuse and deprivation, from slavery and colonialism (Shengold 1989, 1999; Painter 1993), are the origins of the conflict and stress, tension and anxiety, sadness and despair that characterize the postcolonial experience. Geopgiopoulos and Rosenbaum (2005) asserted that assumptions and forms of research in cross-cultural psychiatry were outmoded, providing a platform for emerging philosophical explorations in the Caribbean in the latter decades of the twentieth century. Good (2005) acknowledged that diversity is neither politically neutral nor easily overcome by cultural sensitivity but is deeply rooted in and interwoven with a history of colonialism and violence.
Psychohistoriography and the European-American Psychosis
“…Psychohistoriography …another Caribbean construct lining up in the diasporic challenge to the European episteme which is stepped in our collective psyche, and in our cultural and social history… as a therapeutic instrument for insight catalyzing individual and social change …” (Hickling 2007/2012, pp. 34, 35)
Mental Hospital Deinstitutionalization in Jamaica
The Jamaican Lunatic Asylum
…indescribably desolate and dirty. Overcrowding was unbelievable with patients sleeping on the floor in shocking conditions. The wards were huge bins built of brick and concrete. Vast open courtyards were surrounded by sheer stonewalls twelve feet high. The patients lived in small cells, which housed the more dangerous and violent. The others lived in large dormitories with poor lighting and little ventilation. They were dressed in institutional blue cotton, often dirty and unkempt, and during the days were let out like animals into the open courtyard to wander in the fierce tropical sun. This was not a hospital; it was a prison… howling mad men and women locked away in tiny cells stark naked, smeared from head to toe in their own excrement… The primary therapeutic function of this place was to lock people away – the therapeutic principle of custodialization.
Rehabilitation and Gradual Deinstitutionalization
The seminal work of Caudill et al. (1952), Stanton and Schwartz (1954), Goffman (1961), Basaglia (1964), Wing and Brown (1970), and others heralded the introduction of deinstitutionalization programs and community mental health services worldwide (Tooth and Brooke 1961) in the mid-twentieth century. In keeping with this trend, the Bellevue Mental Hospital (BVH) initiated a rehabilitation program in 1974. At that time, the BHV housed 3100 patients in conditions of squalor and degradation, cut off from their relatives and communities. The majority of them suffered from severe enduring psychoses and symptoms characteristic of persons confined for a long period in a hospital, mental hospital, or prison called institutional neurosis (Barton 1966). The patients assume a dependent role, passively accept the paternalist approach of those in charge, and often develop symptoms and signs associated with restricted horizons, such as increasing passivity and lack of motivation to cooperate in rehabilitation.
Small groups of these patients were selected, renamed clients, and exposed to a specialist in-patient Rehabilitation Unit within the hospital (Hickling 1975). Based on therapeutic community principles (Maxwell Jones 1968), this center taught clients activities of daily living – to prepare and serve their own meals – and were exposed to token economy schemes to modify abnormal institutionalized behavior (Kazdin 1977). They were reintroduced to the world of work through daily occupational therapy and were exposed to daily literacy, art, and dance therapy. The daily therapeutic community group meeting where clients and staff met daily sitting in a large circle discussed the social dynamics and daily activity of the clients. Intense social work activity was initiated for each client; their families were contacted (if available) and reintroduced and reunited to their incarcerated relatives. They were gradually reintegrated into their communities and families and received weekly home-visits, regular medication, and social support by the hospital team. For those who had no family, halfway houses were created to assist in the rehabilitation process until they were able to work and provide independent living facilities for themselves.
Applying Kabinov’s (1973) four principles of rehabilitation – (i) partnership, (ii) the variety of efforts, (iii) unity of psychosocial and biological methods of intervention, (iv) stages – the gradual deinstitutionalization of the nineteenth-century custodial mental asylum and downsizing into a contemporary mental hospital of 700 in 2010 (25.9/100,000) was achieved (Hickling 2010). This improved the patients’ quality of life, largely due to “nontechnical changes” in the care of the person and was not a consequence of new drugs, psychopharmaceuticals, or new discoveries by neuroscientists or geneticists, as is sometimes claimed. Deva (2006) has suggested that even in developing countries the emphasis on rehabilitation as a component of managing mental illness is often neglected in favor of instituting newer generations of medicines with the premise that these will produce dramatic improvements in symptoms and subsequently the level of functioning of the patient.
Community Engagement Mental Health Service
Jamaica was the first English speaking country in the Caribbean to implement reform in its mental health policy (Caldas de Almeida and Horvitz-Lennon 2010), introducing 125 mental health treatment clinics island wide in 1974 (Hickling 1995). This postcolonial innovation laid the basis for the integration of community mental health with primary and secondary health care services. The backbone of this Mental Hospital Law Amendment 1974 that outlawed the arrest of lunacy by the police was the creation of a cadre of Mental Health Officers (MHOs) that provided a cost effective and culturally congruent model of community care and home treatment in an environment where there were few psychiatrists (Beaubrun 1977; McKenzie 2008). At independence in 1965 there were 4 psychiatrists, 4 mental health officers, 1 psychologist, and 2 psychiatric social workers serving the population of 1.7 million people. Since that time the Jamaican mental health program has increased to 40 psychiatrists, 100 mental health officers, 15 psychiatric nurse practitioners, 400 community psychiatric aides, and 108 clinical psychologists serving a population of 2.7M since that time. Today anybody with an acute mental illness can get assessment and treatment within 24 h. There are more than 2,000 general practitioners in Jamaica, who have all been trained in the recognition and management of mental illness and can treat psychiatric illnesses of mild and moderate severity in the community (Abel et al. 2011) and this reflects the total assimilation of mental health care in Jamaican primary care medicine.
Management of Acute Psychosis in Open Medical Wards of General Hospitals
A unique feature of Jamaican postcolonial mental health public policy has been the successful management of acute psychosis in open medical wards of general hospitals (OMWGH), where patients with acute psychotic illnesses have been treated alongside patients with other severe acute medical illness. Patients treated in OGWMH spent considerably fewer days in hospital compared with those admitted to other acute beds in the country and have significantly fewer relapses and readmissions (Hickling et al. 2000). By 2015, more than two thirds (78%) of all patients requiring hospitalization of acute mental illness were treated in OMWGHs (Auditor General’s Report 2016). A Cochrane Review (Hickling et al. 2002, 2007) established that this was a unique primary care mental health phenomenon, which has only recently been replicated in Argentina (Collins 2008; Dirección Nacional de Salud 2010).
Psychohistoriographic Cultural Therapy
Psychohistoriographic Cultural Therapy was pioneered in the Jamaican Bellevue Mental Hospital in 1978 as a novel large group sociodrama technique aimed at stimulating group and community insight and catalyzing change (Hickling 1989, 2007). The PCT modality integrates the science of psychology with a dialectic method of historical analysis to provide insights into the links between the individual and the political. This is then concretized by incorporating a structured use of art, music, and drama to shape behavior modification. The initial PCT analysis in Bellevue Hospital led to the development of the Cultural Therapy program, building on psychodrama concepts as in the work of Moreno, J. L. (1946) and Freire, P. (1972). This manifested as a full length sociodrama pageant called Madnificient Irations, portraying the history of madness and mental health in Jamaica (Hickling 1989) resulted in profound stimulation of community insight about mental illness (Hickling 2004). Additional sociodramas highlighted the life histories of participating patients of the asylum. All the pageants were performed by hospital patients and staff for audiences from the mental hospital and the surrounding community in a 1500 seat Garden Theatre built by the patients and staff from bamboo and other local materials.
The Operational Components of Psychohistoriographic Cultural Therapy
The preliminary work with psychohistoriographic cultural therapy in Bellevue Hospital allowed for the understanding, institutionalization, and dissemination of the critical components of this complex sociotherapeutic process that was applied in several different locations and clinical circumstances internationally. The activity is led by a trained/experienced cultural therapist who invites the group to circle: to stand in a circle – dialogic cultural circles (Freire 1972). The participants are then invited to center: by a series of mindfulness, callisthenic, and breathing exercises, participants are invited to find their center (individual and group). Then the process of culturing (art to define values and mission) is introduced: using a series of musical, spoken word, and physical dance exercises, the group is invited to explore their culture (the ideas, customs, and social behavior of the group). This enables cognitive catalysis (embodied cognition): explored by demanding each individual to create and express a new thought and express it to the group in word and action. The embodiment of cognitive catalysis is triggered by the use of Gestalt psychology for the production of collective poems, songs, dances, skits/plays.
The development of this psychological process that challenges the long-term debilitating effects of slavery and colonialism is perhaps the most important facet of the Jamaican mental health transformation process. Hickling (In Press) highlights this component which challenges the colonial exemplars of the Western GMH movement, as a glaring omission from the Delphi consortium (Collins et al. 2011) proposal. It is suggested that the development of such psychological strategies to negate the all pervasive influence of 500 years of European colonization is a critical component for Global Mental Health with the abolition of medium and long term facilities for custodialization of the mentally ill.
Deinstitutionalization and Its Consequences in Jamaica
A novel alternative to imprisonment for mentally ill persons who came in conflict with the law, called Diversion at the Point of Arrest Programme (DAPA), was introduced in Jamaica in 1974. This allowed Community Mental Health Officers to initiate assessment and treatment in jails for mentally ill persons, thereby bypassing their passage through the Courts and penal services. Under DAPA, the mentally ill persons arrested for minor crimes are treated rehabilitated and reunited with their families, (Hickling and Sorel 2005). By diverting them at the point of arrest, more than 400 patients annually have been prevented from entering the forensic system. There has been a steady decline in the number of beds in prisons in Jamaica since independence in 1962, which has paralleled the decline of beds in the Jamaican Mental Hospitals. This is quite the opposite to the comparative evidence of the consequences of deinstitutionalization from mental hospitals in the United States (Torrey 1997; Canales 2012). By 2014, the number of mentally ill persons in the Jamaican prison system was 0.009/100,000 (Prendergast 2011). Another means of diverting persons from the criminal justice system in Jamaica has been the creation of the Drug Court Act, established in 1999 to facilitate the treatment and rehabilitation of persons who commit certain drug-related offences (Goulbourne 2011).
The findings of a population survey conducted on stigma (Gibson et al. 2008) suggested that, since the 1960s, there has been a gradual reduction in stigma towards mental illness through the engagement of the general population with mentally ill persons. A qualitative general population study (Hickling et al. 2011) corroborated this. This reduction in stigma appears to be a result of the rigorous deinstitutionalization process and the development of a robust community mental health service in Jamaica (Hickling In Press).
On community Attitudes to Mental Illness
Whitely and Hickling (2006) collected, reviewed, and analyzed all stories related to psychiatric de-institutionalization published over a 26-month period from 2003 to 2005 by Jamaica’s principal broadsheet newspaper. All of the stories were positive in orientation. Articles alluded to the therapeutic and economic benefits of de-institutionalization. To allay public fears, articles gave prominence to the views of senior psychiatric experts, quoted supporting statistics and international trends, and translated relevant research findings into lay language. These results are contrary to most studies in high-income countries indicating negative media portrayals of mental illness and the mentally ill. This collaborative destigmatizing process in the Jamaican media has been called psychological deinstitutionalization
Critics of deinstitutionalization claim that the process has left thousands homeless on the streets of large cities of the Western world (Harcourt 2011; Lamb 1984). The latter suggested that the homelessness of the mentally ill is not the result of deinstitutionalization per se but rather of the way in which deinstitutionalization has been implemented. The Jamaican data confirms Lamb’s conclusion. The rate of homelessness in the present decade in Jamaica has fallen by 84% from 0.112/100,000 in 2012 to 0.018 in 2015. The rate of mental illness among the homeless was 34% for the island and 22% in the geographic catchment area of the BVH. The rate of the homeless mentally ill in the geographic catchment area of the Bellevue Mental Hospital fell by 50% to 0.009/100,000 in 2015 (Campbell et al. 2012).
Other Consequences of Deinstitutionalization in Jamaica
The Jamaica Lunatic Asylum was located on 123 acres of land in Kingston, where it presently exists as the Bellevue Hospital (Jemmott (2013). With gradual deinstitutionalization, the hospital physically downsized in 1974 from 120 to 40 acres by 1992, and modernized inpatient facilities, with the provision of land to build housing for the surrounding community. The expansion of mental health positions within the public sector resulted principally from a virement (the process of moving money from one financial account or part of a budget to a different one) of nursing posts from the mental hospital nursing budgetary cadre as a consequence of the postcolonial public policy of the gradual deinstitutionalization the mental hospital. The process has also helped to negate the professional brain drain that often accompanies the postcolonial process in developing countries (Dodani and LaPorte 2005). All the native-born psychiatrists trained in Jamaica since 1965 have remained in this country since that time, with one exception.
Owning Our Madness
…New World psychotherapy must be shaped by the promotion of preventative mental health and increased awareness of the factors that facilitate understanding of the links between individual and social psychopathology… By linking cultural therapies with the media in its many forms and promoting individual actualization and self-reliance within the crucible of collective ownership; we can create the knowledge base to decentralize state power, syncretize self and society, and take control of our own madness. Collectively we will negate the psychosis of Europe … (Hickling 2016, p. 205)
Unmasking Underlying Social Psychopathology
Complex trauma exposure results in a loss of core capacities for self-regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional traumas, and cumulative impairment (psychiatric and addictive disorders; chronic medical illness; legal vocational and family problems) (Cook et al. 2005). Complex trauma rooted in the five-hundred-year experience of slavery and colonialism is evident in the high homicide rates across the Anglophone Caribbean. Jamaica, Bahamas, Belize, and Trinidad and Tobago have some of the highest homicide rates in the world (Agozino et al. 2009; Harriott and Katz 2015). When Jamaica gained independence in 1962, the murder rate was 3.9 per 100,000 inhabitants, one of the lowest in the world (Robotham 2012). By 2006, the homicide rate of 53/100,000 was the third highest in the world after El Salvador and Iraq (Krause 2011). The level of exposure of children to violence is especially high in Jamaica (Samms-Vaughan et al. 2005; Baker-Henningham et al. 2009). Prurience and eroticism manifests itself in the elevated levels of childhood sexual abuse, rape, and adult sexual dysfunction throughout the region (Jeremiah et al. (2017). The rate of 2.9/100,000 of self-inflicted violence, or suicide (Abel et al. 2010), is ranked amongst one of the lowest in the world. Many children in Jamaica have experienced complex trauma (Balbernie 2010) of societal and domestic violence, sexual and substance abuse, absent fathers, attachment disruptions, poor nutrition, poor housing, and substandard education (Pisani 2007). Recent estimates suggest that 20–40% of children reaching high school age in Jamaica have behavioral and academic challenges (Williams 2001). That remittances from Jamaicans living in North America and Europe are the second largest earners of foreign exchange in many of these countries (Beaton et al. 2017; Sampson and Branch-Vital 2013) demonstrates the collective sense of dependency. In 2007, the Caribbean emigration rate was four times higher than Latin America’s overall emigration rate.
A View of Personality Disorder from the Colonial Periphery
Pathological conflict is endemic in almost every aspect of Jamaican society with such behaviour reflecting a significant prevalence of personality disorders in contemporary Jamaica. It is concluded that Jamaican psychiatry needs redefinition of the diagnosis and classification of personality disorder and the need to create novel therapies that can engineer and catalyse social transformation and change of this mental pathology.
Jamaican Political Sociologist, Carl Stone has suggested that the tensions experienced by the Jamaican people in dealing with issues of authority and power have been jumbled since the era of colonial British colonization and these tensions are compounded by ongoing political struggles in which power struggles of competing ideologies, values, and norms have resulted in a disequilibrium of power that has weakened authority in all domains of social space. He has asserted that British colonization and the plantation economy created a warped authority system that engendered long-standing struggle for power and authority within the Jamaican culture, combined with high levels of verbal and physical aggression have been associated with serious personality disorder seen in present day Jamaica (Stone 1992a, b).
Treatment of Personality Disorder in Jamaica
The nosology emerging from this Jamaican personality disorder study suggests the critical need for a therapeutic dialectic involving psychological and political insight into the effect of complex trauma, failures of attachment, authority, and impulse control in personal development and a personalized behavior modification strategy engineered to address these developmental scotoma.
Psychohistoriographic brief psychotherapy (PBP) is a treatment developed for this purpose in Jamaica emerging from the group psychohistoriographic cultural therapy model described above. Other individual cultural therapy strategies exist, such as Dialectical Behavior Therapy (Linehan et al. 2006), Relational Cultural Therapy (Jordan and Hartling 2002), and Intercultural Therapy (Rober and De Haene 2014), but the PBP is a reconstructive psychotherapy model (Wolberg 1967) that differs from these in that it involves a dialectic historical analysis. A study to test PBP established positive outcome responses in a cohort of 100 patients, diagnosed with mild and moderate personality disorder and treated with PBP (Hickling 2013).
The Development of Primary, Secondary, and Tertiary Prevention Programs
The Institute for Work & Health (IWH), Toronto (2015), asserted that primary prevention aims to prevent disease or injury before it ever occurs by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. This suggests that for many health problems, a combination of primary, secondary, and tertiary preventative interventions are needed to achieve a meaningful degree of prevention and protection. The World Health Organization’s (WHO) conceptualization of mental health, where “the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (World Health Organization 2004). Shea and Stern (2011) conclude that a shift in focus from a largely treatment/recovery orientation to one which prioritizes prevention is consistent with the fundamental tenet of public health that it is always preferable to prevent a problem than it is to address the effects of it once it has developed.
Integration of Mental Health into Primary Care Medicine
Abel et al. (2011) describe the total assimilation of mental health into preventative medical services in Jamaica as meeting the World Health Organization (WHO 2004) recommendations of the integration of mental health into primary care through the adoption of a primary care model. By engaging mental health officers (Beaubrun 1977; McKenzie 2008) at a community level, the Jamaican service has met the secondary prevention aims as suggested by The IWH (2015). This is by the provision of strategies aimed at reducing the impact of a disease or injury that has already occurred, by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. The Community Engagement program (Walcott 2012) of the community management of schizophrenia and other enduring psychoses by the development of specialized crisis intervention teams, case registers, and community intervention teams meets the IWH’s aims of tertiary prevention to soften the impact of an ongoing illness that has lasting effects (Abel et al. 2009), in order to improve their ability to function as much as possible, their quality of life, and life expectancy.
The Caribbean Institute of Mental Health and Substance Abuse (CARIMENSA)
…The sanity displayed by the University of the West Indies in proposing the establishment of the Caribbean Institute of Mental health and Substance Abuse (CARIMENSA) … into the Third Millennium was an anticipated and arguably one of the most welcome bits of news for all who are committed to national growth and development… It makes eminent sense that the kernel of the proposed Institute’s operation should be a program of “Cultural Therapy” as the driving force in … delivering mental wellness … to the lingering consequences of a history, which, through slavery and colonialism has bred among many of the region’s population feelings of self-doubt, self-contempt, psychic disarray and turmoil… (Nettleford 2007)
CARIMENSA is Jamaica’s only public health mental health facility and is responsible for implementing mental health projects for research, therapeutics, and social development. The principal objective of CARIMENSA is to link with Governmental and Non-Governmental Organizations to deliver evidence-based mental health therapeutic and health promotion research interventions as antidotes to social psychopathology and to establish research and training facilities to deliver scalable approaches for national workable outcomes. Supporting the development of mental health research and publications and the incorporation of mental health promotion as a sine qua non of clinical and administrative practice have also been its primary role in prevention. CARIMENSA has been able to focus on the national goal of the reduction of poverty, violence, and other high-risk behaviors and to help to map the interventions and strategies needed, the required outcomes, and the achievement of satisfactory goals for this country. The collaboration has also facilitated local evidenced-based research and partnerships with other Universities and organizations in a way that meets the challenges for mental health research capacity posited for LMIC’s (Durlak and Wells (1997); Razzouk et al. 2009).
South-South Preceptorships on Schizophrenia Management for Latin America
The positive tertiary prevention outcome for the management of severe and enduring mental illness (Walcott 2010) resulted in the establishment of three preceptorships by CARIMENSA for 45 senior Psychiatrists from Latin American countries in May 2017, April and October 2018. These were 2-day preceptorships implemented by the Association for Health Research & Development (ACINDES) – a nonprofit, international, academic institution in Buenos Aires, Argentina, founded in 1985 with the mission of providing high level opportunities for promoting postgraduate medical education of physicians and other health care personnel from Latin America and other countries. CARIMENSA provided interactive educational programs related to the community management of schizophrenia in Jamaica. These included site visits to open general medical wards where patients with acute mental illness were currently being treated; primary care mental health clinics in the local communities where medical care was provided for such patients following discharge; and home visits with crisis intervention teams to supervise patients with severe and enduring mental illnesses who were satisfactorily rehabilitated. Senior psychiatrists, psychologists, mental health officers, and community nurses shared their expertise and demonstrated their research and patient care capabilities. These preceptorships were directly in keeping with the injunction of the WHO – Global Forum for Health Research Mental Health Research Mapping Project Group (Razzouk et al. 2009) LMIC’s suggesting that researchers and scientific collaboration should play a more decisive role in strengthening the capacity by enhancing South–South partnerships and networks.
Dream-A-World Cultural Therapy and Cultural Resilience
Awareness of behavioral problems such as poor anger management, conflict, and scant regard for discipline and authority in Jamaican children in and out of our schools has mushroomed into a significant public preoccupation in recent times (Hill 2014). Children have disturbing behavior at an increasingly young age, and this behavior continues into adolescence and antisocial behavior in adulthood (Tremblay 1999; Kendler and Aggen 2014). CARIMENSA has developed a school-based initiative called Dream-A-World Cultural Therapy (DAW CT) to challenge these problems in primary school children.
Derived from the adult program (Psychohistoriographic Cultural Therapy) in the 1970s, the DAW CT program was designed to improve social behavior and academic performance in behavior dysfunctional and underperforming inner city and rural primary school children (Hickling 2006). DAW-CT is a multimodal psychotherapeutic intervention utilizing group therapy, social skills training, creative arts, remedial assistance, and nutritional enhancement to 7- to 10-year-old children (Graham et al. 2006). This transitioned from a small-scale proof of concept (N = 30) in a Jamaican primary school, to evidenced-based scale up (N = 100) in four impoverished inner-city primary schools (Guzder et al. 2013). Following the success of the DAW- CT program funded by Grand Challenges Canada over the period 2014–2016, the Jamaican Ministry of Education (MOE) commissioned CARIMENSA to implement the program in primary schools across the eastern end of the island from 2014.
This implementation process saw a metamorphosis of the DAW-CT program into the Dream-A-World–Cultural Resiliency (DAW-CR) program with significant methodological changes while maintaining the core principles and outcomes. In the new delivery format, the teachers and guidance counselors would be the primary therapeutic agents to 700 at-risk children. A parallel Grade 4 classroom was created within each school with the contact hours increasing from 240 h in the DAW-CT program to 1400 contact hours in the DAW-CR and using the cultural therapy process on a daily basis for one school-year. The theory of change Dream-A-World Cultural Resilience (DAW-CR) pilot project was initiated in August 2014 for 35 schools and has now been implemented in in 87 schools in Eastern Jamaica; cohort 1 (C1) between 2014 and 2015; cohort 2 (C2) between 2015 and 2016; cohort 3 (C3) between 2017 and 2018. Of the total 87 schools (C1, C2, C3) experiencing the DAW-CR program, there were 13 (14.9%) schools scored as having poor implementation; 40 (45.9%) schools were scored as having good implementation; and 34 (39.1%) schools scored as having excellent implementation.
The third DAW-CR cohort (C3) selected 20 schools to provide the randomized control data for the DAW CR proof of concept. In so doing the selection process of 608 students for the current implementation was randomized. The 20 lowest performing Primary Schools in three (3) parishes of eastern Jamaica (Kingston, St Andrew and St Thomas) were selected by the MOE, from which 608 Grade 3 students were selected, with 304 of these being assigned to specially designed Grade 4 classrooms with the DAW CR trained teachers and guidance counselors for one academic year starting in September 2018. The remaining 304 were assigned to the regular school grade 4 classrooms and served as the control group. The Achenbach System of Empirically Based Assessment (ASEBA) was used to measure behavioral and academic functioning of the children.
The ASEBA measurements identified that of the children 65 (21.4%) in the study group and 70 (23.0%) of the control group had clinical problems with Behaving Appropriately, while 112 (36.8%) of the study group and 123 (40.5%) of the control had clinical problems in Learning. The DAW-CR program conducted on the study group resulted in a 32.7% reduction in the number of children having clinical problems in Behaving Appropriately and a reduction of 43.6% for the children in the study group having clinical problems with Learning. This was statistically significantly different the control group that did not have the intervention as they say a 5.4% increase in the number of children having clinical problems for Behaving Appropriately (p < 0.05) and a reduction of only 11% in the number of children having clinical problems with Learning (p < 0.05).
The DAW-CR program is a robust and vibrant primary prevention program for the reduction of behavioral dysfunction and academic underperformance in Grade 4 Primary School children. The importance of this program is that it can be successful replicated and implemented by primary school teachers once the core techniques of the program are implemented. The cost per child for the DAW CT module was US$2500 compared with US$130 per child for the DAW CR module. The Dream-A-World CT and CR programs are inexpensive, cost-effective and facilitate the use of the standard Ministry of Education teaching plans/programs. This program is planned to be implemented in all primary schools island wide in a sustained transition to scale program by the Ministry of Education in conjunction with CARIMENSA.
…There is congruence between all aspects of the Delphi model and the Jamaican experience with the exception of the identification in the Jamaican model of the development of psychological strategies to negate the all-pervasive influence of 500 years of European colonization. As descendants of Africans enslaved in the New World our successful ‘out-of-the-box’ challenges of GMH orthodoxy indicate that we need to go much further in psychological decolonization constructs than the mere assimilation of Western paradigms but that our seminal contribution to the GMH…
The development of a culturally appropriate preventative mental health paradigm in Jamaica pioneered the Dream-A-World Cultural Therapy for behaviorally disturbed and academically impaired 8-year-old primary school children. This is an example of the application of PCT to resiliency building (Guzder et al. 2013; Hickling 2017). It is suggested that the principles of PCT are also applicable to Western psychiatry. Current outcome research on primary prevention mental health programs in Jamaica is encouraging and data continues to accumulate regarding the efficacy of preventive intervention and the Jamaican challenge to the biopsychosocial spiritual Global Mental health model.
- Abel WD, Richards-Henry M, Wright EG, Eldemire-Shearer D. Integrating mental health into primary care: an integrative collaborative primary care model – the Jamaican experience. West Indian Med J. 2011;60(4):476–82.Google Scholar
- Anders G. Pathologie de la liberté, essai sur la non-identification. Rech Philos. 1936/37;7:22–54.Google Scholar
- Auditor General’s Department performance Audit Report Ministry of Health (MOH) Management of Mental Health Services Rehabilitation and Reintegration of the Mentally Ill. 2016. https://auditorgeneral.gov.jm/wp-content/uploads/2016/09/anagement_of_Mental_Health_Services_May_2016.pdf
- Barton R. Institutional neurosis. University of Michigan: Wright. (1976) Butterworth Heinemann; 1966.Google Scholar
- Basaglia F. The destruction of the mental hospital as a place of institutionalisation: thoughts caused by personal experience with the open door system and part time service. London: First International Congress of Social Psychiatry; 1964.Google Scholar
- Beaton K, Cerovic S, Galdamez M, et al. Migration and Remittances in Latin America and the Caribbean: Engines of Growth and Macroeconomic Stabilizers? Working Paper WP/17/144. International Monetary Fund; 2017.Google Scholar
- Beaubrun MH. Mosaic of cultures. Geneva: World Health Organization; 1977.Google Scholar
- Beaubrun MH, Bannister P, Lewis LF, Mahy GE, Royes KC, Smith P, Wisinger Z. The history of psychiatry in the West Indies. In: Howells G, editor. History of world psychiatry. New York: Brunnel/Mazel; 1976.Google Scholar
- Bemme D, D’souza N. Global mental health and its discontents. Somatosphere. 23 July, 2012. http://somatosphere.net/2012/07/global-mental-health-and-its-discontents.html
- Campbell D, De La Haye W, Eldemire-Shearer D. A status report on homelessness in Jamaica. An All Parish Survey Board of Supervision, (For the Relief of the Poor in Jamaica) Jamaican Ministry of Local Government and Community Development. 2012.Google Scholar
- Canales C. Prisons: the new mental health systems. Conn Law Rev. 2012;44(5):1723–62.Google Scholar
- Carew J. The rape of paradise: Columbus and the origins of racism in the Americas. New York: Seaburn Press; 2006.Google Scholar
- Caudill W, Redlich FC, Gilmore HR, Brody ER. Social structure and interaction processes on a psychiatric ward. American Journal of Orthopsychiatry. 1952;22: 314–334. https://doi.org/10.1111/j.1939-0025.1952.tb01959.xPubMedCrossRefGoogle Scholar
- Cheung-Judge LMY. Chapter 16: The social-psychological analysis of manumission. In: Arthur L, editor. Slavery and other forms of unfree labour. London: Routledge; 1988. p. 239–150.Google Scholar
- Collins PY. Waving the banner of mental health revolution: psychiatric reform and community mental health in the Province of Rio Negro, Argentina. In: Caldas JM, Cohen A, editors. Innovative community mental health services in Latin America and the Caribbean. Washington, DC: PAHO; 2008. p. 1–32.Google Scholar
- de Las Casas B. A short account of the destruction of the Indies written 1542 published 1552, Nigel Griffin. London: Penguin; 1999.Google Scholar
- Dirección Nacional de Salud. Camas disponibles destinadas a la atención en Salud Mental y egresos hospitalarias del sector público en Argentina. (Sistema de Vigilancia Epidemiológica en Salud Mental y Adicciones 2.) Available Beds for Mental Health Care and Hospital Expenses of the Public Sector in Argentina. (Epidemiological Surveillance System on Mental Health and Addiction 2.) Dirección Nacional de Salud; 2010.Google Scholar
- Fanon F. L’Hospitalisation de jour en psychiatrie: valeur et limites’. Tun Méd. 1959;10:689–732 (pp. 717, 723)Google Scholar
- Fanon F. The wretched of the earth. London: Penguin Books; 1967.Google Scholar
- Freire P. Pedagogy of the oppressed. Harmondsworth: Penguin Books; 1972.Google Scholar
- Geopgiopoulos AM, Rosenbaum JF, editors. Perspectives in cross-cultural psychiatry. Philadelphia: Lippincott, Williams & Wilkins; 2005.Google Scholar
- Ghaemi SN. Biomedical reductionist, humanist, and biopsychosocial models in medicine. In: Schramme T, Edwards S, editors. Handbook of the philosophy of medicine. Dordrecht: Springer; 2015.Google Scholar
- Gilder Lehrman Institute. Columbus reports on his first voyage, 1493: a spotlight on a primary source by Christopher Columbus. https://www.gilderlehrman.org/content/columbus-reports-his-first-voyage-1493
- Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books; 1961.Google Scholar
- Goulbourne K. Evaluation of the Nonresidential Drug Court Program in Montego Bay, Jamaica. National Institute on Drug Abuse; 2011. https://archives.drugabuse.gov/DirReports/DirRep506/Default.html [11/17/16, 10:48:17 PM].
- Good B. Foreword. In: Georgiopoulos AM, Rosenbaum JF, editors. Perspectives in cross-cultural psychiatry. Philadelphia: Lippincott, Williams & Wilkins; 2005.Google Scholar
- Graham S, Hickling-Hudson A, Hickling FW. Chapter 11: A cultural risk-reduction programme for nine-year-olds in Allman Town Jamaica. In: Hickling FW, editor. Dream A World: CARIMENSA and the development of cultural therapy in Jamaica. Mona: CARIMENSA Press, University of the West Indies; 2006.Google Scholar
- Guzder J, Paisley V, Robertson-Hickling H, Hickling FW. Promoting resilience and competencies in high risk school aged children in Jamaica: a pilot study of a multimodal intervention. J Can Acad Child Adolesc Psychiatry. 2013;22:2.Google Scholar
- Harcourt BE. An institutionalization effect: the impact of mental hospitalization and imprisonment on homicide in the United States, 1934–2001 (March 1, 2007). J Leg Stud. 2011; 40. University of Chicago Law & Economics, Olin Working Paper No. 335; University of Chicago, Public Law Working Paper No. 155. Available at SSRN: http://ssrn.com/abstract=970341 or https://doi.org/10.2139/ssrn.970341
- Harriott A, Katz CM, editors. Gangs in the Caribbean responses of state and society. Kingston: University of the West Indies Press; 2015.Google Scholar
- Harvey D. Spaces of hope. Berkeley: University of California Press; 2000.Google Scholar
- Hickling FW. The establishment of a rehabilitation service at Bellevue Mental Hospital, Jamaica, and an analysis of the first six months of that service. Dissertation for the Degree of Doctor of Medicine, (Psychiatry). University of the West Indies, Mona; 1975.Google Scholar
- Hickling FW. Community psychiatry and deinstitutionalization in Jamaica. Hosp Community Psychiatry. 1995;45:1122–6.Google Scholar
- Hickling FW. Popular theatre as psychotherapy: interventions. Int J Post-Colonial Stud. 2004;6(1):45–56.Google Scholar
- Hickling FW. The African renaissance and the struggle for mental health in the African diaspora. In: Georgiopoulos AM, Rosenbum JF, editors. Perspectives in cross-cultural psychiatry. Philadelphia: Lippincott, Williams & Wilkins; 2005.Google Scholar
- Hickling FW, editor. Dream A World: CARIMENSA and the development of cultural therapy in Jamaica. Mona: CARIMENSA Press, University of the West Indies; 2006.Google Scholar
- Hickling FW. Psychohistoriography. A postcolonial psychoanalytic and psychotherapeutic model. Mona: CARIMENSA Press, University of the West Indies; 2007. Reprinted (2012) Jessica Kingsley Pub London.Google Scholar
- Hickling FW. The treatment of personality disorder in Jamaica with psychohistoriographic brief psychotherapy. West Indian Med J. 2013;62(5):431–6.Google Scholar
- Hickling FW. Overstanding a Caribbean psychiatric residency experience. Lifersline Newsl Am Psychiatr Assoc. 2011;ix(2):10–5.Google Scholar
- Hickling FW. Owning our madness. Facing reality in postcolonial Jamaica. Mona: University of the West Indies, CARIMENSA Press; 2016.Google Scholar
- Hickling FW. Taking the Psychiatrist to School. In The Palgrave Handbook on Global Mental Health: Socio-cultural Perspectives; Eds Ross White, David MR Orr, Sumeet Jain, Ursula M Reid. London Palgrave McMillian; 2017.Google Scholar
- Hickling FW, Walcott G. Prevalence and correlates of personality disorder in the Jamaican population. West Indian Med J. 2013b;62(5):437–43.Google Scholar
- Hickling FW. Sorel E. Introduction. In “Images of Psychiatry: The Caribbean”. Ed Hickling FW, Sorel E. Kingston, Jamaica: Department of Community Health and Psychiatry, University of the Wes Indies, Mona; 2005.Google Scholar
- Hickling FW, Abel W, Garner P. Open medical wards versus specialist psychiatric units for acute psychoses. Cochrane Libr (Oxford). 2002;(1):35Google Scholar
- Hickling FW, Abel W, Garner P, Rathbone J. Open general medical wards versus specialist psychiatric units for acute psychoses. Cochrane Database Syst Rev. 2007;(4):CD003290. https://doi.org/10.1002/14651858.CD003290.pub2. Published online 2007 Oct.
- Hill K. Tackling antisocial behavior in youth. The Gleaner Monday 7 Mar 2014. http://mobile.jamaica-gleaner.com/gleaner/20140317/lead/lead71.php
- Institute for Work & Health, Toronto. At work. Primary secondary and tertiary prevention Issue 80, Spring 2015. https://www.iwh.on.ca/what-researchers-mean-by/primary-secondary-and-tertiary-prevention
- Jemmott J. Institutional care of the mentally ill in nineteenth century Jamaica. Int J Educ Res. 2013;1(6):1–12.Google Scholar
- Jones M. Social psychiatry in practice. The idea of the therapeutic community. London: Pelican Books; 1968.Google Scholar
- Jordan JV, Hartling LM. New developments in relational-cultural theory. In: Ballou M, Brown LS, editors. Rethinking mental health and disorders: feminist perspectives. New York: Guilford Publications; 2002. p. 48–70.Google Scholar
- Kabinov MM. Problems of rehabilitation in psychiatry and neuropathology. New York National Academy of Neurological Science/Voprosi reabilitacii v psihiatrii i nevropatologii. 49th volume of works of the Leningrad scientific research psychoneurologic institute, V. M. Behterev; 1973.Google Scholar
- Kerr M. Personality and conflict in Jamaica. First published 1952. London: Collins/Sangsters Book Store; 1963Google Scholar
- Lane RD. Is it possible to bridge the biopsychosocial and biomedical models? Biopsychosoc Med. 2014;8:3. Leningrad, 1969.Google Scholar
- McKenzie K. Jamaica: community mental health services. In: de Almeida JMC, Cohen A, editors. Innovative mental health programs in Latin America and the Caribbean. Washington, DC: Pan American Health Organization; 2008.Google Scholar
- Moreno JL. Psychodrama, vol. 1: New York: Beacon House; 1946.Google Scholar
- Nettleford R. Foreword. In: Hickling FW, editor. Psychohistoriography. A post-colonial psychoanalytic and psychotherapeutic model. Mona: University of the West Indies, CARIMENSA Press; 2007.Google Scholar
- Painter NI. Soul murder and slavery. The fifteenth Charles Edmondson historical lectures. Waco: Baylor University; 1993.Google Scholar
- Pisani M. Working papers on migration: migration in the Caribbean: current trends, opportunities and challenges. San Jose, Costa Rico: International Organization for Migration; 2007.Google Scholar
- Prendergast S. Over 200 mentally ill persons serving prison time in Jamaica. 2011. http://rjrnewsonline.com/local/200-mentally-ill-persons-serving-prison-time
- Razzouk D, Sharanc P, Gallo C, Gurejee O, Lamberte EE, Mari JJ, Mazzotti D, Patel V, Swartz L, Olifsonl S, Levav I, Franciscol A, Saxena S. WHO – Global Forum for Health Research Mental Health Research Mapping Project Group. Scarcity and inequity of mental health research resources in low-and middle income countries: a global survey. Health Policy. 2009: 94:211–20.Google Scholar
- Robotham D. Crime and crisis in Jamaica. FOCAL Point Publications Archive. 2012. https://www.focal.ca/en/publications/focalpoint/307-september-2010-don-robotham
- Scull AT. Museums of madness. London: Allen Lane; 1979.Google Scholar
- Scull AT. The most solitary of afflictions: madness and society in Britain, 1700–1900. New Haven/London: Yale University Press; 1993.Google Scholar
- Shea P, Stern D. Primary prevention in behavioral health: investing in our nation’s future. Alexandria: National Association of State Mental Health Program Directors (NASMHPD); 2011.Google Scholar
- Shengold L. Soul murder revisited. Thoughts about therapy, hate, love and memory. New Haven/London: The University Press; 1999.Google Scholar
- Smith L. Caribbean Bedlam: the development of the lunatic asylum system in Britain’s West Indian colonies, 1838–1914. J Carib Hist. 2010;44(1):1–47.Google Scholar
- Stone C. The anatomy of aggression. The Daily Gleaner. 12 Oct 1992a.Google Scholar
- Stone C. Values, norms and personality development in Jamaica. Paper presented at the National Consultation on Values and Attitudes, The University of the West Indies, Kingston [Internet]. 1992b [cited 2011 Aug 31]. http://gtuwi.tripod.com/stonearticle.htm
- Thomas H. The slave trade. The story of the Atlantic slave trade 1440–1870. New York: Touchstone, Simon & Schuster; 1997.Google Scholar
- Torrey EF. Out of the shadows: confronting America’s mental illness crisis. New York: Wiley; 1997.Google Scholar
- Tremblay. When children’s social development fails. In: Keating DP, Hertzman C, editors. Developmental health and the wealth of nations. New York: The Guilford Press; 1999.Google Scholar
- Walcott G. Countering the prevailing ethos by practice: the implementation of a community engagement model in inner city communities in Kingston, Jamaica. Global Mental Health: Bridging the Perspectives of Cultural Psychiatry and Public Health. 2012. McGill.CA/DIVISION OF SOCIAL AND TRANSCULTURAL PSYCHIATRY/Videos/ASI Videos
- Walvin J. Black Ivory. Slavery in the British Empire. London: Harper Collins; 1992.Google Scholar
- Williams E. From Columbus to Castro. London: Andre Deutsh; 1970; First Vintage Books (1984)Google Scholar
- Williams, L. Anywhere yuh be, yu not safe: adolescence and violence in Jamaica. 2001. http://www.unicef.org/evaldatabase/files/JAM_2001_803.pdf
- Wing JK, Brown GW. Institutionalism and schizophrenia: A comparative study of three mental hospitals: 1960–1968. London, Cambridge: University Press; 1970.Google Scholar
- Wolberg. The technique of psychotherapy (part 1). New York/London: Grune & Stratton; 1967.Google Scholar
- World Health Organization. Promoting mental health: concepts, emerging evidence, practice (Summary report). Geneva: World Health Organization; 2004.Google Scholar
- World Health Organization. Mental health: strengthening mental health promotion. 2007. http://www.who.int/mediacentre/factsheets/fs220/en/