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Home arrow Language & Literature arrow The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health

Child Mental Health System in Jamaica

Jamaica’s Ministry of Health controls the overall delivery of mental health services. Child and adolescent services are provided at child guidance clinics across the country. However, although they are staffed by a dedicated group of professionals working in difficult circumstances, these do not meet the population’s needs (McKenzie 2008). By early 2000, the Jamaican Government introduced guidance counselors—qualified teachers who have received additional training in psychology and social work—in the school systems to help to stem the tide of the many social problems being experienced by primary and secondary school students across the country (Palmer et al. 2012).

Dream-A-World Cultural Therapy Pilot Project

The use of culture as an instrument for education, consciousness raising and demystification, as well as entertainment is a tool that the peoples of the world have been using in the struggle for freedom, land and better working conditions for centuries. It has been rediscovered and titled ‘people’s (or popular) theater’ in recent years and combines the use of dialect, folk poetry, drama, dance, music and song to mobilize people to utilize their creative cultural energy in the struggle against racism and oppression and in the fight for rights, justice and better conditions. Ross Kidd (1980) described the process as

the people’s medium, drawing on their skills and creativity, expressing their concerns and analysis ... (and) reinforces the growth of identity and self confidence, and must mirror reality. (p. 10)

Paulo Freire (1972, 1995) emphasized the idea of education as cultural action and the liberation from oppression requiring collective struggle. He suggested that the transformation of any society requires the development of revolutionary consciousness and the mobilization of a culture of creativity. An art-based pedagogical Jamaican case study called the Area Youth Foundation[1] led by Sheila Graham, who had been trained in the Freire’s dialogic methodology, demonstrated this method in achieving outcomes for the group of thoughtful collaboration leading to conscientization in terms of deep reflection on their lives for decolonizing education and society (Hickling-Hudson 2014).

A multi-modal risk-reduction pilot study, rooted in PCT, was mounted by CARIMENSA for at-risk eight-year-olds from inner-city Kingston in a community mental health center located within walking distance of their school. In 2006, CARIMENSA employed Sheila Graham to help implement the ‘Dream-A-World Cultural Therapy’ program.

Using large group psychotherapeutic ethnography ... as the central and pivotal psychological activity ... with the children in a large group circle, and the daily discussions, designed to capture the children’s attention, helped them to concentrate collectively on one topic at a time, and to understand the importance of group socialization. The psychotherapeutic objective was to provide a psychological catalyst that would help to transform their behaviour by repositioning their thoughts and their emotions from the realities of their world and their consciousness, into a reconstructed, re-engineered psychological reality of their own creation. (Graham et al. 2007, p. 54)

The essential element of ‘Cultural Therapy’ (Hickling 2007) is the psychological analytic process ofpsychohistoriography, and a series of activities comprising centering—incorporating relaxation techniques such as deep breathing, calisthenics and performing arts’ warm-up routines, and circling (using the circle as the principle formation for teaching and communication) for psychotherapeutic group discussions to stimulate children to critically evaluate their world. A third component called culturing allows the children to freely catalyze their thoughts into artistic modalities of music, dance, art and drama. By weaving the products of their creative imagination into Show and Tell performances, the children are enabled to negate complex trauma by catalyzing creativity. The goals of the innovation were to promote resilience, to increase academic performance, to increase self-control and modify maladaptive behaviors, to increase self-esteem and wholesome identity formation and to increase the creativity and productivity of high-risk primary school children. Three teachers selected 30 cohort children with conduct and behavioral problems and 30 control children matched for age, gender and social class. The cohort and controls were all selected from the group of students who were performing in the bottom 25 percentile of the transitioning Grade 3 who would be advancing into Grade 4 in September of 2006. The risk factors of the selected cohort included poor performance in literacy and numeracy coupled with behavioral factors such as aggression, hyperactivity and lack of motivation. The cohort and the controls were selected exclusively by teachers using the cultural nosology of the ‘bad behaving pickney’ and not on the assessment of a psychologist or psychiatrist (Box 29.1).

Box 29.1 Examples of Children Enrolled in Allman Town DAW CT intervention

Jimmy: A nine-year-old boy of rural origin who had witnessed the murder at age seven years of both his parents had run away from home and was living 'rough' in the bushes in the country. He eventually got to his grandmother in Kingston who adopted him. He was virtually uncontrollable in class, exhibiting disruptive behavior, constantly fighting other children, and unable to read or write.

Mary: One of 13 siblings. A neighbor noticed that she was not going to school. With her mother's permission, the child was taken and enrolled in school. The child's birth was registered, and the school enrolled her in Grade 2. She could not read at that time, and two years later (in Grade 4 at nine years old) she was still barely reading.

Some conditions that these children faced were overcrowded classrooms, overcrowded or substandard housing, poor nutrition, unstable families, absent fathers, low self-esteem, low expectations and ever present threat and fear of violence. Parental consent was obtained for the program, and although the parents’ participation was not required, they were invited at regular intervals to observe the progress and performance of their children. The intervention consisted of a three-week 40-hour summer program. The children were encouraged to participate in a process that intended to ‘Dream-A-World’ (DAW). This involved children imagining and imaging things outside of their day-to-day experience. They were challenged to imagine that they had the power to create a whole new world on another planet, to name it, to conceive the flora and fauna, decide what they wanted to take from this world to the new one and what they wanted to leave behind, imagining their life on a new planet with a new social, ecological world of settings and animals they wished to live with. The most significant outcome of this exercise was getting the children to articulate their clear ideas of good and bad, right and wrong. They showed a clear appreciation of the things that were negative and positive in their lives, and it was clear that they wanted to leave behind the negatives.

They valued the beautiful things of nature to which they had little exposure in their inner-city environment. They appreciated the things that engendered love, kindness and enjoyment and rejected the things that engendered fear and led to violence and abuse. They wanted to take things that were beautiful, that were gentle and the things that were life supporting. They were very clear that they didn’t want things like using foul or abusive language even if they themselves used such language, but what they were saying was that ‘even if we do these things, we know that they are bad and we don’t want them’.

The theory of change behind this approach emerged from the realization of:

The after-shocks and consequences of enslavement, emancipation and colonial

domination (...). (Smith 2014, p. 2)

... on the mental health of contemporary Caribbean societies.Linking the high levels of transgressive behavior and personality disorder reported in Jamaica (Hickling and Walcot 2013) with the international finding that children who were not reading by age eight years were associated with aggressive and dysfunctional behavior in adolescence and adulthood (Huesmann et al. 1987), the therapeutic approach had to be shifted to strengthening the child’s internalizing behavior in an environment of fractured parental attachment and dysfunctional fragmented families and promoting resilience (Robertson- Hickling et al. 2009). This vision was based on the evidence that children in discordant and disadvantaged homes are more likely to demonstrate resilient characteristics if they attend schools that have good academic records and attentive, caring teachers (Rutter 1984).

The DAW CT strategy clarified the role of the cultural therapist who worked to create visionary ways in which psychological challenges can be identified, allowing the children to reflect on their life and their society. Over the course of the DAW CT intervention, the cultural therapists explored the psychological contradictions of children by embedding these in the popular culture to stimulate the imagination to provide limitless scope for invention and change. The children created songs, poems and dances about their world to construct a dramatic performance, later presented to parents, teachers and guests on the final day of each workshop (see Box 29.2). This engagement elicited narrative building and social skills engagement as they cooperated to share and interact with group work. Two-hour follow-up workshops were held fortnightly during the school terms for three years of the program which allowed a ‘refueling’ of the basic social skills, nurturing, holding and literacy components over this period.

Box 29.2 Example of Poem Created by a Child Enrolled in the Intervention

Timmy: Timmy, who was not reading at his age level, was described by the teacher as one of the 'sad boys': 'He was just plain lazy. If you even ask him what's his name you have to be like. ... "What did you say?" That's just him ... a very sweet child, with a nice personality. ... He created the poem "The Bad Crew"'.

One day I was walking with my friends and I saw a group of bad boys.

They were a crew.

The group was walking with a gun.

They shot a man and took away his money and credit card.

The police arrived, saw the boys and took them to the station.

When the bad crew was walking with the police one of the boys escaped.

He ran away when he was taking the picture.

The police called for back up and they saw the man run into the bushes, get away with all the man's money.

That was all about the bad crew.

When you follow bad company they lead you astray.

Several of the children selected for the intervention did not know how to relate to other children without fighting. Almost all the children had symptoms of very poor attention span and hyperactivity. Most of these children were unable to concentrate or focus on tasks over a sustained period of time, and their attention would drift very quickly.

The intervention DAW CT program was evaluated using the Achenbach System of Empirically Based Assessment Teacher Report Form (ASEBA TRF) (Achenbach and Rescorla 2001) and end of term grades for the intervention group compared to matched controls who were offered usual school supports (Guzder et al. 2013). Changes in academic performance were measured using the children’s grades for language, art, mathematics, science, and social studies, obtained at the end of each academic year. All 30 children from the ‘proof of concept’ pilot project failing the Grade 3 Primary School Test and exhibiting severe disruptive disorders had passed the Grade 6 Achievement Test 36 months later, and they entered accredited High Schools. The intervention cohort made significant improvements in school social and behavior adjustment measured by the ASEBA TRF. There were 17 (57%) boys and 13 (43%) girls with a mean age of 9.1 years (SD = 0.41) at the start of the program. Full details of the statistical analyses performed in the study are available in the paper by Guzder et al. (2013). At end of the intervention, the study group children had significantly lower scores for aggressive behaviors and oppositional defiant behavior. This was supported by significant within-group improvements in ratings of aggressive behaviors (p = 0.035), oppositional defiant and conduct problems (p = 0.027), and academic performance and learning (p = 0.026). There were no significant within-group changes for the control group. Within-group improvements in teacher ratings were found for the study group boys on their academic performance, learning, and behaving, rule-breaking behavior, aggressive behavior and oppositional defiant and conduct problems. By the end, the boys received significantly better teacher ratings of their academic performance and their behavior. There were no significant within- group changes for the boys in the control group. Within the study group, the F statistic found strong evidence of differences in the mean of language scores across the four assessment times, which was not the case for the control group. Post hoc regression estimates for study group showed regression coefficients relative to the final testing in 2009 to be significantly less in 2006 and 2008 suggesting improvements in scores over the four-year period, although it was not significant in 2007. Change in mean differences in mathematics (p < 0.001) and science scores (p < 0.001) was found for both groups across the four assessment times (Box 29.3).

Box 29.3 Case study of Child Enrolled in Intervention

Andrew: Living with his mother in a violence-prone inner-city community, he was initially very quiet and communicated little. 'Before DREAM-A-WORLD mi just shy but afta ... mi kinda ... it bruk mi outta dat... it was a place we come and interact with each other, learn new activities, get better at what we could do, like how we draw and ting ... mi always like art from basic school coming up'. After the DAW program he passed the GST Exam, went to a traditional high school, and after five years he passed seven out of eight Caribbean Examination Council school leaving subjects. He is presently in Sixth Form studying art, business and computer studies. He would like to become a professional artist or an accountant, as he is good at business studies.

The three-week summer DAW CT interventions produced artistic cre- ations—paintings, papier-mache masks and costumes—from each child and produced a ten-minute dramatic performance from each school reflecting original music, songs and performances of all the participants from that school, mirroring the thematic concept of the DAW CT activity which reflected the ‘new planet’ that they had imagined, with the aspects of life that they wished to keep and the aspects of life that they wished to discard.

This intervention was especially successful for the boys who achieved behavioral and academic gains (Guzder et al. 2013). The girls did not make comparable statistically significant improvements. Two factors in particular were suggested to having contributed to this. The first related to a stronger therapeutic bonding relationship between the boys and the two older male music therapists on the DAW CT program. Secondly, it was suggested that the powerful female cultural bonding systems in young Jamaican females reinforce conventional psychosocial patterns of behavior in young inner-city Jamaican women. Both hypotheses are untested and require future exploration.

  • [1] Area Youth Foundation (AYF) is a charitable, non-governmental organization which, since 1997, hasbeen working with young people in the inner cities to assist them in developing additional life skills andbusiness training. AYF often uses an arts-based approach and focuses on building bridges of friendshipbetween the divided, marginalized communities of Kingston’ (
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