Religious issues, ethnic minority schizophrenia

By about ten years ago, there was some consensus that there was an overall positive association between the two. Underlying this, there are many effects to consider, many aspects of religion, and many aspects of mental health. The last decade has seen a mushroom-like growth of studies and reviews (see Loewenthal, 1995; Bhugra, 1996; Worthington, Kurusu, McCullough & Sandage, 1996). There is scope for methodological improvements, and many interesting questions to be answered. This review is concerned with one set of such questions: religion and mental health among Afro-Caribbeans particularly those living in the UK and the USA, with particular reference to schizophrenia.

Definition of "Afro-Caribbean" and scope of research in this review.

The Hutchinson Encyclopaedia defines an Afro-Caribbean as a "West Indian person of African descent", and adds that Afro-Caribbeans are descended from West Africans captured, or bought from African traders by Europeans, who shipped them to European colonies in the West Indies from the C16th onwards, until the abolition of slavery which occurred in different countries and colonies at different points in the C19th. Since World War II many Afro-Caribbeans have migrated to the UK, the USA and the Netherlands. 

There seems to be little or no research material on mental illness on Afro-Caribbeans in the Netherlands, but there is a great deal on Afro- (or African-) Americans, and on Afro-Caribbeans in the UK, who are mostly descendants of West African slaves shipped to North American colonies, or immigrants from the West Indies. 

While it is agreed that Afro-Caribbeans in Britain and Afro-Americans in the USA have many similarities in their history and current circumstances, we have not used the terms inter-changeably. We have drawn on research material from both Afro-Caribbeans in Britain and Afro-Americans, as well as on people of African descent in the Caribbean area, in Africa, and occasionally elsewhere.

Schizophrenia among Afro-Caribbeans.

This review focuses on one specific set of questions: how might religion affect the reported over-representation of Afro-Caribbean groups among those diagnosed with schizophrenia in the United Kingdom? Possibly related problems are the greater use of compulsory detention under the 1959 Mental Health Act, including police involvement in hospitalization, and the use of restraint and pharmacological agents in control of Afro-Caribbean patients. Such over-representation also exists of Afro-Americans in the USA, and is by comparison both with other ethnic groups in the UK and the USA, and also with Afro-Caribbeans in African and Caribbean countries, where there has perhaps been a less marked degree of recent disadvantage and minority status (Davis, 1975; Ineichen, 1986, 1991; Cope, 1989; Thomas, Stone, Osborn & Thomas, 1993). Sugarman & Craufurd (1994) have concluded that the very high morbidity risk for schizophrenia among British Afro-Caribbeans is entirely due to environmental (not genetic) factors. 

An interesting claim has been made by Littlewood & Lipsedge (1978, 1981a, 1981b), and others. Littlewood & Lipsedge based their claim on a series of studies of patients admitted with diagnoses of psychosis to a psychiatric hospital in East London. They suggest that the high rates of psychosis among Afro-Caribbeans are explained by rates of schizophrenia similar to those in other ethnic groups, plus rates based on a large number of acute psychotic reactions with paranoid and religious flavour. These latter disorders are diagnosed as schizophrenia, but resemble acute psychotic disorders described in Africa and the Caribbean, and have a sudden onset with a clear provoking agent. Littlewood & Lipsedge's patients were first-generation immigrants. Littlewood & Lipsedge's suggestions deserve further attention, particularly with regard to forms of psychosis in second-generation Afro-Caribbean immigrants, among whom rates of psychosis are reported to be even higher than in the immigrating generation. There has been no comparable work in the USA. 

This review takes up the more general but related issue of the ways in which psychosis in Afro-Caribbeans may be affected by religious factors.

Social history

Afro-Caribbean social history in Britain and USA is dominated by the hideous history of slavery. European slave-traders were buying slaves from the West Coast of Africa in increasing numbers during the seventeenth and eighteenth century, particularly to provide labour for plantation development in the New World (the Caribbean and the Americas), recently colonised by European settlers. The native Indian populations were severely reduced, by desettlement, genocide and European-imported illnesses, and African slaves were a readily-available source of cheap labour for the sugar plantations. Increasing numbers of people from West Africa were kidnapped and sold into slavery, and transported across the Atlantic in horrible conditions of cruelty, filth and disease. Altogether an estimated 10 million Africans were brought to the New World in this way, mostly to the Caribbean area (Curtin, 1969). In the plantations, any family and social networks which had survived kidnapping and transportation were broken up, and the practice of native religion disallowed (Goveia, 1965). This was coupled with cruel retribution for anything other than passive obedience, engendering disorientation, helplessness, and dependence. The abolition of slavery in Europe, the Americas and the Caribbean led to some improvement in social and economic conditions, but these improvements were generally small and the social and psychological legacies of deracination and cruelty remained (Wagley, 1961; Franklin & Moss, 1988). Economic need resulted in steady migration to the Northern United States, and a flood of immigration from the Caribbean to Britain in the 1950s and 1960s. Afro-Caribbeans continue to be beset by racism, exploitation in employment, lack of opportunity, and other forms of social and economic disadvantage in both the UK (Rack, 1988) and the USA, although there have been legislative attempts to remove some of these disadvantages (Franklin & Moss, 1988; Jackson, 1991). 

Religion in Afro-Caribbean life.

Afro-Caribbean religion is said to embody responses to oppression and exploitation, enabling the expression of spirituality (Baer, 1984; Griffith & Bility, 1996), the formation of communitas (Turner, 1969) and hence social support  and identity. The two dominant strands have been native African religions, and European Christianity. The former was suppressed, and the latter imposed upon the plantation slaves and, later, encouraged by missionaries to the freed slaves (Gates, 1980; Brewer, 1988; Chatfield, 1989). The current situation involves a huge range of often syncretistic blends, although the African elements are less overt in British and US black-led Christianity than they are in the Caribbean and its neighbourhood, and in Africa. 

New black religious movements include Black Islam (Franklin & Moss, 1988; McCloud, 1995) in the USA, and Rastafarianism (Hickling & Griffith, 1994) in the Caribbean and the UK. However in the UK and the USA the dominant form of black religion is Christianity with African influences (Jules-Rosette, 1980). Howard (1987) concluded that post World War II Caribbean Christian immigrants to the UK expected a warm welcome from the existing churches, but found them cold and unfriendly, and so set up their own groups. Most Christian Afro-Caribbeans in the UK are now reported to be affiliated to black-led churches, with predominantly black membership. The most popular forms are charismatic and pentecostal Christianity, and Seventh Day Adventists. Howard does not offer figures, but of Cochrane & Howell's (1993) random community sample of black men in the UK Midlands, 27% belonged to generally white-led churches (Church of England, Roman Catholic), 52% were Pentecostal (almost or completely black-led), and 4% were Rastafarian (with 18% non-affiliated).  Leadership in black-led churches is generally strong and respected, since religious leaders have emerged by force of personality, charisma, popularity and dedication to the needs of their communities. There is emphasis on enthusiastic prayer, which may include the gift of speaking in tongues, dance, and trance-like possession states, and on living a moral, family-centred life, with good physical health practices, and kindness and helpfulness to others (Howard, 1987). Griffith (1980) provides a valuable description of a week-night service in a pentecostal group in the USA. The service includes extensive and enthusiastic thanks and praise to the Lord for healing and support, as well as the features described above (speaking in tongues etc.). Healing may be an important religious activity, and services in black-led churches are reported by their participants to be emotionally and spiritually positive experiences (Griffith & Mathewson, 1981; Griffith, Young & Smith, 1984; Maloney & Lovekin, 1985). 

Afro-Caribbean "counter-culture" is said to emphasise partying, promiscuity, drink and drugs (Howard, 1987), but Cochrane & Howell's figures suggest that members of this counter-culture may be a minority among Afro-Caribbeans.

Religiously, the situations in the USA and the UK are somewhat similar, although that the black-led churches in the USA have a longer history than those in Britain, dating from the latter half of the C19th (Franklin & Moss, 1988). Those in Britain date mainly from the post World War II period.

In contemporary religious life in Africa, the Caribbean, and in black communities in Central and South America, the influence of traditional African religions is more overt, and the social-scientific and medical literature shows many examples of traditional African practices relating to health and mental health, some of which will be described in this review.

Definitions of religion

There is a variety of definitions and measures of religion (Brown, 1987). Loewenthal (1995) suggests that religion involves belief in spirituality, a divinely-based moral code, and seeing the purpose of life as increasing harmony in the world by doing good and avoiding evil. All religions involve and depend on social organisation for communication of these ideas. Glock & Stark (1965) suggested five possibly orthogonal aspects of religiosity: experiential, ritual, belief, intellectual, and a fifth dimension reflecting the extent to which the first four are actually applied in daily life. In practice, four popular measures of religiosity are: affiliation, self-definition (as religious), practice (attendance, prayer and other activities), and belief.

Definition of schizophrenia 

(Source: DSM-IIIR,  American Psychiatric Association, 1987):

* no major mood changes (i.e. not depressed or elated), and

* no evidence of organic causes (eg drugs, illness, injury), and

* continuous signs of disturbance of 6+ months, and

* deterioration in self-care, work or social relations, and

* for at least a week, two of: delusions, prominent hallucinations, incoherence or bizarre speech, catatonic behaviour (immobile, unresponsive), inappropriate or no emotional responsiveness, or, one of: bizarre delusions (eg. thoughts are being broadcast on TV), prominent hallucinations of a voice.  

Search strategy

The search strategy was based on some of the guidelines indicated by the UK Cochrane Centre National Health Service Research & Development Programme (Chalmers & Haynes, 1994; Eysenck, 1994; Knipschild, 1994; Mulrow, 1994; and particularly Oxman, 1994), and  by the York University National Health Service Centre for Reviews and Dissemination (1996). These guidelines suggest selecting clinical trials teaching certain standards of research design. The number of such studies in the field under review was negligible, and meta-analytic work was therefore impossible. However the guidelines were followed insofar as search terms and search strategies were defined. These were as follows:

The central problem has been defined as religious issues in schizophrenia among Afro-Caribbeans.

Three groups of search terms were used (where acceptable, the suffix * or ? followed a truncated form of words such as religious, religiosity, religion: i.e. relig* or relig? Otherwise the alternatives were spelled out):

Group 1 (religion)

Relig*

Faith

Belief* 

Pentecostal* 

Adventist

Group 2 (ethnicity)

Afr* 

Carib*

Black

West (W) Indian

Jamaica

Trinidad

Ethnic*

Group 3 (mental health, schizophrenia, and religious behaviour which might be seen as symptomatic of disturbance)

Mental*

Schizophren* 

Possession

Hallucination

Glossolalia

Trance

For electronic databases of articles, books and thesis abstracts, three groups were first formed by searching for any of the search terms in the group. The final search was for material which included at least one search term from each group.

For databases of book titles and theses (which yielded very little using the above strategy), searches were also made by combining search terms from two groups at a time: e.g. relig* afr*, relig* carib*, relig* black etc.

Sources searched

Electronic databases of published articles: Sociofile, Medline, ERIC, Embase, Pascal, PsychLit, BIDS (Social Sciences, Sciences, and Arts & Humanities). In each case the search was made from the earliest year represented in the database up to the most recent; PsychLit contains articles back to 1972, but the other databases start in or around 1982.

Electronic databases of published books: PsychLit, CUPAC, Libertas, BIDS(check). As with databases of articles, the search was made from the earliest year represented in the database.

Electronic sources of unpublished material: theses (Dissertation Abstracts International (1982-1996), AsLib (British M.Phil. and Ph.D. theses) (1970-1992), and WWW.

Other sources: information about ongoing work was obtained by personal contact including conference attendance, by correspondence, and via WWW. 

The main product of these searches was in the form of titles, author and abstract (or book chapters). This first crop was sifted for relevance, and some items immediately discarded. Others were sorted into two categories:

a: of some relevance but no further information needed; some items were subsequently discarded as work proceeded.

b: relevant and original book or article needed. In this latter case the item was either obtained immediately (where available), or via the inter-library loan service. Visual searches were made of the bibliographies of the most fundamental of these books and articles: Griffith (1980); Littlewood & Lipsedge (1981a, 1981b, 1989); Worthington et al (1996); Bhugra (1996).

Conceptual approach

The structure of the review that follows two approaches. Firstly we look at pathways into illness (influences on prevalence), using a broad conceptual framework based on  Brown & Harris (1978, 1989), and which is generally popular in social psychiatric and related work. The framework involves three wide classes of variables:

 STRESS (ADVERSITY) - MEDIATORS (BUFFERS) - DISTRESS (& ILLNESS)

We propose to examine the influences of religion within each of these classes. The second approach is to examine pathways into care. We examine how religion may affect: 

 REFERRAL - DIAGNOSIS - TREATMENT.

The review focuses on schizophrenia in Afro-Caribbean groups, but some related material has been included, on religion and mental health generally, and particularly in Afro-Caribbeans, and on Afro-Caribbean religion, both in relation to healing, and in relation to behaviours which may be religiously sanctioned and adaptive, but which might give rise to mis-diagnosis by psychiatrists and others ignorant of cultural and religious mores.

1. Religious influences on prevalence.

Adversity

Here we consider ways in which religion may affect levels and types of adversity (stress), and ways in which religious factors may moderate the effects of adversity. We consider first the beneficial affects of religious factors, and then the possibility of stress-exacerbating effects of religious factors.

First, then, the question whether religious factors may help to minimise adversity. We are not concerned here with general cultural factors - the economic and social difficulties which may be associated with being Afro-Caribbean.

Loewenthal, Goldblatt, Gorton, Lubitsch, Bicknell, Fellowes & Sowden (1996) suggested that patterns of stress - and therefore possibly distress and illness - differed between traditional religious groups and others, among Europeans. Their main conclusion was that severe, disruptive life-events were less likely among traditional religious groups. This in turn had an impact on the prevalence of depression. We could not find comparable data for Afro-Caribbeans in Britain, but a study of black Americans (Gary, 1984) led to roughly comparable conclusions. This study involved 451 non-institutionalized black adults in Virginia, and one conclusion was that less religious respondents experienced more stressful life circumstances. Further work is needed to confirm the suggestion that religious groups and beliefs may serve to regulate social relations, lessening the likelihood of some forms of stress. 

Finally, an intriguing case study suggests further positive features of religious beliefs on stress. Heligman, Lee & Kramer (1983) reported on an elderly black lady who was able to tolerate major abdominal surgery without analgesia. There was minimal post-operative discomfort. She attributed this to the presence of protective angels. Psychological testing and interviews showed her to be "fully in touch with reality". 

The sparse material described so far has thrown up several recurrent and important themes in understanding the roles played by religion in Afro-Caribbean mental health. First, the probable importance of religion to many Afro-Caribbeans. Second, the importance of religiously-encouraged social support networks. And finally, the occurrence of religiously-based beliefs and ideas which might be taken as evidence of psychological disturbance by professional care workers without sufficient knowledge of cultural-religious norms and values.

Moderating effects of religion 

Table 1 summarises several studies indicating that compared with other groups in Britain and the USA, religion is a more important value for Afro-Caribbeans.

Table 1

Table 1 is replete with suggestions and evidence that religion is indeed important to Afro-Caribbeans in the UK and to Afro-Americans, both in absolute terms and relative to other groups.

We now turn to evidence on the question whether and how religion has a stress-moderating effect among black people.

Table 2

Table 2 tells us nothing directly about schizophrenia, and little about stress-buffering effects of religion, but it does indicate a strong association between religion and various measures of health and mental health: low or absent religiosity is a risk factor for poor (mental) health in black people.

Table 3 summarises evidence on means by which religion may be associated with better mental health among black people.

Table 3

Table 3 focuses on three routes by which religion may lower the prevalence of mental illnesses among black people, possibly by mitigating the effects of stress. 

First, social support: both church and family support are important to well-being, and family support may be enhanced by church membership. But as with research in other groups, the relations between religion and social support could do with further clarification. Social support is important for recovery and prevention of relapse as well as prevention of initial onset.

Second, worship-related activities have been reported to induce feelings of well-being, comfort and other aspects of positive mood, which are likely to have a beneficial effect on mental health..

Third, religion is associated with social-cognitive factors such as identity, self-esteem and beliefs which can have a positive impact on mood.

In all cases however there is a lack of outcome studies. Additionally we know very little about the relations between the factors described, and schizophrenia, in black people.

We now look at possible adverse effects of religion upon mental health.

Table 4

The important suggestions in table 4 are that belief in a relation between sin or wrongdoing, and suffering, may actually cause symptoms of distress or illness. However, these believes may contain the seeds of cure, insofar as they indicate remedies which may sometimes be effective. A further important effect is that "Western" health professionals with inadequate knowledge of cultural-religious mores may view such beliefs as signs of mental disorder. 

We noted that there was no reported evidence that religion plays a role in creating or exacerbating adversity. However, religiously-associated physical/emotional abuse is a possibility that has been suggested - often controversially - among other groups (Capps, 1992) and could be examined in Afro-Caribbeans.

Overall, the weight of evidence and of suggestions is that religion is important to Afro-Caribbeans, is likely to have beneficial effects (overall) in lowering prevalence of mental illnesses, and that these effects operate via a number of routes. We note however that little of the research relates directly to schizophrenia. Research designs are generally observational or correlational or involve the reporting of clinical case material. Further research could focus on schizophrenia, and involve designs which look at outcome either retrospectively or if possible prospectively.

2a. Religious influences on referral

Having looked at religious influences on the prevalence of schizophrenia (pathways into illness) we now look at pathways into care and/or diagnosis. Sometimes there is genuine overlap in research material bearing on the two problems, in which case we have repeated our citations of the studies concerned.

Table 5

The material in table 5 is rather sparse, but as far as it goes supports the suggestion that religious factors may, for various reasons, discourage black people from seeking help for mental illness from (white) mental health professionals: Afro-Caribbeans may fear that their religious beliefs and values may be misunderstood, they may perceive the mental health professions as ineffective or misguided, they may perceive other (religious) helping agents and activities as more effective, and there may be fear of stigma.

If religious helping agents and activities are seen as effective, what are they? Table 6 summarises some information gained in the USA (table 8 offers comparable information from studies on other black groups).

Table 6

The studies in table 6 offer a relatively high degree of quantification, and suggest a range of religious resources seen by black people (at least, those who are church members) as efficacious for mental health problems.

2b. Religious influences on symptoms/diagnosis

An important theme which has intruded throughout this review is the regrettable tendency of (usually white) mental health professionals to regard a range of religious behaviours and beliefs by black people as symptomatic of mental illness. Sometimes indeed there may be a genuine mental illness and it is difficult for the professional to tell whether say, a religious ecstasy, is pathological or not (e.g. Littlewood & Lipsedge, 1989; Csordas, 1987). Table 7 however gives some cause for concern regarding the risk of over-diagnosis of mental illness, particularly of schizophrenia, in black people with religious "symptoms".

Table 7

Table 7 offers a range of descriptive material suggesting that trance/possession, beliefs in evil spirits and witchcraft, and other forms of religious behaviour and beliefs, are particularly likely among people whose background has been influenced by African religion. It is difficult for professionals to distinguish the genuinely pathological from the culturally alien.

An interesting footnote to table 7 is offered by two studies which suggest the presence and amount of religious symptomatology in schizophrenia is actually unrelated to level of individual religiosity (Littlewood & Lipsedge, 1981b; Arnold, 1993).

2c. Religious and related effects in treatment

Much of the literature of Afro-Caribbean schizophrenia suggests that it is characterized by briefer episodes, faster recovery, and less risk of relapse (Littlewood & Lipsedge, 1981a, 1981b; Stevens, 1987). Here we consider religious influences related to these effects. These religious influences have been discussed elsewhere in this review: religiously-encouraged social support (Jackson & Birchwood, 1996; and see Table 2), stronger religiosity, treatment preferences for clergy, religious practices including syncretic rituals, trance, possession, glossolalia and prayer for therapeutic purposes (see table 6). An important possibility is that religion influences the form and possibly the occurrence of a "culture-specific" brief psychosis in Afro-Caribbeans, which may not even be a true psychosis in some cases. Even where it is, the prognosis is said to be very good compared to "Western" schizophrenia.

The main thrust of the available evidence is that these religious influences contribute to the better prognosis of Afro-Caribbean schizophrenia. The chief possible adverse effects of religion lie in the risk of misdiagnosis of religious behaviour and beliefs as schizophrenia (see table 7).

We look finally at some more remote religious influences on Afro-Caribbean mental illness and its cures. 

Table 8

Table 8 shows a range of overtly African-influenced religious practices and beliefs related to mental illness. Although it has been stressed that this kind of information needs to be taken on board by mental health professionals working with black people, there have been no outcome studies in this area. 

The use of culture-sensitive, collaborative, multicultural approaches have been advocated in various ways. Views that black people need to weaned away from "unscientific" beliefs in religious factors now seem out-moded in the face of a two-pronged attack - in one direction from those favouring multicultural approaches in medicine and psychiatry, and in the other direction from an increasing body of scientific evidence that religious factors may play important preventive and therapeutic roles in mental illness. Several postures on multiculturalism have been outlined (MacLachlan, in press); most authors report that Western-trained professionals are pragmatically taking into account other ("non-Western") beliefs, and where indicated, are referring for treatment which is consistent with those beliefs (Burlew, 1992; Brent & Callwood, 1993; Jackson; 1986; Jones, 1990; Lefley, 1981; Lefley & Bestman, 1977; Richardson, 1991; Sandoval, 1979; Stevenson, 1990).

For example, Csordas (1987) describes several case vignettes from a Brazilian psychiatrist who is an initiated elder of the Afro-Brazilian candomble cult. The cases involved cross-referral from the psychiatrist to religious practitioners, and sometimes back again. Of particular interest in Csordas' account is the psychiatrist's observation that some of the religious practitioners are able to distinguish between a genuine religious trance (called orixa), a simulated one, and a hysterical crisis, a feat which the psychiatrist says is beyond the psychiatrist. In the latter case they will tell the client to see a doctor.

Some mental health practitioners have tried to incorporate aspects of traditional healing into their practice - kind of psychiatric syncretism.  However some authors (Oyarebu, 1982) incline to the view that it is wiser for Western and religious forms of healing to co-exist (and cross-refer where necessary).

A careful set of suggestions is made by Maclachlan (in press), who recommends that the clinician should draw up a "problem portrait". This is a description of all the things that are "wrong" with the patient (according to the patient), what s/he thinks caused them, and what s/he thinks other members of their social group/s think cause problems like this. This will enable the clinician to draw up treatment goals in collaboration with the patient, and to draw on healing resources that are seen as appropriate, often using several different kinds of healing resource and cross-referring where necessary.

Summary and conclusions

What then are the religious influences on schizophrenia among Afro-Caribbeans?

Religion is important to Afro-Caribbeans in the UK and to Afro-Americans, both in absolute terms and relative to other groups. Via a number of routes, religious factors may lower prevalence and improve prognosis. This is a bit speculative because most of the evidence relating religion to mental health among Afro-Caribbeans deals with forms of mental illness other than schizophrenia. Clearly there is space for research on the ways religious factors - social support, worship-related activities and social-cognitive factors - relate to prevalence, referral and recovery in schizophrenia. It is suggested that the direction of these effects is likely to be to lower prevalence and referral, and improve recovery. If so, these effects cannot explain any higher rates of schizophrenia referral among Afro-Caribbeans.

However there is also the suggestion that religious factors may influence symptoms, sometimes causing a risk of over-diagnosis of schizophrenia. 

However it is unlikely that the high risk of schizophrenia among Afro-Caribbeans can be explained solely in terms of the added likelihood of "culture-specific" psychosis influenced by cultural-religious factors. If this were so, it would be hard to explain the reported rise in risk of schizophrenia among second-generation immigrants to the UK. Moreover, "culture-specific" psychosis is reported in African countries and elsewhere, where rates of schizophrenia are said to be as low as in indigenous European and other groups. These phenomena might be better understood with better information on religiosity in relation to schizophrenia. 

The only way in way in religious factors are likely to contribute to raised rates of schizophrenia is however in over-diagnosis of schizophrenia among disturbed Afro-Caribbeans presenting with a "religious flavour" to their disturbance. But this is speculative and deserves closer study.

Religious methods of healing are to an increasing extent being taken into account by mental health professionals, including those working among Afro-Caribbean groups. It is likely that this trend will continue. It is to be hoped that outcome studies will appear in this field.

Acknowledgements

We would like thank Emma Lowers for her help in the early stages of the literature search, and the library staff of the Bedford Library (Royal Holloway, University of London) and of Senate House (University of London) for advice and assistance in the main phases of the literature search, particularly Adrian Machiraju and Anne Sergeant of the Bedford Library for their advice in formulating a search strategy and in implementing it.

We would also like to thank the Department of Health for financial assistance with the literature search.