We were encouraged by the many, varied, responses to our paper on the roast breadfruit psychosis (Reference Hickling and HutchinsonHickling & Hutchinson, 1999). We have no intention of defining or creating a new nosological entity. We are proposing the centrality of identity negotiation as a psychological process occurring when one is faced with the concrete reality of racism and social exclusion. This process of negotiation, if unsuccessful, is a mechanism through which psychopathology can result as defined within the rubric of psychiatry. Identity negotiation as a trigger for psychosis must not be confused with nosological definition. One of the by-products of empires has been the European propensity to believe that their nosological constructs are universal and can therefore be applied to the cultural behaviour of their former subjects. This becomes dangerous when nosological characterisation is synonymous with pathology and the need for treatment, again in ways that are determined and deemed appropriate by the colonial hegemony. The construction of semiotic equivalence of knowledge and cultural systems that are widely diverse is another demonstration of the moulding of otherness into terms and perceptions understandable to the European mind and is as such the sine qua non of the European colonial experience. The post-colonial challenge is to seek liberation from these mechanisms and so foster insight into the behaviour and thought processes of both the former colonisers and those people they colonised.

The idea that acceptance can be symbolised with the attainment of Whiteness is nothing new and the continued sale of skin bleaching creams in Africa and the Caribbean illustrates that negative perceptions of Blackness among Black people still persist. Every significant writer of the African Diaspora, in the USA and the Caribbean, has referred to the double consciousness or identity that is evident in the lives of the post-emancipation African in the new world (Reference GilroyGilroy, 1993). Learning to see oneself through the eyes of others; believing that to be civilised is equivalent to being European. All of these ideas originated in the colonial encounter and have had enduring psychological effects. In a social environment where economic and political disenfranchisement give tangible expression to one's powerlessness it was easily possible to result in behaviour that would be deemed sheer madness (Reference SartreSartre, 1974).

The role of culture in this process is crucial. The lens of Western anthropology has divided the world into Western subject and the rest of the world as objects of science and therefore able to be civilised, converted and, yes, colonised, in the name of progress (Reference FoucaultFoucault, 1973). When one's agency as a subject has been removed by the psychological oppression of slavery, colonialism and migration, it is necessary to reinvent and rediscover that subject. This explains why that process of cultural rediscovery in the Diaspora has given birth to extraordinarily novel, powerful and now globally salient cultural forms in religion, language and music. We acknowledge that culture does not and cannot exist in a vacuum, but it must have frames of reference and if these are not defined then culture cannot serve that signal purpose of establishing and defining a group identity. What follows from this group identity is belonging and acceptance. Psychological distress in the absence of this reflects not an increase in risk but a loss of protection. Grier & Cobbs (Reference Grier and Cobbs1968) described African Americans as needing to be paranoid to protect and insulate themselves from the constant hostility of living in a racist world, this is the reality of powerlessness. The pathologicising may take different forms, but it remains pathological. The material trappings of acceptance through educational or economic success may protect those who choose to gain social ascendancy by the wholesale absorption of European cultural values. Best (Reference Best1999) describes the crux of the Afro-Saxon philosophy as the drive to become better than the coloniser in his own idiom as the only way to succeed. It is no surprise that those who seek ascendancy and assimilation hold and defend science and rational thought as their only salvation. They will never embrace native ways of seeing and being.

Although race may be skin deep, it is the colour of the skin that occasions the first response when a Black man is stopped by the police or appears at emergency psychiatric services. Five hundred years of history is distilled in a few seconds. The colonial encounter writ large. With alarming regularity, institutions in Britain admit to their inherent racism, the police, the fire services, academia, now even organ donation in medicine (Reference BarkerBarker, 1999). Colour of skin was what got Stephen Lawrence killed, colour of skin is what makes Black people more likely to be arrested when stopped by the police, more likely to be convicted when charged and more likely to be given custodial sentences when convicted. From this perspective, race can never be an illusion.

Our writings have arisen out of our contact with patients of Caribbean origin in the Caribbean and in Britain who have been deemed to have a psychosis. We continue to see this phenomenon, the closer we explore issues of identity with our patients. The narratives of some of these patients will be the subjects of further discussions. To assure our readers that this is not merely self-indulgent speculation we refer them to the work of Bagley (Reference Bagley, Ai-ISSA and Tousignant1997). His research underlines the effects of slavery and colonialism on the high levels of negative self-perception of Black people in rural Jamaica and the converse of positive self-perceptions among young Black people in urban Ghana. Bagley posits that citizens in Jamaica still feel the scars of slavery and when in a racist country like Britain, the whip of racism is raised again, the response is retreat, anger, struggle, despair and sometimes psychopathology.

It seems almost like hyperbole to state that insight is a desirable attribute for the entire society and should not only be enquired upon from patients. Research and therapeutic agendas cannot be race or colour free. Encouraging new research dimensions in the USA (Reference CarterCarter, 1998) specifically address racial identity and their impact on psychotherapy. Cultural and participatory family therapy can provide the framework to consolidate the crumbling structures of identity and belonging resulting out of confrontation of rejection by a racist society. The process of psychohistoriography (Reference HicklingHickling, 1989) which functions to debunk the myths of colonisation and establish cultural reality as a framework for future action may be especially appropriate in this context. We must be consistently aware that society legitimises psychiatric diagnosis in the same ways that it does racism. Uncritical acceptance of these concepts can be used and reflected in the relegation of otherness and difference to illness. This in turn can lead to another manifestation of the superiority/inferiority motif. We need to understand this in all its potential ramifications if we are to make sense of the roast breadfruit concept and its relevance to psychosis.