The experience of both the psychiatrist and population is of critical importance in the description of indigenous phenomena. This becomes even more relevant when both the researcher and the tested population are influenced by diverse cultures. In the paper entitled ‘Roast breadfruit psychosis’ (Reference Hickling and HutchinsonHickling & Hutchinson, 1999), the authors have extrapolated a cultural concept enshrined in Caribbean humour and pathos into a diseased state. We wish to demonstrate the widespread use of a host of metaphors within the Caribbean and other communities illustrating the concept of cultural marginalisation. This is reflected in the song, prose, poetry and art of the region.

The effect of social and cultural factors in the aetiology, course and outcome of mental illness appears to be an area of renewed interest in British psychiatry. While British psychiatrists have abandoned the fading image of the visiting messianic doctor, the island-hopping academic and the colourful description of culture-bound syndromes in exotic and distant lands, it appears as though there is today a reversal of role.

More recently, new African-Caribbean psychiatrists in Britain seem content to invent syndromes exhibiting mimicry, defying nosology, logic and rational thought and devoid of scholarly description.

The ‘Black-White man’ has never been an issue of the ‘windrush’ of 300 000 West Indians who migrated to Britain between 1951-1961. Nevertheless, politicians, poets, writers and calypsonians have adequately described the phenomenon of ‘Black people who think themselves White’ in the Caribbean. These social commentators did not consider acculturation and assimilation into a new culture as negative factors but as processes of social ascendancy and respectability. This transition was actively pursued voluntarily en masse; in fact, the Jamaican poet Louise Bennett described the exodus from her island as follows:

Following independent status from Britain in 1962, a Trinidadian academic, Lloyd Best introduced into the Caribbean literature the term ‘Afro-Saxon’. It was not intended to be a pejorative term, but a descriptive analysis of the ruling class then, that had adopted, absorbed and internalised the values of the White colonial masters. This, he pointed out was a natural phenomenon, since post-colonialisation, the ruling elites pursued the norms of respectability of the White man and aspired to it for acceptance and survival (Reference BestBest, 1965). Similarly, Samuel Selvon's (Reference Selvon1956) novel The Lonely Londoners captured the feelings and aspirations of West Indian immigrants in Britain.

Selvon, a Trinidadian of mixed Indian and Scottish parentage arrived in London in 1950. Creating from his own experience, he captured in narrative form, the atmosphere of West Indians in London. In his novel, which is part comic, part tragic, Selvon sought “to evoke the bittersweet existence of a rootless community that is both excited and terrified by its new life and the leaving behind of the old” (Reference Ferguson and TaylorFerguson, 1999). Through a number of characters, he most vividly described differing responses to the experience of migration. Such feelings would be expected of any migrant group into a new environment regardless of their colour, race or culture. Disturbed racial identification is, therefore, a natural phenomenon of any colonised or migrant people. It is non-specific and no ethnic group should be singled out.

Naipaul's Man-man “an Englishman - a good class Englishman who wasn't particular about his grammar” or Selvon's “Harris with his bowler hat and copy of The Times” cannot be diagnosed as suffering from ‘cultural schizophrenia’, ‘migration psychosis’, ‘breadfruit psychosis’, or ‘Afro-Saxon psychosis’ for that matter. The rapid tangential progression from ‘thinking’ to ‘rationalisation of identity’, to ‘syndrome’ and then to ‘psychosis’, the description of ‘characteristic features’ which appears subjective in nature and the proffering of ‘racism and/or experiences of abuse’ as precipitating factors are untenable. Without epidemiological data the authors attempted to extend a popular cultural concept into the realm of a disease afflicting African-Caribbeans. Should not such a nosological entity also affect other ethnic groups in Britain?

A wheel reinvented but disguised remains a wheel. Following the Brixton riots in 1981, a group of health care workers at St George's Hospital led by Aggrey Burke, founded a body called ‘The Ethnic Study Group’. From weekly discussions in which the author participated, it was determined that diagnoses such as ‘Balham psychosis’, ‘New Cross psychosis’, ‘West Indian psychosis’ and ‘Migration psychosis’ were nonsensical in nature. These were interpreted as intentions to create nosological entities that did not exist, while simultaneously attempting to negatively categorise Black people in Britain by imposing prejudicial values based on psychiatric imperialism. Many White professionals were severely criticised for over-reacting to Black patients out of fear, or under-reacting out of patronisation, lack of experience and confidence (Reference MaharajhMaharajh, 1992). Similarly, arising from different perspectives but using equally flawed constructs, African-Caribbean psychiatrists should be repudiated for their dicta.

In 1982, the Ethnic Study Group was invited by the Transcultural Psychiatry Society of the United Kingdom to host a conference entitled ‘Is racism a causatory factor in mental illness?’ (Reference BurkeBurke, 1984a ). The coordinator, Aggrey Burke, who has extensively researched racism and mental illness, noted that psychological disturbances due to racism were distinct from those caused by cultural factors (Reference BurkeBurke, 1984b ). This distinction is not recognised by many researchers who unfortunately use both terms interchangeably.

The phenomenon described by Fanon (Reference Fanon1968) in Martinique and Guadeloupe is not applicable to African-Caribbeans in the UK. Fanon described a French system of coercive assimilation incorporating Black people from the colonies into the imperial system, attempting to make them into French men. In Britain, assimilation was by choice. It has been argued that the early African-Caribbean immigrants sought social acceptance and assimilation while the Asian population were contented with economic alliances and contacts. Non-acceptance led to feelings of alienation and rejection among African-Caribbeans, resulting in attempts at redefining their traditional culture (Reference MaharajhMaharajh, 1992).

It is unfortunate that some psychiatrists have become blinkered by their own social and cultural assumption, unconscious as it may be. The infelicitous consequences are distortions and misrepresentations of cultures with the same passion and mimicry of Anglo-Saxon psychiatrists who were criticised for their misrepresentations of indigenous cultures (Reference Maharajh, Clarke and HutchinsonMaharajh et al, 1989; Reference Maharajh, Hutchinson and Clarke-MaharajMaharajh et al, 1990).

Enshrined in ethnic groups' humour and pathos in Britain and other countries, is the cultural concept of marginality. Blacks in Britain are sometimes referred to as ‘coconuts’, ‘Mars bars’, ‘Oreo biscuits’, items that are layered white internally and brown externally. Some Asians are referred to as ‘WOGs’ (Western oriental gentlemen). In Sudan, individuals returning home from France with Western ideals and mores are referred to as ‘Afrangi’. In Trinidad, a former Oxford-trained Prime Minister was referred to as a ‘Balata seed’ - a fruit of a tree (Manilkara bidentata) whose testa is jet black and pulp milk white.

In Spring 1984, I presented a paper at a College meeting held at the Royal Edinburgh Hospital entitled ‘Borderline cultural states’ (further details available from the author upon request). It was pointed out that many individuals in Britain had difficulties in conceptualising the culture they belonged to due to conflicts that may arise from their traditional home culture and the modernising host culture. The problems of identity were described in all ethnic groups and no attempt was made to leap from psychological disturbances to psychosis.

The nature of social and cultural concepts are such that although a cultural phenomenon may be observed, its interpretation must always take into account the cultural milieu that colours its expressions and the views expressed by the reasonable indigenous man. Distortions and misrepresentations can be a reflection of the authors' own experiential prejudices in their primordial needs to defend that which they perceive as belonging to them. This may sometimes result in individual prejudice masquerading as scholarly analysis.