Personal Recovery of People with Schizophrenia in Martinique: A Qualitative Study

Theme 1: Self-Work

Participants described living through painful experiences before they were able to accept their illness. They experienced their illness as a sudden intrusion locking them into a present without prospects, stimulating a sense of constant failure and a loss of certain parts of the self, of projects and dreams, and of parenthood. As one participant stated: “We’re not actually going anywhere; we’re building nothing; we’re exhausting ourselves in fact” (PN).

Some spoke of the injustice of being sick without social recognition. Participants often viewed hospitalization as an unjust punishment, where restrictions on everyday freedoms reinforced their dependency on friends and family without a compensatory affirmation of their subjectivity through their treatment. This led to a sense of illness as causing setbacks: “Each time I had to start over again” (PB).

Very gradually over the span of their illness experience, the possibility of living with the illness appeared in participants’ narratives. Participants also recounted how they made efforts to cope. Aware of their psychological fragility, participants developed different strategies of control (with respect to emotions, words, actions, medication adherence, ritualization, resistance to change, selection of relationships) and avoidance (for example, of attachment relationships experienced as insecure, withdrawal from social relationships). As one participant, who was living like a monk, described this process: “Do you know (…) It is a bit this analysis that I made in my solitude. I behaved a little like a meticulous person, (…) who is very careful” (PM).

Participants engaged in highly disciplined routines to structure their daily lives. They prioritized early-morning rising, rigorous personal and dietary hygiene, regular exercise, and rest as conditions of an active and healthy life, with the aim of “keeping busy” and avoiding intrusive thoughts. In the words of one participant: “Especially getting up in the morning. When you manage to do this on your own, you have gained a lot from the illness” (PA).

In this arduous and lengthy process, patients expressed a need to “hold on,” “serrer les dents,” make efforts, and struggle to constantly adapt, “move forward,” and leave the past behind them.

Participants’ narratives of recovery comprised multiple shifts towards reaching a new equilibrium. For some, a sense of courage, restored dignity, and agency eventually emerged from their efforts to cope. Improving emotional regulation capacities and executive functions helped them regain confidence in their ability to overcome obstacles, to know what was good for them, to reflect about their desires, and even to allow themselves some leisure and risk taking. Awareness of their strengths and weaknesses made it possible for participants to set reasonable goals. Here is an example of a personal decision to choose the day hospital because of the benefits that the participant received: “I also feel free because I am free to go to the day hospital, I don’t have to, and it's me who goes there (…) because it brings me a lot of things” (PF).

While still suffering, participants’ perception that they were improving brought them substantial relief. Most participants associated their perception of progress with a lived experience of reconciliation, of transcending their shame and guilt, and of bridging the gap between their delusions and their dreams or imaginations in a way that all these feelings and thoughts were recognized as belonging to themselves. In the words of one participant: “Recovered is … a better view of everyday life, which was not possible before” (PI).

This long and arduous work on “the self” led to transformations that participants later identified as beneficial maturations and cornerstones of their identity. Their efforts to improve their prognosis evolved through successive experiences: “For me, having recovered is learning to live with what we went through, (…) with what happened, and trying to do something good with it” (PF).

Theme 2: An Evolving Illness Role

Participants referred to their illness and its causation as something outside themselves. They reported experiencing the sudden onset of illness as a rupture, accident, fall, even a catastrophe, that deviated their life from its previous trajectory. Patients understood their schizophrenia as foreign and as deeply disruptive to their sense of self. As one participant put it, their illness was “a moral, psychic, physical disaster, et cetera” (PD).

At the onset of their illness, participants explained their disorder with religion or magic: they perceived it to be intentionally thrust upon them as a Quimbois (spell), an intrusion of the devil or diabolical spirits, an ordeal or divine punishment. This usually was clearly stated: “I don’t really feel schizophrenic, because for me it was not schizophrenia, it was more the Devil who did this to me …” (PE).

Alongside supernatural causes, participants mentioned other external factors such as shocks or trauma, hereditary affective deficiencies, physical and/or emotional abuse, drug abuse, other illnesses, and bad company. They did not see different causal explanations as contradictory.

Participants initially sought out external therapeutic spaces and assistance. To address their illness, they described first looking for outside help, sometimes with the hope of returning to their previous state. All participants turned to traditional magical practices and interventions on occasion. Most, however, also relied on regular prayer and medication. This was described in terms of therapeutic experiences and causal explanations: “A marabout. (…). He got my voices out” (PI); “Despite everything that happened to me, I did well. (…) I think it is thanks to God” (PF).

Participants described the rituals as mysterious and beyond their understanding, which seems to have encouraged them to take a passive role. This is echoed in their approach to medical treatment, which privileged professional discourse, thereby devaluing their experiential knowledge. Participants’ use of different therapeutic modalities provoked tensions. They saw drugs as helpful but as “shooting you” and making you “ababa” (dopey). Participants also expressed doubts about their faith in God during hard times. More generally, participants viewed their magical and religious beliefs as contradicting the medical model, while they also opposed traditional magical rites to religion. This hampered the concurrent use of complementary sources of support:

But most of the doctors would tell me “no, that has nothing to do with religion.” So I was against it from the start, (…) I did not trust. (…) Because I didn’t feel listened to. And I wanted to make religion take precedence over everything, and most of the doctors who saw me talk about religion, they did not agree with that (…) that set me against them even more. (PE)

Participants described taking charge of their illness and care, achieving self-determination. In their trajectories, various magical or traditional practices, such as gadé-dzafé, astrology, clairvoyance, and herbal medicine, were intertwined with biomedical care. They did not distinguish sharply between Quimbois, voodoo, and marabout practices. By trial and error, participants learned to explore these systems and to orient themselves towards wellness in a flexible manner, capable of tolerating doubts and double meanings. As one participant put it: “Through this way, I took my personality, my identity, as well as my strength” (PM).

Participants’ attempts to grapple with their illness and diverse techniques of care became more complex as they integrated these into their lives. Gradually, participants came to see it as existing within them, while still attributing its emergence to external causes. This sometimes conflated biomedical and spiritual explanations: “I take it more spiritually; I take it more like a hallucination” (PE).

Participants symbolized their recovery experience as a rite of passage and/or as a growing pain that strengthened their being. Psychotherapy, theories of magic, and idiosyncratic interpretations bolstered participants’ efforts to understand themselves.

As they progressed, they reported experiencing a sense of restored freedom and of having agency in their recovery, while they continued seeking outside help when needed. Knowledge of the illness—aided by psychological education—allowed participants to build personalized strategies (sport, relaxation, creativity, etc.). They integrated medication as an active tool due to its experienced effectiveness in managing symptoms. The ability to deal with lingering symptoms became a source of control, and their faith a source of inner strength, in which they saw submission to God's will as a deliberate choice: “I tend to have an inner conversation with my voices, so I manage them” (PC); “I first took refugee with God to feel protected because I was so scared. Now I feel free. I’m not so constrained (…). I feel free to keep going with Jesus!” (PF). Finally, they learned to value patience as a source of strength, helping them accept an illness they did not choose for themselves.

Theme 3: Rebuilding Identity

Many participants reported experiencing a loss of their sense of legitimacy within the group. Having felt shame about their condition and moral judgment on their actions, some initially dissimulated their illness. In response to what they perceived as negative judgments, many felt the need to adopt a stoic countenance. Some appropriated the stigma, labeling the illness as dangerous, a form of insanity, incurable, or a “whim” and a product of “laziness.” For many, past delinquent behavior was central to this type of representation: “And it made me do so much nonsense that I don’t even want to talk about it because for me this illness, given what happened, it's shameful” (PE).

In addition to periods of social exclusion, all participants described a divergence between their trajectory and that of others, as well as the loss of communal roles, which in turn generated feelings of incapacity or uselessness. They found it difficult to feel comfortable with and express themselves, which prevented bonding. It nurtured a dependence on loved ones mingled with a feeling of oppression, a desire for autonomy, and a fear of abandonment: “I want freedom, I don’t want to be oppressed, I don’t want those around me to call me … (…) the others I can’t let them in because I wouldn’t know how to react to that” (PM).

Some felt guilty about past mistakes, disappointing their loved ones, or causing them pain. Many felt they owed a debt to family and caregivers; this feeling of indebtedness was, for some, overwhelming, while for others it drove recovery. For many, morality and religion structured their recovery, giving meaning to their disorders and helping them to achieve forgiveness and a sense of solidarity. Adopting a position of humility, austerity, patience, acceptance, and tolerance, as valued by the Christian religion, provided participants with some necessary distance between themselves and their grandiose ideas and feelings of failure, while nonetheless limiting their self-esteem. For some, adopting a moral stance becomes a personal identity: “To be myself, for me it is what morality is about … I identified it to my identity” (PM).

Participants reported getting support from a larger collective in the process of reconstructing their identity. The family group guaranteed reliable relationships and material survival. The mother figure, in particular, was strong and reassuring in their narratives, although sometimes intrusive. The figure of the father was more withdrawn, or often absent. For example, some reported that their fathers were rarely present during hospitalizations, while others said that the person they turned to in times of crisis was usually their mother, as they knew she would be more available.

Being in the hospital remained a difficult time for many, although it led to the formation of some satisfying relationships. Outpatient care centers were seen as protective and associated with therapeutic and re-socializing activities rather than with an image of crowded consultation centers. Participants characterized healthcare professionals as supportive, personally invested, and efficient experts: “It was not so much the doctor, the doctors who passed by who healed me you know, it was the Rehabilitation Center with the sociability that there was, there I felt that I was reviving” (PL).

Psychiatrists were a benevolent authority, almost a parental figure, in participants’ accounts, but some participants criticized them for overly brief consultations that focused narrowly on symptoms and medications. For some, psychotherapeutic work with the psychologist was important:

The doctor really cared about me. Sometimes I disagreed with him. Sometimes he irritated me (…) but even if I did not see him a lot, I knew I could always rely on him. And this made me feel safer. (PA)

Benevolent ways of viewing themselves helped participants to see recovery as a social and moral posture, valuing their reintegration into the community as well as their rehabilitation. They stressed the importance of proving oneself, to not disappoint others and to be worthy of the help they had received: “I try to pay attention to … the clothes uh, what I think about, what I say, to … to still be uh, poised. To be in … to be also uh, a little uh, to be also uh … interesting” (PJ).

Participants actively sought approval through socially valued investments (caring for others, intellectual or artistic activities, sport, work) or by adhering to predefined patterns (home, family, work).

Participants described creating a space of interplay between the self and the collective, helping them regain legitimacy as social actors. For some, work brought a sense of utility and progression along with autonomy, allowing them to contest their disability status.

I feel more stable, more … Better in society. Despite the illness. (PI)

A Particular Emphasis on Social Norms and Support in Martinique

Our results were consistent with studies highlighting the importance of social support (Leamy et al., 2011). However, the weight given to the group appeared to be particularly important in Martinique. As in previous studies, our results showed the important role of identity remodeling, regaining control, and allowing self-determination and empowerment in supporting recovery (Leamy et al., 2011; van Weeghel et al., 2019). For the participants in this study, however, these individual-level factors of recovery are part of broader efforts that aim, first and foremost, to achieve social reintegration, with personal transformation coming second. In other words, conforming with a group appeared to be a condition of personal recovery in Martinique. By contrast, previous models of recovery support a disengagement from social norms to establish distance between patients and the stigma associated with their condition. In the “Identity” dimension of the CHIME model, for example, this is seen as a condition for attaining a sense of personal freedom (Leamy et al., 2011; van Weeghel et al., 2019). In our study, participants instead seem to have viewed—albeit with some ambivalence—community standards as a protective framework that could promote both autonomy and a meaningful social role despite the constraints these standards implied. Thus, our research supports collectivist social theories (Hofstede, 2001; Tse and Ng, 2014) and the interdependent self-construal theory (Markus and Kitayama, 1991; Tse and Ng, 2014), which are often considered to be applicable to recovery approaches across cultures (Tse and Ng, 2014).

Some participants justified the rejection they experienced as resulting from their previous lack of respect for social norms and morals, which they identified as characteristic of schizophrenia. Such transgressions included delinquent behavior, drug use, physical attacks, adultery, or upsetting their parents. Some of spoke of these as “sins” with reference to Christian morality, and many expressed a strong identification to social or Christian moral values. Our results thus suggest that recovery in Martinique requires accountability for faults and re-appropriation of community values—moral and/or religious—with a redemptive aim. Shame, guilt, and debt, although elicited by and sustaining the internalization of stigma, also seemed to be experienced as structuring and driving forces in a dynamic of repair, suggesting that these feelings are a mode of expression of moral values. However, this stance also led some participants to feel a lack of legitimacy in managing their recovery. For instance, despite having a deep understanding of their illness, they still felt less capable than their caregivers of taking control of their own well-being. As a result, they took longer to embrace empowerment and experiential knowledge in their recovery journey. This appeared to promote reliance on external strategies, postponing the utilization of their internal resources.

Freeing oneself from stigma seems to be an essential stage of recovery in the French (Koenig, 2016) and anglophone (Goffman, 1963) contexts. However, its internalization seemed deeply entrenched among the Martinican participants in our study, even at an advanced stage of their recovery. The internalization of stigma has been reported as a barrier to recovery by lowering self-esteem and hope (Link et al., 2001; Yanos et al., 2008), self-efficacy (Kleim et al., 2008), and confidence in one's ability to take part in social interactions (Perlick et al., 2001). Authors have identified various strategies to reduce the impact of discrimination and social stigma on recovery: community-level initiatives influencing the behavior and attitudes of the general public; supporting people throughout their recovery journey to support their ability to resist reactive self-deprecation; and identification of certain harmful professional practices to promote destigmatizing approaches (Corrigan and Phelan, 2004; Kondrat and Teater, 2009). These strategies could be adapted to respect the cultural, moral, and religious values of Martinique.

Most participants reported “distanced” strategies for connecting with other people at an advanced stage of their recovery. This ties in with techniques of “positive withdrawal” (Corin and Lauzon, 1992) or the avoidance of overly exposing relationships (Leamy et al., 2011), which have been described in accounts of people with schizophrenia from the U.S. (Davidson, 2003). These allow individuals to frequent public spaces—a way of “being with”—while limiting overly complex social interactions (Corin and Lauzon, 1992; Davidson, 2003). Work on resilience in Martinique (Laguerre, 2014) suggested the potential use of “avoidant coping” as a valuable strategy. Such “emotionally centered coping” aims to “regulate emotional distress,” and differs from “vigilant coping” which aims to “manage the problem” (Laguerre, 2014). The internalization of stigma could also favor this strategy (Yanos et al., 2008). Furthermore, considering that stigma internalization may be present until late in the recovery process in Martinique, it might be relevant to ask what people really experience as stigma. In other words, people may transform their stigma experience in a singular way that departs from the original definition of stigma, and which helps them develop useful recovery strategies.

More recent work emphasizes “feeling secure” as a factor of recovery (van Weeghel et al., 2019), with reference to the “secure base” in Bowlby's attachment theory (Bowlby, 1981). This denotes the possibility of being reassured when a person feels threatened, thus allowing children—and even adults—to freely explore the world, especially relationships with others, without reactivating fears (Fraley, 2019; Simpson and Rholes, 1998). This secure base-centered approach tempers an emphasis on factors such as courage and controlled risk in the recovery process (Deegan, 1988). Participants in this study reported that the encouragement of loved ones, caregivers, and peers has supported them in their recovery, highlighting the importance of “therapeutic input” (Stuart et al., 2017) in the recovery process. While “distance strategies” can be protective in individuals’ broader interactions, receiving support from close relatives, peers, and caregivers can help personal recovery. Likewise, respecting community standards, as part of a social contract, seemed to provide security to participants.

Reconciling Plural Therapeutic Approaches

Laguerre identified “religious spirit” as a key factor of resilience in Martinique (Laguerre, 2014). Religion also helped many participants in our study give meaning to their experience. This does not, however, seem to be a way of overcoming stigma, as participants did not report seeking God as a means of being forgiven, or absolved from responsibility, for their illness. Participants do not seem to find the three common causal explanations of illness—Quimbois spells, divine or diabolical ordeals, and individual vulnerability factors—to be contradictory. The diversity of responses these entail seem to promote a flexible approach, and play a role in the remodeling of identity and self-determination. This process of being able to combine therapeutic approaches was seen as a “rite of passage” that strengthened individual maturation and spirituality, independently of religious community practices. Descriptions of this process echo those of “personal growth” by overcoming negative trials (Koenig, 2016).

This pluralism is consistent with representations of identity in the West Indies, which is composed of distinct elements that are interlinked but not completely homogenized (Delisle, 2008; Eynaud, 2015). Some authors associate this identity with a process of “creolization,” ¹ following Edouard Glissant's conceptualization of a “rhizome identity” ² or “identity-relation” ³ (Glissant, 1997, 2020), drawing on the work of Gilles Deleuze and Félix Guattari (Deleuze and Guattari, 1987). “Normality” reconciles multiple cultural representations that can be found, for example, in the pluralism of worship and care (Eynaud, 2015).

However, while the use of traditional healers is widely practiced in Martinique (Bougerol, 2008; Eynaud, 2015; Massé, 2002), it is denounced by the Catholic Church (Delisle, 2008) and invalidated by the Anglo-European biomedical model (Eynaud, 2015). Participants described feeling torn between contradictory messages, and devaluing their own capacity to navigate different approaches. Opposition to therapeutic pluralism can postpone recovery. The complementarity of popular, traditional, and biopsychosocial therapeutic approaches (Kleinman, 1980) seems to be consistent with the personal recovery paradigm's prioritization of lived experience perspectives rather than practitioners’ predefined categories (Anthony, 1993).

Martinique's recent Territorial Mental Health Program does not recognize the value of religious and traditional healers’ impact on patient recovery. Our research highlights a need to consider how plural elements of recovery provide overlapping and complementary contributions to patients’ care. This might lead, for example, to health professionals discussing the potential advantages of alternative approaches with individuals for whom they might be meaningful (Mouchenik, 2019). It might also include inquiring about patients’ beliefs and affirming their responses empathetically (Mouchenik, 2019). Professionals might also explore potential interactions between—without imposing a hierarchy on—the medications prescribed by different practitioners. They might even facilitate connections with healers that patients perceive as vital for their recovery, thereby adjusting treatment plans (particularly in cases where conflicting approaches arise) (Mouchenik, 2019). Certain clinics have established transcultural consultations designed specifically to address the cultural aspects of health (Kirmayer et al., 2023; Mouchenik, 2019).

Taking Trauma into Account

Participants in our study described the onset of illness as a sudden rupture—often using hyperbolic terms such as “inhuman,” “disaster,” and “hell”—that overwhelmed their capacities for control. This has traumatic effects that persist, manifesting in hypervigilance among some participants, beyond the residual persecutory symptoms of schizophrenic experiences of paranoia and delusion. This traumatic dimension has been recognized in the recovery literature (Ellison et al., 2018), while the comorbidity of Post-Traumatic Stress Disorder with schizophrenia has also been documented (Seow et al., 2016). Moreover, people with psychosis have an increased prevalence of traumatic experiences in their early childhood compared to the general population (Varese et al., 2012).

Authors have suggested a link between the pluralistic construction of Martinican identity and cultural ways to provide meaning in life as being linked to resilience in the face of adversity—(to survive in slave plantations, for example) (Glissant, 1997). This suggests that both traumatic elements and modalities of resilience have influenced Martinican identity. The violent psychotrauma of slavery, with its physical aggressions (transport, whips, irons, etc.) (Pétré-Grenouilleau, 2006) and psychological torture (separations, identity ruptures, etc.) (Charles-Nicolas, 2018; Wiltord, 2018), has been linked to cerebral effects on memory encoding and stress regulation (Charles-Nicolas, 2015, 2018). Various studies have shown that serious psychological trauma, without therapeutic support, is transmitted to subsequent generations (Miljkovitch et al., 2004; Tarabulsy et al., 2005; van IJzendoorn, 1995). There has been little collective reckoning of this history in Martinique (for example, through official apologies, reconciliation processes, restorative justice, etc.) (Laguerre, 2014), making it difficult to overcome dehumanizing physical and psychological humiliations and abuse (Charles-Nicolas, 2018; Wiltord, 2018).

Thus, various processes—transgenerational, developmental, and experiential—might contribute to psychological trauma in individuals dealing with schizophrenia in Martinique,

intertwining in distressing resonances with one another. Taking these processes into account—with the resulting specificities of identity building—seems essential to support these individuals in their recovery.

The Role of Employment, Housing, and Financial Autonomy in Social Recognition

Participants in our study stressed the importance of having a job, housing, and financial autonomy in order to build a new equilibrium. They presented these as essential conditions of social recognition and reintegration, and thus as factors of recovery. This is consistent with studies showing that access to a job reduces symptoms (Burns et al., 2009). For some authors, the degree of clinical and social recovery is more highly correlated with socioeconomic factors, such as work, than with progress in treatment (Warner, 2004). Access to paid and voluntary employment extends social networks (Rüesch et al., 2004). Consistent with our participants’ testimonies, having a job has also been found to affirm an active and committed identity, rather than that of a passive patient, stimulating in turn a feeling of belonging (Borg and Kristiansen, 2008). In line with the weight of social judgment in participants’ recovery, as described above, these external criteria appeared to be more important to them than symptomatic remission such as the disappearance of voices.

These findings challenge the paradigm according to which symptomatic remission must be secured before addressing socio-economic factors. Recently, interventions have supported an inverse approach, such as “housing first” (Kirst et al., 2020; Laval and Estecahandy, 2019). These recognize the structural barriers faced by individuals with mental disorders in accessing employment and housing (Corrigan et al., 2004). Such interventions were included in the Territorial Mental Health Program in Martinique (ARS, 2020).