DEVELOPMENT OF PSYCHOLOGY AND PSYCHIATRY IN

TRINIDAD AND TOBAGO

Siobhan Burroughs

Introduction

( 7 J ill, p"P<",=i,,, <he hi"ori~l development and relationship between psychology and psy­

chiatry in Trinidad and Tobago as well the influence that psychology has had on both the private and public sectors. However, it begins by first examining the general relationship between psychiatry and psychology then looks more specifically at the case of Trinidad and Tobago.

Psychology and Psychiatry

Myers (2007) defines Psychj)logy as the scientific study of behaviour (anything an organism does) and mental processes (the subjective experiences inferred from behaviour). There are many sub-divisions of psychology which include: clinical , counseling, developmental, social, occupational, school , forensic and neuropsychology. For the purpose of this paper, reference will be made to the field of clinical psychology. "Clinical psychology is the field of psychology that integrates science, theory, and practice to understand, predict and alleviate maladjustment, disability and discomfort, as well as to promote human adaptation, adjustment and personal development. It focuses on the intellectual ,

emotional, biological, psychological, social, and behavioural aspects ofhurnan functioning across the life span in varying cultures and at all socio­economic levels" (American Psychological Association 2008).

Psychiatry on the other hand refers to the medical specialty concerned with the diagnosis and treatment of mental disorders (Stedman'S Medical Dictionaty 2005). The national Mental HealthAct of 1975 defines a mental disorder as a mental illness; arrested or incomplete development of mind. In specific terms, a mental illness means the condition of mind of a mentally ill person, that is, a person who is suffering from such a disorder of mind that he or she requires care, supervision, treatment and control, or any of them for his or her own protection or the welfare of others (The Mental Health Act of 1975).

The field of psychiatry is much older than the field of psychology. In Trinidad and Tobago, clinical psychology has been significantly influenced by psychiatry. A close relationship therefore exists between them. TIlls relationship between psychology and psychiatry will be examined by looking at the similarities and differences between them.

Initially, both psychology and psychiatry were concerned with the problems of mental health. M ental health describes a level of

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cognitive or emotional well being or the absence of a mental disorder. Psychology and psychiatry do not differ in terms of who or what they study. They generally investigate the same mental illnesses, such as mood disorders, anxiety disorders, schizophrenia, impulse control disorders, adjustment disorders, and substance­related disorders. Therefore, their target population as well as the mental disorders and the symptoms that are displayed, are the same. In addition, both clinical psychologists and psychiatrists are trained in clinical settings. In fact, some clinical training occurs in psychiatric inpatient settings under the supervision of psychiatrists. Moreover, diagnoses of mental disorders are based on the Diagnostic and Statistical Manual (DSM), which is psychiatry's classification system. This further contributes to

psychiatry's influence on the field of psychology. Moreover, these professions have made significant contributions to the diagnosis and treatment of mental disorders as they have both developed many new techniques and approaches, which have resulted in a wider understanding of mental disorders as well as an increase in areas of application and positive results (Menninger 1949).

Despite their similarities, there are some marked differences. Firstly, psychiatrists are medical doctors whilst psychologists are not. The suffix "-iatry" means "medical treatment," and '(-logy" means "science" or "theory," Therefore, psychiatry is the medical treatment of the psyche, and psychology is the science of the psyche (Downs 2004). Psychology and psychiatry thus differ in terms of their approach

to the treatment of disorders. Psychiatry is based on medicine and therefore the treatment of these disorders tends to focus on the use of medication. Psychiatry searches the brain and biological mechanisms for mental illnesses (American Journal of Psychiatry 1997) and explains the symptoms of mental disorders, (for example, hallucinations or delusions) in biological terms because the activities of the mind are believed to be reflected in these symptoms. Psychologists also acknowledge the biological etiology of some mental disorders but also recognize that other factors, such as psychological, emotional, social and behavioural factors can also precipitate a mental disorder.

In treating these disorders they thus apply "psychological principles to change habits, behaviors, and lifestyles that increase the risk for a number of illnesses" (Brentar & Mc Narnara 1991). Psychology is more research­oriented than psychiatry. Training in research enables psychologists to assess the effectiveness of different kinds of treatment by analyzing information and drawing conclusions from psychotherapy' sessions. Psychologists undergo more intensive training in therapeutic approaches than psychiatrists. This "training provides an introduction into investigative techniques as well as the experimental method, while the great majority of psychiatrists have had no such opportunity" (Menninger 1949).

Psychiatrists on the other hand, alter "the psyche by prescribing medication but also modulates the psyche with psychotherapies that address mind mechanisms, such as memory or

, Psychotherapy involves anwnber of treatment techniques, (such as individual and group therapy) that help individuals with mental disorders understand the behaviours, emotions and ideas that contribute to their illness; understand and identify life's problems; regain control over their lives; and learn coping techniques and problem solving skills (WebMD Medical Reference 2008) . ..

consciousness." "This modulation works at the neural level by producing changes in the brain" (American Journal of Psychiatry 1997). However, psychologists argue that medication promotes a "disease model of mental illness" (Brentar & Mc Namara 1991). They maintain that drugs do not deal with the underlying psychological disorder but merely masks the presenting symptoms, which are then substituted for other symptoms because the cause of the problem still exists.

Clinical psychology and psychiatry are engaged in a mutually cooperative enterprise. They both fonn part of a clinical tearn along with other mental health providers. They both share their perspectives about specific cases, based on their training and experience, to help alleviate the distress and disability caused by mental illness. Generally, when psychologists see a patient that could benefit from medication, the psychologist refers the patient to the psychiatrist. The converse is also true, as a psychiatrist would refer a patient he or she deems to be in need of psychotherapy or psychological testing.

Despite the strong influence psychiatry has had on the development of psychology, the contribution made by clinical psychology has been critical to the "best practice of psychiatry" (Menninger 1949). Clinical psychology has made a major contribution to the practice of clinical psychiatry by the development and application of various personality tests (Menninger 1949). Menninger (1949,14-15) maintained that "the diagnostic function of the psychologist is now so well established in psychiatry that the competent psychiatrist would no more exclude the special techniques of the psychologist in his diagnostic studies than would a capable internist routinely exclude the findings of the roentgenologist."

Research suggests that both psychology (psychotherapy) and psychiatry (pharmaco­therapy) may be equally effective in the treat­ment of mental illnesses, for example acute depression (Di Mascio et al. 1979; Weissman et al. 1979). However, the combination of expertise can enable the client / patient to receive holistic treatment. This is suppcrted by researchers who found that psychotherapy in combination with pharmacotherapy may improve functioning and decrease relapse rates in people suffering from depression (Di Mascio et al. 1979; Frank & Kupfer 1987; Weissman et al. 1974) and schizophrenia (for example, Falloon et al. 1982; Hogarty et al. 1986).

Psychology in Trinidad and Tobago

Trinidad and Tobago is a twin island republic, which lies in the Caribbean Sea off the north coast of Venezuela. The practice of psychology in Trinidad and Tobago has been (and still is) significantly influenced by the practice of psychiatry. Therefore , the development of psychology in Trinidad and Tobago will be examined in part by investigating the development of psychiatry in Trinidad and Tobago.

The practice of psychology and psychiatry in Trinidad and Tobago has been influenced by the country's rich history. "The influx of many colonizing forces and cultures over the past 500 years have resulted in interesting culturally based treatment modalities emerging from the collective unconscious of its people" (Maharajh & Parasram 1999).

According to Maharajh & Parasram (1999), western psychiatry was introduced to Trinidad and Tobago over 150 years ago, yet a clear distinction still cannot be found with respect to psychiatry and traditional practices,

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such as religion. Psychiatry and psychology by extension is thus characterized by a "unique blend of third world traditional practices and scientific knowledge." Attempts that were made to separate psychiatry in terms of science and religion were opposed. Cox (1996) explained that this may be due to the view that separation was a "peculiarly western phenomenon." Ful­ford (1996) also purported that whilst psychiatry has a scientific basis, it remains an overtly value­laden discipline, which may be closer to religion than other branches of medicine.

Trinidad and Tobago were joined in 1889 and while they have a similar history, they do have differences. Before 1498, a period referred to as the Pre-Columbian period, the earliest known treatment for mental disorders was documented. The Carib and the Arawak tribes (the indigenous Amerindians) had devised their own form of herbal medicine to treat mental disorders (Maharajh & Parasram 1999). These treatments also reflected their interaction with the spirit world. According to Beaubrun et al. (1976), they called the mentally ill "mind-riven" and attended them with lavings and unguents while singing and with salvent herbs, which they also blended with food and left hanging on fruiting trees for those that wander.

During the period of colonization (1498-1797), the incidence of Negro slavery and the influx of Catholics who settled in Trinidad, resulted in a religious melting pot of African practices, Aboriginal (native) practices and Christian practices. These different religious influences fueled the growth of superstition, sorcery and obeah practices in Trinidad. The period from 1797 to 1962 was characterized by the emancipation of slavery; large-scale immigration from India, China and Madeira of indentured labour and the establishment of westem psychiatry in Trinidad and Tobago. Each

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nationality also brought their religious practices to Trinidad and the freed slaves practiced their native customs.

The cultural influence that the colonizing nations brought was also important to understand the history of these twin isles. Whilst Trinidad changed hands among the Spanish, French and the British; Tobago changed hands more than 30 times among the English, French, Dutch and even Corianders (Latvians). Tobago was won by Britain in 1814 and Trinidad and Tobago were joined in 1889. They achieved Independence from Britain in 1962 and became a Republic in 1976. The similarities in their history helps one to understand the culture of the region but the differences in their cultural influences enable one to appreciate the sub­cultural differences in the islands.

These different religious practices and cultural influences created a Wlique environment for the birth of Western psychiatry. "A system oftreatrnent was employed utilizing behaviour modification based on adherence to religious and cultural norms. Out of this system, the modem day village councils were born. Thus the priest, pundit, imam and obeah man remain today the first contact for the majority of patients suffering from mental illnesses" (Maharajh & Parasram 1999).

The Academic Development of Psychology

Internationally, "Psychology is a well­developed discipline with an incredible history" It is among those courses with the highest demand for enrollment in universities. "Hence most Wliversities around the globe have incorporated faculties, schools and research institutions specifically dedicated to its study" (Ramdhanie 1999). However, "throughout the English-speaking Caribbean for most of the

1960s through the 1980s, psychology had been "grossly neglected" as an academic discipline and "largely unpracticed" as a profession (Ramdhanie 1999).

During an interview with Dr. Ramesh Deosaran, Professor of Criminology and Social Psychology, he revealed that prior to 1999, "society was relatively naive about psychology. They saw psychology in terms of horoscopes and reading palms, and felt that they could watch somebody's face and see what destiny they had, if they are lucky or fortunate. Psychology was in the realm of superstitions and predictions. It was popular psychology, faddish as beamed from popular magazines" (Ramdhanie 1999).

All three Campuses of the University of the West Indies (St. Augustine, Trinidad; Mona, Jamaica and Cave Hill, Barbados) did not offer adequate graduate degree programmes in psychology (Ramdhanie 1999). Those interested in pursuing a psychology programme at that time would have had to go to a foreign university. TIlls training however, put them at a disadvantage for adequately dealing with local issues because of the differences in theoretical frameworks, standards and formats received aboard (Ramdhanie 1999).

While psychology programmes were well established throughout Departments of Psychology at universities all around the world, only 2 undergraduate courses were being offered through the Department of Sociology in 1970. These courses included General Psychology and Social Psychology, which were both year-long courses. In particular, social psychology had a compulsory research component, which carried 35% of the final mark. At graduate level, there was a Master of Science (MSc) in Sociology with a specialization in Social Psychology. This was also available at the Master in Philosophy

(M .Phil) and Doctoral (ph.D) levels. Therefore, no "pure" Psychology undergraduate or graduate programme was available during this period. Moreover, no provisions were made for the conducting of psychological research, which is especially impertant at the graduate level.

Research in psychology is facilitated by a psychological laboratory. Courses in psychology typically have a laboratory compenent, which enables students to familiarize themselves with "well-established research on human behaviour in a controlled setting" (Ramdhanie 1999). "Students, especially graduate students, with access to such research facilities would have also been able to under­take innovative research, which may have led to important discoveries , developments, confirmations, or refutations" (Ramdhanie 1999). This would significantly have led to the positive development of psychology in the Caribbean as well as international recognition for the University of the West Indies. The practice of psychology was therefore not supported by local research because the opportunities and facilities for local research were absent. This resulted in a lack of psychological research or contribution to social and even economic policies.

Dr. Deosaran was instrumental in bringing about changes that would create a fertile environment for the further development of psychology. He belonged to the Foundation of Psychological Research, which lobbied for the creation of a Psychological Research Centre at the University. On 24 May 1989, the ANSA McAL Psychological Centre was built. Dr. Deosaran stated that "the money was obtained by the Foundation for Psychological Research from the McEnearney Alstons Group (McAL) and the Centre was passed on to University of the West Indies as a gift for promoting

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psychological research" and for making it a place of learning and proper research" (Rarndhanie 1999). According to Sir Isaac Hyatali , Chair­man of the ANSA McAL Foundation, it was a contribution to the advancement of education in psychology for the citizens of Trinidad and Tobago and for them thereafter to spread their learning and experiences to other students and the rest of the community."

TheANSAMcALPsychological Research Centre vowed to uphold the University's mission statement in attempting to achieve its own mission of "promoting and developing the discipline of psychology with particular focus on research, teaching, professional and policy development; as well as using psychological principles as an integral part of applied social science for personal, social and national development" (Ramdhanie 1999). Some of its objectives included "providing a research facility for psychology undergraduate and graduate students and university staff; addressing national problems through research projects, professional workshops and lectures/ conferences; ensuring that courses in psychology have an accompanying laboratory component; and the establishment of a professional journal and library facility" (Ramdhanie 1999).

Although facing challenges of staffing and space, Dr. Deosaran expressed the view that the Centre has grown from a "well-founded idea to a national and regional icon of academic research, teaching and policy development, par excellence." To date, the Psychological research centre has conducted numerous research projects, surveys, conferences and workshops, public lectures and publications. Additionally, it has made policy proposals to government, (which have been accepted), hosted scholars/ visitors, celebrated students' achievement and supported departmental teaching programmes

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on a variety of themes to much success (Ramdhanie 1999). Moreover, in 1994, "the well recognized international journal of criminology and social psychology was formed," which is in fulfillment of one of the centre's objectives. Another of the Centre's successes has been a significant amount of publications in terms of books, working papers, and international journal articles to date. Further­more, efforts are still being made forthe creation of a psychology laboratory through the efforts of Dr. Derek Chadee, manager of the ANSA McAL Psychological Research Centre and coordinator of the Psychology Programme.

The ANSA McAL Psychological Research Centre served to fill gaps in the education system. Enrollment in the two psychology courses offered by the university was very high and there was a great demand for further psychology courses for personal or work-related reasons. Through the management of Dr. Deosaran, the Centre facilitated the introduction of additional psychology programmes which served to expand its role within the University in terms of psychology.

Between the years 1991-1994, seven new undergraduate courses were added. These included Introduction to Psychology, Personality theories, Developmental Psychology, Abnormal Psychology, Selected Theories in Social Psychology; Contemporary Issues in Social Psychology and a Supervised Research Project in Psychology. In the academic year 199411995, Introduction to Social Psychology, Statistics and Research Design in Psychology, Physiological Psychology, Experimental and Applied Psychology and Community and Environmental Psychology were introduced. In the academic year 199511996, a Bachelors of Science (BSc) in Psychology was offered. In 1996/1997, Advanced Topics in Personality, Industrial and

Organizational Psychology, Psychology and Ethnic Relations and Psychology of Politics were included. Furthennore, in 2007, a Specialization option in Psychology was introduced and included courses such as Introduction to Cognitive Psychology, Sensation and Perception, Motivation and Emotions, Learning and Memory and Advanced Topics in Personality (which are electives for the Major). Today, the BSc. or the Special in Psychology is one of the most sought after programmes at the University.

In temlS of graduate courses, the University offers an M. Phil and Ph.D. in Psychology with specializations in either Developmental Psychology or Social Psychology. Dr. Steve Rollocks, a Senior Lecturer at the University and a Clinical Developmental Psychologist was instrumental in the fonnation and maintenance of the developmental specialization for the M.Phil in Psychology. Similarly, Dr. Derek Chadee, who is also a Senior Lecturer and Social Psychologist, is responsible for the development and continuation of the Social Psychological aspect of the M .Ph il in Psychology. In addition, an MSc. in Clinical Psychology was introduced in 2004 through the Department of Psychiatry at the Faculty of Medical Sciences. The programme is currently coordinated by Professor Gerard Hutchinson, who is a Psychiatrist. Dr. Rollocks is also a Lecturer in this programme and plays a fundamental role in the training offuture Clinical Psychologists. Clinical Psychology students thus benefit from the rwo perspectives, that is, clinical psychology and psychiatry.

On reflection, Dr. Deosaran stated that the Foundation of Psychological Research has "succeeded in both qualitative and quantitative tenns in getting both the community inside the university as well as the community outside of

the university to accept and value psychology as a very cherished discipline, not only for personal development, but for professional and national development as well" (Ramdhanie 1999).

Development of Psychology as a Profession

Hamlin Duncan was the first psychologist in Trinidad and Tobago. Psychology started at S1. Ann's Hospital in the 1960s. By 1968, the hospital had employed a counseling psychologist named Ms. Yvonne Rojas. Mrs. Judith Hinkson was one of the first Clinical Psychologists employed at S1. Ann's Hospital. By the year 1997, there were approximately 30 psychologists in Trinidad, specializing in different areas of psychology. These individuals included those who had Doctorate and Masters level degrees in Psychology as well as a few counselors who had their Bachelors degrees and Diplomas, who practiced as psychologists.

In the 1980s Mrs. Judith Hinkson and Dr. Ghany (Forensic Psychiatrist) saw the need for another psychologist at SI. Ann's Hospital. Dr. Dianne Renaud was employed. Early Psychologists at SI. Ann's Hospital also included Dr. Steve Rollocks, Mrs. Anissa Baksh-Ghany, Dr. Karen Moore, Mr. Steve Le Quoi, Ms. Sharice Stauble, Ms. Waveney Richards and Ms. Anna Maria Mora. Currently, Ms. Ruth Abrams and Ms. Sian Allum are employed at St. Ann's Hospital as clinical psychologists. Ms. Allum is the first regional health authority psychologist that has come out of the Masters in Clinical Psychology programme started in 2004.

Prior to 1992, Psychologists were mostly trained to work in health and education.

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According to Ramdhanie (1999), up to the early 1990s, psychologists were inclined to focus on educational, clinical and drug rehabilitation! counseling areas through working with psychotic, retarded, abusive, addictive, emotionally disturbed, criminal and learning disabled people. However, since 1992, psychologists have delved into "new" fields such as public relations, sports, law and family, in addition to the traditional areas.

There was also a change in the workforce of Trinidad and Tobago that caused the role of psychologists to be expanded in "commtmities, and in prevention! intervention settings, such as commtmity, physical ! mental health clinics and hospitals." In addition, within the educational environment, they were being called upon to contribute to the "formation of attitudes, ideas, beliefs and morals" (Ramdhanie 1999).

Another landmark for the development of psychology in Trinidad and Tobago was the passing of the Trinidad and Tobago Association for Psychologists ' (TTAP) constitution on 25 August 1996. It provided the rules anq regulations guiding the behaviour of its members as well as gave a description of the duties of different members of the executive. Dr. Krishna Maharaj, the current Senior Clinical Psychologist at St. Ann's Hospital, is considered the "founding father ofTTAP" and is one of its early presidents.

TTAP was incorporated as a legal entity on 20 October 2000. TTAP represents all psychologists in Trinidad and Tobago. Their goals include: (l) "promoting the concept of total wellness as it pertains to the psychological well being of all persons; (2) promoting and maintaining the honour and interests of the profession of psychology; (3) promoting and protecting the interests and welfare of psychologists; (4) maintaining and improving the

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standards of conduct and proficiency of the profession of psychology; (5) representing the interests of psychologists ofT rinidad and Tobago in local and international bodies; (6) promoting good relations within the profession, between the profession and other professional bodies and the public generally; (7) promoting good relations between the profession and professional bodies in other countries and to participate in the activities of any international body or association of psychologists and to become a member thereof; (8) promoting continuing education and research in the field of psychology; (9) engaging in publications, seminars, workshops and other activities for the purpose of disseminating information and knowledge of psychology; and (l0) doing all such other lawful things as are incidental or conducive to the achievement of the foregoing aims and objectives" (Trinidad and Tobago Gazette 2000).

TTAP has been given the authority by the government of Trinidad and Tobago to carry out such disciplinary measures amongst its members as it deems necessary for the maintenance and carrying out ofits objectives. However, this authority only extends to its members and not those who have opted not to join the association for whatever reasons. The association will thus be only able to meet its aims of "maintaining and improving the standards of conduct and proficiency of the profession of psychology" to an extent. In addition, "there is yet no official licensing certification apparatus and therefore anyone with a degree in psychology can set up a private practice" (Ramdhanie 1999). The association can thus do little about this as legislation does not exist to protect the public in this way from unqualified persons.

The Association has also been gi ven the power to 'from time to time' make rules for the proper conduct of its proceedings and discharge

of its duties, powers and ti.mctions and such rules may be amended from time to time. Similarly, the making and enforcing of rules extends only to its members.

Influence of Psychology on Private and Public Sectors in Trinidad and Tobago

Public Sector

The field of Psychology has influenced both the public and private sectors of Trinidad and Tobago. Psychology was developed within the psychiatric setting. In 1849 under British rule, the first ordinance was passed to detain insane persons who were charged with offences at the Royal Goal. In 1858, the Belmont Lunatic Asylum was opened with 47 inmates (South­West Regional HealthAuthority 2008). By 1863, there were 101 patients at the asylum. The St. Ann's Asylum was constructed in 1900 to address the poor conditions at the Belmont Lunatic Asy lum. It accommodated more than 500 inmates. The name of the institution was then changed from St. Ann's Asylum to St. Ann's Mental hospital in 1935 and to St. Ann's Hospital in 1961 (Beaubrun et al. 1976) in an attempt to de-stigmatize patients.

Dr. LFE Lewis was one of the first psychiatrists at the St. Ann's Hospital in 1943. He was instrumental in creating changes in St. Ann's during his 45 years of service, one of which was the establishment of outpatient clinics in 1950. In 1959, as Chairman of the Ministry of Health, he produced a comprehensive mental health plan for the territory which was pivotal to the creation ofa psychiatric unit at Port of Spain General Hospital in 1965 and San Fernando General Hospital in 1966 (Maharajh & Parasram 1997).

Psychiatrists from St. Ann's Hospital went to San Fernando General Hospital to treat patients because they did not have a clinical team or a treatment programme. Dr. Helene Marceau­Crooks was the first Psychiatrist to be employed at the San Fernando General Hospital. Dr. Roma Joseph-Thomsonjoined her as Registrar in 1977. Dr. Celia Ramcharan was employed in 1979 and succeeded Dr. Marceau-Crooks as Specialist Medical Officer and Head of Department in 1992. Dr. Karen Ghany joined the staff as Specialist Medical Officer in 1999 and is the current Head of Department (South­West Regional Health Authority 2008). In 1979, Dr. Krishna Maharaj was also employed at the San Fernando General Hospital as a Clinical Psychologist. Ms. Diane Renaud was also employed as a Clinical Psychologist at the San Fernando General Hospital during this period.

In 1975, the first Child Guidance Clinic in Trinidad and Tobago was established (James 1984). Prior to this, children, adolescents and adults were seen in adult clinics by psychiatrists. The Child Guidance Clinic is a specialized clinic, which provides psychiatric and psychological services for children and adolescents up to the age of 18 years (South-West Regional Health Authority 2008). There are 2 child guidance units, one at Mt. Hope Hospital and one at Pleasantville Health Centre. Neither of them has in-patient or day-care facilities. Each unit comprises of at least a psychiatrist , a clinical psychologist and two psychiatric social workers. Dr. A. Thompson is the Clinical Psychologist at the Mt Hope Child Guidance Clinic. She is also one of the few Neuropsychologists in the country. The Community Mental Health Programme was formalized in 1975 with the Sectorization Plan and the Mental Health Act (1975). Professor Michael Beaubrun, a renowned Caribbean

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psychiatrist, who was Principal Medical Officer at the time, was largely responsible for the implementation ofthe plan. He is also referred to as the "Father of Caribbean Psychiatry."

In terms of the sectorization plan, Trinidad and Tobago was divided into 5 sectors or catchment areas (namely, sector I A, I B, 2, 3A, 3B, 4 and 5) of approximately 200,000 persons each. Each sector consisted of a team of psychiatrists, social workers, mental health officers (community nurses) and mental health attendants (paramedical auxiliaries). Psychologists and occupational therapists were few in number and so were not assigned to just one area (James 1984). The multidisciplinary teams were responsible for the care of patients within their respective sectors from inpatient care to community care. The goals were to provide psychiatric care as near as possible to the patients own home; to upgrade the facilities at St. Ann's Hospital ; to introduce sub-specialist services in psychiatry; to develop a system of consultation with the community and to integrate mental care with genera! and public health care as much as possible (Ministry of Health 1975). The development of these clinical teams encouraged the different helping professions to work together to promote wellness in mentally ill persons. Through case conferencing, each professional gave his perspective and a holistic treatment plan was formed for each patient.

In 1975, the Mental Health Act (No. 30 of 1975), which had undergone several drafts since 1960 became law (Mental Health Act, 1975). A new category of mental health officers was created by this Act. In 2000, the Mental Health programme was reformed and became the responsibility of the Regional Health Authorities (RHA) as against the Ministry of Health. It divided Trinidad and Tobago into 4 instead of5 RHAs. These included the North-Western

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Regional Health Authority (NWRHA), Eastern Regional Health Authority (ERHA), South­Westem Regional Health Authority (SWRHA), and the Tobago Regional Health Authority (TRHA). The goals and objectives of the Menta! Health Plan (2000) included encouraging "the development and maintenance of the highest level of menta! health in the population ofTrinidad and Tobago and to provide an adequate level of indi vidualized care for those who have a menta! disorder or are at risk of suffering from a mental disorder," primarily through education and adequate primary, secondary and tertiary care (South-West Regional Health Authority 2008).

The NWRHA, SWRHA and TRHA have psychologists and a programme for treatment. The ERHA does not yet have a programme and is still served by the other RHAs in terms of its mental health staff. The RHAs are autonomous statutory bodies ensuring health care service delivery to all residents in their respective regions. Every hospital, health centre, or outpatient clinic falls under one of these RHAs and treatment is provided by the multi­disciplinary team. Treatment over the years has evolved from custodial care (except in chronic and locked wards) to pharmacotherapy and psychotherapy.

These developments within the public sector have marked the development of psychology within the public sector. To be specific , Psychologists have been employed at St. Ann's Hospital as early as 1968 and have contributed to the well ness of the population of Trinidad and Tobago since then. They formed part of the tearn that was sent to the South-West Regional Authority to help treat the mentally ill in that catchment area., until then this RHA employed its own clinical psychologists to make up its multidisciplinary team. This pattem was seen in all hospitals where the mentally ill were being

treated. Therefore as psychiatrists made their services more available to the public through transformations within the health sector so did psychologists.

Psychologists had been clamouring for some of the aforementioned changes in the health sector. For example, Ms. Yvonne Rojas, one of the first psychologists employed at St. Ann's Hospital, lobbied for the improvement of psychological services; more effective utilization of available resources and sufficient training for clinical staff. These concerns have been addressed to an extent with the reformation of the health sector.

She also made requests forthe development of child guidance clinics and recommended that these clinics should house a child psychiatrist, psychiatric social worker, psychologist and speech therapist. While these clinics exist today, speech therapists for example, are not necessarily part of the multidisciplinary team and have to be out-sourced. Shortages in terms of staff exist even today but Dr. Krishna Maharaj indicated that one 0 f the ways in which this has been addressed is by the proper screening of patients.

However, some concerns raised by psychologists have not been sufficiently addressed. For example, Ms. Rojas also lobbied for a different system of referrals and testing. She wanted to encourage other helping professions to provide adequate explanation for the referrals of their patients as well as to provide sufficient information on their patients, such as age which is important for the scoring of tests. These made the psychologist's role in addressing mental health more challenging.

Ms. Rojas as well as other psychologists also wanted to encourage other hel ping

professions to operate within the boundaries of their respective professions. For example, some psychiatrists make requests for particular tests to be carried out. However, "these requests often do not correspond with the problems that are being presented." While this may be frowned upon, legally, no constraint exists to prohibit a psychiatrist (or any physician) from performing the recognized functions of a clinical psychologist (Iscoe 1957). This issue still exists as is evidenced by the fact that referral letters have to be sent back to get the required infom1ation included or inconsistent infommtion (such as the request for specific tests) removed.

Furthermore, she lobbied for career mobility for psychologists. She believed that the clinical setting (psychiatric units) should also have a Senior Psychologist, Junior Psychologist and a Psychometrist. Dr. Krishna Mal1araj also shared this view as he added that individuals who had their Bachelors in Psychology should have the opportunity to be research assistants so that they can obtain the invaluable experience of working in a clinical setting. These together with other concerns have been echoed by other psychologists. Some psychiatry units have employed at least a senior psychologist as well as ajuniorpsychologist.

However, as one reflects upon the development of psychology in Trinidad or more specifically the public sector, one can see that psychology tends to playa secondary role to other professions (for example, psychiatry) in the clinical setting and other fields in the academic setting, such as sociology. This is also reflected in the Mental Health Act No 14 of1999, which makes no direct mention of Psychologists and the role that they play in providing treatment for the mentally ill. This may be an indicator of the value that is placed on the service that psychologists provide to the country or the level

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of respect for the profession as a whole. The value placed on psychology in Trinidad and Tobago is also reflected in the poor pay incentives and working conditions of psychologists in the past as well as in the present compared to other professions in Trinidad and Tobago or other psychologists abroad. However, a new Mental Health Act was to be released at the end of 2008 or the beginning of next year 2009 and there is hope that it may clearly identifY psychologists and their role in promoting weJlness as well as address some of the concerns that have been raised by psychologists.

Private Sector

Psychology has also influenced the private sector for psychologists are also engaged in private practice. Individually or as a medical health team, psychologists offer the same kind of care as the St. Ann's Hospital or any other psychiatric unit. However, the waiting time is significantly less and there is more privacy for receiving medical health care. Whilst the public hospitals tend to cater for the lower class and the lower middle class, private practice tends to cater for the upper middle class and the upper class.

Psychologists are also hired by private companies to provide Employee Assistance Programmes (EAP) for their employees. The EAP is a confidential service that is offered to employees, and their immediate families to help them "cope with personal and work-related problems," such as "employee/executive burnout, personal trauma, family crises, relationship problems, substance abuse or hostile confrontations." The EAP programme aims to "enhance the health, well-being and productivity of employees" (Neal and Massy Holdings 2008) .

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The Ministry of Education 's EAP provides its employees with "quality psychological services in an ethical and responsible manner to facilitate their personal and professional growth and development." Psychologists form part of their in-house EAP and are also contracted. They provide confidential personal assistance (such as anger management; financial crisis; stress management; mental health issues and time management) and organizational services (such as job coaching, mentoring, team building and retirement policy). When acting in a consultancy capacity, psychologists provide lectures, training sessions and workshops. This is done in order to enhance employee and workplace effectiveness through prevention, identification, and resolution of personal and productivity issues" (Ministry of Education 2003).

Neal and Massy Holdings Limited is another company with an EAP programme. They contract EAP providers, namely "psychologists, therapists and counselors to offer psycho­emotional and psychosocial therapeutic services to employees" (Neal and Massy Holdings 2008). These and other services, which include management and supervisory training; mediation in dispute resolution and critical incident interventions are fully paid by the company.

Elders Associates Ltd. is an example of a group of psychologists who "provide assistance to employees who are experiencing personal problems that may be negatively affecting their job performance" (Elder Associates 2008) on behalf of companies. They acknowledge that personal problems affect productivity, and encourage companies to help their employees work through those issues (especially the ones that affect job performance) as against firing them for there is no guarantee that the workers who are hired would not have the same

problems. Elder Associates Ltd. aim to reduce financial costs to firms by providing assessment, counseling and follow-up. They forecast that investing in employees emotional and psychological wellbeing will reduce insurance claims, sick leave, accidents and injuries, turnover, poor decision making and grievances. This will also improve staff working conditions and public image.

Psychologists also serve the public through non-governmental organizations (NOOs) like Families inAction (FIA). Established in 1988, FIA was developed in an effort to "address the growing problem of drug addiction" in Trinidad and Tobago (Families inAction 2008). They aim to "promote healthy family life, balancing emotional, physical, spiritual, social and psychological needs" in an attempt to "regenerate both the family unit and/or any individual of that unit who is experiencing pain, isolation, addiction or dysfunction" (Families inAction 2008). Their services include child development, confident parenting, youth education and employee assistance through a 24 hour hotline, group and workplace support, counseling, community outreach, assessment and referrals.

Other NOOs address different issues that can affect the quality oflife of the people of Trinidad and Tobago. Some of them include the Trinidad and Tobago Coalition against Domestic Violence (T &TCADV), Childline; Lifeline, Rebirth House Drug Rehabilitation Centre; Rape Crisis Centre; Organization of Disaster Preparedness and Management (NEMA); Serenity Place;Autistic Society and the National Alcohol and Drug Prevention Programme (NADAPP). Psychologists have worked for some of these NGOs to help them achieve their

objectives. Some of these psychologists include Dr. Steve Rollocks, Dr. Camp bel Phillips, Dr. Dorrell Phillip and Ms. AJlyson Hamel-Smith.

Dr. Steve Rollocks is a clinical child psychologist who also specializes in developmental psychology. In addition, Ms. AJlyson Hamel-Smith is a clinical psychologist who specializes in learning difficulties and behaviour problems in children and adolescents. Other Clinical Psychologists who have influenced the private sector include Dr. Karen Moore (who specializes in child and adolescent Psychology); Dr. Judith Hinkson (who specializes in adolescents and adults with mental health or neurological issues as well as career or personal assessment); Dr. Jillian Ballentyne (who specializes in individuals, couples/marital and group counseling as well as treatment for depression, eating disorders and stress) and Ms. Waveney Richards, (who specializes in trauma counseling for older adolescents and adults as well as women's issues). These and other psychologists influence the private sector of Trinidad and Tobago by providing confidential services that promote mental health to individuals of different age groups, ethnicity, sex and socio­economic status.

The field of psychology has steadily developed both in the private and public sectors of Trinidad and Tobago. It is also a product of the history of the region and its religious and cultural influences. Despite being "supported" throughout its development by psychiatry, psychology has established itself as a discipline and a profession in its own right (and continues to do so). This unique blend of psychology has contributed to the improvement or maintenance of mental health and wellbeing to the population.

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