SUMMARY

Frantz Fanon (1925–1961), a West Indian of mixed race, was a French colonial psychiatrist trained in Lyon, France, who worked mainly in colonial North Africa between 1953 and 1957. He was one of the earliest psychiatrists to suggest that the lived experience of ethnic minorities within a discriminatory colonial environment could trigger mental illness. This article focuses on Fanon’s work and contributions to psychiatry, as well as his philosophy, advocacy for social inclusion and pioneering work in culturally relevant rehabilitation. It also examines what lessons could be learnt from his life’s work as a psychiatrist and traces his influence on a generation of psychiatric researchers, suggesting how his contribution may have influenced critical thought and current views.

Frantz Fanon was one of the earliest Black psychiatrists to highlight the inequalities in psychiatric care on the basis of race, culture and religion. Fifty years after his death in 1961, this would be an auspicious time to highlight his pioneering contributions to the practice of psychiatry. His contributions to the genre of postcolonial literature (Loomba 1998; Gibson 2003) and the subsequent controversies surrounding his views on the advocacy of violence as a tool for colonial liberation have largely overshadowed the fact that he was a clinician who experimented with what is now known as social therapy, day hospitalisation and culturally sensitive treatment of people with mental illnesses. The very issues that he championed are still important today and it is my opinion that there is much to gain from reviewing the life and times of this pioneer in ethnopsychiatry, to see just how far such psychiatric theory and practice have moved in the past 50 years and what remains to be done in terms of equality in access to mental healthcare.

In this review I concentrate on Fanon’s contributions to clinical psychiatry. My aim is not to validate his views, but to give a factual historical perspective on his work and contribution to psychiatric practice, in the hope that this may stimulate further scholarship into his writings.

Origins and formative years

Frantz Fanon was born on 20 July 1925 on Martinique, a French colony in the Caribbean islands of the Antilles, to a middle-class family of comfortable means. His father was a Black customs inspector and his mother was a well-to-do shopkeeper of mixed race, whose White relatives hailed from Alsace, France. As in many French colonies, race and skin colour was important; White ancestry was prized and conferred social, economic and cultural advantages (Gibson 1999; Macey 2000).

Fanon seemed to have been relatively isolated from the realities of discrimination and one biographer, Alice Cherki, an intern who later worked with Fanon in a psychiatric hospital in Algeria, said that he had an ‘all round happy childhood’ in Martinique (Cherki 2006: p. 7).

Slavery had been abolished in 1794 in mainland France and in 1848 in the colonies (Castel 1988; Dowbiggin 1991) and there appeared to be distinct and accepted harmonious racial boundaries between people of African descent, the mixed races and the minority colonial White class (Macey 2000). The Black majority aspired to being as assimilated as possible into French culture. Adams noted that ‘blacks derived positive self esteem when they made themselves to be as white and French as possible’ (Adams 1970). In all respects, Fanon considered himself a loyal French citizen.

The radicalisation of Fanon

Fanon joined the Free French Army during the Second World War and was wounded in German-occupied France. He was later decorated for bravery in action. After the war, he found that French soldiers of West Indian and African origin were discriminated against. To a young man who had grown up watching Tarzan films and identifying not with the Black native, but with ‘the white lord of the jungle’ (Fanon 1952a [1967 reprint: p. 180]), this must have been a cultural shock of significant magnitude. Isolated from home, disillusioned by racial discrimination and second-class citizenship, he was to reject his French identity, with its ideals of liberty and equality, for which he had hitherto been willing to die.

Fanon spent the rest of his life in a self-questioning philosophical search for his true identity, using psychoanalytic and psychosexual terms in his writings (Fanon 1952a, 1959a, 1961) to explore what it was like to be Black in a dominant White culture. He theorised that the apparent inferiority of ethnic minorities was a result of what he called ‘epidermalization’ (Fanon 1952a [1967 reprint: p. 4]) of an economic and social process. He felt that the injustices of colonialism mitigated against the Black man integrating into French society, which was supposed to be founded on the principles of justice, liberty and equality for all of its citizens. As a psychiatrist, he concluded that mental illness and racial discrimination were both forms of alienation from society, robbing people of their humanity, and that colonisation itself was a trigger for mental pathology in the native colonised (Fanon 1952a, 1961).

Fanon’s experiences, mainly catalogued in his seminal works (later adopted by postcolonial critical discourse) Black Skin, White Masks (1952a) and The Wretched of the Earth (1961), reveal an intense, somewhat angry individual, impatient for change, who rejected the idea that his very being could be looked at only through the prism of skin colour and that his colour made him a lesser being. He passionately fought against anti-Semitism and rejected the label of ‘otherness’ – a coloured, inferior minority that needed to be whitened or ‘lactified’ (Fanon 1952a [1967 reprint: p. 33]) to be accepted into society.

In 1948, Fanon had a daughter as a result of a relationship with a White French student. He later had a son with another ethnic White woman – a Corsican gypsy, whom he married in 1949.

Fanon did not stay in mainland France, with its lucrative prospects of private practice and research facilities. He felt his services would be more appreciated in working with the colonised ethnic minority and thus most of his practice was in the French colony of Algeria (Macey 2000; Keller 2007a).

His advocacy of violence was apparently borne out of frustration and impotence to change a colonial system that he felt was maintained through indescribable violence. This frustration is encoded within his letter of resignation and subsequent exile as a psychiatrist while working in Algeria in 1957, observing that: ‘If psychiatry is a medical technique which aspires to allow a man to cease being alienated from his environment, I owe it to myself to assert that the Arab, who is permanently alienated in his own country, lives in a state of absolute depersonalisation’ (Macey 2000: p. 299).

Early educational influences

Fanon returned home to Martinique in 1945 after the Second World War and studied for his baccalaureate. He became acquainted with Aimé Césaire (1913–2008), a celebrated Black poet, politician and founder of the Négritude movement (a literary and ideological movement launched by French-speaking Black intellectuals, writers and politicians in Paris in the 1930s). This may have also influenced his use of poetic imagery in his writings and several unpublished plays (Cherki 2006). He studied Hegel and other philosophers and reduced Hegel’s philosophy of dialectics to the effects of colonisation on the colonised, suggesting a binary ‘Manichaeism’ of mutual exclusivity between the dominant White and the ethnic minorities.

Fanon was also conversant with the existentialist writings of Jean-Paul Sartre and Albert Camus, particularly the former’s radical stance against anti-Semitism.

Although not a communist, Fanon had read Karl Marx and been part of radical student movements in France, editing left-wing magazines that were becoming popular among supporters of anticolonial movements (Adams 1970).

Fanon became familiar with deep divisions between Black and White people in the USA’s southern states through the work of African American writers such as Chester Hines and Richard Wright (Fanon 1952a). Some of these influences became the template for his critical discourse on prevailing psychiatric and psychological theories of his time.

Fanon on psychoanalysis

Although Fanon utilised much of Freud’s work on psychoanalysis, he rejected the notion that a universal early psychosexual origin was the prime determinant of all human behaviour (Fanon 1952a). He suggested that Black people’s lived experience (or Erlebnis) within an oppressive colonial milieu was far more important in shaping behaviour. He also felt that Carl Jung’s ‘collective unconsciousness’ was ‘cultural, not acquired’ (1967 reprint: p. 145).

A psychological profile of Fanon’s advocacy of violence may be gleaned from some of his work. In Black Skin, White Masks (Fanon 1952a), he quotes Germaine Guex, a little-known psychoanalyst who propounded an ‘abandoned neurosis theory’ (Guex 1973). The abandoned child was now portrayed by Fanon as the isolated ‘Negro’, rejected by his adopted French identity, then rejecting his very Blackness. One could consider, therefore, that Fanon, feeling helpless to change a colonial system maintained through violence and already a war veteran, regressed into the primitivism of an advocacy of violent revolution.

Psychiatric practice

Colonial psychiatric treatment

It is important to situate Fanon’s psychiatric practice in the context of the practice of psychiatry in French colonial North Africa. McCulloch, commenting in Colonialism and Psychiatry on the purely custodial nature of most colonial asylums, noted that before ‘the 1940s there was virtually no treatment provided’ (McCulloch 2001: p. 83). By the mid-20th century, however, there was a new impetus in the use of psychiatry as a tool for the civilisation of the supposed mentally undeveloped colonised people, including lobotomy – a procedure upon which Fanon frowned and that seemed to be tested more on ‘Muslims than on settler patients’ (Keller 2007a: p. 108). Psychiatrists experimented with now questionable practices like ‘paludotherapy’ or deliberate infection to produce the hyperthermia of malaria to cure syphilis. Other methods included induction of sleep or coma (with insulin or barbiturates) and seizure induction using cardiazol injection to counter schizophrenia. Lumbar punctures were routine and electroconvulsive therapy (ECT) was used rather more frequently than today, for people considered incurable or chronically insane. (For greater detail of treatment methods see Keller 2007a.)

Most Arabs, however, had to make do with patronage of spiritual and traditional healers and the vast majority were left to their own devices to wander in cities and villages (Macey 2000; Keller 2007a).

The ‘Algiers School of Psychiatry’

When Fanon entered Blida-Jonville Hospital (Box 1), colonial psychiatry was dominated by the ‘Algiers School of Psychiatry’ – a school of thought founded by Professor Antoine Porot (1876–1965), an influential psychiatrist who suggested ‘that the North Africans were characterised by primitive brain development and their lives ruled by instinct, given the absence of higher brain functions’ (Cherki 2006: p. 65).

BOX 1

Fanon’s medical education and posts

1946

Entered the medical school in Lyon, France

1951

Worked as an intern at Saint Ylie Hospital, France

1951

Graduated as a doctor

1952

Worked for a few months in the Antilles. Unable to adapt, he returned to France

1952

Joined the staff at St Alban’s Hospital, France, under François Tosqeulles (1912–1994), founder of the movement for institutional psychotherapy

June 1953

Qualified as a psychiatrist under Tosquelles’ supervision

Sept 1953

Worked as a locum at a 500-bed hospice in Portorson, Normandy

1953–1956

Appointed head psychiatrist in the 200-bed Blida-Jonville Hospital, Algeria (now named after him). Practiced what is now considered sociotherapy

1957

Exiled to Tunisia. Appointed consultant at Psychiatrist Hospital, Clinique Manouba, and later founded the first day hospital in North Africa at Charles Nicole Hospital, Tunisia

1961

Died of leukaemia on 6 December 1961, in Maryland, USA, and was buried in Algeria

Keller (2007b: p. 827) noted that the teaching at the time was that the Arab was ‘an inherent primitive and an incipient criminal’. Another psychiatrist J. C. Carothers, in the then English colony of Kenya, had propounded similar views. He suggested also that the typical African had a ‘relative idleness of his frontal lobes’ (Carothers 1951: p. 46).

At Blida, Fanon rejected Porot’s thesis and in an article entitled ‘The North African Syndrome’ (Fanon 1952b) he indicted colonial psychiatry for racism. He argued that rather than this disorder being due to inherited malingering and pathological indolence, it was actually a culture-bound syndrome foisted on the native by a hostile colonial environment.

Early experiments in ethnopsychiatry and sociotherapy

Fanon practiced in segregated wards at Blida with 165 European women and 22 Arab men as patients (Macey 2000). He found different responses to his social rehabilitation experiments, which later became the basis for pioneering work in ethnopsychiatry. For example, Fanon was able to engage White female patients in meaningful social activities, but he mostly failed with those patients who were male, Arab and Muslim. They refused to engage in what was traditionally perceived as female preoccupations, for example basket-weaving. He eventually found success in encouraging them to meet in groups in tea houses and observe religious festivities, popular among the indigenous Algerian population. His efforts, detailed in his biographies (Macey 2000; Cherki 2006), showed that he encouraged patients to have a choice in their treatment. He started a ward-based newspaper, formed a soccer team, desegregated wards and held psychodrama and psychoanalytic sessions (Gibson 2003; Cherki 2006). He emphasised the social inclusion of patients into society, by urging participation in culturally relevant vocational activities.

Although he never spoke the local language, Fanon travelled widely into the interior of Algeria and was one of the first colonial psychiatrists to recognise the value of working with traditional explanatory models of the causes of mental illness, which included views on spirituality, now thought to be important in recovery models (as previously explored in this journal: Bhui 2004).

Early efforts at nidotherapy

Fanon’s efforts in redesigning the hospital environment to make it as unrestrictive as possible is rather similar to modern-day nidotherapy, in which the environment is adapted to clients’ rehabilitation needs, as this journal has reported (Tyrer 2005). Along with colleagues Drs Charles Geronomi and Jacques Azoulay, Fanon was to institute far-reaching reforms, re-building a disused hospital mosque and removing Christian quotations and symbols that adorned the walls, which had hitherto added to the sense of marginalisation for indigenous patients (Macey 2000; Gibson 2003).

Day hospitalisation

Day hospitals had originally been developed in Moscow (Dzhagarow 1937). Fanon’s pioneering experiments in day hospitalisation in Tunisia became the subject of a 1959 article in La Tunise Médicale journal. It suggested that mental illness was a ‘pathology of liberty’, with the authors claiming that out of 1000 patients seen in a 16-month period, less than 1% needed institutionalised care (Fanon 1959b; Macey 2000: p. 321).

Important educational research and clinical drug trials

Fanon wrote and presented articles ranging from ethnopsychiatry to sociotherapy. He also published collaborative research on a culturally appropriate version of the Thematic Apperception Test. He co-authored scientific articles on pharmacological clinical trials on meprobamate and later experiments with lithium therapy (for a comprehensive list of Fanon’s academic publications see Macey 2000). Fanon also participated in developing a curriculum for a degree in psychiatric nursing while lecturing at the University of Algeria and organised symposia and lectures attended by nurses and interns (Cherki 2006: p. 75).

The most remarkable legacy of his practice was that he was a pioneer in advocating religious and culturally sensitive humane treatment of individuals (Bulhan 1985), as well as utilising the then latest available pharmacological and psychological treatments. This is similar to today’s biopsychosocial recovery models (Wolfson 2009).

Advocacy of violence and Fanon

While practicing psychiatry in colonial Algeria (1953–1956) and later in 1957 in Tunisia, Fanon witnessed the suppression of anticolonial insurrection by the colonial French forces, who used physical and psychological torture methods against Arab Muslim detainees. In The Wretched of the Earth (Fanon 1961), Fanon presented psychiatric case histories of Arabs who had been tortured with the active participation of fellow doctors. His duty was to treat French combatants, but he also sympathised with the Arab rebels and offered them medical treatment clandestinely.

His revulsion at torture and its effect on both the medical profession and the victim is clear in A Dying Colonialism, where he observed: ‘ten times the doctor intervenes, and ten times he gives the prisoner back to the pack of torturers’ (Fanon 1959a [1967 reprint: p. 138]).

In 1956, Fanon became a direct combatant within the FNL (Algerian Liberation Front). In his last few years of exile in Tunisia he became passionately committed to the liberation of Algeria and low- and middle-income countries. As chief propagandist for the FNL, he travelled extensively in Africa, urging violent revolution against colonialism. He insisted that this was the only way to combat the armed suppression of the individual rights of colonised people worldwide (Fanon 1990). Although he became an icon for liberation movements in low- and middle-income countries through his advocacy of violence, Fanon was to later conclude that ‘there is no negro mission; there is no white world’ (Fanon 1952a [1967 reprint: p. 178]).

Influences on psychiatry

Influence on practice

Fanon was one of the earliest psychiatrists to propagate the view that mental illness and racial discrimination were both forms of exclusion from society, which required an integrative and culturally sensitive approach. This theme has spawned many research projects, both past and ongoing. Although he was not British and mostly practised in colonial France, many of Fanon’s ideas are contained in current themes for national psychiatric discourse (National Institute for Mental Health in England 2003; Department of Health 2005a).

Fanon’s advocacy of violence remains controversial, but his contributions to psychiatry are undoubted.

Researchers’ critical views on Fanon

Fanon has been quoted by many important researchers in ethnosocial psychiatry. Littlewood & Lipsedge (1982) in Aliens and Alienists referred to Fanon as ‘eloquently describing the immigrant who, lonely, bewildered, is cut off from his cultural roots’ (p. 70). Adams (1970) described him as a ‘social psychiatrist driven by humanism to unmask inhumanity’ (pp. 809–811). Psychiatric historian Richard Keller noted that Fanon was compared to Pinel, the 18th-century psychiatrist who reportedly liberated incarcerated patients (Castel 1988) and concluded that Fanon’s ‘life and work therefore remain important for historians’ (Keller 2007b: p. 826). Bhui, in his seminal work Racism and Mental Health, devoted a whole chapter to ‘The legacy of Frantz Fanon and contemporary representations of racism and mind’. He suggested that Fanon used psychoanalytic thought and process ‘as tools for unearthing the racist in us all’ (Bhui 2002: p. 62). McCulloch (2001) described Fanon as ‘the most eloquent critic’ of colonial psychiatry. Recalling his influence on European psychiatry, McCulloch observed that Fanon was most likely the ‘first practitioner to have read the work of both Francophone and Anglophone specialists’ (p. 79).

Sadowsky, in his treatise on colonial psychiatry Imperial Bedlam, describes Fanon as ‘possibly the most famous psychiatrist to have done clinical work in Africa’. He found Fanon’s view about colonialism causing mental pathology intriguing, but thought that this thesis had an inherent ‘difficulty to establish’ (Sadowsky 1999: pp. 2–3).

Robertson & Walter (2009), writing in Acta Neuropsychiatrica, coined the concept of the ‘Fanonian tradition’, a way of understanding, through Fanon’s writings, the colonial context of politics, history and social power, and ‘the ontological and epistemic question of mental illnesses’ (p. 209).

Fanon is not without his critics, however. Adams (1970: p. 812) referred to him as a ‘sick man obsessed with cataclysm’; others have been less kind. Columnist Robert Fulford (2002) called him a ‘romanticised murderer’ and ‘a poisonous thinker who refuses to die’.

Fanon: 50 years on

The state of rehabilitation in psychiatry is much changed from Fanon’s day. In a faculty report (Wolfson 2009) the Royal College of Psychiatrists emphasises the need for a recovery model that has largely replaced old colonial practices of social control and incarceration, both of which had initially led Fanon to believe that ‘Madness is one way a man can lose his freedom’ (Macey 2000: p. 299).

The hospital today at Blida has lost its past glory – now neglected, underresourced, underfunded and overpopulated (Keller 2007a).

Fifty years after Fanon’s death, such Foucauldian apprehensions of psychiatry as a tool for social control are still alive, with ongoing debates on antipsychiatry, postmodern psychiatry and, more recently, discourse on what critical psychiatry calls ‘the contested nature of madness’, as this journal has described (Thomas 2004).

There have been changes in classification of mental illnesses and their new pharmacological treatments in the 50 years since Fanon’s time, as well as a welcome change in the recognition of culture-bound syndromes.

Fanon’s advocacy of culturally relevant treatments is partly addressed through these changes and European psychiatric training now includes mandatory training in cultural competencies (Quereshi 2008).

Dogra & Karim (2005) highlighted in this journal the need for the recognition of diversity issues, although they observed that teaching in UK medical schools is ‘fragmented’ (Dogra 2005: p. 162). Fanon’s concept of ethnopsychiatry is alive and well. Ethnopsychiatry has now evolved into a broader transcultural psychiatry, which is now included in training for the MRCPsych examination (Royal College of Psychiatrists 2001).

Other scholars, such as Bhugra & Bhui (this journal, 1999), have highlighted the emerging field of ethnopsychopharmacology, taking cognisance of ethnic difference in drug treatment response.

Corroboration of Fanon’s views on racism and mental health

Modern scholars in the UK have corroborated many of Fanon’s views on racism. For example, Chakraborty & McKenzie (2002) suggest that cross-sectional research links perceived racial discrimination with psychosis and depression.

Bhugra & Ayonrinde (2001b) have in this journal previously drawn attention to the idea that racism is likely to act as a chronic stressor and that chronic racism may precipitate psychiatric disorders. Other research suggests that the evidence regarding the Black incidence rate of schizophrenia is shifting in favour of ‘factors of racism and social alienation experienced by Black people in the UK’ (Hickling 2005: p. 256).

Fanon’s legacy

Some of the legacies of Fanon’s advocacy include The Fanon Project Day Centre in Brixton, London, UK (Moodley 1987), and Associazione Frantz Fanon (founded 1996) in Turin, Italy, stimulated by his work to provide culturally sensitive support and counselling for people from minority ethnic groups. Several films chronicling his life have been made (Keller 2007b).

The overall impression is that overt racism in society is less visible but is being replaced by new forms, such as microaggression and institutionalised racism (Sashidharan 2001). The former term, coined by Chester Pierce (1977), describes how everyday forms of discrimination can cause an insidious erosion of self-esteem.

Beyond diversity

Fanon’s work was a precursor of interests in ethnopsychiatry, diversity, culturally sensitive rehabilitation and social inclusion. However, I believe that beyond his contributions still lie unanswered questions. Veling and colleagues (2007) suggest that discrimination perceived by minorities may contribute to an increased risk of psychopathology, a phenomenon that Fanon had identified long ago. Other authors believe that social dislocation and the problems of migration may play a part in the aetiology of an increased incidence of psychosis among African–Caribbean people in the UK, as this journal has previously examined (Bhugra 2001c). The exact link between these causative social factors is still the subject of much research (Sharpley 2001).

On the issue of unequal access to mental healthcare, the jury is still out on whether the current measures to reduce discrimination by displaying antidiscriminatory notices throughout the National Health Service (which I call ‘billboard tokenism’) will ameliorate any proposed social factors contributing to the incidence of psychosis among the migrant population. In addition, there are debates over what exactly a ‘culturally competent clinician’ means (Ferns 1995; Dogra 2005; Quereshi 2008). Fanon’s work may be being taken a step further than he had intended. He advocated the treatment of the individual, all individuals, with equal emphasis on race, culture and creed.

Neighbors and colleagues (2003) have already warned against the production of ‘colour-blind’ psychiatrists who are taught that race should be ignored in public policy and everyday exchange, including psychiatric assessment. It is suggested that these clinicians are likely to make diagnostic errors in disregarding racial and ethnic differences in symptom expression. There is the added risk that new labels such as BME (Black and minority ethnic), although used for administrative reasons, may lead to new forms of stigmatisation.

In conclusion, it is likely that the reciprocity of transference and countertransference between client and psychiatrist requires mutual honesty about individual beliefs and biases not likely to be learned in schools of diversity. This is what Fanon meant when he said (translated from French with deliberately imperfect syntax): ‘The negro is not. Anymore than the white man. Both must turn their backs on the inhuman voices, such that communication be possible’ (Fanon 1952a [1967 reprint: p. 180]).

Department of Health (2005b) Delivering Race Equality in Mental Health Care: An Action Plan for Reform Inside and Outside Services and the Government’s Response to the Independent Inquiry into the Death of David Bennett. Department of Health.

(2003) Racial differences in DSM diagnosis using a semi-structured instrument: the importance of clinical judgment in the diagnosis of African Americans. Journal of Health and Social Behavior43: 237–56.