_ Trauma and Mental Illness in the Haitian Community:
Cultural Considerations for Developing a Broad Clinical and Research Agenda
Conference Held on Saturday, May 5, 2012
at the Massachusetts School of Professional Psychology
221 Rivermoor Street, West Roxbury, MA
_"Our greatest glory is not in never falling,
but in rising every time we fall." (Confucius)
KEYNOTE & INVITED ADDRESSES
(Click on the titles below to download a copy of the presentations.)
Community Mental Health Capacity Building: A Framework
Guerda Nicolas, PhD, Chairperson, University of Miami
There is evidence to suggest that poverty (Sharan, Gallo, Gureje, Lamberte, Mar, & Mazzotti, 2009) is associated with the prevalence of mental disorders, specifically with low levels of education, poor housing, and low-income levels (Lund, et al., 2010; Patel, 2007; Patel & Kleinman, 2003). Whether nationally or internationally, it is well understood that more is needed to address the mental health needs of individuals in various communities. However, it is imperative that we approach such challenges with culturally-informed models that are sustainable. The focus of this presentation will be on describing a community-based, mental health capacity building framework that has been used extensively both nationally and in Haiti. The presenter will highlight examples from multiple initiatives to demonstrate some of the key principles that have guided the successful implementation of this framework in the U.S. and in Haiti.
Mental Health in Haiti after the Earthquake
Dr. Ronald Jean-Jacques
President, Association Haitienne de Psychologie (Haitian Association of Psychology)
In the aftermath of the January 12, 2010, faced with multiple traumatic and unpredictable consequences of the disaster on the life, consciousness and the psyche of the Haitian people, Haitian mental health professionals were called upon to respond to the growing emotional and psychological needs of the Haitian community. The presenter will discuss the first efforts of the few mental health professionals who were present on the ground and the complex challenges that they faced. The presenter will also address ways to bring together our collective energies, means and resources to assist in the psychic and mental reconstruction of Haiti.
(Click on the titles below to download a copy of the presentations.)
What is the Quality of Mental Health Treatment for Haitian Youth in the
Greater Boston Area?
Nicholas Carson, MD, FRCPC, Instructor in Psychiatry, Harvard Medical School
Research Associate, Center for Multicultural Mental Health Research
There has been little research done to describe the quality of mental health treatment for Haitian families living in the United States. This presentation will discuss two recent studies of mental health service use by Haitian youth living in Cambridge and surrounding communities. The two studies used retrospective medical record data both from paper charts and from the electronic medical record. The first study revealed that episodes of mental health treatment for Haitian youth were usually quite brief (approximately four visits). This presents a challenge for treatment quality of common behavioral and emotional disorders among Haitian youth. The second study considered the impact of social determinants on treatment adequacy, emergency room use, and early termination of care. Inadequate treatment and early termination were more likely among Haitian youth from areas with greater poverty and with more female-headed households. The relative impact of poverty on adequate care was higher for Haitians than Whites. There were also fewer medication visits among Haitian and African American youth. Haitians living in poverty in the United States may therefore face greater barriers to mental health services relative to other racial/ethnic groups. The presenter will discuss the implications of these findings for culturally-competent care of Haitian youth, including relevant interventions.
School-Based Community Outreach: A Resource Focused Approach
Fanya Jabouin-Monnay, LMFT & Anne Rambo, Ph.D., Nova Southeastern University
The purpose of this presentation is to share practical strategies for developing a partnership with local public schools to meet the mental health and crisis intervention needs of the Haitian community in a non-threatening and resource-focused manner. In this presentation participants will learn: (1) Strategies for working effectively through the public schools to provide culturally congruent mental health services to immigrant families from Haiti; (2) Resource-focused trauma treatment and cultural play therapy techniques with children and their parents; and (3) Best Practices and lessons learned in implementing a school-based community outreach with schools.
Culture, Trauma, and the Social Life of “PTSD” in Haiti
Erica Caple James, Ph.D., Anthropologist, Massachusetts Institute of Technology
Since the early 1990s, the concept of Posttraumatic Stress Disorder has become a prominent diagnostic category that has shaped humanitarian and development interventions in Haiti in the aftermath of natural and human-authored catastrophes. To some degree, “PTSD” has been imported by Haitian clinicians who have studied abroad and have adopted the DSM categories in their clinical work. PTSD has also been exported to Haiti from multiple international humanitarian relief efforts to treat Haitians in post-conflict and post-disaster settings. As the PTSD construct has traveled beyond borders, it has been influential in the development and sustainability of a “political economy of trauma.” The multiple and sometimes competing international and national efforts to uncover and redress PTSD in Haiti have contributed to forms of governmentality that recall colonial struggles to claim and cultivate particular components of Haitian territory. Findings from fieldwork conducted between 1996 and 2000 in various trauma treatment programs suggest that the adoption of the PTSD construct has created new forms of subjectivity for Haiti’s “victims”—one that emphasizes individual rather than collective experience of “trauma” and that articulates and coexists with conceptions of distress arising from Haitian traditional understandings of personhood and embodiment. While some Haitians manifest emotional distress in response to traumatic events in ways that align with biomedical conceptions of “PTSD,” these “symptoms” are understood and interpreted through multiple meaning systems employed to categorize the perils of social life, including discourses of evangelism, Voodoo, feminism, and human rights.
Clinical Interventions to Address Haitian Clients' Mental Health Needs
Carline Jean-Baptiste, Ph.D., Mel Schmid, LICSW, & Astrid Desrosiers, MD, Cambridge Health Alliance
There are many challenges and divergent needs over the years given the natural, political and economic issues faced by many coming from Haiti to the United States. Over the more than 25 years of its existence, The Haitian Mental Health Team at the Cambridge Health Alliance (CHA) continues to strive in creating a clinical environment that is safe, confidential and welcoming of the clients served. This has been particularly imperative over the last years since the earthquake of 2010 left indelible marks on Haiti as a country and on its people. Haitian individuals, both directly and indirectly affected by the devastation of the quake, have faced multifaceted challenges that have included psychological trauma, medical complexities, and unimaginable loss of family, friends and personal possessions. This presentation will offer an overview of medical, mental health and immigration services offered to Haitian clients at CHA. For a community where preventive measures through primary care and mental health services may be fairly new concepts, CHA strives to create an accessible, supportive, culturally sensitive and relevant space for Haitian clients. Within the context of open access and integration with Primary Care at CHA, the Haitian Mental Health Clinic engages individuals and families through a systems approach to treatment. The first segment of the presentation will identify the various manners by which clinicians on the Haitian Team have used to better serve and engage first-generation Haitian immigrants in mental health treatment; especially those referred through primary care. The second segment will address the unique needs and engagement process in clinical treatments for second-generation Haitian-American clients. The presenters will also discuss the integration of therapeutic needs, along with, psychopharmacological interventions as indicated. Through the treatment process, clients are encouraged to consider new and/or alternative ways of viewing health care, family life, assimilation and acculturation concerns.
Using Therapeutic Workbooks for Healing After the Haitian Earthquake:
My Own Story about the Earthquake in Haiti (Histwa Pa M Sou Tranblemannte Ayiti A)
Jodie Kliman, Ph.D. & Dorothie Ferdinand, Psy.D.
This workshop will introduce participants to the therapeutic, preventive, and educational uses of activity workbooks to help children and teens who lived through the 2010 earthquake in Haiti and Haitian-American children who were indirectly affected by the earthquake to cope. The Haitian version is bilingual, with text in Haitian Creole and French. The workbook helps children tell their own stories about the earthquake and those they have heard, with help from caring adults. It combines therapeutic, educational, and creative activities, using writing or dictating and drawing in a flexible format. It helps children master frightening and sad experiences and to feel hope for the future for themselves, their families, and Haiti by helping them remember good times before the disaster and times when people helped each other and survived together afterwards. Children are encouraged to think about how they can live safe and meaningful lives in the future, including ways they can contribute to their society. They are helped to grieve their losses without being overwhelmed by that grief because the grief work takes place in a framework of hope, resilience, and adult support. The adults helping children and teens with the book are encouraged to let them work at their own pace, so that they do not get overwhelmed. This workshop will combine lecture, discussion, and experiential learning, with participants using parts of the workbook with each other.
Understanding Trauma and Resilience in Haitian Women
Castagna Lacet, Ph.D., Assistant Professor of Social Work, Wheelock College
The experience of immigrating to the U.S. creates many potential risk factors. Immigrants and refugees are leaving familiar ground, social networks and cultural ties. Relocation adds another layer of stress as they seek to find basic necessities such as housing, health care, and other social services. Whatever risks or traumas they may have faced in the homeland could be unresolved and now become complicated by the need to resettle in a foreign place. This presentation will focus on a social work framework for understanding and working with Haitian immigrants. Special attention will be paid to the recent wave of immigrants following the January 2010 Haiti earthquake. Poverty, political and social unrest, and natural disasters in the form of powerful hurricanes have already inflicted layers of trauma to individual Haitians and to the collective sense of being. In addressing the needs of those affected by natural disasters, social workers need to understand both micro and macro issues. Even those who may lack linguistic capacity to work one-on-one with Haitian clients will need to gain competency in how to work in partnership and collaboration to meet the complex needs of these clients.
Healing through the Arts: How Haitian Artists Use the Arts to Journey through Grief and Help Other Survivors Regain Control of their Shattered Lives
Charlot Lucien & Joseph M. Chéry, Haitian Artists' Assembly of Massachusetts
The January 2010 earthquake severely damaged the coastal town of Jacmel, known as the art hub of Haiti. The artist community was deeply affected by the tragedy. They lost family members and colleagues in the earthquake. Their artworks, their properties and their primary market were destroyed. Their lives were shattered. The presenters will examine how, with help from the Haitian Artists' Assembly of Massachusetts, the Jacmel artists are using their art to heal and piece their community back together.
Mental Health Literacy amongst Haitians Post-Earthquake
Linda G. Marc, ScD, MPH, MS, Division of Policy Translation Leadership and Development
and Department of Biostatistics, Harvard School of Public Health
Following the Haiti earthquake of 2010, a study was conducted amongst persons of Haitian ancestry to examine their “mental health literacy” in the context of emergency situations. Mental health literacy is defined as knowledge and beliefs about mental disorders, which aid in the recognition, management or prevention of mental illness. Recognizing the diversity in the Haitian Diaspora, three groups of Haitians were recruited into this study: (1) Recent arrivals living in the US 12-months or less; (2) Immigrants living in the US 5 to 10 years; and (3) American born citizens of Haitian ancestry or Haitian immigrants living in the US a minimum of 30 years. Using a cross-sectional design and mixed methods, the study recruited persons of Haitian ancestry from Boston, Miami and New York City. Nine focus group sessions (N=84 participants) were conducted using an interview guide, which covered themes specific to mental health literacy. A structured demographic interview was also administered. Focus group sessions and quantitative instruments were in Haitian-Creole and English. Qualitative study results show that the majority of focus group participants believe there is a social stigma associated with mental illness, and that seeking professional mental health care is inconsistent with Haitian culture. Participants did not see a need to seek information about mental health post-emergencies. A mental health literacy campaign dispelling myths about mental illness is needed for the Haitian community.
The Haiti SERG Initiative
Michelle E. Michel, MA/MPH, Massachusetts Department of Public Health
Two years after the January 12, 2010 earthquake that ravaged the nation of Haiti, its impact is still felt on the lives of Haitians over 1500 miles away here in Massachusetts, which has the 3rd largest Haitian population in the United States. As part of the state’s continuing response, the Department of Mental Health became the recipient of a SAMHSA Emergency Response Grant (SERG) and contracted with the Department of Public Health (DPH) and Boston University’s Center for Multicultural Mental Health. To date, the nine community health centers in the Greater Boston area subcontracted by DPH collectively have provided over 1,000 individual services, and have conducted almost 300 group sessions. Identified risk categories underscore the loss, with 57% having been in Haiti at the time of the earthquake, 48% with dead or missing friends, 34% with dead or missing family members, and 21% having traveled back to Haiti since the earthquake. Most frequently reported current reactions included sadness (70%), despair (30%) and feeling anxious or fearful (20%). Service modules implemented by the centers involve (but are not limited to) partnering with schools, churches and community-based organizations to provide art therapy, support groups, and Psychological First Aid. Key lessons learned include: 1) Poetry and music are powerful outlets for clients to verbalize their most intense feelings and learn ways to heal; 2) Group sessions are more accepting by this constituency to feel comfortable to share their feelings; and 3) Self-care is very important for the caregivers. Overall, clients seen range from childhood to adulthood to elderly years and have demonstrated improvements even over a short period of time. While grantees are now preparing their clients for the termination of these services, it is very evident that the needs will continue and that instilling empowerment and building self-sufficiency are the top priorities for providers as the SERG grant comes to a close.
Depression among Haitians
Guerda Nicolas, Ph.D., Chairperson, University of Miami
Although national studies conducted demonstrate the lack of attention that has been paid to the mental health of ethnic minority populations, research seems to have established that Black immigrants have higher rates of mental health problems than non-immigrant populations. For example, Haitian women have a high number of health problems, including mental health, as a result of challenges they have faced in history. Among Haitian women, depression can take many forms, and current Western ways of assessing it lack cultural sensitivity and awareness. Three forms of depression have been identified: Douleur de Corps (pain in the body), Soulagement par Dieu, (relief through God), and Lutte sans Victoire (fighting a winless battle) (Nicolas, et al., 2008). In light of this, it is important to consider the type of depression that client presents in order to administer the appropriate assessment that will capture this experience. This presentation will provide (1) a summary of the manifestation of depression among Haitians, especially Haitian women; (2) some guidelines for how to assess depression among Haitian clients; and (3) strategies for engaging and retaining Haitian clients in mental health treatments.
The Boston Medical Center’s Training Program for the Haiti SERG (SAMHSA Emergency Response Grant) Providers’ Network
Regina Pierre, Ph.D. & Shamaila Khan, Ph.D., Center for Multicultural Training in Psychology, BMC
In January 2010, the earthquake in Haiti had devastating consequences reaching beyond Haiti to Massachusetts. The Commonwealth mobilized a response that focused on post-disaster mental health and trauma recovery services for the Haitian-American community. To assist health centers, community agencies and churches with providing short-term behavioral health services, the Center of Multicultural Mental Health at Boston Medical offered trainings for the Haiti SERG network. The trainings were designed to strengthen the skills of the staff at the contracted community health centers, their partners, and those directly impacted by the earthquake. The presentation will focus on discussing the overall training experience, which will include a discussion about the topics covered, feedback received from the participants, and strengths and challenges associated with such an initiative.
Can Metaphors that are Inherent in the Haitian Story-telling Tradition Serve as a Useful Context for engaging U.S. Haitians in Clinical Practice?
Guitele Jeudy Rigaud Rahill, Ph.D., Assistant Professor
University of South Florida School of Social Work, College of Behavioral and Community Sciences
Haitians as a nation have experienced trauma for centuries, but the 2010 earthquake and its consequences have accented the need for mental health interventions with Haitians at home and abroad. The dearth of relevant and efficient strategies that address mental health, child and family concerns for these clients remain a challenge to U.S. practitioners, and a lack of effective engagement strategies on the part of practitioners may be associated with underutilization of mental health and social services in U.S. Haitian communities. The development of cultural-specific practice strategies to engage U.S. Haitians requires that practitioners consider relevant linguistic and cultural elements and understand the context of their ecological culture. The use of metaphors in cultural language was used as part of a strategy to engage a Haitian immigrant with symptoms of posttraumatic stress disorder. In that context, the use of storytelling and metaphors empowered the client’s ability to verbalize his experiences, feelings and hopes in a safe environment and provided him with tools to share his progress with the clinician. Four practice guidelines are offered as a first step in the development of intervention strategies with other Haitians who share similar cultural contexts. Metaphors, as a viable approach to practice, enable practitioners to attend to problems beyond the scope of race and language, to consider the needs and goals of Haitian families within their cultural context, and to incorporate skills and methods of problem solving that are familiar to Haitians. The need to test this approach for effectiveness in larger samples within the Haitian population at home and in the Diaspora is recommended.
Mental Health Response in Haiti in the Aftermath of the 2010 Earthquake: A Case Study for Building Long-Term Solutions
Guiseppe Raviola, MD, Instructor in Psychiatry, Harvard Medical School
Scaling up mental health services that are safe, effective, and culturally sound presents significant challenges in a situation of dramatic human loss, ongoing poverty, and multiple competing needs as exists in Haiti today, two years after the devastating 2010 earthquake. Zanmi Lasante (ZL) and Partners In Health (PIH) have sought to expand, strengthen and integrate mental health service delivery in Haiti’s Central Plateau and Lower Artibonite catchment area of 1.2 million people. Historically, the problem with such acute responses is that they tend to be carried out with insufficient attention to key components necessary for sustainable delivery of care in low-resource settings.ZL and PIH have sought to promote the building of consensus among various actors, both within and across organizations, as to the planning of initiatives beyond the initial emergency response. Given that significant challenges have been documented in the functioning of humanitarian mechanisms in Haiti both before and since the 2010 earthquake, clarity of intent and transparency in planning is, for various reasons, an essential step in moving forward effectively. This talk will consider key components necessary for long-term planning for the integration of mental health services, and for the sustainable delivery of care in Haiti. Participants will have the opportunity to appraise one systems-based approach to the stepped articulation of an evidence-based system of mental health care to meet long-term needs in Haiti following the 2010 earthquake.