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Not Too Soon for Mental Health Care in Port-au-Prince

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Leah James Haiti

With some children at the National Soccer Stadium camp.

"I have an affliction. Bad ideas try to come inside my mind, but I am trying to defend myself. Because we can't live this way...The only food is alcohol. If there is water, I drink it if it is dirty or clear. I don't care...It is hopeless, we are just waiting for our death."

"I'm scared, I'm just scared."

--Responses of IDP camp residents in Port-au-Prince when asked about psychological and emotional problems since the earthquake.

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It is Feb-Mar 2010, Port-au-Prince, Haiti. I am in Port-au-Prince as part of a University of Michigan research team that is conducting a post-disaster assessment, sponsored by the Small Arms Survey and the UNDP. Our principal investigator, Athena Kolbe, a UM doctoral student and researcher who has been working in Haiti for 15 years, has invited me to come along to help with the research and to provide mental health services in IDP camps and at the Aristide Foundation for Democracy in Port-au-Prince. I have some experience treating post-traumatic stress (I do psychotherapy with veterans with PTSD at the VA hospital in Ann Arbor), and I've jumped at the chance to make myself useful.My hope of hopes is to be useful -- in all honesty it seems like a long shot. I worry that my particular skill-set will hardly be relevant -- let alone helpful -- for people struggling to get by in the daily chaos that makes up life in Port-au-Prince. For residents of IDP camps, securing a tent or sturdy tarp, potable water, enough food to get through the day and charcoal to cook it, and medical care for acute issues are daily battles. A friend tells me that while conducting interviews in an IDP camp, she was approached by a near-hysterical woman who tried to push her infant into her arms and then started to run away, as if to leave her with the baby. I hear about a 98-year old woman who has been sleeping in the street since the earthquake, who is unlikely to be given a tent by aid workers because it will inevitably be stolen. I hear about a student who is the only one in her entire grade that survived the collapse of her school. Will these people really have any patience for a therapy group? After all, organizations like the American Psychological Association (APA) have suggested that it's too soon for psychological services -- that volunteers should hold off until things "calm down," and that over-eager mental health providers are likely to be more of a bother than anything else. Maybe so, but with my feelings of being a nuisance somewhat assuaged by my role in the research project, I have resolved that I might as well give it a go. At least see how things look.

And here we are, here I am. Stepping off the plane, the heat is a punch in the chest. There are tents and rubble and soldiers and trucks. We are collected from the makeshift airport by our Haitian collaborators who appear grinning from the teeming crowd outside the gate. They have somehow managed to borrow a police truck to transport us through the Port-au-Prince traffic. And the traffic, with slow-moving tanks and UN vehicles mixed into hoards of generally lawless car, tap tap, and moto drivers, is truly stunning. It is Sunday morning and from the car windows we watch people dressed in spotlessly laundered dresses and slacks sidestep mud and rubble and exposed metal on their way to church. We teach our Haitian team the English word "rubble." It turns out that we use this word a lot.

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Throughout our trip, we work closely with Roger, manager of our Haitian research team and a director of Mabo, a remarkable Port-au-Prince children's center. He and some friends from high school have rented a house where they shelter and care for 27 children. Naomi Levitz, a social worker on our team, has worked closely with Mabo for several years and when we arrive, she is quickly surrounded by a swarm of joyous children. Roger tells us that the children were outside when the quake happened and none were injured. He, on the other hand, was on the roof and the quake threw him into the air -- but he landed, miraculously, on his feet and was unhurt. We spend our first day using Mabo as a headquarters for training a team of 25 young Haitian interviewers in the use of Scantron forms to collect data for the post-disaster assessment. They have never before encountered such ridiculous things, and watch us with a mixture of amusement and frustration as we explain about filling in bubbles all the way and warn against writing in the margins. When we break, we converse with a lovely group of Mabo kids who are not stingy with hugs and kisses and cheerfully tour us through the tents that they have been sleeping in since the earthquake. Despite the fact that the house appears virtually undamaged and has been declared structurally sound by an engineer, the Mabo kids refuse to sleep inside -- as do nearly all children and adults in Port-au-Prince. A chain of aftershocks have discouraged those who initially dared to sleep under a roof after the big quake, and now, as the rainy season approaches, most of the city is firmly committed to tent-dwelling. Our group will spend most nights in tents in the yard of a friend of a friend. On one particularly rainy night we venture inside and are roundly considered crazy for spending the night on the floor of the visibly-unscathed living room.

The next day at the IDP camps, while the Haitian team scatters to collect their data, we conduct qualitative interviews with camp residents with the help of translators. At the camp near the Turkish Red Cross in Tabarre, there is an amazing mobile school organized by the Aristide Foundation for Democracy and funded by the Haiti Emergency Relief Fund. Hundreds of kids sit under an elevated tarp, chattering and squirming and singing and touching their head, shoulders, knees and toes. The director of the Aristide Foundation, Mr. Toussaint, explains to us that the teachers are Haitian college students trained by the Foundation and they are implementing a four-week program aimed at helping children cope with post-traumatic distress. "The first week," he explains, "is simply for singing and dancing and learning to smile again. After this, children start to talk about their experience of the earthquake."

A score of glassy-eyed parents and other adults are perched on the low wall surrounding the school area, half-watching the children sing and half staring into space. Some are willing to spend a few minutes expressing their appreciation for the school -- which had opened just a few days before -- and talking to us about their families' experiences after the earthquake. They describe aid received thus far (occasional food, some emergency medical care, and of course, the marvelous school), and, most often, emphasize a glaring lack of aid (an enormous and upsetting topic to be discussed more fully in future posts). I speak to a very pregnant young woman who says that no doctors will see her -- medical care is for emergencies only. She worries about giving birth in her tent alone. Later, we give her infant-sized clothing from a big pack of dresses made from pillow cases that we've brought to donate. She smiles, but this is nowhere near sufficient.

When asked about "pwoblem sikolojik ak emosyonel," most people we talk to have plenty to say. From a man with a white buttoned shirt -- who later asks us for a job: "Everybody is still in crisis. Even if there is no aftershock, everybody is still awake. They have to be moving all the time. They can't eat or sleep. So that's the problem."

An older woman with wild hair: "I always have a headache and a hearing problem and my legs are also trembling."

A series of younger women draped with children: "Sometimes it is worse to be alive. After each aftershock, the only thing I think to do is run. When a car comes with a loudspeaker, the children run away" and "the children are afraid of noises, for example, a truck, the noise of a truck, or if someone makes some noise, they start crying...They don't want to stay in bed without their mother" and "My five-year-old thinks about the earthquake so much. He says, 'Mommy, I feel the earth shaking.'"

When asked about how they cope, people describe group song and prayer. Haitians are a powerfully religious people, and almost everyone we speak to cite their Christian and sometimes voodoo faith as critical sources of support. After the earthquake, most of Port-au-Prince collected on the grounds of the devastated palace for three days of non-stop prayer. Many people tell us that initially they were sure that earthquake signaled the End of Days and that fire and brimstone and the destruction of the remaining Haitian people were imminent. Some say that they still believe this, but others admit that as the days continue to pass, they have begun to wonder just what is taking so long. When I tentatively initiate discussion about the geological causes of earthquakes or mention their occurrence in places all over the world (Chile, Japan, California), as opposed to only in Haiti, there are mixed reactions. Some people eagerly press for scientific details (which, of course, quickly overstretch my minimal understanding of earthquake mechanics). Others gently inform me that this is quite interesting but ultimately irrelevant in light of the earthquake being a religious prophecy. The end is coming, I am told, and moreover, the sins committed by generations of Haitians mean that the people have only themselves to blame. A young man with earrings in a downtown camp admits that it is somewhat baffling that several months had passed without further disaster, but others see signs of the prophecy all around them. A woman I meet at the camp in the National Soccer Stadium gravely informs me that the unusually cloudy and drizzly weather over the past few days -- it has been overcast all day rather than sunny with sporadic storms as is typical at this time of year -- signal that the end is nearing. When I ask people whether such thoughts are comforting or anxiety-provoking, I am again met with mixed reactions. Many, many people tell us that God will take care of them, that prayer is all that keeps them going, but a few confide that fear about the end and guilt about past and future sins are sometimes overwhelming. One young woman with a baby in her arms tells me that her terror is shameful and must be kept hidden; she should be thankful for whatever God provides and her fear shows that she is a sinner.

I've been asked to run, with Roger's help, some "coping groups" in the camp -- the first of which is scheduled for 7:00 p.m. that night. Roger and I arrive at the rendezvous place, expecting that our "group" is likely to consist of a few of the women we'd talked to earlier that day and maybe a glaring teenager or two. But we are escorted though the dark into an open space surrounded by makeshift tents, and a crowd of about 40 quickly materializes around us. Chairs appear for Roger and I and a layer of small children settle at our feet. We introduce ourselves. I have some notes on a piece of paper, but it is dark and my flashlight won't work so I put the paper away. We know that family comes first for Haitians and that mental health care for oneself can feel unnecessary and even self-centered -- so we start by emphasizing the importance of taking care of oneself psychologically and emotionally in order to be able to take care of children and family members. After talking to camp residents all day, I know that a common complaint is a feeling residents called "trembling" -- the sense that the ground is moving under your feet accompanied by heightened physiological arousal, including racing pulse and hyperventilation. I describe this sensation and as Roger translates, people around the circle begin to nod. Roger -- who is without a doubt bound for fame and fortune as an actor or psychologist or both -- demonstrates a startling response by clapping his hands loudly and then jumping out of his seat, widening his eyes and quickening his breath. Kids laugh, and their parents nod and murmur acknowledgment. We explain why hyperarousal occurs -- that one's body naturally responds to danger by becoming "ready to run" -- a good thing because this feeling helps us to act quickly and keeps us safe from danger. The problem is that our bodies don't always know when the danger has passed and it can take a long time to feel calm again. You're not having a heart attack and you're not losing your mind. The circle of people press in around us and in the dark I can make out looks of relief, particularly as Roger stresses the word "normal."

We discuss trouble sleeping, physical aches and pains, emotional shifts between relief and grief, irritability, guilt, trouble concentrating, and trauma memories and nightmares, and the unique manifestations of these symptoms in children. We outline basic coping strategies for both kids and adults. We talk about prayer and about social support and about letting children know that it is okay to talk about the earthquake, about setting rules and routines, and about holding children to help them feel safe. Finally, we demonstrate some simple ways to make the body feel calm -- abdominal breathing and a soothing bilateral stimulation technique called the "butterfly hug." All around the circle, people cross their arms over their chests and slowly tap their shoulders as though flapping butterfly wings -- left right left right goch dwat goch dwat.

Throughout, our audience is what I'd call "actively engaged" in VA clinic group notes -- plenty of furious nodding and shaking of heads, not to mention spirited commentary. In my experience, Haitian conversation often takes the form of passionate yelling, even among strangers meeting in the street. Often I would stand on the sidelines as a group of Haitians accosted each other with shouting and angry gestures, waiting for things to come to blows. Later, it would invariably turn out it was only the weather being discussed, or family being asked after, or at the very most, some amiable complaining about the government.

As our group concludes, passions increase. When we pause for questions, a woman asks when the food, water, and tents are going to arrive -- they need toilets and cooking supplies -- where are all these promised American donations? Excellent questions, of course, but not ones that I can answer. I empathize as best I can and explain that our research for the post-disaster assessment aims to inform the international community about peoples' needs and the lack of resources received thus far, in hopes of influencing distribution of donated funds. The crowd looks skeptical and the yelling persists, but from the back a tall man announces that even with clean water there will still be psychological and emotional problems...and groups like this can help. Others agree, and the focus of the yelling shifts. Now there is ardent agreement about need for more groups. We agree to come back another day, but I am careful to explain that these first group members have an important job. They are now the "psychologists" for the camp -- it is their job to pass along information about normal reactions to trauma, so that people know that they are not alone, and to teach coping and relaxation techniques, so that people can feel better.

The next week is spent doing similar groups in this and other IDP camps. Roger helps me fine-tune the protocol and offers somewhat brilliant examples that reach people when my own explanations fall flat. Typically we simply show up at a camp and ask the nearest resident where to find the "camp committee" -- most often a huddle of youngish men importantly stationed under a makeshift awning. We conduct a few interviews with the committee about the overwhelming and entirely unsatisfied needs of the camp (again, to be elaborated on in future posts) and then somewhat sheepishly offer our services. Committee members, well-versed in snatching up whatever aid-related services are offered, are invariably enthusiastic. They promptly send kids from tent to tent advertising the group, and in no time there are sizeable crowds. Camp residents, likely at a loss for how to fill long, jobless, anxiety-ridden days, hardly need convincing to come out and gape at a sweaty foreigner rattling on about psychology and gesturing wildly. But once they arrive, many get sucked in for the whole show, and a few inevitably stuck around after the crowd disperses to talk in more detail about their experiences or symptoms or those of their family members.

We also work at the Aristide Foundation for Democracy -- a wonderful organization that hosts an event in which we are able to work with about 100 teachers of the mobile schools that are sprouting up in the camps. These young people have a massive responsibility -- the care and education of Port-au-Prince's often traumatized children will shape the city's future. We run another group for parents and other community members, and as members introduce themselves, many of them speak of a certain Mr. Jules Woodly. A woman gestures across the circle toward a bearded man quietly watching the proceedings from the back of the room. "This is Mr. Woodly," she says, "I owe him my life."

"Mr. Woodly saved me," we hear again and again. "He took me in off the street and gave me a tent and food when no one else would." When the group concludes, I speak to Mr. Woodly a bit more. He is an ex-helicopter pilot, educated in Boston, who has used his own funds to move families off the street into a clean, well-managed camp that he directs himself, called the Centre d'Abri des Victimes du Seisme (CAVS). Since my return, we have been in touch, and although his own money ran out long ago, I continue to receive pictures documenting the amazing evolution of his camp. There is a school there now, miraculously developed through painstakingly scraped-together funds.

Jules Woodly

Jules Woodly distributing food at the IDP camp, Centre des Victimes du Séisme 2010 in Tabarre, that he funds and manages.

In sum, there is room to help. There are reliable local organizations in Port-au-Prince, run by real people, who use donated funds for real things -- small organizations that are not plagued by the ineffectualness, corruption, or massive overhead common to some international aid organizations and Haitian NGOs. There is Mabo, the Aristide Foundation for Democracy, and Mr. Woodly's Centre d'Abri des Victimes du Seisme, to start. And secondly, for those with mental health skills, there is some opportunity to be helpful. This is not to encourage an invasion of volunteers without contacts or safeguards -- Port-au-Prince can be a dangerous place and is not easily navigated. But there is an opportunity.

I and a loose group of others in Southeast Michigan and Port-au-Prince have begun a grassroots effort to establish a safe, effective pathway for a stream of future US volunteers, to offer meaningful work to unemployed Haitians, and to help make free basic mental health services as quickly and as widely available as possible in Port-au-Prince. I will be going back in April with two volunteer psychologists from the Ann Arbor VA, and other therapists from our PTSD clinic have generously committed to future trips. We will work with Roger and our other collaborators, will continue to train Haitian teachers at the Aristide Foundation for Democracy, and aim also to hire and train unemployed Haitians to provide basic, ongoing education and skills for coping post traumatic stress in the IDP camps and throughout Port-au-Prince.

Ultimately, mental health services will be most effective when provided by Haitians for Haitians. Our coping group has been well-received because Roger knows how to talk to people (and in all honesty, he memorized my spiel the second time around; by the end my presence was mostly for show). Unfortunately, Port-au-Prince lacks the basic infrastructure needed to quickly train and employ sufficient numbers of mental health workers to provide these services. Our goal is to create a sustainable system of training and service provision, in which Haitians train Haitians to provide basic psycho-education and skills groups in camps and throughout the city. This is not an effort to train mental health professionals with the skills needed to work with the seriously mentally ill (although this is needed, too). Rather, it is a movement toward widespread dissemination of education and coping skills to benefit the general public. In this town, where much of this general public have lost friends, neighbors, and family members, have seen corpses on the street, heard screams from beneath piles of concrete, and are living day-to-day without regular work, food, medical care or roofs overhead, basic education and skills may not be enough. But it is a start.

All photos in this post are by Leah James, except for photos of Jules Woodly's IDP camp, which appear courtesy of Jules Woodly.