Relief for the Spirit: A Lay Mental Health Worker Project in Post-Earthquake Haiti

We are in Haiti training "Ajan Sante Mantal," lay mental health workers. But first, we need help to pay our Ajan's stipends and their transportation and, ideally, to hire and train more.
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It is early May, 3.5 months post-earthquake and I am back in Port-au-Prince. The streets are busier than they were in February -- there's lots for sale: clothes, heaps of shoes, tall cones of packaged medication, and of course, gallons of gas. There is a "problem of gas" in Port-au-Prince, and much of this visit will be spent waiting for gas in one of the few open gas stations in the city, buying gas by the gallon off the street, watching gas dwindle away in unmoving traffic, running out of gas (2x), buying bad gas (2x), and also, for good measure, getting two flat tires. There is always a problem of something in Port-au-Prince. Some of these are very big problems. Millions are still in camps. There are no jobs. There is still little visible aid. It is rainy season. And psychological problems persist.

Of course they do. This is an entire city of near-death experiences and enormous grief. And it is a city of frozen, unreal images. Downtown is buzzing with street sellers today, but earlier this year there were corpses lined up in the street for identification, children's shoes and hands poking out from under rubble. The average downtown resident out on the streets on Jan 12 and 13 could hear cries coming from beneath unmovable debris -- there were no machines to help unearth people. Everyone smelled the smells a few weeks later. There was a massive rupture in the earth in downtown Port-au-Prince, a crevice so wide that some fell in and plummeted, we guess, all the way to the earth's core. When the earth closed again, a few people lost feet. When I take motos around town, I am preoccupied by imagined images of those unlucky enough to have been on one when the quake happened. We are told that they looked like they were flying. These are memories that sear the mind, leave a mark, get stuck in your throat.

And the trauma continues -- 1,300 IDP camps remain and millions are still in makeshift tents. Birth and death occur in dusty patches under tarps. Even those with intact houses sleep outside; there is enormous fear of another earthquake. The president has been on television to tell the people to expect another deadly quake, but has offered little protection. The "rebuilding" process is not apparent to the naked eye. There are very few jobs and there is little aid -- the "international relief effort" has apparently come and gone without anyone much noticing. Many camp residents have no plans at all, no options really, for the foreseeable future. It is overwhelming.

At this point, Port-au-Prince has almost no existing infrastructure for mental health services. But the massive unmet need also means that there is massive opportunity to help, if only in small ways. I am here to help train Haitian college students to be Ajan Sante Mantal (lay mental health workers) who will conduct basic post-traumatic stress classes for residents of IDP camps in Port-au-Prince.

I was here several months earlier, in late February, running such classes in the camps with help and translation from my Haitian friend and collaborator, Roger Noel. With a University of Michigan research team, we'd conducted interviews with camp residents as part of the UN-funded post-disaster assessment, and found that many reported psychological and emotional difficulties. These were not restricted to a few seriously mentally ill individuals; rather problems with hypervigilance, startle response, sleep, fear, anxiety, grief, anger and intrusive memories appeared to be widespread among the general public. Many people complained of "trembling" - a jumpy feeling, often including the sense that the earth moving under ones feet, after every loud noise.

I study trauma and work as a therapist at a PTSD clinic in the Ann Arbor VA hospital, so, with some research, was able to put together a basic psycho-education class about common reactions to trauma paired with training in relaxation and other coping strategies. But culture is massively important; with Roger's help we emphasized the role of family and community, and of religion - both Christianity and Voodoo. We carefully acknowledged religious explanations for the earthquake - perhaps most commonly that it signifies the prophesied End of Days - while also providing basic education about the science of earthquakes. After agreeing on cultural adjustments, and we went about running the class in camps (see my earlier posting for an account of this). The idea is that even one-time exposure to basic information about common reactions to trauma can diminish the sense that one is "alone" or "going crazy" and increase the likelihood that traumatized individuals will continue to talk to each other, and so continue the healing process long after we are gone. Likewise, one-time training in basic breathing and imagery relaxation skills can reduce the physiological symptoms of post-traumatic stress (rapid heart-rate, hyperventilation, shaking, dizziness, startle response, body pain, sleep disruption) that are so frequently reported by camp residents.

The author running a post-traumatic stress class in a camp for internally displaced peoples in Port-au-Prince.

The post-traumatic stress class was a hit; we always had a crowd and people gathered afterward to talk more. But it became rapidly clear that my role was per functionary at best. After translating a few times, Roger learned the protocol and proceeded to administer the class with enthusiasm and humor and sensitivity and moving examples, while I interjected a few dry sentences every so often. Roger is a pretty brilliant guy, but has no psychology background whatsoever, and it occurred to us that this class could easily be administered by Haitian students after a bit of training. This fit with our general philosophy that the best sort of post-disaster intervention is one that comes from the local community rather than outsiders. There are plenty of capable Haitians in need of jobs who can relate much more skillfully to earthquake victims than can I or most other US imports. The Aristide Foundation for Democracy (AFD), a Haitian humanitarian organization, agreed and proposed collaboration, and thus Soulaje Lespri Moun (Relief for the Spirit) was born. We have a fantastic team - 10 Haitian lay mental health workers as well as a psychologist and two project managers, and on the US/Canadian side, several social workers, psychologists and doctoral students associated with the University of Michigan, as well as Laura Flynn, US board member for the Aristide Foundation for Democracy.

Our goal is to create a sustainable system of training and service provision, in which our Haitian lay mental health workers provide basic, culturally-relevant post-traumatic stress education and skills groups in IDP camps and throughout the city. To be clear, this is not an effort to train mental health professionals with the skills needed to work with the seriously mentally ill (although this is certainly needed, too). Rather, it is a movement toward widespread dissemination of education and coping skills to benefit the general public. While it is clear that some camp residents need more help than our lay mental health workers can provide, we also know that people are amazingly resilient - most trauma victims will not develop PTSD. Even a brief encounter with some basic information and skills training may help them to access their natural resources and speed emotional healing.

We are working in conjunction with the AFD's mobile school program, in which 100 Haitian college students provide education to more than a thousand children across five camps. Soulaje Lespri Moun will complement this program by providing mental health services to their parents, as well as other adults in the community. After all, as good social workers know, mental health intervention is most likely to succeed when the entire family, if not the whole community, is targeted.

Now I am here with two psychologists, Mike Messina and Todd Favorite, colleagues of mine at the PTSD clinic, to help get the project off the ground. Mr. Toussaint, the director of the AFD, has selected 10 Haitian college students from UniFA (the University of the Aristide Foundation) to work as "Ajan Sante Mantal" (lay mental health workers). Our Ajan are enthusiastic and qualified. College has not yet reopened, but prior to the earthquake, they were studying languages or law or computers. Some have spent the post-earthquake months as teachers in the AFD's mobile school program, working with scared and squirmy children in IDP camps for a small stipend. Some grew up in an AFD-sponsored orphanage and have been cared for and educated at the AFD for their entire lives.

Training for Ajan Sante Mantal

The day I arrive, the 10 Ajan-to-be are already waiting expectantly in a circle of folding chairs under mango trees. The AFD is oddly peaceful after the havoc and heat of the road. A groundsman climbs to the very top of the tree for a mango, which he gives me only after I manage to ask for it in Creole: Mwen ta renmen mango! I hand out measures of symptoms of post-traumatic stress disorder. We will track the Ajan's symptoms over the course of the next two months. We're interested not only in whether their mental health classes will benefit the camp residents who participate, but also whether it will prove beneficial to the Ajan themselves. The theory is that re-entering a traumatizing situation in an efficacious and pro-social role can promote healing. We expect that our lay mental health workers will benefit not only from learning the content of the curriculum, but from the very act of implementing the intervention.

Today they appear relaxed and cheerful, but they survived the earthquake too, have had their share of trauma, and are not strangers to these symptoms. One of the project's translators tells us that he was at his college during the earthquake and just happened to be out of harm's way when an entire floor collapsed, killing the dean and the majority of teachers and students. He won't go in to that part of town he says, and sometimes when he closes his eyes he sees walls crumble. Others nod as he speaks. Every so often, planes or helicopters fly low over the AFD and everyone inevitably jumps a bit. When we add their scores later, three of thirteen Ajan and translators will meet criteria for PTSD.

Author and two volunteer psychologists training Ajan Sante Mantal

We are lucky to have Solon, a Haitian psychology doctoral student working with us. He is well-versed in trauma and can be counted on to highlight the importance of empathy. Solon works weekly at the AFD's medical clinic running post-traumatic stress groups for both children and adults. He will help us with training and modification of our class protocol and will meet with the Ajan weekly for debriefing. Running classes with traumatized people in the camps will inevitably be hard, and it will sometimes be heartbreaking. We are wary of overwhelming our Ajan and will do frequent assessment of compassion fatigue and overall mental health.

Solon (far left), psychologist for Soulaje Lespri Moun, running a group for children in an IDP camp while the lay mental health workers conduct workshops with their parents.

Roger and I begin by introducing the project and running the class with the Ajan as participants. I've brought them a (poorly) translated Creole version of an outline of the protocol and they follow along and take notes. We talk about explanations for the earthquake (scientific and otherwise), about physiological reactions like rapid heart-rate and their role in keeping the body safe: you are not going crazy and will not have a heart attack. We talk about images that will not leave your head. The faces of those who died, the falling rubble, the bodies on the street.

We talk about fear and grief and guilt and anger and feeling numb and hopeless. We talk about sexual difficulties. We discuss the presentation of trauma in children and the importance of hugs and talk and keeping a routine. We discuss the many amazing coping strategies that Haitians use everyday - prayer and song and dance. And we talk about other easy things that one can do now to help with hyperarousal, sleeplessness, pain, and stress. When we do the abdominal breathing exercise and imagery with butterfly hug, there are long sighs and no one seems to want to open their eyes. "Oh I'm still here?" a tall and earnest young man says, reluctantly returning to the present, "aw, my girlfriend and I were just getting comfortable!" Roger has informed me that his preferred "culturally-appropriate" example for the imagery exercise involves the beach, lovers, and what Roger translates in a somewhat sultry tone as relaxing. He has assured me that he avoids the pornographic, and until I learn more Creole, I'll have to take his word for it.

When we complete the class, there are many good questions, often with no good answers. A small woman with a strong voice asks, "Some people will say 'who needs psychology'? What we need is food and jobs and dry shelter. They are hungry; they will ask us for money. What can we say to them?" There are murmurs of agreement and then there is a moment of silence because this is a big question. Solon and Roger and I look at each other. We have been asked this question many times. Together we slowly construct a response: First, you can empathize. You can acknowledge, not deny, their suffering and its injustice. It is true that the people need many kinds of help, and we want nothing more than for them to receive everything they need - relief of hunger, of thirst, of poverty. But we do not have those things - we have only one thing. And that is a chance of relief for the mind. There are many things that one cannot change; we are at the mercy of governments and organizations, of other individuals, of the weather, of God. But perhaps we can change our thoughts and this may in turn change everything. And if they keep complaining, Rogers says, just tell them how much it costs to see a psychologist in the US!

There are nods, but the next question is hardly easier. "What if I see a crazy naked person with a machete? How do I help him?" asks a tall and earnest young man. There are some laughs, but it is nervous laughter. You don't, I say. We are not training you to work with seriously mentally ill people - you are, essentially, teachers who will provide information to the public. So, we say, if you see someone who appears dangerous, you run. Then, when you're safe, you can tell someone - the camp committee, mobile clinic doctors, Solon or other psychologists, the police. But the question is at its core an impossible and heart-breaking one. There are many people who are well beyond our help. We instruct the Ajan to make referrals to the AFD's weekly clinic, but most won't make it out here. The development of psychiatric services is critically needed.

We meet several times for more training, and in between, the Ajan meet with Solon to role-play the class on their own. By the time we meet again, they've got the protocol memorized and we go around the circle and they each do a portion. They've clearly got it down, and have added their own twists. This is part of the plan - cultural relevance will come naturally as our model outline is filtered through the Haitian Ajan who implement it.

Ajan Sante Mantal conducting a post-traumatic stress workshop in an IDP camp in Port-au-Prince

We are ready now for a trial-run, but first our ten are officially christened Ajan Sante Mantal. There is some a bit of ceremony around the handing out of the badges. Everyone has brought photos to attach. Badges are important in Haiti. They command respect, and have been known to save one from getting hassled by the police or waiting all day in line at the bank. The new Ajan hop onto back of a pick-up truck for a ride to a nearby IDP camp, CAVS 2010, run by my friend Jules Woodly. An animated guy with dreadlocks and a solid handshake, Woodly welcomes us heartily and tours us proudly around the camp, pointing out the tent he first pitched Jan 12, the day of the earthquake, and the spot where injured and dying earthquake victims were treated by volunteer nurses.

Ajan Sante Mantal conducting a post-traumatic stress workshop in an IDP camp in Port-au-Prince

Today, Woodly helps us form five groups of ten or so and our Ajan pair up and get to work. They're clearly naturals. They've not only got the content down, they're expressive and empathetic and are churning out therapeutic alliances left and right. Despite the heat and mosquitoes and crying children, their participants are engaged. They nod furiously during the education portion, and for the abdominal breathing and butterfly hug, their eyes are closed and their faces relaxed. When they're finished, I get a barrage of hugs from the Ajan. "That was very very good," one says. "They want us to come back! When will we be back?" They are visibly excited and it is good to see. They have the "helping high" -- I hope it sticks.

Ajan Sante Mantal teaching the "butterfly hug" relaxation technique to residents of an IDP camp in Port-au-Prince

Residents of an IDP camp practicing the "butterfly hug" relaxation technique

There are are many things to do. Data collection is an incredible, sometimes ridiculous feat - we're tracking PTSD symptoms in both the Ajan and in the camp residents that participate in their classes. We visit two camps to collect pre-intervention data. It is an amazing thing to witness one of our young men juggling two babies while reading the Harvard Trauma Questionnaire aloud to a small cluster of illiterate women who follow painstakingly along with their handouts and stubby pencils. These women and others are invited back to participate in classes. In July, we hope to teach our original ten to train ten new Ajan. We would like to increase their skills beyond knowledge of our original protocol, and are inviting mental health professionals who would like to provide training as self-funded volunteers. Those with trauma-focused skills for use with children are invited to conduct trainings with mobile school teachers. There are many ideas for the future. We are considering translating the class into drama and enlisting a traveling theater troupe to present the information in as engaging a way as possible. We would like to enhance our understanding of traditional healing practices and incorporate them.

Ajan Sante Mantal completing a measure of symptoms of post-traumatic stress with residents of an IDP camp in Port-au-Prince

Ajan Sante Mantal working with residents of an IDP camp.

But first is the issue of funding. We need help to pay our Ajan's stipends and their transportation and, ideally, to hire and train more. We have applied for some grants but these things take time - to keep the project afloat, we're emptying our own pockets and soliciting for small donations from friends and family. Time is of the essence in preventing long-term PTSD and other mental health problems. It is critical to provide services now, before symptoms and maladaptive coping methods progress and become ingrained. Currently, the Ajan work three days a week in sun and rain, conducting classes in two IDP camps for about 300 people each week. As things stand now, they will stop working in July due to lack of funds. Even small sums can keep them working for a few weeks longer. We are asking, on their behalf, and that of residents of Port-au-Prince IDP camps with psychological distress, that you consider helping if you are able. To donate or for information about traveling to Haiti as a mental health volunteer, please visit the Aristide Foundation website.
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