Dr Robert London

Mental Health in Haiti

Clinical Psychiatry News - Volume 38; Issue 4; Page 7, 2010

The disastrous earthquake that hit Haiti in January not only illuminated the remarkable resilience of the Haitian people. It also galvanized humanitarian and medical efforts, and showed the depth of human compassion. Doctors and nurses, orthopaedic surgeons, infectious disease specialists from the military as well as from civilian life, have given of themselves brilliantly.

But what about the population’s psychiatric/psychological needs? As we know all too well, these needs also must be addressed (see “In Haiti, Mental Health System Is in Collapse,” The New York Times, March 19, 2010, p. 1).

Providing mental health care to Haitian patients requires particular sensitivity. After all, the view of Haitians and their concept of the world are unique. We need to understand, for example, the extent to which spiritual beliefs  and practices shape attitudes about mental illness and compliance with treatment in Haiti (Am. J. Psychother. 2002;56:508-21).

Considering the devastation Haitians have experienced—and continued to experience with numerous aftershocks and the threat of the rainy season—we can be sure that countless Haitians are suffering from posttraumatic stress disorder. PTSD can lead to depression, suicide, aggressive, even homicidal behavior, in addition to flashbacks, nightmares, and unbridled anxieties.

Medication management and supportive therapy, including group therapy, are helpful in treating PTSD, but it is my experience and clear to many behavioral therapists that some form of relaxation therapy, coupled with guiding imagery using behavioral techniques such as reciprocal inhibition and systematic desensitization, generally works best in treating this disorder.

These behavioral techniques can be taught to many groups of nonpsychiatric health care providers, including surgeons [if they have the time], general medical doctors, nurses, and other medical technical specialists providing care. Just as surgical and general medical care tries to reach as many people as possible, by instructing health care professionals in these psychological techniques, including certain problematic issues that might be encountered in psychological treatments, we would be providing a broad-based psychiatric/psychological approach to the many who will be in need and will be helped.

Survivors of the Haitian earthquake continue to need help, and the sanctity of the private office or clinic where we traditionally deliver psychiatric/psychological services is probably unavailable. This means medical personnel must be nimble and flexible when it comes to delivering services.

My understanding is that only a limited number of mental health professionals went to Haiti soon after the disaster, and I would guess that few are in the country today. But there are ways we can help some Haitian patients. I would propose teaching those interested medical personnel who want to offer care for PTSD a basic hypnotic/relaxation technique, as described in The New York Times piece. It’s straightforward, and it uses deep breathing exercises and a focus on simply learning how to relax one’s muscles or muscle groups. This approach would be quite similar to those used by yoga instructors or meditation experts for years in classes and seminars to help control anxiety.

After that, the concept of reciprocal inhibition could be introduced. The idea would be to create an emotional environment in which anxiety would be incompatible with the relaxation.

Next, I would teach medical professionals on the ground in Haiti how to use systematic desensitization. This is a bit more complicated than hypnosis/relaxation/reciprocal inhibition, but it would be doable. The idea would be to develop a set of anxiety-producing stimuli [hierarchies] ***for each individual treated, developing a set of stress related images from their traumatic experiences  then coupling these stressor to  a series of pleasant experiences thus beginning a process  desensitizing the person from the problem or the disorder.  Of course more than one session is necessary and more psychiatric know how may be needed to address other issue that may  occur. Thus making this process more complicated***Most often, the hierarchies of anxieties go from the least stressful to those that evoke strong states of anxiety.«I don’t understand what he is suggesting here--tb»

Providing appropriate mental health care to Haitians requires an understanding of the “strengths of their cultural heritage, such as fortitude; perseverance in the most arduous circumstances; deep religious faith; high self-respect; reliance on the extended family; and the tradition of sharing” (J. Psychosoc. Nurs. Ment. Health Serv. 1989;27:22-5).

As we consider things we can do to help Haitian survivors, we must keep these factors in mind. I spoke with Barry A. Hong, Ph.D., about the importance of delivering mental health services in a culturally sensitive way, and he pointed out that it might make sense to blend these techniques into those used by local healers. In fact, he suggested that it might be helpful to train those healers to use these techniques.

Dr. Hong said it would be it would be a mistake to look at the situation in Haiti through a traditional Western lens, because “to the Haitians and their culture, family structures, communities, and religious resources will give a different substance and meaning to how they cope,

“With the earthquake, once emergent medical needs are met, Western mental health professionals can give much help, but resilience may already be built into the Haitian people. Our mistake will be that we think we fully understand. We will probably learn as much as we provide our expertise,” said Dr. Hong, a professor of psychiatry at Washington University in St. Louis who has expertise in PTSD and disasters.

It will take many years for Haitians to process this disaster. The sooner health care professionals are able to deliver mental health services, the sooner Haitians will be able to return to a more normal way of life. Teaching our colleagues in other medical specialties what we know about psychological interventions—while keeping in mind the unique aspects of Haitian culture—are important first steps.