In 1961-62 I had spent a year in Haiti as a Yale undergraduate anthropologist near Leogane, living with a Vodun priest and his family. I was studying the relationship between child rearing practices, psychosocial development, and spirit possession, trying to understand the dynamics and content of Voodoo possession states.
When the earthquake struck, and I finally reached some of my still living friends, the devastation and death stunned me, my tears leading to determination to go to Haiti to help. I contacted the Washington Psychiatric Society, and they, in turn, put me in touch with the World Psychiatric Association efforts around Haiti. I sent a brief resume, including my past experience in Haiti and rusty Creole. Mario Maj responded quickly, asking for my full resume. I was then contacted by Drs. Lynn Jones and Peter Hughes of the International Medical Corp., who interviewed me and arranged my deployment.
We were one of the first commercial flights into Port-au-Prince, and I was one of the first outside child psychiatrists to set foot on Haiti soil. The chaos on the ground as we emerged from the airport was not so beautiful. The few working streetlights revealed collapsed buildings along both sides as far as the eye could see, with tent cities interspersed with makeshift lean-to’s around standing structures for fear of aftershocks. The streets were thronged with people, some nursing, others hawking goods, many on crutches, several with amputations. We passed the collapsed nursing school where 200 souls had perished in seconds, and then the presidential palace, collapsed and lopsided.
After several days I was sent to Petit Goave, to form a mental health team. Like in military psychiatry, we focused on interrupting stress, anxiety, phobic and depression-based symptoms interfering with normal grieving and self-righting so essential after mass trauma. With scarce resources, limited personnel, little time, and often one chance to help people, we had to be practical, and to link and leverage the work through using and strengthening connection with family, friends and community. We also tried to institute and use brief follow-up techniques.
We also taught a basic psychiatric pharmacy. It had to be very basic, not just because of the experience level of the people we were teaching, but because of the very limited supplies we had. But it was adequate and had the virtue of simplifying the treatment options and teaching requirements. Keeping “stress psychophysiology” in mind, we taught patients portable self-help intervention techniques, like rebreathing in a sac for hyperventilation and palpitation, along with the Valsalva or the childbirth “bearing down” maneuver. We looked for cycles of stress symptoms, and emphasized intervening just as the cycle began, using the above maneuvers, or positive imaging or progressive relaxation techniques to break the cycle. We used behavior and cognitive-behavioral and desensitization techniques to interrupt anxiety and phobic avoidance states. We used journaling and assigned homework, including re-establishing family connections through assigned group discussions of loss, or things blocking grieving. If certain priests refused to give funerals because the loved one’s body could not be found for burial, we recommended finding other more enlightened priests for this important family-unifying, arrested-grief unblocking ritual. And we used brief follow-up clinics to provide the continuity and support of the clinic itself, and its nurses, and doctors to reward and insure that these things were done and that medicines were taken. We only used a “short medication leash”, doling meds out a week at a time to get people back, and to help the Haitian doctors see the value of continuity and supportive follow-up. This also allowed them to see if their diagnosis was correct, and to learn to adjust the medications and see if and how they worked.
During the first weeks, we saw more acute cases, and more cases having to do directly with the trauma of the earthquake. But as time went on, there were fewer of the acute cases, and more of the chronic or severe cases. Part of this was just a matter of the time course of such conditions as the earthquake receded into the past. Some of the change was just natural resolution of acute stress and trauma reactions, some reflected the good work of the clinic, both medical and psychosocial. In effect, possibly we were draining the acute cases from the “catchment area”; at the same time, the presence and reputation of the clinic was spreading into the mountains and surrounding sugar plains, drawing in more long-standing chronic cases. I’m sure there are other explanations also.
Once our mental health clinics began to function, we went from just a few cases at first, to the word spreading and lots of cases being referred. We were not primarily doing a service mission, since our aim was to train the doctors and the nurses to do more of the work, and to get them interested and comfortable with it. To this end, I gave all-day Saturday psychosocial seminars and workshops. I also succeeded in getting an initially reluctant hospital medical staff at the Notre Dame Hospital to begin to refer some cases, first by teaching some of their residents invited to our seminar, and then responding quickly to a pair of very psychotic patients that were quite upsetting to the staff. From this we developed a good mutual relationship. But rising expectations in a situation short of psychiatric manpower is always a problem, which is why it is important to emphasize training the front line Haitian personnel to do the work. They will be staying and we will eventually go home. Finally, though it may seem cost-efficient to centralize these kinds of mental health teaching clinics, and they seem to be a luxury with low patient yield, it is always extremely important to do this kind of work on the front line where the teacher as well as the doctors being taught can feel the same pressure and pain, see what the realities are, and where the most staff of all disciplines can see the work being done and the results happening. It supports everyone in the effort.