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

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.
You can also reach us by email at mentalhealthhaiti@gmail.com.

“I’m scared, I’m just scared.”

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

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 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 posttraumatic 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.

At least my best-case-scenario, 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 member of our research team 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 made as if 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 single functioning terminal 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 side-step 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.

Throughout our trip, we work closely with Roger, manager of our Haitian research team and a director of Mabo, a remarkable Port-au-Prince orphanage and school. 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 scantrons 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 in Tabar, 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 posttraumatic 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 all quite interesting but ultimately irrelevant in light of the earthquake being a religious prophesy. 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 prophesy 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 7pm 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 make-shift 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 startle 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 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 series of clean, well-managed camps that he directs himself. 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 camps.  There is a school there now, miraculously developed through painstakingly scraped-together funds.

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 camps, 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 perhaps there is opportunity. I and a loose group of others in Southeast Michigan and Port-au-Prince have formed Mental Health Haiti, 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 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, and aim also to hire and train unemployed Haitians to provide basic, ongoing education and skills for coping posttraumatic 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 wide-spread 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, education and skills may not be enough. But it is a start, and, as those who work with trauma survivors know, people are amazingly, even shockingly, resilient.