Stage 1: Intervention development and trial-run
An eight-week trial-run (April 27 – June 27, 2010) is currently underway. In April 2010, an American trauma therapist and Haitian psychologist trained 10 Haitian students from UniFA (the University of the Aristide Foundation to work as “Ajan Sante Mantal” (lay mental health workers). Ajan were taught a simple psychoeducation and coping skills protocol, consisting of information about normal psychological and emotional responses to trauma in children and adults, basic behavioral coping skills, and relaxation and self-soothing techniques. This model, developed by an American trauma therapist with culturally-appropriate modifications made by a Haitian collaborator, was used successfully in IDP camps in February 2010. Ajan were also provided with training regarding the identification of seriously mentally ill individuals who require additional care, and provided with referral information for these individuals (e.g. AFD weekly health clinic, or other professional mental health workers in Port-au-Prince.)
The 10 Ajan are currently being paid a stipend to conduct the classes with parents of students attending AFD-organized mobile schools in two IDP camps (Carradeux and Building 2004) over an eight-week period. Contact with these camps is managed by the supervisor of AFD’s mobile school program and approval has been secured with camp committees. Ajan work in pairs to conduct classes for approximately 12 participants at a time. Each participant will take part only once, and referrals will be made if additional services are needed. Each pair of Ajan hold three two-hour classes per week so that approximately 180 camp residents participate in classes each week. Class content runs approximately 90 minutes and the remaining 30 minutes are used for questions and to provide referrals for those with serious mental health problems. After the eight-week trial period, workers will be asked to share successes and failures and the protocol will be evaluated and revised accordingly.
In addition to providing classes for six hours per week, the Ajan meet for one hour per week for debriefing with a Haitian psychologist and with the Haitian project manager. This meeting provides a venue to discuss problems and successes in administering the class, as well as emotional reactions to upsetting content encountered while working in the camps. Ajan will be given the opportunity to discuss their reactions to the traumatic experiences of participants in their groups, as well as their own experiences and those of their families. The psychologist will closely monitor the emotional well-being of these workers and do frequent assessment of PTSD and compassion fatigue symptoms.
During this trial period, a simple evaluation of model effectiveness will be conducted. Initial and ongoing data collection methodology is described below in the “Evaluation of intervention effectiveness” section.
Stage 2: Widespread training and service provision
Following the trial-run, the protocol will be reevaluated and revised and then a larger pool of lay mental health workers will be trained as funding allows. Training will be conducted by American trauma therapists paired with members of the ten-member trial-run team. As the project progresses, successful Ajan will be chosen to be trained as trainers of new workers.
American mental health professionals will be invited to provide training in supplementary, basic, easily-applicable trauma treatment modalities (e.g. relaxation, self-soothing, and grounding techniques) on a self-funded volunteer basis. In addition to funding their own travel and in-country expenses, these volunteers will also be asked to raise $500 for contribution toward payment of Ajan stipends. In exchange, they will be provided with a safe and effective mode of volunteerism in which their skills can be used to evoke wide-spread benefit. In addition to training Ajan, volunteers can provide direct care services at the AFD’s weekly mobile health clinic in which 1200 people receive services every week, and can visit IDP camps to work directly with residents. Volunteers will be invited to camp at the AFD for no charge, or assisted in making hotel arrangements at their own expense. The project manager, Mr. Noel, will be available for hire for transportation, guide services, and translation as needed.
Ultimately, American therapists will ease out of the training process, and the management of the project will be sustained entirely by Haitian employees, with American involvement restricted to financial support and overseeing the research.
Evaluation of intervention effectiveness
We are committed to empirical evaluation of the effectiveness of this intervention model throughout its implementation. We have two hypotheses regarding the effectiveness of the intervention: first that it will decrease symptoms of post-traumatic stress for participants in the classes, and second that it will decrease these symptoms for those implementing the class (the Ajan).
Hypothesis 1: Benefits for class participants
To test our first hypothesis, participants in the classes will complete posttaumatic stress measures both before and after receiving the group intervention. Prior to receiving the group intervention, approximately 400 parents of mobile school students at Carradeux and Building 2004 completed a Creole translation of the 16-item Harvard Trauma Questionnaire (HTQ), a measure of posttraumatic stress disorder symptoms. Ajan assisted participants in completing the measure and read it aloud to those who could not read. Participants at each camp were then randomly assigned to an experimental or to a wait-list control group. Those in the experimental group were told that they would participate in a class in the next two weeks, and were asked to check back on days that Ajan are present to take part in a group. The other half of the participants (the waitlist control group) were told that they would participate in a class beginning two weeks from now, and that they should check back for class assignment beginning in two weeks (May 11). All participants from both the experimental group and the control group will complete the HTQ again in two weeks (May 11). Those in the waitlist control group will then participate in a class over the following two weeks, and all participants will be reassessed two weeks later (May 25). In addition to completing the biweekly HTQ, all participants will also be asked to report their overall impressions of the group and suggestions for improvement immediately following participation in the group. Longer-term assessment of PTSD symptoms will be conducted as possible. This protocol will be repeated at additional camps.
Hypothesis 2: Benefits for class implementers
To test our second hypothesis, our ten Ajan completed the HTQ prior to beginning their training, and then completed the same measure following the training (and prior to official work start date). Preliminary results show significant decrease in posttraumatic stress symptomology between pre and post-training. The HTQ consists of 16 symptoms derived from the Diagnostic and Statistical Manual-IV (DSM-IV) criteria for posttraumatic stress disorder (PTSD). There are four answer categories ranging from ‘not at all’ (score = 1) to ‘extreme’ (score = 4). Scores for the 16 items are added and then divided by 16. , While the average HTQ score among Ajan was 1.83 prior to the training, it dropped to 1.41 following the training (just 5 days later). Prior to the training, two of ten Ajan met criteria for PTSD (HTQ score of 2.5 or higher) but after the training, none met criteria. Ajan will complete the measure again in 4 weeks and in 8 weeks. Compassion fatigue was also assessed prior to beginning work and will be reassessed every 4 weeks.
In the next round of trainings, a control group will be added and a more controlled assessment of effectiveness will be conducted in order to account for demand characteristics (i.e. that the Ajan’s lowered scores are due to desire to please the experimenters), and to isolate the mechanism by which the intervention is effective (i.e. whether lowered PTSD symptoms are due to exposure to the material or to the act of teaching this material to others, or a combination).
Ten new Ajan will be hired and will complete measures before and after the training, and every four weeks after this. They will be matched with twenty other young people with similar characteristics (age, education, income), who will make up two ten-person control groups. The first control group (the “pure control group”) will simply complete measures at the same time periods as the other groups, but will receive no training, employment, or other intervention. The second control group (the “content-exposed control group”) will be introduced to the same material as the Ajan and will be exposed to it for the same amount of hours over the course of a week; however, this group will simply meet to study and to talk about the material rather than to teach it to others. We predict that both the Ajan and the content-exposed control group will show more improvement than the pure control group, but that the Ajan will improve more than the content-exposed control group.
Collaborating organizations, staff and personal:
Aristide Foundation for Democracy. AFD-Haiti was founded by Jean-Bertrand Aristide in 1996 on the principle that to bring real change, democracy must include those at the margins of society: street children, market women, landless peasants, restaveks (children living in Haitian households as unpaid domestic laborers), the urban poor. For 14 years the Foundation has dedicated itself to providing educational opportunities and opening up avenues of democratic participation for those who traditionally have had no voice in national affairs and no access to education. Since the earthquake the AFD has mobilized its staff, doctors, supporters and volunteers to respond to the needs of Haitians living in temporary settlements across Port-au-Prince. The AFD has sought to serve as a bridge between the larger relief effort and grassroots organizations and neighborhood associations across the earthquake zone with whom the AFD has worked closely for over a decade. Since late February the AFD has operated mobile schools in 5 refugee camps, serving 1,260 children. AFD doctors and volunteers participate in mobile medical clinics out to refugee camps along in collaboration with Partners in Health. The AFD also runs a free clinic, which provides primary care to over 1000 people each week. Two Haitians psychologist participate in these weekly clinics, providing group mental health counseling to those exhibiting signs of PTSD.
Ajan Sante Mantal (lay mental health workers) are Haitian high school and college graduates who were studying language and computer sciences at UniFA (the Univeristy of the Aristide Foundation) at the time of the quake. They are now employed to provide psycho-education and coping classes to residents of refugee camps. These students were selected based on their extraordinary academic and interpersonal skills. They themselves come from the communities most impacted by the earthquake (ie the populous neighborhoods Port-au-Prince) and some of them are living in the same conditions as those in the IDP camps. Many of these students have competency in multiple languages and several are also teachers in the AFD Mobile School project.
John Roger Noel, project manager. Mr. Noel is a director of a local child care center (MABO) and has worked as project manager on several research projects with the University of Michigan. Most recently he managed a team of 30 Haitian interviewers for the post-disaster assessment funded by the Small Arms Survey and the UN. He is fluent in Creole, French, and English. In February 2010, he collaborated in the development of the psychoeducation and coping class protocol and provided expertise in cultural translation of concepts and development of culturally appropriate examples. He administered this class in refugee camps during initial trials in February. In April, Mr. Noel provided initial training to the 10 Ajan and will meet with them weekly for ongoing training and supervision. He is also responsible for supervising data collection and entry. Finally, he will provide guide services, translation, and transportation to visiting volunteer mental health workers.
Merry Yves Roche, staff supervisor of Soulaje Lespri Moun and the AFD mobile school program. Ms. Roche is the supervisor of 102 mobile school teachers working with children in refugee camps through the AFD mobile school program. She speaks Creole, French, and English. For Pwoje Soulaje Lespri Moun, she will share responsibility with Mr. Noel for supervision of the Ajan, and will coordinate with the refugee camps in which Ajan will work. She has good working relationships with committees in 5 camps in Port-au-Prince in which AFD mobile schools have been implemented. She will act as a liaison between this project, the refugee camps, and the AFD organization.
Jacques Solon Jean, Psy. Mr. Jean is a psychology doctoral student with significant experience treating symptoms of post-traumatic stress disorder in both children and adults. He is a regular volunteer at the AFD mobile health clinic where he runs trauma-therapy groups for approximately 100 individuals each week. Mr. Jean assisted in initial training of the Ajan and will continue to meet with them on a weekly basis for debriefing and is available as needed by phone. He is responsible for monitoring the mental health of all team members and for coordinating care or referral for seriously mentally ill individuals encountered during work in the refugee camps.
Laura Flynn lived and worked in Haiti from 1994-2000. She helped to found the Aristide Foundation for Democracy, where she oversaw the creation of grassroots literacy programs, micro-lending programs, and advocacy and outreach programs for restaveks and street children. She is the editor of Eyes of the Heart: Searching for a Path for the Poor in the age of Globalization by Jean-Bertrand Aristide (Common Courage Press, 2000). She is currently a member of the board of the Aristide Foundation for Democracy-US, and has been working since the earthquake to bring international support and volunteers to assist in the Earthquake Relief Efforts of the AFD.
Leah James is a doctoral candidate in social work and psychology at the University of Michigan where she researches the effects of cultural belief systems on coping and resiliency to trauma. Ms. James is also a clinical social worker at the Posttraumatic Stress Disorder (PTSD) Clinic at the Veterans Affairs hospital in Ann Arbor, MI, where she provides psychotherapy to returning Iraq and Afghanistan veterans with PTSD. She is currently working with a University of Michigan research team on a post-disaster assessment in Haiti and is providing mental health services to residents of camps for internally displaced peoples (IDP) and to teachers through the Aristide Foundation for Democracy in Port-au-Prince. She is responsible for training and supervising the Ajan and for managing the research components of the project.
Naomi Levitz is a social worker working in Michigan and Ontario. She received her MSW in clinical social work from the University of Michigan and since then has participated in multiple research and humanitarian projects in Haiti. She works closely with the MABO children’s center in Port-au-Prince.
Athena Kolbe is a doctoral student in social work and political science at the University of Michigan She first traveled to Haiti as undergraduate student to work with a group of street children in establishing a children’s radio station. Now a clinical social worker in Detroit, Athena continues to conduct research in Haiti including organizing a national survey of health and harm in 2009, a household survey detailing crime and human rights violations after the 2004 coup, and a study for the United Nations Development Program examining the impact of the January 2010 earthquake on residents of Port-au-Prince. She is also working with a coalition of Haitian social service providers to establish the Institute of Social Work and Social Science, a bachelor’s level degree-granting program in Port-au-Prince designed to train professional social workers.
Michael Varnum is a doctoral candidate in social psychology at the University of Michigan. His research focuses on the relationship between culture, the self, and cognitive tendencies. He will share responsibility for managing the research aspects of the project.