Authors: Guerda Nicolas, Ronald Jean-Jacques and Anna Wheatley
Since the devastating earthquake struck Haiti in 2010, all eyes have been on Haiti. In particular, with the influx of foreign psychological and psychosocial efforts, the country’s mental health infrastructure has been under scrutiny. In the context of a strong familial, community, and religious social fabric, the field of formal mental health services, including counseling, is not as strongly developed as in the United States, or other Westernized countries. In the wake of the earthquake, however, service providers in Haiti within the fields of psychology, psychiatry, and social work are moving toward increased organization and structural cohesiveness. This report provides an overview of historical foundations, current context, and future implications surrounding the state of counseling in Haiti.
Haiti recently came to the forefront of global consciousness as a result of the devastating earthquake that struck Port au Prince on January 12, 2010, killing close to 300,000 people and destroying homes and other infrastructure in the country. Given the tremendous economic and political leadership struggles of the island and its people, it is not surprising that well-being—specifically mental well-being—is a pressing concern. Counseling as an independent discipline is not currently a part of the emerging formal mental health system in Haiti; however, comparable services are available in both psychological and psychiatric provision. Furthermore, the country’s mental health system—in particular, in terms of organization across the field—is experiencing a renewed engagement in development and formalization.
This report presents an overview of the mental health infrastructure in Haiti and a discussion of current needs pertaining to mental health services. The second author’s position as a Haitian psychologist, who resides in and has practiced in Haiti for many decades, provides an opportunity to accurately inform readers of the services and providers existing in the country. We conclude with the initiatives undertaken by local service providers in Haiti to address and redress mental health issues in the nation, especially post-earthquake, with some recommendations for Western-based international mental health organizations seeking to establish services in Haiti.
Historical and cultural context of Haiti
The Republic of Haiti, originally named Ayiti (meaning great mountains or great land) by the Taino Indians (the original inhabitants of the land on the “discovery” of Hispaniola by Christopher Columbus in 1492), is located in the Caribbean and occupies the western third of the island of Hispaniola, which it shares with the Dominican Republic (Nicolas, Schwartz, & Pierre, 2010). Despite Haiti’s legacy as the first independent state (declared in 1801) in the Caribbean and the first independent Black republic in the world, the island and its people have been plagued by decades of social unrest—including political turmoil, leadership instability, and poverty—that have overshadowed the significant role that this country played in the establishment of civil societies throughout the world. In many ways the grasp of colonialism and foreign interests has had a profound and lasting impact. In this context, the social fabric and culture has served a pivotal role in maintaining the spirit of Haitian people in the face of a legacy of adversity. Family, community, and spirituality (religious and otherwise) play integral roles in Haitian norms and practices—including those related to counseling and mental health (Bibb & Casimir, 1996; Nicolas et al., 2010). Catholicism was historically the officially recognized religion; however, there has been an increase in religious affiliative diversity among Haitians (Bibb & Casimir, 1996). In 2003, Voodoo was officially recognized as a religion in the country.
Scholars have highlighted the distinction between religion and spirituality (Worthington & Sandage, 2001) and the psychological benefits of each for different individuals (Hill & Pergament, 2008). Spiritual and religious systems have also informed indigenous healing and coping practices in Haiti. Religion is cited as a means of helping people cope with mental and emotional problems, and also as a means by which spiritual leaders may partner with and encourage conventional treatment of physical or mental health (World Health Organization [WHO], 2010). For example, Voodoo includes guidance for healing practices, health promotion, and prevention of illness and promotion of personal well-being, with theories of illness, treatment interventions, and prescriptions for behavior that are congruent with widely held explanatory models (Augustin, 1999; Vonarx, 2008). It is important to note that, in general, Haitians may have difficulties divulging and discussing personal issues with mental health professionals (Nicolas et al., 2010; Nicolas, DeSilva, Prater, & Bronkoski, 2009). Furthermore, Western psychology is not commonly the mode by which to explain and discuss feelings and symptoms (if applicable). Thus, developing a clearer understanding of Haitians’ beliefs about illness and healing may assist in providing culturally effective treatment for this population.
Historical overview of counseling and mental health issues in Haiti
Limited information is available on the mental health impact of historical, political, and economic conditions in Haiti. A lack of published research is not indicative of a lack of such information altogether, however. The first counseling practices in Haiti began in the late 1980s with the launch of a major AIDS prevention campaign that included face-to-face contact with atrisk populations (Pape, 2000). Counseling services were a major component of the response to increased rates of HIV/AIDS and sexually transmitted infections, as education and counseling were seen as the only available preventative measures (Pape, 2000). More generally, the campaign stressed sex education and awareness for responsible sexual behavior—including condom use and/or the promotion of positive behaviors (e.g., abstinence, reductions in number of sexual partners) and attitudes (e.g., positive sense of self, the future, and the world) among young adults.
These educational campaigns led to recognition by public and private groups of the importance of psychoeducational programs from a prevention/ intervention perspective. Several public and private institutions began supporting various educational programs throughout Haiti that greatly enhanced social services in the country. For example, the Global Fund and the United States’ President’s Emergency Plan for Aids Relief increased and intensified efforts in the field of counseling for behavioral changes in sexual matters. As a result, approximately a dozen psychologists started “youth centers” such as Fondation pour la Sante Reproductrice et l’Education Familiale, Volontariat Pour le Développement d’Haiti, and Promoteurs d’Objectif Zéro Sida.
The prevalence of addiction in Haiti during the past two decades was also a focus of youth prevention programs promoting appropriate conduct in risky situations and seeking to curtail abuse of alcohol and other substances (Jean-Jacques, personal communication, 2011; Sontag, 2010). In many schools (including high schools and colleges) in Haiti’s main cities, psychologists, trainers, and educators worked with youth to provide information and make them aware of the problems of addiction and substance abuse.
With respect to mental health facilities, Haiti inherited the American model of mental health hospitals in the first half of the 20th century, opening Hospital Beudet, the largest public psychiatric facility (120 beds), housed in an old abandoned military camp in Croix des Bouquets, near Port au Prince. In addition, Centre Psychiatrique Mars et Kline, a psychiatric care and psychological service facility with a capacity of only 20 beds, is an outpatient clinic attached to the Hospital of the State University of Haiti in the heart of the capital (Bulletin du Centre de Psychiatrie et de Neurologie Mars et Kline, 1967). The Center was sold to the hospital in 1954 by the SmithKline pharmaceutical company for a low cost as compensation for experiments conducted for several years using the drug Trilafon on Haitians in collaboration with renowned Haitian psychiatrist Louis Mars (Jean-Jacques, personal communications, 2011). In addition to these two facilities, three other private centers (with 100 beds in total) and psychological units in two private hospitals in Port au Prince offered psychological and psychiatric services to affluent members of the community. In other regions of Haiti, four units offered psychological care in public hospitals in southern Les Cayes, Gonaïves in Artibonite, Cap Haitien, and Jérémie. It is important to note that these facilities provide basic services (assessment and support), with staffs of one or two junior psychologists accompanied by two or three nurses (McShane, 2011).
Current status of mental health counseling in Haiti
Many of the mental health professionals in Haiti are Haitians who have completed their studies at the second (specialized or Master’s) or third level (Doctorate) in other countries, such as the United States, Canada, Mexico, and countries in Europe (e.g., France, Belgium, Switzerland). In fact, within Haiti, the Bachelor’s degree is the highest degree awarded in psychology. This is due in part to the fact that there is limited faculty at the graduate and doctoral level at the state university for psychiatrists, psychologists, and psychiatric nurses. On completion of the bachelor’s degree, individuals are able to complete a portfolio that is submitted for licensure as a psychologist in Haiti. There is no formal licensing board for practitioners in the Haitian mental health system, nor are there regulations. Following the earthquake, an evaluation of the current mental health system in Haiti was conducted by faculty members at the Université d’Etat d’Haiti. In contrast to estimates provided by a recent Pan-American Health Organization/WHO (2010) estimate that reported 23 psychiatrists and nine psychiatric nurses, the faculty evaluation found 100 psychologists, nearly 50 social workers, 30 psychiatric nurses, and 20 psychiatrists who are addressing the mental health needs Haitians in Haiti (Jean-Jacques, personal communication, 2011).
Data from the Caribbean Country Management Unit (2006) suggest that nearly half of the population lacks access to formal health care services, and access to mental health services is presumably lower. Among all health care facilities, only 30% are public and located in urban areas. Nearly three quarters of health services in rural areas are provided by nongovernmental organizations (NGOs) and comprise mainly primary health care provision. For a population of nearly 9 million people, Haiti has the lowest rate of professional psychosocial support in the Caribbean and Latin America, and one of the lowest in the world (James, 2004). In contrast, the Dominican Republic has more than 2,000 mental health professionals, and Puerto Rico has no less than 5,000 psychologists and psychiatrists for fewer than 4 million inhabitants (James, 2004, 2010; WHO, 2010).
In the aftermath of the earthquake, a fleet of NGOs and international organizations (IOs) entered the country to provide emergency care and “psychological first aid” to amputees in a state of posttraumatic shock, and those with other physical injuries. Three to six months after the earthquake, however, such care had almost completely disappeared. As a result, many other foreign psychiatrists and psychologists arrived to fill the gap of these NGOs and IOs for 1 to 4 months at a time, providing psychosocial support services in different sections of Haiti. In addition, more than 300 graduate students in social work and psychology (who studied outside Haiti) were employed to provide services. However, many of these students received little guidance and supervision. In the rare cases in which such training was provided to students, it was often led by psychologists and psychiatrists from other countries. Currently, the Unite de Recherche et d’Action Medico Legale—a psychotrauma center established in February 2010 by a Haitian NGO—and the Center of Research and Psychosocial Interventions—established in March 2010—are the only two locations established to provide ongoing services to many individuals experiencing substantial trauma-induced reactions following the earthquake.
Very little collaboration has been established between mental health professionals from overseas and nationals working in Haiti. The few IOs that sought to work with Haitian professionals (i.e., Medecins du Monde, Medecins Sans Frontieres, Association of Black Psychologists, International Organization for Migration, and Pain Without Borders) have maintained consistent contact over time and have created sustainable connections. With these few collaborations, numerous training sessions and exchanges were organized with Haitian psychiatrists, psychologists, and social workers. Several institutions—including IOs, NGOs, and universities (particularly the Faculté des Sciences Humaines, Université d’Etat d’Haiti)—organized psychosocial support services for people in shelters and makeshift camps around the cities of Port au Prince, Leogane, Delmas, Petion Ville, and others. Undergraduate and graduate students have also been involved in related outreach and service provision. In addition, psychologists in private practice and some psychiatrists received many counseling cases of various conditions related to the psychological shock of the earthquake. Those who were able, also organized discussion groups and employed other techniques of group psychotherapy to ensure that more individuals had access to mental health services.
In the first couple of months after the earthquake, psychosocial support services were also organized by many institutions (e.g., Red Cross and United States Agency for International Development) for employees, officers, or other members of their organizations who were in Haiti. Several international institutions, such as embassies, multinational organizations, and bilateral and multilateral corporations, paid for employees to receive psychological care in small groups or individually, with the assistance of Haitian psychologists and psychiatrists. Finally, some Catholic and Protestant missions (often having been stationed throughout Haiti providing relief work prior to the earthquake) have been at the heart of finding ways to implement psychological counseling and economic compensations for their followers and members.
Counseling in Haiti: what does the future hold?
The mobilization of psychologists in Haiti since the earthquake signifies noteworthy progress in the right direction in terms of national mental health policy in Haiti. Seven meetings, with an average attendance of 30 psychologists, were held from March 2010 to December 2010 to plan and implement the formation of l’Association Haitienne de Psychologie (AHPsy). The association aims to be at the forefront, alongside other partners, in defining a national plan for mental health. Significant progress has been made in the development of AHPsy, including establishment of regulatory frameworks, a code of ethics, and an oversight committee.
In addition, AHPsy held its first conference in June 2011, with the following theme: Mental Health in Haiti after January 12, 2010: Trauma, and Treatment Approaches. Local and international psychologists, psychiatrists, social workers, nurses, spiritual healers, instructors, and educators were invited to share insights, approaches, diagnoses, and treatments of psychological trauma and other conditions related to natural disasters. This space for information exchange and communication allowed service providers and other constituents to gain a better understanding of the sociocultural reality and psychological and psychopathological concerns of the Haitian people.
The main objectives of this conference were
- to bring together various mental health professionals for exchange and discussion,
- to establish a platform for discussion of mental health in Haiti via a network of concerned professionals and institutions, and
- to encourage exchange and dissemination of information and scientific research on psychological trauma related to natural disasters.
The creation of AHPsy and its inaugural conference signal the first instance of uniting all Haitian mental health professionals in the country and allowed the international community to see the existing resources that are available within the country. Through this initiative, colleagues from the international community will also be able to collaborate with Haitian professionals in Haiti in ensuring that effective and culturally appropriate counseling is provided to individuals and communities throughout the country.
Following the conference, the network of professionals increased significantly, bringing together more than 150 psychologists and students. Collectively, the association drafted a mental health policy brief in June 2011, asking for the establishment of mental health as an integral part of health, which was submitted to the Department of Public Health. The document is currently under review by the department and AHPsy has been strongly involved in the process. With the election of a new Government in the country, the AHPsy is determined to continue its advocacy for the establishment of a mental health plan in Haiti.
Conclusions and Recommendations
In the context of recovering from a devastating disaster, it is clear that the issue of mental health must become a national priority for Haiti over the next 10 to 20 years. This is necessary given that (1) more than 227,000 people were buried in mass graves, leaving millions of parents and relatives almost unable to mourn—an important aspect of Haitian culture (Brown, 1989; WHO, 2010); (2) more than 40,000 amputees require rehab and treatment appropriate to their new situation; and (3) more than 1 million people are without homes, a situation that is not likely to change in the near future (WHO, 2010). One of the most integral components of moving forward will be to develop a National Mental Health Plan that must include the following key elements:
- Definition and implementation of strategies and actions in the short term (2-3 years), medium term (3-5 years), and long-term (5-10 years);
- Establishment of clear policy and practical training (with a focus on public schools) for mental health;
- Relevant and culturally appropriate training of existing mental health providers in Haiti;
- Decentralization and devolution of psychiatric and psychological services and care throughout the country across geographical departments;
- Creation of multidisciplinary care centers specializing in psychological trauma; and
- Support for and proliferation of studies and research to inform and guide interventions and practices to support the Haitian people.
Renewed attention to Haiti’s mental health infrastructure following the January 12, 2010 earthquake reveals a history of little formal organization and service provision. A review of historical and social context illustrated that Haitian culture and social practices are primary factors in crosscultural differences in illness explanations, help-seeking behaviors, and mental health service provision in comparison with the United States and other Western societies. Even within Haiti, the use of counseling (and other related) services may vary substantially based on factors such as location, religion, and social class (Nicolas, DeSilva, Grey, & Gonzalez-Eastep, 2006; Schininà et al., 2010; WHO, 2010). Moving forward, priority must be given to encourage training of a new generation of Haitian mental health counselors. The formation of the AHPsy represents a momentous step forward in the establishment of a network of service providers, and an opportunity to shed light on both the psychological impact of natural and other disasters and the importance of understanding and appreciating differences in mental health across cultures.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.