Soulaje Lespri Moun: Working with PTSD in Haiti

SLM is a collaborative grass-roots project that provides mental health services and training to internally displaced peoples in Haiti following the 2010 earthquake.

By Leah James, Roger Noel, and Jaques Solon Jean

Haiti’s 2010 earthquake is often referred to as “Goudou Goudou” by local people, a nickname derived from the sound and sensation of 35 seconds of shaking and banging (followed by multiple aftershocks) that devastated much of the country. The massive quake resulted in more than 300,000 deaths, with 160,000 people killed in the Port-au- Prince area alone, and a million and a half made homeless. Today, more than a year and a half later, eight hundred thousand individuals continue to reside in temporary housing in camps for internally displaced peoples (IDP), in which securing basic necessities is a daily battle.

Research conducted by our team and reports published by the World Health Organization indicate that many IDP camp residents suffer from physical and psychological difficulties such as head and body aches, sleep disruption, hypervigilance, intrusive memories, grief, anger, guilt, isolation, and excessive drug and alcohol use. Exposure to chronic stress resulting from inadequate living conditions in IDP camps, a severe job shortage, the cholera outbreak, political instability and electoral fraud, and widespread frustration with the handling of the crisis by the Haitian government and international organizations have exacerbated such issues. To compound the problem, due to political violence, multiple natural disasters, and severe poverty, many Haitians may have already been suffering from traumarelated distress prior to January 2010. By all reports, Port-au- Prince lacks the infrastructure needed to efficiently provide even basic psychological services to displaced individuals.

Soulaje Lespri Moun (SLM; “Relief for the Spirit”), a lay mental health worker project for IDP camp residents, is a collaborative grass-roots effort to fill this gap. SLM was developed through partnership among Roger Noel (project manager), Jacques Solon Jean, (psychology consultant and student at the State University of Haiti), and Leah James (University of Michigan doctoral student and PTSD clinic social worker at VA Ann Arbor Healthcare system), with funding from the Aristide Foundation for Democracy in Port -au-Prince and the University of Michigan Center for Global Health and Rackham Graduate School.

The Soulaje Lespri Moun (SLM) team at a camp for internally displaced persons in Tabarre prior to beginning a new seminar series with earthquake survivorsThe collaboration began when Leah James traveled to Portau- Prince in February 2010, as part of a colleague’s research team (Kolbe et al., 2010), and was asked to provide mental health services to earthquake survivors. Drawing from Leah’s clinical experience with veterans with PTSD and international research experience in Ghana and South Africa, from Roger Noel’s and Solon Jean’s prior experience working with Haitian earthquake survivors, and from extensive discussion with survivors themselves, we developed a basic group protocol to teach culturallycompatible coping strategies. The group was well-received in IDP camps, but it soon became clear that the role of a foreign mental health professional in implementing it was negligible. Roger Noel, who had been providing translation, easily learned the protocol and was able to deliver it independently in an effective and engaging manner. We soon determined that we could best contribute to the relief effort by training local young people to do similar work. Thus, this model is grounded in the belief that the majority of disaster survivors are not in need of therapy or other intensive mental health services implemented by high-cost professionals. Rather, we propose that local lay staff (trained to identify and make outside referrals for seriously mentally ill individuals) running a coping skills and efficacy-building seminar can increase displaced residents’ confidence regarding their ability to manage distress and to help others do so, and so enhance resilience.

In April 2010, we teamed with Todd Favorite and Mike Messina (University of Michigan and VA Ann Arbor psychologists) to train eight Haitian young people to work as lay mental health workers – called “Ajan Sante Mantal” in Haitian Creole. Since then, these workers have conducted free culturally-tailored seminars with hundreds of residents across seven IDP camps. In each camp, the lay mental health workers run three weekly seminars for one month, using two parallel approaches to promote resilience. First, participants are provided with psychoeducation and trained in relaxation and other coping skills relevant to enhancing perceived safety, ability to self-calm, and social support. Second, the seminars aim to enhance life meaning, hope, and collective efficacy by encouraging seminar graduates to lead their own informal seminars to teach coping skills to new participants. To this end, seminar participants are given an exam; those who pass receive certificates, and then are supervised in running their own peer-support groups with other residents. Not only does this model allow for community-building and time-and costefficient dissemination of information and support, we predict that reengaging with a traumatizing situation in a prosocial role has therapeutic properties in itself.

Ajan Sante Mantal (lay mental health workers) teaching a relaxation technique called the butterfly hug to residents of a camp for displaced peoples’ in Port-au-Prince, Haiti (Photo by Paul Burke)We have deeply considered concerns that importing a culturally-incongruent approach to explaining and treating disaster-related distress may disrupt local explanatory and healing models. Fundamentally, we propose that when a model is culturally-sensitive and open, people may maintain and benefit from both local and Western perspectives simultaneously, even if these ideas are not entirely congruent. In other words, one can learn new distressreduction skills, without canceling out the old, so enhancing their “menu” of coping resources. For example, a camp resident suffering from fear and muscle tension described relief resulting from SLM’s “fight or flight response” education paired with relaxation exercises; however, later that week, she reported additional relief following a visit to the voodoo doctor to perform rituals designed to lift a curse.

Despite being grounded in some tenants of Western psychological science, our model entails a series of steps to encourage such diverse and flexible coping. As described, the train-the-trainer model puts Haitian staff in core development and implementation roles, allowing for the filtering of Western ideas through a local perspective. Lay mental health workers are explicitly trained to teach a wide variety of responses and coping strategies. Moreover, SLM aims to tap into the therapeutic elements of cultural practices disrupted by the earthquake – for instance, by incorporating familiar group song, dance, prayer, and game playing. An ongoing priority is the development of collaborative relationships with religious and traditional healers in order to further cultural adaption.

In line with Haiti’s collectivist social structure, rather than focus on individual psychopathology, we use a group peer-led format, framed as a “training seminar” rather than “therapy”, which explicitly provides the opportunity to develop lasting supportive networks and contribute to the community. We suggest that our biomedically-informed symptom reduction content can improve social cohesion and engagement, while social engagement can in turn decrease symptoms of distress.

Thus far, our approach appears to be effective. Preliminary data were collected between April 2010 and June 2011 using a range of methodologies tailored to varying levels of transience and unpredictability in the camp setting. These data show a decrease in PTSD symptoms using the Harvard Trauma Questionnaire and increased coping skills among SLM participants. A parallel hypothesis is that the lay mental health workers, who receive regular debriefing with project staff, will benefit, rather than suffer, from implementing SLM. Indeed, we have observed decreased PTSD symptoms and low levels of compassion fatigue among our Haitian team members.

In January 2011, we conducted interviews with our lay mental health workers regarding distress, functioning, and coping among the camp residents they work with, and trained them to conduct open and closed-ended interviews with 84 camp residents across 4 camps. These data were used for two aims: 1) to assess participant needs one year post-earthquake so as to guide model revision and contribute to our collaborative development of an SLM program manual, and 2) to inform the development of a tailored measure of distress and functioning to replace PTSD checklists, which can obscure culturally and contextually-specific responses. Our results revealed that physical symptoms, such as headaches, stomach aches, disrupted menstrual cycle, and increased or decreased sexual functioning, continue to constitute primary complaints in many cases. These symptoms, as well as commonly endorsed emotional responses to trauma and chronic stress, were accordingly integrated into our distress measure. In June, we tested and finalized the program manual and the new measure. We also trained eight additional mental health worker “interns”, who shadowed the original mental health workers for several months before running their own seminars. As conditions in the camps have stabilized somewhat and our team has gained experience and confidence in evaluation procedures, we are now conducting a more formal waitlist control group evaluation study using the new manual and assessment instrument assess outcomes on seminar participants and determine extent of model adherence.

Future aims include adding a parallel model for children; Dr. Todd Favorite, University of Michigan and VA psychologist, has visited Haiti twice to conduct preliminary research to develop a story-telling procedure to help children cope with stress and trauma. We are also interested in assessing the particular effects of running support groups for others on SLM graduates, to test the hypothesis that the opportunity to help others has its own distinct therapeutic benefits, beyond those of participating in the skills training components of the seminars. Ultimately, we hope that, by proving a model for sustainable, culturally-compatible lay mental health worker services, the development of SLM might contribute to the field of cross-cultural mental health treatment more broadly. For more information on SLM and the work being done in Haiti, contact Leah James.