Healing a shaken psychosis

“Do you know where you are?” Tatiana Therosme gently asked her patient for the third time. The patient, a rail-thin young woman in a cream-colored dress, stared blankly back before mumbling softly that she was at school. “Do you remember where you’re from?” The patient looked slowly around at the other people in the small room at Zanmi Lasante’s hospital in Cange, but remained silent.

The earthquake continues to haunt many survivors, even after the physical wounds are healed.

Tatiana, a psychologist for Zanmi Lasante (ZL) quietly began questioning the woman’s roommate. Yes, she talks to herself out loud, the roommate tells her. Yes, she seems to hear and see things that others can’t. Yes, she cries and sleeps a lot. Tatiana nods. She’s recently seen similar behaviors in another patient.

Less than a mile from the Cange hospital is a small house with a little table set out front displaying tidy stacks of crackers and candy. Esther, the young woman seated next to the table, has spent the morning selling her wares to school children and other passersby. She grins broadly when she sees Tatiana coming down the dusty road and darts into her house to grab chairs for her visitors. But glancing quickly up at the ominous clouds amassing above her (it’s the rainy season in Haiti after all), she decides it’s better to invite her guests into her house instead.

As she sits at the kitchen table, laughing and joking with Tatiana, it’s hard to believe that six months ago, Esther was a completely different person. Like the patient Tatiana met with earlier in the day at the hospital, she once seemed incapable of talking or responding to questions. She would stare blankly ahead, practically catatonic. She heard voices, and sometimes flung off her clothes in public.

Even before the devastating earthquake, getting treatment for mental illness in Haiti was exceedingly difficult, if not impossible. In the whole country, there were only 10 psychiatrists and 9 psychiatric nurses working in the public sector, according to a 2003 World Health Organization report. And most of them worked in the capital city, meaning that patients would have to travel hours, or even days to receive care.

It’s difficult to estimate the true impacts of the earthquake on the mental health of survivors. But in terms of loss of loved ones, life-altering injuries, hundreds of thousands of displaced survivors, and widespread social and economic insecurity throughout the country, the effects are inescapable. In such an unstable environment, many who may have had pre-existing untreated psychiatric problems prior to the earthquake deteriorated in the aftermath.

Since the earthquake, the PIH/ZL mental health and psychosocial team has mobilized more than 65 Haitian staff, including psychologists, social workers and community health workers, to work directly with local communities and the Haitian government to strengthen mental health services at our PIH/ZL health facilities throughout the Central Plateau and Artibonite regions of Haiti. Physicians and nurses at ZL hospitals are also being trained in management of acute psychiatric problems in collaboration with the psychosocial team. The team also began providing care at PIH/ZL’s medical clinics in Port-au-Prince, serving four resettlement camps for displaced earthquake survivors. PIH has a long-term commitment, both to building upon pre-existing psychosocial services and informal mental health services, and over time, to developing a system of care better able to meet the mental health needs of Haiti’s people—from recent amputee patients dealing with post-traumatic stress, to tuberculosis patients suffering from treatment side-effects (such as Tatiana’s unresponsive patient currently in the Cange hospital), to patients with earthquake-aggravated psychoses, like Esther.

Esther remembers the earthquake. She was living in the coastal city of Jérémie at the time, about 170 miles west of Port-au-Prince. “I felt that the earthquake was happening right under my house, there was a terrible noise. Everything was shaking.” She remembers running out of her home, terrified. However, her memories of what happened next are very vague. She can’t remember any of the destruction, or if any of the houses near her fell down.

Following the devastating earthquake, a group of missionaries tried their best to treat Esther’s psychosis. But their prayers and exorcisms failed to help her condition. They knew they couldn’t just leave her in the streets, so some of them who were originally from Cange brought her back with them.

Soon after arriving in the Cange, the missionaries brought Esther to ZL’s women’s health clinic after she began urinating on herself. The gynecologist referred her to the hospital’s urologist, who recognized that Esther may be in more desperate need of psychiatric help rather than his expertise. He alerted Tatiana and her team.

Esther has no memory of meeting Tatiana and does not remember being unable to respond to others at the hospital. After Tatiana’s initial evaluations and therapy sessions, PIH mental health director Giuseppe Raviola, a psychiatrist, examined Esther, reviewed her case history with Tatiana, and started Esther on a low dose of an antipsychotic medication. Tatiana could tell the drug was helping at their next appointment—Esther made eye contact, and began to participate more in her therapy sessions. As a convenient side effect of the medication, she also began to put a little weight onto her thin frame.

Others around her also noticed the amazing change. “You could tell that she was an actual person, she was responding to us,” said the husband of one of the missionaries who helped bring Esther to Cange. “[Before], we didn’t know what to do. You didn’t know what she was thinking, what she was doing, how she was going to live.”  Esther now lives with his family.

And then on Good Friday, just a few weeks after she began treatment, she shocked her congregation by getting up and singing with them during a prayer meeting. After months of caring for the silent woman, the missionaries were overjoyed. Some even cried. Esther laughs and flashes a huge smile at the memory. Today, she regularly sings in the church’s choir. Her host family has also helped her set up a small business selling snacks and other items from the porch of her house to help generate an income.

Esther (left) with Tatiana.

In the fall, ZL will also help her finish her last two years of school. At the mention of school, Esther looks up expectantly at Tatiana. She wants to get her hands on some school books. At 28-years-old (although with her apple cheeks, she could easily pass for a teenager), she’s nervous that it’s been awhile since she was last a student and is eager to use the next few months to catch up on lost time.

“What do you want to do [after you finish school]?” Tatiana asks her. Esther laughs, she hasn’t thought too much about it yet. “What's your dream?” Tatiana asks. “For me, I wanted to be a psychologist.” It’s an odd question coming from her—the two women are actually about the same age, and equally youthful. At this moment, sitting at the kitchen table, it’s hard to tell who is the doctor and who is the patient.

“Psychology is a great thing,” answers Esther slowly, grinning at her doctor. “Maybe I could do that!”

Tatiana smiles back. Post-earthquake Haiti could definitely use more psychologists.

UPDATE: January 2011 - Find out how Esther is doing one year after the earthquake.