Responding to mental health needs

ZL Mental Health and Psychosocial Director Father Eddy Eustache provides a healing memorial service to ZL staff at Cerca la Source.

It is February, one month since the earthquake that ravaged Haiti’s capital of Port-au-Prince. In Cerca la Source, the site of Zanmi Lasante’s most rural health center, a four-hour drive from the capital, a service is beginning in the church next to the hospital. The day is hot, and the coolness of the church interior provides some respite, not only from the heat, but also from the harshness of life in Haiti since the earthquake. Staff members enter the chapel to the sound of children’s choir music. People take their seats, and listen quietly. Some sit and pray with their heads bowed. Others greet friends and acquaintances with a smile, a holding of hands, and a few words. Sadness and tears are close at hand. Father Eddy Eustache, a priest and psychologist who heads ZL’s mental health and psychosocial support team, begins speaking. Over the course of the next hour, with his decisive, undulating, soft voice, he provides a sermon that is a nuanced and moving tribute to the remarkable experiences of loss and survival that have so affected each ZL patient, staff person, and community member.

Over the course of four days, Father Eddy and the ZL psychosocial team, along with ZL/PIH leadership, conducted similar services at nine ZL hospitals. They drove throughout the Central Plateau and Artibonite regions, initiating a process aimed at providing comfort, solace, and emotional healing to staff at ZL hospitals.

When the earthquake happened, staff took little time to seek, protect, and bury family members before returning to their respective hospitals and clinics to serve the urgent needs of others. Father Eddy and the team recognized that religious and spiritual memorial services integrating prayer, singing, and information about mental health and self-care in the face of loss and trauma, would be a critical starting point for providing social and psychological support to staff, and to other people in the community. At each ceremony, everyone is invited to light candles to memorialize lost loved ones, to stand and provide personal testimonial to the audience, and to take moments for reflection and silent meditation. Tense muscles ease, calming emotions and sensations move through the pews, tears dry, and spirits lift moment by moment.

ZL Social Work Director Ermaze Louis lights candles with memorial participants to remember lost family members at St. Marc.

Following the January 12 earthquake, the ZL team brought these healing ceremonies to communities, schools, Haiti’s Ministry of Health, and to other NGOs who have asked to be trained in how to perform services like these. 

No one in Haiti escaped the effects of the earthquake: an estimated 300,000 people lost their lives, survivors lost loved ones, over a million people lost their homes and livelihoods, and hundreds of thousands of people suffered life-altering physical injuries. The ZL team hopes that informal, community-based services like these will create spaces in which communities can begin to heal together. It is their hope that these services can help prevent people from developing more severe indicators of emotional distress.

Since the earthquake, PIH and ZL staff in the community have reported a range of emotional distress responses, from difficulty sleeping or somatic complaints (physical reactions to stress and trauma) to acute psychosis (symptoms of which can include hearing voices, paranoia, and disorganized thinking). For some, pre-existing psychiatric problems that have had gone untreated have only worsened. Life is still far from normal. The people of Haiti are nothing if not emotionally taxed.

Emotional distress in the current context must be considered a normal reaction to a terrible situation. But when people do develop mental health problems, affected persons can often be marginalized from their communities due to stigma. That stigma discourages people from seeking appropriate mental health care, and the human rights of those afflicted by mental illness remain severely compromised, which could lead to even more distress and mental health problems. It is a vicious cycle.

In response to this, the ZL team is teaching staff and community members to recognize signs of mental health problems and illness and to understand that they can be treated. At the request of the Haitian Ministry of Education, for example, they recently worked with teachers and students in schools in the Central Plateau, providing training that emphasized sensitivity to the Haitian social and cultural context.

Prior to the earthquake, Haiti had few mental health professionals and limited formal mental health services. As recently as 2003, Haiti had a total of 10 psychiatrists and 9 psychiatric nurses working in the public sector—that in a country with a population of over 9 million people. Prior to the quake, there were two psychiatric hospitals in the capital city of PAP, one of which was dilapidated and in desperate need of massive repairs. Nearly all of Haiti’s mental health professionals worked in the capital.

Outside the capital region, psychiatric services were incredibly limited or unavailable. At the country’s second largest hospital, l’Hopital Universitaire Justinien, in the far northern city of Cap-Haïtien, psychiatric services were limited to monthly visits from psychiatrists based in Port-au-Prince and foreign mental health professionals.

Prior to the earthquake, the Haitian government understandably focused on combating infectious disease, and maternal and infant mortality. Psychiatric and mental health services received little government funding.

That all changed following the earthquake. The Haitian Ministry of Health declared mental health a national priority. In coordination with the Haitian government, PIH/ZL’s mental health and psychosocial teams have established an active presence in the four resettlement camps for displaced earthquake survivors in Port-au-Prince where ZL is providing medical services and have built on pre-existing services in ZL’s traditional catchment area in the Central Plateau and Lower Artibonite.

Erick St. Juste, psychologist staff member for ZL, prepares new psychologists and social workers for their work.

A talented group of psychologists, social workers and psychosocial community health workers hired and trained in March by ZL in Port-au-Prince.

Within three months following the earthquake, ZL’s Father Eddy Eustache (Program Director), Ermaze Louis (Program Assistant Director), and Cate Oswald (Program Manager) worked with the team to mobilize more than 50 Haitian staff—17 psychologists and 35 social and community health workers, many of whom newly hired—to care for the mental health needs of those most affected by the quake. PIH also added a new mental health director and psychiatrist, Giuseppe Raviola, and a head psychologist, Silvia Gosnell. 

Collaborating organizations have also been working with the PIH/ZL team to develop mental health services. Recently, Peter C. Alderman Foundation psychiatrist Dr. Kathleen Allden travelled to Haiti to teach physicians, nurses, psychologists and social workers about mental health evaluation and treatment of acute mental health emergencies. The psychopharmacologic formulary—the list of psychiatric drugs kept in stock and prescribed to patients—has been strengthened in the hospitals, facilitating the improved treatment of individuals in severe distress from symptoms such as psychotic illness that are not immediately responsive to psychosocial support.

PIH/ZL’s team continues to work to:

• Develop curriculum and continue training for ZL staff
• Facilitate community education and mobilization to work on eliminating stigma associated with mental illness and disability
• Enhance the ability of community health workers to be engaged in identification of mental health problems and referral to care
• Collaborate with PIH/ZL rehab teams to aid in providing support for amputees and people injured during the earthquake
• Assemble a mobile mental health team comprised of a psychologist, prescribing nurse, social worker and rotating visiting mental health clinician-teacher
• Develop a clinical peer supervision program for mental health and psychosocial staff
• Provide psychological support to ZL staff
• Establish a dedicated mental health clinical training service at the Ministry of Health hospital at Verrettes
• Develop a qualitative assessment of local beliefs, perceived needs, and attitudes to different forms of treatment and provision of care, in order to inform future care

Answering the Ministry of Health’s call for support in developing mental health services will require 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.

“Compared to the hugeness of the needs, the team is small,” Father Eddy said. “But we are not the only [organization] providing psychosocial support.” Haiti’s mental health care landscape is changing. In collaboration with the Ministry of Health, the World Health Organization, the International Organization for Migration, other NGOs, and other organizations supporting the development of mental health services in Haiti, PIH/ZL is committed to the development of a long-term sustainable mental health plan accessible to all Haitians.

Learn more about ZL’s mental health initiatives and read a recent interview with Father Eustache.