By Amina Lovell
From a young age Helen Sullivan* suffered from feelings of loneliness and low self-worth. She thought that the world was against her and that she just wasn’t good enough. At 16, Sullivan realized that this wasn’t a universal feeling, which made her feel even more isolated in her thoughts. As she journeyed into her 20s and left home, the feelings intensified. Her career was just taking off, she was traveling all over the world, but the pressures of living abroad were mounting, and constant failed relationships sent her into a depressive cycle. Sullivan eventually became suicidal.
“I felt worthless,” she said, as though I was “taking up unnecessary space.”
Sullivan isn’t alone. An estimated 350 million people suffer from depression worldwide — some more acutely than others. The difference for Sullivan now, is geography. While living abroad she was able to seek help and start taking antidepressants. When she moved back to her small island home of Antigua and Barbuda (where there is just one psychiatrist for a population of 90,000) she found herself like most other depressed or anxious patients in the Caribbean – silent. When Sullivan tried to renew her prescription of antidepressants, she was strongly advised by friends and relatives not to. The pharmacist, her friends warned, would tell everyone and she would be branded as “crazy.”
The stigma of mental illness is heavy in many parts of the Caribbean for a variety of reasons. In Haiti specifically, the lack of mental health resources, the nature of existing facilities, the mixture of traditional culture and religious institutions like Catholicism and Vodou, have combined to make residents reluctant to seek help for psychological troubles. These cultural biases leave mental health professionals in the Caribbean continuously fighting an uphill battle.
“Most do not go to see a psychiatrist, they go to their general practitioner or they just don’t go at all,” Dr. Ronald Chase, a practicing psychiatrist at the Queen Elizabeth Hospital in Barbados, said. It’s been hard to treat patients suffering from illness like depression because of ingrained perceptions.
“They view themselves as bad people,” he said. “The stigma is right up there with HIV.”
The common mental illnesses in Haiti are hard to pin down. There is very little data available and before the 2010 earthquake the mental health system was very thin. The problems treated by psychologists who have Haitian-American patients, whether directly related to the earthquake or not, have most commonly included anxiety and depressive disorders. Post-traumatic stress and clinical depression are rampant, and loss and pathological mourning have trapped a good portion of the population inside themselves. When trauma and depression intersect, the suffering is compounded. Trying to break this cycle down, Caribbean psychologists have found that education by itself is not enough to reduce stigma or encourage seeking treatment.
“There is a tendency to lump all persons with mental illnesses into one group as opposed to recognizing mental illness as a heterogeneous entity,” says Dr. Roger Gibson, faculty member at The University of the West Indies Department of Community Health and Psychiatry in Jamaica, said. The “common attitude” is that people with mental illnesses “deserve pity as opposed to empowerment.”
The health care system in Haiti can be divided into four sectors – public institutions administered by the Ministry of Public Health and Population, the private nonprofit sector comprised of NGOs and religious organizations, the mixed nonprofit sector where staff is paid by the government, however management is carried out by the private sector, and lastly, the private for-profit sector that includes physicians, dentists, nurses and other specialists working in private practice or in clinics in urban centers.
Mental health, however — as defined by Western psychiatry and psychology — has not been a priority for the government. Resources are spread thin and are often not accessible to those who live in rural areas. In the absence of a mental health policy, the country finds its with very few mental health professionals and little to no planning for services.
“There isn’t really a formal language of mental health in Haiti,” Florence Saint-Jean, the executive director and founder of Global Trauma Research Inc., which leads the Haiti Trauma Project, said. “Something simple like depression, the symptoms that we use to diagnose someone here in the United States, won’t make sense for the people of Haiti. They don’t exhibit the same types of symptoms, so whatever diagnosis that is given won’t hold.”
Religious beliefs have a major impact on treatment and coupled with community support, it is usually the sole coping mechanism. Sullivan currently uses prayer in place of her medication.
“When it becomes too much to bear, you have to ask the Lord to pull you back,” she said, “know that you can’t solve all the problems by yourself and surrender to a higher power.”
Knowing her triggers, like sleep deprivation, have also helped her manage.
Trying to “pray it away” is a common practice in place of professional treatment. In Haiti, Vodou is a widely practiced religious belief. Vodou is not only a religion but constitutes a health care system, which includes healing practices, prevention of illness and promotion of personal well-being. Vodou provides information on how to promote, prevent and treat health problems, with theories on illness, treatment interventions, and prescriptions for behavior that are similar to widely-held explanatory models of mental illness.
“If you see someone acting unstable, most of the time people in Haiti would say there symptoms are attributed to Vodou,” Saint-Jean, said. “Specifically, they will say something along the lines of ‘my neighbor put a spell on my sister or my daughter and that’s the reason why she can’t work at school and that’s the reason why she is contemplating suicide.’ ”
These beliefs cause real problems when trying to treat patients, mainly because of the secrecy that surrounds the practice of Vodou. Patients are not very forthcoming when describing problems that they may be having and continues the cycle of suffering. Treatment for Haitian-Americans has had to include sensitivity to these cultural norms.
“Culture plays a role in their interactions, in stigma, in terms of being reluctant and having certain ideas as to what it means to have a mental illness,” Dr. Pierre Arty, a Haitian psychiatrist in Brooklyn, said. “Shame comes into it, guilt comes into it. There are some Christian circles that have belief systems that will encourage someone not to take medications.”
Family and community are very important to people from the Caribbean, Arty said, and while many times family members are a part of the treatment, it doesn’t always benefit the patient.
“They may bring the person in for care but it does not mean that they necessarily agree with [the type of] care.” There can also be friction when it comes to taking medications on a regular basis.
“No one questions the need to take medication for your heart or blood pressure or diabetes,” he said, “but once it comes down to mental illness people give push back. There is resistance and then the stigma comes in. They then come up with self-incriminating ideas like ‘maybe it’s my fault’ or ‘I can do without medications’.”
Since the 2010 earthquake in Haiti, a lot has been done to create better long-term solutions toward mental health treatment. While there was a cluster of international support after the earthquake, a lot of it was ineffective. A lack of training for both local and international doctors led to a difficulty to keep the momentum up. One solution have been projects like the Haiti Trauma Project, which coordinates with university professors and students, community leaders and agencies in the U.S. to provide mental health training. They focus on pathways to care, barriers to treatment, and engagement strategies that influence service usage.
Furthermore, the country’s mental health system is experiencing a renewed engagement in development and formalization. In December 2010, L’Association Haitienne de Psychologie (the Haitian Association of Psychology). The association aims to be at the forefront, along with other partners, in defining a national plan for mental health. Significant progress has been made in the development of the association, including establishment of regulatory frameworks, a code of ethics, and an oversight committee.
There is also an international effort being led by companies like the Haitian Mental Health Network, a Boston-based organization comprised of a group of mental health providers, including psychologists, social workers, psychiatrists, mental health counselors, psychiatric nurses, and pastoral counselors. The network’s vision is to reduce stigmas and raise awareness about mental illness.
“One of the things that we have been doing that is looking good for Haiti when it comes to mental health is we are training people who are readily acceptable by Haitian natives, ” Saint-Jean of the Haiti Trauma Project, said. These trainees are not just doctors and nurses but also include elementary, high school teachers and religious leaders from all religions.
“We trained them with some very, very basic skills,” she said, including, “motivational interviewing, listening, and getting them into long term care or to a hospital, things like that. We also tell these individuals, whatever you are doing that is working, keep doing that.”
*Name changed to protect privacy.