Haiti Disaster: A Psychoanalytical Response

“I don't know what to say to you… Teirible things happen to people in times of war and natural disaster,” said Martha Bragin. The earthquake in Haiti, which demolished homes, shops, and government buildings, killed upwards of 200,000 people, injured more than 250,000, and made hundreds of thousands homeless, was such a time. Government services were devastated, schools destroyed, and churches leveled. Food and water were scarce and tied up in disrupted distribution systems; systems for elimination of garbage and human waste were in disarray. “Demolished,” “killed,” “injured,” “devastated,” “destroyed,” “leveled,” “disrupted,” “disarray.” Written and spoken language are only fingers pointing to an unspeakable reality.

“Terrible things happen to people.” Sometimes it is the simplest words that convey the most meaning. A candidate at IPTAR, a former APsaA Fellow and a member of APsaA's Committee on Psychoanalysis in the Community, Bragin draws upon 25 years' experience working as a consultant to the United Nations, CARE, and many non-governmental organizations (NGOs) on a mental health and psychosocial response to disaster and war The Interagency Standing Committee, the coordinating body that connects the United Nations Office of Humanitarian Assistance with the Red Cross and international NGOs, has a reference group, of which Bragin is a member, that, with a long history of specialized knowledge, has developed culturally sensitive international guidelines for mental health and psychosocial work in emergencies. Their guidelines for Haiti state that “well integrated mental health and psychosocial support [that] build on existing capacities, build upon cultural norms [that] reach more people and are more likely to be sustained once humanitarian aid engagement ceases.” Children's developmental needs must be addressed in the context of their culture and basic services must be managed in a way that enhances dignity and community structures, cohesion, and values. Despite grief and distress, the U.N. document notes that self recovery and resilience are the norm in the face of disasters. That is part of the story.

On Sunday, January 31, a United Nations bulletin in Haiti stated: “According to [the World Health Organization and the Pan American Health Organization] medical teams are reporting a shift in the types of cases they are receiving. There is a decrease in trauma cases and an increase in mental health needs.” It is critical, and the reference group provides guidance, Bragin states, that the mentally ill get competent care. According to WHO projections for disaster areas, an additional 3 to 4 percent of the affected population will suffer severe mental disorders. In Haiti, this amounts to over 100,000 extremely vulnerable people among the three million affected Haitians.

As a member of the reference group, Bragin works with the international team supporting the efforts of those on the ground to provide coordination, fill in gaps, and above all to attempt to support the “do no harm” messages that hopefully will insure that the international community's best efforts do not undermine those of Haitian ministries and community organizers to help their countrymen to survive. This worry that harm will be done, that children will be separated from their families instead of reunited, that resources will not get to those who need them gets her up at 4 a.m. in preparation for a 7 a.m. conference call, and has her endlessly working on protocols, documents, and arrangements, so that teams on the ground can do their work. In the conference call, local authorities and specialists in mental health and psychosocial services and child protection give direction to the international support team. She is a full-time associate professor at Hunter College School of Social Work, has a private practice, does research, and is engaged in programs from Northern Uganda to Burundi.

A History of Upheavals

Interviewed by telephone at 6 a.m. less than two weeks after the earthquake, with a follow-up interview by e-mail, Bragin said, “The immediate focus is on trying to insure that the dead are identified, that children are not separated from loving caregivers, and that the way aid is distributed does not destroy more than it builds.” This requires first and foremost coordination with Haitian colleagues who best know their country. Haiti has suffered many calamities since it was colonized by France in the sixteenth century, African slave labor produced sugar and coffee, mined precious stones, making Haiti one of the most prosperous colonies. Inequalities of wealth, power, and liberty fueled anger and frustration.

A slave revolt at the end of the eighteenth century defeated the soldiers of Napoleon Bonaparte, sending shock waves throughout Europe. The first independent black republic in the Western hemisphere was formed. However, Haiti was forced to immediately buy its freedom from France or face a multinational invasion. To pay off this debt, facing trade boycotts from all slave holding powers including the United States, Haiti was impoverished. The country has suffered the consequences of this debt and poverty ever since.

Haiti has also been devastated repeatedly by natural disasters. An island in the Caribbean that lies in the middle of the hurricane belt, Haiti has been repeatedly struck by major storms. The country has suffered from wind damage, flooding, landslides, and coastal surges. It also rests atop a major fault in the earth's tectonic plates. On Tuesday, January 12, an earthquake, 7.0 magnitude on the Richter scale, struck the country. The quake and its multiple aftershocks ran right through Port-au-Prince, the densely populated capital. These calamities—hurricanes, political upheavals, and earthquakes—have led to the creation of numerous but effective informal systems that have supported Haitian survival in the face of disaster. Efforts are needed, Bragin said, to train those who are flown in to distribute aid under circumstances of duress so that they appreciate and work with these systems. Further, psychosocial support must be provided to Haitians working to alleviate the crisis. Bragin uses her knowledge of psychological development, her social work background, and her organizational expertise to help achieve these goals. “The greatest catastrophe that can befall a child is to lose his parents,” she said. In the past, Haitian families too poor to provide for their children sometimes brought them to institutions promising physical care and education. These institutions have been referred to as orphanages, but the children in them are not orphans. Understanding what is in fact a complex psychosocial catastrophe helps disaster workers respond to a crisis-magnified, culturally driven practice. It is vital, Bragin said, that every child with living and loving caregivers be connected to those caregivers and that aid be administered in such a way as to support consistent ongoing family care. Giving another example, she stated that adolescents are more resilient when they have purposeful activity: They can care for younger children; they can help community leaders organize food distribution. This avoids riots and supports law and order.

Understanding social dynamics and community values can make it possible to avoid chaos. Sri Lankan peacekeepers, already experienced in aid distribution after the tsunami, Bragin said, worked with community leaders in Haiti to identify the most vulnerable—children and the elderly—and saw that they were at the front of food distribution lines. There were no riots. These are the pressing concerns of crisis.

Partners, Not Patrons

External coordinators can organize the multiple agencies involved, but with local Haitian expertise running it. Hillary Clinton, joined by other foreign ministers gathered at an international donors conference in Montreal in January, told The Washington Post, “This is truly a Haiti-led effort,” even though the government currently is barely functioning. “It is important that we see ourselves as partners of Haiti, not patrons.”

From Haiti, a friend writes:

The place is Tabarre, a town just beyond the Port-au-Prince airport, where Aristide used to live. Hundreds of members of a Pentecostal congregation and their friends have sought refuge in a field. With the church building unstable, the pastors moved dozens of pews to the field and erected a tent over them.

The person is Guerlouse Jean-Marie, a first-grade teacher and Girl Scout leader. Her house has cracks and the school was destroyed, though no children died. Friends died elsewhere. She is 33 and was wearing her Girl Scout uniform, complete with neckerchief, as were a handful of girls seated near her. They were all under a shade tree in 90-plus heat.

“It really hurt. I think about it every day. I can't forget it. Sometimes it gives me problems. Sometimes I feel sad,” Jean-Marie said. “But you have to have courage and help the ones who are living.”

How does she cope? She prays and believes in God, often interspersing her remarks with, “grâce à Dieu,” or “thanks to God.” “I still believe God will send help to us.”

Does she know of any kind of psychological counseling? Utterly blank look. As if I'd asked if she owned a private jet. “If you have a friend who can give you a little advice, that's it.”

“The international community cannot come in,” Bragin says, “and de-traumatize people in six weeks after they have seen the earth rise up in flames before their eyes and their children buried under the rubble of their homes.” Addressing the help psychoanalysis can give, she said that it offers a means to understand child development. It respects processes; it does not focus on simply eliminating symptoms, which, Bragin says, are part of valid processes by which the external is integrated into the internal. In a paper that won the Tyson Prize, Bragin writes: “In the midst of Freud's work on the traumatic neuroses of [World War I….he] became acutely aware that it was not just the sounds of shells exploding, but the internal noise of re-awakened unconscious drives that accounted for shell shock, the PTSD of its day.” Bragin states that psychological distress and instability following war or disaster often occurs as the childhood fantasies of omnipotence, aggression, loss and death, still residing in the unconscious, are made actual. Everything, in a disaster, becomes concrete. The symbolic and the actual become hard to sort out. As local mental health workers become less concrete in their thinking; when they and their community begin to symbolize, they begin to metabolize their experiences. Haiti has a rich religious and artistic tradition and history to creatively use as it embarks on this journey.

Saving Memories

On January 23, The New York Times reported on efforts to save whatever could be saved of the culturally significant government buildings, churches, murals, and other artwork. They reported that, “Patrick Vilaire, a sculptor, met on Thursday night with others concerned about saving some of the country's [material] legacy from looters or further building collapses. They put at the top of their agenda preserving the book collections at two private homes, a cache of irreplaceable history, political, and economic texts from the nineteenth and twentieth centuries.

“Asked how he could focus on old books after such a catastrophic event, Vilaire said, “The dead are dead, we

know that. But if you don't have the memory of the past, the rest of us can't continue living.” The Times reported, “Of course, we should care about the people first,” said Axelle Liautaud [an art dealer], who has been trying to save what is left of the murals [at Holy Trinity Cathedral]. “But the reason why there is still a country, despite all our troubles, is our strong culture.”

The Haitian community understands the authority of its past not in terms of a theoretical superego, but as ancestors who have come before and worried about their well-being and the well-being of their children. If the community or one of its members is doing something in the name of the ancestors, it and they can live together in a harmonious future. Local ceremonial projects of mourning and memorialization can begin to push up through the cultural soil. Yet, mourning will take years.

Aggression: War and Devastation

“The people are in shock,” says Vamik Volkan. He responded in a telephone interview as an analyst engaged for decades theoretically and practically with conflict and devastation, war and disaster, on a societal level. He commented that, in a written exchange with Einstein, published as “Why War?”, Freud pessimistically argued against the ability of psychoanalysis to address man's political aggression, restricting its practical usefulness to the consulting room. Volkan believes that view was a defense against Freud's “unbelievable survivor guilt” at the prospect of leaving his sisters and his neighbors behind in Vienna while he, as happened, with the help of Marie Bonaparte and President Roosevelt, escaped the Nazi terror. Volkan states, though, that today there is considerable interest in Europe in psychoanalysis applied in the political world. The weekend of the interview, he was departing for Spain to give a talk on the subject. He regularly receives letters from Europeans studying, thinking, and working in the field. He and Bragin believe passionately that the discoveries, past and ongoing, of psychoanalysis, can help address societal problems.

Speaking from Charlottesville, Virginia, Volkan said the devastation in Haiti was “beyond anything I have ever experienced.” He underlined that the leaders, too, are in shock. Symbols, practices, and patterns of identity have been undermined. “It is the most difficult thing on earth to lose your identity,” Volkan said. The institutions and resources of the mental health community are inadequate to address the needs of tens of thousands of citizens. A fellow of the Erickson Institute at Austen Riggs, Volkan is also a training and supervising analyst emeritus at the Washington Center for Psychoanalysis. In 1987, he created, under the umbrella of the University of Virginia's School of Medicine, the Center for the Study of Mind and Human Interaction (CSMHI). The first of its kind, the faculty consisted of psychiatrists, psychoanalysts, psychologists, as well as former diplomats, political scientists, and historians. Volkan's aim was to expand the concept of “preventive medicine” to include an examination of societal responses to massive aggression due to wars or warlike situations and to develop methods to “vaccinate” large groups against violent acts. CSMHI had grants for projects in the Soviet Union, Baltic Republics, Albania, Kuwait, former Yugoslavia, Georgia, South Ossetia, Turkey, Greece, the USA, and other locations. Volkan directed the center from 987 until his retirement in 2002. He states that ideally mental health professionals should work with the leaders of the country to help them mourn. These professionals should revisit the leaders for several days every three months for the first years after the disaster These leaders, by example and by understanding, can then use the cultural and governmental institutions of Haiti in the long-term project of helping the people mourn.

Bragin writes, “As both Vamik and I have mentioned, culture is not static, and as situations change so do cultural expressions that memorialize. As we work together with our colleagues in Haiti, listening to people and hearing them review their community coping mechanisms, dysfunctional ways will give way and new ones will be created.”

Volkan said that wars and natural disasters differ in part in that one cannot address aggression toward God, nature, or fate as one can address it to an enemy Jay Winter, a noted historian, now at Yale, of war-related loss and mourning in the twentieth century, wrote provocatively in a personal communication: “I tend to think of wars as man-made natural disasters; I know that is a contradiction, but the damage war does to the landscape, to ecological balance, and to areas of dense settlement, as in Gaza, brings war and earthquakes closer together than may appear at first sight.”

Perhaps his insight into a catastrophe of Western Europe can help us understand the catastrophe in Haiti. He wrote, in Sites of Memory, Sites of Mourning, of “the universality of bereavement in the Europe of the Great War and its aftermath.”

“Terrible things happen to people.”