Understanding_the_Mental_Health_of_Haitian_Immigrants_Living_in_the_United_States

Understanding the Mental Health of Haitian Immigrants Living in the United States Although Haiti has consistently been one of the more economically and politically troubled nations in the western hemisphere, immigration to developed countries was not as common in the past as it is today. In fact, in decades before Duvalier’s dictatorship only about 3,000 Haitians migrated to the United States (Eide, 1999), but as a result of the severe economic and political stress experienced by Haitians, many left their home country to come to the United States during the early 1960s. In 2000, immigrants from the Caribbean accounted for almost 10% of all immigrants in the United States (Camarota, 2001). More specifically, Haiti was ranked among the top 20 countries of origin for US immigrants. Overall, about 90,834 legal immigrants and a comparable amount of illegal immigrants came to the United States. Most Haitians have situated themselves in New York, New Jersey, Massachusetts, Illinois and Florida. As the number of Haitians living in the United States continues to increase, it is important for mental health providers to have an understanding of the independent (and additive contribution) of being a migrant and being Haitian to mental health. The purpose of this paper is to 1) provide an overview of Haitian migration history, 2) critically evaluate what is known about the connection between migration and mental health and link these connections to Haitian migration 3) explore Haitian theories of illness 4) and critically evaluate four culturally specific expressions of depression and one propose culturally specific mental health syndrome. Haitian Migration History Haitian immigrants have been active participants in several defining moments of U.S. history. For example, in 1772 a Haitian immigrant, Jean Baptiste Point Du Sable, founded the city of Chicago. Additionally, during the first century of United States independence, several Haitian Americans served as US Congressmen, State Representatives or Senators in the legislatures of Georgia, Virginia, South Carolina and Louisiana, and as Lieutenant-Governors in Louisiana and South Carolina (Laguerre, 1984). Haitian involvement even extended to areas such as civil rights. In 1896, a Haitian immigrant served as President of the Comite des Citoyens; this group was instrumental in orchestrating the Plessy v. Ferguson case. Despite these significant contributions to United States history, discussions of Haitian American history tend to begin in the early 1900s. This is perhaps because Haitians that migrated to the United States prior to this time point assimilated into American culture fairly well. The first relatively important group of Haitian immigrants came to the United States in the 1920s. About 500 of them came to the United States, fleeing abuses that came of the American occupation of Haiti from 1915 to 1935. This group of immigrants primarily established itself in New York. A more significant number of Haitian immigrants have come to the United States over the past 60 years. Over this time period, there have been three distinct waves of Haitian immigration. The first wave, traveled to the United States during the 1950s. They were the educated upper to middle class. They were professionals, mainly fleeing the oppressive Duvallier dictatorship. Duvalier’s pro black platform caused many mulatto elites to flee upon his election, mainly because he promised to take away their privilege and bring power back to the black masses (Harris, 2001). These mulattos were easily accepted into the United States because of their abundance of intellectual and financial resources. Despite the recognized value of these assets, they were still discriminated against because of their immigrant status. The second wave, traveled to the United States during the 1960s and 1970s. As Duvalier’s dictatorship remained in power, Haitians found that they had put their faith in empty promises. By the late 1970s, over half of the labor force was unemployed and even more were illiterate. The per capita income was less than $300 USD a year and almost a third of Haitian children died before their fifth birthday (Harris, 2001). It was under these conditions that the second wave of Haitians began to migrate. They were made up of more middle class professionals than the previous wave of immigrants and were thus not only fleeing political oppression, but economic oppression as well. Again, this group was easily accepted into the United States because of their intellectual and financial resources but continuously discriminated against. The third wave of Haitian immigration begins in the 1980s and is considered to go into the present. This recent group of immigrants has typically not been made up of the lower middle class and has not been as educated as the previous groups. This group has come into the country fleeing economic hardship and immigration laws have progressively made it difficult for this group to enter the United States, as a result many resort to falsifying documents or even trying to sneak in via boat. To summarize Haitian migration history, Haitians have been a part of U.S. history for centuries. They have immigrated to the United States in three distinct waves over the past 60 years, each with varying intellectual and economic backgrounds. Their migration has not been motivated by a sense of adventure or exploration but rather a desire to improve their quality of life. Over the years, their have been increased efforts by the United States to restrict their immigration in to the country. Mental Health and Migration The migration literature suggests that immigrant status is related to higher rates of mental disorder than native status (Struening, 1969). It is possible that these differences are attributable to the actual process of migration. Eaton and Garrison (1992) have previously reviewed four main perspectives on this relationship. The first perspective, is guided by selection theory. Data have supported two applications of selection theory. The first, considers the notion of negative selection, whereby the individuals who chose to migrate may very well be the individuals who are most prone to mental illness. The second application of selection theory considers positive selection. From this perspective, it is actually the most “hardy” immigrants who immigrate. Positive selection would suggest that the “boat people” are the hardy people who survive the journey across the sea, the bright people manage to find a way to get false papers A second perspective on mental health and migration, emphasizes sociodemographic differences. This perspective uses existing knowledge about the link between sociodemographic differences and mental health to suggest that differences in the prevalence of mental disorder between immigrants and natives may be due to the fact that immigrants are more likely to be of lower socio economic status. Having a low SES may be related to several economic stressors which may intern be related to the higher prevalence of stress-related disorders among immigrants. Following this perspective, considering that recent Haitian immigrants are in the lower income brackets, they may be the ones who have suffered from mental illness or had economic hardship due to some of the precursors of mental illness In a third approach to mental health and migration, there is a heavy importance placed on stress form all kinds of sources (in addition to stresses related to SES). From this perspective, immigrants may be prone to stress related disorders such as anxiety or depression because they are trying to cope with issues such as leaving loved ones behind or starting a new life in a foreign place. Haitian immigrants may experience stress about where they are going to live. Because of illegal status they may experience stress leading to anxiety about deportation. They may experience stress regarding news of relatives abroad The fourth perspective on immigration is focused on the context of assimilation. This perspective considers how being an immigrant is related to being ethnically disadvantaged. As such, immigrants are subject to discrimination and stereotypes may cause poor self esteem and lead to mental disorder. Conversely, experiences of discrimination may sometimes be related to better mental health. Eaton and Garrison point to research on self-blame and system-blame to explain these differential findings. Haitians may begin to internalize a sense of shame for being the first free black republic, yet being from the poorest nation in the western hemisphere. Haitians may experience conflict with self and not want to reveal their Haitian identity for fear of being associated with AIDS or asked about Voodoo. Although these theories provide interesting viewpoints to look at the immigration issue, none of these theories or strongly supported. Research (prior to the work of Eaton and Garrison) on the link between mental health and migration has suffered various methodological inadequacies. Some studies have relied on hospital admissions data to ascertain prevalence data, however there are established weak association between hospital admissions and actual mental disorder. This type of research is also confounded by varying rates of service utilization. Additionally, survey studies have relied on one single measure of mental health disorder, which may not adequately capture the psychological experiences of these individuals. In their investigation, Eaton and Garrison came to the conclusion that we do not currently have one theory to encompass that can explain how the immigrant experience is related to mental health. More specifically, it is unclear whether immigrants actually immigrate because they are prone to mental illness or if they develop mental illness based on stressors that are specific to the nature of being immigrants. Investigations, which study mental health prior to immigration and after immigration, are needed. Haitian Theories of Illness While our current understanding of migration and mental health may not be able to provide much insight into the mental health of Haitian Americans, an understanding of Haitian theories of illness may prove to be more useful. To begin with, while Haitians acknowledge the natural causes of illness, many of them also believe that illness may be caused by supernatural forces. These understandings of the super natural are closely related to Haitian religious beliefs. The religious climate in Haiti is such that most Haitians are Catholic, a few are Protestant and it is unclear how many practice Voodoo. Perhaps some may deny the practice because their primary religion does not look favorably upon it. Alternatively, anthropologists acknowledge that some of the voodoo practices have been integrated into the national folk medicine, thus making it to almost indistinguishable from the practice of the religion. This explanation is highly plausible considering the fact that, in addition to providing spiritual rituals, the voodoo priest maintains knowledge of the combinations of plants and herbs that may be used for home remedies. According to Nicolas et al. (2006), strong beliefs in the supernatural lead Haitians to attribute illnesses to three types of causes. The first is a strained relationship with God. In this instance, the individual may feel that they disobeyed a religious or spiritual obligation and as a punishment, they are suffering from illness. Another source of illness may be curses or evil spells. In this case, the spell may be imposed upon a person because someone is jealous of them. Lastly, Haitians who practice voodoo believe that they experience illness because they have offended a Lwa or a spirit by not worshiping it enough. Although Haitians also believe in the natural causes of illness, it is not unlikely that all these beliefs may manifest themselves to varying degrees by an individual. For example, a Haitian may say, AIDS is a sexually transmitted disease (recognizing that it has a physical component) but may also say premarital sex is forbidden and so God has sent AIDS as a punishment. Although some of the beliefs described above may coexist with western medicine (as the previous example has demonstrated), anthropologist, psychiatrist and various types of scholars have identified the belief in zombies as one which poses specific challenges for diagnosing mental illness. This belief is not exactly a theory of illness but rather a theory which obstructs the diagnosis of illness. Haitians who believe in zombies understand these individuals to be people who have come back from the dead. Having come back from the dead, their senses are dulled and they do not have much control over them selves. They are used as slaves to work for the spiritual leader who brought them back from the dead. Knowledge of these beings is widely integrated into Haitian society. Western fascination with this topic has led to the documentation of several alleged zombies. Researchers have not found much evidence to validate this phenomenon. Obstacles to stating a decisive stance on whether or not zombies exist include the fact that few zombies (as well as few people living in Haiti) have consistent medical records which would allow the zombies to be clearly identified. Given this scenario, it is very difficult to exclude cases of mistaken identity or fraud. One of the most popular stories is that of Clairvis Narcisse. He was presumed dead at Albert Schweitzer Hospital in Deschapelles, Haiti on May 2, 1962, yet mysteriously returned to his home town in 1980. In talking about his experience with death, he describes being conscious, but paralyzed when he was being presumed dead. Following a series of questions (that no one else would know the answer to) which he had answered correctly, locals accepted that he was in fact Clairvis Narcisse returned from the dead. Western anthropologists have gone into the country trying to explain this phenomenon. More recently, Dr. Wade Davis, an anthropologist and ethnobotanist, tested the chemical make up of several zombie making powders and chemicals that may induce a state that makes a person appear to be dead who might not actually be dead. However, the validity of Davis’ research has been criticized. The implication of belief in zombies for mental health is that some instances of proclaimed zombies may in fact be individuals who are suffering from mental illness. Louis Mars a psychiatrist in Haiti in the 1940s treated many patients who were considered by the local people to be “ mysterious” beings. On October 24, 1936, in Ennery, Haiti the appearance of an old woman with pale and wrinkled skin which looked like scales of a fish let the towns people to suspect that a zombie was among them. Upon examining the woman, Mars concluded that she had been suffering form some type of eye disease which caused her eye lashes to fall out. Because of this eye problem she could not look into light directly and obscured her face from it when it was present. This may have added to the towns interest in her. One of the families took the women in because they felt she was their long lost relative (raised form the dead). Under examination by mars, she was unable to describe herself. Physical evidence demonstrated that she was not at all the woman they thought her to be, but instead she was suffering from schizophrenia. In summary, Haitian theories of illness encompass both the natural and the super natural, with the super natural being driven by religious beliefs. Back in Haiti, the belief in zombies creates challenges for diagnosis and treatment because individuals in need of care may be taken by strangers as long lost relatives, instead of being taken to at treatment facility. Also, the literature on Haitian theories of illness is limited because it mainly focuses on medical illness and does not provide much insight into mental illness. Most of the research presented by Nicolas et al (2006) on how Haitians view illness is based on physical illness such as HIV aids. This suggests that there is little to know research on whether these beliefs regarding the causes of medical illness may coincide with beliefs about the causes of mental illness. Culture Specific Expression of Depression In thinking about the specificity of syndromes, stress related mental illness such as depression and similar disorders have received most of the attention. Nicolas et al. (2007) points out that Haitians to do not have a word (in their common vocabulary) that exactly describes the DSM definition or Western conceptualization of depression. A term which most closely matches what western medicine considers depression is discouragement. In this instance, depression is a consequence of worry, or shock or trauma. While this definition is not at odds with the DSM’s classification of illnesses, (especially when one considers the importance of rumination and negative life events to this understanding). The expression of this discouragement often takes place in the form of somatizations such as head aches, back pain and other forms of pain. Linking this understanding of discouragement to depression and recognizing that culture influences the way individuals from different backgrounds express depressive symptoms, Nicolas et al. ( 2007) propose three distinct types of depression in Haitian women: 1) Douluer de Corps (pain in the body), 2) Soulagement par Dieu (relief through God.) and 3) Lutte sans victoire (fighting a winless battle). According to Nicolas et al. Pain in the Body “is often described by symptoms such as feelings of weakness (faibless) and faintness.” These feelings of weakness may be accompanied by other physical problems such as stomach pains, headaches and difficulties with digestion. These symptoms are not unlike the symptoms listed for diagnosis of somatization disorder. Typically, DSM diagnosis for somatization disorder requires that one experiences: 1)Four pain symptoms related to at least four different dites or functions 2)Two gastrointestinal symptoms, such as nausea and diarrhea 3) One sexual symptom (e.g. sexual indifference). Nicolas et al. propose that this expression of disorder, although similar to somatization disorder, is unique and insist that these patients would not meet full critieria for somatization disorder. Relief through God “is often associated with specific times, circumstances, and situations in the person’s life and is often mediated by the client’s belief in God.” More specifically, it is related to particularly stressful moments in an individual’s life. According to Nicolas et al. (2007), the symptoms include: Feeling weak, feeling down, crying frequently, being unable to sleep and continuously thinking out their problems. These symptoms peak during high points of stress. Again, these symptoms sound very similar to the existing criteria for a disorder described in the DSM, major depressive disorder (MDD). Nicolas et al assert that while these women do express many of the symptoms of major depression, they would not meet criteria for MDD because they rarely present with a few core symptoms such as a markedly diminished interest or pleasure in almost all activities most of the day, significant weight loss, psychomotor agitation or retardation nearly ever day, loss of energy nearly every day, diminished ability to think or concentrate, or recurrent thoughts of death. They hypothesize that it is the focus on God which protects these women from experiencing some of MDD criteria which interfere with daily living. More specifically, these women believe that if they can endure for just a little bit longer, they will receive relief through God. Fighting a Winless battle “is often painted as a very bleak generalized picture of the individual’s life.” These clients engage in excessive complaining about their lives and tragedies they have endured and express a general fatigue from their daily struggles. They do not view their problems as the end of the world, but instead continue to endure despite the bleak views they maintain of their lives. These individuals are able to work yet they find little pleasure in their lives. This expression is very similar to our existing conceptualization of dysthymic disorder. Again, Nicolas et al justify their conceptualization but stressing the fact that Haitian immigrant women typically meet a few of these criteria but not all. Specifically, they tend to meet criteria A (depressed mood), Criteria c (symptoms for at least two years), Criteria D (no major depressive episode), Criteria E (no manic episode), Criteria F (no psychotic or delusional disorder), and Criteria G (no substance use or abuse). Thes women however are unlikely to meet Criteria B (poor appetite, insomnia, low energy, low self-esteem, poor concentration, and feelings of hopelessness) and criteria h (significant distress or impairment). As we consider the differences in the four different expressions of depressions suggested by Nicolas et al, one key theme is that Haitian women are often able to participate in their daily activities despite their depressed mood. Lacking from their discussion is the consideration of how immigrant status may preclude any desire to miss days from work. Considering the economic pressures related to immigrant status, it may be that these individuals would not have any other means of survival if they did not work and also that they would be letting down other family members at home who depend on their financial support from the states. Additionally, Nicola’s research is based on a Haitian immigrant sample, what is unknown about these identified expressions of depression is how they are related to the migration experience. For example, considering the assimilation processes occurring over time would these women be expected to manifest depression in a similar fashion as the host country' Would their children express depression differently as well' Lastly, since the expressions of depression discusses above are so closely related to existing descriptions of disorder, one might question whether they are really the result of new expressions of disorder or if they are simple to result of an inadequate classification system. Further research is required in this area. Lastly, one important caveat is that research on these culturally distinct expressions of depression are based on the clinical observations of one therapist who saw 55 patients over the course of seven years. Again further research would be required to confirm the existence of these distinct expressions of depression. Culture Specific Syndrome: Sezisman In addition to the different expressions of depression discussed above, Nicholas et al. (2007) have suggested that Sezisman may be a culture specific syndrome. Within Haitian culture, this disorder is described in terms of both physical and psychological causes. From the physical perspective, Sezisman occurs when the normal flow of blood in the body is disrupted. In this case, blood rushes from the head causing physical weakness, headaches, increased blood pressure, and loss of appetite. The psychological connection is that manifestations of Sezisman typically follow moments of indignation, shock, hearing bad news or frightening experiences. A person who suffers from sezisman may become withdrawn or even bed ridden. As such, sezisman can be defined as a “state of paralysis usually brought on by rage, anger or sadness, and in rare cases happiness.” More specifically causes of sezisman may include receiving bad news regarding a loved one, witnessing a traumatic event, seeing dead bodies, family crises, news announcements, or narcissistic injuries. Sezisman may result in the loss of vision, headaches, increased blood pressure, strokes, heart attacks or even sudden death (Laguerre, 1981; 1984). Typically the person who has sezisman is unresponsive, dysfunctional and disorganized. The episode may last several days or only a few days. It usually depends on the individual. Although these symptoms appear to be very similar to experiencing shock, what are peculiar about this proposed syndrome are the varying ranges of physical manifestations that may occur. Unfortunately, there has been no systematic research to explore this particular syndrome and much of our clinical understanding is based on anecdotal evidence. Our understanding of seizisman is different from our understanding of the previously discussed expressions of depression because seizisman is a state of being which has been clearly defined by the Haitian people. The culturally specific expressions of depression however, represent a clinician attempting to make sense of her experiences with depressed individuals who often do not meet criteria for DSM diagnosis. Conclusions Haitian migration over the past 60 years has been steadily increasing due to economic and political struggle in Haiti. As a result, the United States currently consists of hundreds of thousands of Haitian immigrants of varying intellectual and economic backgrounds. Given that immigrant status is often associated with numerous stressful life events, it is inadvisable to overlook their status as immigrants when one discusses the mental health of Haitian immigrants living in the United States. Unfortunately, there are no theories in the migration literature which can adequately describe the experience of these migrants and its relationship to mental health (Eaton and Garrison, 1992). Our understanding of how Haitians conceptualize illness has faired better than our understanding of mental health and migration. A recurrent theme in this body of research involves the importance of the supernatural, which does not often conflict with western conceptualizations of illness, in the mind of Haitian immigrants. Unfortunately, our understanding of Haitian theories of mental illness is limited by its emphasis on medical illness rather than mental illness. The research on culturally specific expressions of depression is still in its infancy and research on seizisman is almost non-existent (Nicolas et al. 2006). In conclusion, research on the mental health of Haitian immigrants would benefit from more rigorous empirical evaluations. It is important to proceed with this line of research because understanding migration process and its relation to mental health may be useful for preparing service providers to address existing needs as well as provide preventative services. Additionally, understanding Haitian theories of illness may facilitate discussion of mental illness and development of culture specific treatment protocols. References Camarota, S. (2001). Immigrants in the United States-2000: A Snapshot of America's Foreign-Born Population: Center for Immigration Studieso. Document Number) Eaton, W., & Garrison, R. (1992). Mental Health in Mariel Cubans and Haitian Boat People. International Migration Review, 26(4), 1395-1415. Eide, G. M. (1999). Haitian Identity: The Effects of Race Through Haitian History and Transnational Migration Focus on the Dominican Republic and the United States. from http://www.hamline.edu/cla/academics/international_studies/diaspora/haitians/paper.html Harris, B. (2001). Heroes and Killers of the Twentieth Century. Retrieved April 27, 2006, 2006, from http://www.moreorless.au.com/killers/duvalier.html Laguerre, M. (1984). American Odyssey: Haitians in New York City. Ithaca, NY: Cornell University Press. Nicolas, G., DeSilva, A., Grey, K., & Gonzalez-Sastep. (2006). Using a multiculural lense to understand illnesses among Haitians living in America. Professional Psychology: Research and Practice, 6, 702-707. Nicolas, G., DeSilva, A., Subrebost, K., Alfiee, B.-N., Gonzalez-Sastep, D., Manning, N., et al. (2007). Expression and treatmetn of depression among Haitian immigrant women in th United States: clinical observatitons. American Journal of Psychotherapy, 61, 83-98. Struening, E. e. a. (1969). Migration and ethinic membership in relation to social problems. In E. Brody (Ed.), Behavior in New Environments. Beverly Hills, CA: Sage Publications.