Hope in the Ruins

January 12, 2010

As we’re bombarded daily with the unending stream of news of fresh catastrophes from around the globe, sometimes it seems like natural disasters take place almost round the clock. I first learned the news about the devastating earthquake in Haiti as I was getting ready to make my sixth visit to Sichuan Province, the site of the 2008 earthquake in China. My colleague Elaine Miller-Karas and I had been going there regularly since the quake to provide training in our biologically-based Trauma Resiliency Model (TRM), which focuses on teaching nervous-system stabilization skills for trauma survivors to local physicians, nurses, counselors, teachers, and first responders.

Once in China, we’d watch the coverage each evening of the Haiti disaster, in which an estimated 230,000 or more people died. There was something surreal about witnessing a country in the acute stage of an earthquake’s aftermath on television from a country still dealing with the longer-term effects of the same kind of disaster. We later learned that the people of Sichuan, having themselves experienced what it’s like to suddenly lose so much, provided the largest number of contributions for Haiti from all of China.

Within just a few weeks after our return from China, we were invited to Haiti to help deal with the enormous psychological aftermath of the earthquake. What follows will give you some picture of what it’s like to set foot in an already impoverished country, in which the difficult conditions of daily life have been transformed for the worse so abruptly.

Late February 2010

As we start developing the plan for our multiphase project in Haiti, I begin researching Haitian history and culture. Once again, I’m embarrassed to realize the extent of my ignorance about other countries. Where was I in geography and world history class? Again and again as we’ve traveled to other disaster areas, I’ve come up against my lack of information about the legacy of colonialism and the other sociopolitical forces that have shaped our world. From my reading, I learn that while the popular images of Haiti dwell almost entirely on its desperate poverty, the country was the first created after a revolution by enslaved people of African descent. I discover that even while the United States was refusing entry to European Jews fleeing the Holocaust, Haiti was welcoming them. I find out that although Haiti has been a nation almost as long as the United States, in certain ways, it’s still a young country: children under the age of 18 constitute almost half of its population of 9 million.

Arriving in Haiti

As our plane descends into Port-au-Prince, I can see military vehicles, boxes of aid materials, and warehouses dotting the area around the airport. Inside the arrival terminal, a mariachi band is playing as we make our way through the chaotic baggage-claim area into the blazing hot mob-scene outside. UN vehicles, a snaking tangle of cars, and throngs of people jam every inch of space. Dust and automobile fumes are everywhere. Soldiers and UN peacekeepers with automatic weapons patrol the street.

It takes more than an hour before we spot the people who are supposed to meet us. They’re holding a sign saying “Welcome TRI,” the name of our ­nonprofit group, Trauma Resource Institute. We never go into a disaster setting without a sponsor—an organization with strong ties in and knowledge of the area—and a source of funding. This collaboration between TRI and the sponsor—here in Haiti, it’s the Unitarian Universalist Service Committee (UUSC)—helps us contact survivors and potential trainees, and helps assure that whatever we offer will fit with local customs and norms. Breathing sighs of relief when we finally find the crowded UUSC van, we settle in for the three-hour journey to Papaye in the Central Plateau, one of Haiti’s poorest rural areas.

Since the earthquake, more than 10,000 people have fled or been relocated to Papaye, swelling an already impoverished population to the breaking point. We’ll be working in sites connected to the Mouvemente Paysan Papaye (MPP), a grassroots service-and-advocacy organization for the peasant population of Haiti, founded more than 30 years ago, which now has more than 35,000 members. Through MPP, we have immediate access to the other organizations in Port-au-Prince and the Central Plateau that can direct us to the people most in need of our intervention program, the Trauma Resiliency Model for Communities (TRM-C), which is oriented to nonclinicians and to creating networks of trauma and resiliency-informed communities.

During the past five years, we’ve brought biologically based interventions to Thailand (post-tsunami), Rwanda (post-genocide), Kenya (with a project addressing female genital cutting and a current project providing TRM-C following the post-election tribal violence), and Sichuan Province (following the massive earthquake there). In the process, we’ve seen firsthand the benefit of using a biological approach to trauma with cultures that are communally, rather than individually, oriented and in which counseling or psychotherapy are considered to be for “crazy people.” TRM-C focuses on the ways in which our bodies react when we experience fear and threat. Regardless of where we happen to live, our bodies are neurologically programmed with the same set of automatic survival responses, which can lead to the same set of trauma-response symptoms when our defense reactions are thwarted.

Four Days in Papaye

During our four days in Papaye, we stay at the MPP site that includes the Lakay Training Center (where most of our workshops will be held) and a camp for internally displaced persons (an IDP camp). This is the first time in our international projects that we’ve lived and and worked at an IDP camp. Within the barren cinderblock building where we’ll be staying, the accommodations and bathroom facilities are extremely basic. As soon as we arrive, I get busy rigging up my mosquito net. Later I learn that the bathroom shower is a cold, intermittent drizzle—which comes as no surprise. Somehow, living under the same conditions as the people we’re working with seems fitting.

All sorts of noises surround us at night, especially howling and barking dogs. During the day, you can see how skinny they are, with their ribs sticking out, and that most are covered with battle scars. At meals, I take to throwing my potatoes under the table to make sure that at least a couple of them will have full tummies when they go out for their night of howling. But it’s the lizards that make the loudest, strangest sounds at night—like the metal sheets that old radio shows used for the sound effects of thunder. Last but not least are the mice that are everywhere. One night, a mouse gets into the energy bars I’d left high on a shelf and makes a big racket having a feast. When I finally get up and noisily turn on my lantern, it scurries away over my duffel bag.

Two nights ago, I woke up at 3:00 a.m. to drumming and chanting from the jungle that lasted for hours. It turns out it was a voodoo ceremony accompanying a funeral. Instead of being put out that my sleep was being interrupted, I lay there entranced. I could feel the visceral pull of a culture that’s seen so much suffering over the centuries facing this latest catastrophe, not with grim solemnity, but with a let-it-all-hang-out celebration of a communal spirit that transcended the individual loss. I wondered how the earthquake survivors I’d be working with might be able to tap in to that spirit to deal with the suffering that lay ahead.

We’re told that there’s been no food distribution up here in the mountains since the earthquake. More than 600,000 people have fled an utterly shattered Port-au-Prince for rural areas that, so far, have received little humanitarian aid. Malnutrition, on a scale even greater than before the earthquake, is on the rise. Sadly, we’re told that some of the farm families have begun eating their own seeds—which means that when the planting season comes, they’ll have nothing to plant.

During our days in Papaye, we conduct a series of introductory TRM-C skills workshops with camp residents and local first responders from various groups affiliated with MPP. We also do a brief orientation for staff at a rural medical clinic and at St. ThŽrse Hospital in the nearby town of Hinche. The hospital psychologist tells us she’s the only trained mental health professional serving a population of 600,000, and that she hasn’t been paid for more than a year.

Anthropologist and physician Paul Farmer, the UN special envoy to Haiti since August 2009, has a concept he calls “appropriate technology,” which, I believe, describes our TRM-C model. He contends that “one should only use the simplest technologies required to do a job.” Where mental health treatment is concerned, I’d add that one should only use the gentlest, least intrusive technologies required. For example, the use of “titration,” which psychologist Peter Levine introduced to somatic therapies, is central to our work. Titration, a term that comes from chemistry, means to work with small increments of traumatic material, watching the client’s level of activation, and then shifting to material that’s less distressing, neutral, or even positive, before returning again to the traumatic material. This rhythm reflects a natural pattern in the autonomic nervous system, where excitation alternates with calming. Titrating exposure to traumatic memory and dysregulated physical sensations while helping people experience more relaxing, positive body states, slowly brings about profound changes at the physical, emotional, and cognitive levels. This is “appropriate technology” in action, where the client can heal gently, with little risk of the retraumatization that can come with diving too far into the traumatic material before the nervous system can tolerate it.

Our workshops include a mix of brief psychoeducation about the biology of trauma, demonstrations of the skills, and practice among participants. We’ve refined our teaching methods so that the pace is fast, and people learn a lot, and have some fun as well. A big hit at all of our trainings is teaching the hokey-pokey, which people around the world love. Another popular icebreaker is having the introductions sung. Each participant sings his or her name and the group sings it back. It’s a playful way to create a safe atmosphere for the work ahead. When I was in Rwanda, one of the trainees introduced me to an effective way to do group introductions, which we’re using in Haiti now: we go around the circle, and one participant says how he or she is feeling at the moment, and the next two people go into the center of the circle and act it out. Everyone has a turn. Sometimes there’s laughter and sometimes sympathetic understanding, but we all know each other much better after the process. It also gives us trainers a heads-up on which of our participants may need some extra attention.

In one introductory circle, a woman said she was feeling sad and had no energy. When the next two participants went into the circle and acted that out, she nodded affirmatively that they’d really shown how she felt. Later, in her small practice group, I asked if she was willing to do a demonstration with me about what she’d described. She told the group that her fiance had died in the earthquake; she’d held his hand when the building had come down on him.

One way we use titration is to consider carefully where to begin in the client’s story. So, at that point, rather than asking for more details about her fiance’s death or her feelings at that time, I asked what she sensed inside, just having told that piece of the story. She said she felt an ache in her heart. I asked if the ache had a shape or color (making the details of an intense feeling concrete by asking questions about color, shape, and texture is a form of titration). She said it was like a big, black stone in the center of her chest. I invited her to sense just the edge of the stone (another titration) and see what she noticed. I saw that she took a deeper breath at that point (usually a sign that the part of the nervous system that calms us—the parasympathetic nervous system—is coming back on line). She said she felt a little “better,” and I asked her to describe the sensations of “better” and to stay with those a bit. I then asked about the stone. She said it was smaller and not as black. I had her just notice the change. I then asked her what was helping her get through the loss of someone she loved so dearly. Shifting to a question about a time after the worst part of the trauma is another way to titrate.

She began to tell me the names of people in the camp who were a source of support for her. With each part of the story of support, I invited her to notice what she was sensing in her body. The remainder of the demonstration consisted of shifting between the traumatic story (in titrated pieces) and the story of support and positive memories of her fiance. After about 45 minutes of working this way, she reported that the black stone was now a pebble. She said that the pebble represented love—the strength of her love for her fiance and the love that she’s receiving from others as she goes forward in her life. Several of us had tears in our eyes as this young woman, having gone through this gentle healing journey, looked back at us with tear-filled eyes and a gentle smile.

Since we’re living at an IDP camp, we begin to hear stories about the positive results people are having as they try the simple stabilization and self-care skills on their own. A few days after the workshop, a man comes up to tell me that he’d taught his wife how to use the stabilization skills when she had a nightmare. He was so proud to have had something to offer her, and especially happy to be able to report that she’d been able to go back to sleep after using the skills.

A small group of engineers from MIT, also funded by the Unitarian Universalist Service Committee, is here at MPP, and they’re doing fascinating work. They’ve designed a way to convert sugarcane leaves, corn cobs, and manioc root into charcoal briquettes. This means that people don’t have to cut down the trees for cooking fuel. The head of the MIT team, Amy Smith—named one of TIME magazine’s TIME 100 (The World’s Most Influential People) for 2010—has designed a small press, which costs about $2 to produce from easily available materials to make the briquettes. Another example of Farmer’s “appropriate technology,” this simple device enables Haitians to make briquettes for their own needs and sell them to earn some much-needed money.

We leave late in the afternoon for Port-au-Prince after many hugs and promises that we’ll all see each other again in July. It’s a hot day, and the dust is horrendous as the van makes its way at breakneck speed up and down the mountains, swerving to avoid potholes and construction debris, passing on curves, stopping in a small town to change a tire. As night falls and the stars come out, we arrive in Port-au-Prince, bedraggled and dusty, and relieved to be off the road.

Four Days in Port-au-Prince

The contrast between the Central Plateau and Port-au-Prince is immense. Most parts of the city are in complete ruins, with piles of debris everywhere and sheet-and-tent camps in every free space. We spend a lot of time during our four days here driving from one camp or local organization to another, following the same workshop formats we used in Papaye. Travel time is long because some streets have been taken over by tents, and others are filled with piles of cement and twisted metal. I take loads of photos of the debris, partly as a way of documenting the conditions for friends and colleagues back home and partly, I realize, to buffer myself from the horror of so much concentrated devastation. There’s no evidence of any effort being made to construct prefab housing, and we all begin to wonder what will happen when the rainy season starts.

Haiti has a low literacy rate, and 72 percent of the population has only a primary-school education. We’ve had our illustration of the nervous system translated into Creole, keeping the labels to a bare minimum. We’re fortunate to have excellent translators on this trip, who’ve quickly grasped the material and goals of our work. By the third workshop, they’re able to introduce the workshop without much input from us. All three translators are survivors of the earthquake, and we know from our work in China how hard it can be for translators to hear so many stories of sadness and loss.

We do workshops for a group from Action Aid, an international humanitarian organization, and for a local NGO called Cozpam (“My Cause”) that partners with Action Aid. The next day, we do a workshop at an IDP camp in Mariani called Foyer Monfort. The nun who runs Foyer Monfort tells us after the session, “Life stopped for many people after the earthquake, and today you helped us regain hope.” The experience of making an immediate difference brings with it a sense of profound connection and gratitude on both sides.

On our last day, we have a meeting at the feminist IDP camp affiliated with SOFA (a solidarity organization for women). Three leaders of the Haitian feminist movement were killed in the earthquake. We’re told that the incidence of rape (already high in Haiti) is rising sharply, since women have no ­privacy when they shower and aren’t safe at food-distribution points. The Women’s Feminist Platform is coordinating the work of a range of women’s groups to increase security and gain more equality for women and their families. When we thank one of the coalition leaders for meeting with us, she says, “Don’t thank me, just come back soon.”

In each place we work, we describe the training programs we’ll be initiating when we return in July. Without exception, every group is interested in participating, and one psychology professor from the UniversitŽ d’ƒtat d’Haiti says he wants all 35 of his students to attend the three days of training. Clearly the demand exceeds our initial plan to train 60 Haitians in TRM-C. We’re now planning additional trainings, if we can find funding.

We leave for the airport in a downpour that began during the night. People are hurrying along, drenched, muddy, and miserable looking. I hand my poncho out the window to a young woman, and she gives me a smile so big it’s as if the sun has come out. I don’t want to imagine what will happen to the crowded, flimsy sheet camps when the rainy season begins in earnest. How much can these people take? Why is there no evidence of more substantial housing being constructed? Where is all the aid money going? There’s a limit to how long people can get by on faith and their natural resiliency.

Having seen so few signs during our time in Haiti that the outpouring of worldwide humanitarian aid is reaching the people who need it, we can only hope that it soon will. There’s a Haitian proverb: Tout bet jennen mode—Animals in poor shape will bite.

Postscript—June 2, 2010

I’ve just returned from a second trip to Haiti with a team of five. Sadly, there’s no visible change in the living conditions of the people in Port-au-Prince: same debris, same endless tent camps. Heavy rain is the only thing that’s been added to the misery mix.

Many of the trainees are the people we worked with in March, and it’s reassuring to hear that they’re doing better as they use the skills they learned from us for their own self-care and that of their loved ones. This time, we trained 94 people in Papaye and Port-au-Prince, even though we’d planned on training only 60. It seemed impossible to turn people away.

The trainees are eager and enthusiastic learners. A highlight of our time was to watch them independently conduct TRM-C’s therapeutic games and individual stabilization sessions with the residents of an IDP camp. We couldn’t stop grinning! It’s an important reminder that nonclinicians—which 80 percent of our trainees are—need to learn the skills we have. They often function as first responders, and it’s a mistake to think that trauma stabilization procedures can be administered only by clinicians and other highly trained professionals. Our TRM-C trainees are competent practitioners, and they’ve learned the skills quickly. Our materials and methods are tailored to nonclinicians and low-literacy populations.

We’ll be back again in July and September to work with the same trainees. After September, we plan to do a one-year train-the-trainer program.

I know that everyone on the TRI team would say we’ve received as much, if not more, than we’ve given, and we look forward to our continued work in Haiti.