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Culture and Depression 1

Sociopolitical, Gender, and Cultural Factors in the Conceptualization and Treatment of

Depression among Haitian Women

Guerda Nicolas, PhD University of Miami

Bridget Hirsch, BA

Boston College

Clelia Beltrame Boston University


Sociopolitical, Gender, and Cultural Factors in the Conceptualization and Treatment of


The important roles that culture and gender play in the manifestation and treatment of

mental illness have been well documented (Burns & Mahalik, 2007; Kleinman & Kleinman,

1985; Mahalik, Burns, & Sysdek, 2007; Sue & Zane, 1987). Although researchers are beginning

to address these issues for some ethnic and cultural groups such as African Americans (Miranda,

2000), Latinos (Bernal & Scharron del Río, 2001), and Asians (Sue, Arredondo, & McDavis,

1992), relatively little is known about Black Caribbeans. Similar to other ethnic groups, the

Black Caribbean community is heterogeneous, comprised of many distinctive cultural groups

located in various regions of the Caribbean islands. In this chapter we present a summary of the

sociopolitical and gender role factors, as well as the health beliefs and conceptualization of

illness among Haitian women. We continue by offering an examination of how these factors

intersect and influence the perception of depression among Haitian women. Finally, using the

Multicultural Competency Model (MCC; Arredondo et al., 1996) as a framework (Sue,

Arredondo, & McDavis, 1992; Sue, Bernier, Durran, Feinberg, Pedersen, Smith, & Vasquez-

Nuttal, 1982) we illustrate the link between culture and depression for Haitian women.

Sociopolitical History and Gender Factors

Although phenotypically similar to other Black Americans (Desrosiers & St. Fleurose,

2002; Rowlands, 1979; Turnier, 2000, Haitians are undeniably distinct from African Americans

with regard to many elements of culture such as beliefs, language, food, politics, history, and

methods of arrival to the U.S. (Huff & Kline, 1999; Zephir, 1996). As noted by Hopp & Herring

(1999), Haitian’s health beliefs and cultural practices significantly differ from those of African

Americans by individual factors, such as ‘‘. . degree of acculturation, country of origin,


education level, socioeconomic level, and the time of freedom historically’’ (p. 219). Through an

examination of the historical role of Haitian women in the social and political events of the

country, researchers and service providers may gain important insight which can aid in the

understanding of the client as well as how best to foster her well-being.

Sociopolitical Factors

As depicted in most history texts, in 1492 Christopher Columbus occupied the island of

Hispaniola for Spain and built the first settlement on Haiti’s north coast. In 1697, through the

Treaty of Ryswick, the island was divided into two parts with the French controlling Saint

Dominique and the Spaniards controlling Santo Domingo. For more than 100 years and at the

height of slavery, Saint Dominique became an important territory to France supplying it with the

island’s natural resources such as sugar, rum, coffee, and cotton. As a result, France enslaved

over 500,000 people, mostly from western Africa, to the island in order to continue its mass

production of these commodities. However, from 1791 to 1803, a slave rebellion, lead by

Boukman, and commanded by Toussaint Louverture, was launched against the colonists and the

Napoleon army. Through many battles, including the Battle of Vertieres in 1803 (commonly

known as the slaves’ ultimate victory against the French), Haiti—or Ayiti in Creole (meaning

mountainous country)—became the second independent state in the Western Hemisphere, and

the first free Black republic in the world.

Gender Factors

In addition to Haiti’s sociopolitical history, the literature on gender roles is an invaluable

source of information in understanding Haitian women’s unique experience with depression.

This section is a summary of the historical and current literature on gender roles for Haitian

women.


Through a historical examination of Haitian struggles to achieve the independence of

their country, it is evident that Haitian women played a pivotal role in the eradication of slavery

not only in Haiti but in the Western Hemisphere (Laurent, 2003). Their role and impact are

apparent through the description of historical figures such as Ezili Danto, known for her spiritual

presence and power behind the many Haitian women who victoriously fought with Toussaint,

Petion, and Dessalines in creating the first Independent Black Republic in the world; Anacaona,

who refused to be enslaved and fought for the liberty of Haitians to her death; Manbo Cecile

Fatiman, Haitian priestess who participated in the well known ceremony known as Bwa

Kayiman with Boukman in 1791 (during which time Haitians decided that freedom was essential

for their survival), and many more. Through a review of these women’s stories we learned of

their courage in combat during the revolution and of their tireless efforts to obtain voting rights

for women before any other country in the Western Hemisphere. The legacies of these women

are passed on through oral history of the people as well as through literature. For example,

Danticat's (2005) book entitled Anacaona: Golden Flower, Haiti, and the art exhibit on Ezili

Danto at the American Museum of Natural History keep their work alive." These women serve

as role models for girls and women in the country and abroad, and their legacy plays a pivotal

role in the development of many grassroots activism organizations in Haiti and in the United

States (Charles, 1995).

The impact that migration and transnational processes have had on Haitian women is

another factor that helped to shape and reshape not only Haitian women’s political identities but

also the current political landscape of the country itself (Gammage, 2004). Gammage (2004)

argues that the “feminization of agriculture and the displacement of male income earners from

the countryside has changed economic roles and may have contributed to the emergence of rural


women as a political force” (p.761). Haitian women’s participation in the creation and

implementation of local and national grassroots organizations has helped the fight for equal

rights, equitable distribution of resources, and overall for the “formation of contemporary Haitian

civil society and the moves toward democratization” (Gammage, 2004, p. 762). These

grassroots and historical events had an everlasting impact on the roles of Haitian men and

women on the island and abroad.

The Development of the Haitian Women Movement. Despite the active involvement of

Haitian women in Haiti’s independence, it was not until 1934 that the first Haitian women

organization, Ligue Feminine d'Action Sociale (Women’s League for Social Action) was formed.

Created by an elite group of middle and upper class professional and intellectual Haitian women,

this organization played an important political role in the country for 25 years. The central focus

of this organization was to obtain legal rights in the areas of equality for married women,

including access to education and suffrage for all women in the country. Through this

association, Haitian women were able to gain the right to vote and attend universities by the end

of 1950s (Charles, 1995). With their successes, however, came many tribulations: many

members of the League were victims of torture, rape, and death under the presidency of Francois

Duvalier (1957-1971) and his son Jean-Claude (1971-1986).

The torture and arrest of Yvonne Hakim Rimpel in 1958, one of the founders of the

League and a prominent journalist, lead to a protest by 36 of its members calling for an

investigation in Rimpels’ case (Zéphir, 1991). The League was subsequently driven to silence for

many years. The 1970s marked the re-establishment of a few professional Haitian women’s

groups in Haiti and the simultaneous establishment of a Haitian women’s movement both in the

United States and Canada. In fact, by the 1980s, the women’s movement emerged and helped to


reshape Haitian society into a more egalitarian and democratic mindset. With the demise of

Duvalier’s dictatorship in 1986, many Haitian women activists returned to Haiti and assisted in

the creation of new organizations such as Solidarité Fanm Ayisyen (SOFA, Haitian Women’s

Solidarity), Klinik Sante Fanm (Women’s Health Clinic), Committee to Defend Working

Women's Rights, (KODDFF, in Kreyó), and Kay Fanm (Women’s House) (Charles, 1995).

Currently, both in Haiti and in the Diaspora, Haitian women are continuing the legacy of the

many women warriors of the past in improving the lives of Haitian women. Individuals such as

Ginette Apollon (Director of the Women's Commission of the Confédération des Travailleurs

Haitiens [CTH], and President of the health workers union affiliate of the CTH) and Rea Dol

(Co-founder and Director of Society of Providence United for the Development of Petionville

[SOPUDEP] and the Coordinator of a federation of women’s organizations that focuses on

women’s rights, education, economic empowerment and social justice) are examples of the noted

grassroots women who continue to fight against social, political, and educational inequalities of

women in Haiti and in the Diaspora (Bell , 2001; Donaldson, 2008). Despite the high rate of

poverty, health issues, and political turmoil, Haitian women have courageously adapted to their

extensive history of fighting for equal rights by coming together collectively as a group to

promote social change and equality. Influence of the Haitian women movement on gender roles.

The evolution and growth of the Haitian women’s movements led to a redefining of women’s

roles, power, and identity in Haiti and abroad (Charles, 1995; Fuller, 1999). Haiti is a country

that, “in any of its dimensions, simply cannot be considered without recognition of the role and

significance of women and their activities” (Gammage, 2004). Haitian women have many

responsibilities from household tasks to agricultural tasks. For example, many Haitian women

are often found along side Haitian men planning and harvesting crops and raising livestocks.


Furthermore, Haitian women are employed in a variety of settings such as schools, hospitals,

community organizations, and factories to name a few. Although historically Haiti has been

dominated by male figures and the institutional power still resides with men on the island, over

70% of rural households are headed by women (Edmond, Randolph, & Guyliane, 2007). In fact,

some authors have referred to Haiti as “matrifocal” highlighting the economic and social power

of the men and the accountability and responsibility of women for children’s’ welfare (Colin &

Paperwalla, 1996, 2003; Laguerre, 1981, 1984). Thus, women are often referred to as the

backbone of the family in Haitian culture. For example, the well- known author, Edwidge

Danticat, observed in her book, Breath, Eyes, and Memory, that “Only a mountain can crush a

Haitian woman.” The quote “Fam se poto mitan” (women are the center post), a common

Haitian proverb, epitomizes the role of Haitian women in Haiti. In fact, recently a film entitled,

Poto Mitan: Haitian Women Pilars of the Global Economy, depicts the current story of Haitian

women’s struggle, courage, resistance, and democracy. Today the perception and gender roles

are continuing to shift in Haiti with the occupation of Haitian women in prominent positions

such as interim President Ertha Pascal-Trouillot (1990-1), the Prime Minister Claudette Werleigh

(1995-6) and more recently the election of Michelle Pierre-Louis (2008) as the new Prime

Minister of the country. The election of Haitian women in prominent political positions both in

Haiti and in the Diaspora (e.g., three terms election of Marie St Fleur in Massachusetts) signals

that the imprints of Haitian women are visible today and will no doubt continue to shift the roles

of women in the culture.

Cultural Factors

The sociopolitical history and evolution of gender roles in Haiti are integral parts of the

cultural identity of Haitians. The link between culture and mental health has been well


documented by many researchers (Bernal & Scharron del Rio, 2001, Trimble & Fisher, 2006).

However, it is only recently that a focus on culture and mental health for Haitians was

undertaken (Nicolas, et al., 2007). In an effort to understand the association between culture and

depression for Haitian women, a summary of the cultural health beliefs of Haitians is provided

followed by an examination of the cultural aspect of depression among Haitian women. This

section concludes with an application of a multicultural framework in integrating culture and

mental health for this population.

Cultural Health Beliefs and Conceptualization of Illnesses Among Haitians

In the Haitian community, being in “good health” is associated with ones’ ability to

maintain internal equilibrium between cho (hot) and fret (cold). In order for an individual to

achieve balance, the person must pray, eat well, give attention to personal hygiene, and have

good spiritual habits (Colin & Papperwalla, 1996; Kirkpatrick & Cobb, 1990). Characteristics

such as being strong, having good color, being plump, and freedom from pain all promote good

health among individuals. In order to develop and maintain these characteristics, a person must

eat right, sleep right, keep warm, exercise, and keep clean (Laguerre, 1984; Miller, 2000). As a

result, the development of any illness is viewed as an assault to the body through many different

etiologies.

Among Haitians, illness (mental or physical) often occurs in several chronological stages

(Angel & Guarnaccia, 1989). Regardless of the severity of the illness, a progression of symptom

reporting will be observed among Haitian clients. An illness often begins with the person

reporting Kom pa bon (“I do not feel well”), which does not lead to the development of any

serious symptoms. This is followed by a decrease in activity, confinement to home and the

person reporting moin malad (“I am sick”). In the next stage, the person may report, moin malad


anpil (“I am very sick”), which is associated with an increased severity of symptoms

accompanied by confinement to bed. The last stage in the development of the illness is a sense of

hopelessness about ever getting better, during which time the person will report moin pap refe ("I

am dying") (Angel & Guarnaccia, 1989; Laguerre, 1984).

In addition to Haitians’ unique conceptualization of illness, the Haitian culture has

significant spiritual beliefs that are the cornerstone of the culture (Miller, 2000), For example

cultural healing rituals such as Voodoo ceremony (performed by a Hougan or Mambo) and the

use of herbs (such as root sarsaparilla and senna) are common practices to alleviate physical and

psychological ailments of individuals. The following excerpt from Prince (2005), an herbal

doctor, provides an example of the practice of folk medicine among Haitians:

I treat people with digestive problems, acid stomach, gas, constipation and sexual

problems. I treat fevers, and colds, and aches. I have medicine, which cleans and purifies

the blood. I treat children who aren't growing well, or who are being persecuted by evil

spirits. In addition, we always make sure that the sick person gets the best possible care

from a medical doctor, and sometimes the doctor works together with me. I work with

people who have chronic illnesses, including diabetes, hypertension, and HIV/AIDS.

While I cannot cure these diseases, there is much that can be done to help a person live a

longer, healthier life. (p. 2)

Consequently, it is important that mental health professionals do not dismiss a report of

“I do not feel well” as not warranting immediate attention or care. It is essential that providers

probe for further information about the symptoms in order to determine if immediate follow-up

is necessary (Holcomb, Parsons, Giger, & Davidhizar, 1996). Also an appreciation and


welcoming of these cultural spiritual beliefs is essential in working with Haitian clients (Miller,

2000).


Depression is a universal phenomenon, yet the experience of it is largely impacted by

one’s native culture, social and political history as well as individual experiences. Although there

is no documented research linking the sociopolitical history of Haiti to the psychological well-

being of its people, it is likely to have an impact on the experiences of individuals. In fact,

scholars have argued, “depression is always influenced by social and political dimensions”

(NiCarthy, 2004, p. 22). While depression cannot be reduced to sociopolitical factors alone, it

must not be fully understood from an individual perspective. In fact, Turnier (2000) attributes the

roots of depressive symptoms among Haitian women to historical events that they experienced in

Haiti. The cultural gender norms, the historical participation of Haitian women in the

independence of the country, and their continuous involvement in activisms for equality of

women on the island as well as abroad must be integrated in the assessment of depression among

these women. Considering the uniqueness of the culture coupled with the ever-increasing

number of Haitians settling in the U.S., it seems imperative for researchers and clinicians to

increase their awareness, knowledge, and skills in understanding the interconnection between

culture and the manifestation and treatment of mental illnesses such as depression, specifically

among Haitian women (Nicolas et al., 2007).

Research findings on the mental health of ethnic minorities further emphasize the need

for understanding and considering cultural factors, and call attention to limitations of current

research, which may not take these factors into consideration. For example, international studies

have found higher diagnoses of schizophrenia among Black Caribbeans compared to Whites


(Jackson et al., 2004). However, researchers caution this could be due to lack of consideration of

cultural backgrounds (Blazer, Kessler, McGonagle, & Swartz, 1994). Nevertheless, it was found

that Black Caribbean women have depressive disorders at higher rates than White women in the

U.S. and they were less likely to seek mental health help (Brown, Schulberg, & Madonia, 1996;

Joe, 2005). Studies of large populations in the US? demonstrate the lack of attention that has

been paid to the mental health of ethnic minority populations, and research seems to have

established that Black immigrants in the U.S. have higher rates of mental health problems than

non-immigrant populations in the U.S. (Jackson et al., 2004).

To date, there are no epidemiological depression studies in Haiti or in the U.S. on the

prevalence or rate of depression among Haitians by any categories (e.g., gender, age). Existing

literature on depression among Haitian women is based largely on clinical observation data

which suggest that depression can take many different forms, and that current Westernized

categories as well as ways of assessing depression among these women may not be culturally

relevant (Nicolas, 2006; Nicolas et al., 2007; Turnier, 2000). For example, Nicolas and

colleagues (2007) have identified three distinctive types of depression in a sample of Haitian

women: Douluer de Corps (pain in the body), which is often described by symptoms, such as

feelings of weakness (faiblesse) and faintness; Soulagement par Dieu (relief through God),

which is often associated with specific difficulties in one’s life, and Lutte sons Victoire (fighting

a winless battle), which often is painted as a very bleak generalized picture of the individual’s

life. These categories are consistent with what other clinical researchers have noted among

Haitians in other countries, such as Canada (Turnier, 2000). Unfortunately, there is no empirical

research on the depression rate of Haitian women and [the few related writings ]” that exist

attempt to integrate their symptoms into the framework of Western mental illness which does not


take into account the culture of the population (Azaunce, 1995; Bevilacqua, 1980; Sargant,

1967). To date, Gustafson (1989) and Nicolas et al. (2007) are the only articles noted on

depression among Haitians from a cultural perspective. Given the role that culture plays in the

manifestation of depression among Haitians, a conceptual framework is needed in order to

integrate sociopolitical, gender, and cultural factors in the assessment and treatment of

depression for this population.

The Multicultural Competency Model and Depression among Haitian Women

Although significant research has focused on the importance of integrating culture in the

diagnosis and treatment of mental health issues among ethnic minority women, these concepts

and models are not easily applied across different cultural groups. In addition, the American

Psychological Association has called for practitioners to develop competency in multicultural

counseling as an effort to ensure that clients are receiving culturally relevant services (APA,

1991). Explicit in this recommendation is a recognition that culture needs to play a fundamental

role in the assessment and treatment of individuals from diverse cultural backgrounds (Pedersen,

1988). Among the many cultural models, the Multicultural Competency Model (MCC)

(Arredondo et al., 1996; Sue et al., 1992; Sue et al., 1982) . is the most accepted model that is

used in the areas of training, supervision, and teaching in the field of psychology (Pope-Davis,

Liu, Toporek, & Brittan-Powell, 2001). Importantly, it provides a three stage developmental

approach in working culturally with ethnically diverse clients (Delgado-Romero, 2005).

Although some researchers have questioned the empirical foundation of this model (Constantine

& Ladany, 2001; Ponterotto, Fuertes, & Chen, 2000), the general principles of the model can

serve as a foundation for researchers and clinicians in how to increase their multicultural

understanding of ethnically diverse individuals. Despite the inherent differences in the


sociopolitical histories and contexts of various cultural groups, ethnically diverse individuals

share the experience of the power, social construction, and socialization that often operates

within various systems (i.e., family, school, and work (Sue et al., 1982). In this section of the

chapter, we provide a description of each of the stages of the tripartite MCC model with

illustrations of its applicability through examples from the Haitian culture.

Stage one. The first stage of the MCC model, cultural awareness, focuses on the

awareness of the researcher and/or clinician’s viewpoint, culture, and biases in conjunction with

the person’s viewpoint from another, unfamiliar culture as well as assumptions that may arise

from the difference between these points of contact (Pedersen, 1988). Sue and colleagues (1998)

noted that “culturally skilled therapists are aware of how their own cultural background and

experiences, attitudes, values, and biases influence psychological processes” (p. 38). This stage

of the model urges researchers and clinicians to examine their cultural beliefs and any biases that

might be held about other cultural groups in order to reduce the risk of alienating or stigmatizing

the beliefs of individuals(Pedersen (1988).

As previously highlighted in this chapter, the health beliefs and practices of Haitians

differ from the Western perspective on the etiology of mental and physical illness. In utilizing

stage one of the MCC model one might ask oneself, “What were my initial reactions to the

summary about Haitian cultural beliefs? How are these beliefs similar or different from my own

beliefs about health as a researcher or clinician? How would I react to hearing about these

beliefs?” These are among the many questions that one can ask in an attempt to become aware of

one’s own cultural viewpoint in comparison to that of another cultural group. Through an

evaluation of these and other questions an individual can begin working through their cultural

assumptions and biases. Furthermore, through such a process, an individual can begin to increase


their cultural knowledge about individuals from diverse ethnic backgrounds. Stage two. The

second stage of the MCC model is enhanced knowledge about the views of clients as well as an

understanding of the function and influence of historical, social, and political events within that

culture which may have impacted the behaviors and attitudes of individuals within that culture

(Sue et al., 1998). According to Sue and colleagues (1998) “culturally skilled therapists should

familiarize themselves with relevant research and the latest findings regarding mental health and

mental disorders of various ethnic and racial groups. They should actively seek out educational

experiences that enrich their knowledge, understanding, and cross-cultural skills” (p. 40). In

order to utilize the most effective assessments, interventions, and treatments it is imperative to be

familiar with the risk and protective factors associated with the specific culture with which one is

working. Being knowledgeable about the sociopolitical history and gender roles of Haitian

women will enable one to recognize significant risk and protective factors for this specific

population. Researchers argue that an examination of the risk factors associated with mental

health concerns among Haitian women must take into account factors such as race, gender and

gender roles, poverty, violence, and stigma (Lawless, 1986; Portes & Rumbaut, 2001a).

Specifically, existing literature on Haitian women suggest that Haitian women’s risks for

negative health issues may be due in part to their sociopolitical history, economic conditions, and

geographical location (Desrosiers & St. Fleurose, 2002; Desantis, 1990; Kessler & McLeod,

1984; Neuman, 1986; Rowlands, 1979; Pierce & Elisme, 2001). In addition, stressors associated

with acculturation and migration patterns (Pape et al., 1986) must be taken into account as

additional risk factors for members of the Diaspora. Specifically, an examination of the different

levels of acculturation (Rudmin, 2003) as well as the various factors associated with

acculturative stress (i.e., physical and social isolation, shifts in gender roles, language, challenges


in maintaining one’s culture) may elucidate important information regarding the mental health of

Haitian women. Although the risk factors for Haitian women’s mental health are abundant

(Lawless, 1986, Pape, et al., 1986; Portes & Rumbaut, 2001b), there are many resources, which

can serve as protective factors for Haitian women. These include religious beliefs (Nicolas, et al.,

2008), strong family connections (Nicolas et al., 2007), and a rich oral story telling tradition.

Danticat summarizes this oral tradition well in her book, Krik? Krak!, stating, “I took to the past

to Haiti--hoping that the extraordinary female storytellers I grew up with-the ones that have

passed on--will choose to tell their stories through my voice” (Casey, 1995, p. 525-526). In her

book, Danticat presents the legacies and visions of Haitian women through narratives of mothers

and daughters whose personal tragedies have contributed to the formation of communities in

Haiti. Through a cultural knowledge of the strengths of Haitians as depicted in art, literature, and

research, service providers and researchers will be better equipped in addressing the

psychological well-being of Haitians in Haiti and abroad.

Stage three. The last stage of the MCC model, cultural skills, is the ability to integrate

knowledge and awareness in the development and implementation of services in a culturally

sensitive manner (Sue et al., 1998). In addition to addressing the enhancement of cultural

knowledge and awareness about ethnically diverse clients, this stage highlights and questions the

expertise of researchers and service providers in delivering effective services to ethnically

diverse clients. Sue and colleagues (1998) suggest that “the culturally skilled psychologist or

therapist has knowledge of models of minority and majority identity, and understands how these

models relate to the therapy relationship and the therapy process” (p. 41). For example, research

on self-silencing theory by Ali, Outley, & Toner (1986) fount that women in individual

psychotherapy who scored high on self-silencing at the beginning of therapy had less positive


therapeutic outcomes from their therapy compared to women who had scored low on self-

silencing. This indicates that self-silencing may be a barrier to successful therapy and therefore,

in the MCC model, attempts should be made to bridge the gap between client and therapist and

enhancing clients' expression of their authentic self. With respect to stressors associated with

discrimination, research has shown that an increase in perceived societal and systemic

discrimination from Whites resulted in significant increases of being diagnosed with major

depressive disorder, conduct disorder, and oppositional defiant disorder among African

American and Caribbean adolescents living in the U.S. (Portes, Kyle, Eaton, 1992). In a study

comparing Caribbean women in living in Canada to those living in the Caribbean, Ali and Toner

(2001) found higher reporting of self-silencing and levels of depressive symptoms among the

Caribbean-Canadian women. They postulate that discrimination may be one factor that

contributes to lower emotional well-being among Caribbean women who had immigrated to

Canada. The results of these studies demonstrate the importance of incorporating cultural

sensitivity into mental health services and programs for ethnically diverse individuals. Given the

cultural influence in the manifestation and expression of depression symptoms, the types of

interventions, as well as the strategies for delivery of services are likely also to be influenced by

the culture of the individual offering treatment. This is especially true considering that mental

illness is not an area that is well accepted in the Haitian culture (Colin & Papperwalla, 1996) and

thus Haitians often underutilize mental health services (Portes, Kyle, Eaton, 1992). In Haiti,

mental illnesses often remain untreated unless they are connected to some significant social

disruption for the individual (Colin & Papperwalla, 2003). Consequently, due to the stigma

associated with mental illness in Haitian culture, an individual who is suffering from depression

symptoms may not admit to it (Colin & Papperwalla, 1996). A Haitian who seeks care from a


biomedical practitioner such as a psychiatrist may not think he was treated unless there was

evidence that a physical exam was done. Given the paucity of intervention research on Haitians

in general, especially Haitian women, it is imperative that not only risk and protective factors are

recognized, but also an understanding of the existing barriers to services should be taken into

account when providing mental health treatment to this population.

Barriers to services. Similar to other ethnic minority groups in the United States, Haitian

women encounter many barriers that impact their access to services within the U.S. These

barriers include institutional racism, prejudice and racism against Haitians, low literacy rate, lack

of acculturation, and limited English language proficiency (Albertini & Barsky, 2003; Metayer,

Jean-Louis, & Madison, 2004; Pape et al., 1986; Pierce & Elisme, 2001; World Health

Organization, 2005). For example, the 1996 Immigration Act in the United States, requiring

financial independence from the government as a prerequisite for citizenship qualification, serves

as a barrier for new immigrants in need of services (Aparicio & Kretsedemas, 2003). In addition,

this citizenship is directly connected to obtaining health insurance coverage, which is another

significant barrier for many immigrant groups, including Haitians, in the U.S. (Coreil, Lauzardo,

& Heurtelou, 2004; Lillie-Blanton & Hudman, 2001). Additionally, insurance coverage in the

United States is directly linked to access as it reduces the financial barriers often associated with

receiving medical care (Guendelman, Scauffler, & Pearl, 2001; Rhoades, Brown, & Vistnes,

1998; Penchansky & Thomas, 1981). To effectively address the mental health needs of Haitians

in the U.S., mental health workers and community members must take a closer look at these

barriers and the development of intervention strategies to prevent or eliminate them.

Access to mental health treatment in Haiti. In Haiti, the health care system consist of

mainly three sections: (1) the public sector (Ministry of Public Health and Population and


Ministry of Social Affairs), (2) the private for-profit section (private practice professionals), and

(3) the nonprofit sectors (NGOs). According to Pan American Health Organization (PAHO)

reports, there are total of 371 health posts, 217 health centers, and 49 hospitals in the Haiti.

However, it is estimated that more than 40% of the population, especially those in rural areas,

uses traditional folk remedies for health problems. Although in 1996 the Ministry of Health

introduced a health policy that would grant access to health care to all Haitian residents, the

political instability in the country has derailed these efforts. To date, Haiti has no organized

structure health care system and only a fraction of the residents have access to any form of health

care services. The majority of individuals in Haiti rely on public and NGO established

organizations for health services where they must pay a minimal fee based on their income and

family size (PAHO, 2007).

Physical health is the main priority of health officials in Haiti; only two government

institutions focus on mental health in Port-au-Prince, the capital of the country.. Thus, most

Haitians are neither familiar with nor seek services from the mental health care system. In fact,

the mental health governmental systems in Haiti are greatly stigmatized and often seen as places

for individuals who have “lost” their minds. The compounded effect of the stigma associated

with mental health, risk factors, barriers to services, and the lack of available mental health

intervention data on Haitians, has prompted several authors (Desrosiers & St. Fleurose, 2002;

Miller, 2000; Nicolas et al., 2006) to offer specific recommendations in providing mental health

services to Haitians in a culturally responsive manner.

In Haiti and in the U.S., understanding how Haitian clients perceive and make meaning

of their symptoms must be the first step in addressing the mental health needs of these clients. In

order to obtain this understanding, it needs to be understood that the way a client perceives the


symptoms may have implications for service utilization and adherence to treatment. Such a

process calls for a shift in the traditional assessment method in understanding the mental health

issues of clients from different ethnic and racial background. Asking Haitian clients questions

such as, “How do you think these symptoms came about?” “What meaning do you make of

them?” and “Why do you think that these things are happening to you now?” may allow the

clinicians to gain a greater understanding of clients’ perceptions and experiences of their

symptoms.

Conclusions

The information presented in this chapter highlights some key areas (i.e. sociopolitical,

gender and cultural health beliefs) that practitioners and researchers must take into account when

working with Black Caribbean populations. Cultural differences play an important role in the

manifestation of mental health issues, as exemplified among Haitian women (Nicolas et al.,

2006). Although some attempts have been made through research to understand how cultural

beliefs impact the perception of mental illness, much more research is needed in this area for

Haitian women.

The importance of multicultural competencies summarized in this chapter calls for an

integration of awareness and knowledge of the various cultural contexts in which individuals

operate, and for the development of strategies to effectively integrate cultural knowledge into

services and research with ethnically diverse individuals or groups (APA, 1991). In this chapter,

we provide a summary of the three main components of the MCC model using Haitians as an

exemplar for how to apply this model to a cultural group. Specifically, in the chapter we

illustrate how researchers and service providers can enhance their awareness, knowledge, and

skill sets within the historical, sociopolitical, and gender contexts of Haitian Women.


Depression exists around the world; however, we must recognize that ways of

understanding the illness, expression of symptoms, and help seeking patterns vary across and

within different cultural groups. In addition, it is evident that not only differences in racial

categorizations need to be taken into consideration, but also differences in socialization, culture,

and belief systems within the same ethnic group need to be accounted for. Thus the information

presented here reinforces the message expressed by many cross-cultural researchers that culture

matters (Nicolas, et al., 2006; Trimble, 2006; U.S. Department of Health and Human Services,

2001) and must be taken into account when conducting research with ethnic and immigrant

groups. Given their cultural background, we recommend that Haitian clients be active agents in

treatment planning in order to develop a sense of connection to the process (Desrosier & St

Fleurose, 2002). This will be consistent with clients’ active participation in cultural ritual healing

ceremonies (DeSantis & Thomas, 1990; Gustafson, 1989).

Haiti has a rich historical, sociopolitical, and gender role history that is an integral part of

the culture and thus of the background of individuals who originate from within that culture.

Enhancing awareness, understanding, and appreciation of these factors will lead to more

engagement and connection with Haitian women, more effective treatment interventions, and

promote culturally relevant research.


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