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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
Culture and Depression 2
Sociopolitical, Gender, and Cultural Factors in the Conceptualization and Treatment of
Depression among Haitian Women
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,
Culture and Depression 3
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.
Culture and Depression 4
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
Culture and Depression 5
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
Culture and Depression 6
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.
Culture and Depression 7
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
Culture and Depression 8
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
Culture and Depression 9
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
Culture and Depression 10
welcoming of these cultural spiritual beliefs is essential in working with Haitian clients (Miller,
2000).
Depression among Haitian Women
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
Culture and Depression 11
(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
Culture and Depression 12
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
Culture and Depression 13
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
Culture and Depression 14
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
Culture and Depression 15
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
Culture and Depression 16
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
Culture and Depression 17
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
Culture and Depression 18
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
Culture and Depression 19
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.
Culture and Depression 20
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.
Culture and Depression 21
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