Case Report, Int J Ment Health Psychiatry Vol: 4 Issue: 1
Clinical Social Work with a Child Experiencing Early Onset Schizophrenia in Haiti
School of Social Work, University of North Carolina, USA
*Corresponding Author : Athena R Kolbe
School of Social Work, College of Health and Human Services, University of North Carolina 601 S College Rd Wilmington, NC 28403, USA
E-mail: [email protected]
Received: Janaury 27, 2018 Accepted: February 09, 2018 Published: February 16, 2018
Citation: Kolbe AR (2018) Clinical Social Work with a Child Experiencing Early Onset Schizophrenia in Haiti. Int J Ment Health Psychiatry 4:1. doi: 10.4172/2471-4372.1000157
Background: Early onset schizophrenia is a rare condition characterized by psychotic symptoms in children and youth under the age of 18. Diagnosis and treatment of this disorder can be complicated by cultural and socioeconomic factors.
Methods: The case of an 11-year-old girl living in urban Haiti who developed a set of unusual symptoms indicative of psychosis, notably auditory command hallucinations, visual hallucinations, and disorganized behavior, is presented in this paper.
Results and Conclusions: The history and development of the client’s treatment plan as well as the various interventions used are outlined. Cultural, social and economic issues relative to assessment and treatment of serious mental illness in Haiti are also discussed.
Keywords: Early onset psychosis; Diagnosis; Treatment interventions; Clinical social work; Socioeconomic status
Childhood onset schizophrenia, usually defined as onset before 12-15 years of age, is a rare disorder on which little research has been conducted. Diagnosed using the same criteria as that for adults, childhood onset schizophrenia is typically associated with a poor prognosis when compared to individuals with adult onset schizophrenia. Generally, for children who are diagnosed, their difficulties continue to progress through adolescence and into adulthood. The prognosis is most favorable for children who have no family history of schizophrenia, those who experienced an acute onset with severe symptoms such as hallucinations (rather than a gradual onset with depressive symptoms), and those who were socially active and well-integrated into their community pre-morbidity [1-3].
The diagnosis and treatment of schizophrenia can be complicated by social, economic, and cultural factors. Haiti, like many developing countries, lacks a national health care infrastructure capable of effectively interceding on behalf of many vulnerable populations experiencing serious mental illness. Port-Au-Prince, Haiti’s capital, has two psychiatric hospitals (Centre de Psychiatrie Mars et Kline, with 20 beds, and <I>Hospital Ary Bordes</I> in Beudet, with 120 beds, with 120 beds) serving an urban population of more than a million. There are four public health units offering minimal psychiatric services outside of the capital, in the cities of Les Cayes, Gonaïves, Cap Haïtien, and Jérémie. Religions missions and nongovernmental organizations mostly provide the ongoing mental health care in Haiti, particularly in rural areas. There is no formal licensing for psychiatric or clinical social work in Haiti and mental health care is often provided without supervision or governmental oversight [4-9].
Cultural challenges also complicate the diagnosis and treatment of mental health problems . Religious beliefs based in Christianity and Voodoo have various, often competing, interpretations of why and how individuals may experience mental illness and symptoms such as hallucinations, depression, intrusive thoughts, anxiety, and somatic complaints. In general, the hierarchy of preference for medical treatment is to first seek home remedies including herbal treatments, then to seek treatment from a traditional medicine practitioner who may use herbs or religious ceremonies, or a combination of both, as a form of treatment. If those treatments do not work, the patient may be taken to see a doctor. This can vary, however, with families in urban areas having more access to western medicine and tending to be more accepting of this form of treatment as an earlier intervention. Medication compliance is often poor in Haiti as patients elect to stop taking medication when they feel better or to share medication with friends or family members who may have similar symptoms.
History and family background
“Yvonne” is an 11-year-old girl who was referred to see a clinical social worker for assessment by her school after teachers reported that she exhibited unusual behaviors. Yvonne lives with her mother, aunt, an adult male cousin (aged 30), and two younger brothers (aged 9 and 5) in a low-income neighborhood in Port-au-Prince. The neighborhood features a high crime rate and infrequent access to municipal services. Yvonne’s mother and aunt are self-employed street merchants and her adult cousin works occasionally as a laborer. All three children are enrolled full time at a local school run by a foreign charitable organization, a children’s Bible study club, and a Sunday school class.
Adult family members described their family as being emotionally close, with respectful, caring relationships and frequent genuine displays of affection for the children and each other. Adult family members share financial responsibility for the household and Yvonne’s mother and aunt are regarded as the heads of the household. The primary difficulties the family described, other than Yvonne’s mental health and behavioral problems, included a lack of material resources, the high cost of living, and the lack of adequate housing.
Yvonne’s early medical and developmental history is unremarkable. Her mother gave birth at home with the assistance of a midwife. Yvonne was a healthy baby and toddler; she experienced no serious illnesses and achieved all developmental milestones on time. She had a mild seizure lasting less than 30 seconds once, at the age of two, during a fever. Yvonne has no history of head trauma or any neurological disorders. There is no known family history of mental illness or substance abuse. Yvonne is not believed to have been abused or neglected, though she was unable to respond to questions regarding this during intake.
Yvonne’s father, who was married to her mother but lived separately (a common arrangement in Haiti) was killed in a car accident when she was six years old. His family members continue to support Yvonne and her brothers by paying for their school fees. Yvonne had an emotionally distant relationship with her father, who played little role in her daily life due to his work schedule which kept him in the neighboring Dominican Republic, where he worked as a construction laborer, most of the year.
I was initially contacted by a foreign missionary volunteering at Yvonne’s school who said he had a student with suspected developmental delays who had “a lot of social problems” and “seems kind of strange”. I referred him to a local Haitian social worker and recommended they also arrange for the child to see a pediatrician to rule out physical health causes for her problems. Five months later, I was contacted by the same missionary who explained that his attempts to obtain a diagnosis for the child had been unsuccessful. Yvonne had been evaluated by a visiting American pediatrician who found her to be physically healthy (with the exception of a mild fungal infection on her scalp, which he treated). The Haitian social worker reported that he was unable to follow through on a home visit because he could not reach the family by phone. That social worker subsequently left his position and was not replaced. I agreed to evaluate Yvonne and make a recommendation for her future care and treatment needs.
I first met Yvonne during a home visit on a weekend afternoon. She were dressed up for the meeting in church clothes: a frilly white and blue dress with leather sandals, her braided hair tied back with matching white and blue ribbons. She looked small for her age, appearing to be 7 or 8, rather than 11-years-old. Her entire household and her paternal grandfather were also present in their best clothes. Yvonne’s brothers greeted me as I walked to the house, explaining to the neighbors in the yard that I was a foreign doctor here to examine their sister.
I was accompanied by a male Haitian MSW student who assisted in translation and some aspects of the assessment. (I am a white American who has worked in Haiti off and on for more than two decades; I have a working knowledge of Haitian Creole but am not of Haitian descent and often struggle to understand colloquial uses of the Creole language). My MSW student’s role was as a partner in the assessment, providing a cultural and linguistic bridge to help translate and appropriately apply Western conceptualizations of mental health in the Haitian context. Additionally, he was charged with orally translating segments of the assessment and planning meetings, to ensure that we all fully understood the situation. I began by explaining the social work process, my role in the assessment, and my MSW student’s role in facilitating and conducting parts of the assessment and planning.
Yvonne’s mother, aunt, cousin, and grandfather all presented a similar picture of Yvonne’s difficulties. Yvonne’s mother and aunt provided most of the information, with her cousin and grandfather interjecting frequently to add or correct details or to give examples. Yvonne’s mother was most concerned about Yvonne’s pattern of unusual behavior. Yvonne was seen talking to herself, but not in a way that is typical of children her age (e.g. singing to self, or talking to her dolls). Rather, Yvonne appeared to be in fierce arguments with people who could not be seen. This began approximately two years prior and happened once every few months for the first year; current frequency was 3-4 times weekly.
Yvonne was described as talking in a way that “doesn’t make sense” or “using words that don’t go together.” Yvonne’s mother and aunt initially punished her for this, thinking she was being insolent, but then realized she didn’t seem to be able to control her own speech. Yvonne was often disorganized and confused when given tasks; though willing to help with household chores, she could not be depended on to finish them and she got confused or lost when sent to the market to buy a small item, though the market was on her way to school and she was very familiar with the route and all of the market vendors.
Yvonne’s grandfather remarked that she appeared to be “someplace else” much of the time. He demonstrated by clapping his hand loudly and, when Yvonne did not react to the sound, explained that she often doesn’t respond when called, does not react to pain (e.g. being accidently burned when handed a hot cup), and rarely laughs or smiles. The family was so concerned by this intermittent lack of responsiveness when it began that they asked the school nurse to check Yvonne’s hearing, which turned out to be fine.
Yvonne often gestured or waved her hands for no apparent reason, sometimes pointing her finger like a pencil and “writing” in the air. She sometimes rocked back and forth, often at bedtime, and during the previous month had begun tapping her head against the wall. Yvonne was described as impulsive, uncontrollable, and bizarre. She could no longer be relied upon to bathe and groom herself in the morning without assistance; Yvonne often forgot steps in the process, coming out to breakfast without her skirt on or having forgotten to wash the soap off of her body.
Bedtime was a particularly stressful time for the family. Yvonne had frequent nightmares, had begun wetting the bed a year or two prior. She would refuse to go to bed for fear that she would “sink” into the sheets and be unable to breathe. Night-time fears also included concerns that she would be killed during her sleep, that spirits would cut off her toes while she slept, and that she would wake up having been turned into an animal. She sometimes got out of bed at night and wandered through the room, muttering about people trying to kill her.
During the previous few months, Yvonne had become even more withdrawn than usual, not feeding or bathing herself regularly and sometimes refusing to go to school. During classes she sat silently, not completing work or responding to the teacher or other classmates. She was observed talking to herself. She would walk, being led from place to place and sitting when pushed into a chair, but rarely initiated any activity or interaction on her own. Teachers reacted by yelling at her or beating her with a leather strap or a piece of wood, however, she did not react to the punishment and her teachers eventually began to ignore her.
Yvonne and her siblings were given crayons and paper to use during the home visit. Yvonne remained on the sofa with her mother, staring at the blank wall over my left shoulder, for the rest of the visit. She did not touch the crayons or a package of cookies her aunt placed on the table for us to share. Yvonne’s brothers played quietly and colored pictures, including a delightfully accurate rendition of their family at home complete with their grandfather’s wheelchair and the family’s collection of chickens. Yvonne was depicted in her older brother’s drawing as frowning. The only response I got from her during that first visit was when I showed her the drawing and remarked that she looked sad in the picture. I asked if she feels sad a lot of the time and then showed her the picture. She looked at it for a moment. Her eyes widened, she nodded, and then went back to staring at the wall.
After the initial home visit, Yvonne was taken by the missionary and her aunt to the Dominican Republic for neurological tests and another full medical work up. Yvonne’s cranial MRI was normal, as were her blood work and EEG, and tests for metabolic disorders. The consulting neurologist stated that her problems appeared to be related to “psychological, not physical health.” The report also noted that Yvonne was in the 15th percentile of her age group for height and the 10th for weight.
During four subsequent sessions (at home and school), peers and teachers described much of the same behavior as had her family members. Classmates reported that they began to avoid her when she started exhibiting socially inappropriate mannerisms earlier in the school year. Yvonne was described by teachers and classmates as shy, friendly, studious, caring, and sensitive, pre-morbidity. As her symptoms worsened during the preceding year, Yvonne’s school performance suffered. Teachers explained that they never knew what to expect from Yvonne; she would turn in a blank test at the end of the hour, not having written anything or might stand up without warning and walk out of the classroom.
Though Yvonne never discussed her difficulties with me or my MSW student during the assessment process, she did nod or say yes/ no in response to some questions about history and symptomology. She alternated between having a very flat affect and appearing overly expressive with a terror-stricken face or laughing hysterically for no known reason.
Yvonne’s family believed that her problem was caused by physical illness, perhaps a fever or infection which damaged her brain, or an imbalance of nutrition and overexposure to heat or cold. Extended family, most teachers, and nearly all the local community members believed Yvonne was possessed by spirits. Others attributed her behavior to a possible poisoning, head injury, an overly sensitive nature, developmental delay, or trauma from her father’s death. From my observations, and the information gathered during the assessment process, it was clear that Yvonne was experiencing auditory and visual hallucinations. Based on Yvonne’s disorganized speech and thought, affect, behavior, and hallucinations, it appeared that she was undergoing psychosis and was given a provisional diagnosis of childhood onset schizophrenia.
Yvonne’s strengths at intake included her premorbid academic achievement, the family members’ commitment to helping her, her family’s willingness to consider unfamiliar interventions (e.g. Western medicine, psychological assistance, social work services) and to do “whatever it takes” to resolve Yvonne’s difficulties, and Yvonne’s own willingness to try to communicate and participate in the process despite obvious difficulty. Despite being very poor, the family had housing, some regular income, access to public transportation, and funds to pay school expenses for the Yvonne and her siblings. The religious charity that referred them to me was also a huge support, and took on the financial burden for much of her medical costs and the transportation to the neurological consult. Though some of the community members were vocal regarding their belief that Yvonne was cursed or possessed, the strong social network of which her family was a member prevented the community from engaging in violence or other forms of abuse sometimes perpetrated against people with mental illness and other disabilities in Haiti.
The first planning meeting was attended by Yvonne’s mother, grandfather, and aunt. Yvonne was invited to participate but declined to come inside; instead she sat just outside the door where she could still hear, though it was unclear at the time if she was listening. I began by explaining her provisional diagnosis, the possible causes for her symptoms, and reassuring the family that it was still possible for Yvonne to live a full and normal life. Planning meetings were scheduled to take place every two days until the process was completed. First, we focused on goals and objectives. During the third and fourth planning meeting we addressed action steps to meet those objectives, barriers to receiving services, and the logistics of how the family and the MSW student (who had agreed to provide home-based clinical services as part of his field placement) would work together. See Table 1, for the objectives from the family’s initial social work plan, which was finalized 16 days after intake.
|Objective #1:||Yvonne will be evaluated by a psychiatrist and take medication if it is prescribed.|
|Objective #2:||Yvonne, her family, and her teachers will receive psychosocial education about Yvonne’s diagnosis and prognosis including methods for approaching Yvonne in a calm manner and strategies for reinforcing Yvonne’s connection to reality.|
|Objective #3:||A crisis plan will be created and used if needed.|
|Objective #4:||Yvonne’s caregivers will encourage her to talk about her hallucinations, their content, frequency, intensity, and meaning.|
Table 1: Initial Social Work Plan for Yvonne and her Family (Finalized on Day 16).
During the initial six weeks of treatment, clinical social work intervention focused on attaining a psychiatric evaluation, overcoming barriers at home and in the community, obtaining and using social work and medical services, as well as educating Yvonne, her family, and her wider social support network at school and church about her condition. The latter proved quite challenging, as existing cultural beliefs about the cause and treatment of psychosis were loudly espoused by some close family friends and teachers who believed that a focus on other forms of traditional treatment or spiritual rites would be more beneficial. In the end, Yvonne’s mother and aunt stood firm in their conviction that traditional herbal and spiritual treatments had failed for other members of the community who experienced mental health problems in the past and that they had chosen to seek Western medical treatment instead. A crisis plan was eventually drafted, with a great deal of assistance from one of Yvonne’s teachers.
A month after the treatment plan was finalized, Yvonne was finally seen by a psychiatrist who concurred with the initial diagnosis and prescribed 1.5 mg per day of Risperidone to be taken at bedtime. During the two weeks following, Yvonne’s family struggled to stay compliant with the medication regime. Yvonne agreed to take medication and would accept and swallow the pill when asked, but her mother and aunt often forgot to give it to her until she was already asleep (so she had to be woken up to take it) or gave it to her too early for fear they would later forget and she became too sleepy to participate in evening activities at home.
Though Yvonne’s bizarre behavior, auditory and visual hallucinations, and blunt affect continued throughout the first six weeks of treatment, her social withdrawal lessened somewhat. As friends, teachers, family, and neighbors were educated about her diagnosis and the fact that it was not contagious they began to interact with her more often. Yvonne continued to be the butt of jokes at school where groups of children ridiculed her, but teachers who had stood silently by in the past began intervening to protect Yvonne and educate her peers. This was a direct result of numerous meetings with the school staff and the MSW intern, who had organized three workshops on child mental health and who gave specific ideas for actions that would facilitate Yvonne’s participation and appropriate behavior while at school.
Treatment planning and interventions (Months 2-6)
A second planning session, held over two days, took place 58 days after intake. Adult family members, two of Yvonne’s teachers, Yvonne, her brothers, the missionary who initially contacted me, and the parish priest were present for the meeting. Participants expressed hope that Yvonne would be able to “return to the way she was” with the help that she was getting from the MSW intern and her doctor. Yvonne responded to some questions with one-word answers, saying that she was doing “okay” at school and that her nightmares were “bad”.
The difficulty family members had in adjusting to Yvonne’s medication regime was a significant focus of the second planning meeting. Yvonne’s mother and aunt reiterated that they fully supported the idea of medical treatment for Yvonne, but expressed difficulty remembering to give her the medicine and with keeping track of time. The family had no clock or watch; they also did not own a phone which could have been used as an alarm clock or to simply check the time. It was decided that the charitable organization which funds Yvonne’s school would purchase an inexpensive cell phone and put a small amount of phone credit on it each month so that the MSW intern could text the family to check on Yvonne and so that the alarm function on the phone could be used to remind them of when to give Yvonne her medication.
No other significant barriers to Yvonne’s treatment were raised at this point. The participants identified Yvonne’s emerging willingness to share her fears regarding her hallucinations and her increasing trust in adult family members and several teachers as her greatest strength in the treatment process. It was decided that for the next three months the MSW intern would continue to see Yvonne for an individual session three times weekly (Table 2). The MSW intern would continue to meet once a week with her teachers and school staff to coach them on methods for supporting Yvonne. The MSW intern also began to meet with Yvonne’s mother and aunt to teach them new ways of helping Yvonne cope with her symptoms and to give them space to talk about their own feelings regarding the situation.
|Objective #1:||Yvonne will take her medication as prescribed and will be evaluated by the psychiatrist once every six weeks.|
|Objective #2:||Yvonne and her caregivers will be assisted in identifying triggers which may precede episodes of uncontrolled behavior.|
|Objective #3:||As Yvonne begins to participate in community activities again (Sunday school, dance class, etc.) Yvonne’s caregivers will put into practice new methods for responding to outbursts and socially inappropriate behavior.|
|Objective #4:||Yvonne will continue to talk about her hallucinations, their frequency, intensity, and meaning, with supportive adults in order to reduce her fears regarding the hallucinations.|
|Objective #5:||Yvonne will implement coping and compensations strategies (e.g. looking for her visual cue poster, asking an adult for assistance) for managing her psychotic symptoms.|
Table 2: Second Social Work Plan for Yvonne and her Family (finalized on day 60).
During months 2-4, the MSW intern noted that Yvonne was particularly responsive and communicative using play-based therapy and thus incorporated dolls, a sand tray, and other creative activities into treatment. Yvonne favored two dolls that she used in most sessions. The dolls were regularly drowned, stomped on, smothered, beaten, strangled, cut, and shot. The dolls also engaged in violence with Yvonne’s assistance: they threw sand at the MSW intern, tore up paper intended for coloring, tossed a cup of juice onto the floor, and stabbed a stuffed elephant with a pair a scissors.
During the fourth month, violence against and by the dolls decreased by roughly by 30%, from every session to twice a week. Yvonne’s odd movements, mood swings, and periods of disorganized speech and/or action decreased as well. Teachers reported that Yvonne was a bit more engaged and focused at times and that she had begun to attempt to complete schoolwork again, though she continued to be too distracted to experience much success. Yvonne began to regularly communicate about her hallucinations, pointing out the location of the ghost or werewolf, and verbalizing her fears about the hallucinations.
The week before Yvonne’s third treatment planning session (157 days after intake) Yvonne was seen by the psychiatrist for review. Psychiatric medication reviews had been scheduled earlier to happen with greater frequency, but the doctor was frequently absent without notice. Based on her continuing struggles with hallucinations, her loose association of ideas, and her disjointed speech, it was decided to increase her dosage of risperidone to 2 mg a day at bedtime. However, this was not implemented until six weeks later as the clinic pharmacy, which supplied her risperidone for a very small fee, relied on donated medications imported from abroad and only had enough in stock for her to continue taking 1.5 mg daily until their donations were restocked.
Treatment planning and interventions (Months 7-11)
Yvonne’s third planning session was decidedly more upbeat than previous meetings and this progress was reflected in her treatment plan (Table 3). She sat at the table, coloring, during the meeting and responded to some questions when prompted. Yvonne’s family noted significant improvement: Yvonne was now bathing and dressing herself with only verbal reminders, she was spontaneously doing activities around the house such as sweeping the floor, and she had begun sleeping through the night again 1-2 times a week. Yvonne’s cousin noted that she went outside to sit with the children who were playing in the yard while previously she had to be walked outside or forced to sit with the other children.
|Objective #1:||Yvonne will continue to be monitored by the psychiatrist and the MSW intern for the effectiveness and side effects of her psychotropic medication.|
|Objective #2:||Yvonne and her caregivers will be assisted in identifying triggers which may precede episodes of uncontrolled behavior.|
|Objective #3:||Yvonne’s caregivers will continue to implement pre-correction and redirection techniques to encourage Yvonne to maintain socially appropriate behavior during community activates.|
|Objective #4:||Yvonne will continue to talk about her hallucinations, their frequency, intensity, and meaning, with supportive adults in order to reduce her fears regarding the hallucinations.|
|Objective #5:||Yvonne will implement coping and compensation strategies (e.g. looking for her visual cue poster, asking an adult for assistance) for managing her psychotic symptoms.|
Table 3: Third Social Work Plan for Yvonne and her Family (finalized on day 165).
During months 7-10, Yvonne’s delusional thoughts diminished in frequency and intensity. By month ten she was participating in church activities each Sunday and was attending classes every day. In month eleven the MSW intern noted no evidence of illogical thought or speech. Yvonne reported that she no longer had auditory hallucinations and that visual hallucinations were limited to fleeting glimpses of spirits, ghosts, or dead relatives, whom she saw out of the corner of her eye, but who disappeared when she focused on them.
During this time Yvonne’s behavior became more goal-directed and logical. She responded very well to a behavior chart created by the MSW intern and implemented by her caregivers at home and school; the chart intervention rewarded the use of coping and compensation strategies and called for a redirection at times when Yvonne was unfocused, uncooperative, or socially inappropriate. Yvonne continued to display some odd mannerisms such as rocking and flailing her hands when she was experiencing an unusual amount of stress, but this generally occurred no more than 3-4 times a month during this period.
Social work services were gradually reduced during month 12 and terminated 14 months after intake. Yvonne’s ability to relate to her family, friends, teachers, and other community members had improved to the point that she was able to resume most of her regular activities. Though she was continued on risperidone (which was decreased to 1.5 mg at bedtime in month 13), Yvonne’s progress overall was striking. Her odd mannerisms, including rocking and hand flailing, disappeared by month 13 and she began to initiate spontaneous play with peers in month 15.
While family members noted that Yvonne was still different from her premorbid condition, they were ecstatic with her progress. Yvonne was able to communicate her own perspective on it as well. Using dolls and artwork, she told stories of a girl who used to be frequently bothered by spirits, but who made the spirits go away. As of this writing, Yvonne continues to take risperidone daily, monitored by her pediatrician. She has had no further episodes of acute psychosis.
One of the primary complications in the diagnosis of childhood onset schizophrenia is the difficulty in completing a differential diagnosis; psychotic and psychotic-like symptoms can also be indicative of organic disorders (such as epilepsy, brain cancer, or metabolic disorders), autism spectrum disorders, developmental disorders, and traumatic brain injury . Some psychotic-like symptoms are also observed in children who have been severely abused or neglected or who have been exposed to overwhelming psychological trauma. In this case, all adult family members and teachers were certain that Yvonne had never experienced a serious trauma, though her mother acknowledged that sometimes children witness or experience something frightening that they never share with adults. She had never exhibited the behavioral changes or other signs indicative of abuse and, thus, this was provisionally ruled out. Some other explanations for Yvonne’s difficulties were discounted based on the history provided by her family and others were eliminated based on medical tests and physical examinations.
Though there is a distinct lack of research on treatment for childhood-onset schizophrenia, the research that does exist supports psychosocial education as an effective intervention . In Yvonne’s case, psychosocial education of her family members, teachers and schoolmates, and other community members, was essential in combatting preconceptions which had previously promoted exclusionary and unhelpful responses to Yvonne’s odd behaviors.
The MSW intern was intentional in acknowledging and respecting larger cultural frames of reference while still giving factual information about mental illness to Yvonne’s support persons and peers. The MSW intern did this by emphasizing that, while some others in the community may have been cursed and had successfully used religious ceremonies to rid themselves of the kind of bizarre symptoms Yvonne was experiencing, that in her case that family had chosen a different option that “works really well for little girls like her”. The MSW intern was careful to honor and respect the use of Voodoo, herbalists, and traditional practices in healing, health promotion, and the prevention of illness, as these are culturally acceptable and often preferred routes for health care seeking [6,10,11]. Clinical social work interventions and pharmacological treatments were framed as an option in addition to, rather than to the complete exclusion of, herbal remedies1.
The missionary who first referred Yvonne was instrumental in this process, sharing stories of other children who had overcome mental health problems. This was followed up with meetings which emphasized the progress Yvonne was making and the impact that including her in the school and church activities had on promoting her recovery. Psychosocial education thus, both imparted information about the diagnosis and prognosis, and also coached those in Yvonne’s life on changes they could implement to assist children who have the difficulties Yvonne experienced. Yvonne’s family is highly respected in their community, which gave them the social capital to stand up to naysayers who disapproved of blan (“foreign”) treatment. This social position also motivated community members to participate in psychosocial education meetings.
For Yvonne and her caregivers, psychosocial education focused on normalizing the challenges that she was faced with in the context of her diagnosis. The MSW intern emphasized that these feelings, thoughts, and behaviors were not the result of Yvonne’s spiritual or personal shortcomings and that it was possible to learn new ways to cope and to overcome some of Yvonne’s limitations. These sessions also focused on understanding how the medication works, the importance of taking it on time each day, and the role of the various individuals who were assisting Yvonne.
One unique feature of this case was the unusually strong support network surrounding Yvonne and her family. Yvonne’s access to medical care through her connection with a charitable mission was unusual for a child of her economic background in Haiti; a typical youngster from her neighborhood would usually be diagnosed based on reported symptoms and a brief physical exam alone, without the benefit of blood tests and a cranial MRI. Yvonne’s school and the religious charity invested extraordinary resources to assisting Yvonne. Without this support it is doubtful that Yvonne’s family would have been able to access social work services, pay for her medication, and obtain the medical care she required.
Another unique feature of this case, when compared to experiences in Haiti in general, was the family’s openness to considering and implementing non-traditional approaches to assessing and intervening to resolve Yvonne’s difficulties. Many Haitian families rely on both herbal and/or traditional spiritualist approaches for understanding and treating mental health problems [10,12,13]. Yvonne’s mother and aunt noted that such an approach had been unsuccessful at assisting a man in their neighborhood whose mother paid more than USD $1000 for spiritual services to remedy his mental illness. The family was eventually driven into financial ruin by their debt and was continually ridiculed by community members for their ineffective attempts to curtail the man’s disturbing behaviors. Yvonne’s mother specifically sought out western medical assistance for Yvonne. This openness to what is viewed as a foreign solution to mental health problems is quite unusual in the cultural context in which Yvonne’s family is embedded.
In addition to cultural beliefs, social and economic factors also influenced Yvonne’s care. The preferred medication dosage was not increased immediately as prescribed because the family lacked funds to buy the medication at a for-profit pharmacy, relying on the charitable clinic’s dispensary instead, which delayed Yvonne’s dosage increase for more than a month. The family’s lack of material resources (such as a phone) initially made scheduling and tracking the administration of medication a challenge. The family’s economic status also inhibited early intervention and timely treatment. The family relied on a charitable clinic for care; appointments were in high demand and the psychiatrist employed by the clinic often prioritized his fee-paying private practice patients over those served by Yvonne’s clinic.
Haiti is sharply divided by a class hierarchy based on education and economic background, with French language being the primary barricade used to marginalize large segments of the population [9,14]. While all Haitians speak Haitian Creole, only a small percentage speak French. University-educated professionals, such as doctors often use French in their work communication (even with monolingual Creole speakers). Yvonne’s family was frustrated that the doctors, approached them speaking French. When Yvonne’s aunt asked for an explanation of a how the medication functioned, the doctor brushed her off saying that she couldn’t understand because of her lack of classical secondary education. This created a barrier which could have prevented Yvonne’s support network from fully engaging in her treatment. In this case the social work intern intervened, asking the doctor to re-explain his treatment plan in Creole, and when that failed, the MSW intern translated the documents into Creole and explained them to the family himself [15,16].
In my experience, often these cultural, social, and economic complications are sometimes enough to discourage families from seeking care. However, in Yvonne’s case a combination of individual determination, openness to new/foreign interventions, external support, the social standing of Yvonne’s family members, and the provision of home-based social work services, coalesced to create a climate where Yvonne and her family had the space and support to recover.
Yvonne is a pseudonym. Yvonne and her adult family members reviewed a Haitian Creole translation of this manuscript prior to publication and each gave consent for their case to be published.
Declaration of Conflicting Interests
The author declares that there is no conflict of interest.
1Yvonne had seen an herbalist and been prescribed a tea to drink nightly during the month before intake. As the contents of the tea (mint, eucalyptuses, lavender, hibiscus, garlic, and asorosi) were determined by the psychiatrist to have no impact on the efficacy of her medication, Yvonne’s family continued to give her this tea each evening for approximately four months.
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