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Article 20

Working With Haitian Immigrants During the Grief Process

Considerations for Counselors

K. Michelle Hunnicutt Hollenbaugh

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Introduction

Haiti, the poorest country in the Western Hemisphere, has struggled for decades with economic hardship and poverty (Coupeau, 2008). On January 12, 2010, a 7.0 magnitude earthquake significantly impacted the capital of Haiti, Port-au-Prince (U.S. Geological Survey, 2010). The devastation was widespread, and the Haitian government reports an estimated 210,000 people were killed, and about 700,000 civilians became homeless or were displaced (U.S. Agency for International Development, 2010). There are about 546,000 Haitian immigrants in the United States today, though there are likely many more that have immigrated illegally (Camarota, 2010). The disaster in Haiti impacted this population significantly. Haitian immigrants struggled in the days after the earthquake as there was little venue for communication with loved ones still in Haiti, and they had little information regarding the survival of family members. As the relief efforts arrived in Haiti, many Haitian immigrants received news that they had lost one or several friends and family members in the disaster.

Though it has been 5 years since this tragedy, Haitian immigrants may continue to have significant difficulty coping with loss in a country separated in distance and culture from their own. According to the Association for Multicultural Counseling and Development’s multicultural counseling competencies, counselors must have an awareness of the client’s worldview and culturally appropriate intervention strategies to effectively and ethically work with multicultural clients (Roysircar, Arredondo, Fuertes, Ponterotto, & Toporek, 2003). Unfortunately, there is very little research on Haitians in the United States, and clinicians may not have the knowledge or skills needed to effectively work with this population. The purpose of this article is to review relevant literature, describe the population of Haitian immigrants in the United States, discuss how individuals of Haitian descent may cope with and honor the death of a loved one, and provide suggestions for counselors working with this population in therapy.

It should be noted that the information presented in this manuscript will apply in varying degrees to Haitian immigrants. This application will be relative to the amount of time they have spent in the United States and their level of acculturation. In addition, individual differences may apply. Socioeconomic class, gender, and other individualized factors may also play a part in how this information applies to clients. It is important to assess the level of acculturation and individual factors of any client during the initial assessment, to facilitate therapy and tailor interventions to meet the needs of the client (Brutus, 2009).

Culture and Religion

The native language of Haiti is Creole, while Haitians with higher levels of education also speak French (Coupeau, 2008). Most Haitians immigrating to the United States are indigent and come with the goal to work and provide an income to bring other family members here. Many Haitians are very optimistic and hardworking and strongly believe in their ability to control their personal situations and future (Desrosiers & St. Fleurose, 2002). However, immigrants struggling with the loss of a loved one may already be dealing with difficult emotions related to adjustment to immigration and maintaining their ethnic identity. Despite many Haitians’ pride in their cultural history, they may also experience a great deal of shame regarding the level of poverty and destitution in their country, as well as the stigma associated with Voudou (Nicolas, DeSilva, Grey, & Gonzalez-Eastep, 2006). Haitian immigrants may have mixed feelings regarding whether they wish to maintain their Haitian identity. This can be especially prevalent for adolescents, who may experience ambivalence about their identity in relation to race, language, and pride in national origin. In order to avoid being seen as an outcast, these adolescents may push away any ethnic relationship to Haiti (Bachay, 1998; Colin, 2001).

Despite the shame some Haitian immigrants may experience regarding their heritage, Haitians have a history of resilience and optimism. In 1791, Haitian slaves staged the only successful slave revolt in the history of the Americas (Coupeau, 2008). Many Haitians are proud of this history and view it as a strength in their culture (Desrosiers & St. Fleurose, 2002). Before the introduction of Christianity with the arrival of Christopher Columbus, Haitians practiced the religion of Voudou (also known as Voudoun or Voodoo). Voudou is an African spiritual belief system that involves the supernatural, and good and evil spirits, referred to as lwas (pronounced L-Wahs). Lwas must be respected and honored through special ceremonies, usually performed with the aid of a Hougan (male priest) or Mambo (female priestess; Nicolas et al., 2006). Contrary to popular belief, this spiritual practice rarely includes cursing others, though Haitians may believe that mental or physical illness, as well as any sort of misfortune, is due to be being cursed by an unhappy lwa or someone that is jealous of them. While members of the lower economic and social classes are the most likely to engage in Voudou practices, most Haitians today are Roman Catholic or Protestant. Many Haitians incorporate Voudou practices into Christian beliefs and believe Catholic saints and biblical characters can also represent lwas (Desrosiers & St. Fleurose, 2002).

Beliefs on Death and Grief

It is necessary to understand the spiritual beliefs and background in Haitian culture to foster understanding and empathy towards Haitian clients in counseling (Roysircar et al., 2003). Knowledge of these beliefs will help counselors facilitate the use of spirituality as strength during bereavement. Those that practice Voudou believe in an afterlife and that every person has two souls—the big angel (gros bon ange), which is a universal life force, and the small angel (ti bon ange), which is the individual soul. It is believed these souls remain near the body for several days following death and can be at risk for capture by evil spirits. During this time, the family will gather to perform rituals and mourn the dead (Lewis, 2010). Response to death is often accompanied with physical displays of emotion, including wailing and crying to mourn the loss (LaGuerre, 1984; National Association of School Psychologists, 2003). At the end of this period, A Hougan or Mambo will engage in rituals to free the soul from its body. It is believed this soul will become a lwa as well, to protect and watch over the family (Lewis, 2010).

The death of a loved one may be easier to accept when the cause seems explainable, while acceptance may be more difficult for clients that believe their loved ones died as result of a curse or an angry lwa. This belief often leads to significant feelings of guilt, anger, and distress. The surviving family members may feel compelled to engage in spiritual practices to appease the angry lwa and be at peace with the loss (Eisenbruch, 1984).

Acculturation and Other Religions

Haitian memorial rituals vary based on the individual family, economic status, and level of acculturation to the United States. As many Haitian immigrants are Catholic or Protestant, they may engage in practices similar to those in the United States. Others may have incorporated Voudou beliefs into Christian beliefs and may express variations on their beliefs regarding the afterlife. Haitian immigrants may also conduct a wake every evening until the funeral to celebrate and remember the life of the deceased (National Association of School Psychologists, 2003). Regardless of the level of acculturation, a death in the family will often elicit the involvement of all extended family members (LaGuerre, 1984).

Application for Counselors

While this population is in need of mental health resources, a very low percentage of Haitian Americans actually use mental health services (Desrosiers & St. Fleurose, 2002). Access to these services is likely related—many Haitian Americans have little knowledge of how to seek out these services or manage the bureaucratic barriers they may encounter (Portes, David, & Eaton; 1992). Haitian clients will most likely be referred to counseling by other health professionals, and they may lack an understanding of the benefits of counseling (Desrosiers & St. Fleurose, 2002). They may also be cautious of counseling services based on experiences with other community or government agencies where they were treated poorly. Research does suggest that second or third generation Haitian immigrants are more likely to have positive views of counseling, to use mental health services, and to find them helpful (Brutus, 2009; Jackson et al., 2007).

While Haitians may go through the Kubler-Ross (1973) stages of grief—denial, anger, bargaining, depression, acceptance—they may manifest differently and therefore be difficult to identify. Haitians often have a holistic view of health and describe health as a variety of physical and psychosocial factors, much like the concept of wellness. However, Haitian Americans do not perceive physical or mental symptoms as an illness unless they are incapacitating (DeSantis, 1993). Haitians may not take notice of symptoms of depression, anxiety, or grief, until they get to the point that they can no longer work or engage in daily responsibilities. As they pay little attention to these symptoms, they will often manifest in somatic symptoms. Haitians that engage in Voudou may believe this is the consequence of being cursed, or not engaging in spiritual rituals to respect lwas (Desrosiers & St. Fleurose, 2002).

Ethnic Identity and Acculturation

The ethnic identity of Haitian immigrants has been found to predict higher self- esteem (Martelly, 2003; Bruno, 2009). Haitian clients may struggle with ethnic identity during this period of grieving, feeling a mixture of emotions regarding their heritage. Counselors can be helpful by fostering ethnic identity and focusing on the client’s strengths as well as the strengths of the Haitian people to overcome this tragedy. While acculturation is a major factor to consider when working with immigrants from Haiti, it also may have an effect on the health of Haitian immigrants. Higher levels of reported ‘acculturative stress,’ or the psychological effects of adapting to a new culture, have been found to be related to decreased quality of life, including physical and psychological health in Haitian immigrants (Belizaire & Fuertes, 2011). Level of acculturation should be considered throughout the counseling process, as this could be an added stressor to manage during the grief process.

Religion

As previously mentioned, religion can be a significant aspect of a Haitian immigrant’s life and this strength should be utilized in counseling. Haitians may be more likely to use religious coping to manage stress in comparison to other Black Caribbean immigrants. This is especially true for Haitian women and married couples (Charters, Taylor, Jackson, & Lincoln, 2008). In addition, Haitian immigrants that reported attending church regularly reported lower levels of grief and maladjustment to immigrating to the United States than those that did not (Prudent, 1989). However, research also shows a negative correlation between education level and the use of spirituality and prayer during difficult times (Charters et al., 2008).

While there are many culture-specific illnesses with relation to Haitian immigrants, the most relevant in this context is Se´izisman. Se´izisman is a nearly catatonic state in which the individual becomes disoriented and unable to function. Haitians believe this is caused by viewing a traumatic event, being informed of a significant loss, or dealing with a difficult situation (Nicolas et al., 2006). It is believed Se´izisman causes a rush of blood to the head and therefore puts the sufferer at higher risk for further health problems or even suffocation (LaGuerre, 1984). This may manifest in every individual differently, and one person may experience Se´izisman for an hour while another experiences it for several days. The proper response to this altered state is caretaking of the individual, including emotional support and physical support, such as massage, herbal remedies, and foods (Nicolas et al., 2006). It is helpful for counselors working with this population to be aware of the signs and symptoms of this illness, as well as the culturally acceptable responses.

It is important to note that individuals who emigrated from Haiti after the earthquake may have their own unique emotional struggles and problems, including anxiety, depression, and PTSD. Orphaned children and adolescents who emigrated from Haiti after the earthquake may be at particular risk, as early separation or death of a parent is highly correlated with mental health problems later in life for Haitian children and adolescents (Morgan et al., 2007)

Interventions

These following intervention suggestions are based on the available literature for working with Haitian American clients, which unfortunately is quite sparse. It should be remembered that this may or may not apply to the client based on individual cultural factors and level of acculturation to the United States.

Counselors should take a strength-based approach with Haitian immigrants, as optimism and resilience are a theme in this culture that can be beneficial during counseling sessions (Desrosiers & St. Fleurose, 2002). Family members can be an important asset in counseling, and if possible, should be involved in the treatment process (Nicolas et al., 2006). This is especially true if the whole family is coping with loss and struggling with acceptance, as the family can work together on how they will cope and grieve in a productive and healthy manner. The counselor should align with the client, even if their beliefs are different from the personal beliefs of the counselor. Haitian immigrants may believe the misfortune that has befallen Haiti is due to evil spirits or curses (Desrosiers & St. Fleurose, 2002). By aligning with them, the counselor can help them work through the grief in their own manner. For example, it may be helpful for the client to engage in a spiritual ritual to respect and remember loved ones and feel that they can move on without the risk of further misfortune.

It may be helpful to adapt traditional counseling methods of managing grief and frame them as a spiritual exercise for the clients. For example, helping the client create a memory box of significant objects that remind them of their lost family members, or encouraging the client to write a message to the deceased and attach it to a helium balloon to be released in a ceremonial manner are both exercises that may help the client process his or her grief (Mallon, 2008). Both of these activities could be framed as a ritual to respect and honor those lost while also helping the client work through and address his or her grief. As Haitian Americans are often hardworking and dedicated to supporting family members, counselors can help Haitian clients understand that unmanaged symptoms of grief can cause them to be less productive and reduce their ability to provide for their family. Thus, the solution is to work through this grief in counseling (Desrosiers & St. Fleurose, 2002).

In addition, consulting with and involving spiritual healers in the Haitian American community can be helpful in working with this population (Nicolas et al., 2006). Healers may have suggestions on how to integrate traditional Haitian spiritual practices into counseling, as well as help clients to trust mental health services. It may be helpful to collaborate inter-professionally with other service providers, including social workers that can to link clients with resources to increase wellness and facilitate the grief process, including medical care, support systems in the community, and financial resources. For example, clinicians may be able to work directly with physicians to manage physical ailments and clarify whether physical symptoms are related to psychological distress (Desrosiers & St. Fleurose, 2002). Haitian clients may want to feel that the time spent in counseling is productive, so counselors should actively engage clients and have a concrete plan of action at the end of each session (Desrosiers & St. Fleurose, 2002). Lastly, counselors should adhere to the multicultural counseling competencies, including an awareness of their own cultural values and biases, an awareness of the client’s worldview, as well as an awareness of culturally appropriate intervention strategies (Roysircar et al., 2003).

Multicultural Competencies and Ethical Issues

We must be aware of our attitudes and beliefs, knowledge, and skills related to our own values, our client’s worldview, and culturally appropriate interventions (Roysircar et al., 2003). These multicultural competencies are directly related to ethical practice, and are woven throughout the American Counseling Association (ACA) Code of Ethics (ACA, 2005). The code of ethics also emphasizes the importance of celebrating diversity as opposed to tolerating diversity, and this applies to working with Haitian immigrants. It would be unethical to simply tolerate beliefs that are different from our own and would be a disservice to our clients. Further, it would also be unethical to stereotype Haitian immigrants solely based on the information provided. Each individual client’s personal culture should be considered, as all counseling is cross cultural, and every person belongs to multiple cultures (Remley & Herlihy, 2005). Haitians have been described as a ‘triple minority’ as they are immigrants, an ethnic minority, and likely underprivileged. This sets them at higher risk for struggles with acculturation, stereotypes, and racism (Belizaire & Fuertes, 2011). It is also important ethically to be sure that we have effectively communicated informed consent to our clients, and as many Haitian immigrants may know English as a second language, informed consent may be conveyed in oral and written form. As in working with all clients that do not speak English, family members should not be used as translators; instead a professional translator should be utilized (Remley & Herlihy, 2005).

Conclusions

Following the devastating earthquake in Haiti in January, 2010, Haitian immigrants may seek or be referred to mental health services to manage issues surrounding their bereavement. More research on how to reach out to Haitian immigrants as well as treat them in clinical settings is needed. Knowledge of their own worldview, knowledge and skills, and awareness of these factors in specific relationship with Haitian immigrants is beneficial for expanding this knowledge for clinicians. While this article is meant to enlighten the reader on the population and give suggestions for working with Haitian clients, it should be iterated that clients may or may not embrace these cultural beliefs and practices, and level of acculturation can have a significant impact on client beliefs and methods of coping with grief and stress. We can better know how to treat Haitian immigrants and help them through the grief process with further research. We can also better create community services and programs for Haitians if we know more about the culture and population and the specific issues they face after coming to the U.S.