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Abstract

Cultural Concepts of Distress (CCDs) are culturally constructed diagnostic categories that exist within a specific society or culture. While several studies have assessed CCDs around the world, few studies have examined them in Haiti. This qualitative study examines manifestations of anxiety and depression via “sent spirits” in the form of maladi nanm (“Soul disorder”) and maladi zonbi (“Zombie disorder”), and bipolar disorder in the form of maladi lalin (“Moon disorder”). Examples of CCDs were recorded as part of a study which interviewed 96 outpatients at the first mental health center in northern Haiti. Using qualitative methods, the authors identified three specific CCDs as reported by mental health patients. Maladi nanm and maladi zonbi represent alternative explanatory models of anxiety and depression in which the sufferer views mental illness as stemming from a sent spirit, or spirit which is intentionally sent supernaturally with the intent to cause harm. Maladi lalin is experienced by patients with bipolar disorder who associate cycles of mania and depression as in-sync with the phases of the moon. Understanding culture-bound forms of mental distress in settings such as Haiti is essential to developing accurate psychometrics for measuring mental health, as well as ensuring culturally appropriate and effective diagnosis and treatment.

Keywords

culture-bound illnesses cultural concepts of distress culture-specific disorders Haiti mental health

Background

Published in 1992, the 10th edition of the International Classification of Diseases (ICD-10) included the category of “culture-specific disorders” which attempted to identify disorders in ethnographic and clinical research in different cultures around the world (World Health Organization, 1992) The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) followed suit in 2000 with the inclusion of 25 “culture-bound syndromes” (Mezzich et al., 2001; Ventriglio et al., 2016). However, with the publication of the DSM-5 in 2013, the 25 “culture-bound syndromes” were reduced to just nine and renamed as “cultural concepts of distress” (CCDs; American Psychiatric Association, 2013; Lewis-Fernández & Kirmayer, 2019). While the terminology has shifted over the years, these classifications generally presume that what constitutes “mental illness” can vary considerably from one cultural context to the next (Ventevogel, 2016). In effect, they not only acknowledge culturally constructed diagnostic categories commonly recognized within a national, ethnic, or cultural group, but also increasingly recognize that all mental distress is culturally framed (Pachter et al., 1992; Teodoro & Afonso, 2020; Ventriglio et al., 2016). Studies have examined a variety of CCDs, including examples such as nervios and susto in Spanish-speaking Latin America, amok in Southeast Asia, and kunfugisisa in sub-Saharan Africa (Baer et al., 2003; Makgahlela & Sodi, 2016; Pachter et al., 1992; Rubel et al., 2020; Teodoro & Afonso, 2020). However, with one of the most unique cultures in the Americas, CCDs in Haiti remain among the least explored in the English-language international scientific literature despite the recent inclusion of maladi moun in the DSM-5 (Toffle, 2015).

With a history unlike any country in the Western Hemisphere, Haiti's identity is defined by the successful revolution of African slaves against the backdrop of the French Revolution in the late 18th and early 19th centuries (Métraux, 1958). Isolated from the rest of the world for much of the 19th century due to its pariah status as a state born of a slave revolt—as well as its identity as a French and Kreyòl-speaking nation in a hemisphere dominated by English and Spanish—Haiti developed a strong spiritual culture of African-influenced Vodou which influences local perceptions of illness and misfortune (Auguste & Rasmussen, 2019; Jean-Jacques, 2019; Meudec, 2007; Pierre et al., 2010). Beginning with Dr. Jean Price-Mars’ Ainsi Parla l’Oncle (1928), Haitian experts began publishing French-language descriptions of popular belief systems surrounding mental health and Vodou. In the years that followed, many other experts released analyses examining the linkage between mental distress and culture in the Haitian context including Justin Chrisostome Dorsainvil (1931), Louis Mars (1954), Alfred Métraux (1958), Emerson Douyon (1969), Laënnec Hurbon (1987), Marie Meudec (2007), Cenat & Dérivois, 2012, Lewis Clorméus (2019), Ronald Jean-Jacques (2019), and many others. Existing English-language studies have also documented “folk diagnoses”—albeit to a lesser extent—related to mental health in Haiti originating from Vodou cosmology including malkadi, pèdisyon, and maladi voye, for example (Coreil et al., 1996; Kiev, 1961; Pierre et al., 2010; Singer et al., 1988). Maladi voye, in particular, represents the unique formulation of sent illnesses or “sent spirits” common in the Vodou cosmology, as well as in many parts of sub-Saharan Africa, in which a spirit is intentionally sent by someone supernaturally with the intent to cause misfortune in the form of an accident, illness, or death (Farmer, 1990; Galvin & Michel, 2020; Kaiser & Fils-Aimé, 2019; Meudec, 2007; Vonarx, 2007). This was incorporated into the DSM-5 in 2013 through the term maladi moun, which loosely means “human caused illness” in the sense that the illness was caused by another human who sent it onto the afflicted party via supernatural means (Nicolas et al., 2006; Teodoro & Afonso, 2020; Toffle, 2015).

Haiti was therefore chosen as a site for this study due to its unique local understandings of mental illness that differ significantly from other countries in the Americas. Additionally, as relatively little existing research has examined the ailments described in this research, this study seeks to further elucidate CCDs in Haiti, and contribute to the English-language scientific literature regarding the relationship between culture and mental distress in the Haitian context. In doing so, this research can also contribute to the burgeoning field of developing locally derived, culturally valid tools for identifying individuals with mental disorders in low-resource and high burden settings such as Haiti (Galvin, Scheunemann, et al., 2022; Kaiser et al., 2013; Legha et al., 2020).

Methods

Study setting and design

This qualitative study surveyed patients about their experience with mental illness at the first mental health clinic in northern Haiti, the Sant Sante Mantal Mòn Pele (SSMMP), between August 31, 2020 and February 15, 2021. Set amongst mango trees on a hillside outside Haiti's second city of Cap-Haïtien, the clinic opened in 2016 as the first facility offering outpatient biomedical mental healthcare services in all of northern Haiti. While it is privately funded and fees are maintained at affordable rates—roughly $11 per visit—it remains expensive to many as a large part of the population lives with less than $1 per day (Cénat et al., 2022). However, the clinic makes an effort to serve all patients regardless of their economic means, therefore no patients are turned away for lack of funds.

Researchers aimed to interview 150 participants for this study, however considerations of attrition led us to determine that a sample of roughly 100 participants would be in line with similar mental health studies (Eustache et al., 2017; Kaiser et al., 2013; Legha et al., 2020). The data utilized for the purposes of this article are qualitative interviews with participants about their beliefs regarding the etiology of their illness, previous treatment experience, and their pathways to care at SSMMP.

Recruitment

The main inclusion criteria for participating in this study comprised: (1) being a person of Haitian nationality of at least 18 years of age, (2) having a history of mental illness, (3) being physically and mentally capable of answering questions in the survey, and (4) having given informed consent. All patients who presented for treatment at SSMMP during the study period who met these criteria were approached by three Haitian psychologists at the clinic for participation and offered the opportunity to “opt-in” to the study if they so desired. Patients did not have to decline but rather were informed of the study's components and opted-in if they were interested. No further questioning was pursued unless patients opted-in to the study. Due to the high illiteracy rate in Haiti—particularly in the north of the country—the informed consent form was read aloud to patients and their accompanying family members prior to signing.

Exclusion criteria included patients with severe psychosis who were unable to provide informed consent or complete the questionnaire. Severe psychosis was by far the most common reason for excluding patients from study participation. As all participants were recruited from SSMMP, researchers were also provided access to the patient's medical chart at the clinic, if agreed to by the patient. Medical charts were analyzed on an ongoing basis by researchers if consent was given by the patient.

All interviews were conducted and recorded in Kreyòl by the three Haitian psychologists working at SSMMP. A translator was therefore not needed. Interviews lasted an average of 45 minutes. Participants were compensated with a 500 Haitian Gourdes (USD $7) reduction in the cost of their visit or medications for participation. This amount was determined in collaboration with Haitian psychologists at SSMMP. Institutional Review Board (IRB) approval was obtained from Washington University in St. Louis (IRB #202005009) as well as with the Haiti National IRB—or Comité National de Bioéthique—(IRB #1920-51). All research was conducted with respect to local COVID-19 guidelines.

Data analysis

During this fieldwork, researchers collected narratives related to CCDs in Haiti during formal and informal interviews and participant observation. All 96 patient narratives were transcribed from Kreyòl to French and English, and analyzed for themes related to CCDs by two researchers fluent in all three languages. Analysis was performed using the constant comparative method including inductive coding (Silverman, 2005). Researchers analyzed participant narratives separately and then compared results. Following thematic analysis, researchers agreed upon nine participants who specifically described their ailment as falling within three different CCDs. Critical Appraisal Skills Programme (CASP) checklist was utilized to ensure appropriate data collection and analysis procedures for this study (Singh, 2013). Given the limitations of current research on CCDs globally—and particularly in very poor countries such as Haiti—this study seeks to establish the groundwork for future investigation in this domain.

Findings

This study interviewed 96 patients, including 64 women and 32 men. Participants ranged between the ages of 19 and 79 with an average age of 43 years old. The vast majority of participants live in rural areas, with a minority residing in urban areas such as the city of Cap-Haïtien. Based on information from patient charts, the majority of participants were diagnosed with depression and/or anxiety (81%), with a minority having a diagnosis of bipolar disorder (19%). In terms of spiritual beliefs, most respondents identified as Protestant Christians (79%), with a minority identifying as Catholics (21%). Among participants interviewed, 75% of participants reported attributing the cause of their mental illness to a sent spirit. Additionally, 42% of participants had previously visited a Vodou priest (ougan) to treat their mental illness. The following qualitative research exhibits the impact these belief systems have on the lived experience of patients and their pathways to care. In particular, analyses depicted three categories of CCDs related to Haitian Vodou beliefs:

Maladi Nanm, or “soul disorder,” which manifests primarily in terms of symptoms of anxiety and depression.

Maladi Zonbi, or “zombie disorder,” which manifests similarly to Maladi Nanm.

Maladi Lalin, or “moon disorder,” which manifests similarly to bipolar disorder.

The following section will describe short health histories, symptomology, and explanatory models of patients who claim to have the above conditions.

Maladi Nanm

Among participants attributing their mental illness to sent spirits, some characterized the root cause as maladi nanm. One patient, Antoinette (all names have been changed to protect the identity of participants) is a 56-year-old woman from the city of Cap-Haïtien who has been suffering with severe anxiety and depression since December 2015. She reports that her symptoms started after her husband left her several years ago. She heard he went to live in the United States but has no news of him. Antoinette also reports being very affected by the death of her parents and the sudden death of her brother over the last several years. Before seeking treatment at SSMMP she spent several years going to her Baptist church at night and fasting in order to be healed. At church, people would say she has a “soul disorder” (in Kreyòl: maladi nanm) and that someone is sending this illness onto her (li gen nanm sou li, se fè y’ap fè li mal). After people started telling her this she became afraid and stopped living in her house for an extended period out of fear that her neighbors were sending bad spirits (move lespri) onto her. As Antoinette describes:

I was afraid to be at home because I didn’t know if someone nearby might be sending bad spirits onto me. (Antoinette, 56)

Similar to the example of Antoinette, Daniela is a 38-year-old woman living in a poor, informal settlement on the outskirts of Cap-Haïtien. She claims she has been sick for many years before seeking help at SSMMP. Her symptoms include hearing voices, feeling something crawling around inside her, inability to sleep, headaches, inability to hear loud noises, and not feeling like herself anymore. Daniela has experienced a lot of difficult events in her life including the sudden death of her mother in 2004, surviving the earthquake in Port-au-Prince in 2010—which killed an estimated 300,000 people—being abandoned by her husband, and taking care of an uncle who also suffered from mental illness until he passed away. As Daniela describes:

The earthquake [on January 12, 2010] affected me a lot and I still think about it all the time. (Daniela, 38)

For many years, Daniela sought treatment for her depression from ougan (Vodou priests) who told her that someone had sent a spirit (nanm) onto her giving her maladi nanm. The ougan she saw attempted various treatments including cutting and burning her skin which resulted in scarring on her back and face.

Maladi Zonbi

Similar to maladi nanm, other participants described their mental illness as originating in a sent spirit, however one that manifests as a zonbi rather than a nanm. One example is that of Annelle, a 35-year-old woman from a rural area high in the mountains who has experienced high levels of depression and anxiety for over three years. Her symptoms include sleeping a lot, not eating for days at a time, crying often for no reason, talking to herself, and becoming violent with others including family members. She arrived at SSMMP with her husband who said that he had taken her to many different ougan over a dozen times during the past three years to treat her illness. As he described:

We think she has a form of zonbi illness (maladi zonbi) that causes her to feel like an insect is moving around inside her (yon bèt kap mache nan kòl). (Husband of Annelle, 35)

Annelle says other people in her family have also had similar afflictions and “regularly have zonbi illness (yo konn gen zonbi),” indicating mental illness among other members of her family as well. However, the expensive visits to the ougan resulted in financial problems for the family, forcing them to sell many of their possessions to pay for her treatments, and leaving them in extreme poverty.

Another example of maladi zonbi is from Antoine, a 19-year-old student from a rural area near the Dominican border. He was brought to SSMMP by his cousin who has been worried about his behavior over the last several months. “He has been acting very strange (li gen kompòtman dwòl),” his cousin said. Antoine says he is often very agitated, has auditory hallucinations including hearing voices that are not real, cannot hear loud noises, and often cannot sleep. When he gets particularly agitated, Antoine says that his family will often beat him so that he will follow their directions. Forced to live with these family members after the death of his mother three years prior, Antoine says he believes he is the victim of a sent spirit (ekspedisyon). He emphasizes in the interview that he is very educated and would not usually believe in such “folklore” if it didn’t actually happen to himself. In seeking treatment, Antoine went to one ougan who told him the sent spirit resulted in “a lot of zonbi being inside of him.” As treatment, the ougan hit Antoine's head against the ground many times and gave him a liquid remedy that “made his whole body burn,” Antoine reported.

A final lived experience example of maladi zonbi is Leonore, a 50-year-old woman from a rural area outside of Cap-Haïtien with high levels of depression and anxiety, her symptoms worsening in the past six months. She came to SSMMP with her daughter and reports suffering for years with vertigo, difficulty sleeping, breathing problems, crying often for no reason, and nausea. Leonore said she also feels like “something is moving around all over inside [her body] (yon bagay k’ap mache tout patou nan kò).” She sought treatment for this with many different ougan but says it never brought her any relief. Paranoid about the idea of others causing her harm via sent spirits, Leonore says:

Someone did this to me, they sent a zonbi onto me, they gave me maladi nanm (se fè y’ap fè’m, se zonbi yo voye sou mwen, yo banm maladi nanm). (Leonore, 50)

She also states she is unclear if her illness is caused by a zonbi or nanm but is likely one of the two.

Maladi Lalin

Among the minority of participants diagnosed with bipolar disorder, several described their depression and mania as waxing and waning with the phases of the moon. These individuals described their illness as maladi lalin or “moon disease.” One example of this is Jean, a 24-year-old single man living with his mother near the border with the Dominican Republic. Suffering from bipolar disorder for 6 years before finally coming to SSMMP in 2019, his mother previously brought him to many different ougan and churches in the hope that they could cure what Jean's family believed to be a spiritual affliction. “I believed the church could cure him,” she stated. While Jean has seen significant improvement in the years since he's been receiving treatment as SSMMP, he says his symptoms still worsen when the moon is full, causing him to become increasingly agitated and, at times, manic. As he describes:

I’m much better now than I used to be but I still feel the illness come back when the moon is full on a cloudless night. (Jean, 24)

Similar to Jean, another patient, Robert, came to SSMMP for the first time with his older sister who said Robert has maladi lalin. Robert is in his late 30s and lives with extended relatives in a rural area roughly 20 miles southwest of Cap-Haïtien. Robert scored very high on the anxiety and depression scale questionnaires and reported symptoms when the moon was full including auditory and visual hallucinations, thinking too much, agitation, and feeling like he is no longer himself. “Every time the moon gets full he starts to get crazier (li vinn pi fou),” his sister says, referring to Robert's mania.

Like Robert, Jacques also is diagnosed with bipolar disorder. He first came with his mother to SSMMP to treat his illness which they identified as maladi lalin. Jacques is 23, single, and lives with his mother in the small town of Milot roughly 30 miles south of Cap-Haïtien. Similar to Jean and Robert, Jacques has also been sick for many years and has struggled to find good treatment. Also similar to the two previous participants, Jacques’ illness worsens when the moon is full, causing him to become restless—bathing 8 or 9 times per day according to his mother—and isolating himself from his family members. Oftentimes during a full moon he will flee the house to live in the streets for days at a time until the moon starts to wane. While people in his neighborhood told him to visit an ougan for treatment, Jacques’ mother refused by arguing they are “people of the church,” and therefore sought cures from local pastors and in prayer groups. When those treatments did not work, they tried hospitals throughout the region before finally receiving appropriate care at SSMMP.

Lastly, Louis is a 25 year old who lives with his brother's family in Terrier Rouge, a small rural town close to the Dominican Republic. Similar to Jean, Louis sought treatment for years from ougan and has large scars on his forehead where the they cut him in order to apply traditional remedies. After these treatments did not work—and only served to worsen his health overall—Louis finally came to SSMMP where he has been receiving treatment for more than a year and has come for over a dozen appointments. During this time, he has seen a great reduction in his symptoms of bipolar disorder. For this appointment, Louis arrived with his older brother who described how Louis’ symptoms improve when the moon is full, and worsen during the new moon. “When the moon is small (lalin an dekou), Louis becomes very agitated [manic],” his brother says. “He starts to talk a lot, he doesn’t sleep, and he talks to people without making any sense (li pale ak moun tankou bon sans li pa sou li).”

Discussion

The above findings describe the lived experience of patients with mental illness in northern Haiti whose conceptualizations of their ailments fall under the DSM's new category of CCDs. This qualitative research highlights multiple examples of patient experiences with culture-bound forms of anxiety and depression—in the form of maladi nanm and maladi zonbi, and bipolar disorder—in the form of maladi lalin—in the understudied rural areas of northern Haiti.

Sent illnesses: Nanm and Zonbi

Supernatural interactions in everyday life are not unique to Haiti, but are common throughout sub-Saharan Africa where witchcraft and sorcery are generally assumed to be true rather than something to be believed in or not (Bourguignon, 1959; Falen, 2018; Kaiser & Fils-Aimé, 2019; Okello & Seggane, 2015; Ventevogel, 2016). In the Vodou cosmology in Haiti, the body “is a permeable space that is accessible to agents that can penetrate it and move around inside it” (Vonarx, 2007, p. 23). The person is therefore always vulnerable to outside forces which can attack one's organism and cause harm. This harm is generally caused by sent spirits which are viewed as stemming from one of two human actions: either as related to “sinful actions” by the person afflicted, or due to persecution (pèsèkisyon) by another party whose intention is to cause harm (Meudec, 2007). This latter example is referred to as sent spirits (ekspedisyon) in which “the soul of a dead person is sent onto a person who one wants to make ill or to kill” (Métraux, 1958, p. 106).

Sent spirits, therefore, are “supernatural punishments” and can manifest in multiple forms: epilepsy (malkadi) and other non-communicable physical diseases are examples of illnesses often considered supernatural in origin, however, mental illness is “almost always considered a supernatural punishment” (Métraux, 1958, p. 86). Thus, while this study focuses on psychiatric disorders which are attributed to sent spirits, it is important to note that sent spirits are also often linked to many physical illnesses. Nevertheless, the majority of rural Haitians attribute mental illness to a curse or spirit possession and often react to these “magical persecutions” from “invisible evil-doers” by aggressively searching for the guilty party (Meudec, 2007, p. 92). As described by one researcher, “the Haitian world is full of supernatural manifestations and reality is teeming with dangers of all sorts” (Vonarx, 2007, p. 23). Two of these dangers are sent illnesses referred to as maladi nanm and maladi zonbi.

Very little research currently exists on these two sent illnesses. Vonarx (2007) writes about an illness called “Soul disorder” (maladi nanm) in which

souls can penetrate a person's body, settle there and create visible and/or invisible disorders and physical symptoms … souls do not always manifest the same way in all sick people [and] can cause pain, fever or other symptoms that may last, vary in intensity and move around in the body. (p. 21)

Similarly, Swiss anthropologist Alfred Métraux (1958) wrote about maladi zonbi in the 1950s, that “spirits that sorcerers captured and sell to their clients are called zonbi, but should not be confused with the living dead type of zonbi”—or “zombie” as they are known in popular culture (p. 139). Davis (1988) also describes how there are two different types of zonbi, one being the type we commonly think of in terms of the zombification process resulting in the “living dead,” whereas the other is indicated as zombi éfface, or “death spirits” used in ekspedisyon. As Davis (1988) writes, “the zombi éfface is the spirit of a dead person that you send on someone” (p. 281).

In the experience of this study's researchers, maladi nanm and maladi zonbi referred to virtually identical sent illnesses in which the individual is possessed by a bad spirit (move lespri). To reinforce this point, one patient, Leonore, was not even sure if she had nanm or zonbi, saying that it could be either. Furthermore, an additional part of this study in northern Haiti involved interviewing 20 local ougan and found that the difference between maladi nanm and maladi zonbi as described by these traditional healers was virtually identical, with some saying there was no difference at all (Galvin, Michel, et al., 2022). Further research could examine these differences in perception of nanm and zonbi as experienced by both ougan and patients to delineate precise distinctions.

Both nanm and zonbi are bad spirits (move lespri) that are sent onto the victim by someone else intending harm. In this sense, both ailments represent subcategories of the DSM-5 CCD of maladi moun (Nicolas et al., 2006; Teodoro & Afonso, 2020; Toffle, 2015). In Kreyòl, the commonly heard expression “se fè y’ap fè’w” translates to “something that someone did to you,” with an implicit reference to sent spirits. As we saw in the examples of both Antoinette and Leonore, the thought that someone was trying to harm them led to extreme paranoia and even fleeing one's own home out of fear of further persecution (pèsèkisyon), in the case of Antoinette. Both nanm and zonbi also manifest by causing symptoms resembling severe depression and anxiety with occasional psychotic symptoms, and both lead to patients seeking treatment by ougan in the hope that they can expel the move lespri.

Lastly, Daniela, Annelle, and Antoine all described something moving around inside them, usually described as an insect or small animal (yon bèt). Among patients and ougan alike, this sensation often referred to the physical manifestation of the nanm or zonbi itself, and reinforced the idea that they needed to have this force removed from their physical being by a traditional healer with faith healing powers.

Maladi Lalin

Separate from maladi nanm or maladi zonbi, maladi lalin is a CCD in rural Haiti that refers to the link between bipolar disorder's cycles of mania and depression as falling in sync with the phases of the moon. Bipolar disorder, formerly referred to as manic depression, is a mental illness that results in extreme mood swings that include emotional highs and lows—in the form of mania and depression, respectively (Belmaker, 2004). Episodes of mood swings can occur rarely or frequently, vary from person to person, and can change over time. Manic episodes can also be characterized by psychosis, or a break from reality. While some research has examined the relationship between bipolar sufferers and the phases of the moon, there seems to be little to no scientific evidence of a cause–effect relationship (McLay et al., 2006; Owens & McGowan, 2006; Wehr, 2018). To our knowledge, this article is the first documenting the existence of maladi lalin in Haiti. Linked to the legend of the werewolf—or lougarou in Kreyòl—lycanthropic folklore emphasizes the impact that the moon can have on the transmutation of human beings (Erren & Lewis, 2019). Sufferers of maladi lalin are patients with bipolar disorder who associate their cycles of mania and depression as falling in sync with the phases of the moon.

As we can see, there are many similarities and differences between these cases of maladi lalin. In terms of similarities, all four of these individuals were young, single men living in rural areas and had or currently have high levels of anxiety and depression. Psychologists at SSMMP reason that it makes sense they were all from rural areas, as people in urban areas are less attuned to nature and therefore do not usually follow the phases of the moon, for example. Rural people, however, pay attention to these phenomena and are therefore more likely to associate changes in nature with changes in a loved one's psychological state, particularly if they are already in severe distress. Rural people in northern Haiti are also more likely to endorse beliefs steeped in the Vodou cosmology and thus believe in werewolves (lougarou) and other shape-shifting beings that have a relationship to lunar phases (Meudec, 2007). Associating mental illness with these environmental phenomena, therefore, is in line with other spiritual beliefs common in Vodou.

In terms of differences between these patients, it is important to note once again that Louis was the only one whose symptoms improved instead of worsened when the moon was full. This was an interesting finding, as all three psychologists at SSMMP insisted that the full moon results in manic-like symptomology for patients suffering from maladi lalin and not the opposite. However, as relatively little research exists on this subject to date, more research will be necessary to fully understand this phenomenon.

While patients with maladi lalin did not explicitly describe their illness as a sent spirit, the fact that Jean and Louis consulted ougan for treatment indicates that they suspected it was supernatural in origin, and thus believed an ougan could expel the bad spirit to cure them. However, Jean and Jacques also sought cures for their illness at church, highlighting the multiple spiritual pathways to care that Haitians follow when seeking relief from illness or misfortune. This highlights how explanatory models are often not mutually exclusive, and that multiple explanations and realities for patients can co-exist and change over time and based on interactions with others (Bhui et al., 2006; Brodwin, 1996; Farmer, 2006; Kirmayer & Bhugra, 2009). Lastly, as all of these patients finally sought care at SSMMP, most Haitians are ultimately pragmatic about care-seeking and will try out multiple spiritual and medical avenues for treatment in their attempt to find a cure.

It is important to note that this study has some limitations. First, this study relies on the experiences recounted by nine psychiatric patients and therefore is not meant to be generalizable to the general population of Haiti. Rather, this study provides specific information about a unique population of interest. Second, we did not collect information about patients who did not opt-in to the study and therefore do not know the characteristics of patients at the clinic who chose not to take part. Lastly, the sample of this study contains a higher percentage of Protestants than is nationally representative in Haiti. As Protestants are generally more likely to demonize Vodou beliefs than Catholics, this could result in a reporting bias regarding visits to Vodou priests and other Vodou practices.

Why study cultural concepts of distress?

The main purpose of sharing these examples of CCDs is because they represent unique ways of conceptualizing common mental illnesses in the context of rural northern Haiti. As practitioners who treat patients with mental illness, it is essential to fully understand what the patient believes he or she is suffering from, and what that means in his or her specific spiritual and cultural context. Without understanding how patients manifest distress, it is difficult to develop effective psychometric measures for mental health, as well as to know how to diagnose and to treat the patient, thereby helping them move toward recovery.

Psychologists at SSMMP argue that it is essential for them to apply a bio-psycho-social approach to psychotherapy when treating their patients. This entails examining not only the physical wellness of the individual, but also examining their mental state as well as the social world in which they live. When treating patients, SSMMP also utilizes an explanatory model approach (modèle explicatif) which looks at the belief systems surrounding the origins of the patient's health problems (Kleinman, 1978). In other words, how does the patient explain what is happening to them? In this sense, SSMMP psychologists attempt to view the illness through the patients’ eyes and work to help them on a path to recovery within their existing worldview—to the extent that is possible. This often means validating spiritual beliefs surrounding their illness that may often differ greatly from one's personal beliefs and/or biomedical explanatory models.

In order to scale up mental health services in some of the most remote and underserved regions of the globe, mental health practitioners must comprehend localized conceptions of mental illness. This includes not only understanding explanatory models, but also how the folk diagnostic categories frame coherent meanings within local cultural and spiritual cosmologies. This will allow for the development of valid psychometrics and the implementation of culturally competent mental health services that can improve the medically-dominated Western psychiatric service model. In so doing, this will allow for enhanced training of mental health clinicians, and begin to close treatment gaps in some of the world's most underserved regions such as northern Haiti. Lastly, this research can also serve to improve culturally competent mental health services for the large Haitian diaspora living outside of Haiti (Dutès, 2019).

Conclusion

This study highlights three CCDs as described by participants seeking treatment at the first mental health clinic in northern Haiti, SSMMP. In particular, participants with maladi nanm and maladi zonbi are experiencing high levels of anxiety and depression, and view their illness as being sent by someone supernaturally to cause them harm. Maladi lalin, on the other hand, involves the cycles of bipolar disorder's mania and depression as following the phases of the moon. As current research on this topic is relatively limited, further investigation is needed on all three of these CCDs and will require more clinical and epidemiological studies, including research on processes of social labeling and cultural interpretation of these afflictions. In this sense, this research seeks to contribute to current DSM-5 understandings of Haitian CCDs such as maladi moun by adding additional context to scant existing scientific literature. Lastly, by better understanding localized cultural conceptions of mental illness, practitioners can learn to approach diagnosis and treatment through new lenses with the goal of promoting more effective therapies and practices that aid in remedying longstanding disparities and treatment gaps in care.

Footnotes

Acknowledgments

The authors of the study would like to thank the patients and staff at Sant Sante Mantal Mòn Pele for their collaboration and participation in this research.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

Research reported in this publication was supported by the Fogarty International Center and the Office of Behavioral and Social Sciences Research (OBSSR) of the National Institutes of Health under Award Number D43 TW010543. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iD

Michael Galvin

Michael Galvin, PhD, MPH, LICSW, is a Global Psychiatry Post-Doctoral Research Fellow at Boston University School of Medicine (BUSM) and Massachusetts General Hospital (MGH). Dr. Galvin's primary research interests center on mental health and the role that one's environment, culture, and belief systems play in mental illness and treatment in low- and middle-income settings. In particular, his work focuses on elucidating cultural models of mental illness and exploring relationships to pathways to care, with the goal of improving cultural adaptation of mental health interventions.

Guesly Michel, MS, is a community psychologist and the founder and director of Sant Sante Mantal Mòn Pele in Cap-Haïtien, Haiti. His published work has focused on the perceived causes and treatment of mental illness in northern Haiti.

Edny Pierre, BS, is a psychologist at Sant Sante Mantal Mòn Pele in Cap-Haïtien, Haiti. His published work has focused on the perceived causes and treatment of mental illness in northern Haiti.

Eurine Manguira, BS, is a psychologist at Sant Sante Mantal Mòn Pele in Cap-Haïtien, Haiti. Her published work has focused on the perceived causes and treatment of mental illness in northern Haiti.

Jude Mary Cénat, PhD, MSc, Cpsych, is an Associate Professor in the School of Psychology, Chair of the Interdisciplinary Centre for Black Health, and Director of the Vulnerability, Trauma, Resilience & Culture (V-TRaC) Research Laboratory and holds the Research Chair on Black Health at the University of Ottawa. His research program explores factors associated with vulnerability, trauma, and resilience, with a particular interest in the role of cultural factors. Dr. Cénat conducts research on racial disparities in mental health and social services, the impact of natural disasters and infectious diseases on mental health, interpersonal and non-interpersonal trauma, and global mental health.

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Maladi Nanm,Maladi Zonbi,& Maladi Lalin : A qualitative study of cultural concepts of distress in northern Haiti

Abstract

Keywords

Background

Methods

Study setting and design

Recruitment

Data analysis

Findings

Maladi Nanm

Maladi Zonbi

Maladi Lalin

Discussion

Sent illnesses: Nanm and Zonbi

Maladi Lalin

Why study cultural concepts of distress?

Conclusion

Footnotes

Acknowledgments

Declaration of conflicting interests

Funding

ORCID iD

References