Howard Levine April 2024

Friday April 12, 2024

Today, IPI is back in its weekend conference location at the Rockville Hilton to study The Unstructured Unconscious and the Repressed Unconscious: A Clinical Paradigm for the 21st Century with Howard Levine as IPI’s distinguished guest. We haven’t been here since the weekend conference with Anne Alvarez in February of 2020.  The place feels so familiar, even the carpets are the same.  Friends I haven’t seen in four years. Students I have met only on Zoom until now.  I am sitting in my usual seat at the back of the conference room with colleagues – faculty and students who haven’t seen one another except online alongside new onsite participants, and other old and new faces on a large screen from various states and countries. It is only the second hybrid conference IPI has designed, and we are all curious and eager to participate in the integratino of our onsite and online learning community.  It’s a work in progress, an experiment in sharing, sensitivity to the needs of others, and experiencing hybrid as an object of study.  “Everyone hates hybrid,” we’ve heard, but our goal at IPI is to develop expertise in creating an effective hybrid learning environment for communicating across cultures.

April 2024 Hybrid Conference

Now Howard Levine is talking.  “Where are we?” he asks.  This is the central question for the analytic dyad in the unique epistemological universe that is psychoanalysis.  Levine, who is highly conversant with the related elements of theories of Bion, Winnicott, Freud, and Klein, warns us that theories tend to be rather final, exhaustive, exclusive of other ideas, and limiting of growth in the individual psyche and in the field of psychoanalysis.  He allows that models highlight characteristic elements which can be useful for making comparisons between various clinical approaches.  However, he reminds us that assumptions made by theories and models for understanding neuroses  (in which the unconscious is structured by representation of repressed unpleasant experience and desires) cannot be made to apply in the psychoanalytic treatment of all cases.  In widening scope cases, the analyst is responding to fragmented or psychosomatically expressed states of mind that are unrepresented because they are non-ideational.   The task here is to reach a wordless experience in the unstructured unconscious.  Here Levine turns to French psychosomatics and the work of Andre Green.  Heady stuff.  Clearly Levine likes to know the boundaries and break free of them.   His parting shot to us before pausing for discussion — “Are you dislocated enough yet?”

Responding to the word ‘dislocated’, my mind returns to his opening question: “Where are we?” I ask why the sense of place is the central question above all others.  He replies that the whole trend in psychoanalysis has been towards knowing and getting it right.  So, now we need to valorize the space for not knowing, for instability, and for acknowledging that the unstructured unconscious is a force without meaning.  Putting it simply, he says, “There is no there yet.” And that is what we have to be able to resonate with.  As for a more complete exploration of my question, Levine responds: “We will have the whole weekend for that!”

And we will be pondering the questions raised for much longer than that.

Jill Scharff

IACFP conference, Lyon, July 2018


A few members of IPI recently returned from the beautiful city of Lyon at the confluence of the Rhône and Saône rivers in the Auvergne-Rhône-Alpes region of France. This was the site of the 3rd International conference on couple and family psychoanalysis organized by the International Association of Couple and Family Psychoanalysis in July, 2018. The program was packed with multiple tracks of small presentations in one or another single language. At the center of the conference venue lay the main auditorium where panel presentations with translation to English, French and Spanish succeeded one another in rapid succession. There was provision for audience response in the form of written questions on scraps of paper. These questions were not to be answered in the open forum but would be addressed in subsequent small group sessions at which the presenters would not necessarily be present. This felt constraining to us, but we respected that it was the conference design and appreciated why the organizers adhered to it to make room for many points of view and global perspectives.

We were grateful to hear in translation some interesting presentations that we could not have understood otherwise. But we found the design so different from what we are used to at IPI that we experienced quite a bit of culture shock. We did not have the leisure to listen to a fully developed presentation and to engage in a multilogue within the large group of the audience as we do at IPI. We experienced frustration as we submitted to the frame within which we found ourselves. As presenters on the dais ourselves, the best we could do was create a dialogue between presenter and discussant so as to avoid the tedium of presentation and discussion being read aloud and without the benefit of immediate audience response.

at the Lyon IACFP Conference, July 2018
Rosa Heiten, Chair of the International Association of Couple and Family Psychoanalysis presents IACFP concerns in dialogue with The IPA committee on Couple and Family Psychoanalysis (Chair, David Scharff) at the Lyon IACFP Conference, July 2018

Imagine our amazement and delight when one of our colleagues from Tavistock Relationships took action. Chris Clulow having kept his discussion short, asked the audience a question. But the audience, previously compelled to silent acquiescence, hesitated to respond. In an astonishing act of freedom, he left the dais and plunged into the audience brandishing his hand-held microphone like a liberating white knight with his lance lowered for the charge. A few hands went up in response, and Clulow extended the microphone towards them as they tentatively negotiated who would go first. Unable to wait, the presenter himself answered the discussant’s question, which gave the conference organizers time to caucus. They reasserted control, and insisted that all questions be written and delivered to the Chair for use in other venues. Chastened, the rebellious Clulow withdrew. A wonderful opportunity was lost, not to be regained in that conference.

It was a moment that highlighted the cultural differences we had come to learn about. It brought home to the English speaking group what a minority we are. Perhaps that is why we hung out together, Americans, British, and Australians. At the end of the day, we Uber’ed to a wonderful dinner that evening at Au Sud where we toasted our new champion, the intrepid Chris Clulow.


Members of the IIPT teleanalysis research group Caroline Sehon (Chair), and Janine Wanlass (Principal Investigator) presented preliminary findings from the first phase of the IPI-Westminster College research project along with their collaborators Tania Estrada Palma (Mexico) and Asbed Aryan, Ricardo Carlino, and Liliana Manguel, (Buenos Aires) at a panel chaired by Jill Scharff during the 49th Congress of the International Psychoanalytic Association in Boston, July 2015.

Our Man in Haiti, Part VII

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Tuesday 3/23 Mirogoane:  Rendezvous with the Past

Today I go to Mirogoane again. But first I need to bring you up to date on something.  When I returned the Iridium phone to Stephanie after the Platon beach party, I was about to leave when she said, “Oh, Kent, one more thing.  I’ve been thinking about your wanting to meet your friends from your field site of years ago.  There’s still a big security problem — another abduction for ransom, probably because the others were freed with a big pay-off.  And there’s a rumor someone from another organization in Cap Haitian was murdered.  I checked it with our top IMC security guy.  We just can’t let you go to Masson, even with armed security.”

“Not at all?”  I was crestfallen, and miffed.  Just that day I had learned how old Stephanie was, just 30, and quite attractive, but not the girl of my dreams at the moment.

“Wait, Kent, I know how important this is to you, and you’ve really been doing good work, so I have an idea.”


“We’ve opened a new IMC Office in Leogane, run by my French friend, Alice.  You met her.  Why don’t you call her and set up a rendezvous at her new Office.  That gets you to Leogane, an easy place for your friends to reach, and nobody in security can complain.  Alice has a guard there 24/7.”

“Brilliant!  Thanks for thinking of me.  I’ll set it up, and check out Alice’s new mobile clinic program, and maybe introduce these guys to her.  She needs people on the ground who know the Leogane area.”

I had despaired of ever seeing them.  My heart began to sing.  I jumped on the Internet, and…it was down.  But the next morning I found the emails with the phone numbers of my friends from Masson — Pierre d’Haiti, Karen Richman’s foster son, and Charlie Fangala, her godson.  Both of them surprised to hear from me, we set up a meeting for Tuesday, March 22, after my Mirogane Clinic.  Then I realized I had a problem: Mirogane was an hour further out the southern peninsula, the opposite direction from Leogane.  I crawled back into Stephanie’s office.  Cars were at a premium.  To my surprise, she said, “No problem.  We’ll send a driver for you. I know how important this is to you.”  I was grateful.  She may not care about food, but she sure knows how to touch this guy’s heart.  This army doesn’t just run on its stomach.

As long as I’m cleaning up my timetable, I should mention that Kathleen, Laurie, and Chrisie from Hopkins left on Saturday.  Dr. Paul from Rush, his fascinating sidekick Alisia from Alaska, and Melissa from Canada, are all arriving Sunday.  As a matter of fact, Melissa and Paul were reclining on our Residence portico when we got back from our beach party.  Paul was all excited, talking up a storm, while Melissa, a new volunteer fresh off the plane Friday, sat there almost mute.  Being a shrink, I announced what I did and finally asked her if she were perhaps a bit worried about what she was getting into.  “My, aren’t we projecting, Dr. Ravenscroft,” she said, “are you always so nervous when you meet new people?”  I knew I had met my match.  Though quiet, she proved quite sharp, a doctor’s doctor, carrying the PDR and Merck Manuel around in her head.  Everyone went to her for drugs and dosages.  She also quizzed Tom mercilessly on latrines and water supplies.  I listened—for a while.

Dr. Paul, on the other hand, showed his brilliance and sense of humor in other ways, some of which you already know.  When I finally managed to get the lab to cough up my INR, he took one look at the numbers, as you know, and said they didn’t make sense, but hedged his bets by telling me not to cut back too much.  He was totally on top of hematology and oncology, but daunted by tropical medicine. His nose was in a book a lot at first.  Truth is, he worried about stuff we hadn’t even thought of.  I was in awe of him.  The only problem was that his last name was Kent.  So every time somebody called for Dr. Kent, we both answered, and it drove him crazy.  But he was flexible, and agreed to be Dr. Paul in Haiti, using his first name like the rest of us.  I was there first, anyway, and had secured the high ground.  People at Rush will wonder why he doesn’t respond to his name when he gets back.  He was also rather selfless, giving up his bed upstairs when new staff arrived.  He pitched his little pup tent.  Where?  Right in the front hall.  I felt sorry for him sleeping on the concrete floor, so I loaned him my cushy air mattress.

Dr. Paul seemed so kind and jovial most of the time, until one evening our Nutrition Program nurse got us to play a fast-paced word guessing game.  Then his killer instinct came back out.  He gloated when we stumbled around and the buzzer nailed us, and hooted when he won.  But I’d put my life in his hands anytime.  He had a heart of gold.  He brought two big duffels in addition to his suitcase, one filled with toys, the other with soccer balls and sports stuff, and all to be distributed at his clinics.  Only someone ferrying them from the airport misplaced them, and only the soccer balls showed up.  He prayed Haitian kids got all the toys, and not the black market.

What does our cook look like?  Sweet Crystal is a pleasingly plump, cherubic young woman who floats around in a fugue state, her faced laced with a perpetual pout, rarely cracking a smile.  Talking to her is like dealing with a somnambulist.  She pretends not to understand my Creole and still ignores Jattu, our proud delegate.  I felt like leaving the doors bolted.   But I thirsted for our next skirmish in the Crystal wars.  Anything to keep my mind off the sadness of facing our clinics.  Working in Haiti calls out my gallows humor. I hope you don’t mind.  But don’t be deceived.  It’s the underlying deadly seriousness of this place that fuels our seemingly innocent by-play.

Only the ‘disaster junkies’ thrive on it, as my slightly cynical journalist friend, Jim Srodes, calls them. (If this hot topic is not your cup of tea, jump ahead four pages.) They are a special breed within the echelons of disaster relief workers—a distinctive but elite few.  These are the folks who move from disaster to disaster with their NGO’s, fueled by the high-octane adrenaline rush of each new catastrophe.  They even hop from NGO to NGO, if necessary, to find a new stable, any stable, to feed their addiction.  Often consummately good at what they do, they never seem depressed or discouraged, buoyed by the intensity of the situation.  Their anti-depressant?  Feeding on the tragedy of the displaced and downtrodden.  These ‘disaster junkies’ all seem to know each other, and are familiar with each other’s organizations, inside and out.  They don’t need a flow chart, having in their heads where they stand in the NGO pecking order.  They speak of first tier and second tier NGOs without losing a beat.  If one disaster peters out, or their funding folds, they are nimble at organization-hopping, showing up to join their buddies at the next dramatic scene, raring to go.

This is both good and bad.  Part of the good is their high level of knowledge and experience with the disaster relief life (and death) cycle.  A well-orchestrated jostling dance always unfolds among these NGOs, those of the unfortunate host country, and the destitute indigenous population.  These disaster clients, helpless hungry, thirsty, homeless, and always grieving, are dislocated into tent cities, needing and demanding everything yesterday, while the news media, like sharks feasting on blood, descend on the worst case scenarios to find tender fault lines in heroic relief efforts.  And, admittedly, aid is spotty, halting and inadequate, faced with the widespread enormity of these situations.  But these NGO’s, who have been brave and professional enough to step into these chaotic seething vacuums, somehow are able to create out of thin fetid air rather amazing life support systems, virtually breathing for their agonized ‘clients’.  They go about this in a well-oiled, though outwardly disjointed-looking fashion, almost running on fumes at first, but often with generous initial compassionate funding, from a stunned world audience, who soon prove fickle, moving themselves to the next touted disaster, itself like a “public disaster junkie’, obedient to the next featured world catastrophe.  Mindlessly enthusiastic, they fade on the previous disaster, and let their pledges dwindle.  Their governments, despite high-sounding initial resolve, often let their pledge dribble to default.  The NGO professionals are left orphaned, destined to fend for themselves, burdened by their newest traumatized public wards, while still taking care of all the other disaster populations already in tow, but now long forgotten by the world.  Oh, the tree huggers and the liberal young periodically try to recall to the public eye this bloody trail of relief efforts, crying shrilly and pointing Darfur fingers, while we all eat our foie gras and sip our wine in front of our telies.  One of the positive bottom lines here is that NGOs know this fickle disaster cycle well.  Recognizing the disgraceful public mind and the thirsty news media, they try to work their own emergency media magic to pump and reap the windfalls of these copious initial disaster moments, valiantly trying to fill their coffers with transient heartfelt outpourings, creating a precious reserve for their past and future obligations, storing nuts for the long winter.  Understandably they must quietly siphon off some of the transient bounty to feed their ongoing forgotten relief efforts, while laying away some nest eggs for the next mass disaster.  The pump must be primed, and the NGO funding nourished.

As a tragedy unfolds, they go about their work with a rugged, time-proven efficiency, rapidly clustering and coordinating, seeking mutual NGO support and collaboration, finding and sharing resources, seeking solace, (and even romance and love) with and from one another, while they expose themselves and reach out progressively to the shredded governments and indigenous populations.      The NGOs are whipsawed, blamed for not being deeply, sufficiently and assertively engaged, while being faulted for being overly intrusive, invasive and arrogantly taking over.  In the face of this indigenous torrent of needs and complaints, all well-known to them from each past disaster dance, the NGOs respond in a mutually sustaining, mature measured fashion, transmuting the angry heat of these expectable complaining encounters into a cooperative energy increasing multinational collaborative teamwork.  Through this process, they identify regional needs and priorities, so that local governments, their own NGO’s, and all the foreign NGO’s can work in increasingly sustainable concert.  This expectable maturing of any given disaster cycle happens over and over again, from disaster to disaster.   These NGOs know it, have been through it before, and know that it will happen again.  They are wise enough to know there are no short-cuts, but only seasoned pacing and patience, trusting all will pay off in the long run—if the money doesn’t run out.

On the other hand, because ‘disaster junkies’ are so seasoned, so hardened, so inured, living off their adrenaline high, and because they are so ingrown with each other, they may become cynical and forget what it feels like for new staff and new disaster clients.  This can lead to a lack of empathy for these newcomers.  And to a jaded feeling about their fickle public benefactors.

Living this kind of high octane life, often flying high on fumes, disaster junkies are prone to two kinds of problems:  they run the risk of never settling down, never taking on the commitments, the trappings and anchors of more normal life, living a myopic nomadic existence, finding friendship and love on the fly with recurrent NGO’ers who, because of this unique life-style, can share their unique mentality and shoptalk, the only constant people in their intense, hermetically sealed universe.  Living this kind of life results in a special set of values, unique points of view, and a stunting of one’s own life trajectory and prospects.  If they mature in NGO office, they lose outside family and friends, miss important family life and events, and the maturity these bring to leaven the heart and soul.  Though a hardy few have the capacity to keep up with their family and friends, and insist on taking trips home–and even vacations–others harden, wither and die in office, warped by the generosity of their dedicated disaster giving.  They have saved, and given life to, so many while starving themselves to death, not to mention their families back home.

Why are people attracted to this life style?  Is it something about them?  Or something about what happens once they get involved?  Is it in their genes, or is character destiny?  Or, does disaster work shape and distort character?  We use the words ‘disaster junkie’.  That’s an addiction metaphor.  But their ‘adrenaline high’ is not just a metaphor.  It actually exists, and plays a role we all know, as it does for gym-freaks, professional athletes, dancers, actors, and gamblers.  Yes, there is something addicting about this work—the compassionate circumstances, the noble calling, the good works, the public support and honor, the media accolades (and diatribes), and the sleek, simplified fighting life style, with the aura of a noble calling, all justifying expedient decisions, and a life of deprivations and excesses,.  In short, the mentality of a holy war crusade.

The bottom line here is that it is a magnificent life-style that is discernibly distorted.  But where would we, and the tragic destitute be, without them.  They are in the same category as saints and martyrs.  Translated from the Scots’ toast I’ve heard from Jill, I salute them: “Here’s to you!  Who’s like you?  Very few, and they’re all dead.”

But how do our revered ‘disaster junkies’, or even our more average disaster relief workers, staff and volunteers, learn necessary survival skills and sustainable self-care?  Most organizations, and especially IMC, stress this, and provide professional prescriptions for training them, essential to their personal and professional longevity.  Otherwise, they suffer the other major casualty, that dread condition of NGO burnout.  We might call it the NGO Phoenix Phenomenon–as disaster junkies fly blindly towards the sun, seeking the bright high of disasters, until their wings, made of mere mortal flesh melt and burn from their arms, and they come crashing to ground, no longer a disaster star, but a black tragedy of their own making.  As they suffer this flameout, they often bring down others with them, and even their organizations.  People around them feel their personal and administrative decrescendo, the spiraling decay of their gyre, and wonder how they can help, when and if they dare to tell them to take leave, lest their behavior result in their underlings taking leave of them.  These phenomena are well known to everyone on the inside, and yet often overlooked or delayed until it is too late.

I am not, or only partly so, talking about my beloved IMC.  I care for this dedicated group, have seen the best of what they can do, and yet have seen some hints of the above phenomena, just enough to get the hang of it, and then to use my Hotel Royal connections, to discuss these ideas with friends in other NGO’s, and then to spin some of my own thoughts into whole cloth.  I could be wrong, I could be making a lot of this up, but I must tell you, it is food for thought, even for my beloved IMC.  Physicians must heal themselves, that they may be whole and full of life, and in good enough health for healing others.  So on with my story.

At the Mirogane Clinic, for the second time, our first patient, 29, talked of his profound sadness and recurrent thoughts of killing himself.  As he spoke, he seemed to be swallowing his tongue.  He told of being unable to work for the last 8 years, but still hoped to pursue his dream of running a business.  His speech was so garbled we had to stop him, asking him to open his mouth.  His tongue was chewed into a large bulbous cauliflower.  “How did that happen?” we asked.  “Every time I have an attack, my neck and head go into spasm, my jaws clench, and I chew my tongue–maybe two or three times a week.  The only thing that stops it is 5 pills of ‘Akineton’. But what the hell is Akineton? I thought. What could this be?  He doesn’t fit Lesch-Neyhans Syndrome. Dr. George and I were stumped. It sounds like a dystonic movement disorder, or maybe a seizure? We pressed on.  His life had gone well until he was 20, but he had never worked after that.  “What happened back then?” we asked.  “I became violent, got in fights, had to leave school.”  “Then what?”  “I was hospitalized.”  “Were you thinking everyone was against you, maybe even hearing voices?”  “How did you know?  Yes, it’s painful to remember.  But thank the Lord it never happened again.  Ever since then I’ve had these attacks and am too depressed to work.”  Suddenly we had our diagnosis, Paranoid Psychosis sad to say.  I whispered, Tardive Dyskinesia to Dr. George, and his eyebrows went up.  It’s that dreadful permanent side effect of the neuroleptic anti-psychotic drugs they gave the man to cure his paranoid psychotic break.  Dr. George said, “Don’t ever use anti-psychotic drugs again, and look, this kind of condition tends to go on, but we can help you manage it better.  We think you ought to try taking an anti-dystonia (anti-Parkinson) drug regularly, and see if we can cut the attacks way down, which would help your situational depression and give you a chance for your dream.  Try Kemadrin daily, and come back next week, tell us how you’re doing.  You can hold on to your Akineton in case you have a full attack.  He was slightly encouraged for the moment, and we were guardedly hopeful.  This is a tough situation.  If this didn’t work, we would try Carbamazepine, in the off chance an anti-seizure med would help these myoclonic attacks.  I have been noticing that we’re attracting more chronic patients now, while seeing fewer acute quake-related cases.

The next case, a 25-year-old woman fit in with this idea.  Trying to purse nursing, she had had three psychotic breaks, each at stressful career junctures, treated with Risperidone.  Now she seemed flattened. Not quite catatonic, and surprisingly confused.  She repeated our questions 8 or 9 times and kept saying, “They’re coming to get me.”  She had lost her meds, and psychiatrist, in the earthquake.  For her serious psychotic paranoid depression we gave her Carbamazepine, but she refused any Haldol because of massive weight gain.  If you are wondering why you keep hearing about the same medications over and over again, it’s because we only had available one or two drugs in each category, and some–like Carbamazepine (Tegritol)–are good for both bipolar and seizure disorders.  We’re realists, not just Johnny-one-notes trying to fit all our patients to one label.

After we saw a 51-year-old woman with a classic depression, treated with Amitryptilene, we met a bright-eyed manic woman with a paranoid tinge coupled with fleeting visual and auditory hallucinations who jabbered at us a mile-a-minute.  We gave her, you guessed it, Carbamazepine.  You’re getting good at this, and so was our Haitian general practitioner.  What really helped, though, was our follow-up clinic, where we could see any improvement and adjust meds as needed.  This lady, though still a little high the next week and wanting our names to thank God in church for us, was in fact cooling off, with no voices and visions, and now eating and sleeping better.  We were thankful too.  We upped her Carbamazepine a little.  Close follow-up is both instructive and reassuring for us all.

Our last patient at the age of 14 was still in first grade.  He was pestered by his mother and teacher who wanted him to progress.  A handsome lad, he was embarrassed and miserable, and yet a little cocky still.  His older brother had the same problem, and finally, when she admitted it, so did his mother.  But she said she had to endure school so why shouldn’t he?  We talked heredity and common sense, suggesting he was a smart proud boy, not too damaged yet, with clear circumscribed troubles with reading, writing, and arithmetic.  So, instead of wasting his time with intellectual challenges he could not meet and ruining his confidence, he (and they) should make a bold, pre-emptive move and seek out some good interesting apprenticeship, find his calling, and get a jump on his life’s career.  He would do well.  A smile crept over his face, and a light bulb went off in mother’s head.  We said goodbye and wished them well.

Coming up for air, I looked around.  Where was he, our jovial alcoholic? I had really hoped he would meet our challenge and come back to see us, ready and competent for a more thorough evaluation.  But he was nowhere to be seen.  I was disappointed but not surprised.  I wasn’t very effective with alcoholics.  Only a few people I know really have the knack, and maybe not in times like these.  I tried not to be too hard on myself.

Today was a lighter load and thankfully went quicker.  I had a very important date to keep.  The driver was already approaching me when I called Samedi.  He and I had had a heart-to-heart early that morning, and he knew how important my rendezvous at Alice’s Leogane headquarters was to me.  He knew of all the friends I had lost there in Brache and Masson, my old field site, and how eager I was to meet Pierre d’Haiti and Charlie Fangala.  I had so despaired of making any contact that this breakthrough opportunity made my heart sing.  I was so lost in fantasy I was surprised when we got to Petit Goave in record time.  I realized I’d be too early in Leogane, so we cruised by Stephanie’s office, landing at the Residence.  Crystal was shocked to see me out of the blue, and even better I found uneaten lunch sitting on the table.  Though I couldn’t figure out who it was for, possession is nine tenth of the law and I dug in.  This was turning out to be a good day.  I woofed it down in 15 minutes, grabbed a few things, hopped in the waiting Patrol car, and we hot footed it on to Leogane.  And I was blind-sided.  First by a call from Alice, “Are you still coming today? Oh, okay, but they’ve called me to a Leogane NGO meeting so I won’t be there when you arrive.  The guard knows you’re coming.”

As we approached Leogane, it all came back, erupting into my head and heart as I saw all the destruction.  When we had driven through the outskirts of Leogane after Brache on the way to Petit Goave, it had registered then, but went by in a flash, or was deep-six’ed by my mind.  But now it flooded me.  Because we were lost at one point, and went deeper into the heart of Leogane, I couldn’t avoid the awful truth.  I had been told that Leogane, the epicenter of the earthquake, had been 90% destroyed.  And it was true.  Everywhere I looked, I saw collapsed buildings.  Because the driver had never been to the new office, in a building just leased and set up by Alice in the last two weeks, we wandered around town exposing me to far more than I had expected.  Though some spotty clean up had begun, the place was a wreck, and tents of every type and description were everywhere.  Though half the population had died or fled, the city was teeming with people, women doing commerce, their brightly colored stands dotting the roadside between piles of refuse and broken walls, with goats, pigs and chickens hunting and pecking for anything they could find.  Dogs scavenged everywhere, dodging brightly colored camions piled high with sacs of produce and charcoal, with people perched on top of that.  Life was everywhere, and death was buried beneath.  For all the world it was like a city gone crazy, more like a New Orleans funeral than a dirge.  I was wracked with feelings, ranging from sadness to admiration.  How could they do it?  But how could they not?  Life had to go on, even in the midst of death and destruction.  I had become so used to things in Petit Goave that this hit me like a ton of bricks, almost literally.

The only thing that buoyed my feelings was the prospect of seeing Pierre and Charlie—if we could only find the place.  We were a little late, and I worried they might be waiting.  I had told them the address during my original calls, but now that I saw how hard it was to find, I was also worried they’d never find it.  What if I came all the way to Leogane and never saw them?  My driver finally rolled down his window, hailing a local guy on the street, “Hey, bossman, where is the new NGO IMC Office.  We know it’s nearby?”  “Just take a right down there beyond that huge sign.”  I looked out the windshield at a fat 30-foot pole going out of sight.  Peering out the side window, I could see it was holding up a huge empty billboard.  Halfway down the side street, the driver began honking, their usual drill to Open Sesame.  On cue, this big red wrought Iron gate slid open and a uniformed guard with cool shades and an ugly sawed-off shotgun stepped out to face us.  Seeing the white Nisan patrol car bearing down on him, he waved.  Alice had tipped him off.  We arrived and I hopped out. The place was deserted.  I asked the guard to call my friends with the directions.  Meanwhile, I had something very important to do.  I knew Alice was French, and not a vegetarian, so would have her cupboards well stocked.  I ran back, almost salivating.  I was right.  Out came the peanut butter and jelly, and some crackers to indulge me.  I hadn’t realized how pent up I was.  Then I pilfered her cabinets for all the power bars, peanut butter crackers, and cookie packs I dared take, stuffing my handy fanny pack.  I knew she had four new medical volunteers to feed, but I had four myself.  Paul, Alisia, Melissa and Dr. Alice would be ecstatic—if Tom and Jattu didn’t have at them first.  I had already done my damage.

Just then I heard the volunteers arriving, surprised to see only two.  And people I knew, my Barbancout buddies from Petit Goave. “Where are Kathleen and Laurie?”  “We had a terrible gas explosion here last night, and she caught it full in the face.  She’s gone to Port-au-Prince to be evacuated.  Kathleen went with her.”  “How bad off was she?”  “She had second-degree burns on her face.  Her hair and eyebrows were singed off, and she was blown back against us.  Some guy installed it wrong.  She was traumatized, but I think she’ll be all right.  We all were.”  Now Stephanie’s constant worry about gas made more sense. I should have known, since my wife and I had some trouble with gas in our place in Fanghetto.  Maybe that’s why the Italians call the gas cylinders “bombolas’.

Just then I heard Pierre and Charlie arriving.  Pierre was older, a dignified young man with a great smile, and warm charisma.  He had started a school nearby, and even built a residence for disadvantaged children in the Leogane area needing education and lodging.  The residence had been damaged in the earthquake.  He had started a fund-raising tax-exempt foundation for his work, and had been able to pick up a nice property with a warehouse-like building on it, and was hoping to rebuild the residence.  Charlie, a bright attractive younger guy had lost his job in the quake, and was looking for work.  To my surprise, Pierre had a very successful high-end carpet installation business back in Virginia, and after installing carpeting for the Red Cross headquarters got to know the president, who gave him a nice donation.  “I’m sure I can’t match that but I have something I brought from Paris for you and Leogane.”  I pulled out my billfold, and gave him $240 US dollars.  My wife and I wanted you to have it.”  “Thank you very much, Kent.  We’ll put that to good use.”  Then I turned to both of them, “I don’t know what will come of this, but I hope Alice comes in while you’re still here.  She may be hiring for various things.  She also needs to know people she can trust who know the Leogane area.”

At this point I brought out my MacBook to surprise them with pictures of Masson some 50 years ago.  Little Tonio and Elminar, kids of Joselia and Ternvil, the voodoo priest I stayed with, would now be in their fifties–their parents and grandparents long gone.  Thinking this, my eyes moistened, not just for them but for the countless people now dead because of the earthquake.  They saw me get quiet, with a tear running down my cheek.  We shared a moment of silence together, than talked of the devastation in Brache and Masson.  They said it was just as well I didn’t come see it because it would bring me even closer to so many sad losses.

We all looked up when we heard Alice coming, accompanied by another familiar face from Port-au-Prince, Mbassi, now second in command for the three new mobile Clinic start-ups in Leogane.  Gressier was now placed in their ballywick.  Pierre and Charlie were glad to hear about medical care outreach finally coming to their area.  And Alice was glad to meet them, and promised to see what she might do with their help.  Though less immediate a homecoming than I had hoped for, I felt my most important private mission in Haiti had been accomplished, and with Stephanie’s and Alice’s blessing.  The only big remaining question mark was my little sponsored three-year-old, in the preschool outside of Port-au-Prince, a question that might remain unanswered.  But I was grateful for what the day had brought me.  Except for one thing.  As I was waiting for Charlie and Pierre to arrive, my camera fell out of my fanny pack and broke on the ground.  I wasn’t able to take pictures of them, or anything else on the trip. I was beginning to feel jinxed—now down my glasses and my trusty camera.  But one thing I did have was a feeling of gratitude toward Stephanie.  Originally I had been quite down on her around not allowing me a visit to my field site at some point.  But all things are relative, and as I came to fully inhabit the risky world we were living in, I found myself deeply moved by her finding a safe, realistic way for me to see my Leogane friends.

Our Man in Haiti, Part VI

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

The Mirogane Clinic

Stephanie, my IMG Director, mentioned that we’d be switching my beloved mobile mental health clinics in the countryside back into the Notre Dame Hospital right in the middle of Petit Goave. To her surprise, I went off like a sky rocket, ranting about how these poor patients were already stressed to the limit, didn’t have any money, and found it hard just to come to our nearby clinic, and, their Haitian doctors and nurses needed teaching where they were.  Plus, we needed to get a first hand sense of what they were up against out there.  Unexpectedly faced with this passionate defense of our mobile clinics, Stephanie was taken aback. “Why are you so angry at me, Kent? YOU were the one who told me the new psychosocial clinic wasn’t supposed to be out at mobile clinics.  Now you’re telling me the opposite.  What’s going on here?”  She got very quiet, and finally said, “I probably shouldn’t say this, but I have an idea why you’re so heated up and didn’t want to lose going to the mobile clinics.  You have personal interests, underneath, so maybe as a volunteer you’re sort of a tourist, wanting to see these exotic places”.

It was my turn to be quiet.  Her comment hurt. “You have a point, and establishing a hospital base is important too,” I finally said, “but I’m no accidental tourist. I’m using everything I’ve got for the Haitians, and they need to be seen in local clinics.”   Turning in, I hunt as usual for the Tarantula Stephanie had seen out back behind my tent.  Nothing in sight.  I tried to sleep but found it impossible.  My local chicken came home to roost.  Then a distant fox hunt began with dogs baying, running in packs around the neighborhood, and waking others as they ran.   Occasionally they would bite each other, no fox in sight, and you could hear the victim go squealing off into the night.

As my early morning clock ticked away, I anticipated my day.  I would be going to the Mirogoane Clinic today, a new clinic that Peter hadn’t checked out yet.   Afterward I would be going to the Notre Dame Hospital to show the IMC flag.  Suddenly, I felt something crawl across my feet.  I screamed and scrambled out of the sack, grabbing my flashlight as I jumped up, quickly shaking the bag out on the tent floor.  Nothing! Or was it my Unconscious, laid bare?  There is something about being in Haiti, and living in a tent, that is forcing me to be closer to my bodily sensations and to my unconscious, with reminiscences of my youth and my approaching mortality (not in Haiti, don’t worry).  Anyway, inside my tent I am spread out all over, insufficiently washed, sweaty clothes hanging everywhere to dry.  I love it.  And I can’t wait to be through with it.

I really love my spacious Shelter Box Tent, given by the International Rotary Club.  My father was a Rotarian all his business life, and now I’m finding out about some of their great work around the world, and around Haiti.  I see Shelter Box tents all over, and it makes me proud.  It was also because of my father I bought the flash light I am using.  He taught me to camp, and had this funky old flashlight run by hand-cranking it.  No batteries.  This one is cool, much more high tech, not requiring constant cranking because of a rechargeable battery.  I look forward to giving it to my son.

Mirogoane is an hour by van, over a road full of ruts, lined at times by beautiful banana trees and sugar cane fields, with a stunning backdrop of crinkled denuded mountains, a mirage of green scrub growth in most places. The trees have been mostly cut down to make charcoal for cooking in this overpopulated area.  Looking ahead from the van I see throngs of people, collapsed buildings, goats attacking burning refuse looking for fruit peels, gaily painted trucks and cycles hurtling toward us, and tent cities rushing by on either side.  The road is periodically scarred by zigzag crevasses and deep cleavage drop offs, stunning reminders of earthquake forces scarring Haiti, and in the tent cities our passage is slowed by make-shift mud speed-bumps.  Pulling up at Mirogoane Clinic, I hauled my red backpack up the steps to a clinic bursting at the seams with Haitians, camping out in anticipation.  I found a cramped back room, moved soiled instruments and half-empty bottles of medicine in there, and scrounged up three rusting chairs and a bench.  There was no door and no ceiling, and the walls went up 9 feet, the high airspace transmitting the hub-bub from the next room.

Our first patient walked in.  She was suffering from anxiety and sadness because of loss, shock and aftershock.  We prescribed some Diazepam and anxiety-reducing exercises and homework with family and friends.  In the midst of this, a toothless wizened old man, drunk as a coot, came rolling into the room giving us all high 5’s and showering us in torrents of words.  At one point, a tear suddenly dropped from one eye when he fleetingly mentioned losing a family member.  I suggested that the Haitian doctor explore what lay behind it.  In response the man told of his sadness and isolation.  He told us he had been drunk most of the time for 8 years, and that it was his sister’s fault.  She had been a raging alcoholic before him, until she saw a voodoo priest who, for a sizeable fee, removed the devil drink from her — and put it in him. I helped the Haitian doctor explore all the possible sequelae of such chronic drinking (the DT’s, Wernicke-Korsakoff syndrome) but the man had escaped them, to our surprise.  We told him that hismain problem was loneliness and he was taking the wrong, self-prescribed medication.  Picking up on his sister’s exorcism, I said to him I knew about voodoo, and had nearly taken the Ason (the priesthood) myself.  I said we would be willing to receive his devil drink if he wished to give it to us.  But, we said, we could not give him a proper examination for diagnosis and a path toward cure unless he were sober to get his body and mind ready for our next visit.  He agreed to come back. We shall see.

Then this lovely robust young woman medical student walked in, complaining in a very soft voice of insomnia, palpitations, visions and voices.  She kept hearing the voices and faces of fellow medical students and nurses who had been trapped together with her in the basement as their building collapsed on top of them, there in Port-au-Prince.  Pinned under rubble in the pitch blackness, she could hear the voices, the screams and cries, of those injured and dying around her.  Over four grueling days she heard the voices of her friends and conjured up their faces to keep herself going, only to hear those voices becoming fainter and weaker, and finally dying out, leaving her alone with only one friend’s voice, somewhere way above her.  This faithful friend knew she was down there somewhere below her, and guided the rescuers toward them.  Then her friend’s voice, too, became weaker, and died out somewhere above her, leaving the woman utterly alone.  At first her voice was too weak to call out on her own behalf, though she could hear the rescuers calling her name.  Finally she found the strength and called just once, loud enough to be heard.  But the rescuers found that the pieces of concrete over her were too big to be moved.  They told her they wouldn’t give up and she should hold on as long as she could.  Hearing voices growing faint above her, she lost hope as she hung in the darkness, no sense of day or night.  Her throat was parched, and her loneliness deafening, but she didn’t give up.  She felt she had to survive.  She was the last of all her fiends.  Finally someone got to her feet.  We found out, at that point in her story, that she had been suspended upside down the whole time!  As she talked with us, encouraged to open up about her darkest hours, her voice grew stronger, calmer, and more certain.  She told us that two thirds of her class of 45 had died, and confessed she was petrified about going back to medical school.  The thought of getting near the collapsed school building was giving her palpitations, hyperventilation, and near panic.  She dreaded finding out if other students had died, and she wondered about her teachers.  We gave her some diazepam to take of the edge off her insomnia and her anxiety, and gave her three desensitization and behavioral techniques which would give her ways to systematically move toward mastering her feelings of fears, her thoughts of impeding disaster, and her phobic avoidance of her school and her future.  We hoped she would use what we taught her to show her friends how to work together, to resolve their fears and mass mourning.  By the end of the session we had a sense she would be able to make it, and shed light on the darkness they faced together.

Next was a follow-up appointment.  This bright, sensitive, timid young man for the second time in his life had lost close friends in a collapsed school.  He had been unscathed himself, but he had lost his hearing because he couldn’t bear to keep hearing all the horrible things he had heard, the voices of fellow students below, the injured screaming in agony in his dreams. The cost of his hysterical negative auditory hallucinations was severe: To stop hearing those anguished cries he had to stop hearing everything.  With talking, support and anti-anxiety medication, he was already beginning to hear better, and as memories and feelings came back with it, he was flooded with grief.  We urged him not to be ashamed of surviving, but to have the courage to share, perhaps in a journal or with friends, and to come back in a week to help us appreciate all the hard good work he was doing.

Our last patient was a cute little girl, with severe developmental delay and seizures.  She had lost her medication when her house caved in, and her doctor had been injured and was unavailable.  So she needed to get her two seizure meds from us.   We breathed a sigh of relief at such a routine request.

It turned out that my gifted interpreter, Tessier, a school teacher out of work because his school had been damaged (in general the schools are still closed) knew a lot of these patients and their families.  After the Clinic, he confessed he felt dizzy, drained, and sick to his stomach.  We both commiserated about what a lot it was to take in.  And yet he felt he was privileged, and learning a lot.  We needed to take care of ourselves too.  My best self-care was the blow-up camp pillow I had spring for. At first I was embarrassed to take it out, until my seat couldn’t take the rock hard chairs any more.  Blowing it up becasme something of a ritual.  Tessier and the doctors, and the watching patients, especially the kids, loved to watch.  And was it incredibly comfortable during those long grueling sessions in Creole!  I noticed that I did not need to pee, even thought I consumed two huge bottles of bottled water during those long hours, almost all perspired away.

When I got back to the Residence at 4 o’clock, my cold lunch was waiting, made by Crystal, including some still good red beans and rice, a vegetable stew, and a wonderful Black Bean soup.  My stomach has shrunk, but not my appetite.  I am feeling healthy and great.  Interestingly, all my joint problems, despite sitting for long periods, have gone away.  Getting over being rusty is a good thing, or maybe it’s my daily sweat lodge.

3/17  The Boat Clinic and the Mad Woman of Platon

I was really looking forward to the Boat Clinic in Platon the next day, and eager for a good night’s sleep.  But at 4;30 am a wild cat screamed a mating call in my ear, after dropping into our yard to eat our garbage.  Fired up by a shot of adrenaline, I screamed bloody murder back and the cat finally skidaddled.  It was deliciously cool by this time in the early morning.  I luxuriated and began drifting off.  Then something big fell on my tent from the overhanging mango tree.  Just a mango I thought, until it began crawling along the tent ceiling.  Was it the cat? Or something else.? Or just my unconscious again. I said to hell with it, and turned over.

I was up before the little guy came around to sweep the fallen mango, avocado and coconut leaves away every morning.  I could hear his swosh-swosh, scrape-scrape, as I did my exercises.  I hoped that whatever was on my tent didn’t bite him, and that he would get rid of it.  After doing my morning ablutions, I walked out to watch the action.  The transportation guys were jabbering in Creole and revving up 4 big 6-seater Nissan Patrol cars and 2 large Nissan 8 passenger vans to cart us around to the various ambulatory clinics.  I had already taken part in this early morning pageant, leaving early, but had to ask Samedi, the dispatcher, where the boat clinic people were.  Now Samedi is cool, and from early on we’ve had a little thing going.   Samedi, which is French for Saturday, is also short for Baron Samedi, one of the most powerful and feared Voodoo gods.  So I call him Baron at times, and he and the drivers crack up.  But it is no joking matter.  The Baron is god of death and the cemetery, and also head of the Bizango Society, which enforces community values, often with summary judgment.  When I was here in the 60’s, Papa Doc Duvalier, with his feared machete and machine-gun toting Ton Ton Macoutes, would actually dress up like Baron Samedi, all in black, with cane and wire-rimmed glasses, and cold, poker-faced reptilean stare.  Over a Barbancourt rum one evening, Jean Blephous Richardot let me know that Duvalier actually held voodoo ceremonies in the Palace and had his own in-house Houngan, or Voodoo Priest.  None of this was lost on his Haitian subjects then filled with fear and respect.

Anyway, Samedi told me the boat people got started a little later than the rest, because they waited for the two Haitian doctors who arrived on Haitian time.  The two boat nurses were already there. They smiled at me and I did a double take: They were the same two nurses from my Saturday seminar who admitted they had no home or tent, no shelter at all.  Piled in the van, we bounced down to waters edge, passing the ruin taken over by goats and going just one street past the turnoff for the Royal Hotel.  When we arrived at the water, already teeming with fisherman and guys mending their nets, I took out my camera and walked past old, brightly painted dugouts and bright yellow fiberglass runabouts.  Picking my way through the refuse and rocks, I realized I had seen this place from the Royal ‘beach’.  I began swinging my camera around to take a picture of the beautiful azure bay and the distant mysterious Il de La Gonave.

As I looked out over the water, memories came flooding back.  I had taken a voyage to that island 50 years ago with Haitian peasant fisherman friends in their rickety sailboat, on a similar, stunningly beautiful, cloudless summer day, arriving at mid-day at their own personal off-sure island, made entirely of conch shells they and generations before them had caught and laid down.  We had already said goodbye to their on-shore wives in the cool of early morning.  And then they had introduced me to their island wives.  Haiti is a polygamous society, for those who can afford it.  And these guys, with their thriving conch, or lambi, fishing, were in good enough shape to pull it off.  I skin dived to my hearts content, and came kicking in for a surprisingly good conch-stew dinner.

My memories continued to flood back.  On the next day, I had gone out with them to the prime lambi hunting grounds to see how they caught them.  I wondered what all the long sticks were for, and found out they lashed them together, to a length of 35-40 feet with a bamboo chock on the end, like a fitting for unscrewing ceiling light bulbs.  I watched them use glass bottomed buckets to pick out big lambis, and then unerringly chock them, keeping the boat steady in the process.  I was foolhardy enough to bet them I could dive down and get one, not realizing how deceptively deep it was, given the crystal clear water.  I dove down, down, down and grabbed one, forgetting I had to come the same distance up.  I felt a tearing pain in my abdomen and shot back up.  I had a stomach ache, and nearly passed out.  The pressure collapsed my lungs and forced the neck of my stomach through my diaphragm.  So much for youthful prowess and vanity.  Older and wiser now, I stick to having my lambi in the buffet line.  Easier to reach.

The fishermen had trouble getting the engine started, but I had had trouble just getting into the boat!  Why hadn’t I listened to my wife when I was packing?  Just once.  She had handed me my water shoes and I purposefully left them under a pile of dirty clothes.  Too much weight and I would never need them.  Well, as we walked down to the boat, which was several feet out into the water, I noticed all the staff had on water shoes, of one sort or another.  Tessier was in the same fix I was.  We finally took off our shoes, rolled up our pants, and walked out through the rocks and water.  Tessier took off his socks, but there I was with my god damn support hose.  So I just walked on out, and happily they dried quickly because the sun was increasingly hot.  I was grateful to be splashed when we headed into swells periodically.

None of this mattered because the boat trip was amazingly beautiful.  We pulled out past a Royal point, cruising across the outreaches of Petit Goave harbor to the left, with a huge Spanish army Hospital ship to our right.  The green undulating foothills, deep ravines and verdant valleys of the foothills gave way to the high mountains forming the spine of the southern peninsula.  Two tankers, one bright red with a rusty water line, the other a dirty streaked white, were anchored in the distance.  Flying fishes skittered across the water, and one of the nurses talked in animated fashion to Tessier describing everything that happened to her and her family during the earthquake.  Jutting out majestically was a high mountain dropping sharply in the azure waters like the side of a fjord, just at the far curve of the sweeping Petite Goave Bay.  The mountainous spine of the peninsula continued out of sight behind it.  Haiti means mountainous in Arawak Indian, the language of the original indigenous population.

We skirted around the rocky promontory, and soon saw some huts surrounded by banana trees.  “Bananier, one of our clinic sites,” yelled one of the nurses.  After passing another site, Goumbe, we plowed to a stop at Platon, a larger isolated fishing village. We had passed a number of boats on the way, some picking up wicker traps, marked by plastic coke, orange, and water bottles.  A stray Perrier floated by. I realized most of the dugouts came from Platon, even though many of her dugouts, and a few primitive sailing craft, were still pulled ashore.  The purr of our motor attracted quite a crowd to the beach, the children running down to greet us, the adults hanging back to keep their place in line.  I discovered the Platon Clinic was open air, shaded by huge Tamarind trees, and a scattering of coconut, banana, and mango trees, many heavy with fruit.  Pigs, chickens and goats had the run of the place.  There were perhaps 50 patients standing or sitting, many with children, some nursing babies.

One of my nurses, Marie, looked around carefully, choosing what she felt was a prime spot behind the single closed building, under a truly majestic Tamarind.  A second tree shaded a boat carpenter cutting and shaving planks.  Ringing him for shade were a half dozen people, chatting and loitering about.  When my table and chairs went up, the group swelled in anticipation. “So how many patients do you have for us today?” I asked.  “Nobody yet,” she said.  She disappeared for a minute, and then came back with a rather sad older lady.  She had lost her husband, and three of her children had died of illnesses, unrelated to the earthquake.  The tremor had taken her house, and her hypertension medication, leaving her without shelter and mounting blood pressure.  As we were just adding Atenelol to her other blood pressure medication to help with her blood pressure, her tension headaches and hyperventilation, we heard a commotion coming down the trail from our left.

A woman came roaring out of the banana trees into our office clearing, a hoe-ax on her shoulder, and a relative trying to keep up.  The woman looked like the voodoo god, Kuzan Azaca, with her tattered dress and scraggly ruck-sack slung over her other shoulder.  She marched straight up to our table, with a retinue of onlookers.  She wasn’t threatening, just dramatically determined. To our shock, and to the delight of the crowd, she threw her dress up over her head to show us her emaciated body and sagging breasts to emphasize how hungry she was.  In Creole she said, “I have no food, no shelter, and my relatives have all abandoned me, and look, the community makes fun of me when I’m crazy like this.  Please, could you build me a house and give me some food!”  We settled her down, saying we would see her next, but she had to wait her turn.  She sniffed, huffed, and wandered back into the crowd.

When it was her turn, the crowd pressed in around our table to listen, gawk, and laugh.  I felt badly about the invasion of privacy and tried at first to clear them out   Then I realized she was doing theatre and so were we, and from what I saw, we would need to involve family and community as part of helping her, with the hope they might re-accept her.  After hearing her sad story and downhill course, on a hunch I asked Dr. Bouge to do her blood pressure, which came in at a staggeringly high 200/110.  This made it clear she had a fluctuating hypertensive encephalopathy leaving her brain progressively pock-marked by myriad micro-stokes, which had eaten away at her mental capacity.

So we had our diagnosis.  We arranged for antihypertensive mediation in a slowly increasing dose so as not to give her a low blood pressure watershed stroke.  We explained it to her and to the community so that they would understand her plight and support her treatment.  As we were doing the next case, she came back by, holding out her hand with a few beans in it, asking if we could give her a few more.  Everyone around laughed and we found ourselves smiling too.  She looked sternly at me and said, “I won’t leave until you agree to build me a house!”  I was kind but repeated that the medication was what we could do to help and that we would like to see her and her family member next week.

The nurses were watching and learning, and the docs found the cases interesting. The boat ride back was great.  I noticed some conchs or lambi, and a few choice lobsters in the bottom of the boat, prize purchases from the local fisherman.  The nurses and doctors bought some.  They looked so good I had the thought: ‘Mine will be at the Royal tonight.’

I made liaison rounds informally in the afternoon.  I met with Lynda, who acts as the training director for the Haitian hospital residents, to ask her if they wanted a seminar.  I got an emergency call through Stephanie from Croix Rouge to see a traumatized mute girl, and made rounds all over the hospital meeting everyone on the search of the patient, only to find out the problem had been solved.  Then I went over to have my own blood drawn to check my own bleeding time since I’m on Coumadin for my old pulmonary embolus from post-knee surgery and thrombophlebitis, but I don’t know the results yet.  I’m sure its fine.

That evening, I was sitting across from Stephanie doing my diary, writing about the robust medical student buried upside down with her classmates.  Stephanie looked up, and said, ”Kent, what’s wrong, you’re crying?”  I told her what I was writing about, and read her some of it, and her eyes glowed.  “You really do care, and you’re dealing with some tough situations.”  Then she told me she was working on security issues.  She got quiet, and then said, “I have to confess something.  The Internet is so slow because of my long Skype call to my friend who was just released by his abductors.  We had so much to talk about.  It was hard. I had a lot of tears too.  You know, Kent, I was abducted too, and by the same people who abducted him in Darfur.  When they let me go, I had a hunch they’d go after him.  He dared to speak out a lot about the rebels.  The motives for abduction at the top are political, but for the guys that carry out, it’s financial.  I had only one moment when I really thought they were going to kill me.  It could happen.”  As she said this, I saw tears in her eyes.

I said to her, “My work is hard at times, but nothing like what you went through.  I’m glad you’ve shared this with me.  I really admire you.”

“Well, what you said about helping that girl be brave about going back and facing her fears so she could carry on, that reminded me of how hard it was for me to come back and do this after I was released.  I was in denial when I took some time off, but after three months, I wanted to get back to work, and that’s when it hit me.  It was hard.”

“But you made it, Stephanie, and look at all you’re doing now.  You found yourself and your calling again.”

“It’s good to talk, Kent.  See you tomorrow,” she said with a warm smile.  I feel much closer to Stephanie now.  I really admire her.

As I walked back to my tent, it began to rain.  It was nice crawling onto my cozy air mattress, lying back to listen to the rain pattering down on the tent.  I felt a peaceful calm, and drifted off to sleep.  Several hours later I was awakened by a loud drumming.  The rain was pelting down in torrents.  Of course, the rainy season was upon us.  I remembered the pools of water in my tent when I arrived.  Flicking on my trusty flashlight, I beamed around the tent floor, relieved to find no water.  When I drifted off again, I had a brief dream I was floating down a river on my mattress.  The rain racket woke me again, and suddenly I felt sad and guilty.  Here I was worrying about a little watery inconvenience, and there were all these Haitians in flimsy, makeshift sheet and paper shelters, with the water pouring through and drenching them.

And then the tentless nurses from the Boat Clinic floated into my mind.  What was happening to them?  Oh, and the Mad woman of Platon, the one beseeching me to give her food, and build her a house, what was happening to her?  As I thought about her, I suddenly realized I had missed the boat with her.  The mantra of IMC is to take care of food, shelter, water and security first, which helps most people through their crisis.  And we had laughed at her pleas without attending to them.  And what about giving her mulitivitamins for Pellagra and deficiency disease causes of dementia?  Yes, we had missed the boat, entirely.  It was then that I determined to give her Norbert’s tent, going unused in the corner of my tent.  And to get Crystal, our cook to buy her some rice, beans and cooking oil.  Yes, there was something I could do.  Except we weren’t supposed to do direct giving like this, partly because of the problem of envy and competition.  Luckily things were much better between Stephanie and me, and I would give it to her quietly, with “Medication” written in magic marker on the tent bag.  When I floated the idea past Stephanie and the nurses later, they were okay with it.  But the next day one of the nurses whispered, “Don’t forget about us!”  And I won’t.  Finally, the rain seemed to quiet down a little, after drumming some sense into my head.

The next day water in fact was in my tent, but nothing serious. But it could get worse.  My wife sent me an email about CNN reports on Haiti, describing the Petionville camp hillside, showed massive rivers of mud and muddy water, running down between the tents, washing around, under and through them, with clothing and bedding ruined or washing away.  It was the beginning of what everyone feared, a disaster.  My worst nightmare seemed to be coming true.

Late the next day the sun broke through, everything dried out, and it has been fine ever since.  But that night of rain is a harbinger of things to come, and I am worried.  I’m sure the Haitians are.  I’ve seen a few more trenches around tents for water protection and runoff.  But I worry people are leaving themselves exposed and open to disaster.  Then, again, what else can they do?  That’s the problem.

Our Man In Haiti, Part V

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

I was in a narrow muddy rutted road between tents when I saw a green steamroller, or maybe one of those big, bug-like French street sweepers, coming straight at me.  Nowhere to hide.  So I quickly rolled over to the side in a panic.  Then I awoke.  It was 4 am and I had landed in my suitcase!  As my mind locked in, I realized I was feeling ill-prepared for my first clinic in Petite Guinee, a beautiful spot on the edge of the azure Caribbean in perhaps one of the most impoverished destroyed areas in the Petit Goave area. My mind started grinding out the supplies I must take: 5 folding chairs — one each for me, my Haitian general practitioner,  my trusty interpreter, Tessier, and the patient, his mother — a folding work table, my pharmaceuticals, chart materials, and lots of water.  It would be sweltering. Then I realized no little tent for my clinic had arrived.  Making mental notes, I fell back to sleep until 6.

My clinic was supposed to start at 10 am, two hours after the Guinee staff had picked up their meds to go set up and get started.  So I had arranged to meet Tessier and our driver at 9.  Only that morning things went hay wire because of transportation snafu’s, and I hastily had to pull up stakes at 7:30 am, loose ends trailing.  But I liked going out with the team, and chatting with the eager but anxious new volunteers, who were amazed at the extent of the damage this far down the peninsula.  One quoted the most recent CNN commentary, which said the rubble from the Haiti earthquake would fill the entire Washington Mall to the height of the Washington Monument.  My heart caught in my throat as a realized the fresh impact of what we were seeing.  We saw a house totally destroyed, with a slanting rough slab, now taken over by goats standing at the peak.  At least they wouldn’t be eaten at night, unlike the ‘free-range’ chickens with nowhere to hide.  I now had more sympathy for the roosters and realized why they were crowing at random hours.  Packs of hungry dogs roamed, seeking food, given the scarcity of left-overs.

I was privileged to see how they set up the clinic. Tables were put up, and blankets suspended and tied into make shift walls in a semblance of private rooms.  Chairs were at a premium, as were tables, so my nightmare and the list it led to was useful as the clinic began to roll. Waiting on fractured cinder blocks for stools or squatting Haitian style all around the periphery, huddled under a huge, slightly twisted corrugated roof with open sides, were perhaps 75 patients, some mothers breast feeding, others holding sleeping children, all eager but respectfully waiting for a turn. I was given a corner up on a cement dais and we saw our first patient.

Pierre, a shy, taciturn eleven old presented with insomnia.  He couldn’t sleep because he kept hearing the cries of a baby and the voices of dead neighbors.  He had been holding a neighbor’s baby when his house collapsed on him.  His mother could only see the boy’s head when she tried to rescue them.  Pierre tried to protect the baby in his arms, but it was gasping when his mother got them out, and died on the way to the hospital.  Pierre felt horrendously guilty, not helped by the baby’s angry grieving parents, whose house had also collapsed.  His mother explained that they weren’t really angry at him personally, but he felt guilty, even for surviving.  He had had a friend die three years earlier and had heard his voice for a long time, and kept thinking he saw him in groups of children.  I worked with the doctor to do the interview, using the interpreter to get feedback and give guidance, at times even speaking to her, the boy, and the mother in my rusty Creole.  Pierre had made it through the mourning of his previous friend, and we told him he now had more complicated grief work to do, but would do fine.  We reassured him that, as he told us, he really did all he could for the baby.  We emphasized he was a shy boy with a strong conscience, making him self-critical, and he needed to ease off.  We told him and his mother he was doing too much work at night in bad dreams and voices, and that they needed to bring the work into the daylight for more effective work.  We advised his mother to have a little session with him in the morning, gathering him and his thoughts and worries into her mind and arms, and another session before bed to help him clear his mind, reassuring him that she would hold the worries and work on them so he could sleep — like Guatemalan worry dolls.  We felt they would be a good team doing their healthy homework.  So we gave no meds, but scheduled a follow-up. They left encouraged and armed with self-help they could carry with them.

The next woman complained of severe palpitations.  On her way home after the earthquake, she passed many friends in front of their destroyed houses wailing for their dead or missing children, and she rushed to see how her five children had done.  She found four of them alive in front of their collapsed house, ‘Grace a Dieu.’  But her fifth child had not made it home from her school, which had partially collapsed. The woman wanted to rush out to find her, but her children reassured her she would come home, and she waited stoically.  Her daughter did eventually return, full of stories of other kids being hurt or trapped.  Three days later the woman had severe palpitations, in response to some random trigger that reminded her of her stoic vigil.  She was already on medication for high blood pressure, but she had never had this before, except when walking up steep hills. Now she was worried her heart was giving out, and that she was dying.  She let us know she was emotionally fit and able to help many of her grieving friends, and so she was sure that her heart symptom was physical.  We agreed she should see her doctor to get checked out, maybe even have that electrocardiogram, but after taking her blood pressure and taking her pulse rate, and listening to her heart, it did seem that she was physically okay.  She had the strength and intelligence to work this out in time, and in the meantime we gave her simple techniques to restore her trust in her body and in life.

I explained the endocrine fear response to her.  Her scary self-diagnosis was escalating her panic.  Her fast walking on the day of the earthquake would make anyone’s heart beat faster, and the new bursts of heart beats were normal fear responses triggered by thoughts, noises, or tremors.  She needed a couple of techniques to interrupt the beginning palpitations. So we taught her the partial Valsalva maneuver, in which she would hold her breath and bear down as if having a bowel movement. The Valsalva works to stop arrhythmia — and is a competence distraction.  We also showed her how to rebreathe from a paper bag sealed around the mouth.  We also suggested noting down each time she had such an attack, so she could outfox the triggers, and disconnect them with an “I told you so”.  She needed to be a kind doctor to herself, just as she was being a good friend to her friend, and not scare herself.  She got the hang of it, and understood the psychology and physiology of it.  She was a school teacher, and so I suggested she could help teach this to scared symptomatic friends, as she herself got good at it.

One other patient had serious insomnia.  Glassy-eyed and depressed, she showed us a certificate of scholastic accomplishment earned by her 21 year old son, his handsome photograph on the front.  Between sobs she told how he was teaching in Gressier, away from home for a while, and was crushed in his little room there by the earthquake.  We listened with near reverent attention, checked on her friendship and religious network, and noted her blood pressure was elevated.  She was consolable but in deep prolonged, but not arrested, mourning.  But it bordered on depression.  I suggested they give her atenolol, a relaxing, sleep-promoting, and anti-hypertensive agent to help her through this sad, sad passing.  She had other children to live for, but we would follow her up closely next week just to make sure she was doing all right.

We saw other patients today, and as time went on I relied on the Haitian doctor more.  We are hoping to give them increased front line competence, a good sense of basic psychotropic meds, and diagnostic acumen for triage and deciding when to refer for specialist care.  Referral should occur only when absolutely necessary.  There is not much psychiatric care to go around, and most people, even if deeply affected, are able to self-right with simple help and access to their own resilience, provided they have their basics met, that is, shelter, water, food, security, and social connectedness.

When I got back to the Residence office, I had to go with Stephanie, my director, and Peter, my colleague, to a meeting for all mental health leadership, which was boring, but necessary, a key brief encounter with the hospital administrator, from whom we must get approval as a hospital resource for medical and surgical inpatients requiring psychiatric intervention.  Though I love this kind of work, I’m feeling spread a little thin.  I also hear there is a movement to base me at the hospital instead of going out to the individual clinics –bad idea for the Haitian docs and nurses, and for the patients.  I am lobbying for staying clinic-based, and we shall see.  I noticed Stephanie was in a good mood, but had forgotten why.  Then I saw her screen saver again, and there he is, her friend and co-worker in Darfur, the man who was abducted for ransom, like her.  That was back in November.  After all this time, after losing hope, he had just been freed, and she was thanking her lucky stars.  It had been a long hard vigil.

Stephanie is a vegetarian, not really interested in food, and eats at sporadic times.  I cooked lunch Sunday, and I made dinner tonight, linguini with olives, onions, tomato and Prego mushroom spaghetti sauce.  Yum, after my fashion, and, Stephanie liked it.  I clued Crystal the cook in on the fact that we would be moving to consolidate all staff and volunteers, making 7 for dinner each night, with the volunteers used to hotel choices and lots of food.  Her eyes got wide, and she thanked me.  My Creole isn’t too bad in a pinch.

I must admit, though, that from a creature comfort point of view, I will be using Haiti, and this experience, as a litmus test of my materialism.  I may think what I am going through at times here is a near-death experience for me, but it is nothing to what the Haitians have gone through.  We had one other woman patient today who lost a child, an aunt, a house and a business, which was crushed and then robbed, and, a van that was trapped under a concrete wall.  So she is without even a tent and no means of livelihood.  She was depressed, and, I sensed, smoldering with rage.  She had been unable to reconnect with her Pentacostal Church, and she seemed close to needing meds.  We started her with a sleep med and not a heavy duty antidepressant, because antidepressants are costly and needed for a long time, and we sensed she might come around the corner. We will see her right away again next week, just to make sure.  Continuity and taking the mental pulse is the key.  We don’t want her remaining children to suffer a maternal suicide, given everything else.

Thank you all for bearing with me.  This blog is bibliotherapy for me, part of my self-care, something we emphasize around here.  It’s a great team down here.

Our Man in Haiti, Part IV

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Saturday came around fast. I had to stand up in front of local Haitian IMC clinic doctors and nurses, and talk for 5 hours about the psychosocial impact of what they and their patients had been through.  As I’ve said, public speaking and lectures are not my favorite thing.  I spent from 4 to 5 am floating on my air mattress, dealing with my anxiety.  Into my mind came the words of Maitress Erzulie Grand Freda, who had told me, as I left Haiti 50 years ago, that I would be successful if I worked hard, that maybe someday I would come back to visit and help her people in Haiti.  Thinking of her words and feeling encouraged by my association with the great IMC staff, I took heart, found my courage, and fell back to sleep, until 5:45, when the cock crowed for me.

I had come out to Petite Goave on the southern peninsula to start up our Haitian psychosocial training program here.  We drove to the Royal Beach Hotel for my first all day workshop, to be on Mass Trauma, Loss, Grieving, Front Line Mental Health Work, Treatment, Triage, Symptoms, and Major Mental Illness.  PTSD, though popular with the press and the world, would be a small part of it, since statistically, surprisingly, it is infrequent in mass disasters, if aid and care are given right.  We would cover the needs of patients with pre-existing conditions epilepsy, mania, severe depressive disorder, and chronic schizophrenia who lost their medicine and psychiatric contact because of the quake, and address new first breaks caused by the tremors and the scarcity of outpatient and inpatient psychiatry.  We hope to leave a legacy of psychosocially competent front line Haitian family practitioners when we leave in two years.

There were 12 Haitian doctors from our 5 clinics, 19 nurses, and others from Notre Dame hospital, and 5 from Croix Rouge with whom we have liaison.  It went fairly well.  I even spoke a little Creole to the group when the translator had trouble with my medical English and concepts. I did a group exercise teaching relaxation and imagery techniques to interrupt cycles of anxiety and repetitive thoughts, and then while in the relaxed state, had them visualize where they were when the earthquake struck, helping them recapture and work on their own inner experience so as to increase their emotional availability to each other and their patients. I stressed cost-effective front line stress reduction group sessions that nurses would lead for people they would identify – groups like the one I was modeling.

I had them form pairs and tell each other about what they had been through, and then used their own thoughts and feelings to illustrate the symptoms and expectable phases of recovery for those without psychiatric diagnoses.  We talked of acute stress symptoms, and how rare chronic serious post-traumatic stress disorder is, and how early intervention on the front line reduces its occurrence drastically.  Without that support in war zones and earthquakes like the one in Haiti, PTSD results from seeing and dealing with dead bodies, and rape, abuse, and violence.

The workers told me that they felt guilty about the long lines ever day and the brevity of their problem-focused encounters with each patient.  I reminded them that their Haitian patients are used to waiting for care.  And in this case they will get care like they had never had before.  Even waiting in the clinic, being near their doctors, and knowing the Clinic is there for them, is helpful.  They deliver care in open tents with all watching, and the word gets out that help is there.  I said that they should never underestimate the importance of using themselves as a powerful part of the healing.  By their presence and their manner of caring, the front-line workers become a transference object of great importance for the camp and village.

I stressed the importance of their presence at the camps and destroyed villages.  I reinforced the impact of their caring, their laying on of hands, their quick but careful exams, their mental health first aid, and triage.  As front line workers, their work and reassurance gives hope and momentum to recovery for this impoverished, yet strong and resilient Haitian people. I reminded them of resilience, and advised them not to over pathologize what they see. I emphasized the need to see their patients’ (and their own) weird thoughts and feelings as normal responses to abnormal experiences, and to set them in the context of the normal, expectable stages of mass disaster recovery.  That’s the way to help their patients not to get stuck and become chronically symptomatic.

Once they felt comfortable with me in discussing the needs of their patients, several nurses and doctors shared their personal experiences of losing family members, seeing their houses destroyed, and living in tents outside their houses.  About a third of them had been affected.  When the topic of tents came up, I noticed two nurses looking down and huddling privately.  I finally asked if they could share what was going on.  With some embarrassment but plucky honesty, one of them confessed she didn’t even have a tent yet and was living outside with family members in one of the camps, grateful the rains hadn’t come yet, and proud she made it to the clinic every day to work, somehow looking clean and kempt.  The clinic was clearly a beacon of hope, care and support for her.  And her own experience gave depth and meaning to her work.  It raises the question:  “Who takes care of the care takers?”

One young doctor came up to me afterward, doubtful about the purpose and usefulness of the group exercise.  When I explained that it had to do with taking care of yourself as well as your patients in times of trauma, his eyes rimmed with tears and he told me about pulling children, some dead, some gravely injured, from under crumbled concrete slabs in the house next to his after he and his kids got out safely, before both houses collapsed.  I’ll be working with him in one of my weekly clinic rotations.   I was deeply moved by my experience wit him and with the group in general. The workshop certainly broke the ice for me, and I hope for them.  Now I am poised to go out and work alongside them.

It seems tents are now in short supply in Haiti and there is still great need.  We have enough tents in our privileged IMC ‘camp’.  We are well taken care of, mostly.  So I have a tent that I am not going to be using.  My extra tent was a gift from a friend who sent me off with a lot of camping stuff, urging me to give it away when I left, bless his soul.  So I plan to give it quietly to this nurse when I go to her clinic, secretly so as not to stir up envy, or a perception of favoritism by IMC.  But that other nurse huddling with her may be in the same plight.  So I have sought a more systematic solution.  I asked Stephanie, my NGO administrator if she can get tents for our clinic workers in need. I don’t want to wait on bureaucracy, but Stephanie seems to make mountains melt for her people.  She’s my kind of NGO person!

My only complaint about Stephanie is that she wouldn’t like me to visit my old field site because of security concerns over the increasing risk of abduction. She said that one abduction can cost an NGO $30,000 to $50,000, and she emphasized that this would mean that hundreds of refugees would have to go without food and care because of the wasted funds.  There was something strange about how she tightened up and how guilty she sounded, and how she used the image of starving refugees to persuade me not to go.  I learned that she had been abducted for 25 terrifying days in Darfur, before negotiators got them to release her.  But all she seems to feel about that, besides wanting to protect us, is terribly guilty about how much she cost IMC for her ransom, and the loss of money for care of the people in Darfur.  She has a lovely amulet she wears every day, given to her in gratitude by her people in Darfur.  I find myself tearing up again as I write this:  I have such admiration for this woman.  Stephanie said she felt she could probably get some tents for my nurses in the next week.

Speaking of Stephanie and tents, just the day before my workshop I had visited a clinic called Beatrice, at the top of a high hill, with a tent city surrounding a small village.  We also visited Petit Guinee, a destitute and now ruined seasoned village, and Trois Soeur, a tent city around a monastery.  Later that day a huge wind came up, and when I got back to the staff residence, I discovered that the big tent covering the Beatrice Clinic had blown down, with everyone in it.  Stephanie was frazzled because she had been called, as usual, to rescue the situation, and had spent the afternoon putting the tent back up with the staff.

After my workshop, I treated myself to a Haitian lobster dinner at the Royal, and two Barbancourt rum and cokes.  I enjoyed the ‘Strict Badou,’ a jazzy, professional Haitian group, with appropriately strong island flavors.  I slept well last night.  Even the roosters failed to rouse me.  Today is a day of rest, and a chance to write.  I made an omelette for me and Stephanie, and gave my novel to Peter who was complaining about nothing to read.   So that’s it for now, except for preparing my materials for my first clinic tomorrow.  I look forward to beginning my clinical teaching and training, though I’ve already begun to worry a little about my lecture in Port-au-Prince at the Mars et Klein Psychiatric Hospital next Saturday, possibly on Adolescence.  I’m all prepared for an Eating Disorder lecture, with slides, but somehow that doesn’t feel quite right for down here.  Anyway, type A is interfering with my day off.   Talk to you later.

Back in Touch Next Week

Our Man In Haiti, Part III

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Fifty years ago when I was 20 I did my anthropology fieldwork in Masson, named for the remains of an old French plantation. I would periodically take a break, hop on a brightly colored Tap Tap or small camionette, and head back to Port-au-Prince to join the Richardot family.  Jean Bleyfus Richardot was head of the United Nations Economic Commission to Haiti at the time, and his lovely daughter, Caroline, had caught my wandering eye.  Her gorgeous mother was not far behind.  We’d go up to the grand Petionville Country Club, swimming, attending a posh cocktail party, swarming with the elite, Haitian military brass and politicians, and NGO officials.  The place would be filled with glittering jewels and conversational gems, awash with five-star Barbancout Rum and festooned with Bougainvilleas.  Things were different then.

Today, I awoke early, knowing for whom the cock crowed, and, with heart in throat, traveled up to Petionville, not with the Ricardots but with Dr. Peter Hughes, a fine Irish IMC psychiatrist, and not for leisure, but to visit our mobile clinic, staffed by Haitian nurses and doctors, and our medical and nurse volunteers.  We turned into the familiar gates of the Petionville Country Club, the metal letters of the name dangling from loose screws.  We were confronted with a jungle of military and NGO vehicles, gun-toting marines, blue-scrubbed doctors and nurses, and Haitian vendors all plying their trades.  I looked over at the tennis courts.  One of them was covered by a behemoth tent housing a dozen small tents, a small orphanage compound, and supplies.  Two courts were pock-marked by tire tracks leading to the back tennis courts where army vehicles and supplies were stored.  With apprehension and curiosity, I walked out onto the Club terrace.  I saw cracked columns, and huge jacks holding up cement cross beams, camo partitions and windbreaks obscuring my view.  The NGO’s (non-governmental organizations) including IMG, were gathering on the left, and the army was on right.  The army guys were buff in their camo fatigues, lounging in front of a huge TV watching March Madness.  Zombie-like I walked forward to the edge of the terrace.  I looked over the empty pool at the withering Bougainvillea, bearing faded red flowers.  I could just see, over the brow of the hill, three NGO tents, their names emblazoned on the sides, and a few army vehicles.  With its panoramic view of Port-au-Prince and the mountains shimmering in the mid-day heat, I could still see the Club’s former grandeur.

Peter, Kettie, our superb Haitian psychosocial nurse, and I had a pre-arranged rendezvous with a Canal 24 television reporter and her video cameraman.  We were their entrée into the camp below, and they were possible resources for donations to Haiti Relief.  And long term relief is essential.  We walked together over the brow of the hill.  I caught my breath at the sight of the multi-colored mosaic of a tent city now housing 40,000 Haitians.  Following the contours of hills and ravines in all directions, the city was displayed like a Cubist painting.  Our group clinic is nestled in the middle of this tent city. NGO psychosocial care and health groups are scattered throughout, and others are placed strategically around the periphery.  We threaded our way down into this warren along dirt alleys, zigzagging our way between tents, Haitian blankets spilling out of their tents onto these walkways, kids playing, mothers nursing and cooking, and men and women selling their wares every few feet.  We met with civility and curiosity at every step, and I often stopped to say a brief hello in Creole, and got a smile and polite hello back.  I took a picture of two girls combing the hair of their Barbie-like dolls, and a bunch of boys with kites made of refuse, one flying quite high.  And then there was the long string trailing behind a little boy with a piece of red refuse at its end.  I caught on quick: He had a red puppy on a leash.  I yelled when Peter almost stepped on it, saying, “Watch out for the puppy!”  The boy and his friends cracked up.  The child psychiatrist in me was on the look out for resilience and strength, and not just tragedy.  We spent several hours at the clinic seeing psych patients, teaching the young Haitian psychiatrist and learning from him about front line work.  We were in awe, as we watched the other doctors see 70 to 100 patients each couple of hours.

I kept thinking back to the Petionville Club.  Its transformation was mind boggling.  It stirred confusing emotions in me, sadness, respect, appreciation, and hope mingled with anger at the cost of the earthquake, Haiti’s impoverished condition, and its smoldering future.  If the Haitian government, despite all the help, takes too long to pull itself out of disarray, there will be trouble. The OXFAM people are worried about various scenarios in Haiti, any of which might result in the complete collapse of government authority and a surge of wide-spread, violent civil unrest.  I heard from a young friend who is studying international relations that the consensus is that the situation may well deteriorate quite rapidly over the next month as the country descends into chaos and a violent upheaval takes hold.  Her father wrote to me, “You may have seen the beginning with the kidnapping incidents, but it could get a lot worse.  Do you have a weapon?”

But my time was up in Port-au-Prince.  So I packed up early two days ago.  I am actually beginning to miss my little tent which had come to feel like home, all cozy and organized.  Even a rooster came clucking and crowing behind my tent to wish me goodbye.  I took pictures of Pierre and Carmen and Alice who fed us ‘di ri ak poi rouge’ (rice and red beans), ‘di ri ak jon jon’ (rice with french peas and jon jon flavoring), overcooked chicken, and ‘banan peze’ (flattened fried rounds of Plaintain), among other things.  We spoke Creole together which pleased them.  I said my good byes to staff, and followed my driver to the IMC Rangerover.  I had thought the drive to Petit Goave on the Southern peninsula would take 4 or 5 hours.  He told me 2.  Just driving to the Gressier Clinic the previous day had taken 1 and 1/2 hours.  So, I was dubious.  We wound our way down the mountain past the chaos of UN yellow tee-shirted Haitian conscripts working to clean the debris from the sides of the roads, where everyone had piled the debris of their shattered houses.  There were more bulldozers and dump trucks lumbering about, often ancient Mack trucks from the ’50’s kept alive by canny Haitian mechanics.  We crept through Carrefour intersection, amidst teams of brightly colored tap taps, camionettes, and huge camions, each with their own pictures hailing Jesus and pop stars, with Grace a Dieu, and Jesus Sauve Tous, written on the front.  The good ship Comfort, all white with a red cross, had departed.  The road was flooded and rutted down 12 inches deep.  The Marines who built it in the 30’s would be aghast.  We drove past the mix of standing, tilting, and crushed houses that I had seen when I went to Gressier Mobile Clinic yesterday.  I recalled again the volunteer doctor who had talked of seeing the sparkling azure blue see and waving palms, beyond the few standing houses.  He felt it was all beautiful, until he realized that he was passing a huge graveyard of unearthed bodies on either side.

We got to Gressier in the expected 1 and 1/2 hours, and shoved on.  The road improved, and my driver began to rocket along, careening around curves, even pulling out around tap taps and huge slow moving Camions, barely pulling back in after a kamakazi chicken game with a daredevil coming the other way.  We had had a security meeting the previous night about the abducted volunteers from another organization (I found out that morning they had been returned alive — for a price), and in passing they commented that if our drivers scared us, or took chances, we should ask them to slow down.  I kept quiet, being used to the Haitian driving and wanting to get there fast.  Unwisely, I kept taking off my seatbelt to take pictures on either side, at one point thrown forward as the driver came to a screeching halt in front of a gaping jagged hole, the Zeus mark of the earthquake.

Finally we crossed the Momance River, and my heart pounded in my chest.  We were at Brache, where I used to get off my Camionette to walk toward my field site at Masson on the blue Caribbean.  It was vastly different.  I don’t mean just the fifty years of build up, including Leogane’s encroachment.  When I heard about a guy from Masson collecting money, I had been dubious.   How could mud huts held by wattle be affected by the earthquake?  But when I saw the devastation, I gasped and my eyes welled up.  The driver slowed down to see what was wrong with me.  He had no idea I knew any Haitians, especially way out in the boonies, but there I was, a tear-rimmed shambles.  I let him know everything about the friends who were gone or missing, and then he told me what had happened to his family.  He had lost his aunt and his house.  After our sad sharing we spent several minutes together, leveled by the earthquake. I told him I wanted to visit the families I had studied.  I wanted to bring them photos I had taken of them as children, and of their parents and grandparents, as well as a nice gift of all my camping stuff and clothes I am using, and (though not mentioned to my driver) a big gift of American cash I had brought with me.  And in Haiti, the greenback is still king!  And I must say, I see USAID tents and tarps everywhere, and the military standing tall and beautiful.  Those yellow t-shirts along the way make me smile.

To my surprise, as we crested a hill, the vista of Petit Goave stunned me. From the pass we could see a majestic bay, with large ships, and a few scattered sailboats curving into a harbor, cradled by hills and mountains, still fairly green.  It was breath-taking, a part of Haiti I had forgotten, since I saw it only briefly on my quick trip my last summer.  Once we entered Petit Goave, my smile faded as I saw the crumpled buildings beginning, and the myriad clusters of tents — blue (UN) and white (USAID) — and other hews of the rainbow from other groups, from Tibet, and Japan, and Mexico, and France, and Canada.  The international care and gifting is amazing.  I was just told that over 900 groups are here right now.  And there are these incredibly ramshackle constructions everywhere, makeshift from every salvageable piece of debris, made by the poor not receiving aid.  It seems 3/4 of the population is living outside.  That’s the incredible short of it, though the long is more complex.  People are living outside of their houses because they are destroyed, because they are too dangerous, because they are under reconstruction, AND because the inhabitants are terrified of aftershocks.  In China many villages in quake-prone areas keep deer penned outside the village with a person dedicated to watching them.  Deer are incredibly sensitive to the slightest ground tremor — great for avoiding approaching predator, AND pre-shocks of approaching earthquakes when the tectonic plates begin slight shakes as they build up for the big one.  Well, people here are now as sensitive as deer.  In a second, I’ll give you an example.

We first pulled up to a gated beach side hotel, which looked promising, but then we found out the residence where I was staying was elsewhere! Off we went, down the dirt side- road of the National Highway filled with small or shattered houses at first, then a few larger gated houses, until we reached one with a guard.   The drive had, indeed taken just over 2 hours, though I had my eyes shut for most of the last of it.  Except for taking in the view from time to time. Stephanie, a French Canadian, the cute young director of our IMG unit, greeted me, her cell phone glued to her ear.  She was doing a million things, full of energy and excitement.  Lunch was underway, which was quintessentially Haitian, except for a veggie stew because our young director is vegetarian.  Tom, a Kenyan evaluation guy from Port-au-Prince, Jattu, a black Russian and English speaking clinical assistant, and Joanne, our Psychosocial Haitian assistant were there.  Right away, I discovered the nurse clinician to be appointed for my team had decided not to take the job, and so I was evaluating resumes for that position.   Stephanie asked if I wanted to stay there, or at the Hotel where she had a room for me.  Stupid me, now a tent addict, I said I’d stay there, close to the staff action.  Well, at about 6 o’clock everyone disappeared.  Stephanie went out and the others departed for the hotel.  I deployed myself in a tent 4 times the size of my homey pup dome tent.  Now down at sea level, instead of up on Petionville, it was HOT.

The weather has been perfect, beautiful blue skies since the third day, no rainy season yet.  But hot, and HU-MID!  The exertion of going to bed works up a sweat, and my exercises make me drip, but my back makes me stretch.  One good thing, I have lost a LOT of weight, so much that I can get my knee not just to my chin, but almost to my ear.   But I’ll tell you why.  Lunch was also dinner for me, the one consumer.  When Stephanie returned, she said she had already eaten.  Not exactly a mother hen.  So I ate what I could, the salad having been sitting out all day, BUT with beets in it, which were irresistible to me, though where the hell did they find beets?  When Stephanie stopped gyrating, she told me that another team had just been added for me to teach, and also that there had been another kidnapping of an NGO volunteer, up at the other end of Haiti in Cap Haitian, where Henri Christope the liberator  of Haiti had his chateau Sans Souci, and his Citadelle, with canons that could make the earth shake and carry 20 miles to the bay, should the French return.  So we were in tighter lock down, and I was informed I couldn’t go out alone.  I was feeling trapped.  The ground was shifting under me.  I was worrying about preparing an all day workshop in two days and organizing and implementing their master clinic plan — not good for a type A guy in retirement.

While I was talking to Stephanie, I saw her jump and start to bolt.  “What’s up?” I said.  “Didn’t you feel that?” she said.  “What?”  “That small aftershock!”  Frankly I didn’t feel a thing, but today it was all people could talk about, that some people were eating dinner at the hotel while the other half were leaping up and running out lest the thing continue and the ceiling cave on them.  Some people, I would say, now a little hypervigilant, turned into a bunch of post-shock deer.  But then again, if I had been through what they have been through I would be hypersensitive and out the door.  Anyway, I had awakened early, so I was eager to email my wife Patti, or hopefully reach her on Skype, so I went to the internet only to find out it was down and had been down all day.  Stephanie went out to do a security briefing.  So there I was – left, alone, having to prepare my talk, which was not my favorite thing to do, lonely, cut of from Patti, no real food, no company, and a strange new tent to sleep in.  Well, I frittered around for about an hour, reviewing things, then hit the hay, or, rather, the air mattress, once again feeling swamped and disorganized.  Where was my psychiatric side-kick, Peter, when I needed him?  I gave him a buzz, told him I’d lined up four nurses for us to interview when he arrived, and he said great.

I was amazed how disabled I felt with no internet, but sleep beckoned, except that my friendly roosters were replaced by the late night carousing of radios of some nearby Haitians and NGO workers. And yet, all was music to my tired ears, as I thought about the mission I was on for all my Haitian friends.  I would only have to be in the altruistic humanitarian mess for three more weeks.  I could stand it, and give as best I could.  My time was now here.

Back in Touch Next Week

Our Man in Haiti, Parts I and II

By Kent Ravenscroft MD

IPI Emeritus Faculty

Part 1

Haiti is an amazing country. It is devastated by yet another disaster, yet the strength and spirit of Haitians is stunning.   I know it well.  I spent time there as a young man learning Creole and writing my thesis on possession and its link to dissociation.  Now I’m in Paris living at the other end of the spectrum.  I hear firsthand from friends who still live and work in Haiti that the devastation is ghastly.  They say that International Medical Corps (IMC) is co-ordinating support efforts well, and that as a child psychiatrist I could be useful to distressed families there and to people suffering from post-traumatic stress disorder and psychiatric sequelae of physical trauma.  I am powerfully drawn to help, and with my wife’s blessing, I decide to leave Paris for Haiti.  She tells me that her sister, a nurse, heard from her colleague on the American hospital ship Comfort off the shore of Haiti, that they’ve been swamped with the worst cases.  No-one in Haiti has seen ANYTHING like this.  No war zone compares.  I am about to leave when my wife tells me this, and asks me if I know what I am getting myself into.  My anxiety shoots up and I make her stop telling me.  It is time to go.

With $300 worth of overweight medical supplies and equipment, I fly to Haiti from Paris.  On the flight I meet a team of water-purification and rescue workers and a top manager from WHO.  Within two weeks of the earthquake the man from WHO was co-ordinating 240 humanitarian groups, medical and otherwise.  Now there are more, but some are pulling out now as the acute phase ends.

In the air I feel a sadness, the return of the repressed, depressed feeling of missing the Haiti I had known 50 years ago as an idealistic, enthusiastic young man, because of the destruction and loss on the ground, resonating with the stage I am at in my life, and  because my last summer there had been a hard one.

We are one of the first commercial flights to land in Haiti, and I am one of the first child psychiatrists to arrive.  The airport is as chaotic as ever, entrepreneurial Haitians hawking baggage trolleys for $2 dollars (American), and several eager cabbies grabbing me and my stuff.  At last, Matthew, the International Medical Corp driver, finds me and the other new doctor, Zurob, who is from Russia, Georgia actually, and we set off for the Plaza Hotel.

Matthew drives Zurob and me through streets lined by collapsed houses and rubbles, teeming with busy or displaced Haitians, past huge tent cities.  Lighting is spotty, and the destruction massive but strangely spotty.  The gaily painted buses and vans move at a snail’s place, with traffic jams everywhere.  Images slide by: A nursing school with 200 young souls, crushed to eternity; the once gleaming, white Palace, of Papa Doc fame during my years there, now lop-sided and caved in, too scary for President Preval to work in.   Matthew and I jabber away in Creole and French, while Zurob pores over his tropical medical manual as we jounce over an incredibly pock marked road, now strewn with rubble.

When I arrive at the Plaza Hotel, I find the main rooms filled with cots and mattresses, eager, excited, exhausted young physicians from all over the world, coming back from a day’s work in one of the remaining hospitals or outlying clinics.   Everyone is talking about life and death, the resilience of the Haitians, the malingerers, and those wanting a doctor for old ailments. Triage, compassion, and breathtaking work is in the air.  I feel anxious and out of place, no one at first receiving or orienting me.  Then it is time to eat – at a surprisingly sumptuous buffet.  The other volunteers begin to clue me in about how wonderful the effort and how great the support from the leadership of the IMC is.  Other volunteers show me where to find a spot to sleep, and tell me about cornflakes for breakfast, about lights out at 10, lights on at 6, bus leaving at 7 for the hospital, AND, where to find the WiFi, which is good, and where to exercise.  I eye the pool eagerly.  Security is good in the compound, not as good on the streets, the staff being like mother hens for us chicks.  My fear of losing 40 pounds as I had done that first summer has evaporated.  I have landed in comfort.

This was not to be for long. I meet Nick, a British psychiatrist, the next morning, with our driver, a Haitian electrical technician with a generator, and a translator, a great guy, but oddly for one in his profession, he stutters.  We sit on morning rounds which last all day, with no food at all.  We go to WHO’s PROMES facility, a huge warehouse complex, to get psychiatric meds for a Psychiatric hospital we are to visit beyond the airport.  We run into red tape for three hours, and then the traffic is incredibly bad, but we finally reach an alley behind caved in buildings and banana stands, bumping over cess-filled ditches, which will finally get washed out now the rainy season is beginning, and that will be good until the mud slides began.  This reminds the electrician that, though the stench of bodies decaying and of rats has abated through dessication, the rains might stir things up again.  The electrician is stoic until we pass a collapsed building where a dear friend was buried.  All the while, Nick is leading us onward, and briefing me about our teaching mission for young Haitian professionals and support and consultation in the hospital and the outlying beach-head clinics.  He is wonderfully British, very warm and supportive, wise and caring, and inspiring hope and confidence in me as I try to imagine myself once again working on the front lines in the trenches under such difficult and compassionate circumstances.

Finally we reach a nondescript gate opened by a shotgun-toting guard to reveal a huge open space ringed by caved-in one-storey buildings and walls, a collapsed primitive kitchen, a tent city, a patient with an American flag bandana screaming and gesticulating, two women frozen in bizarre positions, men marching her and there, half naked women leaping around the grounds, goats feeding and prancing about.  Nick is walking with the psychiatrist, doing a needs assessment as I trail behind, saying hello to all the curious patients.  I meet one who speaks English.  He has just won a Port-au-Prince award for his wonderful drawings, and he wants to give me a portrait for helping them.

We deliver the huge supply of meds, my friend the electrician installs the generator for their water supply, and the heavens begin to rain on us.  Some patients tell me they fear that their gleaming white canvas tents from Russia are old stock and might leak.  Two excited patients insist that they have their picture taken — I oblige.

When I get back to the hotel I am told to pack up to come to the residence where the staff of IMC live, to get to know them better.  I would be oriented to clinics the next day, today, in preparation for assuming leadership next Thursday in one of the outlying clinics in Petite Goave.  The last tremor, the Translator told me, in between stutters, happened a week ago, with a huge, cracking, snapping deep groan, and a slight convulsive shake.  Nick tells me that when one of the earlier major aftershocks happened two weeks earlier, everyone moved outside to sleep from then on.  Some of the surgeons and nurses got freaked out and insisted on leaving immediately; others now sleep inside at the residence; and I now sleep in an assigned tent outside.

Today I head in with Nick to work in the Hospital Psych Clinic where I will begin warming up my skills – medical, psychiatric, and linguistic.  I am inspired, daunted, challenged, and glad I am here among impressive groups and dedicated younger people.  I’ll try hard as I put my ancient oar in these troubled waters.  May the good Lord and my ancient friends, the Voodoo gods, look kindly on our efforts.

Part 2

Yesterday, I went with Nick to see the IMC facility at the Haitian University Hospital, mostly under Haitian control.  The IMC triage, outpatient, ICU, and medical units are in tents.  First we visited the ICU to see a 30-something woman with symptoms of periodic rectal bleeding, and paralyzed left arm and both legs.  The paralysis distribution didn’t make sense, nor did the bleeding pattern. She looked good, showing la belle indifference, which came on more recently, after the quake, and this fit with the diagnosis of hysterical conversion reaction.  Thinking more about the intermittent bleeding pattern, I concluded that she might be faking or feigning her symptoms, which fit the diagnosis of Munchhausen Syndrome. She was a nurse and would know what to do to generate these symptoms.  I just didn’t know how.  In cases like this, I always wonder if I might be making a mistake and I fear that I am missing something serious.  We told the nurse and doctor our thoughts, and advised that she should be transferred to the step-down medical unit because she was taking up valuable urgent care space.  Shortly after we left she had a significant bowel movement with bright red blood, though her colonoscopy was negative.  When we came back this morning, we found out that they didn’t transfer her.  They gave her an indwelling venous catheter to give her blood if urgently needed.   I suggested the next time it happened they should compare her own blood type to the blood in the bowel movement.  I was fairly certain it would not be hers, though I could be wrong.  She still had her paralysis.  While she thought that we weren’t looking, we noticed normal hand gestures in the paralyzed hand while she was talking to her sister.  We were encouraged that she would recover.

The next patient had lost his leg below the knee and was recovering from shock and speechlessness.  Next was a woman with a manic reaction, speaking fragmented English and singing American songs at us, demanding to be let out.  This state of mind had been precipitated by seeing her house collapsing in front of her. Next was a woman who had been hearing the voice of a god inside her head beseeching her to be more faithful, and she was getting better on a mild sedative and so that suggested a diagnosis of temporary confusion, not psychosis.  We saw a quietly sad woman with paranoid delusions, who was homeless and had been found walking naked.  She was pulling herself together.  Another woman who had seen her house collapse had been thought to be psychotic.  Today we got a better history from her and diagnosed psychomotor epilepsy complicated by severe anemia. The two Haitian nurses rounding with us, giving the psychiatric meds, and doing the follow-up supportive therapy, were bright, gracious and serious.  I found my Creole wanting in these situations, and had to turn to them and to the translator.  The translator was a great guy, very bright and helpful, but he stuttered.  What is going on here?

We were late to get over to what I mistakenly heard called Calvin Klein hospital where Nick delivered a great lecture to a roomful of fully participating Haitian nurses and doctors, with the hope that we would be able to influence the situation sooner or later.  (How will I do???) The grounds were covered with tents for the displaced, and all during the lecture there was a horrific metallic banging.  I found out it came from the inmates in isolation cells.

At breakfast this morning I am very sleepy, kept up by very disoriented and disturbed roosters who cried out randomly all night.  I got to know their individual cries, their personal signature calls, and I knew where they lived.  I dealt with my irritation by thinking of purchasing them for dinner.

The head of the outreach team, a young woman who has worked in Afghanistan and Iraq, and was one of the first into Haiti, has arrived.  She asks each of why we are here.  She has in mind a triangle of categories and wants to figure out where we fall in it – careerist, adventurer, or tree hugger?  I am moved by each personal response.  I appreciate the IT specialist objecting that tree hugger isn’t fair for idealists who should be respected as people of balance and realism too.  He tells us his own terms:  Mercenaries, missionaries and misfits.  Just as I am feeling more at home, someone comes in to announce that two women from Medicins sans Frontiers have been abducted last night and that the Haitian NGO community is waiting for the ransom requests.  I am now taking security warnings much more seriously.

I just found out from the Director what I will be doing here in Haiti for the next four weeks. She has designed a mental health clinic, to be attached to a small Haitian general hospital now partly run by IMC in the outlying town of Petit Goave, a little way out on the southern peninsula.  This is a new clinic, not yet functioning, with a Haitian social nurse and a translater.  I will be creating and running the clinic, which will treat outpatient referrals from the hospital’s follow-up, OPD, and family practice clinic.  Haitian family practice doctors in three nearby outlying family practice clinics will rotate one day a week into my clinic to see our patients and be supervised by me, or see mental health patients with me, to train the family doctors to incorporate mental health interview and intervention skills into their frontline work. On another day I will rotate through 4 ‘boat’ clinic outposts to do the same thing.  On two out of my four Saturdays, beginning this Saturday, all the clinic Haitian Health Care workers will come in to have an all-day Saturday mental health workshop.  Hearing all this makes me feel a little anxious and overwhelmed, especially since the trainees are all Haitian. So the workshop will be in Haitian Creole. Not that I have to do it in Creole, since I will have a translator.  But, never the less it makes me anxious.  Even in English, preparing and giving lectures is not my favorite thing to do.

I will be moving out to Petite Goave Thursday to do the first Saturday workshop and start the clinic on Monday.  I will have Wifi out there, so I am told.  I will have Sundays off, and Fridays for paperwork and lecture prep.  But even sooo!

Panic Focused Psychotherapy Study

By David E. Scharff, M.D.

Among the sessions I attended at the Winter Meetings of the American Psychoanalytic Association, one stood out on the findings of a randomized control trial of a new and manualized psychoanalytic treatment for panic disorder, overseen by its principal researcher, Barbara Milrod of Cornell Medical Center in New York City. The presentation was chaired by Stuart Hauser, a leading analytic researcher, and discussed by Peter Fonagy.

I’m writing about it here because it is a hopeful and beautifully done addition to our armamentarium concerning the efficacy of psychoanalytic therapy. It adds to studies being done by Fonagy, Target and their group in London on Mentalization-Based Therapy, and by Otto Kernberg’s group at Cornell, White Plains on Transference Focused Psychotherapy. The studies apparently have a good deal of overlap in their systematic use of transference and basic analytic techniques applied to a brief therapy that is therefore much easier to test for outcome.

In this study, Dr. Milrod and her colleagues treated Panic Disorder – including such symptoms of acute anxiety as intense fear, chest pain, heart palpitations, and shortness of breath — precisely because Panic Disorder has been a focus of CBT and medication outcome studies. Since these studies have been based on 12 weeks of treatment, she designed her Panic Focused Psychotherapy (PFP) study to conform to these parameters so they can be compared. PFP treatment is manualized in a manner similar to Kernberg’s Transference Focused Psychotherapy (TFP), but this is much briefer — 12 weeks of twice-weekly weekly as opposed to a year of therapy for TFP.

(Patients were left on medication if they were already on it at the time they began the study, so that is not in the comparison. Obviously, if they were on medication at the beginning of the study, it was not in itself curing the panic disorder because symptoms of panic attacks had to be present for a subject to qualify for the study.)

Panic Focused Psychotherapy begins with initial evaluation of the symptoms, relating them to the surrounding circumstances and attendant feelings, exploration of the personal meaning of symptoms and episodes. Then the therapist works to identify relevant psychodynamic conflict, focusing commonly on issues of separation, autonomy, and anger. In the first phase, therapy aims for panic relief and reduced agoraphobia.

The second phase of PFP explores panic vulnerability by addressing transference manifestations, and working through the many situations of conflict. In this phase, therapy hopes to result in improved relationships, less conflict and anxiety in the experience of anger, separation and sexuality, and reduced recurrence of panic. Finally, a termination phase permits re-experience of conflict around separation and anger themes in the transference, because a frequent temporary recrudescence of symptoms during termination allows for a review of problems that can again lead to an enhanced ability to manage separation and experience autonomy.

In a paper published in February of 2007 in the American Journal of Psychiatry (164:2 pp 265-272) Dr. Milrod and her colleagues reported on the preliminary study that showed 73% efficacy compared to 39% for Relaxation Therapy. This study prepared the research for later comparison to medication and CBT. But at the presentation in January, Dr. Milrod presented preliminary data on the comparisons going forward with CBT. So far and unofficially, PFP holds up well against CBT and especially shows a better capacity to maintain gains months after the completion of treatment. Although the treatment is “manualized” it is not a rote treatment. The manual offers a guide as to what issues to focus on in evolving phases of therapy. There are compromises with the way we practice analytic therapy that are required to construct such a manualized treatment, but anyone who has read Michael Stadter’s excellent book “Object Relations Brief Therapy” (Jason Aronson, 1996) will recognize the enormous overlap in methodology. Stadter’s model is one of a combined focus on the symptom and the dynamic unconscious structure that underlies it, all treated in the transference using working through and a late focus on termination and loss. Brief analytic treatments can be tested, while it is exponentially more difficult to do so with open-ended, long term therapy. These studies, done in ways that can be compared directly to CBT and medication, offer to give us the ammunition to defend our trade in clear and legitimate ways that have, until recently, been sorely lacking. Peter Fonagy spoke with deep appreciation of Barbara Milrod’s study, particularly noting how arduous and time consuming such studies are, and how thoroughly and rigorously she and her colleagues were in the conduct of this study.

Webb MD’s Denise Mann reported on January 17 that, “The psychodynamic psychotherapy regimen used in the study was so successful that the American Psychiatric Association is in the process of changing its guidelines to reflect the new findings, according to researcher Barbara Milrod.”(Until now the APA has only endorsed CBT and medication as treatments for Panic Disorder.)

This research and the few comparable studies now going on are a cause for hope for our way of thinking and practicing. I look forward to more results from Dr. Milrod and her colleagues.