Metaphors as Contextual Evidence for Engaging Haitian Clients in Practice: A Case Study

Introduction

The need for effective and culturally based response strategies has become more urgent as the number of ethnic minority clients in the United States (U.S.) continues to increase. The absence of relevant and efficient strategies to address mental health and child and family matters for these clients continues to challenge practitioners every day. Underutilization of mental health and social services in community settings may be related to a lack of effective engagement strategies on the part of practitioners (Berger, 2010). Research shows that understanding the social environmental context increases client engagement when cultural content is part of the practice context and is incorporated in the helping process (Liddle, Jackson-Gilfort, & Marvel, 2006). Contextual evidence becomes the framework for best practices with minority clients by placing the focus on cultural strengths and resiliencies over the traditional model focus on deficits.

Although individuals of Haitian ancestry have had a noticeable presence in the U.S. during the past several decades (Boswell, 2005), and comprise an underserved racial and ethnic minority population, they have been recently thrust into the spotlight due to the January 12, 2010 earthquake that traumatized the island nation of Haiti. Developing cultural-specific practice strategies to engage Haitians in the U.S. who are impacted by loss in their Haitian-based social networks requires an understanding of the ecological culture of Haitian clients, which includes the environmental factors (background and living situations before and after immigration), the displacement experience itself, the psychological/emotional reactions to the displacement, coping strategies used in the adaptation process), and the consideration of relevant linguistic and cultural elements. One specific piece of contextual evidence to be considered is the use of metaphors as part of cultural language and as an engagement strategy. Metaphors are highly relevant to the context in which Haitian clients exist. Thus, an emphasis is made in this article to understand the ecological context for engaging with Haitian clients through the use of metaphors.

The Haitian immigrant presence in the U.S. has increased steadily over the past several decades and recently in specific areas such as South Florida. Concomitantly, Haitian-specific literature has emerged to guide practitioners in their work with Haitian immigrants. Such literature provides knowledge concerning immigration, social, economic, historical, religious, health and acculturation challenges that immigrants from Haiti face (Aparicio & Kretsedemas, 2003; Boswell, 2005; Brodwin, 2000; Castro & Farmer, 2005; Colin & Paperwalla, 2003; Corbett, 1988; Coreil, Lauzardo & Hertelou, 2004; Cosgray, 1995; Farmer, 2006; Florida Department of Health, 2003, 2004, 2005; Fouron, 1983; Jean-Louis, Waker, Apollon, Piton, Antoine, & Mombeleur, 2003; Jimenez, 2001; Laguerre, 1984, 1998; Metraux, 1952; Orezolli, 2000; Phelps, 2004; Pierce & Elisme, 1997; Roumain, 1978; Rowlands, 1979; Saint-Jean & Crandall, 2005; Schantz, Charron, & Folden, 2003; Stepick & Portes, 1986; Wingerd & Page, 1997). However, there remains limited guidance on the sociocultural strengths of the Haitian immigrant community and how to access these as resources to guide mental health interventions (DeSantis & Thomas, 1990; DeSantis, 1993; Desrosiers & St. Fleurose, 2002; Durand, 1980; Metro Boston Haitian REACH 2010; Miller, 2000; Purnell & Paulaunka, 2003; Stepick & Stepick, 1990; Turnier, 2002). A striking illustration of the need for effective techniques that would guide improvement to the mental health services provided to Haitians immigrants was Turnier’s (2002) finding that 60% to 75% of Haitians with depression were erroneously diagnosed as having paranoid schizophrenia, and ineffectively treated with neuroleptics and related psychotropic medications.

This article discusses an approach to clinical practice with Haitians in the U.S. that builds on the historical, social and cultural strengths of traditional Haitian families: The use of metaphors in traditional Haitian storytelling. First, there is a definition of evidence-informed practice as it relates to culture based practices. Second, metaphor is defined and its use in clinical and health care settings is discussed. Next, an exemplar using metaphors with a South Florida Haitian immigrant applicant for political asylum demonstrates a positive case outcome. The outcome of this approach is illustrated in the client’s own spontaneous use of metaphors to indicate his progress. Finally, guidelines for best practice in clinical mental health settings with Haitian immigrants are presented. It becomes evident that to identify practice informed by evidence with Haitians, practitioners must attend to problems beyond the scope of race and language, consider the needs and goals of Haitian families within their cultural context, and incorporate skills and methods of problem solving that are familiar to them. The need to test this approach for effectiveness in larger samples within the Haitian population at home and in the diaspora is recommended.

Evidence-Informed Practice

There is a great deal of knowledge generated on the usefulness of evidence-based practice in various practice contexts, including mental health settings (Kazdin, 2008; Pane, 2004). Evidence-based practice involves a decision-making process which includes practitioners’ competent delivery of interventions that are grounded in rigorous research. The term evidence-based practice has been criticized for being too mechanistic and for not reflecting the complexity of the decision-making process (Webb, 2001). Over the past decade, the concept of evidence-based practice has expanded to evidence-informed practice (Chaffin & Friedrich, 2004; Dill & Shera, 2009; Petch, 2009). The term evidence-informed practice is used to more accurately reflect the decision making that involves many forms of evidence, of which research is only one part. The promotion of evidence-informed practice takes into account the practice wisdom of the service provider and feedback from and the views of service users, their expectations, their preferences, and the impact of their problems and the proposed intervention. Evidence-informed practice describes a way of practicing in which the practitioner critically uses best evidence, expertise, and values to make practice decisions that matter to individual service recipients. The point to be emphasized here is that one should select an intervention from the best available information to reflect the client’s values, needs, strengths, and practice preferences (Thomlison, 2010, p. 118). This requires choosing interventions where the outcome findings consistently show the interventions actually help individuals or families change and improve (Drake et al., 2001).

An evidence-informed approach to practice is more than finding empirically supported interventions. Applying research in practice is the end-stage of the search for a practice approach to guide a particular intervention with a unique client. Clinicians engaged in applying practices informed by research must necessarily “continually pose specific questions of direct practical importance to clients, searching objectively and effectively for the current best evidence relative to each question, and taking appropriate action guided by evidence” (Danya International, 2007, p. 6). The present work describes the lead author’s experience and helping process with a male Haitian immigrant political asylum applicant who exhibited symptoms of Posttraumatic Stress Disorder (PTSD). In this case, the process began with a search for the best known evidence relative to mental health or clinical practice with Haitian immigrants in the US. Finding few resources specific to Haitian immigrants, the lead author turned to her practice wisdom and considered the use of metaphors in the traditional Haitian story-telling ritual. She joined with the client to incorporate the use of metaphors as contextual evidence in the clinical environment. Being evidence-informed in the practice setting implied:

In other words, the practitioner found out about issues from the client’s perspective, and tried to make sense of that information using her knowledge base, her practice wisdom and her practice skills. She connected what was observed and experienced with what is culturally determined. The findings were then linked with research to inform best practice.

Metaphors

A metaphor is defined as “A figure of speech in which one thing is likened to another, different thing being spoken of as if it were that other; an expression used to refer to something that it does not literally denote, in order to suggest a similarity; language used in a figurative … sense” (Webster, 1986, p. 310). The use of metaphors has long been recognized as a way in which people express their way of thinking and frame their “reality” (Lakoff & Johnson, 1980). Metaphors, proverbs, analogies and stories are commonly passed down from generation to generation and are usually embedded in cultural beliefs.

Metaphors in Clinical and Health Practice

The concept of metaphor, as used by clinicians, refers to “A therapeutic analogy to characterize family relationships; a condition, such as a symptom, that represents another condition by analogy” (Brown & Christensen, 1999, p. 319). The origin of using metaphors as a therapeutic tool can be traced to Adler, who encouraged the use of early recollection and dreams to enhance the understanding of the client’s reality. Although Adler did not directly use metaphors as a tool, his approach set the foundation for incorporating clients’ familiarity with proverbs in clinical intervention with clients.

The use of metaphors, proverbs, stories and analogies have been incorporated in cognitive behavioral therapy (CBT). In such contexts, metaphors have been used to establish rapport, to promote change, and to obtain new insight into clients’ issues. One of the specific aims of using metaphors in CBT has been to translate key messages that the clinician wants to convey during the session in the context of a client’s framework, thereby increasing the likelihood that the client will remember those messages (Blenkiron, 2001). The meaning an individual transfers to a situation in a given metaphor can provide a glimpse of how an individual perceives a particular situation. Thus, in the context of practice, a client’s use of metaphors may be a powerful tool to understand the client’s assumptions and perceptions (Lyddon, Clay, & Sparks, 2001).

Lyddon and colleagues discuss the use of metaphors as having various functions in psychotherapy: 1) communication that will enhance the practitioner’s understanding of the client’s world, 2) establishment of rapport with the client so that a “working alliance” is formed, and 3) as an indicator of change (Lyddon, et al., 2001). These suggest that the use of a new metaphor by a client may, in fact, illustrate a shift in the client’s view of his or her situation, and that it is the client’s use of a metaphor that will help the counselor better understand how the client conceptualizes his or her situation (Wickman, Daniels, White, & Fesmire, 1999).

Zuniga (1992) describes the use of Latino proverbs and sayings called dichos as a way for Latino clients in the U.S. to understand and express their feelings, and as a way for the clinician to combat culturally founded resistance. Zuniga offers that the use of dichos allows the clinician to “transform what could be a foreign experience for the client into a culturally palatable and less alienating service” (p. 56). In Zuniga’s work, there is precedence for the use of metaphors in practice with Haitian immigrant populations in the U.S., to help them comprehend the “foreign experience” of therapy.

Other professions have also employed metaphors as methods of communication. In some medical fields, patients can use metaphors to describe their symptoms, and health care professionals use “neuro-talk” to translate medical terms to patients and family members (Gregory, 1998). Metaphors have been used to enhance the explanation and understanding of disease physiology, prognosis and diagnosis. For example, balloons have been used as metaphors for normal lungs that are normally inflated and deflated, and contrasted with paper bags that do not inflate and deflate properly, to explain the physiology of chronic obstructive pulmonary disease (Arroliga, Newman, Longworth & Stoller, 2002). Finally, as mentioned above, the use of metaphors is common in different cultures and in different contexts.

The importance of metaphors in Haitian storytelling is reflected in the value ascribed to proverbs as an important aspect of teaching and reinforcing practical wisdom and values to children and community members. The existence of two separate texts in which 999 to more than 3000 Haitian proverbs are documented serve as evidence of the importance of these proverbs and their centrality in traditional Haitian culture (Fayo, 1980; Jeanty & Brown, 1976; La Pierre, 1995). A sample of proverbs that can be used in practice with Haitian clients is in Table 1.

Despite the seemingly negative messages that many proverbs seem to convey from an etic perspective, they rely extensively on metaphors, and their familiarity to Haitians as individuals who share historical and socio-cultural contexts make them very attractive for use in practice with Haitian immigrants. As important as the Haitian story telling tradition and the use of metaphors in those stories, is the social context of the stories.

Context of Haitian Storytelling

The traditional network of support for Haitians is grounded in the lakou. According to Edmond and colleagues, the lakou refers to “clusters of homes in which Haitian families reside, as well as to the extended and multiple-generation family form that is prominent in Haitian culture; the members of a lakou worked cooperatively and provided for each other with financial, and other forms of support” (Edmond, Randolph & Richard, 2007, p. 19). The context of the Haitian storytelling tradition in which the metaphors are used is the Haitian lakou. At night, when all chores have been completed, a person from the lakou may begin the story-telling by calling out, “Krik!” and all who wish to hear a story will respond “Krak!” (Danticat, 1996). Although these stories are often fabricated by the storyteller, they are referred to as kont, meaning an “account” of something. For clinicians and other professionals who engage Haitian immigrant clients, the familiar metaphors and proverbs that are a part of the Haitian story telling tradition in the Haitian lakou may be untapped resources for mitigating barriers related to trust, safety and literacy that such clients may encounter when seeking help. As an example, we summarize a case study in which the lead author faced the challenge of working with a Haitian immigrant male political asylum candidate who exhibited symptoms of Posttraumatic stress disorder (PTSD). Central to the client’s asylum case was the determination of whether or not his claims of politically related threats of danger were factual, as evidenced by PTSD symptoms. The lead author’s primary concern was to insure, as defined by evidence based and evidence-informed practice, that the client achieved optimal therapeutic outcomes through collaboration that drew on her knowledge, skills, values and experiences as a Haitian-born clinician, and that also incorporated the client’s own values, culture, skills, strengths, needs and desires. For purposes of confidentiality, the pseudonym Jean-Pierre is used, and the name and location of the agency are withheld. The lead author narrates the details of the case, including the source of referral, the therapeutic process and the use of metaphors in clinical practice with Jean-Pierre.

Use of Metaphors with a Haitian Client

Jean-Pierre’s case was a referral from a refugee advocacy group in Miami, Florida. His attorney, an intern with that office, still possessed the candor and sincerity that is characteristic of professionals fresh out of school. She requested a psychosocial assessment to determine if her client might be exhibiting symptoms of Posttraumatic Stress Disorder (PTSD), so that she could decide how much time to invest in his political asylum application, given her large caseload. She explained that Jean-Pierre had come to the U.S. by boat as an undocumented alien. The attorney knew, through an interpreter, some details of his story, but we agreed that I would meet with him without any details from her so as to avoid pre-conceived notions.

Intake: Defining the Therapeutic Process for the Haitian Client

When Jean-Pierre first walked into the office, he appeared nervous, looking about cautiously, but something about his posture suggested resignation. (Much later he would tell me that he sincerely believed the attorney had sent him to a place where “Imigasyon” [Immigration] might be waiting to deport him.) He had not been able to distinguish between me and the attorney who had referred him to me, in terms of role and function. He followed me slowly and guardedly into the office where the interview was to take place.

In the office, Jean-Pierre sat stiffly on the edge of the chair offered to him. He visibly jumped, his whole body quaking, when a car door was slammed outside in the parking lot. Gently, I explained to him that the parking area was right outside the office window, and that he could expect to hear occasional movement, voices and other noises filtering through our walls. He responded, “Wi” meaning “Yes.” In fact, he, like many Haitians, when unsure of their relationship to an unknown person, behaved with deference, saying Wi,” often before I could complete a sentence. As his frequent “Wis” became distracting for me and to the interview process, I gently affirmed that he was as much an adult as I was. I explained that his allowing me to finish a sentence before saying “ Wi” would be helpful to both of us, as I could be sure that he heard me—since our hearing and understanding each other was crucial to what we needed to accomplish. This validation of the client as an adult and as a human being was purposefully directed to create a safe environment in which he could expect to be treated with respect and dignity.

Among the matters which were mutually decided at the initial interview, were that we would meet at least three times, and then would evaluate together how many more sessions we would have. Jean-Pierre offered, “I know a lot of people out there tell lies, but what happened to me, no one could imagine that a child of God would do that to another child of God.” He agreed that I would tell his attorney precisely what I assessed, based on my meetings with him. I explained the stipulations of my license as a Licensed Clinical Social Worker and the values and codes of conduct of the profession, and told him that I could not and would not lie to him, or on his behalf. I also offered that he did not have to return after the initial interview, but that I would have an hour slot available for him at the same time every week until, together, we determined that our meetings could end.

Establishing Rapport

Jean-Pierre had no prior experience with therapy or the “language” of therapy, making the experience challenging. Despite my native fluency in Haitian Kreyòl, it was difficult even to define the word “feelings” for him. The word “feeling” is translated as “emosyon” in Haitian Kreyòl and I was fully aware that “emosyon” can be perceived as a negative state in Kreyòl because it defines the actions taken when a person acts out a feeling, rather than the internal emotive state. Instead of asking him to talk about “feelings,” we agreed that when he came to sessions, we would play distinct roles: He would talk, and I would listen. That posed another challenge because he stated that he did not see how talking could help him. After all, he had told his story so many times and no one seemed to believe him.

I knew that if my assessment was to be valid and any intervention effective, I needed to offer him a trust-based relationship, but his participation was crucial and I had to show him that he possessed skills and strengths that he could contribute. I became aware that we needed to develop a language and a means to first identify his feelings, and to provide him with a verbal context that he could use to communicate those feelings. Seeking a point of reference, I jokingly said “Krik”, to which he responded eagerly, “Krak,” and leaned forward slightly in his seat. He then warned me that it was unlucky to tell kont (traditional Haitian stories typically told at night) in the daytime. We agreed that the next session would be scheduled at night. I felt, then, that we might be able to use the metaphors and familiar proverbs within the traditional Haitian story-telling tradition to help him define his experiences.

Challenges of Earliest Sessions: Engagement

Jean-Pierre did not make eye contact during the earliest sessions, and sadly, I realized it was because he was showing me the respect he thought I deserved as an authority figure. I was compelled to tell him that it was okay to “gade-m nan je” (look me in the eye), and eventually, he did. Although, he did so infrequently and with hesitant, nervous smiles, it was, nevertheless a small gain in engagement.

In order to make progress, we used two sessions to engage in the “Krik-Krak” story telling tradition. Laughter was a part of these early sessions, followed by a discussion of “Which of these characters are most like you?” “What could this character have done differently?” At the end of the second session, an attempt was made to use a metaphor as part of the clinical process to help him communicate his experiences. I began with: “Have you ever seen what happens to a balloon when you blow too much air in it?”

This attempt at using a metaphor failed due to my failure to take into account the client’s rural background and the diminished access to toys such as balloons to children who reside in rural sections of Haiti. Since the ultimate objective was for him to devise his own metaphors to communicate his experience and his feelings, the next attempt included a metaphor using objects and contextual cues that would be common to his own unique experience in rural Haiti.

Making Metaphors Work: Sample of Conversation from Session with Jean-Pierre

So it was that during the following session, Jean-Pierre was invited to “Tell me a story that has you in it.” Tearfully, the client began his own story, often rising from his seat, acting out his words and memories, as if reliving the story. Tears and loss were the content of the story. Concern for the wife and three small children he had left in Haiti and what would happen to them in his absence or if he were deported were a large part of his story. He experienced constraints on communication with family in Haiti. Jean-Pierre was preliterate, having been too poor to receive a formal education in Haiti, and his wife and children resided in a rural area of Haiti where they had no access to telephones. Their communication included sending and receiving cassette recordings, a process which often took months to carry out because of the lack of infrastructure in rural Haiti.

He spoke of recurrent nightmares in which he was re-experiencing the horrors he’d detailed in his “story” as member of a peasant mobilization group in Haiti. He also exhibited other symptoms of PTSD, including survivor guilt concerning his older brother who had been taken away by armed men one night and never returned. Sobbing, he choked out, “I wish I had died ten times rather than live without my brother.”

The next few sessions proceeded smoothly, with Jean-Pierre arriving to each session with a look of urgency and expectancy.

Termination

During what was to be the last session, Jean Pierre had made significant progress and I had in mind that we would conclude within two or three weeks. Although I had carefully let him know during the first session that there would be a point of termination once I had obtained all the information that was needed for his case, I had been having a difficult time with how to reveal that we were approaching the point of termination. Jean-Pierre initiated the conversation that day, stating: “I am going to tell you a story about you, if you permit me”

Jean-Pierre’s summary of his personal gains from our sessions yielded important data regarding his clinical progress and concerning the usefulness of the tools that were used to assist him. His statement reflected autonomy and hope, i.e., his decision to approach his attorney about his family’s joining him in the US.

Follow Up

I did testify as to my findings in court, and his political asylum was, in fact, one of the few cases granted that year. Most significant, however, is how I was able to use metaphors in the client’s Haitian cultural context, and how the use of metaphors fit nicely into the Haitian story-telling and proverbs traditions, facilitating healing for the client.

Discussion

The purpose of this paper was to demonstrate that the incorporation of metaphors in clinical practice with Haitians living in the U.S. is a useful approach for offering finely tuned, culturally sensitive, and competent health and mental health care. Metaphors, as a process for engaging Haitians, can extricate information that is embedded in language, can lead to understanding the influences of problems, and can clarify the Haitian client’s expectation of mental health treatment. The use of metaphors can be a powerful means of engaging Haitian clients regardless of literacy level, because the Haitian story-telling and proverbs traditions are already rich in the use of metaphors. Metaphors can be used as a way for the practitioner to establish a relationship with the client, and to understand the client’s assumptions and perceptions (Lyddon, et al., 2001).

The Haitian culture is rich in an oral story telling tradition, born of their African ancestry. Drawing from this rich oral story-telling and proverbs traditions, a culturally relevant therapeutic intervention can be developed that integrates these cultural strengths in an effective and competent approach. The storytelling is traditionally done in the context of safety and fun, and serves as a forum for displaying individuals’ story telling skills in the process. The use of metaphors can provide a way for clients to tell their own story, express their mode of thinking, and share their lived experiences in a manner that is not threatening to them.

For the practitioner, thinking of a Haitian client in the U.S. as a long and fascinating story will facilitate the process of engagement and provide the opportunity to harvest rich and extensive data and evidence on the client’s situation. In using metaphors with Haitian immigrants, the practitioner can minimize the tendency to look outwardly for solutions to problems. Moreover, the clinician will furnish the Haitian client a simple and familiar tool for defining his or her position within a crisis, a mechanism for expressing and managing symptoms and discovering options, and a means of obtaining relief through a self-directed process. The practitioner, then, is merely a facilitator of that process.

Implications

Several lessons for mental health practice with Haitians in the U.S. seeking help can be derived from the literature and the case study presented here. First, it is important to note that before using metaphors, proverbs and stories with their immigrant clients, practitioners need to assess their clients’ literacy levels and the familiarity of their clients with the storytelling tradition. This is particularly important when working with second generation immigrants for whom the story-telling experience may be limited. The practitioner may initiate using a metaphor, allowing the clients to provide a metaphor familiar to them or to comment on the metaphor. These exercises will help the practitioner to better understand the level to which the conversation should continue.

Second, the practitioner needs to be aware of culturally appropriate rhetorical tools (e.g., metaphors, proverbs and stories) when dealing with clients, especially those from cultures with story-telling traditions (e.g., Haiti) and with limited educational attainment levels. From the example above, the use of metaphors in story telling with Haitian clients helps practitioners build rapport with their clients. For instance, the practitioners could use the metaphors to clarify concepts that are difficult to explain, to translate (e.g., emotion) or to conceptualize. Stories incorporate metaphors, have morals that are often expressed in proverbs, and are important rhetorical tools. As noted by the literature, storytelling can engage the clients as agents of change and provide the practitioner with new insight on clients’ issues. Further, the use of storytelling and metaphors can influence clients of various ethnicities and literacy levels to disclose their worldviews, experiences, feelings, and hopes in a safe environment, validating them as individuals worthy of respect and dignity. Besides, the stories make mental health therapy more engaging and entertaining for the clients.

Third, it is important that practitioners enable their clients to become authors of stories that are uniquely their own. Practitioners need to clearly describe their role in the treatment process, as well as the client’s role and the purpose of the sessions, while providing the client the option of modifying the objectives of each session. Practitioners stand to gain more insight from the story-telling process, by merely being the facilitators of the process and allowing clients to display their creative skills with their stories.

Finally, while working with Haitian clients and clients of various ethnic origins, health and mental health practitioners need to go beyond focusing on the language barriers that may exist, and focus, rather on understanding the context of subcultures (e.g., rural vs. urban) within their country of origin. Understanding such contexts is significant not only for an adequate understanding of clients’ stories, but also for appropriate use of metaphors and proverbs in story-telling while initiating communication with clients and in ongoing treatment.