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Metaphors as Contextual Evidence for
Engaging Haitian Clients in Practice:
A Case Study
GUITELE RAHILL, Ph.D., LCSW*
MICHELE JEAN-GILLES, Ph.D.#
BARBARA THOMLISON, Ph.D.#
ELSA PINTO-LOPEZ, Ph.D.†
Haitian immigrants remain underserved in the United States (U.S.), despite
their large presence and their visibility, which increased after the January 12,
2010 earthquake. Employing cultural-specific practice strategies to engage
Haitians in the U.S. who experienced loss in their social networks, requires
understanding the context of their ecological culture and consideration of
relevant linguistic and cultural elements. Through a case example, we
describe the use of metaphors in cultural language as part of a strategy used
to engage a Haitian immigrant with symptoms of posttraumatic stress
disorder. Outcomes indicate that the use of storytelling and metaphors
facilitate disclosure of clients’ worldviews, experiences, feelings and hopes in
a safe environment while providing them with tools to determine progress.
We identify four practice guidelines for intervention strategies with ethnic
minority groups who share similar cultural contexts. Metaphors, which are a
viable approach to practice, focus on cultural strengths and resiliencies over
traditional models of deficit and can enhance access to needed effective
services for underserved populations, such as Haitians in the United States.
KEYWORDS:Haitian immigrants; evidence-informed practice;
metaphors; 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
* University of South Florida, Tampa, FL.; #Florida International University, North Miami, FL,
†University of Puerto Rico in Rı´o Piedras, Puerto Rico.
Mailing address:
School of Social Work,
College of Behavioral and Community Sciences, University of South Florida, 4202 East Fowler Ave,
MGY132, Tampa, FL. 33620-6600. e-mail: Gjrahill@usf.edu
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 65, No. 2, 2011
133
(U.S.) continues to increase. The absence of relevant and efficient strate-
gies 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 pres-
ence 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 consid-
ered 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 pro-
vides 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 De-
partment of Health, 2003, 2004, 2005; Fouron, 1983; Jean-Louis, Waker,
Apollon, Piton, Antoine, & Mombeleur, 2003; Jimenez, 2001; Laguerre,
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134
1984, 1998; Me´traux, 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 ap-
proach 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 recom-
mended.
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 in-
volves 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
Metaphors As Contextual Evidence
135
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 expec-
tations, 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 effec-
tively 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 incor-
porate the use of metaphors as contextual evidence in the clinical envi-
ronment. Being evidence-informed in the practice setting implied:
●Asking “good” questions about the client’s issues so as to identify
practice strategies;
●Being informed about the culture so as to understand key discourse
about the client’s issues;
AMERICAN JOURNAL OF PSYCHOTHERAPY
136
●Using traditional story-telling or narratives so as to clarify client
values and experiences, in order to build on strengths for resilience;
and
●Listening to what the client reported about service preferences and
case progress.
In other words, the practitioner found out about issues from the client’s
perspective, and tried to make sense of that information using her knowl-
edge 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 symp-
tom, 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
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137
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 com-
munication. 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 rein-
forcing 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,
AMERICAN JOURNAL OF PSYCHOTHERAPY
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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.
Table I SAMPLE OF HAITIAN PROVERBS, TRANSLATIONS AND SUGGESTED
INTERPRETATIONS
Haitian Kreyo`l English Translation
Suggested Interpretation of
Proverb
Rad sal se nan
fanmi sa lave
Dirty clothing are washed
only amidst family
Family Secrets supported
Makak karese pitit li
jouk li touye’l
The monkey caresses its
child until it kills it
(Caveat against showing affection
to children or may be seen as
warning against spoiling
children)
Zwazo ki gen plim
pa chante
Birds who have feathers
don’t sing
Lesson in humility and against
vanity
Le`ke` ti poul
kontan, konnen
malfini pa lwen
When the chick’s heart is
glad, know that the
hawk is not far away
The world is not a safe place—
ever impending danger
Ront pi lou pase sak
se`l
Shame is heavier than a
sack of salt
Lesson of avoidance; caveat to
protect one’s integrity
Krapo fe`ko`le`,li
mouri san de`ye`
The frog throws a
tantrum/ or shows
anger–it dies without a
backside
Warning against acknowledging or
expressing anger
Ne`g fe` lide-l, Bon
Dye ba-l dwa
A man may make his
plans, but God grants
permission
Respect for the supernatural or
the invisible
Sa je pa we`pafe`ke`
tounen
What the eye doesn’t see,
does not turn the heart
Family Secrets; lesson of
avoidance
Je we` , bouch pe The eye sees, the mouth
remains silent
Family Secrets; caution against
whistle blowing
Se moun ki pran
kou ki pare kou
It’s the person who has
received blows who
knows how to ward
them off
Lesson of avoidance . . . context of
violence
Le` male`de`ye`-w, le`t
kaye kase te` t-ou
When you are destined for
bad luck/ evil, even sour
milk can break your
head
No matter what you do, you
cannot avoid harm
Mwen fin mouri,
mwen pa pe` santi
I am dead already. I don’t
fear stinking
Learned helplessness, fatalism
Metaphors As Contextual Evidence
139
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 fabri-
cated 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
AMERICAN JOURNAL OF PSYCHOTHERAPY
140
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 inter-
view, 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
Metaphors As Contextual Evidence
141
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 Kreyo`l, it was difficult even to define the word “feelings” for him.
The word “feeling” is translated as “emosyon” in Haitian Kreyo`l, and I was
fully aware that “emosyon” can be perceived as a negative state in Kreyo`l
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 partic-
ipation 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.
AMERICAN JOURNAL OF PSYCHOTHERAPY
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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?”
“A balloon? A blad?”
“Yes.”
(Nervous laughter).
“Did you have balloons when you were a child?”
“No, we made a kite, my brother and I and it was good, but no balloons.”
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 communi-
cate 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
The next session began with, “What are your favorite foods that your
mother or wife would prepare for you?”
“Fish, corn meal, beans and avocado.”
“If someone were to take a nice big plate of fish, corn meal and avocado
and put it in a nice box for you and wrap it up as a beautiful present, and
placed it in front of you, would you like that?”
“Yes.”
“What if you left all that great food wrapped up in the pretty box and
didn’t open it and left it out in the sun for two months, what would
happen?”
“It would turn into chawon-y (stench of carcasses), it would stink”
“Would it stink only inside the box?”
“No, if it stayed in there long, the stink would invade the whole lakou, the
whole neighborhood.”
“That is how it is when we keep bad experiences locked up in our hearts.
You see that even good things can turn bad when locked up. If you don’t
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143
begin to air the bad experiences that you have had, they will affect your
life, your wife and children in Haiti, and your experience in the U.S. Next
time, I will ask you to tell me a story that has you in it, to help you get
things out of the box. Do you think you can do that?”
“Okay.”
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.”
“Go ahead, please.”
“It’s as if you found me locked up in a tiny, tiny (his emphasis) room. It was
dark in that room. It had no air in the room. I was toufe! (suffocating).
Lespri-m te brize! (My spirit was broken!) I knew I could never come out
and would stay there forever.”
AMERICAN JOURNAL OF PSYCHOTHERAPY
144
“Go ahead, please.”
“You came, you opened the door, you let the light in the room and I can
breathe again. I think I will begin to speak to the attorney about how to get
my family to join me in the United States.”
Jean-Pierre’s summary of his personal gains from our sessions yielded
important data regarding his clinical progress and concerning the useful-
ness 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
Metaphors As Contextual Evidence
145
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 prac-
titioner 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 op-
tions, 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 practitio-
ners 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 meta-
phors 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
AMERICAN JOURNAL OF PSYCHOTHERAPY
146
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.
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