Sunday, November 22, 2015

After Paris, After Everything: Reflections on Death and Dying With Special Reference to Trauma

45e Convegno di Studio
“La Dimensione Umana del Morire e Il Sostegno alla Famiglia”
Accademia di Psicoterapia della Famiglia
Roma – 13-14 Novembre 2015

After Paris, After Everything:
Reflections on Death and Dying
With Special Reference to Trauma

Vincenzo Di Nicola


Psychiatrist-Psychotherapist-Philosopher Vincenzo Di Nicola attended the Convegno in Rome, “La Dimensione Umana del Morire/The Human Dimension of Dying,” 13-14 November 2015. This is his report.


Death and trauma as exceptions

Death and dying are eminently philosophical questions. Albert Camus famously asserted in The Myth of Sisyphus that suicide is the only serious philosophical problem.

The death of Socrates is a foundational myth for Western thought that heralds the mortal danger of critical inquiry. Accused of corrupting the youth of Athens, Socrates was condemned to death by hemlock for inviting them into his relational dialogues that led them to question received wisdom.

The earthquake that levelled the city of Lisbon in 1755, killing many of its citizens, was a seminal incident in European history that triggered critical reflection and theological questions such as the beneficence of God and divine providence. Gottfried Leibniz coined the term théodicée (teodicea, theodicy) to frame the question of how a good God could permit evil acts. Voltaire satirized Leibniz’s position in his provocative novella, Candide, whose protagonist Professor Pangloss pronounced, Tout est pour le mieux dans le meilleur des mondes possibles.”  (“All is the for the best in the best of all possible worlds.”)

The First World War in Europe destroyed not only countries and empires but a European culture of hope and progress. The 19th century positivism of August Comte had articulated this hopeful atmosphere, with its motto, Ordem e Progresso (“Order and Progress”) emblazoned in Portuguese on a banner on Brazil’s flag. Its undoing is reflected in the work of artists like Otto Dix who portrayed the war and its physically and spiritually traumatized soldiers and citizens. In this era, too, Freud began his research on war and death, memory and trauma. His use of the word invoked “trauma” as a breach, a rupture in the order of things, and thus an exception. His essay, Zeitgemäßes über Krieg und Tod (“Thoughts for the times on war and death,” 1915) is one of the most pained expressions of his humanistic concerns beyond the psychoanalytic couch.

Each generation since then has rediscovered and re-invented some new representation of horror and disaster that we call “trauma”:

·      * “Shell shock” (WWI combatants)
·      * “Combat fatigue” or “battle neurosis” (WWII combatants)
·      * “Concentration camp syndrome” (Nazi death camp survivors)
·      * “Post-traumatic Stress Disorder – PTSD” (Viet Nam war veterans)
·   * Genocide and post-genocidal societies (the Armenian Genocide, the Holocaust, the Rwandan and Bosnian Genocides)

Concerns about trauma are so prevalent today; they take up so much space in the collective imagination of sensitive and thoughtful people, that we may call our times the age of trauma. In invoking the age of trauma, I am not approving of this preoccupation but witnessing it.

The contemporary discourse of trauma implies that we are all at risk for trauma, if not actually traumatized. This creates a paradox whereby trauma, which is by definition an exception (a breach, a rupture in the order of things), becomes the norm, which by definition applies to all. This is precisely the contemporary predicament that Italian philosopher Giorgio Agamben has limned in his series of studies called Homo Sacer, notably in his historical-philosophical essay, Il stato di eccezione (The State of Exception). The state of exception, with its origins in the banishment of a Roman citizen who was legally neither inside nor outside Roman society, neither protected nor allowed to be killed, took its paradigmatic form with the Nazi death camps, justified by the legal philosophy of Carl Schmitt and sanctioned by German law. Do they exist today? Agamben asked in an interview:

Bisogna chiedersi se esistono dei “Campi” oggi in Europa …
Questi luoghi sono stati pensati come “spazi di eccezione” fin dall’inizio.
Sono zone pensate come zone d’eccezione in senso tecnico, come zone di sospensione della legge, così come zone di sospensione assoluta della legge erano i campi di concentramento, in cui – come dice Hannah Arendt – “tutto era possibile” perché appunto la legge era sospesa.
Giorgio Agamben, “Nei campi dei senza nomi,” Il Manifesto, 1998

We must ask ourselves if these “camps” exist today in Europe …
These places were imagined as “spaces of exception” from the beginning.
They are zones imaged as zones of exception in the technical sense, as zones where laws are suspended, just as concentration camps were zones of the absolute suspension of laws, where – as Hannah Arendt says – “everything was possible” precisely because law was suspended.
Giorgio Agamben, “In the camps of the nameless,” Il Manifesto, 1998

In this contemporary cultural logic, we are all in a traumatic situation, we are all living a kind of death, una muerta anunciada (“a death foretold”) to invoke the title of a novel by Gabriel García Márquez. The cultural-historical dynamic that brings us to this predicament is an exquisite sensitivity whereby we wish to acknowledge and witness kinds of suffering. Some decry this as a form of political correctness that becomes authoritarian and condescending. I will go further and call it nihilistic.  

I contest this way of thinking and propose precisely the contrary: trauma is and remains an exception. Trauma is neither the condition of all of us nor should this be an accepted way of living. Most of us, most of the time, cannot identify with the exception that is trauma because it is not a shared experience.


The possibility of witnessing death

In the middle of the conference, between the two conference days, the Paris terrorist attacks occurred in which 129 people were murdered. As if to make my point, at a meeting of several hundred sensitive and thoughtful people, no one could find the words, a way to address what had happened in Paris until the very last minutes of the conference when it fell to a younger man, a therapist-in-training to ask how we could close the conference with no mention of what had occurred. As it turned out, there was a sizeable group attending the conference from Palermo, Sicily that was in mourning over the loss of one of their members. Instigated by the student’s courage, Maurizio Andolfi, the Director of the Accademia di Psicoterapia della Famiglia, spoke to these two kinds of losses and asked the Palermo group to stand as we observed a moment of silence.

As an exception, trauma is like death: we do not have easy access to it. Vittorino Andreoli, an Italian psychiatrist-neurologist, novelist and playwright, asserted in his keynote address to the conference that, “morte e dolore sono le espressione più umane,” that bring out in us, “la voglia di auitare.” (“Death and pain are the most human expressions,” that bring out in us, “the wish to help.”)

I do not know what it means to say that pain and death are the most human of experiences. Is it a description of the human condition? Does it mean that they are universal, unavoidable and hence define our very existence? Is it rather a prescription for how to be more humane, if not human? Does it mean, as Andreoli suggested, that it brings out in us the need to be understood and the wish to help others in their pain? Many of us healers identify with that. But callous indifference and sadism are also the lot of humanity.

I would like to comment first as a philosopher, then as a psychiatrist-psychotherapist. The issue is whether we can witness the exception without living it ourselves. To make this come alive for you, I recommend a reading of Maurice Blanchot’s brief story-memoir, L’Instant de ma mort (“L’Istante della mia morte”), where he asserts, “Solo io posso testimoniare alla mia morte.” Condemned to death, the author-protagonist of the memoir awaits his death but does not die. In this context, he was able to testify to the possibility of death, as he says, “at the instant of my death.”

How are we to read – to understand, to signify, to grasp – this text? Philosopher Jacques Derrida in a companion piece called Demeure (Dimora), marks the distinction in German between Dichtung (fizione, fiction) and Warheit (verità, truth). Is the text a fiction or is it the truth? Is it a short story or a memoir? Is death then an understanding (that is, a construction) or an experience? This creates these antinomies:

Dichtung                    vs.                    Warheit
Construction              vs.                    Truth
Culture                       vs.                    Nature 


Is this “most human of experiences,” in the words of physician-novelist Andreoli, face to face with the finitude of our mortal existence, a construction or a truth, a shared cultural experience or a natural one? Spared of dying by another’s death, Blanchot’s protagonist feels a légèreté, a “lightness” which Derrida claims is neither a relief nor a salvation. In the end, Blanchot writes about the impossibility of testifying to one’s own death and asks who has the right to declare the instant of my death?

Now, the community of healers – psychiatrists, psychologists and psychotherapists – may well ask why does a philosopher offer this reflection? Of what use is it to us? Blanchot’s writing both closes and opens perspectives on dying. In problematizing the question of testifying to death – problematizing is a kind of enclosure, giving form to a question – Blanchot opens for us the possibility of a relational understanding of dying. Not the journalistic truth of what can be documented, nor the phenomenological truth of what is experienced, but of what can be communicated and witnessed interpersonally. A shared human experience of our finitude.

In his profound reading of Primo Levi’s writings about Auschwitz, Quel che resta di Auschwitz: l’archivio e il testimone/What Remains of Auschwitz: The Archive and the Testimony, Giorgio Agamben says that all we can do is to read Levi as a witness who was there. A witness not of his own death but of the lives and deaths of others in the spazio di eccezione, the space of exception where a new forma-di-vita, form-of-life took hold – la vita nuda, bare life. Even when the inmates living a bare life could not witness their own deaths and testify to them, the survivors have the imperative to bear witness and to testify. This is a relational understanding of the truth of existence, of life and of death. It is not easy, it is not common, it cannot be taken for granted, but the effort to do so – to witness and to testify – makes us more human, even as the state of exception makes it everyday more arduous and more tenuous.

When the conference ended, I waited to say goodbye to my friend Maurizio Andolfi as we were both travelling to other places while the Palermo group sat silently, huddled together for comfort, wordlessly reaching out to Maurizio, and indeed, as everyone else left, Maurizio stayed there to bear witness.  And I write this to testify.

This is now the task before us, as psychotherapists, after Paris, after everything.

Saturday, November 21, 2015

Defining Global Mental Health

Global Mental Health & Psychiatry Newsletter

Global Mental Health Forum


Prof. Vincenzo Di Nicola, MPhil, MD, PhD, FAPA
Université de Montréal


Defining Global Mental Health & Psychiatry


Issue: What is Global Mental Health & Psychiatry?

Forum Question: Is there an emerging consensus for re-visioning mental health and psychiatry in a global way that includes social concerns, recognizes cultural diversity, and embraces the mission of public health, comparing mental illness across cultures and around the world?

A metaphor for health: If we imagine health as a river winding around the world, there are tributaries which feed into the larger river, which flows into the sea.

The river of health and its tributaries:

* Medicine and well-being is the river
--“Global Health & Medicine” is its name
* Psychiatry is a tributary, with many rivulets: 
--Social Psychiatry
--Transcultural or simply Cultural Psychiatry (Lim, 2006)
--HBM Murphy (1982) of McGill defined this field as Comparative Psychiatry, “the international and intercultural distribution of mental illness”
* Public Health and Epidemiology are tributaries

In this view, Global Mental Health & Psychiatry is the emerging term for the tributary that collects all the rivulets (e.g., Social Psychiatry, Cultural Psychiatry, and Public Health) merging into the river of Global Health & Medicine (Cf. Okpaku, 2014; Sorel, 2012).

These rivulets and tributaries represent broader envelopes or contexts for psychiatry than more narrowly-defined disease-specific (e.g., mood disorders, eating disorders), age-specific (e.g., child, geriatric psychiatry), or intervention-specific (e.g., by therapeutic approach – psychodynamic psychiatry; or by activity – consultation-liaison psychiatry, integrated care) approaches.  


Challenges for GMH:

1.     Re: “Global”

Why does global mean?
(Cf. Okpaku, 2014; Sorel, 2012)
A global – i.e., “general” – approach?
A globally “embracing” approach, collecting and integrating approaches, schools, and traditions?
Global as in “worldwide” – in a democratic way or an imperialistic way?
(Cf. Ethan Watters, Crazy Like Us, 2011)

2.     Re: “Mental Health” vs. Psychiatry

Why mental health instead of psychiatry?
Marketing (health is more appealing than illness or “disorder”)
vs. identity (as physicians)

3.     Who is invited/feels welcome under this new umbrella?

Psychiatrists? Psychologists? The therapeutic communities of practice?
Public Health and Epidemiology?
Social scientists?
Policy makers?
Legislators?
Client groups?


References

Lim, Russell F. (2006). Clinical Manual of Cultural Psychiatry. Washington, DC: American Psychiatric Publishing, Inc.

Murphy, H.B.M. (1982). Comparative Psychiatry: The International and Intercultural Distribution of Mental Illness. Berlin: Springer-Verlag.

Okpaku, Samuel, Ed. (2014). Essentials of Global Mental Health. Cambridge, UK: Cambridge University Press.

Sorel,  Eliot, Ed. (2012). 21st Century Global Mental Health. Burlington, MA: Jones & Bartlett.

Watters, Ethan (2011). Crazy Like Us: The Globalization of the American Psyche. New York: Free Press.

Saturday, August 29, 2015

UNDEAD! Phenomenology as the Zombie Science


Phenomenology has lost any real meaning!

It has largely become a way to unite people who have misgivings about their given field - philosophy, say, or psychology and psychiatry - and is a large and handy umbrella because it can mean anything you want it to mean, just as Lewis Caroll's Humpty-Dumpty declares.

Unlike Groucho Marx's concern about what kind of club he was joining, self-declared phenomenologists don't much care about the company they keep and whether any coherent theory or principles link them.

There is an important book called, "The End of Phenomenology" (Edinburgh University Press, 2014) by Tom Sparrow that says this eloquently and devastatingly.

After dedicating a year-long seminar at the Université de Montrèal to phenomenological philosopher Emmanuel Levinas, I concluded ever more clearly and somewhat bitterly that phenomenology is indeed dead. 

Or worse: undead! Phenomenology is that idea which, having no life and no power, refuses to lie still! This is phenomenology as a zombie science!

As I said in my essay, "States of exception, states of dissociation: Cyranoids, zombies and liminal people--An essay on the threshold between the human and the inhuman" (Di Nicola, 2011), zombies have become a contemporary trope for what is lifeless, dead but not buried, stagnant but obstinately clinging to a kind of life, like someone in a vegetative state neurologically but on artificial life support.

As an example of this meme or cultural trope in the larger culture (not just philosophy or psychiatry), a recent story in the New York Times describes China's "zombie factories" and a similar practice in Japan: 

"To protect jobs and plants, the government and its state-owned banks sometimes keep money-losing businesses on life-support by rolling over or restructuring loans, providing fresh credit or offering other aid." 

"In Japan, such businesses, known as 'zombie companies,' are blamed for contributing to that country's two decades of economic stagnation." 

Zombies are everywhere in contemporary culture - from video games to television and films on the big screen to descriptions of lifeless, unproductive companies "stalking" Asian economies and certainly as empty signifiers in philosophy and psychiatry. As a contemporary cultural trope, zombies signify the evacuation of the human.

Phenomenology, which prides itself so much on understanding and dignifying what is human about our experience, has become an empty exercise at best and a signifier of the very opposite of its vaunted ambitions at worst. By its imprecision and incoherence, phenomenology today has come to mean the evacuation of the human.


References

Di Nicola, Vincenzo. "States of exception, states of dissociation: Cyranoids, zombies and liminal people--An essay on the threshold between the human and the inhuman." In: Letters to a Young Therapist: Relational Practices and the Coming Community. New York & Dresden: Atropos Press, 2011, pp. 149-162.

Schuman, Michael. Zombie factories stalk the sputtering Chinese economy. International New York Times, August 28, 2015. 
http://www.nytimes.com/2015/08/30/business/international/zombie-factories-stalk-the-sputtering-chinese-economy.html?hp&action=click&pgtype=Homepage&module=first-column-region&region=top-news&WT.nav=top-news&_r=0. Accessed: 29.08.2015

Sparrow, Tom. The End of Phenomenology: Metaphysics and the New Realism. Edinburgh: Edinburgh University Press, 2014. 


Sunday, August 2, 2015

So Much Trauma, So Close to Home: Seeing Beyond the Bidonvilles to Celebrate Porosity in Port-au-Prince


Newsletter of the Global Mental Health & Psychiatry Caucus
of the American Psychiatric Association

Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, FAPA
Professor of Psychiatry, University of Montreal
Representative to the APA Assembly
Past-President of the Quebec & Eastern Canada District Branch
Newsletter Zonal Co-Editor for the Americas

AS A LIFE-LONG STUDENT of trauma and as a francophone psychiatrist working in Montreal, a sojourn in Haiti’s devastated capital, Port-au-Prince, beckoned me for many years. Whenever I asked a Haitian colleague about visiting Haiti, he would say, wait for things to settle down. First it was due to politics, following the ouster of President Aristide in 2004, later it was the devastation in the wake of the earthquake that fairly leveled the capital city in 2010.

Almost no one encouraged such a visit! Neither Haitians themselves, nor my colleagues in health care supported it. Their message conveyed a perfect storm of devastation, destitution and danger. Those who survived the earthquake and those who worked there in its aftermath transmitted lessons about “trauma”—traumatic events (poverty, violence, disasters), a traumatized population in survival mode, and traumatizing experiences (alienating experiences on the streets and with the health care system). Finally, with support from three sources – the University of Montreal’s Department of Psychiatry, APA’s Global Mental Health & Psychiatry Caucus, and the Harvard Program for Refugee Trauma – I was on my way.

When the Global Mental Health Caucus meeting was held at the APA Annual Meeting in Toronto this year, I spoke to the disabling notion that we come to other places as experts with knowledge and skills, diagnoses and solutions. On the eve of my first visit to Haiti, I set myself the challenge to learn from my hosts and my encounters with Haitians.

So, what did I learn during my Haitian sojourn?

“LA KAY SE LA KAY.” First, it would be foolish to deny the problems that are evident everywhere in Haiti. To adapt the title of Raymond Carver’s short stories, in Haiti there is so much trauma, so close to home. And yet, I believe that as psychiatrists, we see trauma after the fact, like an ambulance arriving after the accident. It’s a crucial point: we often see effects and consequences, not the trauma itself. We do not have direct access to the human experience that we call trauma. And these impacts are not always traumatizing, which I understand to mean limiting or disabling. In Port-au-Prince, signs of physical disaster are more evident than signs of disabling human trauma. While the walls of the city declare in Creole, LA VI PA FACIL, Life Isn’t Easy, they also affirm that, LA KAY SE LA KAY, Home Sweet Home.

“This Too Shall Pass!” Second, there is the question of state structures, resources and solutions. In geopolitical circles, the concepts of failed states, collapsed states and fragile states have been floated. Do they apply to Haiti? Well, it depends. While I prefer the nuances of fragility rather than failure, it depends on whether the concept applies strictly to a state’s sovereignty or to the people. If it’s true that the state has failed or is fragile, it’s equally important to witness that the people have not! One of my hosts taught me a Haitian saying, “CAP—Cela aussi passera!” This too shall pass! Several of my Haitian hosts understand this attitude not as fatalistic but as pragmatic resignation. What would trigger a strike in the neighboring Dominican Republic, over bus fares, for example, is met with weary resignation by Haitians, according to my Haitian host, psychiatrist Dr. Hans Lamarre, President-Elect of our APA District Branch in Quebec and Eastern Canada. Haitians are at once both resigned and guardedly hopeful!

A palpable spirituality pervades the entire public experience of Port-au-Prince! I asked this question many times: Did the earthquake change the people’s faith? The unanimous answer, declared on the buses and walls of the city with such affirmations as—DIEU TOUT PUISSANCE, All Power Is God’s, and BON DIEU AVANT TOUT, God Is Good, Above All—is that disasters fortify rather than shake the people’s faith.

Porosity. Finally, my visits to other places helped me see beyond half-destroyed, half-rebuilt buildings, to witness material poverty abutting cultural richness. I avoided the “disaster tourism” that I experienced in Rio de Janeiro, New Orleans, and Buenos Aires. Ghettos, favelas, bidonvilles—whatever we call them, from Portugal’s barrios de lata (shanty towns) to the ciudades perdidas (lost cities) of Mexico, slums dot the world, residing within, on top of, beside or below the world’s major cities.

Port-au-Prince, in mountainous Haiti, is one big Rio de Janeiro with bidonvilles clinging precariously to the mountains while the government buildings, hospitals, schools and churches that still stand after the 2010 earthquake crowd the city’s plateau. But it is also a Caribbean Naples. Walter Benjamin’s essay on Naples captured its most abundant quality—porosity. And like Naples, Port-au-Prince is porous, incomplete, unfinished, with boundaries and categories bleeding into each other, overflowing with jarring juxtapositions: funky art galleries beside “Gingerbread” ruins, street slogans and banners in the people’s Créole amid a panoply of ads for private schools in proudly refined colonial French, symbols of African Vaudoun that we know as “Voodoo,” intermingled with French Catholicism, and everything for sale on the streets in a city suffused with spirituality. Port-au-Prince is vulgar and refined, sacred and profane, impoverished and privileged—much as Naples, New Orleans, and Salvador, Bahia, port cities of the world where the culture rises from the sea and the ground up.

In sum, as a cultural psychiatrist, I observe everywhere that the work of culture—dialogues and relations, knowledge and solutions—is acquired and constructed, not merely hard-wired. This was magnificently manifest during my sojourn among Haitians through the beauty of their poetry, their art and sculpture, their adaptability, and their unshakeable faith. And the Creole art of living porously is what will bring me back to learn more about the culture of Ayiti, Haiti.

Haiti Mission Report and Strategic Plan


In the spirit of the above carnet de voyage or travel diary, here is a partial list of activities, contacts and projects during my first mission in Haiti in May of 2015:


· Inaugural lectures on child psychiatry at the Faculté de Médecine et des Sciences de la Santé, Université Notre Dame d'Haïti (FMSS-UNDH), supported by the Dean, Dr. Jean Hugues Henrys, and the Vice-Dean for Teaching, Dr. Audie Metayer, of FMSS-UNDH. These were the first lectures on children’s mental health needs in Haiti. Furthermore, there are no child psychiatrists in Haiti and no child psychiatry services there.

· Visit to the Mars and Kline Psychiatric Hospital, Port-au-Prince, where I participated with Dr. Hans Lamarre in a clinical seminar with psychiatry residents and medical students.

· Colloquium at URAMEL - Unité de Recherche et d'Action Médico Légale – Fondation de France/Unit for Research and Forensic Action, Port-au-Prince, on “Our Youth at Risk,” attended by psychiatry residents, psychologists and a variety of local health care professionals and medical leaders.

· Meeting with psychiatric and business leaders, Dr. Claude Manigat and Mr. Oswald Brun, who have recently founded the Fondation Haïtienne de la Santé Mentale/Haitian Foundation for Mental Health. I offered to work with them concerning youth and families in Haiti.

· Meeting with Pastor Clément Joseph's interfaith group – Mission Sociale des Églises/Pastoral Social Mission – to help them build a plan for psychosocial support in the wake of disasters, natural and man-made. Pastor Joseph is a strong leader with charisma, an ecumenical mission and an established community resource base. We have reached out to Dr. Eliot Sorel, the Chair of the Global Mental Health & Psychiatry Caucus, and U.S. Gen. Russell Honoré, a distinguished leader in the field of disaster planning, both of whom have offered their assistance to this group. Pastor Joseph invited me to work with two groups – the interfaith coalition and a group of 25 pastors to sensitize them on children and family issues.

· Meeting with Haitian psychologists who are foreign-trained (France and Belgium) and in private practice seeking training, supervision and support in couples and family therapy. They could be the founding group for Haitian marital and family therapy with our support. They plan to bring me back to Haiti for advanced training, supervision and professional support.

There are too few psychiatrists and no child psychiatrists in Haiti, a country of an estimated population of 9.446 million people in 2006. A WHO study published in 2011 identified 27 psychiatrists there, but the leaders I met informed me that the number is perhaps only half of that! More critical than the limited human resources is the “treatment gap” in children’s mental health care. Even where there are epidemiological studies that establish the prevalence of identifiable mental health challenges, significant treatment gaps exist between those challenges and access to care, including in much better resourced nations such as the USA! 

In the light of these observations, I want to identify people who are already working with youth, families, and communities in order to find local partners for my mission. I believe we can identify four distinct groups: 

  1. FMSS-UNDH for preparing future physicians and planting seeds. Dr. Richard Mollica, Director of the Harvard Program for Refugee Trauma (HPRT), has been working with Fr. Jean-Charles Wismick, Ph.D., Vice-Rector for Academic and Scientific Affairs at UNDH, to establish a mental health program with both teaching and clinical components.

  1. URAMEL for their broad NGO-style mandate to work with medico-legal issues but also a wider vision that includes mental health.

  1. Mission Sociale des Églises/Pastoral Social Mission – community-based and outreach-focused interfaith group with a mission and a vision.

  1. High-level professionals with training and experience at international standards who are in private practice and who serve a certain class while taking part in planning and support to other organisms with a broader reach; my hope is that supporting this group will establish new ideas and practices in Haiti, that eventually, through “trickle-down” and “tracking-through,” will benefit more of Haitian society.

In short, the local and national human resources in Haiti are solid, creative and inspiring! They have the leadership, drive and task-orientation that is needed for building a better society. My own limited mission is part of a larger one that involves colleagues in pediatrics and will soon include obstetrics-gynecology and surgery.

Our mission in global mental health involves Dr. Hans Lamarre, Haiti Mission Director, and Dr. Emmanuel Stip, Chair of the Dept. of Psychiatry at the Université de Montréal/University of Montreal, working closely with Fr. Wismick at the UNDH and Dr. Mollica at the HPRT, and the support of Dr. Sorel, Chair of the APA GMH&P Caucus. Together, we are participating in a historic opportunity to build sustainable programs for integrated, total health of children, families, and communities in Haiti.