'No Five Fingers are Alike': What Exiled Kurdish Women in Therapy Told Me

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This is probably the only book of it kind that focuses exclusively on refugee women, and one of the few that limit their scope only to one group of refugees - the Kurds, in this case. Although the book is about Kurdish women in Norway, its appeal and contents are nevertheless of universal value and applicability. The general reader will get an unparalleled insight into a therapeutic way of working with refugees and the specialist reader will have a vast range of themes to feast on. These include theoretical considerations of ideas about collective trauma, narrative life stories, working cross-culturally, mental health perspectives on refugees, and the formation of meaning, to mention but a few.

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1. The interdisciplinary challenge

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The Extended Use of Clinical Data

This work is a study of trauma, not from the narrow perspective of psychiatric pathogenesis, but from a wider, interdisciplinary viewpoint, that is, including a comparative psychocultural analysis. It takes as its theme two rather problematic concepts – namely trauma and culture. Both of these concepts are highly relevant to the research on forced migration from the developing countries and so called ‘traditional settings’ to the urban western context. My ultimate aim is to reconsider the impact of trauma and culture on victims of forced migrants in order to further our theoretical insights in this area. However, the themes of this study also carry other implications for the analysis of cross-cultural treatment and the psychological consequences of cultural change and migration more generally.

Because of the fact that illness and suffering always originate within a particular psychosocial environment any investigation of its patterns must also relate to the cross-cultural aspects of this fact. In view of the traditional religious settings from which the migrants at issue here come, it becomes particularly obvious how illness and suffering are intertwined with moral problems, and how recovery and further coping are therefore not only dependent on modern medicine, but ontological validity as well.1 It is my firm conviction that any successful psychotherapy is dependent on getting things right from the patients’ point of view, i.e. the emic perspective of the insider, which the medical anthropologist Arthur Kleinman (1980; 1988 a) calls illness. And which he saw as distinct from the external etic concept of disease that denotes the theoretical interpretations of pathology as used by professional helpers.

 

2. Psychological trauma reconsidered

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The Weakness-Exhaustion-Demoralisation Constellation and Post Traumatic Stress

One of Freud's major early discoveries was the fact that certain childhood experiences had had a crucial influence on the subsequent adult lives of his patients. This discovery impressed him because of the specific role they played in the development of illness and the formation of symptoms. Although practically all children have such experiences, events which result in pathological formations in some, are experienced by others without ill effects. Judging by the results obtained from research in the emerging field of traumatology, there is little doubt that intrapsychic factors play a decisive role here.

In medicine, the concept of trauma denotes physical injury, but when transferred to the psyche, it refers to emotional shock. In the process of defining psychological trauma in more detail, Freud himself was to view it from many interrelated angles:

— In Studies on Hysteria (1893/See 1964) trauma is described as any experience which calls up distressing affect such as fright, anxiety, shame or physical pain.

 

3. The torture versus exile trauma

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Collective versus Individual Meaning and Management of Trauma

At this stage the question arises as to what the trauma actually constitutes for these exiled clients. Traumatic experiences do cause PTSD, but cannot of their own create the type of anxiety which appears from these clients’ stories. A traumatic experience, especially when inflicted by others during torture, is generally assumed to damage the victims to the extent that they actually lose touch with common sense reality. To be ‘one of the living dead’ is a common description of the subjective experience of such total helplessness reported in the clinical literature reviewed in the previous section. Moreover, under such extreme circumstances, socially authorised shared values prove to be insufficient for imbuing meaning into what the victims have experienced. By their very nature such abnormal experiences initiate a sense of discontinuity, which threatens the clients’ confidence in the construction of reality as simultaneously internalised by him or her, and externally anchoraged in a collective world view, and thus their ability to cope with life.

 

4. Violation of gender

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The Silence of Women – the Shame of Men

Social violence is widely practised by, and directed at men, just as torturers are as a rule male1. However, the sexual violation of women is a widespread war crime, which has not been accorded corresponding status, despite the increased attention given to it recently2. Out of a desire to help it is, however, easy to forget that the rape of a tradition-oriented woman is always also a rape of her male protectors. This being the case, focusing on it on the level of a particular case, if public revelations are involved, adds to the dilemma of all those involved in this kind of suffering. Indeed, I would go so far as to say that no rehabilitation which ignores this fact, and thus also the problems confronting men in bringing their women home after such acts of violation, can possibly succeed.

Episodes of this kind will, irrespective of any individual guilt, risk bringing the whole family into disrepute. Sexual violation and the torture of women and children therefore remain underreported, and it takes much courage for clients to reveal them, even in the course of therapy3. According to Mollica (1989, 374-5), non-western women generally do not seek help for the medical and psychological effects of sexual violence. Instead, they are referred for treatment of problems related to the trauma, such as pregnancy or suicidal behaviour, while at the same time the women deny sexual abuse or keep the fact that it has taken place a secret.

 

5. Violations of intergenerational obligations

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The Dutifulness of the Young – the Right of their Elders

The techniques used for establishing a distance between the genders, however, are not purely addressed to sexual issues. Protecting women from undesirable sexual contact is not the sole purpose of purdah practices, even though this is offered as a rationale by the subjects themselves, but must rather be viewed as part of a larger pattern of avoidance behaviour influencing group cohesion1. While honour is considered of utmost importance for one's status, the extent to which it is attainable is dependent on one's kin group as an entity. Besides concern for collective disgrace through the interaction of female relatives with outsiders – particularly men – the structural integrity of, and the need to preserve at least formal harmony within the confines of the kin group is a very important by-product2.

Gender segregation thus becomes a useful means of maintaining internal cohesion in the extended family, while the patterns of deference involved prevent conflicting interests from undermining its social fabric. Kurds live in families, for their families, and, often, from their families. As long as the prosperity of the kin group is bound up with a means of production that renders everyone economically dependent on everyone else, this makes it necessary to prevent overt discord between its members. The nuclear family group is, therefore, not considered to be extraneous to the rest of the joint family; husbands have no means of contradicting their elders, even on issues concerning their own household, nor do parents have any right to display overt preference for their own children who are brought up to regard half-siblings and cousins as brothers and sisters without partiality.3

 

6. Clientification as a re-actualised trauma

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‘Guilt’ and ‘Shame’ in Culture and Treatment Ideology

According to Varvin's (1998, 67) clinical experience many refugees manage fairly well while they are living under a repressive regime or are in flight; i.e. as long as they have the possibility of projecting their painful experiences – as I would add, rightfully – on to the enemy. However, as soon as they reach the country of exile, they are, it seems, often left on their own to cope with their painful inner objects and anxieties as these have been presented in previous chapters. Confronting an understanding or, possibly, rejecting authority can precipitate a feeling of misery, but it may also, according to him, allow for the projection of ‘bad’ parts of the self onto the former. My own focus has been more on the fact that by the time they arrive in the West many third world refugees harbour phase specific unrealistic expectations of what their new life in a western welfare state holds for them. Such expectations may be of decisive importance for further developments, especially their relationship to the host authorities; here evidenced by Shirin, who was in danger of losing her children1.

 

7. The collective dimensions of trauma

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Violation of Ritual and Ritual Emotion

I will now again shift focus to include the issue of whether the changes in living conditions, which have provoked such traumatic experiences in the clients, are in any way related to collective ritual requirements of the ingroups at issue. The psychological foundations of rites de passage have long been debated within the history of religion and related subjects.1 The significance of such rites for facilitating emotional readjustment to a new life situation has been particularly stressed. However, the available material has been able to verify this only indirectly as it has mainly consisted of merely observing the rituals or collecting traditional lore.

The interpretation of emotions raises particular problems in cultural research because of its primary preoccupation with collective analyses. The emotional reactions of the individual therefore remain largely outside the scope of ethnographers’ focus. Although researchers such as Clifford Geertz (1973) and Victor Turner (1969; 1974; 1979: 1991) have suggested that ritual symbols affect the way individuals experience their world, they have not looked in detail at the individual subject in order to substantiate their ideas. Since the functions of rites are frequently depicted as dependent on personal meaning, the perspective of participatory observation is not sufficient ground on which to base an analysis.

 

8. The millenarian heritage of the modern age

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Urban discontent and Islamic Fundamentalism

According to Barkun (1974, 166-167) millenarian activity tends to flourish in backward areas and agrarian segments of the population and almost disappears with urbanisation. If disaster strikes an agrarian population it is likely to assume collective proportions, since the imagined society and actual place of residence coincide. For those of fixed abode, the loci of personal identity and actual life coincide. Where there is a feeling that such a whole life is in the process of being lost, this is likely to be perceived as disastrous to the subject's way of life. Disturbing events are thus more clearly shared by highly homogenous communities.

On the other hand, urbanisation draws discontented people from a rural setting into a pluralistic setting, but without an accompanying identification with place of residence. Many migrants continue to internalise as their ‘true’ society the place they left, and thus possess it internally in an idealised, stable form1. It remains their area of primary identification even after they have been forced to leave, thus creating a disjunction between their locus of personal identity and the physical existence of their present life; so aptly portrayed by Nasreen when describing the sculpture-like quality of her exiled home (N ex.1: A Topsy-Turvy World), or as reflected in Aisha's dynastic coping strategy described in chapter twelve: On the Narrative Approach and Meaning-Formation.

 

9. The cumulative effects of trauma

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A distinction is generally made between natural and man-made disasters. To study psychological trauma is to come face to face with human vulnerability in the natural world as well as to confront the capacity for evil in human nature1. It is to face man-made destructive-ness of such intensity that the prevailing collective traditions, which usually serve to create basic trust in the community, cannot adequately respond to such appalling detrimental experiences (cp. chapter 7: The Collective Dimensions of Trauma). As a result, these forms of suffering tend to be suppressed socioculturally as well as psychologically. Moreover, if the traumatic events are natural disasters – acts of god – those who bear witness sympathise readily with the victim. When they are of human design, however, those who bear witness are caught up in the conflict between the victim and perpetrator. The supernatural justification of the infringements themselves and the accompanying lack of shame on the part of the iranian offenders, however, further complicate the picture for those victims who regard themselves as believers in the same religion.

 

10. Patterns of exchange in cross-cultural trauma therapy

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On the Issue of Object Relations in Integrating Traumatic Content

I will now, again, turn to the clinical evidence from a somewhat different angle, and focus on interpersonal coping strategies. One could then ask “Did the clients ‘make it’ during the period we worked together? What about those whose world is so mutilated by organised social violence that there seems to be no safe place left to flee to? Can they find a way out of the chaos and recover basic safety in the face of the further problems they experience when they must face yet more problems in cross-cultural exile?”

If integration of the traumatic content haunting the clients – linked as it is to the internal and external worlds – can be used as an indicator of successful therapy1, some additional factors must be considered before returning to this issue. First, it must be recognised that the therapeutic outcome as reflected in the narrative content and the accompanying emotional responses, is a collaborative composition between three persons: narrator-patient, the interpreter and the investigator-therapist. And, moreover, that the interrelationships of these three involved persons are tied up with the success of therapy through transference reactions. All of them become active constructors of reality in the process; the narrator-patient selecting and reconstructing his or her past, while reflecting about the present and projecting onto the future; the interpreter and investigator-therapist contributing to this process by way of their reaction to the issues at hand.

 

11. The aesthetics of cross-cultural therapeutic interaction

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Challenging the Neutrality of the Therapist's role

In order to gain a better understanding of the dialectical interaction of inner and outer life worlds surrounding cross-cultural therapies, I will now compare certain cultural concepts prevalent in the iranian context with some of the emerging (western-style) therapeutic working alliances and, by extension, the transference reactions of these therapies. Killingmo's (1984) exposition of the principles of dynamic psychotherapy will be used as a benchmark for clarifying the process involved. In a paper on the relationship between theory and technique in psychodynamic therapy, he draws some important demarcation lines, while at the same time criticising the widespread eclecticism in therapeutic interventions “for confusing the principles of validation”. This is because, in his view, such a situation invites dubious practice without the necessary measures of control embedded in an articulated theory.

Although the structure and content of therapy may vary, enabling the patient to re-connect with the good objects of the past is considered to be the most important feature of psychodynamic therapy with those who have survived torture or other forms of organised social violence1. Because perverted forms of interpersonal relationships have explicitly caused their symptoms, recovery suggests some form of correcting affiliation. In this sense, according to psychotherapeutic thinking, there has to be a similarity between the pathology formation and the curative process. What is more, real life is not thought to possess, in itself, the power to erase such horrendous imprints of the past, which insidiously spill over into and contaminate the present. The undoing of such malignant experiences within the confines of psy-chodynamic therapy therefore presupposes the role of a neutral therapist who refuses to be exposed in order to remain ‘a blank screen’ for the reconstruction of the misrepresentations of the past. The patient will come to regard the therapist as some significant figure in their past, and transfer onto the therapist feelings and reactions, which undoubtedly applied to that particular prototype.

 

12. On the narrative approach and meaning-formation

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Refugee Narratives and ‘Time’

Following on from the preceeding analysis of the emerging cross-cultural therapeutic space from an interactionist perspective, I will now proceed to consider the identificatory migratory process as it is reflected in the clients’ narratives. The stories told to me by the participants in this study vary a great deal, for example regarding issues such as time, context and persons involved. When the clients narrate, the culture of their origin and primary reference group speaks through their mouths, so to speak. Moreover, for a psychologically competent listener, the story can to a certain extent also reveal the traumas of the narrator's lives, such as those depicted in this study. I would however go even further and claim that the story itself changes as a result of the narrative encounter, the main reason being that there are several ways of listening to it. For example, therapists who are used to listening to the suffering of their patients, are attuned to the fact that the emerging illness narrative will shape the events in retrospect, so as to distance – or actually integrate – an otherwise frightening reality (chapter two: Psychological Trauma Reconsidered).

 

13. Symbolic shelter in a changing world

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Gender Mobility in a Cross-cultural Setting and the As-if Strategies

Ideally, all interaction, whether cross-cultural or not, presupposes that the parties know how, and in what ways, to find a place in and to fulfil their duty within the system. No one, however, is ever completely merged with existing codes, but will inevitably find themselves in some kind of a more or less reiterative or renewing relationship to these codes. At the same time they could not be anything specific without a relationship to these codes, as illustrated here, for example, by contrasting the role of Aisha as enclosed by her traditional gender role (‘The Frog in a Well’ in All ex. 2) with that of Fatima as ‘the fallen woman’ rebelling against the prevalent gender code of her culture of origin. In real-life situations, not to mention cross-cultural ones where it is not possible for everyone to know their exact position vis-à-vis others, nor to comply with it, a good deal of energy is spent trying to establish mutual positioning, as pointed out when considering the initial phase of these therapies conducted across cultural dividing lines, as well as what I have called withdrawal behaviour in preceding chapters.

 

14. On methodological choice and the study of sensitive

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Defining my Concern on Sensitive Research

As for its subject material, the present work is bound by what a few cases of kurdish women refugees with trauma-related and/or adapta-tional problems brought into an extended number of therapeutic sessions. In many ways the clients represent hitherto invisible migrants, who have seldom been the focus of research despite a considerable exposure to the scrutiny of the public health system. While the perspective of studies in migrant mental health has up to now been poorly integrated into studies in the field of cultural research, the postulations of this work have developed out of themes raised by my earlier work on the ideological encounter between muslim migrants and the norwegian society1.

Any research design carries at least a minimum of such more or less implicit theoretical formulations which serve as a blueprint for the study. If the aim of the study is to develop interdisciplinary insight, the focus of the research issues should either be similar to those previously studied or deviate in some clearly defined ways. I myself ventured into this project with a question of common concern to scholars working in the field: How does the refugee-trauma influence a life course? With one exception the informants of this study showed clear signs of post traumatic stress at the outset of treatment.

 

Appendix: List of Clients’ Narratives Found in the Text

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List of Clients’ Narratives Found in the Text

Aisha:

ex. 1. (initial) “THERE IS NOTHING BEAUTIFUL ABOUT US“ p. 31

ex. 2. (initial) “WHEN THEY TRAMPLED UPON OUR HONOUR” p. 33

ex. 3. (initial) ABOUT THE MEANING OF LIFE p. 66

ex. 4. (medial) PURDAH OF THE HEART p. 80

ex. 5. (medial) THE SHAMEFUL PHOTOGRAPHS p. 83

ex. 6. (medial) DONKEY-RIDE INTO DEATH p. 87

ex. 7. (pre-medial) CHILDREN DROWNING AS IF IN AN ENORMOUS OCEAN p. 88

ex. 8. (pre-medial) SHE WHO WOULD HAVE CARED FOR HER OLD MOTHER p. 97

ex. 9. (initial) “WE CAME AS GUESTS BUT ARE TREATED LIKE BEGGARS” p. 101

ex. 10. (post-medial) THE CASE OF AISHA'S DAUGHTER CONTINUED p. 108

ex. 11. (medial) FROM GHOST TO SECOND ‘SHAHID’ p. 125

ex. 12. (post-medial) ABOUT THE ‘SECONDARY SHAHIDS’ p. 130

ex. 13. (post-medial) ‘HAVVU’ p. 156

ex. 14. (post-medial) ONE YEAR AFTER HER MOTHER'S DEATH p. 184

ex. 15. (medial) HOSPITALISED FOR HEART TROUBLE p. 196

ex. 16. A SOCIOCENTRIC TRANSFERENCE? p. 198

ex. 17. (medial) THE GUEST HOUSE p. 236

ex. 18. (medial) ON THE LAP OF THE PATRIARCH FATHER FOR A LITTLE TOO LONG p. 238

 

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