Patricia Foxen & Lucie Nadeau
This text discusses the multiple and sometimes contradictory narratives confronted by clinicians through the course of therapy, and the ways in which therapists react to, and strive to cope with, the ambiguity and uncertainty created by changing and conflicting stories related to their patients' past. Throughout the process of therapy, multiple narratives are constructed by different actors - including patients, family members, clinicians, cultural brokers and professionals from other institutions. These stories come to impact on each other in numerous ways - that is, they can become integrated at various levels by individual actors or engender conflicting representations and dynamics. At the same time, such narratives also vary through time for the different actors, and can often take on or provoke sudden unexpected, and confusing, detours, particularly when a newly recast story appears to contradict past explanations.
The variable and changing nature of stories is often particularly marked when working transculturally with refugee families, who find themselves struggling to negotiate individual, family and collective reconstructions of a traumatic past, and devising coping strategies for an uncertain present, in the face of both various cultural models and complex family and institutional dynamics. Within the field of transcultural psychiatry, medical anthropologists and other mental health professionals have pointed to the importance of a meaning-centered approach to therapy which emphasizes the need for therapists to avoid assigning meaning from an outside perspective that does not take into account the symbolic and semantic networks through which cultural Others make sense of their illness or suffering (Good and Good, 1982; Kleinman and Good, 1985). At the same time, simplistic conceptions of the cultural Other that assume a coherence and unity of his/her culture run the risk of stereotyping or caricaturizing others' experiences and beliefs. In either case, there is a danger of objectifying cultural difference and missing the complex interactions that guide the patient's or family's experiences within the broader environment, including the continuities and ruptures existing between home and host contexts, between different family members, and between "traditional" and "modern" belief systems.
Using this interpretive approach, some researchers have examined the narrative dimensions of meaning in constructing stories of illness and suffering, which underline the relation between culture and experience. As Byron Good argues, the illness narrative, like all narratives, is "a form in which experience is represented and recounted… in which activities and events are described along with the experiences associated with them and the significance that lends them their sense for the persons involved" (Good, 1994, p.139). Good describes narratives in terms of the following characteristics: 1) They always describe events from the perspective of the present, and are thus never complete or finished but change depending on present circumstances, motivations and audiences; 2) Narratives have plots, through which the narrator orders meaning within a particular explanatory logic which permits him not only to communicate such meaning to others but also to shape experience for himself; these plots are culturally and morally constituted and represent a resource through which the story-teller can give meaning to past and present circumstances; 3) Narratives also include a "subjunctivizing", or imaginary quality, that allows one to project experiences into the future, organize strategies and desires toward imagined ends and negotiate action in the face of uncertainty. And 4) Narratives always involve a listener, reader or interpreter who engages imaginatively in making sense of the story, and of opening the narrative to the possibility of change. In brief, illness narratives, like others, are told from what Ricoeur calls "the blind complexity of the present as it is experienced" (Ricoeur, 1981, as cited in Good, 1994), and engage in an imaginative evaluation of the potential meanings of the past as well as future outcomes. In this sense, narratives are always subject to multiple readings and outcomes; the telling and retelling of stories point to present concerns and future outcomes that "are feared, longed for, or seem ironically or tragically inevitable" (Good, 1994, p.145).
Although this multiplicity of narratives is present in all clinical setting, it becomes particularly salient when working with refugee and immigrant families. First, as mentioned above, displacement and trauma often produce various forms of rupture - spatial, temporal, cultural and emotional - that are remembered, re-negotiated and transformed in the present. These processes can vary considerably through time and amongst different family members, depending on both the nature of and interpretation given to traumatic experiences, and on various factors influencing the family's experience in both home and host contexts. For refugees and victims of violence, pre-migratory experiences are often highly confusing and chaotic, and are often recounted as such; as Barsky has noted in a criticism of the IRB, their stories rarely fit the linear or coherent narrative forms required in the refugee claim process (Barsky, 1994). Moreover, in the host context refugees often cope with problematic circumstances such as fragmented families, social isolation, diminished status, and exposure to radically different value systems (Rousseau, 1995). Balancing multiple references from both past and present, home and host contexts, can produce a multiplicity of shifting, and seemingly contradictory, self-representations that are put forth or played down depending on present circumstances, audiences, and to whom one implicitly compares oneself at a given time (e.g. who one was back home, who one is in relation to one's community here, or in relation to Quebec society, or who one would like to be in the future). As Ewing (1990) has pointed out, all people project multiple and inconsistent representations, not only of the individual self but also of other's and of one's memories. For many refugees, such multiple and changing representations, rather than signifying a pathological diffusion or denial, can reveal rather a positive flexibility that allows one to assert oneself in the midst of rapid cultural change, powerlessness, and marginality (Foxen, 1994). In this sense, the retelling of stories is closely related to notions of identity and memory; narratives can be viewed as tools or rhetorical strategies through which both identities and memories are reworked and juggled in an ambiguous present. Here it is useful to point to Ricoeur's notion that, while narratives can serve to create coherence, they can conversely function by shattering repetitive or conclusive images of the past, thereby creating fragments of memory and reinscribing new imaginary possibilities or "unexploited potentialities" into the present (Ricoeur, 1984). As such, the silences, uncertainties, paradoxes and contradictions present within and between refugee's stories might be seen as part of the on-going and open-ended process through which individual, family and collective identities are constantly revisited.
The narrative approach allows us to view not only patient's stories as complex and dynamic processes, but also points to the notion that the various "listeners" themselves -both therapists and professionals from other institutions working with the patient/family - are themselves "immersed in narrative" (Brooks, 1992). In this sense, the listener's ability - or difficulties-in engaging with the patient's various narratives comes from the fact that he himself is immersed in a narrative process through which reality is ordered, the past is given meaning and the future anticipated. Both narrator and listener, then, are situated "at the intersection of several stories not yet completed" (Brooks, 1992, p.3, stories that are chiseled within particular cultural, moral and motivational frames. Moreover, the therapist's own revision of the patient's story becomes influenced not only by his own narrative process but also by those of the other professionals (e.g. DYP, teachers, social workers) with whom he consults and may serve as mediator. The multiplicity of narratives present in everyone's life is interesting here in as much as it influences the reaction of the therapist, the decisions of institutions involved, and the outcome of the refugee families.
When clinicians are confronted by numerous, seemingly inconsistent narratives - that is, when the patient himself, or others involved in his life, present conflicting stories of the past - the destabilization created by such incoherence can lead the clinician to attempt to restore a certain "truth" in synthesizing and ordering other's stories. In part, this reaction is a natural impulse to create meaning and frame realities which otherwise might seem disordered or even chaotic. In the case of clinical assessments, this reaction is reinforced by the need to provide a diagnosis and treatment plan. The notion that there is one stable, bounded story of the past is also often reinforced through psychiatric training, which emphasizes the objective dimensions of symptoms and syndromes that can be elicited through assessments and evaluations. Although we do not dispute the clinical importance of diagnostic categories in treating refugee populations, we argue here that they do not always offer the key to understanding the complex pasts and social dynamics experienced by these populations, which may become critical issues in the course of therapy. Clearly, moreover, most psychiatrists are well aware and sensitive to the fact that their patient's presentation of reality, as well as their own diagnoses, are complex and may evolve and change through time. However, given this impulse toward cohesion, and the particularly complex nature of refugee narratives, there can be a temptation to privilege one story over another, thus viewing the multiplicity as a form of deceit or lying on the part of the patient or family members, or to interpret shifting or diverging stories as a defense mechanism or denial caused by a traumatic past experience. Such reactions can have misguided, and perhaps even damaging repercussions, when working with refugee populations in particular.
First, the implicit or explicit assumption that the patient (or family members) might not be telling "the truth" can feed into the negative relation refugees have often experienced with authority figures. Victims of political or social violence have often been subjected in the home context to multiple accusations of lying and deceit, strategies of silencing and terror often used by aggressors. In the host context as well, refugees are often submitted to a grueling refugee determination process in which the "truth" of their story is sometimes questioned and in which inconsistencies are viewed as outright lies. Moreover, people who have lived in situations of chronic fear or terror often learn that an important survival strategy is to reveal only partial truths and produce shifting or fragmented narratives. Finally, styles of narrating reality - for example what is acceptable to tell in certain places or times, or the tolerance for exaggeration, ambiguity and paradox - vary tremendously from culture to culture regardless of violence. Given all these factors, the fragility of refugees may be reinforced by their own suspicion that they are not perceived as trustworthy, or that they are simply misunderstood by the therapist. In addition, we are reminded here of the fragility of therapists themselves vis-à-vis stories of violence. The unfathomable nature of extreme trauma stories, in which suffering is so painful, barbaric or beyond the realm of experience that it cannot be given human significance (Scarry, 1985), can produce a reaction of profound anxiety, denial and projection for the therapist, who may then be led to either question the refugee's truthfulness or impute his own interpretation.
Secondly, the assumption that contradictory or incoherent stories must reflect a "traumatic" response of repression or denial can also be problematic, as it privileges one part of the refugee experience - that which is centered on the individual's aggression and violation by outside forces - at the expense of other parts of his/her experience (the pre-violence story, the post-migration context, family power relations and dynamics) that may be contributing to the multiplicity of stories. As several authors have pointed out violence and suffering are experienced, interpreted and given meaning within particular political and cultural frames, and are "handled as a function of individual personality strengths, the meaning assigned to events, and of social factors operating for good or ill at home or in exile" (Summerfield, 1998, p.20). Some (Eisenbruch, 1991) have shown that what might be interpreted by a Western clinician as "symptoms" of psychological distress may not always be experienced by the patient as pathological, and may even be carriers of meaning, or cultural signifiers that enable people to articulate suffering and mobilize cultural interpretations and practices. As argued here, stories of trauma and suffering are situated in and shaped by particular fields of social relations that involve different family members, clinicians and institutions, all of whom interact with each other in pragmatic ways, and all of whom "emplot" stories at various times to suit present needs for meaning and action. In presenting the following narratives, we seek underline this intersubjective quality of clinical narratives by illustrating not only how various actors create their own, changing, indeterminate narratives and plots through which they structure their own actions and beliefs, but also to elucidate the role of power relations in the "pragmatics of story-telling", which frame the ways in which different stories are told or who has the authority to speak at any given time.
The cases presented here are part of the data collected for a broader evaluation of the transcultural psychiatry services provided at the Montreal Children's Hospital with Dr. Cecile Rousseau's team. As part of this evaluation, a qualitative approach using both retrospective and prospective methodologies were utilized. In the first approach, cases were reconstructed by interviewing the primary therapist working with the patient and his/her family, and by interviewing the team of clinicians, as well as others involved with the patient throughout the course of therapy. Here, the retrospective approach did not allow to record the particular narratives of patients and families - rather, these were filtered through the reconstructed history provided by the therapist and others, and therefore allowed us to see how different institutional actors remembered both the patient's story and the course of their experiences throughout the therapy process. However, because some of these cases were not conclusive, in the sense that the family returned to our services following the research interviews, the data from the "reconstructed" stories were sometimes supplemented by additional, on-going discussions with the therapist concerning the patient's continuing story. In these cases, we can see how, rather than having clear clinical "outcomes", the family's multiple narratives continued to change through time, as did the therapist's own involvement and understanding of these narratives. The second approach used a prospective method where both the processes of assessment and treatment were followed as they evolved. Here, we recorded the initial assessment interview that took place with the family and team; approximately six months after the initial encounter, separate interviews were conducted with both the clinician and the family. In between these two periods, field notes were taken at team meetings when the cases included in the research were discussed. In using both of these methodologies, then, we were able to collect various types of narratives at various temporal interludes, included the experience of the family in the clinic, the experience of the family outside of the clinical setting (in daily life, with other institutions),the experience of the clinician with the family. Because there is not enough time here to discuss the different narratives of all the actors, the following presentation in effect reveals another narrative dimension, that is our own (the researchers') reconstruction of all the other stories. As such, it echoes all the other narrative "levels" or dimensions from which the research built, and seeks to recreate the evolution of the clinician's reactions and organization through the course of therapy in the face of contradictory stories.
We have chosen the following three cases to illustrate three different types of multiplicity in the clinical setting. The first describes a situation where the clinician was confronted by diverging stories, or multiple voices, among different family members. The second looks at the multiple and shifting stories of a single patient, and how these impact on the shifting interpretations of the actors and institutions working with her. And the third case illustrates the ways in which the narrative of a single patient can be silenced and then re-emerge through time over a longer-term perspective.
Narrative 1: Mohammed
Mohammed, was a 7-year-old Algerian boy when he was referred to our department in a state of extreme dissociation: he was absent, fearful and withdrawn, had concentration and memory problems, slept poorly and had little appetite, was asthmatic, and, the referring doctor stated, had witnessed a lot of grief and violence. Our team met Mohamed with his entire family, including his six siblings and parents. At the initial evaluation his mother did much of the talking, while his father remained quiet and sad, due to the fact that only a week previously his own father had been killed in Algeria, found strangled at the doorstep of their house. Mohamed's mother explained that because the family is educated and that she belongs to an influential and intellectual family, the entire family had been targeted and threatened in Algeria. At this first meeting, Mohamed's withdrawn behavior was explained by his parents in terms of a number of factors related to his past traumatic experience and to fact that Mohammed was a special child. First, the mother stated, Mohammed was special in light of the fact that his pregnancy was long and difficult, that he was born with one eye bleeding, and that he did not open his eyes until seven days. Secondly, according to the parents, one particular episode explaining his behavior occurred when he was just over a year old: as his paternal grandparents were bringing him home at nightfall, Mohammed took a great fright along the road, and was returned to his parents filthy and in a tantrum. The father explained that a jinn had probably cursed Mohammed, though the mother said that he had most likely seen something bad happening along the road. The parents went to see a traditional healer (Imam), who said that Mohammed would probably die; however, following a traditional religious treatment involving reciting verses from the Koran, he survived but became completely detached. Thirdly, the parents state that Mohammed, unlike the other children, had been exposed to much violence and corpses back home. Fourth, because the parents and the youngest child had come to Canada two years before the rest, the remaining children had stayed with the maternal grandparents, during which time, they stated, Mohammed was kidnapped for two days by aggressors. When Mohammed finally arrived in Canada, his mother had had two other children; Mohammed did not recognize his mother, had lost his place in the family, and felt disoriented. Thus, the parents explain Mohammed's vulnerability and sensitivity in terms of these events: his special birth, his fright along the road, his kidnapping, his particular exposure to dead bodies, and his separation from his parents.
Following this evaluation, the team decided that the family was extremely fragile: the father was clearly depressed, and the mother seemed overwhelmed with her children and with her inability to communicate with various institutions. Both had chronic health problems, and the family was in a dire economic position. Despite these difficulties, the family seemed united and concerned with Mohammed's well being. Given his traumatic past and his difficulties in communicating, it was decided that Mohammed should come for therapy sessions, which focused on play therapy and expression. He was followed by a clinician (a francophone female art therapist) and translator/cultural broker, an Algerian man who became quite close to Mohammed and his family. The play therapy, designed to provide a safe, trusting space for Mohammed, was based largely in the idea that the two therapists might bridge Mohammed's different worlds - Quebec and Algeria - in a certain harmony that would show him that difference and conflicts can be worked out without violence or fear. Although Mohammed did not verbalize his feelings, he slowly began to express a range of emotions during his sessions: anger, frustration, and sadness. His withdrawn and dissociated demeanor slowly improved, and he was increasingly able to concentrate at school.
However (and relating back to the notion of narrative described above), the clinicians were eventually confronted with a new family narrative told through the perspective of different actors, which showed that the story constructed earlier was far from complete or simple. Two years after starting therapy with Mohammed, it became apparent that there were many more problems within the family. The mother told us that her two teen-age daughters had been placed by the DYP in foster homes, that she was forbidden to see the daughters and was terribly distressed. Following several meetings between the therapist and the mother, the latter revealed with much embarrassment, that her daughters themselves had called the DYP and reported being mistreated and threatened by the mother. At this time, the therapy team's first reaction was that the DYP had somehow failed to grasp the cultural and traumatic context of the family, and that the girls' placement with a foster home was hasty and misguided, and a result of institutional misunderstanding.
At the request of both our team and the DYP the two daughters came reluctantly to see another therapist on the team. The girls told her that their mother was cruel, abusive and manipulative: that she made them work until after midnight cleaning the house, that they had to repeat their tasks until perfection, that the mother had sworn on the Koran with a crazy look in her eye that she would kill them. They recounted numerous stories of abusive behavior back in Algeria by their mother, and said that when they lived with their grandparents they were not required to work so hard. Echoing this version of their story, we then learned that in their legal decision to remove the girls from their home and forbid any contact with the mother, the DYP appeared to frame the story in terms that evoked the story and plot of "Cinderella", referring to an imagery that emphasized the mother's profound cruelty and the tattered daughters' victimhood, thereby giving a particular explanatory logic to their story that strengthened their decision.
The sisters also told the therapist that what the mother had previously told us about their life in Algeria was largely exaggerated and partially fabricated: that their town had not seen much violence, that Mohammed was not so much exposed to dead bodies - since, they said, the older siblings themselves protected him and their other younger siblings - and that Mohammed was never kidnapped. They told us that their mother had been possessed by a jinn, and that a traditional religious treatment, similar to that given to Mohammed, was performed on her also but without positive results. The girls' therapist was not sure what to believe though it seemed apparent that the girls were very angry with their mother for favoring Mohammed and for neglecting them; now that they had been able to place themselves in a powerful position with the help of a powerful institution (DYP), they provided a new rendition of the family's story. At first, the daughters vehemently asserted to us that they refused all contact with their family. Slowly, however, it became apparent that the hostility of the girls did not indicate the desire for a rupture. To our surprise, it became obvious that despite their DYP orders and harsh words about their mother, the girls were having contact with their family during their removal in indirect ways. Moreover, in the therapy sessions, the girls were able to express complex and tender feelings toward their mother, and to also implicitly talk about the violence at home through poetry readings, which they linked to their mother (who had been a teacher in Algeria). Eventually, the girls accepted an invitation from their father to attend a meeting with the entire family in a park, to which the therapist and the DYP worker were also invited. At this point, the mother was able to recognize and apologize for her part in the conflict with her daughters, thus making the various narratives less polarized, and resulting in the daughter's eventual return home.
Here, we have seen how the therapists working with Mohammed's family themselves constructed, at first, a story focused on the violence and trauma lived by the family as a whole; this story was put into question and destabilized with the daughter's placement by the DYP and their subsequent new version or emplotment of the past. At different points, this uncertainty led them to question the veracity of the different narratives: was Mohammed kidnapped, and had he indeed witnessed a lot of violence? Was the mother an overwhelmed victim or an abusive parent? Did the DYP make, or not make, a mistake in placing the daughters? Whose story -the mother's or the daughters' - was "true"? We can also see how the evolution of this family's collective story developed within changing power dynamics: as the daughters positioned themselves within a more authoritative position over their mother, they articulated a different suffering which had less to do with the family's collective experience of political violence than their own individual suffering and feelings of neglect within an unequal family power dynamic. The latter version - though not divorced from the broader trauma experienced by the situation in Algeria in which Mohammed's, his sisters' and his mother's suffering was situated, opened up the complexity of the family's dynamic and integrated elements of uncertainty and ambiguity in the therapists' own assessment of the family's past.
Narrative 2: Leila
When Leila, a 15-year old Tunisian girl, was referred to us by a CLSC social worker, her story seemed relatively clear. Leila had arrived in Canada a few months earlier to meet her biological father, whom she had never known: he had left Leila's mother before her birth, and had a family in Montreal, but had now requested that his daughter visit him in Canada for a couple of weeks. During her brief initial stay in Canada, Leila claimed that her father sexually and physically abused her. Finding herself alone and destabilized, she confided these events to her new Canadian grandmother (her stepmother's mother), who encouraged her to report this abuse to the police. Although she was reluctant to do so (as this would not be customary in her culture, where a girl would not reveal such an event out of shame and fear), she eventually did place a complaint with the police, but subsequently returned to Tunisia as planned. A few months later, the Canadian police summoned Leila to return to Canada and present herself in a legal case against her father. She returned, was placed under the care of a community organization providing services to refugees, and began to live in a group home. Leila was advised by her social workers to apply for refugee status; due to her fragility and story of sexual abuse, she was also referred to our team.
When she arrived at the initial assessment, Leila appeared very shy and was wearing a veil, which indicated to our team her attachment to her traditional culture. At this point she did not discuss the issue of sexual abuse with us; she did, however, appear extremely anxious, biting her nails compulsively and having difficulties concentrating. She told us that she was not happy with her group home situation and that she wished to be placed with a Muslim family. It was decided that Leila would see an art therapist on our team for weekly meetings, who agreed to coordinate the course of therapy with the other social workers involved in the case.
In attempting to discover whether it would be beneficial for Leila to return home (to Tunisia), our team communicated with the mother, and found out that Leila's return would not be accepted by her family: Leila's presence would soil the family's honor, not only because she had been sexually abused but because she had dared disclose the event. Her mother's present husband, as well as her two grandmothers, no longer wanted her to be associated with the family, and her mother, for her own survival, would be unable to protect her. Eventually, Leila also disclosed to us that upon returning to Tunisia from Canada her uncle (her father's brother) had also intented to sexually abuse her. The feeling of rejection, particularly by her mother and maternal grandmother who had raised her, the multiple abuses and the loss of control over her situation engendered symptoms of depression in Leila, who evoked suicidal ideas and was twice hospitalized for acute anxiety and hyperventilation.
Throughout the months that followed our initial meeting, Leila's story took on several confusing detours and layers; her own positioning within the narrative changed not only over time but depended on which of the multiple intervening actors and institutions she was addressing at any given time, which came to include the police involved in the sexual abuse case, the refugee board and her immigration lawyer, the DYP, various group homes and foster homes, a multitude of social workers in different institutions, and the transcultural psychiatry team - and resulted in a rather tumultuous course of therapy.
In the first place, when it came time for Leila to present the case against her father in court, Leila, in front of the judge, vehemently denied the entire story of sexual abuse and refused to testify against him. Despite this sudden change, or perhaps in order to explain it, she told us that she was afraid that her father's revenge, and that she did not want him to go to prison. Secondly, Leila's own initial self-presentation as a shy, veiled Muslim girl also seemed to shift quite radically: according to her social workers and the group home, her relations with men appeared to be numerous and promiscuous, a behavior that was criticised by a number of the care-givers working with her, and seen as an indication of her deceptiveness. Within the context of therapy, however, Leila played down her relationships with boys, and maintained that she was religious, prayed regularly, and that she wished to be placed with a Muslim family. Thirdly, despite this stated desire, Leila also vacillated constantly between saying that she wanted to return to Tunisia to live with her mother, and that she wished to return to her father; indeed, it was discovered that she had tried and succeeded, on a fairly regular basis, to communicate with him. Her father, in turn, claimed that Leila's story of sexual abuse was a fabrication caused by her anger against him for not allowing her to go out and frequent men when she lived under his roof. Prior to this explanation, however, when originally presented with the court summons for the abuse case against his daughter, the father had fled to Europe and was arrested upon his return; he has since taken steps to try to have his daughter deported.
As we can see, Leila's story in and of itself is complex; however, the perplexity created around the story was exacerbated by Leila's shifting stories and positionings, as well as by the number of actors working on her case. From the beginning, it became obvious that Leila was very adept at seducing and endearing those around her into a strong desire to protect her in her fragility and vulnerability; she was equally adept, however, at then turning her anger toward her protectors, changing stories, and causing in turn much resentment, and a desire to regain control, on their part.
Following months of confusion and conflict amongst the various institutions regarding the best solution for Leila, the situation soon reached crisis proportions. Although our team felt that returning Leila to Tunisia would be severely detrimental to her well being - the worst case scenario- one of her social workers at another institution, perhaps in anger toward Leila over feeling manipulated and lied to, or perhaps in anger toward our team for seeking to protect her, took a fairly radical step beyond her jurisdiction and without consulting either the other institutions or care givers. She independently convinced Leila to retract her refugee claim and to begin steps to return to Tunisia, a turn of events our team discovered one day before Leila was due for deportation, when her case had been closed and her return ticket bought. At this point, our team decided that, since all efforts to mediate with Leila's many caregivers seemed to have failed, retiring from the case would be the best option. However, concerned for Leila, we contacted the social worker's superior to find out if her institution had taken steps to ensure that Leila would not be ostracized by her family upon her return. Our "hands off" approach had an interesting result: it forced the other institution to verify the potential consequences of this decision - and after communicating with Leila's mother, the superior realized that deporting Leila would leave her entirely unprotected and vulnerable back home. This episode, however, had created a fair amount of hostility and conflict between various actors and institutions working with Leila; a meeting invoking all the actors was then called with the aim of restoring some balance and common goals. Leila's immigration lawyer quickly reversed the annulment of her refugee claim and set a new date for an immigration hearing; Leila, in the end, received refugee status.
Since this episode, Leila's story has continued to take numerous detours, engendering a constant feeling of puzzlement and crisis for those around her. She has been placed in, and removed from, a number of foster homes. In most cases, after a sort of "honeymoon" period during which she has seemed pleased to feel protected, she has become angered with her foster parents for their perceived excess of discipline, for their accusations that she is deceitful, or for other reasons. In turn, the foster parents have repeatedly felt unable to cope with Leila, or even enraged with her, often coming to accuse Leila of being a bad girl, a liar, and a thief.
As we can see, Leila's own actions have certainly been destructive toward both herself and toward those working with her. Her constant play with reality, put into place and illustrated by her shifting narratives, might be seen to be rooted in profound psychological splits and cleavages caused by several interrelated factors. In the first place, they seem to indicate an internalization of aggression often present in cases of family abuse or abandonment. Leila has undoubtedly experienced profound feelings of loss, and anger, with respect to both of her parents, neither of whom will claim her or have been able to protect her. Her feelings toward each are quite split and ambiguous, however, as indicated by the fact that she continues to have contact with each, albeit in fairly compartmentalized and idealized ways. For example, she has stated repeatedly that she is never angry toward her mother, and continues to call her regularly, despite the mother's clear inability to defend or protect her. Her father, for his part, seems to be seen as both hero (whom she might have idealized through her life in his absence) and aggressor. Unable to cope with these splits, or with her anger and rage toward her parents, Leila then displaces these feelings toward all other adults, whom she views as potential aggressors.
In doing so, Leila creates an ambivalent and unbearable situation whereby she shifts from innocent victim to aggressor herself, creating a self-perpetuating feedback loop. First seducing adults to protect her vulnerability, then provoking reactions of anger whereby she is accused of being manipulative, immoral and undeserving, she then internalizes this worthlessness and becomes anxious and depressed. This split is not uncommon among victims of sexual abuse; at the same time, by playing the game of both victim and aggressor with all adults, Leila in a sense seeks to preserve her parents, to avoid destroying them with her rage. At the same time, by positioning herself differently depending on her interlocutor, her own cleavages become projected onto her various caregivers, who, as we have seen, interpret and act on Leila's multiple and changing narratives in frustrated and sometimes conflicting ways. By constantly testing all of her relationships in a context of expected rejection, and by selectively presenting, or concealing, different aspects of herself to all at different moments, she sets everyone up against one another: mom against dad, care-givers against parents, care-givers and institutions against each other, and against the foster parents, creating an additional web of drama and conflict around her.
In addition to these splits, Leila displays difficulties with the cultural cleavages created by her rather rapid move from a Tunisian childhood to a Quebecois adolescence, in which she has been forced to cope with the responsibilities, freedoms and independence associated with the latter. Indeed, connected to the split between mother and father is a profound division between the home and host societies, in a sense between the traditional and the modern. Leila has shown much difficulty in bridging these, and in fact has demonstrated a clear anxiety when the two worlds are brought together. She has repeatedly refused, for example, to allow her therapist (a non-Muslim Quebecois woman) to meet with her in the presence of other Muslim women - whether it be a social worker or a foster mother - again, finding a need to compartmentalize her narratives and behaviors depending on the cultural background of her interlocutors. At the same time, and as with the other cleavages in her life, she plays with and manipulates the cultural split -for example, months after the initial assessment, she told the therapist that she had been wearing a veil for a while not out of tradition but to hide the short haircut her father had forced her to get, which she found unattractive.
Narrative 3: Kevin
As illustrated by the third case, the plurality of narratives may be encountered within a much longer temporality as well. We first met Kevin, then a 6 year-old boy, three years ago, when his parents were struggling with his difficult behavior. Though the parents were originally from Congo, Kevin was born while both of them were studying abroad in China. They told us about the difficult environment and precarious financial situation they were living in at the time of the child's birth. The mother offered as an example the fact that she once needed to choose between eating a dish of cockroaches or starve. They felt fragile as parents, and stated that because Kevin was their first born they had suffered from the absence of the extended family, who could have advised them on how to raise a child. They seemed to have experienced difficulties with the shift from student life to a parental role; these difficulties increased by their precarious financial situation and the fact that the mother had to assume the entire care of the child during the time periods when her husband returned to Congo for visits. We knew Congo was struggling with political difficulties and collective violence at the time, but the parent's narrative did not these issues in any detail. The question of an organic compound to Kevin's behavior had also been brought up by the reference person since the child had previously suffered from a physical trauma and had had some episodes of seizures. At the time we also sensed that there were difficulties within the couple, though this issue was not vocalized at the time.
The explanation offered by the parents at this time concerning Kevin's difficulties centered on their lack of confidence with respect to their parental capacities, and seemed to be relevant explanations for Kevin's behavior. The other aspects mentioned could have contributed to the difficulties but seemed at the time either less relevant (the organic compound) or not immediately accessible for therapeutic work (the couple's difficulties). Given the limited observation of the child we were able conduct at the evaluation, no specific or important worry emerged concerning the child that we felt would require immediate psychiatric assistance. The treatment plan was thus oriented towards working on the parent-child relation and on their confidence as parents. Our therapeutic recommendation was that the family break their social isolation and create links within their community and its parental rôle models. We proposed that they contact a woman who could be recognized by them as an aunt - a person who, in their culture, would traditionally be asked for advise. The woman with whom we connected the family was also known for her traditional therapeutic capabilities; we felt that she might be able to uncover other familial issues once a good relationship was established. Our team thus hoped to bridge the family's cultural habitus, and traditional community roles, with a western therapeutic setting and frame. Though we did not know if they would get in touch with this person (since their desire to get involved in a therapeutic process was unclear), we believed that this was an appropriate way to resolve or improve the situation and Kevin's well being.
We did not hear from this family for three years. During this time, the team's perception of this family's situation remained framed essentially within the representations offered during the initial meeting: in this sense, the story seemed to be on hold for us. Eventually, the referring pediatrician asked us to see the child again in order to know if it was appropriate to think about an attention deficit and hyperactivity disorder, this time emphasizing the question of an organic compound. The pediatrician's perspective thus put into question the team's narrative about the patient, contrasting it more clearly with a medicalized narrative (a possibility put forth by Kevin's school).
After setting up a couple of appointments, whereupon it was made clear that there was a certain reluctance to come, we met again with the mother, Kevin, and his younger sister. At this second assessment, the mother directly stated that she had not disclosed information three years earlier as she had felt uncomfortable to do so at the time. She phrased this acknowledgment referring directly to the clinician ´ I did not tell Nadeau ª. Though she did not offer an explanation as to why she acted that way, we could sense that the silence was motivate by a feeling of being trapped within important couple difficulties that could not be told at the time. Talking about them would possibly have unsettled a precarious equilibrium, and brought about a crisis she could not afford to live through at the time. At that time, she had been pregnant and expecting the baby in the following weeks. Indeed, as she now stated, she had separated from her husband only two months after we had last seen them, immediately following the baby's birth.
Although in her first encounter she had primarily discussed issues of parenting and Kevin's difficult behavior, in the meeting three years later she put forward a different narrative of the past, framed around issues of domestic violence with her husband. In this narrative, issues of violence within the family now took on a larger part of the explanation for Kevin's problems than those of parental capacity. But the surprising part of this interview was that she mentioned just towards the end of the assessment that she also had a new spouse and a baby girl born from their union. After discussing this new situation and having invited the rest of the family for an appointment, the mother came to talk not only about the violence she had experienced in her own family, but also about the organized violence encountered in her country of origin, a topic that she had not been able to touch upon before and which was revealed to be an important part of her family's story.
This third case illustrates how the notion of temporality, the passing of time, may bring a plurality of narratives as well. As time passes, we, as humans, view our past differently, we remember certain aspects of our history rather than others. This is not to negate that the construction of this past follows a logic respectful of major events of our life, and that one usually acknowledges a coherence of one's past time. However, we want to emphasize how the modification of one's life experience, and of one's situation trough time, influences present narratives, in particular if the context has been traumatic.
Already within the first meetings, the narrative to come three years later was announced, but it seemed that both the passage of time, and the event of meeting a new spouse (or leaving the first), mediated the possibility of talking about the lived violence and brought a renegotiated meaning to the situation. A the initial meeting, it was not possible for the mother to narrate or discuss these broader issues, given that her husband was present and maybe also the short length of time since her arrival in Canada. In this sense, it was neither culturally or emotionally convenient, nor safe, to address these broader issues in the setting of a psychiatric clinic, and she felt too fragile to discuss them. By the second meeting, however, because the mother's daily life was manifestly less harsh than it had been in the past, a new narrative space was opened. Within this temporal and emotional space, the mother was able to look at her relationship with her child as being influenced by a broader experience of violence, both domestic and collective. As we can see then, a discourse that was previously hidden now took on a major space, silence became a less urgent defense mechanism, and the flexible dynamics of the narrative were mobilized.
These cases illustrate how stories of past trauma and suffering take on multiple perspectives through time and through the voices of different actors in the therapy process. As we have seen in each case, narratives recast the past to elicit new dimensions of and reflections on experience; through their plots story-tellers can give meaning to past and present circumstances, in order to both create order and negotiate different versions and experiences of reality. The relevance of this multiplicity to therapeutic work is highlighted by the following discussion points:
1) When working with all patients, but with refugees in particular, we are often working with numerous splits and cleavages which can lead to multiple, conflicting representations and narratives. In Mohamed's case, for example, we have seen how the splits between various family members affected the construction of multiple stories. In Leila's case, we noted numerous splits present within both the cultural and the more subjective, internal dimensions. As argued here, it is critical that therapists and care-givers be sensitive to and try to identify these splits, and find gentle ways to work with patients in order to bridge them within a temporal and spatial frame -therapeutic, family and cultural -that makes sense to the family. In addition, as pointed to in the cases, it also becomes important for the therapist to be open and receptive to the manners in which some patients might utilize these splits in ways that are not necessarily destructive or pathological, but rather become part of a pragmatic reconstruction and reconfiguring of relationships and lives in the aftermath of migration and/or trauma. Moreover, accepting and tolerating the multiplicity narratives may allow the therapist to safeguard against reproducing these cleavages in his/her own understandings, and to avoid entering into such splits (as happened for several of the care-givers in Leila's case, for example).
2) The multiplicity of narratives is revealed not only through contradictions or changing stories, but also is seen in the dialectic between silencing and putting into words. As we have tried to illustrate, particularly in the third case, certain elements of one's past and present experience can only be revealed at certain times in a persons' psychological life, or within certain safe periods. In this sense, silence and contradictions may be legitimate aspects of one's self-representation and dynamics, which much be understood within the context of a person's pragmatic and emotional present life. For example, Kevin's mother was only able and willing to talk about her experience with violence once she felt secure within the relationship with her second husband. Rather than viewing silence, then, as a necessarily pathological or negative reaction (as in trauma models that emphasize disclosure), we highlight here that what might appear as hiding, repressing or denying the truth may, rather, be perceived as an important part of a mourning process. In this sense, it is useful to approach silence in terms of its narrative dimension, as a necessary part of all stories: while we give voice to certain aspects of our lives, others are somehow concealed, for different reasons, consciously or unconsciously, and to different degrees. Viñar and Viñar (1989) help us to think around the importance of the dialectic between saying and silencing within the therapeutic setting:
Il faut néanmoins savoir que l'assimilation complète du vécu est
impossible : des zones de silence sont nécessaires et le thérapeute doit
respecter ces limites infranchissables, sans les entendre comme des
3) We have seen in all three stories how the professionals involved were inclined to elevate one version of the story as "the truth" at different points, depending on factors that include the demands of professional decision making, personal feelings toward the patient or his/her behavior, cultural assumptions, or simply the need to make sense and plausibility out of conflicting or confusing plots. We have also seen how the need to create "truths" concerning patient's past can lead to problematic decisions, or at least to incomplete understandings of the complexities and multiple dynamics of the family's stories. We thus argue that a critical aspect of coping with ostensible contradictions is the need to resist striving to reach an immediate coherence, which might lead the clinician or others to bring judgement as to the veracity of different actors' stories: believing neither the whole truth, nor the whole untruth, of people's stories, becomes an important element of a therapeutic perspective in which the acceptance, and tolerance of uncertainty and ambiguity becomes essential.
The role of the therapist, in this sense, might be likened to the reader of a text, who, as she proceeds through the story, its various plots and voices, views the narrative moment by moment, seeking to uncover and anticipate the structure and meaning of unfolding events. Like a reader, the therapist is thus involved in an intersubjective process whereby she enters imaginatively into the world of the text, shifts viewpoints to follow the various perspectives presented by the narratives and their narrators, and reconfigures past events as the story unfolds. As Good states, stories of illness and suffering "have indeterminacy and openness; therapeutic actions, motives of participants, the efficacy of interventions and events are open to reinterpretation as life goes on, revealing hidden aspects unavailable to the blindness of the present. There is no final judgment about their meaning or significance. Narratives are organized as predicament and striving and as an unfolding of human desire" (Good, 1994, p.164). In the clinical setting, then, if we view patients' narratives as unfolding and indeterminate, it becomes essential to understand not only the roots of multiplicity, but also how shifting stories are used pragmatically by actors in particular dynamics, and how the therapist might be able to serve in a supportive, patient way, to create bridges and links between fragmented stories and identities.
Of course, this sort of "reading" of multiplicity can become problematic in a therapeutic context where important decisions - both clinical and diagnostic decisions, as well as institutional decisions (whether child should be placed, medicalized etc.) - must be made within a specific and often short time frames. Clearly, diagnostic categories can help a therapist to organize complex aspects of a patient's difficulties, and the diagnostic process is often a critical step in deciding upon a treatment plan. While we do not want to negate the importance of clinical diagnoses as therapeutic tools, and while the cases presented here may lead us to think around certain diagnostic categories (e.g. PTSD in Mohammed's case, multiple personality or dissociation in Leila's), we do highlight the limitations if diagnostic categories, which can not integrate the human, social, inter-personal complexities within which patient's experience and suffering (pathological or not) is situated. The point of our discussion is rather to highlight another aspect within the logic of therapeutic treatment - the presence and meaning of multiplicity - which we feel is important in finding clues and keys to a good intervention.
In addition, the temporality and circumstances of some cases allow therapists to take a slower approach, to mediate between families and with institutions without too much damage (e.g. Mohammed, where the DYP changed its decision and the sisters went home). However, in cases such as Leila's, where rapid decisions must be made regarding the patient and where all actors - the patient, the parents, the social workers, the institutions, the foster parents - are trying to exert immediate control and power (and therefore create totalizing narratives that emplot her as either "manipulator" or "victim"), the situation can be disastrous. In these cases, sometimes pulling back and not trying to force decisions may be best solution.
4) As we have seen, patients' stories become intertwined as well with the multiple stories of institutions. In this respect, it becomes important for the therapist to be aware not only of the patient/family's multiple stories, but also the different narratives - all emplotted within their own moral and cultural logic - of different caregivers (including the therapist's own) and institutions. Indeed, a particular patient can become a vessel for, or a reflection of, various institutional discourses (on refugees and immigrants, on "problem" children, etc.), thereby engendering unspoken debates amongst the institutions surrounding the case. Recognizing these various interpretations and discourses, and serving as a mediator between the clashing or contradictory narratives of different institutions or actors, can become an important therapeutic goal.
5) While arguing that there are multiple narratives and versions of past "truths", it is important also to point out the broader academic point that the conceptualization of "truth" and "memory" themselves must be distinguished within the various frames, contexts and purposes within which they are utilized. In this sense, the type of formal narrative of past suffering and trauma that is narrated to (and required by), for example, a Truth Commission or Refugee Board, may be quite distinct from the "messier" stories that are disclosed and discussed in intimacy. As Viñar and Viñar (1989) ask,
Que dit un torturé à son jeune enfant? à ses êtres chers ? Cela n'est pas étranger, sans doute, à ce qu'il peut se dire à soi-même et aux limites impossibles entre mémoire et oubli. Quelles sont les frontières entre une parole intime et une parole publique ? Qu'est-ce qui est propre à une situation thérapeutique et quelles sont les frontières et les clivages avec le monde médiatique et les institutions des droits de l'homme ?" (p.162)
Here, we point out the importance of recognizing the particular space of therapeutic setting - that is, the pragmatic, social, inter-personal, and emotional dimensions - that enable people to construct particular types of narratives, balanced somewhere between formal and intimate, collective and individual, within which patients' narratives are constructed. Because the therapeutic space does not have the mandate of a legal court, for example, which requires that "a truth" be revealed in order to promote a particular social framework for justice, it enables the uncertainty, chaos, absurdity and contradiction of suffering to come forth in the telling (or silencing) of stories. As such, the therapist's role becomes not only to validate people's suffering by listening to more structured or certain explanations of past violence, but also to hold the tremendous uncertainty and ambiguity of people's recollections and experiences, rather than downplaying or denying them.
In conclusion, we have argued here that the therapist must create an open-ended, in-between narrative which restructures all of the stories without excluding or privileging one or another. Rather than attempting to unearth one "true" story, one must look beyond the obvious contradictions and frustration such multiple stories engender, and instead work creatively with these contradictions and conflicts, recognizing the open-ended and multiple nature of both the telling, silencing, and the interpretation of different stories. Particularly in cases of past trauma and violence, this approach can thus allow the therapist to reflect on how political or social violence interacts with other issues such as power dynamics within the family; it also allows one to examine how both older trauma and new conflicts become integrated, and perhaps exaggerated, by the experience of violence and displacement. As illustrated in the above cases, seeking to engage with the inconsistencies and contradictions of different stories can be part of a slow process of negotiation through which family members may be encouraged to restore a familial balance disrupted by trauma and displacement.
Barsky, R.F. (1994). Constructing a Productive Other: Discourse Theory and the Convention Refugee Hearing. Philadelphia: John Benjamins Publishing Company.
Brooks, P. (1992). Reading for the Plot: Design and Intention in Narrative. Cambridge: Harvard University Press.
Eisenbruch, M. (1991). From post-traumatic stress disorder to cultural bereavement: Diagnosis of southeast Asian refugees. Social Science and Medicine, 33,(6): 673-680.
Ewing, K.P. (1990). The illusion of wholeness: Culture, self, and the experience of inconsistency. Ethos. 18(3): 251-278.
Good, B., (1994). Medicine, Rationality and Experience. An Anthropological Perspective. Cambridge: Cambridge University Press.
Good, B. & Good, M., (1982). Toward a meaning-centered analysis of popular illness categories: "fright illness" and "heart distress" in Iran. In A. Marsella & G. White (eds.), Cultural Conceptions of Mental Health and Therapy, (pp.141-166). Dordrecht: D. Reidel Publishing Co.
Kleinman, A. & Good, B., eds., (1985). Culture and Depression: Studies in Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. University of California Press.
Ricoeur, P. (1981). Hermeneutics and the Human Sciences. Edited and translated by John B. Thompson. Cambridge: Cambridge University Press.
Ricoeur, P. (1984). Time and Narrative. University of Chicago Press.
Rousseau, C. (1995). The mental health of refugee children. Transcultural Psychiatric Research Review. 32 (3): 299-331
Scarry, E. (1985). The Body in Pain: The Making and Remaking of the World. New York: Oxford University Press.
Summerfield, D., (1998). The social experience of war and some issues for the humanitarian field. In P.J. Bracken & C. Petty (Eds.), Rethinking the Trauma of War. London: Free Association Books.
Viñar M. & Viñar M., (1989). Exile et torture. Paris, Editions de Noel.