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Culture, Trauma, and Subjectivity: The French Ethnopsychoanalytic Approach

Gesine Sturm, Thierry Baubet and Marie Rose Moro Traumatology 2010 16: 27 DOI: 10.1177/1534765610393183 The online version of this article can be found at: http://tmt.sagepub.com/content/16/4/27

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Theory

Culture, Trauma, and Subjectivity: The French Ethnopsychoanalytic Approach

Gesine Sturm1, Thierry Baubet1, and Marie Rose Moro2

Traumatology 38 16(4) 27 The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1534765610393183 http://tmt.sagepub.com

Abstract This paper discusses the French Ethnopsychoanalytic approach to trauma in transcultural therapy situations. The authors first describe the basic principles of the French Ethnopsychoanalytic tradition and the theoretical developments of this tradition within the last 30 years. These approaches combine a psychoanalytic understanding of therapeutic processes with a constant reflection on the social and symbolic contexts that appear in the patient's discourse. The specific way of referring to culture and belonging is exemplified by a detailed case-study of a therapy with a female patient who flew from West Africa in order to escape from an arranged marriage. While discussing some key moments of the therapy with this patient, the authors illustrate the co-construction of shared meanings within a dialogue about different cultural frames. They stress the need of a process-orientated and situational understanding of culture and show how the dialogue about culture helps to open the space for a re-interpretation of the current and past life-context of their patient. They also insist on that each comment on culture and belongings is interpreted within the therapeutic process and the relational dynamics this process implies. Keywords clinical interventions, interventions for the traumatized, culture, race, ethnicity, gender In the last 20 years, there has been growing interest in trauma and especially in work with refugees and displaced persons (Ingleby, 2005). Different authors have described these developments in terms of a discursive shift, where the perception of refugees as victims of political violence has been increasingly replaced by a more medical conception of suffering: refugees as persons suffering from posttraumatic stress disorder (PTSD; Richters, 2001; Silove, 2005; Summerfield, 1999, 2005; Young, 1995). The social, political, and medical implications of this discursive shift (and its counterpart, the moral disqualification and criminalization of unsuccessful asylum seekers) have been widely discussed (Fassin & Rechtman, 2005, 2007; Watters, 2007). Critics have blamed the one-sidedness and reductive character of a purely symptom-orientated conception of trauma and have raised questions about the social consequences of the predominant focus on PTSD. They have shown that the rise in trauma-centered discourses has a considerable effect on service provision for refugees and asylum seekers. We also find increasing criticism about the PTSD conception of trauma from clinicians who use psychoanalytic approaches.1 Alongside all these criticisms on PTSD conceptions of trauma, we find new paradigms that integrate a critical reflection on the institutional, professional, and political contexts of clinical work with refugees and asylum seekers (Watters, 2001). They contest dominant conceptions of the traumatized individual in different ways. Some authors propose to focus on the experience and the reconstruction of lifeworlds of refugees and asylum seekers (van Dijk, 2001). Others emphasize the need to include a reflection on social, institutional, and political contexts and constraints (Rousseau, 2003). Others again, such as those who use ethnopsychoanalytic approaches, propose a multilayer approach to therapy, combining psychoanalytic thinking with specific ideas about work on the cultural dimension in therapies with refugees and asylum seekers (Baubet, Le Roch, Bitar, & Moro, 2003; Baubet & Moro, 2003; Sturm, Baubet, & Moro, 2007; Sturm, Heidenreich, & Moro, 2009; Sturm, Nadig, & Moro, IN PRESS). In this article, we would like to develop and discuss these latter approaches.

Complementarism in Transcultural Psychotherapy

Many ideas we find in current ethnopsychoanalytic approaches are based on the work of Georges Devereux (1967, 1970, 1972).

1 2

Universit Paris 13, Hpital Avicenne, Bobigny, France Universit Paris Descartes, Hpital Cochin, Paris, France

Corresponding Author: Gesine Sturm, Clinical psychologist and anthropologist, Universit Paris 13, Dpartement de Psychopathologie de lEnfant et de la Famille, 74, rue Marcel Cachin, 93003 Bobigny Cedex Email: gesine.sturm@gmail.com

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28 In France, Devereuxs idea of complementarism as a metamethodology for interdisciplinary research practice raised particular interest and led to interesting developments in this field. In complementarism, researchers analyze their data using different perspectives in a simultaneous but separate way. The confrontation of these different readings is set aside until the final step of the investigation, when the results of each analysis are related one to the other. In Devereuxs work, we mostly find examples of a confrontation of psychoanalytic and anthropologic readings of the research material. In the 1980s, the psychologist and psychoanalyst Tobie Nathan returned to this idea, reinterpreting it as an intervention technique for transcultural psychotherapies (Nathan, 1986a). He proposed the use of a double dialogue in these therapies, a dialogue where the work on inner conflicts and family dynamics (the idiosyncratic level) is separated from the analysis of cultural frames (the cultural level). Although psychoanalytic interpretations may be used to understand inner conflicts, the understanding of cultural contexts should be established from an anthropologic point of view. In Nathans work, this point of view mostly appears as knowledge about specific culturescultures he conceptualized mostly as traditional cultures. From the 1990s on, we have seen some quite engaged discussions about Nathans work and his somewhat static and holistic conception of culture (Corin, 1997; Fassin, 2000; Fassin & Rechtman, 2005; Rechtman, 2000). Even though he proposed some very interesting insights into the interaction between cultural frames and psychic factors, his static conception of culture led to an approach that lost the dynamic aspects of the relation between culture and subjectivity out of sight (Nathan, 1994). His interest in emic representations certainly questioned the dominance of medical or psychiatric conceptions of suffering and distress. However unfortunately, he defined those emic representations in a decontextualized and ahistorical way, conceiving them almost exclusively as cognitive frames and guides for social reorganization. By doing this, he finally missed the chance to construct an approach that permits to think the complex interactions between culture and psychic suffering in our increasingly creolizing world (Kirmayer, 2006). The critiques on Nathans approach led to new developments within the French ethnopsychoanalytic approach. The most important innovations are linked to the work of the child psychiatrist Marie Rose Moro and her team. Moro redefines the complementarist work in therapy. As Nathan, she proposes to separate the work on the idiosyncratic and the anthropologic level. Still, we find a quite a different way of conceiving these levels. When working on the anthropologic level, therapists are not supposed to reconstruct existing cultural frames, but they are invited to open a dialogue about different representation systems and to coconstruct new meanings and bridges between existing representation systems. Culture is not thought of as a fixed frame but as a process created in human interactions (Moro, 1998). Moro (1998) refers to anthropologic knowledge about the inner logics of cultural

Traumatology 16(4) representations, but she uses this knowledge to get to a deeper understanding of inner-psychic dynamics, of the very subjective way a person refers to these representations. We consider that Moros shift from a substantial, essentialist conception of culture to a dynamic understanding is a mayor development in ethnopsychoanalytic theory. It has several important implications. Culture is not only about traditions and the past but also more generally about the interaction between different symbolic universes that have to be situated within concrete social, historical, political, and economic contexts. The reflection on culture also implies a reflection on representation practices and ways of constructing an image of oneself and the cultural other (Hall, 1997). The use of a nonholistic conception of culture, and especially the interest in cultural complexity (Hannerz, 1992), leads to an interrogation about plural lifeworlds and representation systems. Patients may describe their experiences while commenting, questioning, and criticizing the cultural contexts they happened in.

Trauma and Culture

From its very beginnings, French ethnopsychoanalysis showed a strong concern for the question of trauma, its effect on subjectivity, and the complex interrelations between trauma and culture. We can identify two main ideas that have occupied a central position within French ethnopsychoanalytic theory about trauma: the idea that migration experiences can lead to a specific vulnerability and the idea that trauma can be understood as a process of transformation.

Migration and Vulnerability

In his early publications, Nathan (1986a) introduced the idea that the integration of cultural representations was fundamental for the development of the human psyche. Furthermore, he suggested that cultural representations needed to be constantly reaffirmed to stabilize the cultural envelope2 of the human psyche, giving a person the feeling of being protected and whole. If a person has migrated to a different and unknown environment, this reaffirmation could be diminished or missing. This is why Nathan (1986b) concluded that the experience of migration is necessarily traumaticthe cultural envelope can no longer prevent the intrusion of non-elaborated experiences. This does not mean that a person would automatically develop posttraumatic disorders such as trauma neurosis or PTSD but rather that he or she would become more vulnerable to potentially traumatic experiences. Moro took over the basic idea that cultural representations stabilize the development and the functioning of the human psyche (Moro, 1994, 2003), but she refused to conceive the migration experience as necessarily traumatic. She tried to identify factors that could lead to specific vulnerabilities (like isolation, lack of contextual knowledge, loss and bereavement,

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Sturm et al. or the motherhood constellation). Nevertheless, she also showed that migration experiences could release considerable cognitive and emotional resources, especially if the migrant was supported by social networks (Moro, 2007).

29 traumatic experiences. Ritual practice can certainly be a powerful tool for confronting the dissolution of social bonds and the disintegration of symbolic representations (see Wilson, 2007). However, this process is only possible if social bonds are previously reconstructed and if the person who goes through this kind of ritual practice feels ready for it. In therapy, we should be extremely careful when offering interpretations in which experiences of rupture, meaninglessness, and perversion of human relationships are understood as part of a meaningful process of transformation. Sometimes it will be more important to be able to apprehend the fact that no meaning can be constructed and that human relationships and trust have been profoundly affected by traumatic experiences. In these situations, ready-made interpretations about the ritual or spiritual meanings of traumatic experiences may enhance patients feeling that we do not understand them.

Trauma as a Process of Transformation

In psychoanalytic theory, trauma is considered as an overwhelming experience that cannot be represented and integrated into the network of psychic representations. Traumatic images enter into the psyche without being transformed and appropriated (Ferenczi, 1933; Freud, 1953, 1960). This is one of the reasons why intrusion, repetition, and the reorganization of the psyche after traumatic experiences are ideas that are central to psychoanalytic conceptions of trauma (Garland, 1998; Lebigot, 2005). As Nathan (1986b) and later Baubet and Moro (2003) have pointed out, we may find similar ideas in many cultural representations linked to human experiences of trauma and fright. Furthermore, Nathan (1987) argued that experiences of fright within a ritualized context imitate the transformation of the human psyche through trauma. According to Nathan, ritual uses the logics of trauma within a controlled setting order to provoke a profound change in the person.3 It appears necessary here to open a short parenthesis about ritual and its relation to traumatic experiences. Nathan (1987) argued that ritual practice implies moments of disaffiliation and inversion that may be akin to certain aspects of traumatic experiences. According to van Genneps model of the rite of passage (van Gennep, 1909), rituals are organized in three steps: a first phase of disaffiliation with the old identity, a second (liminal) phase of transformation, and a third phase of reaffiliation to a new social status. During the liminal phase, common social rules are inversed, disgusting or forbidden experiences may be provoked, and all aspects of the old identity will be denied or turned to their opposites (Turner, 1969). Baubet (2008) argued that this opens interesting possibilities for therapies with traumatized persons. In therapy, traumatic experiences can be reinterpreted a posteriori as nonconcluded transformations where the third period of ritual, the reaffiliation to society with a new status, has not taken place. Nevertheless, Baubet emphasizes the constructive character of this kind of reinterpretation. Obviously, traumatic experiences have a fundamental difference with regard to liminal experiences within a ritual: Although traumatic experiences isolate the person and remain an unrepresentable experience, outside the network of meanings, liminal experiences in a ritual occur within a context of strengthened social ties and symbolic references. Ritual enhances feelings of belonging (the experience of communitas in Turners work), and if the individual is confronted with moments of inversion of meanings, this serves to strengthen meaningful reinterpretations on a new level (e.g., the secret knowledge of an initiated person). This leads us to a rather cautious view of ritual (or allusions to ritual practices in therapy) as a possible way to overcome

Transcultural Therapies With Traumatized Asylum-Seekers and Refugees at the Ethnopsychoanalytic Outpatient Clinic in Avicenne Hospital4
Trauma-related symptoms in refugees and asylum claimants often lead to demands for consultation at the Avicenne Hospital in Paris, France; this is partly due to diagnostic questions concerning clinical presentation and also due to a lack of adequate mental health services for traumatized refugees. Often mental health care services are reluctant to work with refugees because they fear the complexity of their needs, the entanglement of psychic and social suffering, and the time- and money-consuming character of holistic interventions for this population. Often these patients are refused on the argument that they do not have an actual address or that there is no budget for the intervention of an interpreter in therapy. The services we offer to refugees and asylum-seekers often include not only psychotherapy and psychiatric consultations but also social advice by a social worker and other interventions such as pain treatment. For severely traumatized patients, a special consultation with a small group of cotherapists has been set up. In this group setting, several therapists work together with one patient. Some of them have a migration background; all having experiences in the field of transcultural and trauma therapies. The trauma group is a second- or third-line intervention. It is proposed to patients with severe posttraumatic disorders (Baubet et al., 2004; Baubet, Marquer, Sturm, Rezzoug, & Moro, 2005). We would like to illustrate and discuss the French ethnopsychoanalytic approach to trauma therapy with a case study. In some aspects, this case may be atypical because the asylum seeker was asking for protection on the basis of a quite unique life history where gender violence and violence within the family played a central role, which is not the case for the majority of our patients. Still, we think that this case is very appropriate for presenting our work because it exemplifies the way

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30 in which the work on the cultural and the idiosyncratic level are combined in therapy. Our presentation is based on records that were produced by professionals from the trauma team at the Avicenne Hospital (a psychiatrist, a psychologist, and cotherapists of the trauma group). First, we will present some extracts from our records of the first encounter with the patient. After this, we will add some information about the therapeutic interventions we proposed and discuss some key aspects of the therapeutic process. The records and resumed descriptions of therapy sessions are given in italics, the comments in bold.5

Traumatology 16(4) repudiated her when she was on vacations at her familys place with her children. After mentioning the repudiation by her first husband, Ms Kitigo starts to talk about the violence and the humiliations she had been submitted to during her marriage, and she also mentions the fact that her husbands family never liked her. Then she comes back to the story that led to her flight. One year after her repudiation, Ms Kitigos family tried to impose a new marriage to her. This time she was utterly opposed and tried to defend her wish to live alone with her children. The family tempted to break her resistance by violence: She was heavily beaten and exposed to cigarette burns by her brothers. As the first moments of a therapeutic encounter are generally of particular importance, we may stop here for a moment to have a closer look at the interaction between Ms Kitigo and her therapist, asking ourselves how they coconstruct and reinterpret cultural meanings. On the therapists side, we note an active exploration of cultural contexts, especially when she is trying to understand Ms Kitigos comments on her first marriage. The questions the therapist brings in bear testimony of some general anthropologic knowledge about West African cultures and different forms of family organization. At the same time, they are not constructed on a sophisticated proficiency about the specific cultural and linguistic group Ms Kitigo belongs to. We could say that the therapist brings in her knowledge to signal to the patient that she has some contextual information and, above all, that she is conscious about existing cultural variability and about different subjective ways of experiencing a cultural practices. These first exchanges about cultural issues will play an important role for the construction of a supportive relation and an alliance between patient and therapist. We see that they immediately provoke more emotional and detailed narrations. Ms Kitigo starts to talk about her vulnerability and the violence she had been submitted to at different moments of her life. In the following, they also open the way for the disclosure of traumatic childhood-experiences that have probably been reactivated by the violence Ms Kitigo recently experienced during the tentative of a forced marriage. After talking about her first marriage, she brings in a new aspect to her story, an aspect she has never talked about before: When she was 7 years old, she was sold by her mother to work as a housemaid in a family that lived far away and had no special relations to her own family. The woman who received her (the lady) treated her very badly; she was frequently beaten and insulted. When the therapist asks So you were not confined to a family your mother knew as it is often done in West Africa? Ms Kitigo answers No, not at all: I was sold, like a slave! During her stay with the lady, Ms Kitigo did not go to school, unlike the other children from the family. She was sent to the marketplace to sell vegetables. When she did not bring enough money back, she was heavily beaten. I was so afraid of the lady that sometimes I did not dare to go home. Then there were

Case Study: Ms Kitigo6

Ms Kitigo, a 42-year-old patient from Mauritania, lives in a CADA7 in B (about an hours drive from the Avicenne Hospital). She has filed an asylum petition and is at present awaiting the outcome. About a year ago, she arrived in France, after fleeing from Mauritania. She had refused an arranged marriage and had been severely mistreated (tortured) by members of her family to force her into marriage. Now she lives with her 6-yearold son and has left a 9-year-old daughter in Mauritania (both from a first marriage). Ms Kitigo contacted the outpatient clinic of the Avicenne Hospital and asked for an appointment with one of the doctors because she had heard that at our hospital, it would be possible to talk about African issues. Following our usual procedures, she was first received by a clinical psychologist (GS) for an evaluation. The first encounter with the psychologist At the beginning of the interview, Ms Kitigo explains that she has already started psychotherapy at the local CMP,8 not far away from the CADA she was living in, but she has only been there twice. She says that she did not really feel good about talking there. She does not feel the need for talking in her mother tongue (she speaks excellent French), but she explains that her problems were linked to African issues that the psychologist from the CMP would not understand. She had heard about the Avicenne Hospital and thinks that she could discuss the cultural dimension of her problems more easily, given the reputation of this place to be open to cultural issues. Asked about her current difficulties she talks about frightening nightmares and the feeling of an immediate vital threat. These dreams seem to indicate some supernatural thread to her. When asked about her social situation and her family, she talks about her first marriage and her two children. The psychologist brings in some questions to understand the social and cultural context of this marriage: Was it arranged by the family? Did she participate in the decision and the preparation? Did she agree? Was she the first and only spouse or was it a polygamous marriage? Ms Kitigo explains that her marriage was arranged and that she had not been opposed to it. She had not been happy with her husband, but still her marriage seemed acceptable to her at that time. After 10 years of marriage, her husband

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Sturm et al. those men who offered me money, and then they abused me. I was the woman of all the men of the village. I did not belong to them, I was considered an outcast. I was a real slave. After 3 years, her aunt managed to get her home by paying back her price, and she also paid for her to go to school, the only place where Ms Kitigo would feel safe in the following years. She still has a very strong and trustful relationship with her aunt, who also organized her escape from Mauritania. Her feelings for her mother are more than ambivalent; she talks about a mix of hatred and fear. According to Ms Kitigo, it was her mother who mobilized the family to impose her marriage, and she remembers with sadness, fear, and anger that her mother never cared for her. Now she feels threatened by her mother and thinks that she could destroy her from distance by means of sorcery. If we look at this sequence, we may note that the therapist is using once again her contextual knowledge about West African cultures, but in a more indirect way. She confronts Ms Kitigos narration about having been sold as a slave to the cultural practice of confining a child, a practice where children are raised by relatives or close friends to strengthen social bounds (Lallemand, 1993). The knowledge about this practice is not used to relativize or reinterpret the patients experience. It is introduced through a negative formulation (so you were not confined . . . ) and invites the patient to comment or disagree. Ms Kitigo answers by depicting a sharp contrast between her own experience and the cultural practice of confining a child. Her formulations underline the experience of rupture, desocialization, and dehumanization. Taking things in more general terms, we could say that the introduction of a common cultural practice and the implicit invitation to comment it lead to a statement where the patient talks about a singular, subjective experience and relates it to existing cultural frames. This perspective is still a comment on culture. It is as subjective as the narrations we find in Lila Abu-Lughods anthropologic account on Womens Worlds (Abu-Lughod, 1993).9 In our case study, we are confronted to severe trauma and we do not find the same creative potential as in Abu-Lughods account, but still we find a subjective perspective and a statement about acceptable and nonacceptable cultural practices. In the following, Ms Kitigo comes back to her dreams, complaining about nightmares where she is persecuted by black men who beat and rape her. She feels that these figures are not simple human beings but rather evil spirits or destructive forces sent by her mother. Then she asks the therapist explicitly about the meaning of her dreams. The therapist answers by naming different possible frameworks of dream interpretationthe savant (or psychological) frames the therapist is familiar with (where these dreams could be understood as a symptom of repetition related to traumatic childhood experiences) and also cultural (or emic) frames where they could be seen as supernatural signs of a menace by sorcery or attacks by evil spirits. In this sequence Ms Kitigo comes back to her nightmares, dreams she already had introduced while specifying that they

31 were related to cultural issues. This time, she introduces supplementary information: she mentions the fact that she is raped in her dreams, and she explains that she feels menaced by her mother. By doing this, she relates the menace by cultural issues to the narration about her childhood she just made. When asked about the meaning of these dreams, the therapist first proposes a psychodynamic interpretation that associates these dreams to her story (telling her that her dreams could be understood as a symptom of repetition linked to her traumatic childhood experiences). However, she also introduces the possibility to interpret Ms Kitigos dreams while referring to emic representations. This makes the therapists framework explicit, and it introduces the possibility of combining different frameworks. The therapist asks Ms Kitigo if she has tried to get help or protection by cultural meansdid she consult healers or did she use other strategies to protect herself from the menaces on a spiritual level? Now Ms Kitigo relates that she had consulted a healer in Mauritania, just before her flight to France, but she had not been able to conclude the treatment. She also relates that she had severe doubts about the healerWas he trustworthy? Would he abuse her? Was she making a fool of herself when consulting a healer, given the fact that she was an intellectual? She adds that she also had consulted a psychiatrist, who had diagnosed her with depression. Still, she had not been able to relate her story to him because of her fear that he could break the professional secret. She also was afraid to be considered as a fool when consulting the psychiatrist. Since her arrival in France, she does not see any possibility of being helped by a traditional healer: The marabous she could encounter in Paris do not seem trustworthy to her, and consulting a healer in her home country with the aid of her aunt seems too dangerous to herit might expose her to evil actions from her family. Ms Kitigo adds that she is determined to be followed at the Avicenne Hospital and that she would not be able to confide in the psychologist at the CMP because she would not understand the supernatural nature of her dreams. When looking at Ms Kitigos help seeking strategies in Africa, we find an interesting fact that may inform us about the relational dynamics Ms Kitigo is experiencing: The main obstacles to treatment, be it traditional or savant, have been quite similarMs Kitigo did not really trust the other. She thought that the African psychiatrist could have betrayed her by breaking the medical secret, and the healers in Africa might have been charlatans who would try to exploit or even abuse her. When talking about healers in Paris, she stresses the fact that they are most likely to be incompetent crooks. Ms Kitigo seems to be alternating between the tentative to be reassured by a savant, rational approach to her difficulties which exposes her to the fear that this approach is not valuable for dealing with spiritual issuesand a cultural approach which awakens her fear of being subjected once again to potential violence and disregard. Her idea to consult at the Avicenne Hospital, a place where savant knowledge and traditional

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32 thinking could coexist, may be seen as a tentative to bring two disconnected and sometimes contradictory parts of herself together. From a psychological point of view, the relational mode of lacking trust into the other is not surprising; it is quite common in posttraumatic situations including sexual violence and in cumulative trauma (Garland, 1998). This certainly informs the therapist that the establishment of a trustful relationship will be of major importance. However, Ms Kitigos explanations may also be read as statements on her own cultural position. She is positioning herself as a West African intellectual who belongs to the savant world, but she also talks about her strong and ambivalent bounds to a more traditional cultural environment. Still these two cultural affiliations are not juxtaposed as equivalent, and they are invested in quite different ways. The savant world is brought forward, even though she fears that it could be bypassed by the supernatural and irrational character of the menaces she is experiencing. The traditional context is much more menacing. It could provide help, but it could also lead to mistreatment and abuse. At the end of the session, the therapist tells Ms Kitigo that she will discuss with her colleagues about possible therapeutic propositions and fixes a new appointment. Notwithstanding our general guideline to privilege continuity and proximity in health care, we decide to accept Ms Kitigos request for treatment at the Avicenne Hospital. Ms Kitigos engagement by the disclosure of her traumatic childhood memories and the urgent need to contain her anxiety guided us in this decision. We think that the reputation of the team at Avicenne (to be able to deal with African issues) was very important for her and helped her to have some trust in our capacities to deal with her problems. We also think that refusing her demand would have been dangerous in terms of psychic decompensation and risk of suicide because she would most likely have felt abandoned and exposed. Therapeutic proposition and subsequent sessions of the psychotherapy After the first encounter with Ms Kitigo and a discussion within our trauma team, we decide to propose a multiprofessional treatment at the Avicenne Hospital, including therapy sessions with a psychologist (GS) and consultations with a psychiatrist (TB). As she complains about strong headaches, she will be also followed by a specialist for pain treatment. The consultations with the psychiatrist will be used to adapt medical treatment, but they also include discussions about her daily life, the asylum petition, and her relation to her children. During psychotherapy, she will talk a lot about her past, her feelings of being menaced by destruction, and the more irrational part of her inner reality. Although presenting elements of the following therapy sessions, we will focus once again on the way the dialogue about culture is coconstructed between patient and therapist, and how this dialogue is related to the therapy process. Summary from the psychologists notes During the following psychotherapy sessions, Ms Kitigo continues to talk about her childhood, about her nightmares,

Traumatology 16(4) and about the feeling of being threatened by immediate destruction by spirits or sorcery. She also introduces a different kind of dreams: strange dreams where a group of blacksmiths follows her, trying to intrude into her house. She has experienced these dreams for a very longtime; she has had them since her infancy in Africa. Ms Kitigo regularly comes back to this topic, telling the therapist at the beginning of each session that she had these dreams again and asking her explicitly about their meaning. This leads to a month-lasting dialogue about the meaning of her dreams and the enigmatic figure of the blacksmith. During this process, the therapist asks Ms Kitigo to give her a clue about the cultural significance of this figure. At the first moment, Ms Kitigo just answers that she does not have any idea. Then the therapist asks some more precise questions about the status of the blacksmiths and about the role of their specific caste in West African societies. In her response, Ms Kitigo explains important aspects of her own cultural position. She relates that she comes from a family that belongs to the caste of the nobles and describes the particular position of the blacksmiths and the ban on intercaste marriages. However, still she continues to be in the dark about the meaning of these figures in her dreams. She does not find any meaningful interpretation: There were no blacksmiths in her family, no conflicts with them, and generally they were considered to be powerful, but they were not feared. Not any of the information concerning the symbolic or social status of the blacksmiths seems to help her to make sense of her dreams. Following a more psychoanalytic procedure, where associations play a central role, the therapist also asks about memories from encounters with the blacksmiths. This leads Ms Kitigo to a description of the spectacular presentations the blacksmiths regularly made in the villages to show their power on knives and other metals. These presentations were part of a shared public amusement and children generally loved to watch them. Nevertheless, Ms Kitigo remembers that she was terrified when she attended them: They have a special power over knives and all things made of iron. They could cut themselves with knives without feeling any harm. She evokes the panic she felt when they were approaching. She could vaguely recall these memories, some dated from the time before her stay at the ladys house, most from the time after she had come back. She definitively remembers that there were no blacksmiths presentations in the village where she was staying with the lady who bought her. After several months of regular discussions about this topic, Ms Kitigo comes up with another memory from her childhood. She relates a situation where a blacksmith came into their farmyard. As soon as the blacksmith entered, the sheep started to tremble. I was wondering how could they know that he was the blacksmith? He did not have any knife with him and he was not wearing his working clothes Oh, did I say blacksmith? That is not the right word; I meant to say, the butcher! Evidently this revelation of a month-long lapse opened new ways of interpreting her dreamsthe butcher as a threat to life, the sheep as a symbolization of her helplessness, and

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Sturm et al. her position as an outcast who was deprived of human protection. The dream also indicates possibilities of symbolization for her present feelings of being exposed to an immediate risk of destruction by evil forces. If we come back to the process of coconstruction of cultural meanings in therapy, we see once again that the discussion about cultural contexts precedes the incidence of detailed narrations and childhood memories. The month-long discussions about the cultural meaning of a character (the blacksmith) that was finally not really the one who appeared in Ms Kitigos dreams played a very important role in the therapeutic process. These discussions had a double functionthey certainly not only helped to keep a certain emotional distance with regards to the image of the butcher, but also permitted to approach her past while discussing about cultural contexts. More interestingly, the childhood memories about the spectacular presentations concerned the butchers association and not the blacksmiths. Still, it took a longtime until Ms Kitigo used the right term and could link it to the other childhood memory about the butcher entering into the familys yard. In this case, the lack of contextual knowledge on the therapists side (she did not know the presentations by the butchers associations) prevented an earlier disclosure of the symbolic meaning of Ms Kitigos dreams. However, maybe the lack of understanding was even protective in this situation. While talking about the blacksmiths, Ms Kitigo could strengthen her ties with the therapist and construct narrations about vital aspects of her social environment while maintaining psychic defenses against the terrifying character of her childhood memories. The feelings Ms Kitigo expresses when talking about the memory from the butcher entering into the farmyard also give new insight to the meaning of the cultural representations she introduced at the beginning of the therapy. When talking about the threat by sorcery and by evil spirits, she uses these cultural frames to talk about the existential menace she is experiencing. She does not say that she feels as if her life was in danger, but she says that her life is really menaced on a spiritual level. If we understand her use of these cultural representations as a tentative to communicate her fear to be literally destructed (killed like a sheep), we are accepting a frame that helps to communicate extremely terrifying feelings. The asylum petition and its effect on the therapeutic process Before discussing the function of the dialogue about culture in ethnopsychoanalytic therapies with victims of violence and severe traumatic experiences, we would like to bring in another aspect of Ms Kitigos therapy. It concerns the effect of social, administrational, and political factors on the therapeutic process. The understanding of Ms Kitigos quite unique way of facing these specific aspects of French culture is of major importance for the therapeutic dialogue and process. When Ms Kitigos asylum petition is refused some weeks after our first encounter at the first-level decision,10 her nightmares become more frequent, and she complains about voices calling her name. In therapy, she talks about intrusive images

33 of the men who raped her during her infancyimages she had forgotten since her childhood. She is terrified and does not dare to answer when somebody calls her and knocks at her door because she is afraid that evil spirits are persecuting her using human voices. She still manages to organize her daily life with her son but as soon as he is asleep, her life turns into a nightmare. She is having thoughts about suicide, feeling guilty for having left her daughter in Mauritania. I should have stayed with her, not to live, but to die at her side. As in many therapies with asylum seekers, the outcome of the asylum petition has major consequences for the patients psychic health. In Ms Kitigos case, it reactivates feelings of lacking protection and being exposed to an extremely hostile environment. She is so overwhelmed by the intrusive images of her childhood that she seems to be in risk of disconnecting with reality. She also develops suicidal ideas. At this moment, we propose a supplementary therapy in the trauma group, with the idea that she could benefit from the holding that this group offers and also because we think that this setting might facilitate the discussion about the frightening cultural representations she talks about. The psychologist discusses these possibilities with her before starting the group sessions, but finally she uses the trauma group in her own way. In the group, Ms Kitigo never talks about her infancy, and she never mentions the idea of being possessed or being threatened by sorcery or evil spirits. Instead, she uses the mainly female trauma group to talk about her position as a mother, her concerns about her daughter, and the fears she has with regard to her fateWill she ever meet her again? Is she in good health? Will she be safe? And will her aunt be able to protect her from the threat of genital mutilation and forced marriage? During the same period, the therapy sessions with the psychologist will be characterized by discussions about the intrusive images of her past. She talks about her feelings of hatred and her wish to destroy these men who destroyed my life. She also talks about the moment when she had been submitted to female genital cutting during her stay at the ladys house. She insists on the traumatic character of this experiencethe surprise, the extreme pain, and her fear to die from bleeding. She also talks about her feelings of being mutilated, of lacking a part of her femaleness, about her anger, and about her fear that her daughter could be doomed to the same fate. Sometimes she comes back to the life she had during her first marriage and expresses her astonishment: How could I accept this position in my marriage? When I was at work, I was an emancipated woman, but at home, I was completely submitted to my husband. When looking at the development of Ms Kitigos narrations during this period, we may note that she gradually reconstructs her position of a subject who may think and act on her environment. She uses the holding offered by the trauma group to talk about her position as a mother and about the fear that she could not be able to protect her daughter who is still in Mauritania. In the individual therapy, she first talks about the hatred she feels. At the beginning, she feels extremely menaced by the

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34 intrusive images and feels exposed and condemned to death. Later, she will gain confidence and take a more active position. She uses her relation to the (female, White and European) therapist to have a critical view on the cultural practice of genital cutting and the experience to be submitted in marriage. When the appointment with the appeal commission (Commission de Recours (CRR)) comes closer, Ms Kitigo becomes increasingly anxious. The psychiatrist proposes an appointment with a jurist from Amnesty International who is specialized in gender issues. She agrees. In therapy, she relates the first encounter with this jurist with a lot of enthusiasm and hope for the future: The jurist from Amnesty told me that I would have to argue and convince. He told me that my fate is in my hands. As for defending myself, I know how to do that. My whole life has been a fight. In the following weeks, she prepares her case file and what she will say to the commission. The jurist from Amnesty has explained that her situation might fit into the category of violence against minority groups. As a woman, she received death threats in the context of a custom, and the State did not protect her from the threats of her family. He told me that I would have to explain how things happen in my country and in my culture. I will do that. My lawyer does not know West African cultures very well, so I will explain it myself. She also decides to include a new element in her defense: she had been raped by the man who wanted to marry her by force. The psychiatrist offers to write a certificate for her to ask for a hearing without public audience. The introduction of the jurist of Amnesty International played a crucial role for Ms Kitigo during the period of preparation of the hearing at the CRR. When proposing the appointment with the jurist while insisting on his competency for issues of gender violence, the psychiatrist invites Ms Kitigo to face her situation using all her intellectual capacities and organizing actively her defense. The reputation of Amnesty International also helps her to redefine her position: She is not a victim who is condemned but a subject who may struggle for her rights. At this moment, the multiprofessional approach and the work in different therapeutic settings is very important. In psychotherapy, Ms Kitigo is facing the inner menace of her childhood memories and feelings of helplessness. The work on her inner world enhances the return of these feelings, and she will only gradually regain confidence in the possibility to defend herself. In the sessions with the psychiatrist where the conversation focuses on the outer reality of her current life, she may more easily connect to her capacities as adult, as a thinking subject without being overwhelmed by the memories of the past. In the trauma group, she may develop still another aspect of herself and rethink her position as a mother while being surrounded by a group of well-disposed co-mothers (Moro, 1994). A week before the commission, Ms Kitigo has an appointment with the trauma group. She surprises the therapists with unexpected news: her daughter has arrived in France! Her aunt has managed to have her come but had kept the secret until the very last moment. Ms Kitigo is happy to have her daughter with her. Now she feels able to do anything. Some

Traumatology 16(4) weeks later, she meets the group again. She does not know the outcome of her request yet, but she feels proud because she was able to talk. The judge even congratulated me for my defense. Even if the result is negative, she adds, they heard me and I am pleased with what I said. Finally, she brings good news: Her demand has been accepted. The fleeing is over and she can prepare her future in France. Very quickly, she finds a job, a new place to live, and even a good school for her children. Further developments and outcomes of the therapy The therapy with Ms Kitigo is still ongoing, but there have been some important changes since her asylum petition has been approved. Many of these changes are linked to her new situation and the practical implications of her acknowledgment as a refugee. However, we think that we can discern some effects of the therapy. These effects may be seen both on the level of the inner psychic and relational dynamics. She has become more conscious about her own vulnerability and developed new strategies to deal with closeness and distance. She still is very cautious in human relations and only admits closer contact to a very restricted number of persons (her aunt in Mauritania, a friend she came to know in France). But now she does not feel the same risk of being betrayed (or even destroyed) by the other any more. She is very conscious about her intellectual capacities, and often she uses them to defend herself in conflict situations. She also developed considerable skills in dealing with French institutions and in organizing her family life as working single mother. She also developed a very conscious way of dealing with racist attitudes she is confronted to. Since her acknowledgment as a refugee, the discussions in therapy are much more focused on issues of her daily life. She uses the therapeutic space to discuss possible ways of mixing cultures: how to educate her children as an African mother, how to pass on certain things she loves from her background, and how to approach others she does not want to talk about with her children. Sometimes she needs someone to listen and to give a feedback, and sometimes she comes back to the story of her childhood. She still has nightmares when she is feeling bad, but she does not feel menaced to the same degree as she did before. She also talks about traditional issues, about the need to protect herself and her children. When confronting the feeling to be menaced on a spiritual level, she now relies on a quite creative mixture of cultural practices from her home country (using protections her aunt send to her), a referral to Islam and the use of modern technology (using Internet to have the Koran read in loud voice in her apartment). When she comes back to the story of her childhood, she does it in a different way. She talks about the experience of having been sold and considers the possibility to give a written testimony. She is still looking for a way to make her voice heard, without exposing her vulnerability and without being used to condemn African traditions without any differentiation. The intercultural encounter between a White, European Female therapist and a Black, African female patient is certainly

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Sturm et al. a challenge for building bridges between different life-worlds and subjective experiences. It also entails the need of raising issues of power and dominance. In the therapy with Ms Kitigo, this work was intimately linked to a reflection on cultural practices and their status in different societies. First, there was a long period where the discussions about the Ms Kitigos position as a woman in a West African society played a central role. During this period, she relied on her therapists position as White, Female, and supposedly emancipated woman to blame the violence she had been submitted to. Later, after having been acknowledged as a victim of gender violence, she began to elaborate about other aspects of her position, she defines herself as a Black African woman, and she talks about the lack of understanding, the stereotypes, and the racism she encounters in French society.

35 but it was equally important to give her the possibility to comment on the specific (and in this case traumatic) way cultural practices had been used and reinterpreted by her family. This leads us to some important conclusions about the possibilities of using cultural representations with traumatized patients. An exploration of cultural contexts must always be done in a way that gives the patient the opportunity to comment, to question, and even to reject cultural practices. Otherwise, patients could be submitted to the traumatic experience that their subjectivity is denied in therapy, in the name of a culture that is defined by the others, be it the therapist or even a cultural mediator. Recent theories in sociology and cultural anthropology insist on the inner diversity of cultures (Hannerz, 1992), on power and its interrelatedness to cultural practices (Bourdieu, 1977; Swartz, 1997), and on the importance of subjective ways of experiencing and reinterpreting culture (Abu-Lugod, 1983; Clifford & Marcus, 1986). In the field of transcultural psychiatry and psychotherapy, the implications of these innovations are still to be explored and developed, even though there are promising examples of the possibilities as we may see in the more recent work of Arthur Kleinman and colleagues (Kleinman, Daas, & Lock, 1997). In French ethnopsychoanalysis, cultural representations are considered in their function not only as shared symbols but also as subjectively appropriated and emotionally invested representations. We think that Gannanath Obeyesekeres work on culture and subjectivity and his notion of personal symbols (Obeyesekere, 1990) provide a useful theoretic framework for thinking about the dynamic interaction between culture and inner-psychic processes. According to Obeyesekere, we may distinguish two types of emotionally invested representations or personal symbols. On one hand, there are those that are used in an inner-psychic dynamic of repetition. These regressive symbols symbolize inner-psychic conflicts, but they do not open the way for change and resolution of conflicts. They symbolize subjective experience, but they do not lead to shared interpretations and do not link collective symbols to an interrogation about subjective experience. Using Lorenzers hermeneutic approach to psychoanalysis, we could say that these symbols are used to symbolize inner conflicts, but their meaning is build on the basis of an unconscious chain of associations. They carry private meanings (Lorenzer, 1970), meanings that are not understandable without having access to the chain of associations that give meaning to them. On the other hand, the other type of personal symbols concerns those that are used in a more reflective way to have a new perspective on ones life and inner feelings. Obeyesekere calls them progressive symbols. These symbols link subjective experience to cultural frames, and they may be used to symbolize and transform inner conflicts while linking them to shared symbols. They open the way for an interrogation about subjective experience and its relatedness to social, cultural, and political contexts. We could consider that therapy is about transforming private meanings or regressive symbols into shared meanings or

Discussion: Working on Culture and Psyche in Ethnopsychoanalytic Therapies With Traumatized Patients
As we exemplified in our case study, ethnopsychoanalitic therapies focus on the interrelatedness of subjective experience and the sociocultural contexts this experience is happening in. Therapists actively explore the social, historical, and cultural contexts the patients narrations are situated in. As we saw in the example, this interrogation about contexts leads to increasingly detailed narrations. It also helps patients to reflect on these contexts while redefining their own position within them. Using a hermeneutic framework (Qureshi, 2005), we could say that the active exploration of cultural contexts and the verbalization of contextual knowledge make the therapists preunderstandings about the patients lifeworld more explicit. This enables the patient to respond while confirming, modifying, or contesting these preunderstandings. This does not only lead to a deepened understanding and a better therapeutic relationship, but it also gives the patient the opportunity to develop an increasingly conscious and differentiated reflection about his or her cultural identity. It also implies that patients become conscious about choices they have and that they can take an active role in their relation to cultural ideologies and norms: Some may be accepted whereas others transformed or even rejected. This aspect is even more important in the work with traumatized patients who went through the experience of a negation of their subjectivity. Cultural representations can be important resources for the elaboration of new subjective positions, but sometimes they can also serve as reminders of traumatic experiences and the violence endemic in the society in question. In Ms Kitigos case, trauma was experienced in the context of cultural practices and ideologies concerning the status of children and women in society. These practices contributed to the traumatic experience of a denial of subjectivity and corporal integrity. In Ms Kitigos therapy, it was certainly important to understand the cultural context of her traumatic experiences,

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36 progressive symbols. The relation between therapist and patient and the common interrogation about the meaning of cultural symbols lead to a reappropriation and reinterpretation of these symbols. In our case study, several symbols such as the ones appearing in Ms Kitigos dreams (the black people persecuting her, the blacksmith) could be considered as regressive symbols, coming close to the posttraumatic symptom of repetition. In the relationship with the therapist, the patient transforms these regressive symbols and private meanings into shared meanings; cultural symbols become linked to subjective experience. In Ms Kitigos case, this process of transformation of regressive symbols into progressive symbols leads to the rejection of certain aspects of the cultural and family context she is coming from and also to the elaboration of a very personal way of living her African identity in French society. The case study also brings interesting insight into the interrelatedness of trauma, family separation, and the fear for the safety of close family members. The turning point in the therapy occurs at the moment when Ms Kitigos daughter arrives, even before the asylum petition had been accepted. This illustrates to what extent fear for close family members reactivates past traumatic experiences. In Ms Kitigos case, it was very difficult to work on the difference between her past subjective experience and the real danger faced by her daughter. The inner reality of her traumatic past seemed to have taken over completely/occupied all her attention. Once her daughter joined the family, Ms Kitigo started to elaborate a much more differentiated perception of her own and her daughters positions. But more than that, the fact that her daughter escaped from the danger of mistreatment by the family convinced Ms Kitigo that escape would be possible for her, too, that she could be protected in France. On the relational level, our case study exemplifies the possibilities of an intercultural therapy. The cultural difference between therapist and patient not only is a challenge for communication but also opens the way for the creation of new meanings through translation and contextualization. On a relational level, this playful construction of new meanings is based on the therapeutic relationship and the construction of a holding. It opens the way for the formulation of subjective perspectives, perspectives that may sometimes contest dominant conceptions, be it in the French context of within the communities. In this way, we could consider the dialogue in transcultural therapies as a creation of a third space (Bhabha, 1994), a space where difference may be used to develop new and sometimes subversive readings of past and present experiences. In work with asylum seekers, the processes of transformation and the elaboration of subjective positions should not be seen isolated from the global strategy of psychosocial care that includes advice and advocacy during the process of the asylum petition. The interplay between intrapsychic factors and the destabilizing effect of an unclear legal situation demands the creation of different but interconnected spaces within a global

Traumatology 16(4) psychosocial approach. The focus on inner reality in therapy can only be useful if there are other spaces where patients may work on their social and legal situation. The support and holding environment therapists offer can become a powerful tool that serves to enhance agency because it helps patients reestablish their subjectivity and faith in the possibility of change. These therapeutic approaches, however, have to be combined with advice and social support. The focus on subjectivity in therapy could even be damaging if it is not combined with those interventions on the social and legal level. In the worst case, it could provoke the feeling that social pressure and experiences of retraumatization during the process of asylum petition are just not taken seriously by the therapist, as if part of the inner life of the patient, part of his or her fantasies. As Rousseau (2003) pointed out, this kind of negation of subjectivity can be one of the most violent forms of retraumatization. Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.

Notes
1. Symptom-oriented treatments such as cognitive behaviorist therapies and eye movement desensitization and reprocessing (EMDR) (both use PTSD conceptions of trauma) did not prove to be efficient in the treatment of complex and sequential trauma. High dropout rates and high levels of nonresponsiveness to treatment were observed. In these cases, psychoanalytic treatments seem to offer promising alternatives (Schottenbauer, Glass, Arnkoff, & Gray, 2008). 2. This notion was developed on the basis of the work of Didier Anzieu on the Skin Ego (Anzieu, 1989). 3. Sironi (1999) further developed this idea not only for work with victims of torture but also for better understanding of the processes that are used to fabricate aggressors. 4. Hpital Avicenne, AP-HP, Service de psychopathologie de lenfant et de la famille et de psychiatrie gnrale, 129 rue de Stalingrad, 93003 Bobigny Cedex. 5. We would like to give a special thanks to Jerme Pradere, the supervisor of the trauma group, and to Maya Nadig and the members of the Institute of Cultural Studies at the University of Bremen (bik) who gave inspiring comments on this case study. 6. To protect the anonymity of our patient, we have changed her name and some information about her background. 7. Hostel for asylum seekers, includes social services and some help for administration issues. 8. Centre medico-psychologique, part of the public health system. 9. The narrations (of Bedouin Women in Egypt) Abu-Lughod (1993) presents in her book pick up central aspects of cultural norms and practices, but, most interestingly, the narrations

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Sturm et al.
confirm and deconstruct all those categories at the same time, showing 1,000 ways of transforming and bypassing them. 10. If the asylum petition is refuted in the first instance, the asylumseeker may contest this decision at the appeal commission (Commission de Recours).

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