2 through a narrative lens honouring immigrant stories by ann kogen

Through a narrative lens: Honouring immigrant stories AUTHOR Ann E. Kogen Ann Kogen is a clinical social worker who works with immigrants and refugees in Evanston, Illinois, USA. Ann can be reached by email: annkogen@yahoo.com This article describes how cultural understandings can be utilised in re-authoring stories of individuals suffering from hardships as a result of torture or trauma. Anthropological research about the varied ways in which people express and experience emotion opens possibilities for therapeutic practice. Through an example of therapy, the author illustrates how cultural idioms and understandings can be integrated into a narrative that is healing and empowering.

Keywords: stories, cultural idioms, trauma, cultural meanings, re-membering, emotional expression, somatic reactions, narrative therapy

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INTRODUCTION Just as the photographer uses different lenses to obtain either detailed or wide angled images, mental health clinicians are trained to use certain lenses through which they see people.

These lenses guide how clinicians will think, what they will look for, and how they will treat suffering individuals. A few years ago, as I began to work with immigrants who were seeking asylum, I was curious to find out more about how other cultures viewed mental health. I discovered that most global organisations were using the western model for mental health in disaster relief. This approach was not always culturally sensitive or appropriate.

Most clinicians are taught to see through the lens of the Western diagnostic framework, a frame that privileges biological explanations for mental illness, using a medical model to guide diagnosis and treatment. This model assumes certain ideas about individuals that reflect Western cultural norms: what a ‘self ’ is, how emotion is experienced, the privileging of rationality over irrationality, and how healing should take place. Narrative therapy, on the other hand, provides an alternative paradigm for working with cross-cultural clients that can honour cultural meanings (Waldegrave, Tamasese, Tuhaka & Campbell, 2003). The narrative model (White & Epston, 1990; White, 2006) seeks to provide an open, culturally responsive approach to working with individuals from different cultures.

Telling stories appears to be a significant aspect of life across all cultures. What’s more, the sharing of stories seems to carry the potential for healing within diverse cultural contexts. The perspectives of people from many different cultures, as well as anthropological research, demonstrate how people from diverse cultures experience both emotion and healing in different ways, hence the importance of finding therapeutic approaches that honour cultural traditions and customs.

The following story of Isabel, a woman originally from Cameroon, seeks to demonstrate a narrative approach to trauma which emphasises eliciting alternative stories of strength. My experience with Isabel has shown that when a story that encompasses a person’s hopes, desires and values can be identified and made more visible, the dominant trauma story can be moved aside. I think this illustrates the significance of bringing a story of strength and meaning out of the shadows and into the light. In addition, it illustrates the importance for us as therapists to work in culturally responsive ways.

A cross-cultural story: Isabel Isabel and I first met in a quiet room, where I introduced myself and explained that I could meet with her weekly as her therapist.

An agency that works with victims of torture had contacted me to meet her because they thought she was someone who could benefit from therapy. Confused and depressed after living in the USA for nine months, living with and working for a Cameroonian family for no money, Isabel found her way to English classes and learned about immigrant resources from a fellow student. She was initially very cautious about telling her story. At the agency, she had been evaluated, diagnosed with Post Traumatic Stress Disorder (PTSD), and offered my therapeutic help to assist her transition.

Isabel is an intelligent, well-educated woman who had worked for an international organisation in Cameroon, and graduated from University with a degree in French Literature. Her family came from a rural area, but she lived in a city where there were better jobs. Although not married, she had been with the same man for many years, and they had no children. Through the years, seeing the disparity between the very rich and the many poor, Isabel had been involved in working for social justice in her country. She was a member of a democratic organisation and worked hard to teach the poor about voting, working with children and orphans to try to make their lives better. During the early 1990s, she was detained by the government and put in jail for her activities.

Despite the fact that she had stopped her activities for many years, the police grabbed her off the street in 2008 as she was going to work one morning and put her in jail. During the times she was in jail she was tortured and raped. The police demanded that she agree to spy on her friends in the organisation, but she refused to betray them. When they let her go, she and her family decided that she had to flee the country or she would be ‘disappeared’. They arranged for her to leave so she escaped to the United States where she at first lived with a Cameroonian family. She did not know the family previously, and they treated her unjustly, making her work for them for no money. It was during this time that we first met. Over some months, she was able to obtain asylum, settle into her own apartment, work as a nurse’s aid, and slowly begin to build a life for herself in America.

Openly discussing different ways of understanding mental health In our early conversations, care was taken to introduce Isabel to the idea of therapy. Initially, it was important to explain the concept of confidentiality which led to a discussion of how dealing with mental health concerns was different in America than where she came from. Isabel was invited to explain how mental health issues were predominantly viewed in her country.

She explained that when she came to America she did not know what would happen if she spoke about what had happened to her. In her country, she said, rape is harshly stigmatised. When women have been raped they cannot talk about it because they will be blamed and outcast. Living with the shame and fear, and being socially dislocated, can sometimes cause people to become mentally unstable. As her story unfolded, when I asked her how people dealt with difficult emotions, Isabel described the prevalent idea in her culture of ‘no big deal’. This idea suggested that if you talk about things they will become worse, and if you don’t talk about them they will eventually go away. ‘This idea of “no big deal” is something we train children to do’, Isabel said, ‘because it can be useful by protecting people from becoming overly emotional’. Isabel explained that there is a belief that if you don’t do it this way your emotions can become a problem: ‘If you keep drawing the devil on your wall, it will come out’.

Additionally, she spoke of how sometimes there could be physical consequences to keeping ‘emotions inside’. Isabel had experienced some physical symptoms herself after the trauma, including high blood pressure, which she linked to not being able to talk openly. After explaining how mental health issues are predominantly understood in her country, and after speaking about her own perspectives on the values of both ‘no big deal’ and talking about experiences of hardship, Isabel decided that it would be helpful for her to share her experiences by talking with me. Later on in the therapy, Isabel reflected that if she had kept

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her experiences secret, she would have had more mental and emotional challenges.

Because of these initial discussions about different ways of understanding mental health, Isabel then took up opportunities to tell many stories about her life. These included stories of her earlier life, stories that included painful memories of torture, and stories about her time in America.

Stories of what Isabel gives value to Telling stories of her life before coming to America was significant in that these re-tellings linked Isabel to important aspects of her identity that had been lost to the effects of trauma. Isabel explained that in her earlier life she loved to teach children, and that she loved promoting social justice. These activities embodied strongly-held values that had long histories in her life. Together we explored these values and the meanings they held for her. As the weeks passed, Isabel rediscovered her love for children and began to participate again in the Sunday school at her church. Some of our conversations explored how these steps were reconnecting her with her pre-trauma self. She also started to explore how she could carry on these values in a new country (see the work of Rwandan Ibuka counsellors in Denborough, 2010). Telling stories about what she had always given value to, what her grandmother and mother had taught her, allowed Isabel to re-connect with an important part of her identity.

No Big Deal

Identifying the cultural idiom ‘no big deal’ was significant in the work with Isabel, but it was evident that this idiom provided a subtle contradiction that also needed to be deconstructed in terms of when it was useful or not. Therapy provided a different context that encouraged acknowledging the harsh effects of trauma. Considering the limits of applying this idiom to aspects of her situation allowed us to see its usefulness and limitations. On one hand, ‘no big deal’ served the useful purpose of decreasing the focus on problems that could not otherwise be addressed in her culture but, on the other hand, talking about traumatic events and re-storying these events was important therapeutic work. It seemed important to make this paradox explicit when applying the idiom. Therapy that addressed trauma stood in contrast to the general idea of ‘no big deal’ and it was important to deeply acknowledge the effects of the trauma she had experienced. As Isabel realised, she needed to talk about her story, which was a ‘big deal’, and yet at the same time she was able to use the idea of ‘no big deal’ in a more general way that helped her manage her emotions, allowing her to let go of certain experiences in her past and focus on the present and future. All cultures are multistoried, and the ways in which people engage with and re-make cultural meaning within any culture vary enormously. Through our conversations, Isabel both honoured and altered her engagement with the cultural idiom of ‘no big deal’.

Stories of torture Learning that she could share with me her stories of hardship without shame or stigma, helped Isabel to cope with the effects of the rape. While this process was at times difficult and painful, Isabel said it allowed her to think about her memories in a different way and to move on. Significantly, Isabel also described how the cultural attitude of ‘no big deal’ enabled her to not dwell on the traumatic past.

Throughout our conversations, I tried to use a narrative approach to honour important storylines of Isabel’s identity that the effects of trauma had hidden. Building a new story that included her values to social justice had the effect of calming and centring her so that she could focus on the challenges of navigating a new country. Rediscovering her love for children and honouring the value she places on social justice, and the histories of this, allowed her to remember or re-emphasise certain aspects of her identity and to ‘feel herself again’. In the process, she was able to free herself from many trauma symptoms including an intense fear of police, a sense of being damaged, nightmares, and constant sadness.

Acknowledging people’s cultural scripts Isabel had her own culturally scripted idea of what happened to her, what it meant, and how to address the trauma. When I initially told her that she had been given a diagnosis of Post Traumatic Stress Disorder (PTSD), she seemed confused by this.

She could not relate to the idea of PTSD nor what it meant for her. The label of PTSD only partially described the rich stories that Isabel had lived, and it did not accurately describe how she viewed her own symptoms.

If Isabel’s therapy had been strongly influenced by the diagnostic western frame, it would have been focused on symptom relief, using medication and techniques that focused exclusively on her symptoms, without honoring the meaningful stories that inform her of who she is and what she stands for. It was the strengthening of these stories that so contributed to her recovery.

By discussing her cultural ideas of how to handle trauma and mental health concerns; by allowing her to tell stories about what she cares about in life; by enabling her to share experiences of profound suffering; and through reclaiming aspects of her old life and reincorporating these into the present; Isabel underwent a process of re-writing the story of her identity. In doing so, she utilised a cultural idiom of ‘no big deal’ to diminish the story of torture that had depleted her personal sense of identity.

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Questions for therapists that elicit cultural meanings Certain kinds of questions can elicit cultural meaning and can be asked during therapy discussions. Such questions can open up space for customs and cultural meanings to be explored and incorporated into the larger therapeutic story. Examples of these questions might include: • How would this problem be understood or addressed in your country?

• What kind of things (words, ideas, beliefs, songs, memories) did you learn in your home country about this kind of problem?

• Who would you go to, or what would you do, or what would you think, in your country for relief from this problem?

• What ideas do you have about how to heal your problem?

The therapist can also attempt to find out how mental health issues are viewed by asking open-ended questions about different aspects of the culture. For instance, asking ‘What would happen to you if you had this problem in your country?’ opened space for Isabel to speak. These questions are starting points for discussions that can inform the therapist about the cultural responses to and resources for problems.1

Cultural idioms and emotional expression Healing narratives in many parts of the world may be based on quite different assumptions than those of the Western mental health system. Western ideas of ‘processing’, ‘working through’, or ‘confronting events openly’, are very different than the coping or grieving practices of some other cultures (see Waldegrave, Tamasese, Tuhaka & Campbell, 2003).

There is an enormous diversity of cultural idioms to define what is called ‘trauma’ in various regions of the world. For instance, some Salvadoran refugee women experience calor, a feeling of intense heat in the body. Some Cambodian refugees have experienced being visited by vengeful spirits with an accompanying feeling of distress due to the fact that they could not perform rituals for their dead due to fleeing their country.

I have been told that in Afghanistan, asabi is a kind of nervous anger, and fish-e-bala a sensation of stress or pressure. Some idioms reflect long-term stress or trauma that is specific to a culture, such as nakary (collective suffering), or llaki (individual experience of sorrow). These are terms and understandings from Peru which reflect the conditions and horror of guerilla warfare that people there were subject to for many years.

Honoring culturally specific idioms when working with individuals from diverse cultures can allow the individual to connect with familiar ways of speaking and understanding. If as therapists we try to understand these important cultural stories that influence individuals, we can then together decide if such idioms are relevant or helpful for the therapeutic process. This can be true whether we are working with people with whom we share a culture, or when we are working across cultures.

It’s important to note that idioms can be particular to a culture,

but also to a time and place. There can also be differences within cultures as to how people define and experience ‘trauma’ – class and gender considerations are also relevant. All cultures change and all individuals relate to their cultures differently. Isabel, for example, both drew upon her cultural understanding of ‘no big deal’ and questioned it. And personally, although I am EuroAmerican, I tend to question and challenge the mainstream Western psychological understandings of life that are currently dominant in USA culture.

Anthropological research shows that humans do not experience emotions in a universal way. Rosaldo (1984) points to an ‘interpretive concept of culture’ that allows for cultural variations in how people think about emotion, selves, and personalities. She cautions against assuming that affect is universal, and states that ideas of self and affect are culturally influenced and intimately connected to one another. When doing therapy, it is therefore significant to consult people to try to understand how particular cultures experience and express emotion. Constructions of the ‘self ’, how emotions are communicated, how the body is involved, and how distress is expressed, are all culturally mediated.

Individual/socio-centric experience of emotion Acknowledging that notions of the ‘self ’ are inherently cultural (Rosaldo, 1984, p. 137), it seems relevant to note that an egocentric model of self that emphasises a particular form of individualism has heavily influenced contemporary Western culture (Guarnaccia, 1996, p. 344). In more socio-centric cultures, ideas of self are embedded to a greater degree within larger social networks. In such contexts, emotional reactions are differently inter-subjective, social, and even political (Guarnaccia, 1996, p. 360). For example, in a study that looked at how people from the East and West assess a character’s mood in a series of drawings that included five figures with one central figure, the Western responses rated the central character’s mood high, while the Eastern responses rated according to the moods of the other figures in the drawings (Nagourney, 2008). While in no way wanting to inscribe homogenous understandings of cultures, the boundary between individual and social differs across (and within) cultures (Shweder & Sullivan, 1993), and this has implications for our practice.

The repertoire of ways in which individuals show emotion or distress also varies across (and within) cultures. I have become particularly interested in physical expressions of emotion that are found among all cultures throughout the world: ‘Although its prevalence and specific features vary considerably across cultures, somatization in patients seeking help is universal, and somatic symptoms are the most common clinical expression of psychological distress worldwide.’ (Parker, Gladstone & Chee, 2001, p. 861) While common in all cultures, in contexts in which the mind and body are viewed within an epistemology of continuous unity (‘harmonious wholes’) between the individual and the social world, physical expression of emotion can take on different meanings: ‘Social relations are understood as a key contributor to individual health and illness … The body is seen as a unitary, integrated

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aspect of self and social relations. It is dependent on, and vulnerable to, the feelings, wishes, and actions of others, including spirits and dead ancestors. The body is not understood as a vast and complex machine (as in Western medicine), but rather as a microcosm of the universe.’ (Scheper-Hughes & Lock, 1987, p. 21) If this is true for the people who are consulting us, how can our questions, our practices, be open to diverse expressions of emotions or distress (including physical expressions)?

Perhaps Nichter’s (1981) concept of ‘idioms of distress’ can be helpful. Idioms of distress are embodied modes of expression that also reflect cultural values, norms, or themes. For instance, Ataque de Nervios (‘attack of nerves’) can occur in many Latino societies throughout Mexico, Central and South America when a social bond is damaged or broken, as in death or divorce, resulting in desperation. This ‘is a highly developed metaphor that encapsulates key (Latino) values and social relations’ (Guarnaccia, 1996, p. 361). Nervios is characterised by uncontrollable crying and shouting, trembling, aggressiveness, sensations of fear, trembling, dizziness, crying. Physical symptoms include pounding heart, feeling hot or cold, headache, ulcer, high blood pressure, or asthma (Low, 1994, p. 150). Guarnaccia (1996) emphasises the importance of seeing this idiom as an expression of social distress. He says ‘that bodily expressions of distress need to be understood as more than individual experience; that they are commentaries on the broader social and political world’ (Guarnaccia, 1996, p. 344).

As I try in my work as a therapist to bridge diverse cultural constructions of self and diverse practices of emotional expression and/or distress, I am finding useful the concept of narrative and the practice of narrative therapy.

Narrative

Philosopher Jean Paul Sartre (1964) said, ‘A man [sic] is always a teller of stories, he lives surrounded by his own stories and those of other people, he sees everything that happens to him in terms of these stories and he tries to live his life as if he were recounting it’ (Sartre, 1964, p. 22).

Through language and symbols, metaphor, speech, song or dance, people narrate histories or experiences that convey important meanings. Stories validate the past, verify the existence of people, and carry the capacity for self-knowledge and healing. According to Barbara Myerhoff (2007), the performance or telling of a story can even contribute to the creation of a ‘soul’ (Myerhoff, 1978, p.

18). (See note about the work of Barbara Myerhoff) Therapy based on the narrative metaphor assumes that people seek help when the narratives in which they are storying their experience do not sufficiently represent their lived experience.

There may be significant aspects of their experience that contradict the dominant problem narrative. Instead of focusing only on the problem narrative, a narrative approach seeks to identify or generate possible alternative stories that will enable individuals to perform new meanings that will then be perceived to be more useful or an improvement (Myerhoff, 2007, p. 15).

Aspects of lived experience that fall outside of the dominant story are termed ‘unique outcomes’ and are ‘excavated’ for details that accompany them. Unique outcomes are pieces of the person’s story that are hidden by the dominant problem narrative, and can include feelings, thoughts, intentions, values and actions in the past, present or future. Meaning is ascribed to these events as they assist people in writing new stories that fit with their preferred ways of living.

In this way, as White (2006) explained, people’s lives and identities are multi-storied. Through re-authoring conversations, ‘the identification of what people give value to opens the door to the further development of the alternative stories of people’s lives’ (White, 2006, p. 56). These alternative stories can illuminate histories of strength, resilience, and empowerment.

Isabel, for instance, reconnected with a storyline about herself as a person who worked for social justice, who found meaning impacting the lives of others. This story was essential to how she viewed herself. By reclaiming this aspect of herself, the value of social justice, she identified with her previous resilience and was able to cope better with the trauma related symptoms she experienced. Her story about working for social justice reflected deeply-held beliefs about herself in the world.

Significantly, bringing a narrative metaphor to therapy can also allow for local idioms, metaphors and cultural meanings to be included in the therapeutic process

Revisiting Isabel’s story

During a series of weekly sessions, Isabel’s story unfolded as she described what had happened to her and how she came to seek asylum in America. In our early meetings, she was depressed, agitated, and had high blood pressure. The effects of trauma had narrowed her worldview, keeping depression in the forefront of her mind. She was sleeping and eating poorly and felt miserable – in short, the traumas of rape and relocation had significantly changed how she was experiencing herself.

At her own pace, Isabel related the stories of her torture and other stories about what she gives value to. As her therapist, I provided her with an ‘outsider witness’ to her experiences and discoveries. At times, the therapeutic journey seemed like uncharted territory, with my concern about how we might be communicating on different cultural assumptions. As time went on, it seemed important to check in on whether we were understanding each other. Lapses of communication were inevitable, but over time, as the relationship developed, Isabel felt freer to speak about her experience of coming to the USA, including a sense of confusion about how things work in this country, what things mean, how life operates.

My therapeutic listening stance is informed by the idea of the ‘absent but implicit’ (White, 2006). As we worked together, I was always striving to listen for what values were implicit in Isabel’s expressions of distress and anguish. While listening in this way, it was possible to ask questions with the intent of bringing out stories of value and meaning that could connect her with her

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own stories of strength and resilience. And these values were something that Isabel could readily offer since her faith was very strong. As I have mentioned, the storyline that emerged for Isabel was a powerful one entwined with the theme of social justice.

Isabel related how she was a person committed to social justice, had worked hard to teach poor people how to vote, and that she had worked hard for children so that they could lead better lives. In remembering these purposes, she identified the skills of teaching and caring that she possessed and held dear. In one conversation in particular, as she vividly recalled sitting under a tree with children as she used to do, connecting and speaking with them, a sense of personal agency emerged that gave her hope. She remembered that her grandmother had told her ‘On Earth we have to do what we’re called for’ and ‘Nobody can resist love’. She recalled stories and messages from her grandmother and her mother, important figures of strength in her life. These powerful messages helped her to remember the spirit she had lived with in Cameroon, the values that fueled her work on the street and at an orphanage. This reconnected her with an important part of her identity and made her determined to keep those meanings alive in her present life in Chicago. Relating stories of her life in Cameroon grounded her and enabled her to reclaim parts of her identity that had been lost for a time as a result of trauma.

As we continued to meet, some of Isabel’s trauma symptoms resolved. She became less sensitive to triggers such as seeing the police or being afraid of men. Her blood pressure decreased to a normal range and, significantly, she overturned the stigma of rape. She came to believe that it was important for women to view rape as violence and to ‘educate people so they can be free’. The concept of ‘no big deal’ allowed her to focus on and give importance to other areas of her life. At the same time, she recognised the effects of the cruel experiences she had been through and was determined not be a victim.

Isabel was eventually granted asylum. Today she is still adjusting to life in the USA, lives in her own apartment, spends time with children at her church, and is a caregiver who plans to attend nursing school. By storying her experience, through telling and re-telling her stories of strength, Isabel has stepped away from the torture narrative and into a more familiar one of herself as a social justice activist who is devoted to the wellbeing of children and others.

Conclusion

Sitting alongside people from other cultures, as a narrative practitioner, I am trying to find ways to honour culturally specific ways in which other cultures deal with trauma; express emotion; and engage in the journey of healing. This is a continuing exploration. Already, in collaboration with Isabel and others, I am finding that asking about cultural idioms or expressions, and including these into storylines, can empower people to use their own cultural narratives in preferred ways. This lens has also allowed me to see my own culture from another angle, but that is a story for another time.

A note about the work of Barbara Myerhoff As the work of anthropologist Barbara Myerhoff has been particularly significant in the field of narrative practice, it seems appropriate to describe her work a little more fully here.

The healing power of stories was vividly illustrated by Barbara Myerhoff (1978) in her book Number our days, an anthropological study of the life histories of a group of elderly Jewish eastern European Holocaust survivors who lived in Venice, California.

Self-narratives figured prominently in the project. ‘All storytelling has to do with testimonials of self ’, she said, ‘I see “making text” and “making self ” as inseparable’ (Myerhoff, 2007, p. 44). Myerhoff provided a way for these seniors to tell their stories, noting that relating their stories allowed them to leave a necessary legacy and a record of their lives in pre-war Europe, before their towns were eliminated and their relatives were killed. They had an important set of memories and spoke of family, events, and of their community. Myerhoff notes that telling their stories was implicitly healing, the most important work they could do at their advanced life stage (Myerhoff, 1982, p.102). For the group, the performance of their stories was a way of preserving something that could have been lost forever. Myerhoff described the storytellers: ‘Death, impotence, invisibility were omnipresent threats. But the atmosphere in the community was not one of defeat or despair. On the contrary, in it there was intensity and vitality, humour, irony and dignity. Always people exuded a sense of living meaningful lives … Their self-consciousness, promoted by collective performances and private self-narration, their recounting of stories and life histories, influenced and nourished their success as old people’ (Myerhoff, 1982, p. 103.).

Myerhoff closely evaluated the narratives of the senior citizens and discovered that certain memories evoked a more powerful recollection than others. These memories were distinct in intensity and allowed the individual to ‘relive’ the past, resulting in a sense of completeness. She called this experience ‘remembering’, indicating a special kind of memory triggered by sensory or physical movement, such as dancing, which allowed the individual to experience him or herself vividly. Re-membering is a detailed account of the experience, similar to providing a ‘thick description’, and implies deeply knowing and describing something, often recapturing a knowledge or ability that had been hidden. Such memories were experienced as comforting, allowing the individual to feel that her remembrances were eternally valid, and providing a sense of continuity of the self by restoring what had been lost and bringing it into the present. The redemption the Jewish participants felt in the process of their storytelling was profound, in part because they were afforded an audience and a way of securing that their histories would not be forgotten. As one participant said, ‘Without re-membering we lost our histories and our selves’ (Myerhoff, 1982, p. 111). The telling of the story and the witnessing of the telling, the listening, allowed them to reclaim life in the present knowing that their history would not be lost forever.

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Myerhoff, B. (2007). Stories as equipment for living: Last talks and tales of Barbara Myerhoff. Ann Arbor, MI: University of Michigan Press

Notes 1. The Just Therapy Team also recommends forming long-term partnerships with key cultural consultants so that therapists of the dominant culture can work within and through relationships of partnership accountability (Waldegrave, Tamasese, Tuhaka & Campbell, 2003).

Nagourney, E. (2008). East and West Part Ways in Test of Facial Expressions, The New York Times, Retrieved from: http://www.nytimes.com/2008/03/18/health/18face.html?_r=0 Nichter, M. (1981). Idioms of Distress: Alternatives in the expression of psychosocial distress: A case study from South India, Culture, Medicine and Psychiatry, 5, 379–408.

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