By Josephine Anthoine-Milhomme
Clinical Psychologist, Psychotherapist/Trainer,
MHPSS (Mental Health and Psychosocial Support) consultant
Ethics committee approval:
The client signed an informed consent for publication of an article describing her experiences and treatment. The Center for Victims of Torture reviewed this article and gave permission for it to be published.
Key implications for practice:
- The use of NET by therapists working in conflict areas can be done by psychotherapists with a psychoanalytical background
- As with any therapy, NET needs close supervision to analyse transference and countertransference dynamics
- If all the therapeutic conditions are present, victims of repeated rape can be treated by NET
This article presents the case of an Iraqi woman victim of rape, who was followed during Narrative Exposure Therapy (NET) over two months.
The author of the article intends to show how NET can be successfully used by a therapist with a psychoanalytical background. In particular, the paper stresses how the framework offered by NET facilitated the emergence of a surprising element of the client’s vécu – the victim’s expression of some ambivalence and empathy towards her aggressor.
Having followed the woman’s case through NET the author then discusses her counter-transference, with references to psychoanalytical theory, to better understand how NET operated within this context.
Based on her experience, the author of the text proposes some recommendations when using NET.
Narrative Exposure Therapy, Rape, Case presentation, Counter-transference, Empathy
The effectiveness of Narrative Exposure Therapy (NET) in reducing Posttraumatic Stress Disorder (PTSD) symptoms has been well documented in many studies (Robjant and Fazel, 2010; Zang et al., 2013; Bichescu et al., 2007; Neuner et al., 2004, op.cit., 2010; Adenauer et al., 2011).
Recently, a heated debate has taken place, questioning the efficacy of NET (Mundt et al., 2014), pointing out the risks of short-term therapies for PTSD within different social and political contexts. It has triggered a number of interesting commentaries by several researchers and users of NET (Intervention Journal, 2014), creating openings for further exploration and articles on the crucial question of trauma treatments in conflict-affected areas.
The overall objective of this paper is to explore how NET can be used not only by therapists with a cognitive-behavioural perspective but also by therapists with a psychoanalytical background. I will focus on the counter-transference dynamics and in particular on how NET can operate as a function of protection, being used as a “mediative object”.1
I present the case of an Iraqi woman refugee who fled her country for security reasons to Jordan and who was followed in therapy for four months –nearly once a week including the thirteen NET sessions – at the Center for Victims of Torture (CVT) in Jordan.2
The CVT is a Non-Governmental Organisation (NGO), based in Minnesota, U.S.A., which has international projects providing interdisciplinary care (psychological, physiotherapy, social services) to torture survivors and war trauma victims and their families. (www.cvt.org).
Narrative Exposure Therapy
Narrative Exposure Therapy is a “short-term treatment for traumatic stress disorders” (Schauer, Neuner, Elbert, 2011). NET sessions adhere to a strict and systematic methodological sequence, beginning with a psycho-educative session in which the detailed procedures are explained to the client and informed consent is obtained. This is followed by one “lifeline” session, unfolding a rope along which the client labels his or her main life traumas and positive events, symbolized by stones and flowers. Each stone (if relevant) and maybe one or two flowers are then narrated in slow motion, recalling the sensory details and memories of the events.
NET integrates testimony therapy (Cienfuegos, Monelli, 1983), neuroscience and components of cognitive-behavioural exposure therapy, including habituation of the emotional response to traumatic memories. Habituation of the emotional response is only one of the mechanisms at stake (Neuner, 2004) as some additional theories suggest that “the reconstruction of the autobiographic memory and a consistent narrative should be used in conjunction with exposure therapy” (Neuner, op. cit.).
It is important to mention that NET revisits memories in a manner that is non-intrusive, giving space for sensations to emerge safely within the context of recalling the highly traumatic events experienced.
When I met her, Fadia3 had already attended ten group sessions4 at the Center for Victims of Torture, where she was able to get some initial psychological attention. She is a well-educated, middle-aged married and mother of teenagers.
She was referred by her husband, who complained about the incapacity of the family to overcome Fadia’s kidnapping rape, which and had occurred six months ago.
Fadia’s main complaint was her inability to function in her daily life, as her days were invaded by unwanted memories of the rape. The assessment5 confirmed traumatic features, including a high number of flashbacks, a constant body alertness and hyper-arousal, and the same repetitive nightmares of the rape experience. These were accompanied by depressive symptoms such as loss of appetite, loss of sleep and constant sadness.
We proposed an individual modality to Fadia as she needed her space to settle back to her daily life after what had happened to her and although to be able to think the unthinkable and pass this dramatic feeling. As well as Fadia and myself, the meeting was held with two counsellors, both young Arabic women, one translator and the other one as a note taker6 7.
As her lifeline showed, Fadia had many Histories in regards to her bad memories, however, it was not appropriate mention all of them in slow motion, as not all were traumatic events currently contributing to her distress.8 It was difficult for her to find flowers symbolizing positive events.
The first memory was an experience of bombing near her house, when she was 10 years old. Fadia described her terror when she found out she was alone, her mother out of sight. She progressively identified later what had been so overwhelming and she starting memorising the scene, it was not the sound of the bomb, the light of the fire balls, the smoke and confusion all around, or the thousands of car alarms ringing loudly, but the fact that her mother was not with her, immediately, such as a child would wish. This memory opened a therapeutic window, as she could now put words to this feeling of emptiness she had ever since the event.
Another event worth to be mentioned, this time, she was at home when American soldiers broke into her house. During military intrusion, she was not wearing her veil and was in a nightdress. Many things were difficult about this for Fadia: there were several humiliations that night, the intrusion of the army into her house while she was in her nightdress being one of them. I think it was this event that carried us on to the main traumatic event – the intrusion of a man inside her body.
Fadia was kidnapped at nightfall and pushed into a car with hands folded and head covered then she was locked inside an empty room with no furniture other than a hanging light bulb and a small stool. A man started threatening her: “I will know how to hurt you”. Then he left the room, leaving her to wait alone thinking. She was thinking about one of her neighbour who had been abducted and severely tortured, then killed; her thinking eventually brought her into the vision of a drill entering her head. It was my (unspoken) understanding that, bringing the image of the drill going into her head, she is been sexually assaulted, also the intrusion in her mind, which left an emergency case to be opened about a bad image and memory, not only for the bad feelings, emotions or acts but also the rapist did not leave the room immediately. He stayed on, staring at her, for about an hour.
The trauma that rape can cause is not only the event of a forced sexual physical sexual assault and rape. Here, the trauma is certainly related to a combination of many things. In between the physical sexual acts, he was looking at her, but all she was perceiving was just “his trousers not yet pulled up, crumpled on his feet”, as she was kneeling on the floor. During that time, she was thinking that he was looking at her; she even thought that he might be regretting his act. This was the second time that she would think about his thoughts (the first time was when she thought that he was just obeying orders). Eventually, he left the room and she slept for a while. When she woke up, the same man was there once again, and he raped her a second time. It was more violent and aggressive. She said that it looked more like a fight. After this rape, he left the room. When he returned he had brought food with him. She describes being awakened from a painful numbness by the smell of an “Iraqi kebab, an expensive and tasty kebab”. Kebab is made of meat and spices rolled into a long kind of sausage and grilled on charcoal. He asked her to eat it. She refused, thinking that she just wanted to die. The man then offered to feed her with his own hands, putting the kebab just in front of her lips, telling her to eat. She said that she could not eat because she wanted to die. Initially, I did not understand, as I had an image of him trying to force her to eat the kebab. When I clarified this point with her, it seems that he was not using any violence to make her eat, and she says, “he wanted me to have some strength” and “he was kind, offering me food, thinking I might be hungry”.
Some methods of torture introduce paradoxes deliberately, to create incomprehension in the victim. Here, no thought of this seems to have come to Fadia’s mind.
We continued the NET narration, narrating one rape per session. Outside the sessions, Fadia was transforming. Once, she came with makeup; another time, with nice new clothes. Her posture changed as well. She no longer sat on the edge of the couch, folded over her body. Furthermore, her internal life seemed to be moving, as she began to have dreams of the rape. She had nightmares, flashes of the rape, and for the first time she reported having some dreams in which she saw a man who wants to rape her but where there was a beginning and an end. It was no longer only in “pieces”, she said during a follow-up session.9
The third rape was different. This time, she said, he had some “desire”, wanting even “to raise it” in her. It started when she asked to go to the bathroom, with a painful bladder and the need to put some water in her mouth “to rinse it after this horrible night”. In the corridor on the way to the bathroom, he grasped her shoulder “like friends would do”, and when he said he was going with her inside the toilet, she refused, instead preferring not to urinate. He put some water in his hands, and gave it her. On the way back to the cell, he was trying to caress her neck, “trying to raise desire in me”, she said.
Fadia did not question the fact that he changed the way in which he related to her; she simply said that he might have had regrets. He raped her once again, but “his body was different this time … he wanted to show me his desire”, she said.
This time, the rapist did not wait a long time to get dressed. He quickly put his clothes back on, in hurry, as “others would see what he had done”. Another two men entered the room. She thought she was going to be killed and that this was her end. She stared at her rapist ”all the time, he was very confused: maybe he wanted to rape me at the beginning but he was regretting it now” she said, adding, ”I was thinking that he knew they were going to kill me and he felt sorry about it.”
When they put her in a car, she thought of her death, secretly wishing it.
She was finally thrown out into a deserted field. The first image she saw was the face of an old man who removed her blindfold. She felt very scared, confusing the old man with the perpetrators until she realized he was just a man passing by. He had the face of her father-in-law, “a good man”, and his wrinkled face reconnected her with the world.
In the last sessions, Fadia shared that she was surprised at how far away the rapes seemed now, “as if I were looking at it from outside”. She said she wanted to write a book about her story.
The narration of a rape experience puts the therapist and the client into the realm of the unknown. No one can really predict what will emerge. Several times, I felt myself to be at my limits of tolerance for the intensity of the intervention; the word transgression even came to my mind. We were facing several transgressions: the transgression that it is rape, forcing someone to have sexual relations (forbidden religiously, morally, physically, legally…); the transgression of hearing about it, as no one wants to hear it. And I felt I was doing something at the edge of human experience, but NET gave it a framework and safety.
During the narration, it quickly became apparent that Fadia had no intention of destroying her aggressor. She harboured no hatred towards him. Disgust maybe, and the enormous shame of the rape.
Often, when a victim talks about the perpetrator, it is to present someone opaque, impossible to read. Yet, it seemed that the therapy offered to Fadia (with all the ingredients mixed together producing something exceptional) produced an unusual conclusion: Fadia was empathic to her aggressor.
This fact is sufficiently surprising and unusual to make taking a more detailed look at what happened worthwhile.
Exploring further the concept of empathy as the capacity to understand what the other is thinking (cognitive empathy – taking a mental perspective) and what the other is feeling (emotional empathy – vicarious sharing of emotion) (Smith, 2006), Fadia clearly identified her aggressor’s empathy towards herself, given that she made the following comments during the narration in slow motion:10
“He left the room, probably to give me some space.”
“He was probably sorry for what he did.”
“He was probably obeying orders.”
“He brought me some food because he might have felt guilty for what happened.”
“He wanted to help me in the bathroom because I had my eye covered.”
“He had some desire for me and wanted me to have desire for him.”
“He knew that they were going to kill me (the other men) and he felt sorry for what he had done to me before I would die. He probably did not want me to be dead now.”
At the beginning of the narration, it was easy for us (the therapists) to play the role of holding Fadia,11 through the accepted shared fact that the rapist was an odious and despicable person; we hated him. But gradually, a shift occurred. The evil was no longer what we would have expected. He began to have thoughts and emotions through her. He was becoming a human.
I did not know what to do with this twist at first. I remember my perplexity when I realized that Fadia had no rage, but empathy towards her aggressor. I had the feeling of touching something different from identification with her aggressor, as this did not seem to be a defence mechanism used to “protect the self from hurt and disorganization” (Freud A., 1936) and Fadia was not “hypnotically transfixed by the aggressor’s wishes and behaviour, automatically identifying by mimicry rather than by a purposeful identification with the aggressor’s role” (Howell, 2014). During the therapy I never felt any moments of aggressions towards me neither did I feel “anxiety-ridden identification and introjection of the menacing person or aggressor” (Ferenczi, 1949), nor did I recognize any signs of the Stockholm syndrome: there was no adhesion of the aggressor’s ideal and no positive feelings towards her aggressor (Cantor, Price, 2007; Namnyak, 2008).
Fadia faced a perpetrator but her perpetrator was not presented as a despicable person, even though he had raped her, and this is probably why she needed to tell someone. She needed to disclose this, but had no need to destroy her aggressor. Her ambivalence laid in the fact that her aggressor was a human person for her. He was not the archetype of a rapist or a monster. At any time she could have expressed feelings of revenge during the therapy: feeling bad, humiliated, filthy, ashamed… It was not a question of like or dislike, the aggressor. It was not about excusing the aggressor. Her life was destroyed in her mind, and she had no excuses for that.
In a ‘classical’ therapy, I could have been ‘trapped’ by my counter-transference, not able to receive her ambivalence or perhaps not able to manage it. Progress may be paralyzed during therapy by ‘neurosis transference’, as Freud called the effect of the analytical relationship where symptoms and pathological behaviours of the client acquire a new function and a new meaning in the transference, where the subject repeats a reviviscence of ancient emotions (Freud, 1914). The emotional component raised by the rape situation in this transference context was neither bearable nor manageable, or it would have needed more sessions, time and close analysis of the therapy.
Pariset (2009) describes the risk of a person being confronted with the feeling of emptiness in a situation where they were the victim of sexual abuse as a child and had developed some sort of identification with the aggressor as a defence. The paradox here, for the therapist (in neurosis transference), is to have to renounce to this admiration for the aggressor, representing an ego ideal. Pariset explains that to avoid the client’s feeling of the irremediable loss of his defence and for him still to feel protected, he needs a place to deposit his secret. A transitional area can then be proposed during the transference, to be able to interpret it. In the same text, Pariset cites Abraham and Torok (1972), who explain the reason for leaving a space, that they call the ‘crypt’, for the secret:
Crypts are constructed only when the shameful secret is the love object’s doing and when that object also functions for the subject as an ego ideal. It is therefore the object’s secret that needs to be kept, his shame covered up (op. cit., 1972).
The risk, for the therapist, is to confront this crypt and to be caught by some countertransference expressions born from a dangerous transgression (here for Abraham and Torok, the dangerous transgression is the love of the object).
Needless to say, the phantom object haunts the process of countertransference as well and this fact represents a real danger in psychoanalytic therapy. Analysts may unwittingly target the phantom object, not realizing that for the melancholic, the phantom (the incorporated object) is the only partner. And yet, we analysts are meant to recognize the love object behind all the disguises of hate and aggression. (op. cit., 1972)
NET allows the emergence of ambivalence but also, we, the therapists, were able to hear and accept the “unacceptable” of Fadia’s ambivalence.
Ambivalence is expressed and validated but never interpreted. Through NET, the opposite to what is done in analysis happened: the narration is facilitated. We (therapists) do not wait for it and we do not interpret. With NET, we link and put the ambivalence into narrative, but no intervention, or barely one, happened during narration. We ask questions, all the time, but our questions are not particularly directed through our counter-transference. In NET, time is taken and we try to recreate the situation as it was, close to the sensations, the ‘hot memories’.
It was in this sense that NET took on the function of a “mediative object” as defined by René Kaës (2002). The different functions of a mediative object, he says, are that it arises from a relationship. It is a “found-created object”, as Winnicott described it (Roussillon, 2010),12 which emerges through the relationship and is found by surprise. It has a regulating function between the relational and emotional, between the self and the other, and for the self. This object provides a support for associations and fantasy. It has a function of container and deposit, giving shape to something that could not be thought before. Therefore, it serves the function of transformation.
The interpretation of the perpetrator’s empathy was not manageable for me, the therapist, at the time of the sessions, and I realize this now, in retrospect. Even if the narration of the rape was an extreme and transgressive experience, NET functioned as a mediative object, as a relation object, because Fadia could continue to narrate, without me ‘resisting’, or reacting against it. It worked as something in between, which protected everyone present from movements of transference: me from being and acting as a persecutor,13 or even from making any interpretation, and her, to be able to deposit her ambivalence in the reconstruction of the actuality of the trauma. The risk mentioned by Pariset and by Abraham and Torok is that shame would be the result of the therapy, and not the access to Fadia’s ‘encrypted secret’, in other words her ambivalence towards her aggressor. The ‘transgression’ of Fadia’s unconscious empathy for her aggressor became ‘dangerous’ for me in my countertransference and this explains the moments when I felt extremely uncomfortable during the therapy. NET could operate as a mediation with the need to continue the therapy and the acceptance of the transgression. The danger was that I could have become her ‘aggressor’.
There is another aspect of the use of the NET, which had a significant impact on Fadia’s treatment.
If we consider Fadia’s fear in the narration of the first stone, about an incident when she was ten, she literally had a fear of breakdown. This type of fear is described by Winnicott in his last text (Winnicott, 1974). He highlights a particular anxiety, the “original agony”; which is complex because, he explains, when it was felt, the ego was too immature to be able to experience it:
The purpose of this paper is to draw attention of the possibility that the breakdown has already happened, near the beginning of the individual’s life. The patient needs to ‘remember’ this but it is not possible to remember something that has not yet happened, and the thing of the past has not happened yet because the patient was not there for it to happen to.
Could it be that, during NET, there is the possibility of experiencing what it had not been possible to experience when it happened? We go back to the event, even if it is in retrospect, and reconstruct the emotional response and the fragmented memories. So, could NET take Fadia back to where it had been impossible, at the time, to experience that early trauma? Fadia’s ambivalence, at least, was experienced during the therapy.
Was Fadia empathic during the trauma of the rapes, or did this empathy develop during the therapy?
We are faced with at least two levels of the “après coup”14 of a trauma (”Nachträglichkeit” Freud, 1895) when Fadia is narrating. Even if NET is the nearest one can get to the facts of the event, it remains the narration of a past trauma during therapy. What is interesting is not the reality of the events, but the combination and confrontation of the things that emerged within and after the therapy – all the images, assumptions, hypotheses, intuitions. It is important to see that what is working is not the accurate narration of an event. It is not the objective of NET, rather, it is to create links and bonds to overwhelming traumatic events, events which are otherwise not possible to assimilate or integrate. In NET (or in other therapy models) we are in the narration of the aftermath of a trauma sustained by another person, and the clinician, who listens to it, facilitates a process of coming to terms with this trauma.
I have no answer to the question of when the empathy appeared, in the “après coup” of the therapy or during the event, but I do not think this is such an important point. The fact that the ambivalence could be deposited somewhere, and given to someone else, is what mattered for Fadia.
Can clinicians with a psychoanalytic background gain from the use of NET?
Like in any therapy, transference and countertransference dynamics should be observed and reflected upon. NET has a strict and systematic methodology, which does not leave space for free association or interpretation. Nevertheless, through this case it was found that even if it is not malleable, the structure of NET can take on the function of a mediative object, of a relation-object. This could operate, as the expression of my counter-transference was reduced. As a consequence, I can definitely state that the use of NET by a clinician with psychoanalytical background offers rich possibilities.
If NET no longer needs to prove itself, this article shows how it nonetheless requires delicate progression and a sensitive response as illustrated by Fadia’s case. Using NET in this context was extremely rich and gave us a wonderful tool with which to help Fadia to deal better with her internal life and her life in general.15
Nevertheless, as a mental health professional, I would not recommend the use of NET without close clinical supervision. This is essential in order to provide a space for the therapist(s) to identify and work on transference dynamics because of the high emotional intensity of the sessions.
Working as part of a team is essential, and I must mention here how much the physiotherapy team helped in this case, even though this aspect is not developed in this article.
Not all mental health organizations can afford such an investment, as it can be quite demanding in terms of human resources and time spent; in spite of this, the Center for Victims of Torture, where this treatment took place, was able to provide the appropriate conditions to treat this woman.
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(1) Mediative object in the sense of “object of relation” (Gimenez, 2002), an object between one thing and another. This will be explained in more detail in the discussion below.
(2) For confidentiality reasons, the political and cultural context of the client cannot be disclosed.
(3) Not her real name, as all the names mentioned.
(4) The group sessions at the CVT are adapted from the Judith Herman stages of trauma recovery (Herman, 1992)
(5) Each potential client is received for an intake assessment. The form was devised by the CVT, and records socio-demographic information, main traumatic events, main features and complaints of the client, the symptoms and their frequency. No diagnosis is made.
(6) Fadia was talking in her mother tongue, Arabic, which was translated into English; I am fluent in English; my mother tongue is French.
(7) At the beginning of each new session, we read and reviewed the previous session with the client. At the end of the NET, the notebook was given to the client.
(8) For example, some traumatic memories about a back injury.
(9) Each client seen in therapy at the CVT has a clinical follow-up one, three, six months and one year after their initial intake, using the same checklist questionnaire.
(10) It is difficult to state if the client elaborated those thoughts during the event itself, or in its aftermath. This point will be discussed later.
(11) NET is also “holding tool”, we do not know where we are going, but we know how we will get there. It is well prepared and not obscure. The fact that we were several therapists together in this case also made a difference. We provided direct support (with grounding techniques for example) and consolation (by taking the time to hear in detail about what happened to the client).
(12) The ”trouvé-créé” (found-created) object is a French term that is not a direct translation of Winnicott’s terminology but proposed and developed by R. Roussillon. However, it has recently been widely used in the French psychoanalytic literature and refers to Winnicott’s concept of the process involved in “creating the object”.
(13) In NET, the “psychoeducation session” explains in detail what we are going to do, which facilitates the “justification” of asking many questions about the event, which can be perceived by the torture survivor as being as intrusive as a perpetrator.
(14) Deferred action.
(15) As the marked reduction of the symptoms and better daily life routine showed in the follow ups.