Voices of Dialogue and Directivity in Family

Therapy With Refugees: Evolving Ideas About

Dialogical Refugee Care
LUCIA DE HAENE*
PETER ROBER

PETER ADRIAENSSENS

KARINE VERSCHUEREN**
In this article, we reflect on our evolving ideas regarding a dialogical approach to
refugee care. Broadening the predominant phased trauma care model and its engaging
of directive expertise in symptom reduction, meaning making, and rebuilding connect-
edness, these developing dialogical notions involve the negotiation of silencing and dis-
closure, meaning and absurdity, hope and hopelessness in a therapeutic dialogue that
accepts its encounter of cultural and social difference. In locating therapeutic practice
within these divergent approaches, we argue an orientation on collaborative dialogue
may operate together with notions from the phased trauma care model as heuristic
background in engaging a polyphonic understanding of coping with individual and
family sequelae of forced displacement. This locating of therapeutic practice, as
informed by each perspective, invites us to remain present to fragments of therapeutic
positioning that resonate power imbalance or appropriation in a therapeutic encounter
imbued with a social context that silences refugees suffering. In a clinical case analy-
sis, we further explore these relational complexities of negotiating directive expertise
and collaborative dialogue in the therapeutic encounter with refugee clients.
Keywords: Refugee; Trauma Rehabilitation; Dialogue; Trauma Narration
Fam Proc 51:391404, 2012
DEVELOPING FAMILY THERAPEUTIC PRACTICE WITH REFUGEES:
LOCATING ORIENTATIONS OF EVOLVING PRACTICE
A
cross the world, western societies receive substantial numbers of asylum-seekers
who escaped human rights violations and who seek to restore a meaningful life
*Education, Culture and Society, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven,
Belgium.

Institute for Family and Sexuality Studies, KU Leuven, Leuven, Belgium.

Faculty of Medicine, KU Leuven, Leuven, Belgium.

**
Faculty of Psychology and Education Studies, KU Leuven, Leuven, Belgium.
Correspondence concerning this article should be address to Lucia De Haene, Education, Culture
and Society, Faculty of Psychology and Educational Sciences, KU Leuven, Vesaliusstraat 2, 3000
Leuven, Belgium. E-mail: lucia.dehaene@ppw.kuleuven.be.
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PROCESS
perspective within their borders. While a large body of research regarding the
increased prevalence of posttraumatic stress, depression, and anxiety in refugee pop-
ulations accounts for the disruptive impact of collective violence in refugees home
societies (e.g., Fazel, Wheeler, & Danesh, 2005), refugee studies equally document the
pervasive mental health sequelae of postflight stressors in resettlement countries.
Pervasive marginalization, discrimination, or extended asylum procedures form
major sources of psychosocial distress (e.g., Montgomery & Foldspang, 2008; Weine
et al., 2011), thereby locating refugees suffering within invisible forms of violence
that characterize our host societies.
The majority of clinical models in refugee care conceptualize the intervention pro-
cess on the basis of the three-phased trauma rehabilitation model (Ehntholt & Yule,
2006; Murray, Davidson, & Schweitzer, 2010). This predominant model involves the
structured sequence of phases of symptom reduction, the integration of traumatic life
experience, and the rebuilding of social participation (Herman, 1992). First, the sta-
bilization phase concerns a primary restoring of refugees experience of control in the
wake of traumatization. Here, psycho-education, identifying reexperiencing triggers,
symptom reduction, and modifying trauma-induced dysfunctional cognitions all
involve a clear problem- and symptom-focused approach to regaining safety and struc-
ture in dealing with posttraumatic distress (e.g., Basoglu, Ekblad, Baa rmhielm, &
Livanou, 2004; Kinzie, 2007). Second, the integration phase consists of the guided
reconstruction of traumatic memories throughout narration of a coherent, meaningful
trauma story. The vast majority of trauma-focused refugee treatment models essen-
tially revolve around this revisiting of traumatic experience as reparative mechanism,
either in cognitive-behavioral interventions (e.g., Hinton et al., 2005; Murray, Cohen,
Ellis, & Mannarino, 2008), testimonial approaches (e.g., Weine, Kulenovic, Pavkovic,
& Gibbons, 1998), or narrative exposure therapy (e.g., Neuner, Schauer, Klaschik,
Karunakara, & Elbert, 2004; Onyut et al., 2005; Ruf et al., 2010). Third, the socializa-
tion phase aims at reorienting refugee clients from avoidance toward connectedness
in the social world. Through supporting adaptive intimate and social relationships,
refugees are encouraged to develop relational networks and new future perspectives.
In this article, we reflect on developing refugee therapeutic care in the context of a
family therapy project.
1
Relating our therapeutic work to systemic approaches to refu-
gee rehabilitation that broaden the phased models individualizing focus toward an
emphasis on the relational impact of trauma and mobilizing family and community
resources in promoting adaptation (Walsh, 2007; Weine et al., 2004a,b), our family
therapeutic practice aims at supporting family relationships as a primary vehicle of
restoring continuity (De Haene, Grietens, & Verschueren, 2010).
In our therapeutic practice, clinical encounters with refugee families have initiated
our ongoing reflection on the phased trauma care model and its implications within
the therapeutic relationship. In specific, the encounter with cultural difference and
life experiences of atrocity in refugees suffering initiated our questioning of the role
1
This refugee family therapy project was initiated as a collaboration between the Faculty of Psy-
chology and Educational Sciences and the Centre for Child Abuse and Neglect, and further developed
in cooperation with the Centre for Marital, Family and Sex Therapy, University Hospital, University
of Leuven, Belgium. Referrals of refugee families (with diverse ethnic, religious backgrounds) by asy-
lum centers or community-based organizations are mostly oriented at supporting clients in dealing
with their family history of severe human rights abuses prior to leaving their home countries.
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of directive expertise and its potentially disempowering impact on refugee clients.
Here, our understanding of how directivity could imply a relational resonating of
power imbalance within the therapeutic space led us to explore possibilities of adopt-
ing a collaborative position (Anderson, 1997). Drawing on refugee family therapy
practices that move away from the phased models expert position toward narrative
and collaborative ideas (e.g., Blackburn, 2010; Sveaass & Reichelt, 2001a,b; Wood-
cock, 2001), we engaged in exploring a dialogical framing of refugee family therapy
oriented at the circulating of a multiplicity of voices within a collaborative encounter.
Current dialogical perspectives have emphasized an understanding of the thera-
peutic process as the negotiating of multiple ideas and beliefs between participants
(Seikkula & Trimble, 2005). In being present and engaging with the polyphony of
voices in outer conversation and conversational partners inner speech, therapeutic
conversation evolves to open new dialogical spaces of meanings from which clients
may feel enabled to reauthor their lives (De Haene, 2010; Rober, 2005a). As this dia-
logical approach developed in therapeutic contexts dealing with diverse nonrefugee
populations, we engaged in exploring potential modalities of collaborative dialogue in
the specific context of refugee care. Hereto, we explored intersections between dialogi-
cal ideas and transcultural refugee research and clinical work.
This article develops an account of these evolving notions of dialogical refugee fam-
ily therapy. First, we present our current reflection on potential modalities of dialogi-
cal practice with refugees. Hereto, we revisit the phased refugee care model from the
perspective of dialogical ideas and their linkages to transcultural refugee research
and practice, evolving into a delineation of possible meanings and modalities of dialog-
ical refugee care. Furthermore, we address possibilities of broadening the phased
model with these evolving dialogical notions. Hereby, we reflect on how containing
polarities between both approaches may provide a way to remain present to fragments
of therapeutic dialogue that resonate directivity and power disparity. A clinical case
analysis further explores these relational complexities of negotiating directive exper-
tise and collaborative dialogue in practice.
BROADENING THE PHASED APPROACH TOWARD EVOLVING NOTIONS OF
DIALOGICAL REFUGEE CARE
Diagnostic Expertise: From Vocabulary of Fear Toward Narratives of Exile
In the phased refugee rehabilitation model, the diagnostic entity of posttraumatic
stress disorder structures the therapeutic process around the identification and
reduction in symptoms of intrusive memories, avoidance, or arousal. This structured
process reflects a medical model in which the diagnostic identification of a fixed con-
struct of morbidity leads to a clearly defined treatment plan. In contrast, a dialogical
approach implies a radical questioning of objectifying definitions of pathology. Here,
therapeutic dialogue aims at exploring unique ways in which family members share
and crystallize meaning around lived experiences of their selves and relationships
and, hence, seeks to respectfully engage with those stories through which clients
express their worlds (Rober & Seltzer, 2010).
In refugee care, this moving beyond the protective certainty of diagnostic expertise
invites us to broaden the understanding of refugee mental health from the predeter-
mined vocabulary of fear toward the unique meaning making through which refugee
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families express their experience of forced migration. From the perspective of a dialog-
ical therapeutic relationship, refugee family members accounts of distress are not pri-
marily framed as articulations of fixed diagnostic entities but, instead, explored as
multilayered individual and relational biographies in the face of trauma and displace-
ment.
Trauma Narration: From Autobiographic Disclosure Toward Coauthored Stories
of Remembering and Forgetting, Meaning and Meaninglessness
The guided reconstruction of destructive life experiences into a coherent trauma
narrative constitutes the core mechanism of posttrauma recovery in the phased refu-
gee rehabilitation model. Seemingly, this process of integrating traumatic life events
into a meaningful life story closely relates to dialogical approaches central emphasis
on meaning making and reauthoring narratives in therapeutic conversation. How-
ever, we argue that each approach develops a fundamentally different perspective on
trauma narration.
The role of disclosure
In the phased approach, the verbal or symbolic remembering assumes the healing
function of open disclosure, in which retelling and revisiting traumatic experience
operate as central mechanisms of recovery. In contrast to this dominant notion of dis-
closure, a dialogical perspective aims at refraining from predefined ideas of reparative
strategies and seeks to develop a therapeutic relationship in which a multiplicity of
voices and resources in dealing with suffering can coexist. In this context, a dialogical
approach develops an understanding of narration as a complex transaction of disclo-
sure and silencing, rooted in family members experiences in sharing pain (Rober,
Walravens, & versteynen, in press). Furthermore, a dialogical orientation addresses
how silence may constitute a vital aspect of the expression of traumatic suffering itself
and focuses on the ways in which the clinician encounters this unspeakable pain in
actively experiencing clients narratives (Rober, 2010). A dialogical approach does
therefore not primarily aim at establishing open disclosure, but instead engages with
clients remembering and forgetting and invites a reflection on the meanings they
assign to their hesitation or silencing (Rober, 2002).
Linking these dialogical notions to the context of refugee care, this respectful
acknowledgment of the complex balancing of remembering and forgetting seems
vital. Rooted in cultural coping strategies or in an attempt to protect self and fam-
ily members from reliving unbearable pain, refugee families often share patterns of
silencing or active forgetting of traumatic life events (e.g., Angel, Hjern, & Ingleby,
2001). A one-sided focus on trauma disclosure may thus counteract cultural and
community systems practices of avoidance and neglect how silencing responses to
collective violence may operate protectively in dimming overwhelming experience
(Rousseau & Drapeau, 1998). Here, a dialogical framing of refugee care would
invite a careful exploration of forgetting and remembering in family and commu-
nity responses to traumatization. Working through destructive life experiences
would not solely focus on guiding family members from silencing toward disclosure,
but primarily aim at the active inclusion of forgetfulness through responsively join-
ing with the hope and fear that accompany refugees memories of unspeakable life
events.
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The role of meaning
In the phased model, trauma narration centrally revolves around the clients move-
ment from disintegrated traumatic experience toward a coherent life narrative, rein-
scribing destructive life events into a meaningful experience of self and relationships.
In essence, this working through traumatic life events aims at the alleviation of
meaninglessness and fragmentation in stories of trauma. Although a dialogical
approach clearly engages a joint process of negotiating meaning, its participatory
understanding of therapeutic dialogue counters an exclusive focus on a meaningful
life narrative as single adaptive outcome. Instead, the responsive joining in family
members narratives primarily aims at holding clients lived experience of meaning
and meaninglessness, creating new spaces of dialogue through remaining present
with both hope and hopelessness (Flaskas, 2007).
In the therapeutic encounter with refugees, containing clients experience of both
sense and absurdity might form an important theme (Rousseau & Measham, 2007).
Indeed, massive atrocity and its disintegration of social worlds seem to invoke the per-
vasive breakdown of narration, depriving language of its capacity to construct mean-
ing and coherence (Uehara, Farris, Morelli, & Ishisaka, 2001). Beyond the focus on
the construction of continuity in clients life narratives, a dialogical therapeutic
encounter with refugee families would thus aim at witnessing and remaining present
with fragments of radical doubt and hopelessness and anchor the search for meaning
within clients profound encounter with meaninglessness in the face of violence and
injustice.
From individual toward relational understanding of trauma narration
In the phased approach, trauma narration develops as an autobiographic process of
rebuilding a meaningful story in working through traumatic events that were part of
the personal trajectory. Contrary to this biographical notion of the trauma narrative,
a dialogical understanding emphasizes how stories told within the therapeutic
encounter evolve from the interactive processes between therapist and client system
(Rober, 2005b). Here, the trauma narrative emerges as a coauthored story in which
both clients and therapist negotiate how clients suffering can be expressed within
their ongoing relationship. Here, the question of the therapists role arises. If the
trauma narrative develops as a relational endeavor, how do we understand the clini-
cians participation in the sharing of trauma narration?
The Therapist Position: From Problem-Oriented Directivity to Collaborative
Dialogue About the Encounter of Social Worlds
Whereas the phased models therapeutic position is strongly characterized by prob-
lem-focused technical expertise, a dialogical orientation questions the potentially
disempowering effect of directive input and explicitly seeks to broaden such interven-
tionist therapeutic positions by emphasizing the clinicians personal experience and
exploring how the therapist may engage his/her experiencing to create constructive
spaces of dialogue (Rober, 1999, 2010). In the specific context of refugee care, this
dialogical emphasis on the therapists reflective engagement with his/her personal
experience may provide a window into specific relational complexities involved in the
transcultural encounter with refugees. First, a therapists active listening to inner
voices may invite us to reflect on how his/her position may echo the wish of remem-
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brance within the dual imperative to both forget and witness which is often lived by
individuals and communities in the wake of man-made atrocity (Kirmayer, 2002). In
listening to his/her inner experiencing as potentially echoing fragments of what can-
not (yet) be expressed in refugee families narratives, the therapist may understand
his/her position as part of complex transactions between remembrance and forgetful-
ness and search for a careful expression of his/her inner voices into a respectful dia-
logue on silence and witnessing. Second, the therapists use of his/her inner
conversation may deepen his/her reflective engagement with the experience of other-
ness in refugee care. Indeed, the clinical space entails an encounter of cultural worlds
in which the refugee client may appear as stranger, taking part in a vastly different
understanding and performing of illness, suffering, and healing (Kirmayer, Groleau,
Guzder, Blake, & Jarvis, 2003). Here, the resonating of cultural difference in his/her
inner experience may lead the therapist to recognize the multiple knowledge systems
at stake in clients realities and invite him/her to install an open negotiation of these
divergent universes of meaning and action. Furthermore, the refugee client may
equally come to embody otherness as he carries a story of atrocity (Kirmayer, 2007),
interrupting the clinicians protected world of social order. Indeed, refugee clients
bring in the realm of violence and may thus invoke the therapists inner voices of fear
evoked by uprootedness and inhumanity. Lastly, the attentive presence to inner
voices may invite the therapists reflection on the implicit ways in which the power
relationship between a host society representative and those who hope to find a future
in this social world encroaches upon the ongoing dialogue. Indeed, being part of a
health care institution inherently implies the therapists position as an accomplice to
host societies pervasive marginalization of refugee communities, imbuing all dialogi-
cal partners by the imbalance between power and powerlessness (Bala, 2005).
In sum, all these relational meanings may resonate in the therapists inner voices
and hereby invite his/her careful engagement with a negotiation of remembering and
forgetting, otherness, and power disparities within the therapeutic relationship. In
remaining present with powerlessness or distrust as potentially evoked by these rela-
tional transactions in the therapeutic encounter, the therapist expresses his/her will-
ingness to accept coauthorship for what is said, not said, and not feasible to say in a
clinical space that is inevitably located at the nexus of subjective and sociopolitical
meaning.
TOWARD THERAPEUTIC PRACTICE: VOICES OF DIALOGUE AND DIRECTIVITY
This exploration has delineated how our evolving ideas about dialogical refugee
care involve a fundamental broadening of the phased models understanding of heal-
ing in the aftermath of refugee trauma. Moving beyond the structured approach of
reestablishing meaning throughout the clients disclosure of personal autobiography,
a dialogical perspective aims to invite the unique lived experiences of trauma and
exile, and explores how to hold meaning and absurdity, disclosure and silencing in a
process of coauthored narration that accepts the relational echoes of social and cul-
tural difference between therapist and refugee client.
An integral part of this broadening of the phased model toward evolving dialogical
ideas on refugee care is our reflection on how to situate therapeutic practice between
both approaches divergent notions of directivity or collaboration, diagnostic entity or
narrative, and model or dialogue. In this exploration of how to locate the therapeutic
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position within the tension between expert or participant, witness or coauthor, we
relate our developing dialogical perspective to its primary orientation of moving away
from an expert position that may evoke the relational resonating of power disparity. If
a respectful presence with the voices of refugee clients is at stake, we propose not to
limit our therapeutic position and experiencing by a single conceptual approach, but
rather to be guided by the clients we encounter in informing our presence and conver-
sational activity by each perspective and continuously exploring their value as dia-
logue unfolds. Here, a dialogical orientation on polyphonic conversation may operate
together with notions from the phased rehabilitation model as heuristic background
of expertise on modalities of posttrauma healing or problem-focused techniques that
may be tentatively engaged as invitations into dialogue.
At the core of this ongoing reflection on informing our therapeutic positioning by
voices of dialogue as well as directivity is our concern not to assume the possibility of a
nonhierarchical therapeutic space in adhering to a dialogical orientation. Instead, we
propose to remain present to the tensions that arise in encountering fragments of ther-
apeutic positioning, inner speech, and language that are marked by diagnostic exper-
tise, guiding notions of healing as symptom reduction, meaning making, and social
connectedness, or echoes of unequal social positions that appropriate or silence refu-
gees voices. In a therapeutic space marked by a societal context that silences refugees
lives and in which a relational resonating of power disparity and coercion may echo cli-
ents traumatic predicament itself, locating the therapeutic relationship within dia-
logue as well as directivity may urge us to remain present with these fragments of
coercion, imposing meaning, or inability to listen and invite a negotiation of their intri-
cate relational meanings in the therapeutic encounter. Below, a case analysis
2
further
explores this containing of voices of dialogue and directivity in therapeutic practice.
A mother and her 11-year-old son from the Caucasus were referred for trauma-
focused support in dealing with fear and grief. Malika and Murad belonged to a
highly respected family in their home country. During their countrys political vio-
lence, father went missing. For years now, Malika and Murad dont know whether
father is alive and whether they will ever see him again. Then, a bombing severely
injured Murad. In need of specialized medical care, Malika decided to seek asylum. In
Belgium, the family was granted resident permission and Murad received medical
treatment. Malika learned the host societys language and found a job of packing sand-
wiches.
When I (first author) first met the family, Malika recounted fragments of her suffer-
ing and migration story, but at the same time emphasized her wish to focus treatment
on supporting her son in dealing with fear. Anxiety seemed to affect Murads daily life
quite pervasively: he was afraid of future medical treatments, had recurrent night-
mares, and felt fearful when being alone at home. At these moments, he said, he used
to take his plastic machine gun and hide behind a door or in the closet, hoping to pro-
tect himself from intruders.
Initiating family treatment, I focused on psycho-education with the aim to rebuild
control through increasing the clients knowledge regarding posttrauma responses.
2
This narrative account of subsequent sessions is based on detailed written notes made during and
immediately after sessions. The therapist was this articles first author. All identifying details have
been omitted.
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Introducing the family session, I clarified that I wanted to explain how extreme
destructive life experiences lead to posttraumatic reactions. On the whiteboard, I drew
a large, empty figure of a human being and invited family members to write down
important sources of concern around it. Murad wrote: thinking about family, dad,
hospital, bombing. He wrote hesitatingly while I noticed that Malika started to cry.
I experienced the burden of their missing of father and their broader family and, at the
same time, felt confused by their input. I had aimed to address anxiety symptoms, but
Malika and Murad predominantly seemed to bring in their experience of loss and grief.
I again focused on trauma-education, explained posttrauma symptoms as evoked by
devastating life events, and asked each family member to write down where they expe-
rienced these symptoms in the figure on the board. Murad came and drew tears on the
figures face. Again, I experienced doubt on my psycho-educative focus and asked
whether they somehow recognized these symptoms. Malika responded it felt quite nor-
mal they were affected by the events in their home country.
Aiming to explore how the parentchild relationship could be structured around
symptomatic functioning, I asked Murad whether he knew when mom experienced
fear. I dont know, he said. And do you know when she feels sad? I wondered.
Murad responded: I always sit next to her when she cries. I asked Murad whether he
could draw this. He started enthusiastically and drew two figures sitting on a couch:
The smaller person had his arm around the bigger person. Malika cried while looking
at Murads drawing. Are the two of you often sitting like this? I asked. Yeah, Murad
responded. Does mom feel less sad when you come and sit next to her? I wondered.
Yes, Murad nodded. And you, do you feel less sad too? He nodded again. I told Ma-
lika and Murad how I strongly experienced their missing and addressed their mutual
support in their silent presence with each others pain.
Initially, my directive approach merely operated within the language of trauma
nosology and did not connect with family members lived experience of forced migra-
tion. Yet, in their drawing, Murad and Malika invited me to loosen the certainty of
diagnostic entities and psycho-educative directivity and to share in their experiential
realities of displacement as a story of missing and loss. Although fear clearly formed
an identifiable part of their refugee experience, their account of distress articulated
the impact of forced dislocation beyond this vocabulary and indicated the uniqueness
of refugee families biographies of trauma and exile.
In the following individual sessions with Murad, I was informed by cognitive-
behavioral techniques oriented at decreasing his anxiety.
I proposed to Murad that we work together on becoming master of his fear. Murad
seemed to like that idea and talked about riding the quad bike with his friend. I told
Murad how important this feeling of being strong on a quad bike must be, and how dif-
ferent this must feel than waiting for his mom in the closet. I invited Murad to work
together on becoming this master, like on his quad bike, at home too and introduced
the triangle of thought, feeling, and behavior, explaining him how we could explore
alternative sequences of cognition and emotion. At the end of the session in which we
explored fear-reducing thoughts, I asked: Maybe we can make a large triangle with
you on a quad bike inside of it?
In the next session, Murad entered the room with a bundle of beautiful quad bike
sketches. His drawings formed the starting point of our joint search for ways to feel less
frightened. We made a small quad bike triangle and copied it many times, in order for
Murad to write down and learn to identify fearful thoughts at home. We constructed a
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large traffic triangle on cardboard, with a drawing of Murad on his quad bike inside.
Murad took this large triangle home, to remind him of his work on changing fearful
thoughts. During these activities, Murad seemed very enthusiastic. It made me believe
we would manage to decrease his fear.
Following these individual sessions, we concluded the session with Malika joining
us. In these family meetings, Malika responded to Murads recounting of his ongoing
work by expressing fragments of her own suffering. While reiterating her choice not to
engage in therapy herself, she talked about her loneliness, her wish to talk to someone,
her profound encounter with injustice, and powerlessness in her home country. Here, I
experienced disappointment in her reaction to Murads regaining of control. Why did
she choose not to respond to the change Murad was telling her about? Did she counter
his story of hope with her story of hopelessness?
In a final individual session, Murad brought his school bag filled with drawings:
wonderful sketches of flowers, landscapes, trees, animals, white clouds. Soon, the floor
was covered by his colorful drawings. When Murad was guiding me through them, I
asked him how he was doing in being master of his fearful thoughts. Murad
recounted how he felt less afraid and now knew he could become master by playing
on the computer: in that way his fearful ideas would stop. He seemed very proud that
he didnt feel frightened during a medical check-up. When I asked Murad whether he
would like to go on practicing to become master, he responded: Sometimes I feel
sad. When I asked Murad what he wanted to tell me about this sorrow, the room filled
with silence. Murad cried. I told him how deep this pain seemed to be and how it did
not seem to find words. Sitting in front of him, I strongly experienced Murads missing
of father and the uncertainty about his death. One part of me wanted to bring fathers
absence into conversation, another part felt hesitant and was afraid to speak about
what felt unspeakable. In fact, Murad said, I want to become a master a little bit
more. I am still afraid of snakes sometimes.
How to locate my directive intervention in these sessions within polarities of direc-
tivity and dialogue? Did our interaction merely involve the guided modification in
fear-provoking thought-feeling sequences or did this process engage a dialogical activ-
ity of exploring and negotiating control? Beyond understanding my directive input as
merely supporting modified cognition, these structuring interventions may as
strongly have operated as signifiers of change, as invitations into a joint engagement
with doing hope (Weingarten, 2000). Indeed, the use of cognitive-behavioral tech-
niques clearly evolved into a shared, active expression of mobilizing and believing in
change, in which Murad may have connected with his own strength and potential of
expressing his resources through creativity.
In listening to Malikas reactions, my inner voices of disappointment point to my
strong engagement in Murads process of growth. Indeed, my reluctance amply shows
how Malikas expression of suffering disrupted my focus on restoration, echoing the
fear that is evoked by the encounter with violence and that provokes the inclination to
restore hopelessness into hope. This may have precluded my willingness to share in
Malikas voice as she wrote fragments of her pain around Murads story of growth,
accounting for the injustice inflicted upon her family and, hereby, weaving her fragile
engagement with change into his story of stabilization.
Following a conversation regarding the familys difficulties in initiating a social
network, subsequent family sessions were oriented at exploring how family members
coped with social isolation.
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I put four hoops on the ground and explained how one pair of hoops represented
home while the other pair reflected outside. I then asked Malika and Murad to
stand in the hoop in which they resided most. Both chose a hoop of home, next to each
other. When I asked who went to an outside hoop most often, Murad reacted: I do,
when I am playing outside with my friend. I invited Murad to stand in an outside
hoop. Malika and Murad both laughed with this playful exploration and Murad
jumped in an outside hoop. How are you doing in there?, I asked. Fine!, Murad
responded eagerly, I am playing. I then approached Malika and wondered how she
felt in her home hoop. She expressed how she felt lonely and would prefer Murad to
come home. Standing in his outside hoop, Murad recounted that his mom always
phoned him to make him come back. Do you feel sad in here?, I asked Malika. Yes,
she nodded. And here, I asked Murad, do you feel sad too, outside here? No, he
reacted. I added: If you go outside, you feel less sad. While Malika was listening from
her home hoop, I went on to explore Murads understanding of going back home to
support his mother and listened to his view that it would make her feel better to come
outside more often. Then I asked Malika whether there was maybe a part of her that
would like to go outside more and invited her to come to try an outside hoop. She told
the story of a colleague inviting her for coffee, and how she declined. I felt very moved,
seeing Malika shyly laughing and moving to her outside hoop. But, Malika added,
if I would go out for coffee, Murad would call me and ask to come home again. We
explored how both mother and son were afraid of losing each other, linking their fear
to this migration history.
In a next session, I invited Malika and Murad to choose one of the hoops on the
ground again. This time, Malika went to the outside hoop and recounted that she
liked to go walking now. Murad chose the home hoop. He silently sat down in his
hoop and I wondered if he felt downhearted. Malika then recounted that Murad
wanted her to stay home and we all laughed in remembering it was the other way
around before. I asked: It seems to be that mom stays at home when you go outside,
and that you stay at home when mom goes outside? I added: You always make sure
someone is at home.
I felt surprised by my own words and wondered whether Malika and Murad always
made sure someone was at home to have someone hold their sadness, to have someone
waiting all the time for the moment father would return. Here, I experienced how the
heavy silence between us loudly spoke of fathers absence. Hesitatingly, I expressed my
thoughts: May I think that you are both taking care that someone is always waiting at
home? May I think of father? Both family members responded with silence. I won-
dered whether my naming of father was too painful and at the same time felt inclined
to bring this burdening silence into conversation. Standing in the middle of all those
hoops, I felt fearful, hesitant about my choice to bring in father this explicitly. I invited
Malika and Murad to come out of their hoops and sit in the chairs again.
I told the family that I felt how much it hurt to talk about father and asked them if
they could help me understand why it was so difficult to speak about him. Its not
right to talk about him, Malika said. Can you tell me more about that?, I asked.
Malika cried and Murad approached her. I dont want Murad to remember him. We
manage better if we dont talk about him. Silently, I sat in front of Malika and Murad,
encountering the impact of violence and atrocity in their suffering, immersed in their
pain, experiencing their hope to see father again, the intense fear for what might have
happened to him in a cruel war, their grieving and not yet grieving. I wondered how I
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could join their choice to remain silent about father, and felt torn between respecting
their avoidance and exploring a way in which this silence could become less burden-
ing. Here, I wondered aloud about how both talking and not talking seemed to be pain-
ful and expressed my understanding that Malika and Murad shared their suffering
even in remaining silent about father. I asked: Would it help if we would search for a
word that you can tell each other at those moments when you feel one of you is sad
because of father? Could it help to think of a word to then say to each other, without
having to talk further? Malika nodded. That we miss him, Murad said. Missing,
would that be the word? I asked. Malika nodded again and I wondered how that word
would sound in their language. Sagatlo, Malika responded. I asked her to write
down the word and invited the family members to take it home with them. Malika
wrote down sagatlo twice. She handed one paper to Murad, and put the other in her
bag.
In these family sessions, Malika and Murad invited me to broaden my initial orien-
tation on socialization. In moving between home and outside, they made me share
in their balance of social connection and disconnection within the parentchild rela-
tionship, both operating as meaningful strategies through which a future-oriented
positioning toward the social world would coexist with holding pain.
In the following session, I explicitly linked family members social isolation with
remembering and missing father, hereby inviting Malika and Murad to understand
their balance between home and outside as the intricate moving between waiting
and future, between hopelessness and hope. Here, my inner conversation may have
provided a window into what remained unspeakable between family members and
made me experience how the burden of remembrance shifted to my position within
the clinical space. Furthermore, while my fear to talk about father may have reflected
my encounter with echoes of trauma in the clients life story, my doubt equally points
to the fragile division between inviting and imposing expression in a therapeutic posi-
tion imbued with power disparities. Balancing on the fine line between containing
grief and imposing expression, my taking up of a share of disclosure tentatively
explored a respectful balance between remembering and forgetting while holding fam-
ily members experience of despair. The invitation to find a word for silence sought to
support clients remembrance in a way that would protect family members sense of
safety and cultural disclosure strategies. In our sharing of a word for silence, for
someone who is not there and yet always there (Boss, 1991), we may have engaged in
a dialogical process of holding remembrance and forgetfulness, meaning and mean-
inglessness, hope and hopelessness.
CONCLUDING NOTE: VOICES OF REITERATING AND RESTORING TRAUMA
IN THERAPEUTIC DIALOGUE
This account of evolving dialogical notions of refugee care engaged an explora-
tion of how to negotiate voices of dialogue as well as directivity in developing a col-
laborative encounter with refugee clients. Our emphasis on informing therapeutic
positioning, inner speech, and language by these divergent voices of collaboration
and directivity carries our ongoing reflection on how to contain those fragments of
implicit violence activated by directive intervention, the invisible parts of violence
evoked by the clinicians reductive diagnostic notions, push toward disclosure or
appropriating language, and amplified by the therapists powerful position as host
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society representative. Through remaining present to these voices of directivity, we
may accept the relational resonating of coercion and inequality and hear how these
voices echo refugees traumatic predicament in therapeutic dialogue itself. In
accepting responsibility for a therapeutic space imbued with a social context that
silences refugees lives, in containing voices of revisiting trauma as evoked by
the encounter itself, therapeutic dialogue may move beyond a mere reliving of
trauma toward sharing voices of powerlessness, distrust, and violence as deep
expressions of humanity, holding the promise of continuity, and restoration in the
face of adversity.
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