**4. Different path on trauma and healing: two case studies illustrating a humanistic-existential therapeutic process**

#### **4.1. From object to subject: Mark's path through healing connexions**

I first met Mark while I was working on an oncology ward as a psychologist. Mark had been diagnosed with lymphoma a few months earlier. His tumor had grown fast and spread to major lymph nodes. Mark started his treatment with great energy, hope, and trust to "*fight*" his cancer and go back to his "*normal, busy life*."

However, one of Mark's lymph nodes, located on the right side of his neck, had grown fast and altered his ability to breathe, talk, and eat normally. Therefore, Mark had to go through surgery to remove the mass. During his surgery, he experienced the so-called "*awareness*"—a rare phenomenon reported by some patients under general anesthesia. Awareness usually occurs when one of the medications given fails. In fact, usually, different types of medications are given: one intends to "*cause unconsciousness*" and the other one to "*relieve pain*." If the medication to render the patient unconscious fails, awareness may occur, although no pain is experienced. In other words, the patient wakes up, becomes aware of what is going on in the operating room, and of what is being done to his body. However, the patient has no mean to signify his awareness because of the muscle paralysis induced by the anesthesia. Therefore, the medical team does not know about the patient's experience, unless it is reported after anesthesia. In some cases, PTSD may arise after intraoperative awareness, causing the patient to require counseling for an extended period [25].

Mark was referred to me by his oncology nurse to whom he reported that "*he saw everything*." He was distressed, but also very aggressive and upset about what happened during the surgery. He mentioned that the surgeon was treating him as a dead animal, and that he felt like "*a piece of fabric under a sewing machine*." In fact, it seemed that Mark's awareness occurred precisely when the surgeon was stitching his neck following tumor removal. Mark wanted to leave the hospital as he no longer felt safe there. He refused meeting his surgeon and oncologist for postoperative follow-ups not trusting them anymore. He mentioned he would rather die home alone than to be assaulted by disrespectful physicians. Mark's medical condition (postoperative, immunosuppressed) and psychosocial situation (living by himself) made it impossible for him to go back home. His nurse convinced him to meet with me and to tell me his story of what happened in the operating room.

deeply believed that the suffering experienced from trauma may be transformed in an opportunity for growth. When the physical self, or even the psychological self, are threatened by trauma, the individual faces new forms of suffering. To be tolerated, this suffering has to be transformed in opportunities to find meaning. The possibility to give a meaning diminishes psychological suffering. Inevitable suffering can offer the opportunity to discover a meaning. Conscience is the tool that enables the identification or discovery of meaning. For Frankl, despite life experiences, human beings always have an opportunity to discover a meaning

For Frankl, if living necessarily involves suffering, surviving means giving meaning to suffering. As such, surviving from trauma would mean giving meaning to suffering and searching for new life meanings. Frankl's approach, alongside with humanistic-existential basic premises on human being, healing and growing offers support to explore, identify, and transform the experience of suffering from trauma. In the following section, we will explore how the humanist-existential approach, inspired by Frankl's theory among others, can

**4. Different path on trauma and healing: two case studies illustrating a**

I first met Mark while I was working on an oncology ward as a psychologist. Mark had been diagnosed with lymphoma a few months earlier. His tumor had grown fast and spread to major lymph nodes. Mark started his treatment with great energy, hope, and trust to "*fight*"

However, one of Mark's lymph nodes, located on the right side of his neck, had grown fast and altered his ability to breathe, talk, and eat normally. Therefore, Mark had to go through surgery to remove the mass. During his surgery, he experienced the so-called "*awareness*"—a rare phenomenon reported by some patients under general anesthesia. Awareness usually occurs when one of the medications given fails. In fact, usually, different types of medications are given: one intends to "*cause unconsciousness*" and the other one to "*relieve pain*." If the medication to render the patient unconscious fails, awareness may occur, although no pain is experienced. In other words, the patient wakes up, becomes aware of what is going on in the operating room, and of what is being done to his body. However, the patient has no mean to signify his awareness because of the muscle paralysis induced by the anesthesia. Therefore, the medical team does not know about the patient's experience, unless it is reported after anesthesia. In some cases, PTSD may arise after intraoperative awareness, causing the patient

Mark was referred to me by his oncology nurse to whom he reported that "*he saw everything*." He was distressed, but also very aggressive and upset about what happened during the surgery. He mentioned that the surgeon was treating him as a dead animal, and that he felt

through creative, experiential, and attitudinal values.

188 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

concretely inspire psychotherapy with PTSD patients.

**humanistic-existential therapeutic process**

his cancer and go back to his "*normal, busy life*."

to require counseling for an extended period [25].

**4.1. From object to subject: Mark's path through healing connexions**

I first met Mark 2 days after his surgery, at his bedside. He was quite agitated and hyperaroused. His nurses confirmed that he was awake and agitated most of the time and that he refused all medications. He would take some pain killers, but only if they were administered by a particular nurse he trusted. Our first meetings allowed Mark to tell his story in details and to slowly build alliance with him, as he felt quite threatened by the whole medical team. I spent a few sessions seeing Mark every day, sometimes twice a day, to see how he was doing. Slowly, but surely, he started trusting me. He was still quite hyper and slept very little; despite the pain medication he was taking. At several times, we had multidisciplinary team meetings about his case to facilitate the team's understanding of his situation and to pay more attention to the way they approached him, knowing he felt threatened. As a matter of fact, Mark's young surgeon felt terrible about what had happened. At some point, he mentioned: "*I don't recall being rough or different with this patient… I had no choice to manipulate his body to remove the tumour… I don't know… maybe I wasn't careful enough*." The medical team validated that, indeed, it was a hard procedure and, although every medical gesture was well-intended, it must be traumatizing to experience such body manipulation while being awake. While I was building trust with Mark, I realized that his hyperaroused state made exploration difficult. I started thinking that introducing a light medication may facilitate our therapeutic process. Mark was still sleeping very little and experienced recurrent nightmares of his body being cut into small pieces and thrown away in the garbage as a waste. He would wake up in the dream, realizing that his body was cut into pieces and then, would actually wake up.

Regular sessions with Mark allowed further exploration of his lived experience of the surgery and nightmares. Mark kept asking to go home so he could rest and sleep. I validated his subjective experience of assault to his body during surgery and, as a result, that his body did not feel safe to rest. I mentioned that this state of hyperarousal might in fact be overwhelming for him and for his whole body. Hence, he asked: "*can we do something about it*"? I told him that we had different choices: we could wait a little longer, try relaxation techniques, or introduce a light medication that would help him feel calmer. Mark raised his fear of being asleep at the hospital and that his body would be mistreated. I validated this fear of being mistreated as a result of feeling mistreated by his surgeon. I also shared that I trusted his current medical team. He finally agreed to take a little dose of medication at night, so he could rest.

The following sessions allowed deeper exploration of Mark's experience of being assaulted. Indeed, although no assault to Mark's body was intended, he experienced a fundamental assault by the surgery experience, and it shattered his assumptions that his medical team was there to support him and care for his life. At some point, he reported how he felt like a rotting carcass and, likewise, that is what will happen to him when he dies from his cancer. His body will be thrown away like a waste, with nothing left. At this point, I actually had the thought that Mark may be afraid of dying from his cancer, although he kept emphasizing his hope and trust. I was also stroke by how he experienced himself as a body uniquely, like nothing would be left of him after his death. However, at this stage, such intervention or interpretation appeared to be premature so I gave more reflection to Mark's experience of himself and his body. From a phenomenological stance, the sensitive body is not an object in the world, but the place of anchoring from which it is lived by experience. Mark's PTSD happened notably from the awareness of being treated as an object by individuals he trusted.

I was then able to explore and validate Mark's experience of being treated as a "*thing*." One week after surgery, since nobody had clearly explained to him the "*awareness*" phenomenon, I decided to. Providing a rational explanation of Mark's experience was not used to confront him with the objective reality, but to start exploring other meanings in what had happened. Mark developed the understanding that the medical team did not know about his experience, including the surgeon. Although this information seemed to have partially comforted him, he added:

#### "*They should be more careful*." *– They should care more about people… we are not cars, nor animals and we are not dead yet*."

The day after, I was at Mark's bedside when his surgeon went by to assess the wound. Mark did not say much. He was not very collaborative, but did not display any aggressive behavior. As the surgeon quickly left, still feeling embarrassed about the situation, I asked Mark: "*How was it to see him?*" He responded that "*it was ok, but that the surgeon still doesn't care*." I asked him: "*How do you think that your surgeon feels about what happened with you experiencing awareness and feeling mistreated in the operating room*?" He responded that "*surgeons don't feel anything; otherwise they wouldn't be able to do their job*." As of that moment, there was a transformation that allowed Mark to relate differently to his surgeon and to his experience. We could therefore agree that he experienced an assault, but that such assault was not against him as a person, but against his cancer to cure the disease present in his body.

From then on, PTSD symptoms of hyperarousal lowered, but Mark still had nightmares. When he left the hospital after surgery, I continued seeing him as an outpatient, since he still needed to receive chemotherapy treatments. Because he was feeling much better physically, we started a deeper exploration of the story of his life and his experience of illness.

#### *4.1.1. Mark's personal history and psychotherapy process*

Mark had been divorced for nearly 10 years and had little contact with his three children, aged between 15 and 20 years. His mother was still alive and he also had a brother. Both lived in a distant city and so family contacts were quite limited. Since his divorce, Mark reported "*having a series of relationships*," none of which lasted more than 2 years.

Mark describes himself as a "*doer*." He dedicated the bulk of his time and personal resources to work. He filled many jobs, often in the field of management for various engineering and telecommunication companies. On several occasions, he attempted to start up his own business, with no success. Mark was curious, a hard worker and very ingenious. He constantly had new ideas for solving all kinds of practical problems, but had a hard time completing his projects. Enthusiasm often led him to become scattered and overloaded. Thus, he accumulated aborted projects despite his innovative ideas. Left with a feeling of failure, he occasionally blamed others and claimed bigger financial rewards for his work. In fact, Mark lived under precarious financial conditions. When he received his cancer diagnosis, he was living with his then-girlfriend who supported him financially. Mark's girlfriend ended the relationship few weeks following the diagnosis, as she felt she could not cope with it. He expressed being concerned and having regrets not having built any material and financial heritage for his children.

carcass and, likewise, that is what will happen to him when he dies from his cancer. His body will be thrown away like a waste, with nothing left. At this point, I actually had the thought that Mark may be afraid of dying from his cancer, although he kept emphasizing his hope and trust. I was also stroke by how he experienced himself as a body uniquely, like nothing would be left of him after his death. However, at this stage, such intervention or interpretation appeared to be premature so I gave more reflection to Mark's experience of himself and his body. From a phenomenological stance, the sensitive body is not an object in the world, but the place of anchoring from which it is lived by experience. Mark's PTSD happened notably

I was then able to explore and validate Mark's experience of being treated as a "*thing*." One week after surgery, since nobody had clearly explained to him the "*awareness*" phenomenon, I decided to. Providing a rational explanation of Mark's experience was not used to confront him with the objective reality, but to start exploring other meanings in what had happened. Mark developed the understanding that the medical team did not know about his experience, including the surgeon. Although this information seemed to have partially comforted him, he

"*They should be more careful*." *– They should care more about people… we are not cars,*

The day after, I was at Mark's bedside when his surgeon went by to assess the wound. Mark did not say much. He was not very collaborative, but did not display any aggressive behavior. As the surgeon quickly left, still feeling embarrassed about the situation, I asked Mark: "*How was it to see him?*" He responded that "*it was ok, but that the surgeon still doesn't care*." I asked him: "*How do you think that your surgeon feels about what happened with you experiencing awareness and feeling mistreated in the operating room*?" He responded that "*surgeons don't feel anything; otherwise they wouldn't be able to do their job*." As of that moment, there was a transformation that allowed Mark to relate differently to his surgeon and to his experience. We could therefore agree that he experienced an assault, but that such assault was not against him as a person,

From then on, PTSD symptoms of hyperarousal lowered, but Mark still had nightmares. When he left the hospital after surgery, I continued seeing him as an outpatient, since he still needed to receive chemotherapy treatments. Because he was feeling much better physically, we started

Mark had been divorced for nearly 10 years and had little contact with his three children, aged between 15 and 20 years. His mother was still alive and he also had a brother. Both lived in a distant city and so family contacts were quite limited. Since his divorce, Mark re-

Mark describes himself as a "*doer*." He dedicated the bulk of his time and personal resources to work. He filled many jobs, often in the field of management for various engineering and

from the awareness of being treated as an object by individuals he trusted.

190 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

*nor animals and we are not dead yet*."

but against his cancer to cure the disease present in his body.

*4.1.1. Mark's personal history and psychotherapy process*

a deeper exploration of the story of his life and his experience of illness.

ported "*having a series of relationships*," none of which lasted more than 2 years.

added:

During our sessions, it occurred to me that Mark was very labile. He would fluctuate between expansion movements, during which he was extensively discussing about his past accomplishments, and moments of profound distress where he would connect with his terror of death, a feeling of deep solitude, and his suffering of being ill. His chemotherapy treatments made him very symptomatic. It was stealing away his energy and affecting his ability to center himself and concentrate. He came to explicitly question the meaning and goal of his life. Along uncertainty, a constant monitoring of the progression of his tumor led him to first experience total despair and later idealized an improbable future in which he would be fully healed and where he would finally succeed in accomplishing the grandiose projects he was dreaming of.

At one point, I reflected to Mark how success at work had always been an important aspect for him. He agreed and added that it was, until now, the only important thing for him. In some way, it had been the unique source of meaning in his life. After a while, he was able to open up to the idea of having other sources of meaning in life, which were more consistent with the limitations imposed by the disease. In parallel to this exploration, Mark's life experiences led him to open up to various experiential values; he occasionally mentioned being touched by the care he was receiving, although he did not feel safe at first. Moreover, Mark felt good about the fact that the oncology personnel recognized him, remembered his name, and his situation from week to week. He also recalled passing by his surgeon while walking to his chemo treatment. His surgeon asked him how he was doing and, as a mean of connecting with him in a positive way, mentioned he did his best. Mark reported the event with mixed feelings of gratitude and sadness. Afterwards, he did not report having the same recurrent nightmare.

Mark also felt a lot of sadness and compassion toward the other patients he was in contact with and whose situation was sometimes more precarious than his. Often, Mark treated this information as insignificant details. However, during session, we started taking more time to stop and deeply explore these states of compassion and gratitude. By giving it time and attention, these states became more meaningful to a point where they eventually were consciously named as one of the meanings in his life. Because life contained such bursts of compassion and fraternity, it felt worth living.

Thus, the experience of being ill and the psychotherapy allowed Mark to raise his awareness to a new meaning through experiential values. Moreover, we came to identify an important role of suffering in the discovery of new values and sources of meaning. Compassion became possible with the experience of being sick. Suffering could then become a transcending experience and allow for new possibilities of being.

Several months later, Mark had to be hospitalized again for pneumonia. He felt extremely isolated and suffered even more. I continued visiting him at bedside. He could phrase that he was terrified by the idea of dying. His suffering was so important that he even wished to die. However, being accompanied through his solitude allowed him to realize the importance of emotional bond and human connexion. This growing awareness led him to rebuild contact with his children and ask for his mother and brother to visit him. To this day, Mark still has contact with two of his children. The relationship is sometimes hectic, but he satisfies himself from having found the courage to reunite with his family.

Further to his hospitalization, Mark was admitted to a long-term care facility where he currently lives at a relatively independent level. He is assisted in managing his medical situation, which calls for constant monitoring. His gratitude toward life increased. He changed his need to fulfill himself into a modest but concrete implication in the center where he lives. He puts his ingenuity to the service of other residents by improving life conditions, by performing valuable services, and organizing new activities. Sometimes, he mentions that he wished he had "*done more*," but he realizes that his actions have never been that concrete to contribute to the world around him. Most importantly, this became a source of meaning for him. Mark lives modestly but in a much consistent way.

On several occasions, Mark shared his feeling of failure for not having accumulated a material heritage. In the face of this unchangeable situation, the last stage of the psychotherapy permitted a change of attitude. He certainly did not have money, a house, or any objects to leave behind. Nevertheless, the richness of his experience was invaluable. He had faced illness with courage and committed to a profound transformation through a physical challenge. Hence, he was not leaving anything material behind, but his legacy was one precious teaching. This thought was very comforting for Mark who has now engaged in writing his story for his children.

After just over a year of psychotherapy, Mark still lives with a cancer although currently medically controlled. The progression of his illness is constantly monitored and he is well aware that relapse may occur at any time. However, for the first time, he reports that even if his cancer reoccurred, he could leave with no regret. He also keeps inside the profound truth that he is capable of a humble happiness, that he was able to transcend suffering, and that his illness will never steal away his gratitude, his good actions, and his capacity to love. It is therefore with confidence in his ability to transform psychologically that Mark views the future. He remains sad and sometimes anxious about the suffering that awaits him, but these fears do not dominate him as before.

Mark's psychotherapeutic process allowed the exploration and some transformation of his relationship with himself, others, and his world. It allowed some reintegration and reconstruction of different part of himself. As he said, he metamorphosed from doing to a being. The therapeutic encounter and the support received by the medical team and the exchange with his surgeon enabled him to rebuild and reconnect with a sense of humanity and with a view of a world as meaningful, caring, and benevolent. Mark no longer defines himself as a doer. He has come to experience himself as a relational and existential being, with a past, a present, and a future. He also sees his current illness as a transformative experience. He considers this transformation as an opportunity for legacy and transmission that is not material, but that may support his children in their own search of meaning and purpose in life.

#### **4.2. Eleanor: meaning of survival**

possible with the experience of being sick. Suffering could then become a transcending

Several months later, Mark had to be hospitalized again for pneumonia. He felt extremely isolated and suffered even more. I continued visiting him at bedside. He could phrase that he was terrified by the idea of dying. His suffering was so important that he even wished to die. However, being accompanied through his solitude allowed him to realize the importance of emotional bond and human connexion. This growing awareness led him to rebuild contact with his children and ask for his mother and brother to visit him. To this day, Mark still has contact with two of his children. The relationship is sometimes hectic, but he satisfies himself

Further to his hospitalization, Mark was admitted to a long-term care facility where he currently lives at a relatively independent level. He is assisted in managing his medical situation, which calls for constant monitoring. His gratitude toward life increased. He changed his need to fulfill himself into a modest but concrete implication in the center where he lives. He puts his ingenuity to the service of other residents by improving life conditions, by performing valuable services, and organizing new activities. Sometimes, he mentions that he wished he had "*done more*," but he realizes that his actions have never been that concrete to contribute to the world around him. Most importantly, this became a source of meaning for

On several occasions, Mark shared his feeling of failure for not having accumulated a material heritage. In the face of this unchangeable situation, the last stage of the psychotherapy permitted a change of attitude. He certainly did not have money, a house, or any objects to leave behind. Nevertheless, the richness of his experience was invaluable. He had faced illness with courage and committed to a profound transformation through a physical challenge. Hence, he was not leaving anything material behind, but his legacy was one precious teaching. This thought was very comforting for Mark who has now engaged in writing his story for his

After just over a year of psychotherapy, Mark still lives with a cancer although currently medically controlled. The progression of his illness is constantly monitored and he is well aware that relapse may occur at any time. However, for the first time, he reports that even if his cancer reoccurred, he could leave with no regret. He also keeps inside the profound truth that he is capable of a humble happiness, that he was able to transcend suffering, and that his illness will never steal away his gratitude, his good actions, and his capacity to love. It is therefore with confidence in his ability to transform psychologically that Mark views the future. He remains sad and sometimes anxious about the suffering that awaits him, but these

Mark's psychotherapeutic process allowed the exploration and some transformation of his relationship with himself, others, and his world. It allowed some reintegration and reconstruction of different part of himself. As he said, he metamorphosed from doing to a being. The therapeutic encounter and the support received by the medical team and the exchange with his surgeon enabled him to rebuild and reconnect with a sense of humanity and with a

experience and allow for new possibilities of being.

192 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

from having found the courage to reunite with his family.

him. Mark lives modestly but in a much consistent way.

children.

fears do not dominate him as before.

I met Eleanor, 22, a few years ago while I was starting my private practice as a psychologist. Eleanor has lived in Canada for 12 years. She left Rwanda—her country of origin—in 1998, following the 1994 genocide against Tutsis. Eleanor was referred to me by Dr. Lemond, one of my previous clinical supervisors, who had been Eleanor's psychologist a few years ago. Dr. Lemond was now retired and she called me to meet with Eleanor, as she knew I had worked in Rwanda with survivors in the past. With Eleanor's approval, Dr. Lemond sent me a short report of her story and healing process. Dr. Lemond had been involved with Eleanor shortly after she immigrated to Canada as a refugee. She saw Eleanor as an outpatient at the children mental health facility where she was working at the time.

When Eleanor called me, she quickly mentioned being tired and having some nightmares "*again*" but that those "*were not the same as they used to*." Eleanor mentioned that she would prefer not having to tell her story again, especially since that "*her current situation was not related to her past*." To Eleanor, it did not make sense to talk so much about the past and she explicitly mentioned seeking consultation to feel better in the present and to go on with her future.

I had considerable hesitation about reading Eleanor's story before actually meeting her, especially given her insistence that her current difficulties were not related to her past. Having worked in Rwanda before, I had heard many stories of trauma: most survivors had witnessed horrors perpetrated by neighbors, had escaped death during weeks, had to deal with grief for an entire family; family they had seen perish in violent deaths… and more… I certainly did not want to have strong preconceptions that may reduce Eleanor's whole experience to her traumatic story. I also wanted to connect with Eleanor's strength and current life experience. Nevertheless, given Eleanor's consent and probable expectations about me knowing her story, I decided to read Dr. Lemond's report. After reading, as consciously and as reflexively as possible, I tried "*suspending all judgments about what would be real*" about the person she had become years after. I wanted to take a phenomenological stance that would allow the exploration of Eleanor's subjective current life experience of the here-and-now.

#### *4.2.1. Eleanor's story*

Eleanor was 6 years at the time of the genocide. As a member of a Tutsi family, she had grown in a world of tensions in which her identity as a Tutsi defined her as a minority. The mass killings in Rwanda happened from April to June 1994, following the crash of the presidential plane by extreme Hutu radicals. Then, massacre against Tutsi started.

Six-year-old Eleanor and her family were attacked in mid-April 1994, at home, overnight. Eleanor had witnessed the cruel killing of her mother, father, and big sister as she was hiding under her sister's bed. Being the youngest of a family of four kids, Eleanor did not have her own bed and used to sleep either on cushion, on the floor, or sometimes in her big sister's bed after begging her for a little room. The night of her family killing, Eleanor was on the floor right beside her sister's bed, who was already asleep.

Eleanor could not sleep as she was noticing a conversation between both her parents in the living room who were worried about the recent death of close Tutsi community members. Eleanor recalled being so afraid while listening to her parents' conversation that she could not sleep. At some point, she noticed more and more noises coming from outside. She recalled hearing men yelling and women screaming. Afraid of those distressing noises, she hid under her sister's bed. Noises became louder and louder until she realized that there were people in her house. She recalled hearing her mother's and father's voices, but could not remember what had been said. At that point, her sister woke up and screamed for her mother. Eleanor remembered that people entered the room. She heard screams and hits that seemed to her as not having lasted long. After a while, there were no more noises. Eleanor, terrified and distressed stayed under the bed for hours, as she recalled it. She finally got out of her hiding place and discovered the bodies of her mother, father, and sister. Afraid, she left the house and went hiding into the woods for … "*a while*," as she remembered.

Somehow, Eleanor made her way—alone—to a refugee camp close to the border of Uganda. She lived there by herself for almost a year, taken care of by nongovernmental organization (NGO)1 workers. At some point, a Canadian NGO worker named Marissa, accompanied by someone from the Canadian embassy, happened to be looking for her. As mentioned in Dr. Lemond's report, Eleanor reported feeling confused while speaking with Marissa and "*the other Mzungu*. 2 *This Mzungu, she was very nice to me. She just explained to me that I had an aunt in Canada who was looking for her family members here, in Rwanda*.

As a matter of fact, Eleanor happened to have an aunt, Eglantina, in Canada. Eglantina, aged in her early fifties, was actually the sister of Eleanor's grandmother. She had left Rwanda in the 1980s. She had fallen in love with a Canadian humanitarian worker and the couple married in Rwanda in the 1980s. Very aware of the ethnic conflict that was getting increasingly violent, they decided to fly to Canada and live there. Eglantina still had some contact with her family in Rwanda, but could not reach them during the genocide. In the fall of 1994, Eglantina started actively searching for her family by making contact with different Canadian and foreign NGOs. As her research was progressing, she discovered that most of her family had perished. The whole process has been accompanied with great grief and losses.

Fortunately, she was able to find Eleanor and, as a mean to reconnect with her Rwanda origins and traumatic losses, adopted her. Eglantina facilitated her immigration to Canada as a refugee. Eleanor flew to live with Eglantina and her husband, Louis. Both Louis and Eglantina offered a supporting environment to Eleanor. By the time Eleanor started school in Canada, she was almost 10. Needless to say she was struggling with adjusting to this completely new and different world. She experienced more and more anxieties, and struggled with adjusting

<sup>1</sup> Non-governmental organization

<sup>2</sup> This term is a familiar designation given to white people in Rwanda.

to different life areas. She had frequent nightmares and night terrors, panic attacks almost every day, social anxiety, introversion, tear bursts, etc. At school, she could not concentrate and she did not seem to be able to make contact with other kids, nor teachers. Following Eleanor's teacher's advice, Eglantina and Louis sought professional help at the outpatient children clinic close by. From the age of 11–15, Eleanor has been followed by Dr. Lemond.

#### *4.2.2. Meeting with Eleanor*

under her sister's bed. Being the youngest of a family of four kids, Eleanor did not have her own bed and used to sleep either on cushion, on the floor, or sometimes in her big sister's bed after begging her for a little room. The night of her family killing, Eleanor was on the floor right

Eleanor could not sleep as she was noticing a conversation between both her parents in the living room who were worried about the recent death of close Tutsi community members. Eleanor recalled being so afraid while listening to her parents' conversation that she could not sleep. At some point, she noticed more and more noises coming from outside. She recalled hearing men yelling and women screaming. Afraid of those distressing noises, she hid under her sister's bed. Noises became louder and louder until she realized that there were people in her house. She recalled hearing her mother's and father's voices, but could not remember what had been said. At that point, her sister woke up and screamed for her mother. Eleanor remembered that people entered the room. She heard screams and hits that seemed to her as not having lasted long. After a while, there were no more noises. Eleanor, terrified and distressed stayed under the bed for hours, as she recalled it. She finally got out of her hiding place and discovered the bodies of her mother, father, and sister. Afraid, she left the house and

Somehow, Eleanor made her way—alone—to a refugee camp close to the border of Uganda. She lived there by herself for almost a year, taken care of by nongovernmental organization

someone from the Canadian embassy, happened to be looking for her. As mentioned in Dr. Lemond's report, Eleanor reported feeling confused while speaking with Marissa and "*the other*

As a matter of fact, Eleanor happened to have an aunt, Eglantina, in Canada. Eglantina, aged in her early fifties, was actually the sister of Eleanor's grandmother. She had left Rwanda in the 1980s. She had fallen in love with a Canadian humanitarian worker and the couple married in Rwanda in the 1980s. Very aware of the ethnic conflict that was getting increasingly violent, they decided to fly to Canada and live there. Eglantina still had some contact with her family in Rwanda, but could not reach them during the genocide. In the fall of 1994, Eglantina started actively searching for her family by making contact with different Canadian and foreign NGOs. As her research was progressing, she discovered that most of her family had perished. The

Fortunately, she was able to find Eleanor and, as a mean to reconnect with her Rwanda origins and traumatic losses, adopted her. Eglantina facilitated her immigration to Canada as a refugee. Eleanor flew to live with Eglantina and her husband, Louis. Both Louis and Eglantina offered a supporting environment to Eleanor. By the time Eleanor started school in Canada, she was almost 10. Needless to say she was struggling with adjusting to this completely new and different world. She experienced more and more anxieties, and struggled with adjusting

workers. At some point, a Canadian NGO worker named Marissa, accompanied by

*This Mzungu, she was very nice to me. She just explained to me that I had an aunt in Canada*

beside her sister's bed, who was already asleep.

(NGO)1

*Mzungu*. 2

1

2

Non-governmental organization

went hiding into the woods for … "*a while*," as she remembered.

194 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

whole process has been accompanied with great grief and losses.

This term is a familiar designation given to white people in Rwanda.

*who was looking for her family members here, in Rwanda*.

The first meetings with Eleanor allowed the exploration of her current life's situation. I also explored Eleanor's experience of therapy as a kid, and the meaning that therapy have for her. She mentioned feeling very grateful for the help provided by Dr. Lemond. The therapist, who she recalled as a nice, kind, and very patient woman, reminded her of her own mother. From her first psychotherapy process, Eleanor reported that it felt good to have someone knowing her complete story. She also mentioned that although she had a hard time with telling the things she saw, it helped her to stop thinking about it. With time, her images had become blurrier every day, to a point that she could not quite remember her parents' traits. Eleanor had tearful eyes when talking about it, but also stated that she learned to live with it. She mentioned still struggling at times with not knowing what happened to her brothers who were not home the night of the killings as they were studying in a boarding school in another city.

Eleanor said that therapy enabled her to feel calmer about her souvenirs and more "*ok with everything that happened. It took three years for me to be cured from my trauma*," she said. She added that "*the techniques with the eyes* (EMDR)3 helped her to feel calmer. Eleanor was aged 16 when she completely stopped seeing Dr. Lemond. She recalled feeling quite well; she was doing well at school and managed to graduate from high school. Excelling in school, Eleanor decided to go to college, and to become a nurse. She was still living with Eglantina and Louis, who kept supporting her in her new life project. Although Eleanor had some difficulty adjusting to "*so much studying*," she felt happy with her choice.

Eleanor became increasingly anxious as she started her first practical training. Although she felt proud about her career choice, she mentioned feeling sick when being at the hospital. She also reported feeling dizzy, not being able to think clearly, and experiencing confusion in the presence of sick people. She precisely described an event in which she was in the emergency room and had to witness her supervisor do the assessment of a 10-year-old girl who had been in a major bike accident. The young girl had multiple fractures, and blood all over her. The smell of blood made Eleanor instantly sick and she had to leave the room to vomit.

This event made Eleanor even more anxious. She was afraid of falling in front of everybody. As a result of her anxiety symptoms, she started missing days of training. She would stay in her room all day either sleeping or watching TV shows to change her mind. Eglantina and Louis started being concerned about Eleanor's change in mood and behavior. They first interpreted it as a lack of motivation to work hard. Eleanor kept saying that she was tired and

<sup>3</sup> EMDR stands for Eye Movement Desensitization and Reprocessing. This type of therapy is commonly used for the treatment of traumatic memories. For more details, see [26].

started to lie about her schedule or obligations. Quite upset about her attitude, Louis and Eglantina tried to confront her. Eleanor recalled a conversation with Louis, in which he mentioned: "*You should feel responsible to do something meaningful with your life*."

After this conversation, although Eleanor's anxieties were still present, depressive symptoms took over: she was sleeping more and more, staying in her room all day, and not eating. She reported being tearful at times, without understanding why. Following Eglantina's suggestion, Eleanor started to consider psychotherapy again.

#### *4.2.3. Eleanor's current experience and psychotherapy process*

I started exploring Eleanor's current situation, as she experienced it. I tried to suspend all my preconceived interpretations, and to inquire about how she felt here and now. I notably asked Eleanor about the reasons that brought her to seek psychotherapeutic help. She responded by asking me if I knew her story. I answered that I had spoken with Dr. Lemond and that I had read about her psychotherapy process with her. Then, Eleanor responded that her current situation was not about her past. So, I asked her what was going on for her. She responded "*I am tired all the time*." Therefore, I explored Eleanor's fatigue, asking her to further describe her experience of being tired:

*M: How is it like for you when you're fatigued?*

*M: How is it like for you when you're fatigued?*

*E: I don't know… I just feel like sleeping…*

*M: And… how is it like when you actually sleep?*

*E: It depends… sometimes it's good…I don't feel anything, so it's good…but sometimes I have nightmares…again…*

*M: Again?*

*E: Yeah… I used to have them when I was younger… But they are not the same. They are not about the past*.

*M: Do you feel comfortable sharing one of your nightmares with me?*

*E: …Yeah…it's always the same that keeps coming back…*

*M: Okay… Tell me about it…*

Then, Eleanor explained that she always dream of being at the hospital, as a nurse. In her dream, there are people crying and screaming for help. There are people everywhere and not enough staff to take care of them. At some point, Eleanor's supervisor asks her to be more efficient and to work faster. She tries to get someone's medication and then she freezes. She cannot move. People scream louder and louder and Eleanor's supervisor yells at her to hurry up, but she cannot. She usually wakes up after her supervisors tells her she is fired for being lazy, useless, and worthless.

Eleanor kept her eyes on the floor while narrating her dream. When she finished and looked up at me, her eyes were in tears. I delicately asked her what made her tearful. She responded feeling guilty about not being strong enough to become a real nurse, who actually cares for others. I was surprised with such a statement and further explored what it meant for her not to be "*strong enough*." Then, she reported the incident in the emergency room, where she felt sick seeing the young girl who was injured and covered with blood following her bike accident. She reported feeling bad for the young girl and feeling guilty for not being able to provide a proper response to the situation, as was expected from her.

started to lie about her schedule or obligations. Quite upset about her attitude, Louis and Eglantina tried to confront her. Eleanor recalled a conversation with Louis, in which he

After this conversation, although Eleanor's anxieties were still present, depressive symptoms took over: she was sleeping more and more, staying in her room all day, and not eating. She reported being tearful at times, without understanding why. Following Eglantina's suggestion,

I started exploring Eleanor's current situation, as she experienced it. I tried to suspend all my preconceived interpretations, and to inquire about how she felt here and now. I notably asked Eleanor about the reasons that brought her to seek psychotherapeutic help. She responded by asking me if I knew her story. I answered that I had spoken with Dr. Lemond and that I had read about her psychotherapy process with her. Then, Eleanor responded that her current situation was not about her past. So, I asked her what was going on for her. She responded "*I am tired all the time*." Therefore, I explored Eleanor's fatigue, asking her to fur-

*E: It depends… sometimes it's good…I don't feel anything, so it's good…but sometimes I have*

*E: Yeah… I used to have them when I was younger… But they are not the same. They are not about the*

Then, Eleanor explained that she always dream of being at the hospital, as a nurse. In her dream, there are people crying and screaming for help. There are people everywhere and not enough staff to take care of them. At some point, Eleanor's supervisor asks her to be more efficient and to work faster. She tries to get someone's medication and then she freezes. She cannot move. People scream louder and louder and Eleanor's supervisor yells at her to hurry up, but she cannot. She usually wakes up after her supervisors tells her she is fired for being

mentioned: "*You should feel responsible to do something meaningful with your life*."

196 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

Eleanor started to consider psychotherapy again.

ther describe her experience of being tired:

*M: How is it like for you when you're fatigued?*

*M: How is it like for you when you're fatigued?*

*M: And… how is it like when you actually sleep?*

*M: Do you feel comfortable sharing one of your nightmares with me?*

*E: …Yeah…it's always the same that keeps coming back…*

*E: I don't know… I just feel like sleeping…*

*nightmares…again…*

*M: Okay… Tell me about it…*

lazy, useless, and worthless.

*M: Again?*

*past*.

*4.2.3. Eleanor's current experience and psychotherapy process*

Although Eleanor mentioned her feeling about the situation, we agreed to discuss it further since the event seemed to have precipitated some of her current suffering. In a following session, we discussed the scene again, with phenomenological exploration. We explored bodily sensations she had experienced back then, as well as the bodily sensations she may experience while remembering the scene. To her, the smell of blood was particularly unbearable and she would be nauseous in the session just remembering it. Gently, I dared to inquire what images came to her mind while smelling blood. She then recalled the view of her family, covered with blood and explained how she ran away from it as a little girl. Crying loudly, she expressed that maybe she should have stayed there and died with them; or maybe they were still alive. She should have tried to save them. She felt like betraying her sister by hiding under her bed. She should have died with them. She described herself as weak and selfish to have escaped instead of facing her destiny. She should have at least tried to save them and to be courageous enough to face death doing so. Why did she think that her life had more value than her parent's or sister's? Why them and not her? She was now stuck to survive. Even worst, she had to do something worth with her life so she could pay back her debt, but was too weak and worthless to actually do it.

Phenomenological and detailed exploration of Eleanor's experience of fatigue, sleep, nightmares, and bodily sensations allowed revealing her feelings of guilt and worthlessness. In fact, Eleanor experienced herself as being guilty to survive and in debt toward life and her family. As she was trying to pay back her debt as a survivor, she felt stuck—again—with a sense of worthlessness and weakness.

With Eleanor, therapy involved slowly trying to reinterpret her past differently and to find new meanings in her experience as a child and as the only survivor of her family. Psychotherapy aimed at exploring and sharing about her story, so that she could slowly build a new understanding of herself, as being resilient, courageous, and compassioned. As a therapist, I started supporting her whole being, including her unique qualities. At some point, I even mentioned that I wished she could see herself as I saw her. We worked on developing her selfcompassion. We worked on understanding her sensibility and great empathy toward others as a strength she developed through her own suffering.

We also revisited the strength, discipline, and resilience she had to exert to survive physically and emotionally. We discussed how she had already healed from most of her traumatic experience and that now, there was an opportunity for growing from it by existing more fully as a whole person, not only as a survivor in debt. We discussed how such a process of growth was complex and profound, and that it required time. We worked on reintegrating her story in a different way, so she could try to relate to herself, to others, and to the world more freely.

While Eleanor seemed to slowly get better (having more energy and no more nightmares), she wanted to know more about "*growing*" from trauma. At this point, I decided to lend her my book "*Man's search for meaning*" [27], in which Frankl tells about his own history of concentration camps and in which he extrapolates his theory on life's meaning. Eleanor was particularly moved by the understanding that suffering may have meaning. Following this reading, she initiated rich and deep discussions about the different sources of meaning in her own life. Notably, she mentioned increasing her awareness and gratitude of the value of the relationship she had with her adoptive parents. She would still feel guilty at times for what the world has given her, but would also be able to relate to her experience differently, which motivated her for a fuller engagement toward life. In fact, Frankl's strong thoughts about self-engagement toward life empowered Eleanor to continue to search for and to create her own unique and valuable way of living a purposeful existence.

In the meantime, Eleanor continued to take nursing classes on a part-time basis. She temporarily postponed her practical training and started volunteering at the hospital to see if she could develop a new way to relate to others' illness and suffering. By volunteering, Eleanor experienced rich human contact and compassionate care with patients and got progressively used to witnessing suffering. She created significant bonds with patients and other caregivers, and received good feedback on her listening abilities, kindness, and compassionate way of being. Such bounds may have facilitated her sense of worth and value. Eleanor started giving meaning to her suffering, thinking that her past history contributed to cultivate her sense of humanity and compassion. We worked on cultivating this self-compassion, especially when her feelings of guilt and worthlessness would surface.

After a moment, Eleanor felt that she was ready "*to fly a bit on her own*." The overall psychotherapy process lasted 18 months, on a regular weekly basis. Before saying goodbye, Eleanor and I identified what her next challenge may be: for the first time, she was thinking in building an intimate relationship with someone. Although the idea pleased her, she was still terrorized by physical and psychological intimacy and quite aware of the challenges it would be to develop attachment toward someone. She fluctuated between states of hope (being with someone), desire for self-protection, and preservation (it is easier to be alone) or self-depreciation (no man would be interested in me). To date, Eleanor still struggles with self-worth at times, but has come a long way from the first time I met her.
