Accueil du site > N°22, Troubles de la personne et clinique du social > Troubles de la personne et clinique du social > Political violence, traumatism and the (re)creation of clinical professions. (…)

Jean-Luc Brackelaire, Marcela Cornejo, Darius Gishoma

Jean-Luc Brackelaire, Professor at the University of Namur and at the Catholic University of Louvain (UCL), clinical psychologist at the Mental Health Service of Louvain-la-Neuve (Belgium). jean-luc.brackelaire chez
Marcela Cornejo, Professor, Pontificia Universidad Católica de Chile, Department of Psychology. Research on the Professionals of the Commission of Chile forms part of the project FONDECYT N°1070855 « From Testimony to Narrative : psychological processes among the professionals of the National Commission on Political Imprisonment and Torture ». The researchers directing that research are Marcela Cornejo, Germán Morales, Juanita Kovalskys and Dariela Sharim. marcela chez
Darius Gishoma, Lecturer at the University of Rwanda, Mental Health Department, College of Medecine and Health Sciences. gisho3 chez

Political violence, traumatism and the (re)creation of clinical professions. Towards a clinical approach to social responsibility in dealing with psychosocial traumatisms

Résumé / Abstract

Situations of political violence cause psychic and social traumatisms of immense scale and for the long run. These psychosocial traumatisms destroy the professions treating the psychic and social sufferings of others. What is required is the (re)mobilization and even (re)creation of those clinical professions. The authors illustrate and develop their remarks in basing themselves on two clinical research projects carried out, respectively, in Chile and in Rwanda - following the dictatorship (1973-1990) and the genocide (1994). Such research work contributes to re-establishing a clinical approach to social responsibility which attempts to restore the social and psychic possibilities to respond to others after attempts, in one way or another, to reduce them to nothing. The article analyses and articulates the processes of coercion and expropriation at work between self and other in the political violence phenomena studied. It calls for dialoguing with the various and multiple forms of attacks on social responsibility which together call out to be recognized and taken in charge of - clinically, politically and epistemologically.

We dedicate this text to the memory of Naasson Munyandamutsa who inspires us unceasingly.

Situations of political violence are intrinsically traumatizing. They provoke psychic and social traumatisms of immense scope and on a long term basis (Brackelaire, Cornejo & Kinable, 2013), attaining, among other things, inter-generational transmission. These traumatisms have to be understood in the sense of psychosocial traumatisms (Martin-Baró, 1988), where it is not only the persons directly affected by the violence who are afflicted but the whole society in its constitutive relationships, intergenerational bonds (Faúndez, Cornejo & Brackelaire, 2014) and collective memory (Cornejo & al., 2013 ; Welzer, 2010). Thus these traumatisms are also particularly harmful for the clinical professions, which we understand here as those taking charge of the psychic and social sufferings of others. How to practice those professions in these contexts and their aftermaths, when caught up in the various manifestations and after effects of political violence ? Don’t such situations attack their very principles : that of a profession of care provided for others ? And don’t they even necessitate a remobilization or even a (re)creation of these clinical professions ?
We will try to illustrate and develop these remarks in basing ourselves on two clinical research projects carried out respectively in Chile and Rwanda in the aftermaths of the dictatorship (1973-1990) and the genocide (1994). They will contribute to the construction of a clinical approach to social responsibility which will attempt to restore the social and psychic possibilities for responding for the Other (Autrui) after an attempt, in one way or another, to reduce it to nothing.

1 Responsibility against violence

Because when political violence is exercized in the name of the State, an ideology or a totalitarian power, in a dictatorship or a genocide to cite only those cases, the human principle of the Other (Autrui), of care and duty towards others, vanishes in the terror and horror of its crushing and destruction. Such destruction is at issue at the heart of these disasters but also in their causes and aftermaths.
The relationship to the Other (Autrui) and the dialectic of social responsibility it mobilizes are at stake for man and between men generally. It would be well to first demarcate this human and humanizing characteristic anthropologically. In the theoretical model we will have recourse to here (Gagnepain, 1991 ; Laisis, 1991 ; Quentel, 1992 ; Brackelaire, 1995 ; Dartiguenave, 2001 ; Le Bot, 2002, 2010), responsibility in relation to the Other (Autrui) is - with identity in the relationship to the Other (Autre) - one of the two constitutive facets of the person and relations ; we will accentuate this facet without forgetting the other. To enter into human social exchange, in trying to answer for the Other (Autrui) as for oneself, is unceasingly trying to transform the natural power relationship between subjects into a social transaction between actors, present and future. It presupposes defining and delimiting not only the respective identities but all the roles between oneself and others, meaning the power and competencies belonging to each one, to enter into the transaction by apportioning responsibilities, as a function of respective duties with respect to others.
This is to say that the dialectic of responsibility in itself involves several orders of violence and their psychic and social transfiguration : that of the power relationship played out between subjects, that of the radical divergence of roles between Self and Other (Autrui) and that of the social transaction to be established in the confrontation between the parties involved. Seen from this angle, engaging social responsibility is the human response to asocial or antisocial violence in relations. Its dialectic makes life personal and social as much as it results from it. Acceding to this personal and social life does not simply result from a sociogenesis or an ontogenesis, its implementation is not historically explained by a society’s conditions or a person’s life ; it does not naturally emanate from the characters of a collective or an individual. Rather it is precisely this emergence, its mobilization and re-mobilization, following a human disaster for example, which explains sociogeneses and ontogeneses, which produces the construction of a history, the society’s as well as the person’s and their various groups, and whence the various figures that collectives and individuals may adopt emanate from.
More particularly, it is indeed this dialectic which is at the heart of relationships of responsibility between generations, parents and children, and between the parties involved in any service provided. The particular and central dimensions of responsibility, and particularly important for our interests, are in effect those “between generations” (Uwineza & Brackelaire, 2014), parentality and profession. These dimensions are interrelated. Gagnepain (1991) claims that childhood is to parentality as play is to work. And we might add : as generation is to transmission. This brings generation (and the generations) of the natural succession of time (and their natural succession in time) to make it (them) enter, without making it (them) disappear in the transgenerational order of cultural, social and political relationships of bilateral responsibility at play between generations.
Thus we also see this principle of the Other (Autrui) in the concern of mothers and parents for the infant and for children, from the perspective of their subsequent assumption of this human principle and its dialectic. The attention paid to them is measured by their destitution, their distress, their immaturity and the requirements of their ongoing development. And we watch over their excesses faced with others, with whom they will have to learn to live, without taking possession. The Other in some way remains exogenic to them. It doesn’t yet occur to them, not being third parties to them (Maldiney, 1975). We do it in their stead and observe it between them and us, even if it’s as best we can, until they, and so that they, assume the principle. It does not emanate naturally from little ones growing up. But it’s what culturally structures their evolution in placing it in systems of relations organized according to relationships of childhood and parentality. Parentality is an essential figure of the Other (Autrui). Between parent and child the human dialectic of responsibility is played out, as in the social play of professions and intergenerational transmission (Quentel, 1992).
We develop the idea that that dialectic, that of responsibility (we would be more correct in saying that of identity and responsibility), is precisely at stake, is targeted, threatened, attacked, affected, crushed and decimated in phenomena of political violence like dictatorships and genocides. This is so in a distinct way in each of these two phenomena, taken here as typical examples. In both cases, it is also what has to be restored during the work of healing which follows such psychosocial traumatisms at a distance. The shared principle of concern for the Other (Autrui) is broken there. We must ask ourselves about the conditions, ways and means for working towards a restoration and repair of this attack on anthropological responsibility.
The question is also to be located in time, in the particular temporality that that attack induces, the freezing of time it involves and its effects on inter-generational transmission (Métraux, 2004 ; Munyandamutsa, 2008 ; Faúndez, 2013 ; Gishoma, 2014). We know how it affects the victims and families, and the whole society in its process of production and reproduction. Those who work clinically with these catastrophic events are privileged examples and witnesses. By their existence and professional exercise, they illustrate the pervasiveness of these disasters and the conditions of their psychic and social healing. And they can attest to the processes which allow or prevent that healing. Their specific responsibility involves recognizing the undermining of responsibility in itself and working at relaunching it.
It is important to underline that this responsibility is also that of researchers. Clinical researchers have a particular responsibility in these situations : that of accompanying and questioning how the clinical services resulting from these situations are constructed as well as how it works. It is a responsibility they share with the professionals, patients, community networks, associations and institutions involved and having a stake in these contexts. We will illustrate our theme in turning to two clinical research projects. One was carried out under the direction of Marcela Cornejo among professionals who had participated at the National Commission on Political Imprisonment and Torture (NCPIT) in Chile (Cornejo, Morales, Kovalskys & Sharim, 2013 ; Cornejo, Brackelaire & Mendoza, 2009 ; Morals & Cornejo, 2013). The other was carried out by Darius Gishoma and the team accompanying him in his study of the Ihahamuka crises occurring during ceremonies commemorating the genocide in Rwanda (Gishoma & Brackelaire, 2008 ; Gishoma, 2014).
These research works question and clarify the function and role of professionals in each of these situations. Function and role first of all designate here the analysis the professionals implicitly carry out themselves regarding their responsibility in intervening in these situations (Brackelaire, 1995). We talk about professionality and craft in this sense : to designate the person’s interior relationship to the profession and the craft, meaning how he analyses his function, qualitatively, in terms of distinctive competencies, and simultaneously, how he analyses his role, quantitatively, in terms of acknowledged professional capacities (Gagnepain, 1991). This implicit analysis of his responsibility dialectically precedes his reinvestment, in situ, in the exercise of his specific professional duties and the practice of his profession within the collaborative relationships he organizes.
On the first level of official listening involving political imprisonment and torture during the dictatorship in Chile, and in a public space-time manifesting the horrors endured during the genocidal massacres in Rwanda, victims and professionals teach us a lot about the processes at work in the recognition of traumatisms, their expression and the conditions for their possibly being psychically and socially healed. They raise the question of knowing how - under these conditions - clinical professions are created and recreated, and the thread of the narrative and story rewoven, and how the possibilities of responding for the Other (Autrui) are restored.

2 Listening to torture : professionals of the National Commission on Political Imprisonment and Torture in Chile

The first of these research works was initiated in 2006 in Chile, addressing professionals employed by the National Commission on Political Prison and Torture (NCPIT) organized in 2003 and 2004 under the mandate of President Lagos. The Commission’s goal was to identify persons who were victims of imprisonment and torture on political grounds and through the intervention of government officials or people in their service during the Pinochet dictatorship (1973-1990). The Commission collected the testimonies of 35,865 people, interviewed in the capital but also in seats of provincial government, isolated localities, as well as consulates and embassies abroad. The Commission Report published a list of names of 29,201 persons recognized as victims of repressive actions committed by agents and institutions of the State, deprivation of liberty and torture on political grounds. In 2011, a reoverture of the Commission led to 31,841 new requests, of which 9,795 were retained as cases of political imprisonment and torture.
To declare his experience before the Commission, each person filled out a document collecting data on his detention, what he had undergone, and then presented it in an approximately one hour interview to a professional hired for that reason by the NCPIT. Most of the declarants spoke for the first time about the experience they had undergone. Personally depositing their testimony was at once a considerable ordeal, inevitably recalling painful memories and in part unutterable, and an essential step towards an official recognition of the abuses undergone in the name of the State. The professionals hired by the State had to listen to these testimonies attentively, in an atmosphere that had to be one of respect and confidence.
The Commission had an impact on the victims, their families and the Chilean society as a whole (Cornejo, Rojas & Mendoza, 2009). The research we are referring to focussed its attention specifically on the professionals hired as “listeners of the State” (Cornejo & al., 2013). What was the impact on them of testimonies transmitted to them by people who had lived through imprisonment and torture ? How did they receive the traumatic character of those experiences ? Research has shown how collecting those testimonies intersected with their personal, family and social histories. For the majority, it upset them, setting in motion processes for dealing with the traumatic, biographical and social impacts of what they had heard (Cornejo & Morales, 2013). The professionals became bearers of testimonies which the Chilean society itself had to deal with through them. An important dimension to consider here is that of time : this involved testimonies delivered 30 years after the facts, in a country which had neither wanted to hear or listen, and where tortures and violations suffered were denied for years. Setting oneself the task – in research – of listening to professionals having taken part in the NCPIT constituted a metaphor of the social and the transmission, the professionals representing a generation of citizens receiving from the mouths of those who had lived them testimonies of the facts of terror which had taken place in the country and remained hidden.
We would merely like to underline some of the elements which came to light in this research and enrich our subject. Focussing on professionals places the accent on what is in our view a point of articulation. Their professional function established them precisely between what the victims underwent imprisoned and tortured and the conditions and paths toward recognition and assumption of responsibility for this experience by the State and the whole society. What was transmitted to the professionals, through and beyond the testimonies, can only be understood from what the victims lived and the function of the professionals employed. They fit into what might be conceived of as a chain of listening (Cornejo & al., 2009) remobilizing the possibilities of transmission against the chains of silence and the risks of repetition.
What was transmitted to the professionals and which they shared with the researchers in their accounts of life is, in particular, the feeling of being bearers of a “secret” : that of the horrors lived within the confines of the dictatorial State and by agents in its service, and of wondering what to do, how to assume the onus, the impression of being different from others in this respect, of having to personally assume the mission of ensuring that the enterprise of revelation comes to fruition against the risks of it’s being violently smothered (Cornejo, Brackelaire and Mendoza, 2009). There’s often a certain angst. They feel the threat of undergoing what the citizens who transmitted their testimony to them underwent, fear that political violence might repeat itself, of being followed, pursued, persecuted (Cornejo & Morales, 2013).
Imprisonment and torture in the context of a dictatorship attacks responsibility towards the Other (Autrui) radically. The quality of the other as being able to be, with his competence, the possibility of his political identity as different, opponent, militant, are sought out to crush, kill, eradicate and erase the traces, a pure object over which to exert an absolute power in the name of a totalitarian political entity where he no longer has a thing to say. The dictatorship, the prison, the torture expropriate his quality of other. It is denied or rejected. It no longer structures the bond and exchange between humans. One no longer shares with others the common human responsibility for relations, for what may happen between the parties engaged.
The secret transmitted to the professionals and then by the professionals, notably to the researchers, insists on this non-sharing. As the first official link in listening about imprisonment and torture, they are established in this function of receiving what is unsayable. It is unsayable, but unsayable to other at the risk of making it disappear and wounding all over again. But it’s up to them to take charge of it within the limits of their mission, as that works itself out in any service, in any human exchange, in the profession of being human - precisely what political imprisonment and torture do not do, prevent, reject or even attack. What ended up suspended, blocked, ejected, undermined, is up to professionals, through them. It is up to them through what the declarants communicate to them, between narrative and silence, terror and the horror they have been subjected to. And it is up to them through the function entrusted to them to receive those testimonies and contribute to public recognition of the abuses committed and of their victims.
It’s a frightening and essential function in the sense that it involves collecting and the very collecting puts in danger the principle of any ‘professional’ human function, the responsibility towards the other it implies. The secret it finds itself in charge of, the stake of having to assume it, the difference it acknowleges with regard to others, the mission – it makes itself the author of – knowledge and recognition of the other and his crushing and the possible persecution you set yourself up against, all that states the unsayability of the experience and the effects of political imprisonment and torture reducing the other to silence. That also draws in negative the features constitutive of the relationship to the other and states both the need and the attempt inherent in exercising the function of restoring.
Even if some of them were psychologists by training, the professionals hired by the Commission did not in this context have the function of psychologist, psychotherapist or clinician. And we do not take things from that angle. If we propose taking the clinical dimension of their function into account, it is not inasmuch as it would pertain to a clinical profession strictly speaking. Their function has a clinical character because by its very creation, existence and exercise it contributes to re-establishing the human function of responsibility towards the Other that political imprisonment and torture came to remove. Any approach which cares for a human principle, distinguishing, looking after, restoring and relaunching it, would be clinical in the broad sense. That includes attacks on that principle as well as the whys and wherefores of those attacks. Like their causes and effects, they are the responsibility of various, multiple and changing orders of reality and professions.
It is in this context that psychosocial traumatisms and their aftermaths necessitate the creation of professions with clinical functions, in the broad sense, coupled with the installation of clinical functions within various professions, as well as the construction or transformation of more specifically clinical professions. These situations oblige us to act. They oblige us humanly and deontologically. Field researchers dealing with these extreme traumatisms take part in this process of responsibilization and the remobilization of responsibility. The research does not just abstract them from the field ; it involves them differently there. Whether the clinical nature of their role in these situations is specified by their object, their technique, their very profession or their method, it behooves them to measure and assume what’s at stake and the scope of their interventions.
Research carried out with the professionals of the NCPIT opened our eyes on the importance and delicacy of the restoration of the other at the threshold of the first official encounter for its recognition faced with the crushing suffered during the traumas caused by the dictatorship. That can shed light on the clinical character of many professions in such post-traumatic contexts. The professionality at stake in their exercise contributes to restoring the other (autrui) earlier destroyed. The clinical professions are enlightened too. As clinicians, we too learn a lot about the functions of our profession in those particular circumstances. We also learn more general things about our profession. These extreme situations sharpen our eyesight in connection with other situations, in some aspects ordinary, situations which may be analogous on certain points, but also poles apart on others.

3 Accompanying Ihahamuka crises during commemorations of the genocide in Rwanda

In 1994, Rwanda experienced a genocide which cost over a million human lives. In the immediate aftermath, the genocide survivors were devastated by the violence they had been subjected to, the loss of family members, the loss of everything their existence had been founded upon. The psychic and social distress was on an immense scale. All forms of human responsibility had to rise up against what condemned that society to disappearance. To deal with the violence, destruction and distress, the restoration and relaunching of social responsibility involved here, as elsewhere, the creation of previously non-existent clinical professions and the repair of social institutions capable of making further living together possible.
Confronted with the immensity of the needs, humanitarian aid organizations were the first to build spaces for listening, especially for the women and children manifesting signs of psychological suffering. However, the difficulty in these first initiatives lay in their being short term plans. They were financed and managed by mental health professionals – essentially foreign, most of whom withdrew around 1997, at the end of a period considered “urgent”. The State, as well as local organizations, subsequently took things in hand, creating their own places for reception, listening, care and working-through the trauma (perlaboration). Beside places providing such services, they above all created training centres, thereby institutionalizing those professions locally.
As of 1995, the counsellors or “traumatism counsellors” were the first Rwandan interveners. Most were trained by Trócaire (An Irish charity) then by a Local NGO, the Rwandan Association for Traumatism Counsellors or RATC/ARTC-RUHUKA. Their training was organized after the genocide, at a time when training structures for psychiatric nurses, clinical psychologists and psychiatrists were still non-existent in Rwanda. The candidates recruited had a basic formation in human sciences (nursing sciences, social sciences, pedagogical branch or normal primary) and had to manifest a sense of responsibility towards others, expressing itself through a desire to help one’s neighbour. They completed a year of formal and practical training and began to put in place – as early as 1995 – structures for listening to persons traumatized by the genocide.
Through the Ministry of Education and the University of Rwanda, in 1998 the State opened the first training programme in the country for psychiatric nurses : a two-year programme (then three, from 2000 on) designed to meet the emergency requirements in mental health following the genocide. At that time Rwanda was coping with its serious shortage in mental health professionals and did not have the means for investing in long-term training. Training a psychiatrist for example would have required waiting several years. 348 psychiatric nurses have graduated to date and run 43 mental health units disseminated throughout the country in district hospitals. In 1999, the University of Rwanda also opened a department of clinic psychology, the first of its kind in the country. Since its inception, it has trained 599 psychologists who also play their part in the intra and extra hospital milieu, beside the counsellors and psychiatric nurses. By 2013, the time had come for the University of Rwanda to launch a post-graduate programme in psychiatry. Today there are 7 psychiatrists in activity and there will be 15 by 2018. There were none in 1994.
In the aftermath of the genocide, all of this testifies to the progressive construction of clinical professions as the response of a society which is (re)responsibilizing itself in the face of suffering – for the wellbeing of its members. It is important for us to underline that this function of clinician in the field of mental health concerns a multiplicity of new local professions (traumatism counsellors, psychologists, psychiatric nurses, psychiatrists, etc.). But we might well wonder what would have happened if the situations of psychic suffering in Rwanda had had to wait for consultations with a psychiatrist, a clinical psychologist, an adviser in traumatism or a psychiatric nurse to organize themselves. Many Rwandans have never met any of those professionals and will undoubtedly die without ever having met one of them. However, the development processes are ongoing and will continue to be put in place and follow their course via several psychic and social pathways. That means that the contribution of the clinicians, if it is invaluable and useful, has nonetheless only a limited range, beside other psychosocial mechanisms which have been set up or put back on their feet, with a wider scale clinical significance and which can function in complementarity.
We must keep in mind that we are dealing with a country of 12 million inhabitants (in 2012) and that a mental health unit in a district hospital, managed by a handful of psychiatric nurses and psychologists, is supposed to serve 250,000 inhabitants on average. It is obvious that clinicians remain a rare commodity given the magnitude of the needs. Then too every situation requiring assistance does not necessarily require the contributions of a mental health professional. Lastly, certain practices, in clinic psychology for example, might seem odd and unsuited to the population, particularly in the villages, a context where the effects of psychosocial trauma are however strongly felt. The development of a diagnosis of responsibility/responsibilization, like that we have described, endeavouring to restore the social and psychic possibilities of responding for others, involves processes which may also take place outside the walls of clinical establishments : in social space, under the impetus of politicians, honest men or other social agents, and sometimes the clinicians.
The Gacaca, literally : justice on the grass, popular courts reactivated in Rwanda after the genocide, are an example. Indeed, from 2001 to 2014, one day a week (often Saturdays), the inhabitants of each village in Rwanda met in the middle of the village to talk about what happened in 1994, about the victims, the guilty, the missing, responsibilities and the need to reconstruct. The debates were animated by honest men and women elected by the population. That attempt at justice on the grass did not take place without certain pitfalls (Munyandamutsa, Godard, Rutembesa, Mutarabayire, 2012). There are many other examples of arrangements which emerged in social space. The creation of “artificial” families by the orphans themselves (Uwera & Brackelaire, 2011 ; Uwera, 2012 ; Uwera, Brackelaire & Munyandamutsa, 2012), associations of widows of the genocide who came together spontaneously to cry, tell their stories and rebuild their districts also show the rebirth of the shared principle of concern for the other (Uwineza, 2014 ; Rwagatare & Brackelaire, 2015). The same can be said for the annual commemorations of the genocide. The crises which result from it constitute the object of the second research we will focus on. This research also shows that in the precise context of post genocide Rwanda, the society, the clinicians and the researchers have tried to meet the new challenges occasioned by the passage of time. The clinical diagnosis has had to adapt itself year by year to new forms of suffering, people’s needs and trauma situations that are only gradually emerging. These commemorations may be seen as a socio-community process intrinsically centred on the reactivation of social responsibility.
Every year since 1995 Rwanda has commemorated the genocide for one week - from April 7th to 13rd – called ‘national mourning week’. These commemorations have a history. They have travelled a course which teaches us much about the possibilities of the task of healing and (re)responsibilization offered by this space as well as the difficulties it exposes us to. As Gishoma’s study (2014) has revealed, the annual commemorations of the genocide committed against the Tutsi have followed a logic of development which is far from being linear. However, if we provide ourselves with an overall picture of the ceremonies from 1995 until now, on the succession of central themes of the commemorations, on the speeches by the authorities and survivors, on the artistic compositions serving the rite as adjuvant, we may discern a certain evolution in the commemorative process. Indeed, we detect several movements in them which may be grouped together in two principal tendencies.
The first tendency is best expressed in saying that for the first ten years (1994-2004) the dominant topics evoked the genocide, detailed descriptions of how it was perpetrated and its multiple consequences -still very intense among the survivors. The intensity of the brute effects invaded the space of the commemorations to the evocation of the past and the sight of mutilated bodies. The genocide immersed the space of the commemorations which proceeded not facing monuments carrying a symbolic plaque but on barely covered mass graves. The commemorations took place on spots where thousands of people were executed yesterday and the principal commemorative activity consisted in their burial. There was a fresh presence of death and genocide on the site itself, in the activities of burial and the speeches. The expression of “ceremonies of memory”, correct in its use, nonetheless seems to us insufficient to describe this atmosphere, for the genocide was still almost present.
The commemorations of the second decade (2004-2014) allow us to describe a second tendency. The dominant topics at commemorations of the second decade after the genocide contrast clearly with those of the first. They were marked by the emergence of topics relating to hope and the effort to extirpate themselves – for the people and the community - from the genocide’s consequences. One noticed there a tendency to tell “positive” stories of survival which help in orientiation towards the future (Lala, McGarty, Thomas, Ebert, Broderick, Mhando & Kamuronsi, 2014). Hope seems to have become the keyword during the commemorations. The past was certainly evoked, but there was by then a question “of celebrating” and sowing the seeds of resilience (Lala & al., 2014). The topics often dealt with personal reconstruction (we are reconstructed, we’re not crying any more, the hardest is behind us), on the family (we have welded our families together, we’ve built new ones, gotten married), the idea of happiness (we live happily with our children ; dear departed parents, you didn’t know them but they look so much like you we have the impression you’re still alive through them), an environment once again habitable (we’re no longer surrounded by ruins, we’ve rebuilt our houses), studies, professional advancement, assets (I bought back all the land they took from us, our cows are the envy…), on the future of the country, etc.
This evolution tells us about the desire of the survivors, their associations as well as the Rwandan State’s “to do away with” the genocide’s pitfalls and its effects on the survivors. These commemorations are part of socio-community and local efforts intended to cleanse the genocide, to wring its neck, as well as its traumatic effects. There is a redefinition and repositioning of communities in relation to the commemoration procedures. That testifies to evolutions in representations of the event the genocide is and to a dialogue between the ceremonies’ actors, whose contents have evolved.
But those moments of commemoration can also prove traumatic. In fact, the week of national mourning is marked by the recrudescence of an epidemic of collective crises which take place during the activities commemorating the genocide of 1994. In a movement of contagion, certain participants are siezed by vivid flashback episodes during which they relive the genocide exactly as if it were going on. Others replicate gestures aimed at escaping and react as if they were being chased by the killers. They hide under chairs or raise their hands to protect their heads against the onslaught of machete attacks. These crises are characterized by an overflow of anxiety, psychomotor agitation and a momentary loss of temporal and space orientation. The wide range of symptoms may also include severe hiccups with suffocation, states of stupor, states in which people have the impression of having lost their sensitivity or motricity while remaining conscious. In other cases, it’s rather a loss of consciousness which prevails. There may also be states of unconsciousness with muscular agitation, reminiscent of epileptic fits.
The survivors’ participation in certain activities of commemoration, in particular the sight of bodies or a close relative’s clothing during the ceremonies of burial with dignity, watching a documentary film on the genocide, listening to a testimony, a poem or a song dealing with the genocide, often prove to be factors triggering the first crisis. Prolongations and the triggering of new crises often result from the fact of seeing a friend or stranger succumb to a crisis, of hearing it said that the militiamen are attacking the spot, leading people to fail to differentiate the time of the genocide from that of the commemoration. But the traumatic experience may also be awakened following seemingly neutral factors like a moment of silence, a rain shower (recalling what fell during the genocide), nightfall or a power outage. Given the degree of hyper-sensitivity resulting from internal traumatic memories, even a moment of silence may be enough to trigger a crisis. Whatever the type of triggering event, powerful or neutral, once the first crisis has been set off, the phenomenon of contagion is frequently observed, with one individual’s crisis setting off another among the people nearby, reaching some fifty or a hundred people on just one commemoration site. These crises, which may last between 30 minutes and 2 hours, are called Ihahamuka in Rwanda and generally affect - throughout the whole week of April 7th to 13th each year - between 3,000 and 4,000 people on the various commemoration sites (Gishoma, Brackelaire, Munyandamutsa, Mujawayezu, Mohand & Kayiteshonga, 2014).
The research-action begun in 2006 was carried out using several complementary techniques. Semi-directed interviews were carried out with 22 professionals in the field (psychiatrists, psychologists, mental health nurses and counsellors) who have participated in these interventions since their inauguration during the commemorations and who, by their experience, aid in understanding the appearance, evolution as well as the mechanisms constitutive of the phenomenon of Ihahamuka crises. This research has also involved the collection of 35 accounts from people having been victims of Ihahamuka traumatic crises on various commemoration sites. The research team then set up a post-crisis support system via talk groups for people having been victims of these crises during 10 months, in one of the country’s 30 districts (Gishoma & al., 2014).
The principal researcher, Darius Gishoma, also participated concretely in interventions alongside professionals for several years (from 2006 to 2014), receiving and accompanying people in crisis, and sharing questions and problems related to their work with the local professionals. Apart from commemorations, the researcher participated in meetings planning and preparing interventions and in decision-making, as well as implementing the schemas discussed, in addition to the context of training courses for young professionals, besides the interventions properly speaking. After the interventions, he also had a stake in their evaluations, redefinition and their renewal year by year, under the supervision of the Health Ministry’s Mental Health Division. In the context of this article, it is neither possible nor relevant to take up all the aspects discovered by this research. As for the research mentioned earlier in connection with Chile, we have only looked at a few elements which clarify our subject.

4 Expropriation and restoration of the Other (Autrui)

This study of the Ihahamuka crises occurring during the ceremonies commemorating the genocide of the Tutsis in Rwanda shows us how a genocidal process produces a psychosocial traumatism which in turn obligatorily generates (in a deontological sense) forms of creation or re-creation of clinical professions between the actors and networks concerned. When the Other (Autrui) must be and is exterminated, he then comes back to haunt the scene of the crimes like a ghost it is up to survivors to recognize and listen to. It is up to them to give him his place, to give him back his role, to take care of in recreating a human relationship with him. The fundamental duty of a progressive restoration of the Other (Autrui) to social life is played out between victims, professionals, citizens and communities. “Ihahamuka” might be translated as “having one’s lungs outside of oneself” or “bringing out what is inside oneself” (Gishoma & Brackelaire, 2008). The name created speaks at once of the expropriation of oneself, the placing outside oneself, to take up Roland Gori’s words analysing the shock of the horror (2002, p. 113), and the attempt to give it a form in the language and professional field of care to be proffered to others.
Thus studying these crises is simultaneously studying the official context they occurred in from year to year and the evolution of their formal and informal, social and professional, accompaniment, during the commemorations and outside of them. In an articulated manner, the work of Darius Gishoma and his accompaniment team describes and analyses the evolution of the commemorative process in Rwanda, the collective crises themselves, from the viewpoint of both the people in crisis and the professionals, as well as the interventions meant to deal with the crises both during the commemorations and in their prolongation.
Within this collaborative network we can point out the specific role of the clinical research. Studying the crises via several methods of intervention, before, during and after the crises, represents an attempt at remobilizing the responsibility of the researcher, clinicians and universities in facing phenomena resulting from the critical crushing of social responsibility during the genocide. If the research-action techniques did not allow us to contain the crisis phenomena, which was not their goal, they had the merit of improving the psychosocial wellbeing of the people who experienced the crises. But above all : the research-action on the Ihahamuka crises ultimately itself took part in the construction - (re)creation – of the profession/professions of clinician, through a dimension that represented at once research and clinical involvement – all in formulating clinical procedure. An integral part of research lay in trying to contribute to restoring and mobilizing human responsibility with respect for the other.
Similarly, but along the other axis for analysing responsibility, the research carried out with the NCPPT professionals in Chile contributed in its own way to recognition and repair of the deeds and effects of political imprisonment and torture exercized in the State’s name during Pinochet’s dictatorship. Like the professionals themselves and the Commission establishing them, it reveals the obligation to restore the fundamental human function of recognition and respect of others officially, due to those who were victims, directly and by extension, of the politics of terror. The very concept of function, understood as the qualitative analysis of our responsibilities in relation to the Other (Autrui), the clinical function for example, speaks of the need for the mediation of a deontological structure of analysis at the heart of the relationship of powers and duties shared between one another.
A dictatorship, on the contrary, in a pure power relationship, states how things have to be for everyone. Imprisonment and torture, carried out in the name of a totalitarian power, strive to extirpate from the other – opponent, militant, “communist”, “extremist”, “terrorist”, … – the qualities of personhood which make his divergence and through which he is involved in common social life. On the backdrop of the ravages this attempt at crushing the other carries out, what is extirpated makes inevitably its return in a radical appeal, which traverses generations, for an official recognition of this criminal political violence, for the public restoration of dignity, for the expression of and a listening to what was torn away, crushed, silenced, stifled hidden away, kept secret, rejected, encysted.
Ximena Faúndez’s doctoral research (2013) with grandchildren of victims of political imprisonment and torture by the Chilean military dictatorship participates in this appeal and contributes to this recognition. It gives them the floor, and the narration of their stories, recounted as grandchildren of tortured ex-political prisoners shows the struggle they wage to get out of the grip of the traumatic experience transmitted by their grandparents and appropriate it in their lives. Two scenes of terror and horror make irruption in the narration : that of the arrest and that of the torture of the grandparent. The first is described in detail, in present tense, by elements frozen out of time, like an image in a photo or drawing you look at, of what couldn’t have taken place. The second is denounced without being able to be depicted or narrated (Faúndez, Cornejo & Brackelaire, 2014). But they transmit precisely that that cannot be represented, in more ways than one. They indicate the two extreme poles of the narration in its impossibility.
The arrest is transmitted with features of reality which fix the real irruption of the totalitarian power in a history from which it uproots others. It is like the “first blow” Améry received from the Gestapo and which “already contains everything that followed in an embryonic state” : imprisonment, torture and the system founded on it (Améry, 1966). It’s the very principle of the Other (Autrui) they attack and try to root out, his divergent qualities, his distinctive affiliations, his political virtues, the oppositions he displays, the functions he incarnates. In that scene, we assist impotently and captive at the wrenching of the grandparent from his history, his person, those closest to him - from self. His divergence, his alterity, is also the narcissism by which he relates to himself as other (autrui) and relaunches - from himself (Fierens, 2016) - his history, and in particular his narrative, here petrified, stunned, struck with stupor faced with the disaster, announced, spilling forth, communicated. Elements of the arrest, like the family home invaded, the grandfather’s clothing, all the protagonists transfixed on the spot, the threatening weapons, the colour of the vehicles, …, create and fix a kind of hallucination, like an image in a dream, a nightmare. They reveal the scene. They are like isolated, highly coloured remains of an erupting story you are trying to find memorial and historical traces of, to remember, make present, have recognized. We can see and hear the arrest scene like a pleading call for witnesses, a startling cry to be heard. It calls beyond the generations like a radical appeal to the principle of responsibility - which is the fundament of intergenerational transmission (Uwineza & Brackelaire, 2015) - for official recognition of its crushings.
The scene of torture denounces itself but in silence. We decipher the annihilation of the person of the other (autrui) they want to rip speech from and who henceforth has to be protected and reestablished in his dignity. The humanly instituted relationship of duty toward the person of others, attacked in its principle with the “first blow” of the arrest which withdraws him from public space, in the torture becomes a relation of absolute power exercized in the State’s name on a victim held in a secret place. This scene carries paralyzing traces of terror, the horror, the pain, the consequences of torture and the political system fundamentally associated with it. It denounces them by everything it transmits, implicitly, in a deafening silence. Thus what’s called the torture scene transmits everything that’s unsayable, inaudible, but heard : what cannot be engaged in, shared, extended to others or recounted. Because torture precisely attacks the very possibility and process of taking charge of others and being taken in charge, in other words of sharing, listening, narrating and healing.
It is important to note how this scene accords with the preceding one. In the glaring reality of its details, the arrest scene explicitly transmits the expropriation of an implicit human principle blown to bits. The torture scene implicitly transmitted our plunge into what cannot be humanly explained. The two scenes testify together. They take as witness those listening to political violence abolishing the function of testimony and exercizing without prosecution witness. The other is made to disappear and everything turns against him. They testify to the short-circuiting of the dialectic of responsibility implicitly obliging us to recognize the other in his divergent functions in each trying to explicitly assume the loads to be born together.
So it is up to those composing the “chain of listening” to take over reception and transformation of the effects of political violence (Cornejo, Brackelaire & Mendoza, 200). Clinicians are a professional first line in listening, recognition and healing this violence. And a lot is at issue for them there, as we have underlined. They are formed and transformed in those clinical contexts, particularly those calling for a clinical approach to responsibility in dealing with psychosocial traumatisms. That clinical approach works to restore the function of the other by recognizing him as such in his radical divergence, which they wanted to tear away from him, and restore his role of other to him in inscribing it into a relationship where everyone has his part, where the attempt has been made to exterminate it. The two poles - divergence and convergence – of the dialectical process of responsibility may petrify : by a form of encystment or confinement of the other (autrui) in self or, at the other pole, by a kind of cruel domination or persecution of self by an expropriated other (autrui) who comes back in revenge (Nshimiyimana, Brackelaire & Rutembesa, 2017). In this field of attacks on human responsibility, clinicians and researchers encounter this double risk : on the one hand to bury the other (autrui) away in the self or in his possession or, on the other hand, to disappear as self in or in the form of a threatening other. They confront it in themselves as they do in others because it is (re)played between themselves and others, under the effects of trauma. These same interrelated processes are also played out on other levels and in other configurations, according to the nature and personal, family and social coordinates of the trauma. This opens the way to several remarks, involving resumption and overture, in concluding.

5 Resumptions and overtures

We began with two specific contexts where, as clinicians and researchers, we have worked with the effects of two forms of extreme political violence which took place : Pinochet’s dictatorship in Chile, and the genocide of Tutsis in Rwanda. These situations are altogether different. It is advisable to insist at the outset on the idea that comparison of these phenomena, of these historical contexts, of the effects of this political violence as well as the modes of interventions generated in each case can prove to be dangerous and unfruitful because each situation retains its singularity. Yet it is important to turn our attention to the fact that anthropologically similar and complementary human mechanisms are at work in the two phenomena and, more broadly speaking, in these two orders of phenomena. The dictatorship and the genocide we have dealt with here are particular examples of more general processes of destruction of the other (autrui) by eradication of his dissenting qualities or extermination of what would make his unity both ontologically and deontologically divergent, in being and having to be.
These mechanisms and processes relate specifically to humans strengthening and exercising their responsibility towards the other. Of course, questions of identity and responsibility are bound together like the two joined faces of personal and social life. It is out of concern for precision and for simplification’s sake that we do not elaborate here on the ways in which these two faces each find their justification in the other, as we are reminded by what we have just said about the genocide of Tutsis. The dialectic of responsibility, as we have indicated, operates along the two axes of analysis, taxinomic and generative, or, further, qualitative and quantitative, which found all human processes in Gagnepain’s vision (1982, 1991). Here, for Man and all men, they consist, always under different figures, to at once define respectively the differential identities and contrastive unities of responsibility, that is their functions and roles in relation to the other (autrui), to then reinvest that analysis in the social situation. On this point too, we simplified the subject-matter in not dealing with an essential articulation of these two axes in projecting themselves on one another, creating similarity and complementarity between one another. Yet we might nevertheless have been aware of the latter two in realizing the extent to which what was said about the processes attacked by the dictatorship and mobilized in its aftermaths was also true in the case of the genocide, and conversely. Each of these two phenomena involves the two axes and we would need to further specify how, in taking the dialectic of the whole into consideration on this level of rationality - the only one we took into account in this text, once again because it is central to our goal and to clarifying its blueprint.
What we have to underline now is that these processes attacking human responsibility are at issue in other situations - not only social but clinical. They are at once very distinct from one another and nevertheless very close due precisely to the fact of involving the same human principles and processes, which can make them clarificatory in relation to one another, in both the clinician and the researcher’s eyes. This point belongs to the coordinates at the origin and destination of this work.
In perversions and psychoses Jean Gagnepain saw the person’s identity and responsibility troubles, as he had seen sign disorders in aphasias and tool disorders in atechnias, and as he was to see rules and desire disorders in neuroses and psychopathies. For psychoses, he was inspired by the professional fields of psychiatry, psychoanalysis and institutional psychotherapy and, as is well known, his exchanges with Jacques Schotte, as well as Jean Oury, enlightened both his theoretical and clinical constructions. In total, he resituated and reorganized psychoses on the socially contributory facet of the person, that of responsibility, a facet where he also places sadomasochism (Gagnepain, 1995). Thus these entities lend their configurations to a new and systematized ensemble of ‘responsibility problematics’.
Such an ideal and clinical model is under construction - by definition might one say. It orients us in elaborating the work this text furnishes an account of. Our journey has reciprocally questioned the creation and re-creation of clinical professions that deal with psychosocial traumatisms. It directly raises the question of the roles and functions of professionals within particular societies, and those in transformation, in the recognition (or lack of it) and accompaniment (or lack of it) of clinical problems. Indeed the latter are always expressed personally and socially in the folds of psychosocial dialectic we have spoken about. Culturally they bring into play the relationship which establishes and constitutes itself and may do away with itself between self and other. We mean that they are always in some way shared between the subjects who incarnate them or incorporate them or even appropriate them and the other citizens of the city (among whom those we have called the clinicians, who have to assume particular responsibilities). This is also to say that these problematics vary and transform themselves as a function of a historical and social dynamic, that they are apportioned depending on the existence or non-existence of a facility for listening and professions dealing with them and that they themselves may contribute to constructive or destructive changes in the social and professional life concerned.
We think that the various orders of trauma, in the broad sense, which attain and transpierce responsibility, whether it be from inside or outside the dialectic belonging to it, oblige us all, as clinicians and researchers, to forge our profession in consequence. Professions of thought and word do not escape here. On the contrary, they urge us to pose the problem epistemologically. All forms of attacks and wounds to responsibility are thus susceptible of providing us matter for reflection in pursuing the theoretical, clinical and social approach in the area, above and beyond their differences, which thence become heuristic. A clinical appeal to responsibility thus involves varied and multiple problematics which may find themselves rearticuled and remobilized in relation to one another.
Human responsibility, which we have seen attacked and wounded in the context of psychic and social disasters like a dictatorship and a genocide, is also at issue, for example, in psychoses and certain perversions, like paraphrenia and schizophrenia or, at the other pole, sadomasochism and paranoia, where its dialectic breaks down, but, according to our assumptions, also in narcissistic and borderline personality disorders, which destabilize the subjective conditions of its emergence and implementation between self and other, in “wayward adolescence” which seeks a place to appropriate self psychically (Douville, 2007), in neurological attacks which injure it in its cortical substructures and bases, or again in multiple social, economic, political and religious forms…, a partial obstacle or massive prevention of its full exercise, which finds itself suspended.
These kinds of suspensions (Brackelaire, 2009) or attenuations (Dartiguenave & Garnier, 2014) of responsibility operate through various mechanisms, like processes of precarisation (Dartiguenave, 2001 ; Furtos, 2008), with precarity indicating precisely states or situations wherein one can no longer exercize one’s responsibility, or else the “tensions of flexibility” Thomas Périlleux (2001, 2016) highlights in contemporary transformations of the labour world and relational professions or, further, like conformism, voluntary servitude and imposture, whose (2013) procedures of manufacture at the heart of various fields of our societies Roland Gori exposes, in an appeal for a personal and social reappropriation of our lives under a neoliberal grip - and on the backdrop of State disengagement.
These voices in suspension may resonate with those of folly as with those of the phantoms haunting the scenes of the totalitarian crimes we spoke of or with the inner voice of a wayward adolescence on the margins of society (Quentel, 2011 ; Douville, 2014). We think a voice is a role and the voice a function waiting to be heard and recognized. Letting it speak and beginning to listen, to hear those voices and render them their roles is at stake in each of these situations. As in every clinical and social human situation, might one say. But above all in a very specific way. Not only because these voices solicit us in our responsibility as clinicians, researchers and citizens. But more specifically because they invite us to answer, to answer for what nobody answers for or no longer, to answer for the expropriation they all testify to. These clinical involvements and these various engagements can shed light on one another, relaunch one another, answering for one another as the situations generating them answer for one another : folly and wars (Davoine & Gaudillière, 2006), genocide and a frightful passage towards adulthood for the surviving generation (Uwineza & Brackelaire, 2014), strategies of imposture and trauma that in our societies provoke the fact that citizens see themselves dispossessed of their mission of cultural creation (Gori, 2013), etc. Such a dialogue between these spheres of personal and social life appears essential to us, politically and epistemologically, particularly to continue to implement and think together clinics of responsibility lending an ear to the voices sounding forth from the multiple interlaced forms of stranglehold and expropriation between self and other.

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Pour citer l'article

Jean-Luc Brackelaire, Marcela Cornejo, Darius Gishoma« Political violence, traumatism and the (re)creation of clinical professions. Towards a clinical approach to social responsibility in dealing with psychosocial traumatisms », in Tétralogiques, N°22, Troubles de la personne et clinique du social.