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8 Violence, Culture, and the Politics of Trauma

图书名称:Writing at the Margin: Discourse between Anthropology and Medicine
图书作者:Arthur Kleinman    ISBN:
出版社:Berkeley: University of California Press    出版日期:1995年

Violence is now a major preoccupation in the media and in academic circles. Scholars, journalists, physicians, and politicians draw upon images of violence to discuss subjects as various as international security, public health policy, the moral status of television programs, and national and local politics. In writing the report World Mental Health: Problems and Priorities in Low-Income Countries (Desjarlais et al. 1995), we have become specially interested in the appropriation of the images of violence and the uses to which the traumatic consequences of violence are put by professionals, the media, and laypersons. In this chapter, we try to think through a few of the key questions on this topic, particularly regarding the trauma that results from political violence. What sort of problem is such trauma? What do the health professions have to say about it? Why is it being medicalized? And what are the consequences of making a victim (or a victimizer) into a patient ?

Political violence carries the most ancient provenance. Wars, executions, and torture have been the authorized forms of asserting state power throughout the historical record. Although it is tempting to see the current level of political violence as a pandemic, political violence has been endemic over the centuries. Enormous eruptions of violence such as this century's two world wars have punctuated an already devastating record. It is chastening to remember that as violent as our times seem to because of the close coverage of "low-intensity" conflicts (a troubling euphemism), the terrible conflicts of the Second World War led to 50 million deaths and the uprooting of hundreds of millions of people (Gilbert 1989). Although the killing fields of the Great War were more narrowly bounded in geography and resulted in less than half the carnage that would mount so gruesomely and wantonly in the 1940s, the trench battles between 1914 and 1918 marked—physically and psychologically—almost an entire generation (Fussell 1975; Keegan 1976).

Nonetheless, the end of the twentieth century is a bloody time. The insurgencies in Angola and Mozambique, the repressive regimes in Guatemala, El Salvador, South Africa, and China, the "dirty wars" in South America, the civil wars a Cambodia and Sri Lanka, and ethnic, religious, and civil strife in the Balkans, the Middle East, South Asia, and much of Africa have all contributed to the grim statistics on mutilation, death, displacement, and societal breakdown. The suffering that results from political violence includes a range of traumas: pain, anguish, fear, loss, grief, and the destruction of a coherent and meaningful reality. "Low-intensity" warfare, for instance, expressly aims at control of populations through the application of terror and destruction to entire communities. State violence is meant to control people through fear and suffering, a fact that much of social scientific analysis has focused on. The leading social theories have been heavily influenced by a long-standing continental critique of the abuses of authoritarian states. Yet, in this period we are also increasingly aware of the violence that accompanies social disorganization and political disolution. Liberia, Somalia, Bosnia, and Rwanda are examples of the horrendous consequences of violence when there is no state authority capable of maintaining order and assuring security. The frailty of the nation-state and of the transnational world in which we now live suggests that violence and terror will mark any new world order that might ensue.

Images of violence are taken into the process, so that pictures of mutilation and destruction are used to terrorize and control. Daniel Santiago writes of the "aesthetics of terror" in El Salvador:

People are not just killed by death squads … they are decapitated and then their heads are placed on pikes and used to do the landscape…. It is not enough to kill children; they are dragged over barbed wire until the flesh falls from their bones while parents are forced to watch. (1990:293)

The mass use of rape in Balkan villages occupied by Serbian Chetniks, the burning of whole families in South Asia, the mutilation of corpses in Liberia, the "disappearances" favored in Argentina, terrorist actions in the Middle East, the necklacing of those labeled informers in South African townships—all of these performances affect populations through direct observation and through the symbolic imagery of the popular culture. Images of torture, destruction, and dislocation, as well as the abandonment and orphaning of children, are calculated to demoralize and to intimidate. Thus, human trauma is a planned and desired outcome. (See also Keen 1994 on the political uses of famine in Africa.) Its significance is manipulated through control of the cultural apparatuses of meaning making. For example, during the worst days of China's great famine from 1959 to 1961, the state-controlled newspapers reported bumper harvests at the very moment that 30 million were starving to death. In this way, a moral critique of the immense failure of the Chinese Communist Party's policies of the Great Leap Forward was preempted, but also, the state ruthlessly conveyed the idea that it could authorize or deny any reality. It did so again in the aftermath of the Tiananmen Massacre, when dissident workers were executed with special silver bullets, a bill for the cost of which was later sent to their families. The message: we (the Chinese government) hold all the political as well as moral power.

Cultures of fear have been created by other repressive regimes in the former Soviet Union, Cambodia, South Africa, Cuba, Chile, and Guatemala. Creating helplessness and mistrust through images of suffering is also a traumatic (and, at times, calculated) consequence of political violence. These techniques of violence are meant to intimidate witnesses, to suppress criticism, and to prevent resistance. They seek to propagate pusillanimity. They continue to break bodies long after the political situation that produced them has changed, as in the case of the persistent toll of traumatic amputations owing to the millions of land mines that combatants planted during the active phase of the Cambodian wars. These techniques of violence are intended to tyranize through the development of cultural sensibilities and forms of social interaction that keep secret histories of criticism secret and hidden transcripts of resistance hidden (Scott 1990). That is, trauma is used systematically to silence people through suffering.

When those who experience violence escape to places of refuge, they must submit to yet another type of violation.[1] Their memories of violation, their trauma stories become the currency with which they enter exchanges for physical resources and achieve the new status of political refugee. Increasingly, those complicated stories, based in real events, yet reduced to a core cultural image of victimization, are used by health professionals to rewrite social experience in medical terms. The person who undergoes torture first becomes a victim—a quintessential image of innocence and passivity who cannot represent him-or herself—and then becomes a patient with posttraumatic stress syndrome. Indeed, to receive even modest public assistance it may be necessary to undergo a transformation from one who has lived through the greatly heterogeneous experiences of political terror, to stereo-typed victim, to standardized sufferer of a textbook sickness. Given the political and economic import of such transformations, the violated themselves may want, and may even seek out, the moral as well as the financial consequences of being ill. We need to ask what kind of cultural transformations they undergo, and what the implications of these transformations might be. What does it mean to invest those who are traumatized by political violence with the moral status of a victim or a patient?

There is a troubling issue. The countries of the North, in their applaudable quest to support solidarity for human rights and offer sanctuary and protection, appropriate trauma stories and images of violation from political upheaval and oppression in Asia, Africa, the Middle East, Latin America, and the Caribbean. Yet these places of refuge in North America and Western Europe include societies in which violence is a crucial part of commercial culture. The danger is that tales of human misery from abroad will become part of that commercial culture as "infotainment" on the nightly news. Spectacular forms of foreign trauma disguise routinized domestic misery. This cultural representation even carries the self-satisfying message that in spite of all the degradation in our midst we are "above" that kind of abuse which we associate with the incorrigible failings of the "old world" and with a Conradian view of the barbaric side of the formerly colonized nations. It is a comforting myth that obscures our nation's role in the major economic and political transformations that have intensified violence in the South. Stories of untamed violence in the so-called third world are then used to domesticate our own forms of oppression. Images of violent political events are of crises that disguise the everydayness of routine violence. Paul Weaver (1994) talks of the media's validation of crises as collusion between journalists, public officials, and narrow interest groups in the selling of stories.

The Medicalization of Suffering: Posttraumatic Stress Disorder

Given the economic, cultural, and political forces that exert pressure on health care in the United States, the medicalization of violence can at least partially be understood as integral to the troubling irony we have just described. To wit, the way in which professionals in health institutions think and talk about trauma situates it as an essential category of human existence, rooted in individual rather than social dynamics, and reflective more of medical pathology than of religious or moral happenings. Psychologists and psychiatrists construct violence as an event that can be studied outside of its particular context because of its putative universal effects on individuals. They place it in an overly simple stress model, as the distress produced in a person who has undergone a traumatic episode. Collective trauma is not mentioned. Personification has always been a preferred means of representing the trauma of suffering, as in the Bible and in writing today (Mintz 1984). A group's trauma is pictured in the bodies and words of individuals. The voices and facial expressions of individual victims or patients, which can so vividly portray the trauma of the person, do not show the interpersonal and community-wide effects of violence. Let us turn to the professional personification of political violence as posttraumatic stress disorder (PTSD) in the American Psychiatric Association's diagnostic system, DSM-IIIR , the official version at the time this chapter was written, for an illustration of how social problems are transformed into the problems of individuals, how collective experiences of suffering are made over into personal experiences of suffering, and how, thereby, social traumas are refigured, for policy and intervention programs, as psychological and medical pathologies. (The ideas presented here on PTSD have been influenced by the writings of Allan Young [1990; and see chapter 9 below].)

DSM-IIIR states that PTSD's essential feature

is the development of characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience (i.e., outside the range of such common experiences as simple bereavement, chronic illness, business losses, and marital conflict). The stressor producing the syndrome would be markedly distressing to almost anyone, and is usually experienced with intense fear, terror, and helplessness. The characteristic symptoms involve re-experiencing the traumatic event, avoidance of stimuli associated with the event or numbing of general responsiveness, and increased arousal. (American Psychiatric Association 1987:247–250)

The DSM enumerates trauma-inducing stressors, and then describes the variety of traumatic experiences:

Commonly the person has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is reexperienced. In rare instances, there are dissociative states … during which components of the event are relived, and the person behaves as though experiencing the event at that moment. There is often intense psychological distress when the person is exposed to events that resemble an aspect of the traumatic event or that symbolize the traumatic event, such as anniversaries of the event. (American Psychiatric Association 1987:248)

The DSM description continues with a list of additional features of the experience: persistent avoidance of the stimuli associated with the trauma; numbing or diminished responsiveness to the external world; persistent symptoms of arousal; symptoms of depression, anxiety, difficulty concentrating, emotional lability, headache, vertigo; and muteness or nightmares in children. Notably, the official text points out that "studies indicate that preexisting psychopathological conditions predispose to the development of this disorder." The differential diagnosis includes anxiety, depressive, adjustment, and organic mental disorders. The DSM section ends with its classic presentation of diagnostic criteria as a forced choice among listed symptoms. The minimal criteria include one out of four forms of persistent reexperience of the trauma, three out of seven types of persistent avoidance, and three out of six persistent symptoms of increased arousal. The draft text for the next edition of the DSM, DSM-IV , which appeared in 1994, proposes several useful changes in the diagnostic criteria. However, the comments here are confined to the official document that guides current practice.[2] Among the hundreds of studies that have applied these criteria to special populations are reports of high rates of PTSD among political refugees, victims of ethnic conflict, survivors of natural and industrial disasters, and those who have experienced serious domestic violence (see Desjarlais et al. 1995).

A cultural critique of the official text (DSM-IIIR ) is revealing in several respects. First, the differential diagnosis does not mention the possibility of ruling out normal responses to trauma. The expectation seems to be that response to trauma, no matter how appalling that trauma, should not lead to persistent reexperience, avoidance, or arousal. The prose emphasizes that the traumatic event is outside the range of "usual human experience" such as bereavement, illness, business loss, marital conflict. But given the downright common, even routine experience of political trauma in many parts of the world, the idea of what is usual sounds suspiciously ethnocentric, even provincially middle class and middle Western. Indeed, the text itself says that "stress … would be markedly distressing to almost anyone." But what is a common stressor under conditions that obtain in Bosnia, Haiti, Colombia, or even South Central Los Angeles may seem remarkably uncommon in Cambridge or the upper eastside of Manhattan. We have no doubt that political violence has physiological, psychological, and social effects that can be devastating, but why call these effects, even the worst of them that are experienced by only a minority of sufferers, a disease?

Just as Vietnam War veterans claim serious effects of PTSD, the diagnosis could be seen as covering the effects of warfare that formerly were labeled "shell shock," "battle fatigue," and the like. As Samuel Andrew Stouffer (1949) and his colleagues showed in their research on American soldiers in the Second World War, the longer a soldier—any soldier—was in battle, the more likely it became that he would suffer these traumatic effects. After more than six months in active combat without relief, most soldiers in a unit would experience such symptoms, which made them unfit for battle. As John Keegan (1976) suggests, these symptoms are probably normative for soldiers, at least since Waterloo when diary accounts of the effects of warfare became available. If this is a disease, then it is one that has a protective consequence—namely, removal from the killing fields—and direct origins in the "normal" terror of battle.

Second, strong emphasis is placed on the "psychological" effects of the traumata: "a psychologically distressing event" that is "usually experienced with intense fear, terror, and helplessness." As with the rest of the DSM , the locus of the experience is taken to be the mind of the individual. The criteria for PTSD do include those of physiological arousal, but the text's emphasis seems very much on emotional responses. The problem with mapping distress in the mind of the individual is that such a cartography tends to overlook the fact that the causes, locus, and consequences of collective violence are predominantly social. Political violence devastates families and communities and destroys the routines of everyday life; the physiology of trauma is as much a result of social trauma as it is an entity unto itself. The experience of suffering is interpersonal, involving lost relationships, the brutal breaking of intimate bonds, collective fear, and an assault on loyalty and respect among family and friends.

A third point worth noting is that PTSD's diagnostic criteria repeatedly emphasize persistence of symptoms. The idea is that the experience is pathological because it persists. The implication is that a normal response to trauma does not involve continuation of complaints. This is very much the way bereavement is handled too. Uncomplicated bereavement ends, psychiatrists claimed in the past, usually by six months, nearly always by one year. Bereavement lasting more than thirteen months is prolonged, even pathological. In the DSM-IV draft criteria, a bereaved person's sadness, agitation, guilt, difficulty concentrating and sleeping, and thoughts about death, if they last more than two months , can be diagnosed as a major depressive episode. The bereaved person is expected to !E to work, get into a new relationship. In much of the world and still for many in America, fidelity to the dead lasts more than two or even thirteen months, even for a lifetime. (See Nadia Seremetakis's [1991] description of grieving in Greece, which, like grieving in many societies, is for the long term.) The idea in the DSM is that suffering can not and should not be endured. It should be brought to an end. This is central to the ideology of America: there is nothing that needs to be endured. Even memories can be "worked through." It is sadly wrong. Most poor people worldwide and in the United States must endure the often unendurable; not even the middle class can escape certain forms of suffering. And key memories of trauma—collective and individual—are not to be erased but to be worked with, even commemorated. Indeed, commemoration of collective trauma is one of the means by which societies remember (Connerton 1989).

Not surprisingly, the authors of this influential text have very little, almost nothing really, to say about human suffering; yet, the examples that are given—natural disasters, accidents, combat, rape, torture, death camps—are exactly what most of us would take to be quintessential examples of suffering. John Bowker (1970), who writes about how the world's major religions deal with problems of human suffering, canvasses some of the same problems, but from an entirely different point of view. In Christianity, Judaism, Islam, Hinduism, and Budhism the experience of human misery, from sickness, natural disasters, accidents, violent death, and atrocity is taken to be a defining condition of people's existential plight. With more than one hundred conflicts in societies in the North and South and violent repression as a policy of state control in many nations, the brutal experience of violence including combat, torture, and rape is fairly ubiquitous on our planet in our time. Add natural disasters and injury from automobile and other serious accidents, and it is arguable that most people in the world dwell in settings in which such events are commonplace, even routine. Clearly the DSM 's authors have a very different set of normative social experiences in mind. Suffering in North America is thought of as perhaps no longer normative, or it would seem, normal.

And that is one of our chief complaints about PTSD: it medicalizes problems as psychiatric conditions that elsewhere and for much of human history in the West have been appreciated as religious or social problems. All told, the ideology underlying the notion of PTSD reproduces a very specific ontology of the person—that of upper middle-class society in the United States. As the moral and political philosopher Charles Taylor (1990) has noted, that human beings are radically detached from their social environments, are defined by a rich and "inward" depth of emotions, and are driven by zeal to change and remake themselves is an idea quite recent to the West. The common-sensical force of the idea of deep indwelling subjectivity is helping to shape the discourse on PTSD. The situation is straight out of Michel Foucault: a series of statements, like those found in the DSM , create a certain reality or "visibility" (Deleuze 1988) that effects a form of being that "can and must be thought" (Foucault 1985:7). As anthropologists, however, we must advocate that there are other ways to think about trauma (Das 1994).

The social construction of human misery as PTSD is just the latest example of what Max Weber (Wrong 1976) had in mind as the increasing application of the technical rationality of bureaucratic institutions to spheres of life that were previously handled by the religious and moral idioms of everyday experience. It is a colonization of the lifeworld by professional discourse. Professionals may not (probably do not) explicitly aim at advancing professional power and the division of labor of the bureaucratic state. Indeed, they often regard themselves as resisting the interests of social control. Yet with several hundred thousand well-meaning social workers, psychologists, and psychiatrists in North America competing for a limited number of patients, PTSD certainly has to be seen as a form of medicalization that is influenced, at least in part, by the interest of economically hard-pressed professions to increase jobs and income in an era when health care is faced with shrinking resources. You cannot bill third-party payers for coming to the aid of those who have experienced political trauma. You can bill them for major depressive disorder, any one of the anxiety disorders, or PTSD. Every conceivable psychological problem is listed in the DSM as a disease, precisely because treating disease is authorized for remuneration, whereas responding to distress is not. Thus, there is a political economy to the use of the disease concept (see Kirk and Kutchins 1992). Don't misunderstand our point. We do not deny that those who are traumatized are genuinely suffering or that mental health professionals are working with competence and compassion to aid them. Treating persons with PTSD may improve symptoms and limit distress. We do not deny this or derogate its significance. We are, however, asking mental health professionals, patients, and laypersons to attend more fully to PTSD's implicit cultural, political, and economic implications. What constraints do (or should) those implications place on clinical practice?

Violence and the Local Setting of Social Experience

Yet this is not the only, or even the chief, thrust of our critique of the way political violence is being turned into a health problem. Rather we seek to argue that the medicalization of political trauma violates the experience of that trauma. As a result, purely medical phrasings distort and neglect the social experiences that sufferers undergo. Included in these experiences are moral, religious, and social processes that contribute to the most egregious human effects of violence. A call to "experience" is, of course, yet another discourse, but one that attends more closely, and with more reflexivity, to the local complexities that pattern any form of suffering. Simply put, medicalizing political violence removes the human context of trauma as the chief focus for understanding violence. It treats the person as a patient, the host of a universal disease process, victim of inner pathology. Many persons who experience political violence are the victims of intentional and systematic harm that is motivated by issues of power, not pathology. They may develop a posttraumatic syndrome. Do they have a disease? Or are they experiencing a greatly distressing, yet normal, psychobiological reaction? The disease model tends to remove agency. Yet, even when faced with the vast machinery of state power, human agency continues to operate (Levi 1988). Some contribute to their own problems owing to the dynamics of their local world. A firmer ground for analysis is an understanding of how that local world mediates between broader political forces and the responses of individuals. Let us consider a case example.

On the Fourth of July, 1991, Mrs. Fang, a woman from a rural county town in an interior province of the People's Republic of China, traveled several hundred kilometers to undergo a series of medical evaluations in a major urban medical center, where she was interviewed by Arthur and Joan Kleinman. Complaining of headaches, dizziness, visual symptoms, numbness, and whole body pain that had incapacitated her for two years, Mrs. Fang told a story—a familiar tale of political oppression in China—with which she has for many months been preoccupied, perhaps even obsessed. In 1989, when pregnant with her second child, she was forced to have an abortion in the third trimester of pregnancy. It was her third abortion since 1986. Each abortion, she claims, was forced upon her by the leaders of her work unit. Since 1989, she has been grieving and in a state of continuous, pervasive anger. She is openly critical of the forced abortions and of the acquiescence of local bureaucrats in an oppressive policy. The doctors in the medical center heard her out, but ended by diagnosing a long-term personality problem and short-term stress-related psychosomatic syndrome and by prescribing various medications.

Told this way, the story could easily appear in a North American newspaper to illustrate the trauma of routinized political oppression in an authoritarian Communist country whose one-child-per-family policy has become a focus of criticism by human rights advocates and has also received recent notoriety in the media as a common reason given for seeking political refuge by Chinese who have illegally entered the United States. That is the way stories like Mrs. Fang's are most often appropriated. The stress-related condition is seen as the traumatic effects of a form of political violence: the inscription into the female body of the social memory of state control.

However, there is much more to Mrs. Fang's story as told by her and the cadre who accompanied her on the long journey of medical help seeking. To understand that narrative, we must position ourselves in her world: a factory in a modest-sized rural county town in a poor and remote region. The factory has been repeatedly criticized by the local population control authority for failing to assiduously enforce the one-child policy. Mrs. Fang had come to believe that owing to that local campaign of criticism, the leaders of her work unit, whom she otherwise liked and regarded as reasonably tolerant and supportive, would be unwilling to accept her pregnancy. (Indeed, she had been requested to undergo her first abortions early in two previous pregnancies.) But precisely because she and her husband had a good relationship with them, and found their unit's cadres to be sympathetic, she believed that once the baby was born, the unit's cadres would have no recourse but to accept the reality of a second child in their family. Therefore, she hid her pregnancy. She did so, moreover, even though her friends and coworkers, who also wanted more than one child, had agreed collectively to avoid pregnancy for a limited time, while the work unit was trying to get out of the spotlight of political criticism. After a while, workers and cadres had agreed, the intensity of the political campaign would abate, as it had so often in the past, and it would be possible to secretly negotiate additional births in the work unit.

When Mrs. Fang, now so evidently pregnant that she could no longer avoid public disclosure, revealed her pregnancy, the entire work unit—workers and leaders—were deeply angered. They accused her of being selfish and reckless. She was also accused of breaking the social compact, and thereby threatening the entire community, including those women who had not yet had even a single pregnancy. When she brazenly responded that all of the accusations were unfortunately true but beside the point, since she would soon be delivering a baby, she created pandemonium in her unit. Both cadres and workers told her that her behavior was unacceptable. Why should she be given special license, they demanded, especially when she had betrayed a social strategy aimed at assisting all the women in the unit and had lied to them all to boot? The general sentiment was strongly against her. Mrs. Fang's response was like pouring cooking oil on an open fire. She agreed with all the accusations, but, "smiling" at her "comrades," as she herself told the story, while the accompanying cadre shook her head in amazement at the brazenness of the act, Mrs. Fang told them that they would just have to accept it, whether they liked it or not, since they were now stuck with the result.

The members of the work unit were outraged. Furthermore, when the population control cadres learned of the pregnancy, the work unit's leaders confronted a crisis that had gone beyond the boundaries of their domain of control. The dramatic consequences are a story to be told at length in another place, but among the results were a collective demand for abortion, a suicide attempt by Mrs. Fang's husband that was precipitated by her accusation that he was too weak to protect her and the fetus, suicidal behavior by Mrs. Fang herself (which was held by her coworkers to be manipulative and insincere), the forced abortion, grieving. Then came a pendulum swing in accusation from the accusers to the accused, with demands for financial restitution, various failures at compromise, and Mrs. Fang's illness career that first met grudging acceptance, but after two years of help seeking that had seriously depleted the work unit's medical insurance fund, was now causing a recrudescence of accusation and conflict.

The point we seek to illustrate is that to understand Mrs. Fang's suffering, we must enter her world and attend to its complex array of discourses, sensibilities, and competing demands. That world is not a passive recipient of the vector of macrosocial forces, such as the one-child-per-family national policy, any more than is Mrs. Fang. Rather, the local world actively mediates the effect of political pressure on persons. In the interactions between positioned participants that make up that world, the dynamics between victims and victimizers turn on what is locally at stake. There is social and individual agency. While the biographical details of Mrs. Fang's life and the description of the setting assist us to understand the nature of the political trauma Mrs. Fang suffered, the diagnosis of a stress-based psychosomatic condition does not. Nonetheless, that diagnosis will become consequential in the social process of suffering itself. It creates an interpersonal experience of which Mrs. Fang is the central (but not the only) part.[3]

Suffering is interpersonal; political trauma is more than and different from a disease condition even though it has physiological effects; and the political process is as central to the appropriation of the images of suffering as it is to the experience of suffering. The experience itself is characteristically cultural, elaborated in ways that differ from its development in other societies. That is the lesson of Mrs. Fang's case.

Mrs. Fang has persisted in her reexperience of trauma, in the disabling complaints she associates with that trauma, and in yet other ways that would allow a diagnosis of PTSD, were it used in China, which it is not. But in our view PTSD would be an inappropriate formulation of this case, for several reasons. Mrs. Fang is not a passive sufferer of traumatic stress. There is no single trauma story for her case either. Each positioned participant tells a different, even conflicting story. Mrs. Fang's persistent symptoms are in part the result of Mrs. Fang's persistence. The trauma itself is social in consequence, and Mrs. Fang helps to create it. Is she pathological? If so, is her pathology the consequence or cause of the trauma? And what kind of pathology is it? (PTSD is not the only label that might be applied to Mrs. Fang's experience that would seem problematic. Resistance to political authority would be equally problematic. So too would be the imagery of innocent victimization. And while personality disorder will come to mind for psychotherapists, does that contested label solve or deepen the problem?) How then should we engage the problem of the traumatic consequences of political violence?[4]

Toward an Ethnography of Political Violence

From our perspective, the epidemiological statistics, comparative psychometric surveys, and high-level discussion of political violence as a public health or clinical condition provide an inadequate basis to understand its sources, forms, and consequences. In the ethnographic view, political violence is situated in native social spaces: a home, a street, a park. These are the contexts of ethnic conflict and religious riots in Sri Lanka and India where, as Stanley Tambiah notes (1993), the police may decide in one community to pull back and forgo their responsibilities for protecting the public, while in another they hold the line against aggressors. These are contexts where, as Veena Das (1994) shows for religious conflicts in India, crowds do not spontaneously lose control but rather are mobilized, armed, and incited to violence by political activists and thugs who want particular persons to be "taught a lesson"; contexts where neighbors on one block kill one another, while those on another with a different history of interests and relationships shield one another (Das 1995).

The description of the dynamics of political violence in distinctive life contexts clarifies how large-scale forces alter interpersonal relations. Certain categories of persons and certain individuals are placed at great risk, while local worlds protect or even strengthen the position of others. The parochial world is the setting where violence is taken up in networks of relationships that either intensify or dampen its effects, networks that have a genealogy, a concrete configuration of events and stories. Violence qua violence is a difficult category to understand, whereas particular contexts and histories of violence can be studied and compared. Instead of focusing our analyses on the psychological reactions of victims, or the putative "essential," "inherent" aspects of violence as a phenomenon, we would do much better to attend to political violence and its consequences as processes that are motivated by the layered specificities and inexpediencies of social and political forces. The focus on local worlds enables us to examine the social processes that underwrite the targeting, implementation, and response to violent actions. In this way, violent actions at the community and even neighborhood level, and discourses on those actions at the national and international level, pattern one another.

In the ethnographic perspective, those who suffer the traumatic consequences of political violence are more effectively approached as a greatly heterogeneous category of social sufferers, rather than as patients or victims. The violated need not be romanticized or cynically deconstructed. There should be no problem in acknowledging that those who experience violence have physiological as well as psychological responses. Those reactions can be studied collectively as well as individually. Those responses tell us as much about the moral quality of our interpersonal worlds as about inner worlds; moral-somatic worlds are inseparable from the experience of trauma. Trauma links inextricably the social and psychobiological processes that animate human experience. Experience, so conceived, can be (and really is) as readily dehumanized by social science perspective that attend only to the social side of that dialectic as by health sciences ones that permit only biological explanations. Sufferers of social trauma can also actively participate in victimization, their own and others. It is understandable that health care institutions, to the extent that they must provide rapid and effective treatment, think of sufferers more as patients. A problem arises, however, when the medicalization of distress goes beyond the hospital wards and forms part of the standard public discourse on violence and its consequences. The idea of "victim" is also problematic, and shows that medicalization is not the only discourse on violence that creates difficulties. The cultural codes of our age appropriate the imagery of victimization to serve a variety of political purposes. "Victim" is a highly politicized and even commodified category. Victim has come to mean authorization for indemnification. We also listen to the voices of victims for their moral uses in the commercial culture. We are supposed to feel morally improved, even uplifted, having heard their cries and seen their anguish; we, in turn, at times appropriate their misery to authorize our own criticisms and demands. The cultural dynamics of witnessing have become ethically murky; witnessing sells TV programs! Victims have become cultural capital. Their outrage is compromised by commercial interests, so that indifference and complicity unmake moral responses, which must be one of the more appalling commercializations of human experience.[5]

Emphasis on the microcultural context of violence should assure that the complex ironies of atrocity and routinized oppression can be examined without disaffirming the human experiences at stake in trauma. The ethnography of political violence, for all its ethical ironies, is still at best an engagement that can describe a native place in which violence is distinctly human. Political trauma is interwoven with moral-somatic processes that bring social memory into the body and that project the individuality of persons into social space. Thereby, context and event, process and person are inseparable. That space of social experience in which violence is a way of living (in Wittgenstein's terminology, a form of life) needs to become the focus of research, if ethnography is to advance understanding of the actualizing of violence.

The ethnographic gaze must attend also to the appropriation of images of violence. Those images are powerful sources of motivation for reprisal, revenge, and recurrent cycles of assault. They are also potential means for local prevention. The images tell us about the dynamics of both macro and micro political processes. Narratives and pictures of torture are appropriated by those in national and international agencies who are engaged in managing the outcomes, and political capital, of collective violence. Here the labels applied to the process, as well as to the participants and the outcomes, carry with them entire technologies and rationalities of which medicalization is only one (albeit a major) example. The professional appropriation of violence in narratives and images of terror extends to the various academic constructions, none of which can any longer be permitted to pose as "objective" and lacking self-interest.

The objectification of political violence as a "problem" for national and international security, as a social "crisis," or as a public health and mental health "epidemic" is also amenable to ethnography, this time focused on the appropriations (and appropriators) of violence. How an identified public problem gets created out of the complex uncertainty of everyday life is the story of culture in the making, the realization, or emergence, of cultural patterns out of the everyday processes of social interaction and interpersonal experience that include class, ethnic, factional, and gender differences. The story of how our local or wider worlds come to be is the story of those who possess the authority to legitimize certain narratives while silencing others. The problem of violence and its traumatic effects must be articulated in this broader context if we are to identify the major junctions for intervention (compare Gusfield 1981).

Our argument is not that clinical and public health formulations of trauma do not have appropriate uses. They do. Nor do we think that witnessing misery and acting to assist sufferers is bad faith. It is not. Rather we seek to place clinical, public health, and social policy problem frameworks in a wider discourse on violence as a cultural problem, one in which, moreover, the analysts, the experts, and the observers participate. We all should, indeed we must, respond to trauma as a form of social suffering. Yet we must all also be aware of the way our language, actions, and professional competences are caught up in cultural and political forces that contribute to the very problem we seek to remedy. So powerful are the technologies and accompanying technical rationalities that we use to diagnose, treat, and evaluate mental health problems that we must be sure that sufferers of violence are not exposed to potentially disruptive or unnecessary interventions. The first goal of cultural analysis should be to assess how the dominant policy frameworks contribute to the burden and abridge the prospects for repair. That is in large part a question of how those frameworks themselves are taken up in much larger cultural-political economic processes that make up our world.

Where a diagnosis of PTSD can assist in directing humane, effective care to people with real needs, it should be applied. Where it can guide preventive programs, it also deserves to be tried. But we should also keep in mind that any articulation of "trauma" effects a specific and limited social-political reality. Given the tenuous balance between therapy and violence, the diagnosis of PTSD should be avoided whenever it is an encumbrance or irrelevance. That same reflexive approach should extend to concerns for the way those who have undergone political violence are at times labeled as "victims," an oversimplification. That category will be valid for many, perhaps most, but not for all; it needs to be understood, moreover, as an active category of social agency in a moral and political process.[6]

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