Interaction between cc-MHPSS programme time-space and a natural community time-space

In the initiation of engagement in a cc-MHPSS programme, participants are transferring elements they experience in a wider community time-space into a group time-space, and elements they experience in a group back into a wider community. Elements that participants brought from communities into groups include conflict-related suffering (eg, narratives of the loss of family members, rape, torture or trauma),11 21–26 29–34 37 everyday issues (eg, daily stressors, issues related to agriculture, finances, family),22 24 25 27–29 32 35 36 38 39 community narratives (eg, societal norms or attitudes of what is acceptable and non-acceptable),21–27 29 31 34 39 and communal activities (eg, singing, dancing, advice giving).11 22–27 32 34 35 38 39 This is demonstrated throughout all synthesised articles.11 21–39 Through the act of transferring elements, a processing of elements occurs, in which there is a change in participants’ perceptions and attitudes.

Some elements from natural communities, such as communal activities, worked as community assets within groups. One such example is from participants of the Healing of Life Wounds (HLW) programme. The HLW programme is a community-based, group-based, mental health programme for adults and was implemented following the 1994 genocide in Rwanda. Following the session end, participants in the HLW programme would engage in communal activities, such as visit with each other to talk about the day’s session, sing, dance, recite poetry together, or attended a morning church service.39 These elements from a natural community were present within the group time-space and according to participant observations, the group ‘seemed to rekindle and nurture the practices that had been expelled from postgenocide life.’39 (p423) This is evidence that elements from the natural community time-space are integrated into the group time-space, along with evidence of change in the social connections among participants of the group.

However, some elements from the natural community, such as sensitive topics of the 1994 genocide in Rwanda were difficult for participants to present in the community time-space. Participants were more comfortable presenting these elements in the group time-space. Oftentimes, these participants were sharing their conflict-related experiences among a diverse group, which may mirror the wider community population and community narrative of the genocide. In King’s and Sakamoto’s 2015 study of the HLW programme, groups were made up of ‘survivors,’ those who were directly targeted by genocide and ‘nonsurvivors,’ those who were not targeted by the genocide.37 In this particular case, tensions that are present within the community narrative, arise in the group context. Rosa, a ‘survivor’ participant, remarked in the first session of the HLW programme:

‘I am tired of telling and hearing stories of the survivors alone about this and that, all about the genocide they experienced. I do not understand why those who were not hiding cannot tell us what they saw or know. If they did not do anything, or did, they were not hiding, if we are lucky to be gathered here, in a protected space, why cannot they tell us?’37 (p386)

King and Sakamoto indicate that Rosa’s remarks ‘seemed to be the expression of a desire for an audience that would confirm and legitimise the suffering of survivors.’37 (p386) Rosa’s remarks were not addressed by other participants in the first session. Emma, a ‘nonsurvivor’ participant, in the second session addresses Rosa’s remarks:

‘I was very hurt by the question that Rosa asked at the end of the first session. When she mentioned those who were not hiding, I felt she was talking about the Hutu and I happen to have that identity. And I am not saying that the Hutu did not do bad things. Sometimes I feel ashamed to talk about the genocide because it is almost like a family sin, committed by the members of the group to which I belong.’37 (p387)

This interaction demonstrates how elements from the community (eg, community narrative of the genocide) are transferred and integrated by participants into the group, which is an assumed ‘protected space’. Later, King and Sakamoto explain some instances of change, evidenced by the interpersonal connection and humanisation of the wider community within the group structure among the ‘survivors’ and ‘nonsurvivors.’ Such interactions and change within the group are suggested to have been translated to the wider community’s time-space.37

By contrast, some elements were shared within a natural community’s time-space but not transferred to a group time-space. In Otake’s ethnography, many study participants of the Musanze region in Rwanda were victims of the abacengezi war, the insurgency of the northwest event (1997–2003) (abacengezi meaning ‘infiltrators’), in which the majority Hutu inhabitants were massacred. Victims of the abacengezi war have received little government support (eg, MHPSS programmes), as the majority of the population are not survivors of the 1994 genocide. Since many victims of the abacengezi war did not have MHPSS programmes available to them, they engaged in other social groups within the community that facilitated healing experiences. For example, members of a church-based group would ‘visit(ing) and talk(ing)’ (‘gusura na kuganira’) with those who had socially withdrawn due to family loss. In these visits, talking would aid in socially withdrawn individuals’ social reconnection to the community. These topics would focus on talking with each other about scripture or events in the Bible, which would bring comfort to the participating group members. In this case, talking with each other did not focus on talking about traumatic conflict-related experiences, as is present in the groups of the reviewed articles.11 Otake suggests that the act of ‘visiting and talking’, through social reconnection, impacted participants’ healing. In this example, elements of the natural community, like this process of ‘visiting and talking’ with each other, are not transferred to group time-space since MHPSS programmes were not available to victims of the abacengezi war.

How then, does the transfer of elements happen from natural communities to groups, and vice versa? Across the reviewed articles, elements that were labelled by the programme as ‘appropriate’ to share and perceived by participants as ‘safe’ to share among the groups were likely to be easily moved from natural communities’ time-space to groups’ time-space. For example, a husband participant of a multicouple therapy (MCT) programme in the DRC shared his experience of witnessing others of the group share elements from the natural community. MCT was a group-based programme for torture-surviving, heterosexual Congolese couples, following the 1998–2003 conflict:

‘There was, for example, a diminishment of strength, for sexual relationship, and I thought it was just me in my marriage with my wife. Listening to/witnessing the others, it happened to others, too. They didn’t have strength from working, and the body was exhausted… I thought I lost a lot in the war. Then I got into the group, and I found that there were others who had lost, too. And to see friends who continued to have the same marriage, despite the suffering, that really encouraged me to say, ‘We, I can keep going with my wife in this marriage.’24 (p11)

One of the treatment goals of the MCT programme included ‘talking to one another (the respective spouse), as well as other couples about their experiences during war, including its effects on their relationship’ (online supplemental material, p5).24 Experiences during the war, elements from the natural community, are labelled as ‘appropriate’ to share based on the MCT treatment goals and perceived as ‘safe’ to share by participants. This facilitates the transfer of elements from the natural community time-space into the group time-space. This is evidenced by group participants sharing their experiences from conflict-time in the group time-space. In this husband’s experience within the group, ‘listening to and witnessing’ others share their experiences facilitated his recognition that he was not alone in his suffering of his marriage. The time-space within the group to share conflict-related experiences and receive others’ experiences (ie, listening and witnessing of others’ experiences) seems to allow for a processing of elements (eg, conflict-related experiences) from the natural community, as is also evidenced in King’s 2014 publication (ie, Anatole’s and Emma’s comments on [making] my story theirs, and I [making] theirs mine’).39 (p422) This example is visualised in figure 2.

Further, sharing experience and witnessing others’ experiences provides a starting point in the development of group member connections and relationships. This was the case of some of the participating women within a sociotherapy group programme, which was a community-based, peer counselling programme for adults in Rwanda following the 1994 genocide. The participating women in the programme shared their conflict-related experiences of rape and experiences of discrimination and social isolation:

‘[The women] discovered in the course of the sociotherapy sessions that they are not alone in their suffering…The women started to care for each other […] They even started to meet with some of the people they had deeply hated.’33 (p588)

In this case, the sharing and reception of conflict-related experiences among the women of the sociotherapy group also facilitated the recognition that they were not alone in their suffering. Following a processing of this element (eg, conflict-related experiences), the women formed social connections within the group and natural community. This is evidence that through participants, elements from the group time-space are successfully transferred and integrated into the natural community time-space.

Another instance of the transfer and integration of elements from the group time-space into the natural community time-space was that of a wife participant of the MCT programme in the DRC. She commented on how she was able to speak about the experience of rape from conflict-time within a group session: ‘The husband can understand the difficulty that I have. The man can hear what you asked there.’24 (p11) Markedly, processing within the group time-space allowed for the further processing of issues within the marriage in the natural community time-space. Morgan et al reported ‘many couples expressed that after in-group processing of the sexual violence, they could discuss the issue within their marriages.’24 (p11) In this case, wife and husband participants transfer the elements from the group time-space to be used in their marriages in the natural community time-space.

In addition, other elements from the group time-space such as the session teachings and materials were transferred by participants to the natural community time-space. Martha, a participant of the HLW programme, comments on sharing her HLW handouts with her daughter, who did not participate in the HLW programme: ‘I gave her the handouts to read and I encouraged her to come and sit with me and we did the exercises together.’39 (p423) Other participants of the HLW programme, who had limited readings skills, shared and completed their programme handouts with community members:

[The HLW participants] appreciated that they were able to remind themselves of the discussions held by asking another person to read the material aloud. They reported using these occasions to share what they had learnt.’39 (p423)

This is further evidence that participants facilitate a transfer of elements between the group and natural community time-space. This introduction and integration of elements from the group into that of the natural community time-space promote sharing reflections and communal sharing among group participants and community members. This suggests that healing and the process of engagement are not solely confined and designated to the group time-space. Healing and engagement processes may also happen in the natural community time-space.

The relationship between a cc-MHPSS programme and a natural community is dynamic. It is uncertain the extent of the elements brought into and out of each of the settings’ time-space, in which participants facilitate the transfer. Further, it is uncertain of the specific pathways of participants’ process of healing (ie, mechanisms which contribute to processing elements in and between the group and natural community time-space, how elements change, etc).

Topics shared comfortably

In the previous theme, ‘the experience of change in time and space,’ some participants expressed appreciation for having the group time-space to share and listen to other group members’ experiences. These participants expressed that the time for sharing in the group was constructive and facilitated healing. Topics that were safe to speak about were most-commonly those representative of community life, collective identity, and topics accepted by culture and society. ‘Safe’ topics are related to the facilitated transfer of elements between the group and natural community time-space. These included shared farming,35 entrepreneurship,34 religious (Christian) events, singing, reciting poetry, dancing39 and extramarital sex, in which it is deemed non-acceptable behaviour in the community culture.33

Some participants reported the positive impacts of speaking about ‘safe’ topics in the group time-space. Ana, who participated in the solidarity groups in the DRC, spoke about the social improvement she experienced since joining the programme:

‘My situation has changed since joining the group. We meet each Saturday and learn how to herd…and how to farm vegetables that help life. We are beginning to work together in the home. In the community we talk together about the group, and share food.’35 (p364)

In Ana’s case, speaking of ‘safe’ topics, such as best herding and farming techniques, resulted in social connection with the solidarity group members and communal sharing (eg, shared farming and food). Another participant of the solidarity group, Nadia, speaks about how her relationship with the wider natural community has improved:

‘In the community it has changed because people know how to talk together through education of children and families. In the community, we set an example for the rest of the community to follow. The leader of the village tells children to listen to the group members.’35 (p367)

For Nadia’s case, participation in the solidarity group has increased her social connection with her community. This is evidence that elements, such as ‘safe’ topics, from the group time-space are transferred into the natural community time-space. Topics that are ‘safe’ to speak about in the group are also easily spoken about in the natural community time-space. For Nadia and other women of the solidarity group, it is evident that ‘their relationship within the community improved because they gained respect,’35 (p367) as ‘safe’ topics facilitated participant change, through the reformation of social connections in the community.

Uncomfortable topics

When a topic was not accepted by the community but was encouraged to share and voice in the boundaries of the group time-space, participants needed ‘courage’ to talk about it. For example, Faina, shared her experience of conflict-related sexual violence and issues with her husband within the sociotherapy group in Rwanda. Richters et al observed that Faina had the ‘courage’ to share only ‘part of her story’ with the group.33 Morgan et al observed that many of couples, participating in the MCT group in the DRC, had ‘developed the courage and strength to speak about their experiences, especially on learning that other couples had similar experiences.’24 (p11) This is related to the theme of ‘the experience of change in time and space,’ in that listening to and witnessing others share their conflict-related experiences facilitated the subsequent sharing of experiences from other couples and recognition that they were not alone in their suffering.

Differently, there were situations in which some group participants’ experiences did not fit a wider community narrative. In such cases, ‘the freedom to talk did not come immediately’ for these participants.39 (p422) King and Sakamoto explain that many Rwandans use the social categorisation of ‘survivors’ and ‘nonsurvivors’ to distinguish people who were or were not targeted by the genocide, respectively.37 (p385) ‘Survivors’ refer to ‘Tutsi and, in some cases, Hutu women who were married to Tutsi men, and their children.’ ‘Non-survivors’ refer to ‘Hutu men and women, perpetrators or bystanders. Tutsi women married to Hutu men may identify with either group (survivors or nonsurvivors), based on their experiences during and after the genocide.’37 (p385) The community narrative and social categorisation of ‘survivors’ and ‘nonsurvivors’ indicate that only some were affected or suffer from events of the genocide. In one of the first sessions of the HLW programme, King observes some survivors sharing experiences of familial death. Alternatively, she reports nonsurvivors’ non-disclosure on the experiences of familial death:

‘The survivors who were able to talk shared stories of the genocide and loved ones who were killed without going into detail or showing any emotion. The non-survivors did not talk about family members that had died, although it is well known that almost every Rwandan lost relatives in either the violence or the mass flight from the country. Many nonsurvivors focused on family and land-related conflicts, (including) theft of crops…these initial exchanges…created tensions between the members of both subgroups.’37 (p384-385)

Initially, a community’s narrative of social categorisation may impact the sharing and silencing of experiences in the group time-space. The experience of Emma, a ‘nonsurvivor’ participant of the HLW programme and whose experience did not fit in the community narrative, is presented:

‘The freedom to talk did not come immediately. At first, I did not feel that I had anything to tell those who were with me in the group…my small group members were people who have had problems during the war [genocide] and I did not feel that I could say anything… I wished I was transferred to another group.’39 (p422)

This is noteworthy in that Emma’s labelled social identity, of a ‘non-survivor’ among a group of mainly ‘survivors,’ could have contributed to her not disclosing her experience within her group. This example is visualised in figure 3.

By contrast, there were instances in which a group narrative was different from a wider community narrative. Otake suggests that implemented MHPSS programmes in Rwanda apply a Western-derived understanding of trauma and healing to post-genocide mental health, which did not fit with the natural community’s understandings of trauma and healing processes.11 One such example is the offered cc-MHPSS programme within the Association des Etudiants et Éleves Rescapés Du Genocide (AERG), a support organisation for genocide survivors. This AERG cc-MHPSS programme was a group-based psychological counselling programme. Murekatete, an active participant, expressed her connection with the AERG cc-MHPSS group, but also shared that she experienced social isolation from the local community:

‘I have not been able to be sociable with other people (of the local community). In fact, I do not do so. I ask myself what I can talk about with them […] Our lives are not similar so I haven’t been able to feel confident with others.’11 (p6)

In this case, Murekatete’s ethnic identity, a Tutsi genocide survivor, could have impacted her not forming social connections within the local community, in which the majority of the community members were Hutu victims of the abacengezi war.11 Though Murekatete disclosed her experiences within the group time-space, she did not disclose in the wider community; there was not a transfer of elements from the group to the natural community.