Mental Health in the War on Terror: Culture, Science, and Statecraft

Terroristic events no doubt leave indelible scars on the psyche of the victims and can create societal backlash toward individuals or groups of people perceived to be the source of the terror. On the one hand, society has to deal with the problem of providing safety for its citizens; on the other hand, without understanding the cultures involved, reflex backlash could also affect individuals from similar subcultures. Using medicine or psychiatry as a vehicle for this backlash could be detrimental to the integrity of the profession. For that reason, books that critically look into societal reactions to terroristic events could be insightful. Such work should strive to be balanced while educating us, when intense fear creates huge biases that influence our diagnoses and delivery of treatment. It also cautions us against pathologic politicization of our noble profession.

Dr. Neil Aggarwal's ethnic background, medical training, and extensive work in cultural psychiatry uniquely qualifies him for research in this area. The book is masterful in using specific examples to portray various aspects of biases. Chapter 1 deals with mental health, culture, and power in the war on terror. It posits philosophical underpinnings of the battle between the clinician and the patient during evaluations. Every aspect of what we do is subject to philosophical interpretations that could influence decision-making, exemplified by referencing Michel Foucault's view of an inpatient unit as a religious domain without religion and a domain of pure morality. Medicine's striving toward equitable distribution of scarce resources was particularly explored as was the role that culture, social truths, and social resistance play in these determinations.

Chapter 2 covers bioethics and conduct of mental health professionals in the war on terror. Dr. Aggarwal walks us through case vignettes to portray the dilemmas faced by the clinician in the context of the pressure being exerted by the employing organization. He highlights how an evaluator may get pulled in multiple ethics-related directions, even when his professional associations have been unable to issue position statements. Readers would be enriched by Aggarwal's exploration of Focauldian discourse analysis and bioethical scholarship.

Chapter 3 dissects the meanings of symptoms and services for Guantanamo detainees. The use of Guantanamo Bay to avert constitutional conflict has aroused ethics-based and legal debates among constitutional scholars. Aggarwal homes in on this dilemma by pointing out that even President Obama, who campaigned for closing the facility and even mentioned it in his acceptance of the Nobel Peace prize, yet was unable to close it throughout his eight years in office. Aggarwal's exploration of the ethics and cultural basis of these decisions helps educate readers on how complex these situations usually are and that there are no straightforward answers.

Chapter 4 sheds light on how Arabs and Muslims are depicted in psychodynamic scholarship. The concept of “Muslim mind” and “Orientalism” are explored, including how we inadvertently peculiarize Arabs and Muslims based on our ingrained perception of cultural differences between East and West. This cultural conditioning¹ creates stereotypes and pathological schema of alien groups and influences our decision-making. In Chapter 5, Aggarwal uses Alison Howell's concept of securitization of medicine and medicalization of security concerns to analyze the mental health construction and psychopathology of suicide bombing.

This book has palpable flaws. Throughout the text, Aggarwal allows his sentiments to taint his impressive discourse analyses. In the preface, he refers to how psychiatrists conjecture about the irrational motivation of suicide bombers, the wish of the state to punish undesirable populations, and the political use of psychiatry. There is minimal analysis of the origin and credibility of the fear that prompts this negative backlash from the lens of the affected society. Even though case vignettes are used to buttress the dilemmas faced by clinicians, readers are unable to identify how such vignette selections were made and how this selection process could bias the overall narrative.

Even scholars like Elisha Davar (p 90) and Fakhry Davids (p 91) who balanced their arguments and warned against stereotyping Islam, were accused by the author of reproducing East–West dichotomy and fostering divisions. Aggarwal's proposal (p 132) for a Guantanamo court to use a cleric from the Al-Qaeda Organization in the Arabian Peninsula (AQAP) to serve as an expert witness is emotive and controversial. Stating that the United States government markets patriotism by valorizing economic growth (p 15) is not constructive. Wanting someone to be diagnosed with posttraumatic stress disorder because the diagnosis will improve his life (p 19) should not be the role of a forensic evaluator. In these situations, Aggarwal does not consider the difficulty in wearing two hats (as a physician and as an objective evaluator), but rather portrays medical system as “agents of social control through our presumed objectivity” (p 20). Condemnation of how Muslims and Arabs are depicted is regarded as noble, yet prejudicial motives are ascribed to scholars and mental health practitioners.

Overall, this is a powerful book that will challenge our assumptions and facilitate emotive debates on culture, medicine, and psychiatry. It is recommended reading for lawyers and forensic clinicians and nonclinicians alike.

• © 2018 American Academy of Psychiatry and the Law