THE WAR ON TERROR HAS entered its second decade, with no end in sight. I have attempted to demonstrate that the war has changed the culture of mental health, and vice versa. I have employed three themes from medical anthropology and cultural psychiatry—differences in interpretation based on clinical roles, demonstrations of power in deciding which interpretation is authoritative, and the use of medicine for purposes other than healing—to establish a cultural analytical framework for the forensic functions of medical systems, using the War on Terror as a specific case study. Government restrictions on access and information based on claims of national security have necessarily inspired new forms of inquiry and methodology to address the War on Terror (Goldstein 2010). Therefore, I have used discourse analysis as a method to glean recurring values, beliefs, and practices in the War on Terror in government documents, scientific publications, legal texts, and policy statements. Rather than affirm their scientific or legal truths, I have treated these texts as an archive of source materials for cultural analysis.
I have arrayed this book’s chapters according to how the War on Terror has impacted medicine: the first three chapters examined how the American government has transformed mental health knowledge and practice, whereas the last three chapters examined the responses of people responsible for such knowledge and practice. Chapter 1 used narratives on the differential application of a diagnosis of post–traumatic stress disorder to veterans and detainees as a window into the role of psychiatric power in determining disability. Chapter 2 focused on medicolegal debates and arguments to ponder how cultural values inform ethical practices in light of reinterpreted legal frameworks. Chapter 3 randomly selected cases in the military commissions system at Guantánamo to trace the process and arguments of legal teams for detainees requesting mental health evaluations. However, those responsible for creating mental health knowledge and practice are not just recipients of government dictates, but also manufacturers of new forms of culture. Chapter 4 directed attention to discrepant representations of Arabs and Muslims in the psychodynamic and psychoanalytic literatures. Chapter 5 assessed models of pathology to explain suicide bombing. Chapter 6 concentrated on the role of mental health professionals in conceptualizing, developing, and assessing the deradicalization of militant Islamists.
Discourse analysis not only discloses power-knowledge relationships within texts but also presents a method of understanding a historical episteme, defined as “the divergences, the distances, the oppositions, the differences” of a time period (Foucault 1991, 55). This method allows us to move beyond the idea of an independent author writing without any cultural influences so that we map the range of ideas within boundaries of intellectual domains. Assuming that an episteme comprises multiple discourses, we can look at intradiscursive, interdiscursive, and extradiscursive transformations to formulate hypotheses about the history of ideas. I understand intradiscursive as ideas within an intellectual domain, interdiscursive as common ideas among intellectual domains, and extradiscursive as external ideas influencing an intellectual domain. Each chapter has focused on intradiscursive differences by categorizing ideas within a selection of texts in that discourse. At this point, we can now speculate on interdiscursive transformations throughout the War on Terror:
1. The salience of trauma in contemporary thought: Post–traumatic stress disorder (PTSD) emerged as a new cultural form of knowledge with the return of American veterans after the Vietnam War (Young 1995). PTSD has become a symbol of meanings for detainees wishing to contest the conditions of their confinement (chapter 3) and an explanatory model for causes of suicide bombing (chapter 5). The field of trauma has expanded to include any type of knowledge that can classify the actions of others—even enemy detainees—afflicted by violence. Trauma serves as a cultural prototype to explain how events outside of the self come to influence one’s psychology.
2. The management of terrorism as a military problem that necessitates new knowledge, practice, institutions, and resources rather than a problem handled through extant mechanisms of law enforcement: Because of reconfigured international laws and treaties, bioethicists have debated ethical practices among military health professionals (chapter 2), and the Office of Military Commissions has enacted new procedures for mental health evaluations (chapter 3). Mental health professionals have also contributed to counterterrorism knowledge and practice through deradicalization programs (chapter 6). The War on Terror is seen as a “state of exception” that needs unprecedented legal solutions. In bioethical debates and mental health evaluations at Guantánamo, the government has transformed mental health. However, mental health has also transformed counterterrorism policies by lending new vocabularies and concepts to deradicalization programs. Terrorism is managed as a problem at the intersection of mental health and legal cultures: why are the terrorists the way they are (mental health) and how can we dissuade or prosecute them (legal)?
3. The medicalization and racialization of violence to Arabs and Muslims: The last three chapters prove this point most forcefully. Psychodynamic models of the mind, the self, and family have been used to explain violent tendencies among Arabs and Muslims through literary styles of medical Orientalism (chapter 4). Authors on suicide bombing adopt this perspective to call for “moderate” Arab and Muslim leaders to promote nonviolence (chapter 5). Ironically, texts from al-Qaeda also exhibit East/West divisions in Orientalist fashion to issue religious justifications for suicide bombing, further perpetuating the racialization of violence (chapter 5). The notion that “faulty” or “corrupt” religious beliefs are responsible for violence then leads certain mental health professionals to propose deradicalization models based on theological reform rather than secular concepts (chapter 6). Religious reform recalls psychiatric treatments based on notions of right and wrong (“moral treatment”) rather than biological understandings of pathology (Bockoven 1963; Foucault 1988, 2006; Gold 2010; Scull 1989). The medicalization and racialization of violence destabilizes boundaries between intellectual domains across such fields as “religion,” “medicine,” and “politics.”
The themes of terror management and the medicalization and racialization of violence to Arabs and Muslims also correspond to social realities outside of texts. Since 9/11, Arab and Muslim communities in the United States and Canada have been forced to apologize for others and to express patriotism (Howell and Shryock 2003; Rousseau and Jamil 2008). Public opinion polls have shown that majorities of Americans do not understand the basic teachings and tenets of Islam, yet feel that the religion is “very different” from theirs and that the 9/11 attacks represent Islam “to a great degree” or “to some degree” (Panagopoulos 2006). Suspicions against Arabs and Muslims led to the passage of measures such as the USA PATRIOT Act to protect “an American Us” against the “dangerous immigrant Other” (Ewing 2008, 2) through surveillance, internment, imprisonment, and interrogation with vast amounts of funding for a new security regime (Ernst 2013). This idea of a “dangerous immigrant Other” conflates Arabs with Muslims in the media and in political writings without recognizing internal differences (Lawrence 2011). These themes of racializing violence to Arabs and Muslims pervade mental health texts, and the extent of this thought merits future examination in other genres of medical and psychiatric writings. These texts routinely seem to overlook that the violent actions of a few individuals cannot be generalized to an entire ethnicity or religion. Authors prefer to adopt broad sociological explanations to explain violence through ethnicity and religion rather than analyze commonalities that predispose individuals to such violence.
The literary and cultural critic Homi Bhabha writes: “We have to learn to negotiate ‘incommensurable’ or conflictual social and cultural difference while maintaining the ‘intimacy’ of our inter-cultural existence and transnational associations” (2003, 31). To what extent have mental health professionals successfully negotiated cultural differences within the intimacy of coexistence? Cultural competence initiatives in mental health arose in the late 1960s and early 1970s in conjunction with the civil rights movement, the growing population of immigrants and refugees, and a greater desire for social activism in medicine (Shaw and Armin 2011). The unintended consequences of such programs have been that medical professionals tend to reduce culture to outdated notions of race and ethnicity or to assume that people fit within broad racial and ethnic categories without exploring individual identities (Carpenter-Song, Schwallie, and Longhofer 2007; Jenks 2011). If one goal of cultural psychiatry is to continuously interrogate its bases of knowledge and practice (Kirmayer 2007), then we must acknowledge the complicit role of mental health professionals in medicalizing and racializing purported social and cultural differences. Foucault (2003) contended that “racism is inscribed as the basic mechanism of power, as it is exercised in modern States” (254) as “a way of separating the groups that exist within a population” (255). We have witnessed throughout this book that mental health professionals may willingly separate and classify populations by race even without the need for state intervention. Racialized medicine persists as the looming sinister shadow of cultural competence.
How can we change this situation? Since culture is a concept that has captivated scholars in many disciplines, a multidisciplinary approach can stem the tides of racialized medicine and medical Orientalism. Cultural psychiatrists can continue to examine representations of racial and ethnic minority groups in mental health knowledge and practice. Recent work has shown how African Americans in the 1960s were diagnosed with schizophrenia based on their sympathies with the civil rights movement (Metzl 2010) and how treatment non-adherence among Latinos is assumed to be the result of ethnic rather than socioeconomic factors (Santiago-Irizarry 2001). Globalization calls our attention to how global flows of information and capital affect local contexts (Kearney 1995); social scientists can conduct ethnographies to inspect how ideas prevalent in War on Terror discourse appear in everyday psychiatric practice and institutions around the world, as in deradicalization programs or interviews with former stakeholders at Guantánamo. In addition, newer methods in Islamic and Middle Eastern studies have attempted to move beyond Orientalism by connecting the study of texts to contemporary questions and debates (Ernst and Martin 2010), and medical discourse offers new textual sources for analysis among scholars of religion.
At the same time, we should continue to pursue cultural studies of biomedicine and the law, and especially at their intersections for those of us interested in health law, legal medicine, or forensic psychiatry. The forensic functions framework offers an interpretive method for scholars in the social sciences and humanities, the law, and mental health to pursue comparative cultural studies of mental health knowledge and practice across time and place. I favor a multidisciplinary attitude to cross-cultural analysis to incorporate scholarship in the humanities and social sciences beyond the prevailing medical paradigms of biological and clinical research. Only then can we truly, comprehensively appraise how the War on Terror has changed medicine and how medicine has changed the War on Terror.