NOTES
1. MENTAL HEALTH, CULTURE, AND POWER IN THE WAR ON TERROR
1    The name of the institution has been changed to protect the identities of patients and employees.
2    I have changed Brian’s name, dates, and family information to protect his identity. His clinical presentation and our exchange are accurately reflected.
3    The diagnostic criteria for PTSD from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) were operational at this time. Criteria for DSM-IV disorders are provided throughout the chapter for unfamiliar readers.
4    According to DSM-IV-TR criteria, alcohol abuse is defined as “a maladaptive pattern of drinking, leading to clinically significant impairment or distress, manifested by at least one of the following within a 12-month period: recurrent use of alcohol resulting in a failure to fulfill major role obligations at work, school, or home … ; recurrent alcohol use in situations in which it is physically hazardous … ; recurrent alcohol-related legal problems … ; continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.” The term “rule out” indicates that not enough information exists to make a full diagnosis.
5    The American military’s acceptance of PTSD contrasts with the British military’s, as British soldiers have rejected psychiatric explanations for Gulf War Syndrome, linking cultural conceptions of masculinity, toughness, strength, and the “stiff upper lip” to mental health (Kilshaw 2008). Therefore, the VA system’s compensation by PTSD-related disability can be seen as an American cultural phenomenon.
6    Mohamed’s account is further explored in Aggarwal 2009a.
7    I develop this point extensively in chapter 3, on forensic mental health proceedings at Guantánamo.
8    This budget includes treatment for veterans of all wars, not just the War on Terror.
9    My critiques of the American military’s differential use of PTSD for veterans and detainees should not be misread. I have provided direct care to veterans who have served the country honorably and meet criteria for diagnoses of PTSD. Brian clearly represents a minority among veterans. I am also not advocating for extending PTSD to all detainees in American custody. I am simply pointing out that social and cultural forces influence diagnostic meaning making.
10  Kleinman (1995) later disavowed this theory as representative of “functionalism,” an outmoded research tradition in anthropology. Nonetheless, this theory has value for hypothesis testing in cultural mental health research and can serve as a starting point to analyze interrelationships among mental health, culture, and power in forensic health systems.
11  Clinical and forensic functions can occur within the same patient-clinician relationship. For example, patients who are involuntarily committed may eventually view their clinical circumstances as therapeutic. Alternatively, a clinician who does not interpret disease at the beginning of a patient’s illness experiences may confirm a diagnosis after detecting symptoms.
12  Rosner (2003, 3) lists the numerous psychiatric-legal issues under consideration: civil forensic psychiatry: “conservators and guardianships, child custody determinations, parental competence, termination of parental rights, child abuse, child neglect, psychiatric disability determinations (e.g., for social security, workers’ compensation, private insurance coverage), testamentary capacity, psychiatric negligence and malpractice, personal injury litigation issues”; criminal forensic psychiatry: “competence to stand trial, competence to enter a plea, testimonial capacity, voluntariness of confessions, insanity defense(s), diminished capacity, sentencing considerations, release of persons who have been acquitted by reason of insanity”; and legal regulation of psychiatry: “civil involuntary commitment, voluntary hospitalization, confidentiality, right to treatment, right to refuse treatment, informed consent, professional liability, ethical guidelines.”
13  I have modified Kleinman 1980 and Rosen 2003 to elaborate the forensic functions model.
14  The sociology of scientific knowledge represents a formidable tradition with an extensive literature. See Collins 1995, Franklin 1995, and Shapin 1995, among others.
15  This book is overtly concerned with medicolegal issues, specifically forensic knowledge and practice for those considered enemies in the War on Terror. The clinical services of soldiers, civilians, and others of a healing nature lie outside the scope of this book.
16  Several objections could be raised to this methodology: First, I am, in effect, creating a discourse where none may exist by aggregating publications on the basis of search terms. I would counter that any qualitative researcher must decide how to delimit a discourse. By presenting the search strategies for each chapter, I allow others to evaluate the merits of my search. I reflexively call attention to the co-construction of discourse as a finite set of texts as well as an object of study. Second, I have not selected other databases. I would counter that since medical researchers use these databases the most, then they represent accurate opinions in these scientific communities.
17  I am not against these types of literature reviews and syntheses. I am merely pointing out that their goals differ from the goals of this book.
18  Critical discourse analysis (CDA) examines the processes of social change in their discursive aspects (Fairclough 2001). Fairclough (2001) lists assumptions of CDA that I accept for medical discourse analysis.
2. BIOETHICS AND THE CONDUCT OF MENTAL HEALTH PROFESSIONALS IN THE WAR ON TERROR
1    The Geneva Conventions constitute four treaties (dated 1864, 1906, 1929, and 1949) and three protocols (1977, 1977, 2005) that form the basis of international law on the humanitarian conduct of war among countries.
2    Many bioethicists have disputed these critiques. For example, the social scientists cited above have recommended that bioethicists utilize ethnography as a methodology to demonstrate the cultural bases of morality. However, ethnography has been criticized for cataloging ephemeral situations through impressionistic analyses whose results cannot be corroborated (Herrera 2008). Ethnography may also yield interesting information on bioethical conflicts, but does not actually help bioethicists resolve conflicts (Bracanovic 2011; Callahan 1999). Bioethicists have responded that universal ethical principles are needed to protect the world from groups such as the Nazis, who used cultural beliefs to justify the killing of others (Callahan 2000).
3    In accordance with protocols of systematic reviews whose rigor I seek to adopt for medical discourse analysis, I present the search strategy in full for this chapter. Search 1: ethics OR ethical; Search 2: bioethics OR bioethical; Search 3: “Abu Ghraib” OR “War on Terror” OR Guantánamo; Search 4: (Search 1 OR Search 2) AND Search 3. The search produced 49 results on July 2, 2013.
4    Miles quotes Article 33 of the Geneva Conventions from August 12, 1949, which reads: “Although they shall be subject to the internal discipline of the camp in which they are retained, such personnel may not be compelled to carry out any work other than that concerned with their medical or religious duties.”
5    The Federal Bureau of Prisons explains: “The decision to force treatment upon the inmate is a medical decision, preferably by a written physician’s order, with potential legal implications. When it appears to medical staff that the inmate’s condition is deteriorating to the extent that intervention may soon be required, the Regional Counsel must be notified so any legal issues may be addressed. Although legal counsel has been notified, medical staff should not suspend or delay involuntary treatment if the physician is convinced to a reasonable medical certainty that there is an immediate threat to the inmate’s life, or permanent damage to the inmate’s health. Regional Counsel will determine whether it is appropriate to contact the local U.S. Attorney’s Office” (U.S. Department of Justice, Federal Bureau of Prisons 2005).
6    The Eighth Amendment of the U.S. Constitution: “Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.”
7    Common Article Three of the Geneva Conventions:
In the case of armed conflict not of an international character occurring in the territory of one of the High Contracting Parties, each Party to the conflict shall be bound to apply, as a minimum, the following provisions: (1) Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed ‘hors de combat’ by sickness, wounds, detention, or any other cause, shall in all circumstances be treated humanely, without any adverse distinction founded on race, colour, religion or faith, sex, birth or wealth, or any other similar criteria. To this end, the following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above-mentioned persons: (a) violence to life and person, in particular murder of all kinds, mutilation, cruel treatment and torture; (b) taking of hostages; (c) outrages upon personal dignity, in particular humiliating and degrading treatment; (d) the passing of sentences and the carrying out of executions without previous judgment pronounced by a regularly constituted court, affording all the judicial guarantees which are recognized as indispensable by civilized peoples.
(2) The wounded and sick shall be collected and cared for. An impartial humanitarian body, such as the International Committee of the Red Cross, may offer its services to the Parties to the conflict. The Parties to the conflict should further endeavour to bring into force, by means of special agreements, all or part of the other provisions of the present Convention. The application of the preceding provisions shall not affect the legal status of the Parties to the conflict.
8    In a memorandum for William J. Haynes II, then General Counsel for the Department of Defense, dated January 9, 2002, Deputy Assistant Attorney General John Yoo wrote: “We conclude that these treaties do not protect members of the al Qaeda organization, which as a non-State actor cannot be a party to the international agreements governing war. We further conclude that these treaties do not apply to the Taliban militia … Al Qaeda is merely a violent political movement or organization and not a nation-state. As a result, it is ineligible to be a signatory to any treaty. Because of the novel nature of this conflict, moreover, we do not believe that al Qaeda would be included in noninternational forms of armed conflict to which some provisions of the Geneva Conventions might apply” (Yoo 2002).
9    From Hamdan v. Rumsfeld:
There is at least one provision of the Geneva Conventions that applies here even if the relevant conflict is not one between signatories. Article 3, often referred to as Common Article 3 because, like Article 2, it appears in all four Geneva Conventions, provides that in a ‘conflict not of an international character occurring in the territory of one of the High Contracting Parties, each Party to the conflict shall be bound to apply, as a minimum,’ certain provisions protecting ‘[p]ersons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by … detention.’ Id., at 3318. One such provision prohibits ‘the passing of sentences and the carrying out of executions without previous judgment pronounced by a regularly constituted court affording all the judicial guarantees which are recognized as indispensable by civilized peoples.’ Ibid. The Court of Appeals thought, and the Government asserts, that Common Article 3 does not apply to Hamdan because the conflict with al Qaeda, being ‘ “international in scope,” ’ does not qualify as a ‘ “conflict not of an international character.” ’ 415 F. 3d, at 41. That reasoning is erroneous. The term ‘conflict not of an international character’ is used here in contradistinction to a conflict between nations. So much is demonstrated by the ‘fundamental logic [of] the Convention’s provisions on its application.’ Id., at 44 (Williams, J., concurring). Common Article 2 provides that ‘the present Convention shall apply to all cases of declared war or of any other armed conflict which may arise between two or more of the High Contracting Parties.’ 6 U.S. T., at 3318 (Art. 2, ¶1). High Contracting Parties (signatories) also must abide by all terms of the Conventions vis-à-vis one another even if one party to the conflict is a nonsignatory ‘Power,’ and must so abide vis-à-vis the nonsignatory if ‘the latter accepts and applies’ those terms. Ibid. (Art. 2, ¶3). Common Article 3, by contrast, affords some minimal protection, falling short of full protection under the Conventions, to individuals associated with neither a signatory nor even a nonsignatory ‘Power’ who are involved in a conflict ‘in the territory of’ a signatory. The latter kind of conflict is distinguishable from the conflict described in Common Article 2 chiefly because it does not involve a clash between nations (whether signatories or not).
(Supreme Court of the United States 2005)
10  “As provided by the Constitution and by this section, the President has the authority for the United States to interpret the meaning and application of the Geneva Conventions and to promulgate higher standards and administrative regulations for violations of treaty obligations which are not grave breaches of the Geneva Conventions” (Military Commission Act of 2006).
11  Article 16 of Additional Protocol I on the General Protection of Medical Duties: “1. Under no circumstances shall any person be punished for carrying out medical activities compatible with medical ethics, regardless of the person benefiting therefrom. 2. Persons engaged in medical activities shall not be compelled to perform acts or to carry out work contrary to the rules of medical ethics or to other medical rules designed for the benefit of the wounded and sick or to the provisions of the Conventions or of this Protocol, or to refrain from performing acts or from carrying out work required by those rules and provisions. 3. No person engaged in medical activities shall be compelled to give to anyone belonging either to an adverse Party, or to his own Party except as required by the law of the latter Party, any information concerning the wounded and sick who are, or who have been, under his care, if such information would, in his opinion, prove harmful to the patients concerned or to their families. Regulations for the compulsory notification of communicable diseases shall, however, be respected” (International Committee of the Red Cross 1977).
3. THE MEANINGS OF SYMPTOMS AND SERVICES FOR GUANTÁNAMO DETAINEES
1    Although I have opted for the spelling “Guantánamo,” I retain the original “Guantanamo” when present in the works of others.
2    The official title of the Walsh Report is the Review of Department Compliance with President’s Executive Order on Detainee Conditions of Confinement.
3    President Obama also issued a signing statement in December 2013 upon signing the National Defense Authorization Act of Fiscal Year 2014: “The detention facility at Guantanamo continues to impose significant costs on the American people. I am encouraged that this Act provides the Executive greater flexibility to transfer Guantanamo detainees abroad, and look forward to working with the Congress to take the additional steps needed to close the facility. In the event that the restrictions on the transfer of Guantanamo detainees in sections 1034 and 1035 operate in a manner that violates constitutional separation of powers principles, my Administration will implement them in a manner that avoids the constitutional conflict” (White House 2013b).
4    Available at: http://www.mc.mil/CASES/MilitaryCommissions.aspx. As of this book’s preparation, all of the Internet links in this chapter were current.
5    MCA 2006’s exact definition: “The term “unlawful enemy combatant” means— “(i) a person who has engaged in hostilities or who has purposefully and materially supported hostilities against the United States or its co-belligerents who is not a lawful enemy combatant (including a person who is part of the Taliban, al Qaeda, or associated forces)”; or “(ii) a person who, before, on, or after the date of the enactment of the Military Commissions Act of 2006, has been determined to be an unlawful enemy combatant by a Combatant Status Review Tribunal or another competent tribunal established under the authority of the President or the Secretary of Defense” (Military Commissions Act of 2006, 3).
6    “Who may convene military commissions. A military commission may be convened by the Secretary of Defense or persons occupying positions designated as a convening authority by the Secretary of Defense. The power to convene military commissions may not be delegated” (Department of Defense 2006b, 27).
7    Interestingly, RMC 706 also discriminates “bad” antisocial conduct from otherwise “mad” mental disorders as Rhodes (2000) has pointed out in her work within the American prison system.
8    This list was compiled on March 14, 2013, based on OMC’s website.
9    The National Institute of Military Justice (NIMJ) expressed reservations that Kamin was declared competent to stand trial without meeting the board. The NIMJ is a nonprofit organization composed mostly of former military lawyers committed to military justice, invited by OMC for impartial observation (Aggarwal 2009a).
4. DEPICTIONS OF ARABS AND MUSLIMS IN PSYCHODYNAMIC SCHOLARSHIP
1    Psychoanalytic treatment typically requires greater length and frequency of work compared to psychodynamic treatment, though many authors use the terms interchangeably and definitions are in dispute (Jacobs 1994).
2    See Eisenberg (1986) and Lipowski (1989) for representative arguments.
3    Said also referred to East Asian populations as a part of the West’s fascination with the “Orient,” but I concentrate on the Middle East in this chapter.
4    These mentions occur on pages 78, 79, and 162 (Said 1994). He treats scientific Orientalism with greater depth.
5    I retain Said’s terms “power political,” “power intellectual,” “power cultural,” and “power moral” throughout the chapter.
6    I updated this search on June 18, 2013. The search produced 570 records on the first round.
7    Freud proposed the term “Oedipal complex” based on the archetype of the Greek protagonist Oedipus: “It is the fate of all of us, perhaps, to direct our first sexual impulse towards our mother and our first hatred and our first murderous wish against our father” (1965, 296).
5. DEPICTIONS OF SUICIDE BOMBERS IN THE MENTAL HEALTH SCHOLARSHIP
1    My analysis of texts on suicide bombing from outsider (mental health professionals) and insider (al-Qaeda) perspectives resembles anthropological methods of studying etic (external) and emic (internal) approaches to language and behavior (Pike 1954).
2    Social scientists frequently group psychiatry, psychology and other mental health professions together as the “psy” disciplines, since they all study the psyche and its afflictions. Such a designation disregards the different theoretical approaches and practices employed by the different disciplines (Rose 1998).
3    Howell uses the term “racialize” to discuss how suicide bombing and martyrdom have become attributed to Muslims. Although Muslims do not constitute a “race” as much as a religion, I retain the terms “racialize” and “racialization” in dialogue with her work.
4    Mental health authors have variously used these terms based on their political views (Aggarwal 2009b, 2010b). I updated this search on June 25, 2013, which produced 307 records on the first round.
5    For example, the search excluded articles on treatments for victims of suicide attacks.
6    I recognize that authors who have trained in other disciplines could be housed in departments of psychiatry and psychology, just as psychiatrists and psychologists could be housed in other departments. Suicide bombing corresponds to what Fairclough (2001) calls a “nodal discourse,” in that it covers multiple types of knowledge written by scholars in political science, international relations, and other fields. I am interested specifically in mental health representations of suicide bombers.
7    Umma is an Arabic word used to refer to the Muslim community.
8    The dissociative disorders in DSM-IV are characterized by impairments in identity, memory, awareness, and/or perception (American Psychiatric Association 2000).
9    Benedict writes: “In anthropological studies of different cultures the distinction between those which rely heavily on shame and those that rely heavily on guilt is an important one. A society that inculcates absolute standards of morality and relies on men’s developing a conscience is a guilt culture by definition. … In a culture where shame is a major sanction, people are chagrined about acts which we expect people to feel guilty about” (2005, 222).
6. KNOWLEDGE AND PRACTICE IN WAR ON TERROR DERADICALIZATION PROGRAMS
1    For example, the search excluded publications on deradicalization in other conflicts such as programs for Sinn Fein militants during the Irish movement for independence in the 1980s and 1990s.
2    “A cognitive behavioral model is therefore concerned with the cognitive activities that surround behavioral events and seeks to determine how anticipatory, concurrent, and post hoc cognitions contribute to adaptive and maladaptive patterns of behavior” (Kendall 1985, 360). See Beck et al. (1979) for the classic exposition of cognitive behavioral therapy.
3    The War on Terror exemplifies the dark side of globalization with war now waged against internal and external enemies of the state led by the United States of America (Medovoi 2007).
4    Commentators differ over which verses can abrogate others, a contentious issue since the Quran is considered to be the word of God (McAuliffe 2006).
5    For example: “The prevalent opinion is that all verses on jihad cannot be interpreted independently of each other. They are to be studied together to derive the true understanding of jihad in Islam. In this respect, the Muslim scholars have agreed that verses which are general and unconditional must be interpreted as conditional. Thus, the meaning of verses from chapter 9, which is unconditional, would fall under the meaning of the verses; fight the non-Muslims only when they fight you” (Hassan 2006, 42).