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

MENTAL HEALTH IN THE WAR ON TERROR

Mental Health in the War on Terror

CULTURE, SCIENCE, AND STATECRAFT

Neil Krishan Aggarwal

    COLUMBIA UNIVERSITY PRESS    NEW YORK

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E-ISBN 978-0-231-53844-2

Library of Congress Cataloging-in-Publication Data

Aggarwal, Neil Krishan, author.

Mental health in the war on terror : culture, science, and statecraft / Neil Krishan Aggarwal.

      p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-231-16664-5 (cloth : alk. paper) — ISBN 978-0-231-53844-2 (e-book)

I. Title.

[DNLM: 1. Mental Health—ethnology—United States. 2. Bioethical Issues—United States. 3. Prisoners of War—psychology—United States. 4. Terrorism—psychology—United States. 5. Veterans—psychology—United States. WA 305 AA1]

RC451.4.p7

616.890086'97—dc23

2014020991

A Columbia University Press E-book.

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Cover image: © AP Photo/Brennan Linsley

References to websites (URLs) were accurate at the time of writing. Neither the author nor Columbia University Press is responsible for URLs that may have expired or changed since the manuscript was prepared.

The question or questions that have to be asked are: What types of knowledge are you trying to disqualify when you say that you are a science? What speaking subject, what discursive subject, what subject of experience and knowledge are you trying to minorize when you begin to say: ‘I speak this discourse, I am speaking a scientific discourse, and I am a scientist.’ What theoretico-political vanguard are you trying to put on the throne in order to detach it from all the massive, circulating, and discontinuous forms that knowledge can take?

—Michel Foucault, Society Must Be Defended

CONTENTS

PREFACE

ACKNOWLEDGMENTS

CHAPTER ONE

   Mental Health, Culture, and Power in the War on Terror

CHAPTER TWO

   Bioethics and the Conduct of Mental Health Professionals in the War on Terror

CHAPTER THREE

   The Meanings of Symptoms and Services for Guantánamo Detainees

CHAPTER FOUR

   Depictions of Arabs and Muslims in Psychodynamic Scholarship

CHAPTER FIVE

   Depictions of Suicide Bombers in the Mental Health Scholarship

CHAPTER SIX

   Knowledge and Practice in War on Terror Deradicalization Programs

EPILOGUE

NOTES

REFERENCES

INDEX

PREFACE

FOUCAULT’S PENETRATING INSIGHTS INTO THE connections between knowledge and power, between science and politics, have gripped me since the declaration of the War on Terror. I entered medical school in 2000 and watched the 9/11 attacks unfold on live television. As I attended medical conferences, I began perceiving the creeping influence of politics within academic discussions: bioethicists debated the philosophical grounds for torture, and psychiatrists conjectured about the irrational motivations of suicide bombers. Medical scientists placed certain theoretico-political vanguards related to national security on the throne of science at this exceptional moment of American history. What perspectives were becoming minorized and majorized in the War on Terror, and how did these perspectives immortalize cultural values, beliefs, and orientations as scientific knowledge? In a broad sense, how has the War on Terror changed medicine, and how has medicine changed the War on Terror?

The goal of this book is to analyze the cultural meanings of mental health knowledge and practice produced throughout the War on Terror. My frameworks for studying the interrelationships of mental health, culture, and power come primarily from cultural psychiatry and medical anthropology. Central to both disciplines is the tenet that medical systems are cultural systems with beliefs, behaviors, and meanings transacted among individuals in social institutions. I aim to show through a wide array of materials that we can study medical systems in the War on Terror as cultural systems. These source materials include government documents; reports and position papers from nongovernmental organizations; legal files such as charge sheets, motions, rulings, and transcripts; direct and indirect interviews; newspaper articles; and scholarly publications. These analyses are not intended against the mental health system as a whole, and they certainly do not belong to the antipsychiatry movement. As a psychiatric clinician and researcher, I have witnessed the healing power of effective medications and psychotherapy. However, mental health suffers from a long history of stigma in much of the world. The peculiar cultural construction of mental health knowledge and practice in response to the War on Terror may exacerbate this mistrust. This book is not an exhaustive catalog of mental health knowledge and practice in the War on Terror, nor is it meant to be polemical or apologetic. On the contrary, the book takes seriously the idea that mental health routinely faces sharp challenges from the state. Mental health knowledge lends itself to conflicts of interest between the individual and society because it is employed in practice to differentiate normal and abnormal states of being within society. The state may wish to punish undesirable populations, and political uses of psychiatry may result when mental health professionals work uncritically toward state interests.

This book appears at a time when three cultural trends have affected medicine. First, most attention to mental health in the War on Terror has centered on bioethical debates. While mental health professionals involved in coercive interrogations or questionable clinical practices certainly deserve scrutiny, bioethical violations represent a larger issue of employing mental health knowledge and practice to advance the goals of statecraft. Investigating this larger issue is the goal of this book. Second, cultural psychiatry has typically drawn upon many disciplines—psychology, sociology, anthropology, and cultural studies—to create a vibrant specialty that understands mental health and illness in its social and cultural contexts. The rise of evidence-based medicine has disqualified ways of knowing and learning aside from large clinical trials. In my capacity as a psychiatric researcher and educator, I worry that our trainees ignore the social sciences and humanities, which have much to teach us about those areas of life, such as birth, death, pain, and suffering, to which medicine should not lay exclusive claim. Third, the representation of Muslims and Islam in medical scholarship has often gone unchecked. Many stereotypes that would not be countenanced for other groups are willingly tolerated and even promoted. Scholars of religion and cultural psychiatrists can collaborate to ensure that such negativity is not disseminated under the guise of science. I hope that this book will stimulate critical discussions around the cultures of biomedicine through incisive examinations of its professional literature.

ACKNOWLEDGMENTS

I HAVE INCURRED MANY DEBTS in writing this book. Several people wished me well throughout its execution. In 2000, Amer Sidani, Rachna Dave, Omer Bokhari, and Moustafa Banna first suggested that I write. In 2003, Ravjot Singh Pasricha and Arun Janikaraman encouraged the process. In 2011, Nimay Mehta told me that he would be the first to purchase the book. Parvinder Thiara and Luvleen Sidhu supported the book through its end in 2013. Ricky Shah and Samir Rao helped me consider how to market the book. Thank you to you all.

My teachers at Sewickley Academy cultivated my love for learning. Kenneth Goleski, Sira Metzinger, and Karen Coleman helped me discover a capacity for languages; Larry Hall, Peter Golding, and Ham Clark encouraged me to question authority through polite but incisive arguments; Bill Barnes, Joan Reteshka, and Larry Connolly taught me to write; Vicki Polinko and the late Barbara Salak refined my aesthetic sense. At Case Western Reserve University, Marie Pierre Le-Hir, Jackie Nanfito, and Vincent McHale pushed me in supervising my theses. Atwood Gaines, James Pfeiffer, and Rachel Chapman introduced me to medical anthropology.

In medical school, Paul Farmer challenged me to think about applying social theory to clinical medicine and sustained a three-year correspondence with me as I considered graduate school. Joy Marshall, Stuart Youngner, and Max Mehlmann encouraged me not to relinquish my interests in the social and cultural determinants of health. Jerrold Post exposed me to the intellectual borderlands between psychiatry and political theory. These rewarding experiences drew me to Harvard University and my most formidable academic encounters. Early on, Ali Asani grasped that I would work at the intersection of medicine, social theory, and South Asian religions. Michael Witzel, Larry McCrea, Wheeler Thackston, Carl Sharif El-Tobgui, Moustafa Atamnia, Shahab Ahmed, and Sunil Sharma taught me patiently. Discussions of social theory with friends such as Rehan Ali, Dan Sheffield, Mark Breeze, Nick Walters, Aliya Iqbal, Harpreet Singh, Sarah Pinto, Adia Benton, Sharon Abramowitz, Ernesto Martinez, Nabilah Siddiquee, Manata Hashemi, and Sarah Eltantawi have clarified my thoughts considerably. Byron Good pushed me to explore how social theories can be brought into clinical practice. Arthur Kleinman has been a mentor who expects academic excellence.

I used my training at Yale University to develop independent academic and clinical interests. The university chaplain, Sharon Kugler, entrusted me with advising the Hindu community and shared my vision of fostering dialogue between the fields of mental health and religion. Paul Kirwin, Ezra Griffith, Jean Baptiste, Joe Check, Seth Powsner, Claudia Bemis, Deborah Knudson-González, and Eric Berger helped forge my clinical concerns in patient care. My friends Ke Xu, Jessica Chaudhary, Nabyl Tejani, Emily Tejani, Andres Barkil, Frank Appah, Zaheer Kanji, and Bibhav Acharya spent hours discussing cultural psychiatry. Many of them attended my Culture and Mental Health class that introduced the tensions of working with culture in clinical practice through readings in cultural psychiatry and psychiatric anthropology. The constructive criticisms of the class forced me to develop these concepts further. I learned a great deal from discussions on social theory and religion with Hussein Abdulsater, Matt Melvin-Koushki, and Sayeed Rahman.

At Columbia University, the Center of Excellence for Cultural Competence has provided me with a remarkable home. Roberto Lewis-Fernández had shared my vision for making cultural psychiatry relevant to the contemporary practice of all mental health clinicians. More than anyone else, he has taught me that the best academic work requires the patience to read, synthesize scholarship, and analyze relentlessly. Andel Nicasio and Marit Boiler have been warm friends and colleagues. Ravi DeSilva was always available for coffee and thought-provoking discussions. The Cultural Formulation class for the second-year residents has never ceased to make me realize just how insignificant cultural psychiatry can be without daily clinical relevance. Schuyler Henderson was a tough writing partner who propelled this book’s proposal and submission for review. Jennifer Perillo, Stephen Wesley, and the staff at Columbia University Press have been unflinching supporters of this book and struck the rare balance between warmth and professionalism. Though mentioned before, Ezra Griffith and Sarah Pinto also graciously read through the entire manuscript and suggested valuable, constructive revisions.

Finally, I reserve my greatest appreciation for my community. I grew up in Weirton, West Virginia, and attended the Hindu-Jain Temple, which served as the social and cultural headquarters of our expatriate Indian community. I thank this social family and the Vidya Mandir Sunday School for inculcating whatever positive virtues I now have. In particular, Billu and Nilu Aichbhaumik, Amrit and Veena Aggarwal, Vijai and Sarita Singh, Vinita Srivastava, Sarika and Nandu Machiraju, Rajiv Ahuja, and Shawn Badlani encouraged me in various ways to pursue this book. The Mary H. Weir Public Library, my favorite place in Weirton, was where I first learned to read, and I miss this library now that I live in New York City. Dean, Eugenia, and the late familial matriarch also named Eugenia Makricostas have been our Greek American family for three decades. My in-laws, Niraj Nabh and Anshu Kumar, have always treated me more like a son. My sisters-in-law, Reema Aggarwal and Radhika Kumar, have helped me find humor in every situation. I honor the memories of my grandparents, Sarla Aggarwal, Shyam Lal Aggarwal, Kesar Devi Aggarwal, and Nanak Aggarwal, who struggled to establish our families after migrating from Pakistan to India during the Partition of 1947. My parents, Madhu and Krishan Kumar Aggarwal, have furnished me with boundless love. Many Hindus believe that one cannot repay parents except through raising virtuous children, and I hope that I can accomplish this task. My father has always pointed to heroes such as Meera, Kabir, Shivaji, Guru Nanak, and Guru Gobind Singh, who never hesitated to voice concerns about injustice. My father has always supported my dreams, and this book is a testament to his trust, patience, and inspiration. My brother, Manu Aggarwal, has been my best friend for three decades. It is to him and to my wife, Ritambhara Kumar, that this book is dedicated. Ritambhara has been the love of my life ever since we met in Andaaz at Harvard in 2007. May our lives continue to surprise us with unexpected success, happiness, and prosperity, especially now that little Amaya Ishvari has come into our home.

Mental Health, Culture, and Power in the War on Terror

TO ACCESS THE INPATIENT PSYCHIATRIC unit of the East Coast Veteran Affairs Medical Center (ECVA)—the destination for veterans judged imminently suicidal, homicidal, or unable to complete basic activities such as feeding and grooming—each person must clear security checkpoints.¹ Psychiatrists, psychologists, nurses, social workers, secretaries, and other hospital workers present photo identification to a security officer. Patient visitors complete sign-in sheets requiring names, times of entry, destinations, signatures, and times of exit. Patients reach the unit in two ways, always supervised by a security official: either outpatient clinicians who suspect that patients meet criteria for admission consult with clinical supervisors or emergency room clinicians consult with the admitting attending psychiatrist. Clinical supervisors and emergency room psychiatrists then inquire about bed availability from the inpatient charge nurse. In all cases, staff, family members, friends, and patients ascend from the lower floors of surgery and internal medicine to reach the inpatient unit. No one enters or exits the inpatient unit without permission.

Five steps from the elevators, a corridor traverses the length of the hospital floor. A sign directs traffic on the left end to the Special Day Treatment Program (SDTP) and on the right end to the inpatient psychiatric unit. The doors to the SDTP are open throughout the day, permitting views of the entire unit, but the bulky beige doors of the inpatient unit remain shut. SDTP visitors walk to the office area at the center of the unit to check in with staff, but inpatient visitors must step within view of the ceiling-mounted security camera and press the button on the wall for entry. Patients on the SDTP come and go at will during the daytime to visit homeless shelters, group homes, apartments, and potential places of employment as they transition to life outside of the hospital, but inpatients can exit the unit only to attend recreational activities or meet with clinicians in the courtyard downstairs. The SDTP and the inpatient unit are diametrically opposed, both spatially and philosophically.

After graduation from medical school, all psychiatry residents must train in outpatient and inpatient units. The outpatient units treat people with common disorders whose severity does not warrant hospitalization. In contrast, rotations on an inpatient unit accomplish several goals: they familiarize trainees with the most threatening conditions; they introduce trainees to the practices and procedures of inpatient life; they expose trainees to the benefits and challenges of working in multidisciplinary teams of psychiatrists, nurses, psychologists, and social workers with varying experience; and they allow trainees to hone their skills in diagnosis, treatment planning, initiating and monitoring medications and psychotherapy, writing daily notes with requisite information for billing, and consulting with other medical specialists when psychiatric patients suffer from disorders like diabetes or high blood pressure. American psychiatric residency training lasts four years and mixes rotations through different service settings and medical specialties.

I began my psychiatric training in June 2007 after six months of internal medicine and two months of neurology. Working in other specialties imparts the competence to unmask psychiatric disorders from disguised illnesses. In a classic example, the cluster of depressed mood, poor energy, poor appetite, physical sluggishness, and loss of interest in pleasurable activities can be either hypothyroidism or major depressive disorder. The first-line treatments for these problems differ: hypothyroidism requires synthetic thyroid hormone, while major depressive disorder is treated with antidepressants and psychotherapy. On February 29, 2008, the last day of my neurology rotation, I rejoiced at the end of internal medicine and neurology but worried about my knowledge of psychiatry. My knowledge of internal medicine and neurology was rudimentary, but I could treat high blood pressure and high cholesterol better than generalized anxiety disorder or schizophrenia. The ECVA inpatient unit rotation of three months heralded three years of psychiatric rotations designed to remedy this imbalance.

I approached my ECVA rotation with apprehension about my abilities and anxiety about the risk for violence, since inpatient units treat those with the most severe pathologies. I did what was expected before every rotation: the night before, I called the resident who was transitioning off the team to obtain sign out. Sign out, the list of all patients under the care of a specific resident, is provided at times of transition, such as when the night resident on call takes over for the day team or when the resident rotates off a clinical service. Exactly what sign out contains varies by medical specialty, but the patient’s name, age, admission diagnosis, current medications, and plan of action in case of emergency are essential. The resident and I spent a minute each discussing the plan for his five patients as I dutifully recorded all details.

On the first Monday in March 2008, I ascended by elevator to the inpatient unit at eight A.M. I pressed the intercom button: Hi, I’m Neil Aggarwal, one of the new residents starting today.

A voice crackled over the speaker: Hi. Your badge works. Come on in. Just make sure that there aren’t any patients hovering around the door.

I flashed my badge, heard the doors unlock, and walked into the unit. All residents who have rotated away from an inpatient unit for a period of time can find their bearings even in unfamiliar surroundings, intuiting meanings and behaviors associated with space in mere seconds. The locked room on the right side with a closed shutter over the window must be a room for patients and clinicians to meet privately. The large desk ahead bisecting the unit by length like the vertex of the letter T must be the nurses’ workstation. The open doors on both sides of the hall after the workstation must be patient bedrooms. I peered inside a window and saw four men lying in two perpendicular beds against opposite walls. I returned to the workstation, turned my back to the desk, and examined the other hallway. The two doors with grated vents closest to me must be bathrooms. The two locked doors with closed shutters at the end of the hallway must be meeting rooms. The hallway ended at a door different from all the others—made of steel, not wood, and with a conspicuous lock; this must be the entrance to clinician offices.

Behind the workstation desk were two bureaus with several computers, bulletin boards, and a large whiteboard on the right wall behind the inpatient unit secretary: Hi. Write your name and pager number under the line for ‘Residents.’ Here is a schedule for the unit and a key to the doctor offices straight ahead. The wall opened into a nurses’ conference room.

Medical inpatient units contain a large board over a wall in an area visible to clinicians so they can make decisions about admissions and discharges outside of patient view. This design protects individual patient health information from public exposure. The ECVA whiteboard followed a fixed format, with content differentiated by color. A grid in one color with patient initials, admission date, anticipated discharge date, and privileges to leave the unit occupied the vast expanse of the board. Radiating from the grid in a different color were common telephone numbers for different personnel such as patient transport, the emergency room, the main pharmacy, kitchen staff, security, internal medicine consult, dental consult, art therapy, the four psychiatric residents on service, the three attending psychiatrists on the unit, the clinical psychology trainees, the unit clinical psychologist, and the unit social worker. The whiteboard orients clinicians and administrators to the unit’s flux and turbulence like an airplane pilot’s instruments: more patients with recent admission dates imply acute pathology; more patients with restricted exit privileges cue us to disciplinary problems.

I glanced at the paper schedule, also laid out on a grid. On the left side were rows listing daytime hours. On the right side were columns by days of the week. Each cell contained activities by hour. Key activities were common to all medical specialties, such as times for morning rounds, medication dispensation, and general visiting hours. Other activities were peculiar to psychiatry, such as group therapy, art therapy, and times for individual meetings with psychiatrists, psychologists, and social workers. Certain activities were peculiar to the ECVA inpatient unit, such as recreational activities in the courtyard or excursions to the hospital cafeteria for those with exit privileges. The grid explicitly included basic activities: waking, grooming, breakfast, lunch, dinner, and sleeping times. Other than morning rounds, patients had no psychiatric meetings until the afternoon, with the evening reserved for visitors and recreational activities. The schedule focused on patients, not clinicians. I would discover my schedule by talking to others who had previously been in my position.

In that sense, the inpatient unit acculturates patients into patient-hood and physicians into physician-hood through different channels. Its inhabitants operate within a highly regulated time-space continuum. In all societies, people assimilate local knowledge about where they can go and when they can go. Some spaces are always accessible, such as the twenty-four-hour store or our bedrooms. Other spaces, such as workplaces, are accessible only at certain hours. Hospitals function paradoxically: although anyone can come at any time for any medical complaint through the emergency room, only specified people can access inpatient and outpatient units during designated hours. The inpatient unit qualifies as a total institution (Goffman 1961), since sleep, play, and work are regulated by authorities, in the company of others, and tightly scheduled. Staff and inpatients occupy distinct roles with defined rules, punishments, and privileges. For example, I learned from speaking with the attending physician that morning rounds—the practice of discussing the diagnoses and treatment plans for all patients—started between eight thirty and nine thirty A.M. and lasted up to