Much of Aggarwal’s thoughtful approach in this book is prefigured in its opening lines: “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” (p. ix). Given this beginning, it is fitting that Aggarwal goes on to write as a clinical psychiatrist and anthropologist, as an observer of the War on Terror, and with a Foucauldian eye toward the intersection of medical, legal, social, and political authorities. He sets himself to examine the cultural practices of mental health within the War on Terror, specifically the role of mental health professionals in helping the state define and adjudicate who is normal, who is abnormal, and who is a terrorist.
Aggarwal offers many useful and interesting contributions over the course of this work, but three stand out. First, he turns the lens of cultural analysis directly on forensic psychiatry, which he borrows from the American Academy of Psychiatry and the Law in defining as the “subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts … and in specialized clinical consultations in areas such as risk assessment or employment” (p. 23). By tackling the specific subfield of psychiatry most likely to be called on in adjudicating questions of medicine and law—i.e., determining who is mad and who is bad—Aggarwal confronts the interfaces where mental health and the moralities of culture and state are most clearly on display.
Aggarwal’s second contribution is to propose, in Chapter 1, a framework for examining forensic medicine. Adapting Kleinman’s (1980) model of “core clinical functions” shared by all medical systems, Aggarwal proposes five “forensic functions” of medical systems to explore what he calls the “nonhealing uses of medicine,” including “the cultural construction of a medicolegal issue,” the “procurement of clinical evidence relevant to a medicolegal issue,” and, ultimately, “the legal outcome based on the clinician’s medical opinion” (pp. 23–26).
In the remaining chapters, Aggarwal explores each of these functions as they have occurred across the War on Terror, within the bioethics of mental health professional-aided detainee interrogations (Chapter 2); the strategic uses of mental health diagnoses by legal teams representing detainees at Guantanamo (Chapter 3); the approaches of psychodynamic scholarship to discussions of Arabs and Muslims (Chapter 4); efforts within mental health scholarship to make sense of suicide bombers (Chapter 5); and the development of national “deradicalization” programs aimed at rehabilitating former or potential terrorists (Chapter 6).
Aggarwal’s third main contribution is in considering scientific publications, government transcripts, and policy statements as social artifacts and using discourse analysis as a tool for examining the themes, values, and practices embedded in these documents. He makes a compelling argument early on for the use of discourse analysis in cultural psychiatry, then carries this method throughout each of the chapters/case studies that follow.
His description of his methods is slightly disconcerting in that, while the criteria for literature searches are described in admirable detail, he offers little information on how individual articles or other documents were selected for in-depth analysis, nor on how major themes within those articles were identified. Given that each chapter narrows in on a relatively small body of texts, this ellipsis makes it difficult to understand how selected texts are situated within the wider literature. Similarly, although the topics of each chapter are fascinating, they do not always hang together in a cohesive way. I would have appreciated discussion of how these topics were chosen for examination, and more reflection on their summative value. Even so, the analyses presented within each chapter are rigorous and revealing, both theoretically and topically rich and informative.
Perhaps the least compelling element here is Aggarwal’s answer to two questions he raises early on: “How has the War on Terror impacted medicine, and how has medicine impacted the War on Terror?” (p. 22). Although the questions themselves are riveting, I found few answers here, either within or across the case studies. The availability of material to analyze these questions would seem to be plentiful—few if any wars have been so copiously documented, and few eras of medicine and science so generative—but beyond some useful observations as to the role of trauma as the explanatory category that subsumed all others, these questions are left largely unaddressed.
Nonetheless, this book displays an engaging willingness to consider how changes within knowledge and ethics emerge in particular moments. This may be best illustrated in Aggarwal’s descriptions of how trauma and PTSD are differently constituted and argued among U.S. veterans and Guantanamo combatants in Chapters 1 and 2. Aggarwal articulates the complex medico–legal arguments around PTSD and trauma as its understood catalyst in a clear and incisive way.
To my mind, this book stands as an excellent example of how carefully positioned work can move the field forward—in Aggarwal’s case, by offering a path for understanding how forensic psychiatry can allow us to observe the fault lines between knowledge and power and science and state, and by providing meticulous theory and method to inform the journey. There are moments of valuable insight throughout—a favorite snippet from his discussion of how Arabs and Muslims are described in psychoanalytic writings reads: “Racialized medicine persists as the looming sinister shadow of cultural competence” (p. 161)—and if the rigorous conduct of discourse analysis occasionally threatens to become dry in later chapters, the overarching questions are interesting and provocative.
This text is likely to work well in an upper-level undergraduate or graduate course on medical, legal, or political anthropology or theory; the past few decades of medical anthropology and cultural psychiatry are thoughtfully considered and cited throughout, and individual chapters are likely to function well as discrete readings.
1980 Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. Berkeley: University of California Press.