From civil war to forensic psychiatry.

I was at the 2012 American Academy of Psychiatry and the Law meeting in Montreal last fall when Dr. Stephen Xenakis spoke on the role of psychiatry in 21st century warfare. He described torture in the military and the role of psychiatrists as leaders at times that exacted heavy costs personally and professionally. He discussed the moral dilemmas psychiatrists face in working with the military and with institutions in general. As an example, he presented the case of a military psychiatrist faced with diagnosing posttraumatic stress disorder (PTSD) in a prisoner of war and being reluctant to do so for fear of exposing torture in the military. The assessment raised the question of the role the psychiatrist played in responding to an ethics-related and humanitarian question and, in a way, upholding justice. It was eye-opening to see how many of the audience members were unaware of torture practices and the consequences of war, even when the United States, a nation with existential claims on just practices, is involved. Having been raised in Lebanon during the civil war of 1975 through 1991, surrounded by injustice, I found my personal experience resonating with the talk. It reminded me of the men and women who were apprehended during the war. They were tortured, and some returned, but many did not. In Lebanon, individuals who stood up for justice were at risk of being assassinated. It did not matter if they were politicians, journalists, physicians, construction workers, or homemakers. I do not recall a time when I was unaware of the injustices that came with violence, crime, danger, death, corruption, and war. This is not my story though; this is the shared Lebanese experience, and I know it applies to any warstricken community. The Lebanese civil war was a result of a complex set of political and economic circumstances that could be traced to the fall of the Ottoman Empire after World War I. The creation of Lebanon as a French mandate included the mostly Christian inhabitants of the Lebanese mountains and the mostly Muslim inhabitants of the coastal cities. When Lebanon gained independence from France in 1943, the majority Christian population created a religionbased government in which power would be shared with the Sunni and Shiite Muslim political groups, the second and third largest religious groups in Lebanon. At the same time, representation in the new government would reflect the majority Christian population. By the 1970s, however, demographics had changed, and the majority group was now Shiite. When demands for political reforms were made, the Christians resisted, and all groups formed private militias as a result of a fractious government and military. This background, however, describes the context, but not the fuel for the war. In fact, each group would eventually be divided against itself, and personal vendettas and material gains would come to take precedence over political concerns. Beirut became divided, with Christian East Beirut against Muslim West Beirut, by the Green Line, which was a five-minute drive from our home. This division would play a role in Beirut and other parts of the country. A person would risk his life if he crossed Dr. Alam is a Resident, Psychiatry Training Program, Georgetown University Hospital, Washington, DC. Address correspondence to: Marie Rose J. Alam, Georgetown University Hospital, 2115 Wisconsin Ave NW, Suite 200, Washington, DC 20007. E-mail: [email protected].