To the Editor: I was delighted to read Griffeth and Bally's timely article in the February issue. Last year I was called to active duty as chief psychiatrist of Task Force 344 Med, whose mission at Forward Operating Base Abu Ghraib, Iraq, included care of thousands of foreign detainees in U.S. custody. Indeed, the problem of unreliability of assessment information is significant and due not only to linguistic and cultural barriers but also to socioeconomic differences and to the distortion of information unique to wartime circumstances.
Detainees are a heterogeneous group, including terrorist masterminds, lower-level street thugs, innocents caught in the wrong place at the wrong time, and medically ill opportunists incarcerating themselves to obtain U.S. medical care. Reports of hopelessness and suicidality were not uncommon. Some developed symptoms at the onset of incarceration; others presented later, after long family separation and mounting frustration at the pace of the Iraqi justice system.
One phenomenon seen repeatedly was that a single intervention with detainees who reported suicidal ideation was often sufficient to relieve such ideation and restore adaptive thinking and behavior. The pattern of symptoms and response seems to validate the "social integration" theories of Okasha that are cited by the Griffeth and Bally (1). Intervention often took the form of a heated discussion on a variety of topics ranging from hope versus despair, to the current affairs and future of Iraq, to questions of God's benevolence, to the feelings of the American people toward Iraqis and Arabs. Interventions were held out of earshot of other prisoners but, typically, within their line of sight. To give a prisoner in a yellow jumpsuit and sandals an audience with a field-grade U.S. Army officer in "full battle rattle," with a military entourage of other officers and enlisted team members, likely conferred a sense of respect for the individual's opinions and elevated the detainee's self-esteem, even if only temporarily.
I found it useful to acknowledge that I could not accelerate the resolution of their legal situation, but as a U.S. Army officer, I could assure them respect for their rights and dignity, safety while in U.S. custody, opportunity to redress grievances, and access to medical care. Detainees often expressed gratitude and affirmed a restoration of their will to live and to cope with life in the camps.
We do not know what individual patients told their tent-mates after these intense interlocutory sessions; patients could have offered any explanation, including one that further enhanced their esteem in the eyes of other detainees. In line with the theories of Okasha, it is plausible that an audience with "the American Army officers" altered the patient's status and role within his immediate social group and thereby played a therapeutic role in altering his mental status.
Regarding language barriers: over the course of a tour of duty, one can learn dozens of Arabic words and phrases. To begin and end conversations directly with patients in their native language and to communicate such thoughts as, "Kulna Ichwan?" ("Are not all men brothers?") or "Inshallah, t'kon zien" ("With God's help, may you be well") helps break down barriers and advance a therapeutic alliance.
Dr. Pastor, who is a lieutenant colonel in the U.S. Army Reserve, is associate clinical professor of psychiatry and human behavior at George Washington University Medical Center in Washington, D.C., and assistant adjunct professor at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
1.Okasha A: Mental health in the Middle East: an Egyptian perspective. Clinical Psychology Review 19:917-933, 1999