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Behavioral Health Issues and Detained Individuals

Chapter 40

BEHAVIORAL HEALTH ISSUES AND 

DETAINED INDIVIDUALS

RICHARD TOYE, PhD,* and MARSHALL SMITH, MD†

INTRODUCTION

TRAINING THE TEAM

Predeployment Preparation

The Clinical Process in Detainee Care

Unit Transition

EFFECTIVE USE OF TRANSLATORS

DEVELOPING A TREATMENT PLAN

Behavioral Management Considerations

Medication Management and Distribution

Communicating With Other Sites

SPECIAL CLINICAL ISSUES

HUNGER STRIKES: A UNIQUE DETAINEE CLINICAL ISSUE

Assessment

Intervention

Consultation

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Army Reserve; Company Commander, 883rd Medical Company (Combat Stress Control), 495 Summer 

Street, Boston, Massachusetts 02210; formerly, Brigade Behavioral Health Consultant, 804th Medical Brigade, Fort Devens, Massachusetts

†

Lieutenant Colonel, Medical Corps, US Army; Chief, Behavioral Health, Landstuhl Regional Medical Center, CMR 402, Box 1357, APO AE 09180; 

formerly, Chief, Outpatient Behavioral Health, Landstuhl Regional Medical Center
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Combat and Operational Behavioral Health

INTRODUCTION

The US military provides appropriate healthcare 

services for enemy prisoners of war and other individuals detained during operations. Doctrine and international treaties require that detainees be provided 

“equivalent care” to prevent deterioration of their 

condition. The scope of detention healthcare operations is dictated variously by the magnitude of the 

detention activities in theater, the typical duration of an 

individual’s detention, cultural norms and situational 

factors affecting the problems presented by detainees, 

and the availability of resources in theater.

In Operation Iraqi Freedom, behavioral health 

services to detainees first emerged as a critical operation in 2003, when it was discovered that local psychiatric inpatients had been released into the streets 

by retreating enemy forces, and that Coalition troops 

had captured and detained many of them in facilities 

at Umm Qasr. The emergent need to distinguish between distressed psychotic individuals and acting-out 

enemy combatants required immediate diversion of 

combat and operational stress control assets to the 

detention mission. At that time, noncombatant detainees who were seriously mentally ill were discharged 

to community care. In 2004, as detainee operations 

stabilized, nongovernmental organization surveyors 

expressed concern that seriously mentally ill individuals retained in detention were receiving care from 

providers other than licensed behavioral healthcare 

practitioners and that the standard of equivalence 

of care was not being met. At the time of this text’s 

preparation, three separate medical task forces with 

augmented behavioral health teams have rotated 

through theater detainee healthcare operations in 

Iraq. This chapter provides a basic framework of operations in detainee behavioral healthcare, reflecting 

the lessons learned by the first two contingents, Task 

Force Medical (TF MED) 115 and TF MED 344. To 

help the units tasked with this challenging job apply 

these lessons, the chapter will discuss critical mission activities and common problems in the process 

of preparing and executing the detention behavioral 

healthcare mission.

TRAINING THE TEAM

Predeployment Preparation

Predeployment is a stressful time for all involved. 

The unit mission focus is on common training tasks; the 

command emphasis is on facilitating service members’ 

transition from the home environment to the combat 

environment. Nevertheless, every effort should be 

made for personnel to receive appropriate missionspecific training prior to deployment to a detention 

mission. Predeployment preparation should include, 

at a minimum, four essential components: (1) reviewing current Department of Defense (DoD) and federal 

and state corrections healthcare policy and procedures, 

(2) establishing communication with unit personnel 

currently on site in theater, (3) reviewing cultural information specific to the host nation, and (4) gaining 

familiarization with the detention care setting. 

Most DoD behavioral health providers have never 

worked in the corrections environment, much less the 

detention healthcare environment; a review of current 

corrections policy and procedures is a must. Detention 

healthcare is similar to healthcare given to patients 

overseen by the Federal Bureau of Prisons, an agency 

of the US Department of Justice. Bureau of Prisons 

standard operating procedures (SOPs) provide the 

model used to develop military protocols for detention 

care. These various SOPs1,2 address essential topics 

including suicide prevention, medication distribution, 

and screening procedures, all key elements in the detainee care mission. If time permits, personnel should 

consider visiting a local corrections establishment to 

talk with the medical personnel about providing care 

in a corrections environment. 

Perhaps the most important step in preparing to 

deploy is establishing communication with the personnel being replaced. This point cannot be stressed 

enough. The current active unit has implemented SOPs 

that will be suitable for most purposes, and deploying staff should obtain and review them to become 

familiar with current operations and capitalize on 

lessons learned before arriving in country. The currently deployed unit can also provide information on 

particulars of the environment such as billeting information, recreational facilities, supplies to bring, and 

available resources. Communication may be difficult 

because of time zone differences, but multiple channels exist: e-mail, telephone, or even videoconference, 

if available. Exchanging contact information benefits 

everyone; for the outgoing unit, the process of training 

the incoming unit has its own value. Most units have 

tremendous pride in their organization and appreciate 

others’ interest and willingness to accept their feedback 

and experiences. Changes in existing protocols will 

undoubtedly be needed, but current SOPs provide a 

good place to start. 

If no behavioral health unit was previously in country and the mission is to establish the first detention 

behavioral healthcare program in the area occupied, 
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Behavioral Health Issues and Detained Individuals

it is especially important to understand the standards 

by which behavioral healthcare will be evaluated, as 

well as learning what assets will be available to support the mission. Although the program is mandated to 

provide detainees with equivalent care, the perception 

of what “equivalent” means can vary widely, so it is 

important to establish as soon as possible what services 

and level of care are intended. DoD doctrine, US Bureau of Prison standards, and community standards 

within the area of operations (AO) can help inform 

this decision.1–5 

In most cases, detainees are from a different culture 

than the typical service member patient. Cultural differences can be an obstacle to establishing rapport and 

to patient care delivery. Misunderstandings between 

patient and clinician can be frustrating in an already 

tense environment, so it is important for providers to 

be familiar with common local customs and courtesies. This information can be found on the Internet, in 

textbooks, and in other historical sources. If possible, 

a briefing by someone from the particular culture 

will be very helpful. Prior to deployment in 2005, TF 

MED 344 enjoyed extensive cultural briefings from 

Iraqi expatriates, which made the transition into that 

environment much smoother than it might otherwise 

have been.

Additionally, briefing by a medical provider from 

the culture is invaluable. Names of medications and 

the social significance of different forms of treatment may differ. It is essential to know some of the 

cultural differences in the way medicine is practiced; 

for instance, the perception of mental illness can vary 

tremendously among cultures. Understanding some 

of the basic differences and perceptions increases the 

effectiveness of even basic treatments; however, it is 

important to assess the quality of source information. 

For example, TF MED 344 was repeatedly informed 

that rural Iraqis considered behavioral health issues to 

be signs of malign influence, and that the indigenous 

personnel were unsophisticated and wary of behavioral health issues. In fact, the population appeared 

to have a good knowledge of behavioral health issues 

and protocols. One illiterate farmer, detained during a 

sweep of his community, thanked providers for their 

interest in his mental state and acknowledged that he 

was depressed, but stated his preference to work with 

his local cleric about his feelings of loss over the death 

of his sons in the conflict.

Cultural issues and phenomena are limitless, and 

there is no way to be totally prepared for the situation 

in theater. For example, it is common knowledge that 

psychosis often presents differently in different cultures. When TF MED 344 staff encountered a detainee 

who reported concerns about his visions of a talking 

chicken, the question arose as to whether this was a 

psychosis or malingering. Certainly in a US population, malingering was more likely. Discussion with 

translators and other detainees provided no indication that chickens had any particular significance in 

this culture, and other psychotic individuals in camp 

tended to have auditory hallucinations without visual 

manifestations. While it was not possible to be sure, 

the subsequent presentation of several other patients 

with exactly the same hallucinations suggested to 

staff that the “talking chicken” phenomenon was 

malingering behavior. In stark contrast, the extremely 

high incidence of self-injurious behavior turned out 

to have several cultural antecedents, including both 

an acceptance of excoriation as a religious ritual and 

a history of self-mutilation among prisoners during 

the Saddam Hussein regime to avoid being brutalized 

even more by their guards.

While cultural issues are legion, it also is important 

to recognize the universal nature of mental illness. For 

example, one patient managed by TF 344 reported 

that God spoke directly to him and told him that all 

infidels would die. This presentation could certainly 

have reflected the social-political context of the conflict; 

however, other camp residents repudiated the patient’s statements and were concerned for his welfare 

and safety. The individual was truly psychotic and 

responded well to antipsychotic medications. Another 

detainee presented with a long history of self-injurious 

behavior, and swallowed any sharp object he could 

find. His behaviors increased as attention to them 

increased. He was diagnosed as a self-destructive 

borderline personality and required extremes of behavioral management.

The context of care in a detention camp differs 

significantly from deployment to any other forward 

operating base or operations center. In a detention 

camp, the enemy is not only outside the perimeter, but 

has a large presence within the perimeter as well. This 

has two main effects. First, security protocols assume 

a significant place in day-to-day operations. Second, 

coalition personnel are confronted with a uniquely 

stressful task of interacting on a daily basis with the 

enemy, creating a number of behavioral health issues 

that can affect operations.

Security issues are always legion during deployment to a hostile AO. In detention care, security is 

doubly important. Access to the patient routinely 

requires special clearance and passes, and time must 

be planned to allow for multiple security checks. 

Patients are not seen privately. “Outpatient” interactions may be through a security barrier. Armed guards 

accompany hospitalized patients or those seen in a 

clinic. Clinical schedules must be coordinated with the 

guards’ transportation schedules for these custodial 

staff. Daily operations are likely to be interrupted by 
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Combat and Operational Behavioral Health

head counts, missing person checks, or crowd control 

operations. In the Iraq AO, detainees were assigned 

numbers rather than being referred to by name, 

making it difficult to track cases, especially because 

detainees were routinely shifted from camp to camp 

as a security precaution.

Medical and custodial staffs are patently affected 

by having to interact with the enemy on a daily basis. 

They cannot treat the enemy aggressively, and must 

provide compassionate care even when threatened 

or disparaged by the detainee. They cannot establish 

friendships or trusting relationships with the individuals they see most often each day. The stress of detainee 

care causes irritability, anger, and dissatisfaction rarely 

seen in other healthcare or operations centers. Management of this distress is an important part of the 

behavioral healthcare mission.

The Clinical Process in Detainee Care

The clinical process in detention care also differs 

markedly from that in other clinic-based operations. 

Staff may or may not need a refresher in basic clinical 

assessment and brief counseling techniques, but the 

team invariably requires training in detention operations. Training should address screening, assessment, 

intervention expectations, crisis response, and coordination of care.

Every new detainee is screened for behavioral 

health risk factors as part of their initial medical 

evaluation. A brief questionnaire covering previous 

behavioral health treatment and current behavioral 

health concerns is administered through an interpreter. 

Familiarity with the screening process and with typical 

detainee reactions to the behavioral health interview is 

a must. Intake screening is a volume business: screening must proceed at the pace of internment operations. 

This can range from 50 screenings a week to 150 a day, 

with little advance notice, depending on the pace of 

operations in theater. It will be tempting to assign one 

or two individuals to the screening process, because 

it is inherently different from other clinical operations 

and can be accomplished best by personnel who are experienced with the procedure. Even when this is done, 

however, every member of the team must be able to 

complete the screening interview both to provide surge 

capacity and because this is a must-do procedure that 

if not completed delays the movement of the detainee 

into the camp.

The intake screen identifies new detainees who need 

follow-up evaluation. Detainees may also be referred 

for evaluation by military police, by the medical team, 

by other detainees, or through self-referral. At Abu 

Ghraib in 2004 and 2005, after systematic improvements in the detention facility were established, it was 

typical for providers to see a dozen individuals for 

new assessment and disposition each week. Personnel must be comfortable with conducting a functional 

assessment leading to initial diagnosis and disposition in sparse conditions, using an interpreter for the 

interview portion of the assessment. Clear criteria 

for assessment and disposition should be established 

and practiced prior to deployment. Mobilization site 

training will most likely provide “typical” cases that 

are florid in their presentation, a training model that 

is unrealistic and not useful. Instead, training should 

focus on assessment of anxiety disorders in an anxietyprovoking situation, identification of malingering, 

and differential diagnosis of adjustment disorder and 

major depression. The patient cannot be expected to 

be a reliable informant; the information received will 

be distorted by translation; and the setting will create 

ambiguities that make a typical assessment model 

untenable. The behavioral health clinician must rely 

on behavioral signs and reports of functional impairment from collateral sources at least as much as on the 

patient’s own report.

Ongoing review of the active caseload is more 

complex in detention care than in the clinic or in the 

corrections setting. Patients do not have regular appointments; they are scattered across a barbed wire 

encampment and are moved frequently for security 

reasons. A concerted effort must be made to develop 

and sustain a patient tracking system. Once continued 

care is established, clear outcome criteria should be 

established and monitored for each case. Establishing 

outcome criteria will probably be the part of this process most reminiscent of normal clinical practice.

One of the most frequent questions asked by providers outside of this setting is whether the military 

really “does therapy with those guys.” Odds are that 

most intervention will involve medication management, behavioral intervention, and education or brief 

supportive counseling rather than psychotherapy per 

se. Among the many factors mitigating against the establishment of therapeutic trust are the likely brevity of 

care, as well as cultural and privacy issues preventing 

in-depth treatment in most cases. However, as in any 

setting, treatment approaches should be adjusted to 

meet the needs of the individual.

Detention care can be volatile, and is a 24-hour 

operation. The clinical team is on call at all times. 

Although the facility includes physical safeguards to 

keep aggressive and suicidal detainees secure, custodial staff values the reassurance and direction that 

on-call behavioral health consultants provide when 

detainees have problems off-shift. Clinicians must 

respond to every call, even if the situation is under 
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Behavioral Health Issues and Detained Individuals

control. A common problem is threats of self-harm to 

obtain camp privileges. In Iraq, where many historical 

factors facilitated self-excoriation, it was not uncommon to be called to attend to a detainee who had cut 

himself shallowly across the chest and threatened 

further self-harm if his demands were not met. In the 

United States, this behavior would be an indication of 

serious underlying pathology, but in this setting the 

behavior was more often than not an extreme example 

of manipulative or coercive behavior on the part of a 

detained individual.

Finally, the behavioral health team will not operate in isolation. Detainees receiving behavioral health 

services are also under care of the medical team. Some 

primary healthcare providers will prefer to prescribe 

their own psychotropics, and some will use medicines 

from the behavioral health formulary for other purposes, such as pain management. Nongovernmental 

organizations are often involved in coordinating social 

services for the detainee. It is necessary to establish 

protocols for coordinating medication procurement 

as well as coordinating care with the healthcare team, 

including medication procurement, record keeping, 

and social service contact management. The behavioral 

health team should train on and practice these protocols before entering the operational area.

Unit Transition

Several things can be done to optimize the transition 

from one unit to its replacement at the detention center. 

The outgoing unit will probably know their replacements at least a month or two before the transition. If 

the incoming unit has not contacted the outgoing unit 

in that period, the outgoing unit should work through 

their leadership to contact and establish a working 

relationship with their replacements. In addition to 

preparing for a successful handoff, preparing the 

detainees over a period of about a month is useful in 

minimizing disruption. Replacements should arrive 

early enough that outgoing staff can demonstrate current procedures for at least a week. 

This staffing overlap is commonly referred to as 

the “left seat/right seat ride.” To set up the new unit 

for success, it is strongly recommended that staff with 

similar roles be paired with outgoing staff during duties for several days, allowing newcomers to adjust to 

the environment, see the day-to-day operation, and ask 

questions. A date should be designated for the takeover 

of duties by the new staff, accompanied the first time 

by outgoing staff. Optimally, the oncoming unit should 

have at least a day or two to function independently 

prior to the departure of the outgoing unit, although 

this schedule can run into problems. In both TF MED 

115 and TF MED 344 some medical teams were ready 

to relinquish their duties the day replacements arrived. Others, feeling pride of ownership, did not feel 

comfortable standing by while the replacement staff 

took over and learned the job.

Tours are generally for 1 year and invariably rapport will be established between staff and detainees. 

Detainees talk among themselves and with other 

medical and nonmedical staff, and often have some 

idea when units are scheduled to depart, knowing 

that units usually change somewhere around the 11- or 

12-month point. Detainees have an active interest in the 

transition and may ask detailed questions. They will 

understand the transition process and probably try 

to find out exactly when the new unit will take over. 

Some appreciate the care they received and will feel 

anxiety about the upcoming transition and termination. However, operational security should be kept in 

mind: detainees should not be given specific dates or 

any other information that may be used to threaten 

security. Personnel should be vague and ensure detainees that their care will continue; no information 

about troop movements should be divulged. 

Units preparing for departure often shift focus to 

the task of reintegration and manage ongoing tasks 

with less interest and enthusiasm. Personnel should 

maintain operational focus: the outgoing unit has the 

responsibility to prepare both the detainees and the 

gaining unit for a successful, seamless transition. A 

modified termination process and a well-planned and 

executed left seat/right seat ride will give the outgoing 

unit closure, knowing that the mission they conducted 

and improved upon will be handed over to people they 

were able to train. The gaining unit will build upon and 

modify procedures to optimize the care they deliver 

over the course of their tour.

EFFECTIVE USE OF TRANSLATORS

Communication with detainees is essential to effectively assess and treat them. Most detainees will not 

speak English, and unless the medical staff speaks the 

detainee’s language, the use of a translator is vital in 

obtaining a good history. In some settings, translators 

are intentionally rotated among sites and services as a 

security measure, making it impossible to thoroughly 

train a few select individuals. This may be a source 

of contention. Frequently, as a medical team becomes 

familiar with a translator, they feel confident in them 

and request sole access to them. This is not good practice. During TF MED 344’s tenure, no fewer than three 
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proficient and apparently friendly translators were 

removed from service: two were found to have passed 

information to hostile elements, and one was removed 

for continually asking for cast-off uniforms. Incessant 

questions about vacation plans or other personal information, which might be normal in other settings, 

are not a sign of a reliable interpreter.

It is unlikely that many translators will have expertise in behavioral health or behavioral health terminology. Some cultures may have different understanding of 

terms such as “hallucinations” or “delusions,” so questions about these symptoms may get lost in translation 

and render the assessment ineffective. Other concepts 

may be uncommon in a particular culture, and some 

questions might be seen as offensive or disrespectful. 

Translators may have their own opinions about the 

patient’s problems, and may not make the effort to 

translate the questions exactly. Furthermore, personnel 

must be aware that hired translators may be traditional 

enemies of the detained population: they may come 

from neighboring countries in conflict with that of the 

detainee, or they may have opposing politics.

Personnel should take time up front to get to know 

the translators and ascertain their understanding of 

behavioral health terminology, as well as their ability 

to convey information to a detainee. Translators should 

understand the importance of asking the patient every 

question posed, rather than providing answers themselves. Hired translators should be used when possible, 

but the unavailability of hired translators should not 

impede the successful execution of the mission. In the 

absence of a hired translator, detainees who are fluent 

in English may be required to serve as translators. 

Custodial staff may be able to recommend a detainee 

who has proven to be effective and may have assisted 

them on other occasions. Although clinicians might 

initially be reluctant to use a detainee as a translator, 

having a trusted detainee assist can be both extremely 

effective and enlightening. Detainees may feel more 

comfortable opening up to a fellow detainee who they 

respect and admire than to a hired translator they may 

not trust. Establishing a rapport with the detainees is 

important for successful treatment, and sometimes 

having a working relationship with one of their peers 

who speaks English can facilitate an effective therapeutic relationship. 

DEVELOPING A TREATMENT PLAN

It is important to bear in mind, in this setting more 

than most, that diagnosis is functional: the goal is 

not necessarily to determine the etiology and nature 

of the disorder but to develop effective treatment. 

International standards for care in this setting specify 

treatment of mental disorders that result in incapacity 

to care for oneself or in increased risk of deterioration of function or health; the emphasis on functional 

impairment must be highlighted. Functional impairment is a critical ingredient in deciding to provide 

care, especially if resources are limited. To that end, 

personnel must 

	 •	 diagnose only to the level of the available

data; 

	 •	 develop treatments using rubrics that maximize functional outcome as simply and as 

safely as possible; and 

	 •	 rely on outcome monitoring to adjust and

eventually to titrate treatment. 

Diagnosis and treatment in detention care is vulnerable to many problems not experienced in other 

settings: language and cultural barriers to establishing 

good communication, subtle cultural factors associated 

with the meaning of mental illness for the detainee, 

pressure in detention to acquire marketable drugs or 

to garner attention or respite from the compound, and 

group dynamics affecting the individual’s behavior. 

The absence of good collateral information and the 

biases of the interpreter and custodial staff toward 

mental illness and toward the detainee complicate 

matters immeasurably. Available information includes 

the self-report of the detainee, third-party reports from 

camp mates and custodial staff, records from medical 

services provided during detention, observation, and 

functional assessment. Because the translation may 

be unreliable, the clinical interview should rely more 

heavily on behavioral observation than most clinicians 

are accustomed to. 

Behavioral Management Considerations

Establishing a program for managing behavioral 

problems, or providing consultation, is an essential 

part of a successful detainee behavioral healthcare mission. Military police deal with behavioral challenges 

daily and often turn to the behavioral health team for 

advice and support. Some detainees test the limits of 

acceptable behavior, which must be handled effectively 

to prevent others from acting in similar fashion. Often, 

unacceptable behavior occurs to achieve secondary 

gain, and the behavioral health team can educate the 

corrections staff on appropriate means to address the 

behavior without rewarding the detainee (which reinforces the behavior and causes others to engage in the 

same or similar behavior). The behavioral management program can empower the corrections staff and 
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Behavioral Health Issues and Detained Individuals

significantly curtail inappropriate detainee behavior.

Detainee custodial staff members have one of the 

most challenging jobs in the military. Staff members 

may have a corrections background, and these personnel can utilize their prior experience and training to effectively manage inappropriate behavior. Others have 

no prior corrections experience and may be operating 

in a detainee environment for the first time with very 

limited training. Faced daily with hostile and belligerent detainees, most custodial staff do an exceptional 

job maintaining order and discipline. When detainees 

engage in behavior that poses a threat to themselves or 

others, custodial staff will call on the behavioral health 

team for assistance. To facilitate teamwork, behavioral 

health personnel should establish a working relationship with custodial staff early in deployment. Behavioral health personnel should introduce custodial staff 

to the most common behaviors associated with mental 

illness and encourage them to get the behavioral health 

team involved early if they have concerns or are unsure 

of how to handle a particular situation. Custodial staff 

will appreciate knowing they can call on behavioral 

health professionals if they need assistance. Often, 

the behavior can be controlled by simply removing 

the detainee from the environment or by giving the 

detainee some time alone away from other detainees. 

Furthermore, the behavioral health team is responsible 

for training the custodial staff to recognize when a 

detainee may be psychotic, experiencing another Axis 

I disorder, or having a primary Axis II problem so they 

can contact the team to make an assessment. A good 

clinical assessment will aid in determining what the 

primary problem is and help in making the appropriate decision to resolve the situation. 

Primary Axis II problems, common in any corrections population, can be expected in the detainee 

population as well. Common reasons for acting-out 

behavior involve secondary gain such as wanting more 

cigarettes, wanting to get out of the heat and into an 

air-conditioned building, and a host of other reasons 

primarily viewed by the detainee as obtaining pleasure 

and reducing suffering. Inappropriate behavior may 

include self-injurious behavior such as cutting, eating 

barbed wire, making suicidal statements, making suicidal gestures, and faking seizure-like activity or other 

medical conditions that commonly require removal 

from confinement and evaluation in the hospital setting. This behavior can be significantly reduced by 

having a medical or behavioral health team evaluate 

detainees in their living space and by transporting 

them only if medically indicated. However, contact 

with the behavioral health team on site can itself become a detainee’s goal.

Despite some similarities to corrections setting, the 

detention care setting is unique, and common clinical 

assumptions about the etiology of acting-out behavior 

must be suspect. Although some detainees cut themselves or threaten suicide for reasons such as trying 

to leverage a move to a better tent, other acting-out 

behavior may have a more malign purpose: creating 

a distraction so that another detainee may be threatened or killed, distracting custodial staff from efforts 

by detainees to build a tunnel, or signaling a plan for 

a riot. At times there may be no apparent reason for 

such behavior. On one occasion in 2005, detainees were 

received at Abu Ghraib from an Iraqi prison. All were 

screened for health and behavioral health needs, and 

most were found to be in poor condition because of 

harsh conditions at the Iraqi prison. Somewhat to the 

surprise of providers, most expressed pleasure at being returned to Abu Ghraib, where they had initially 

been triaged months earlier before being turned over 

to the Iraqis. One such individual, who was extremely 

vocal in his pleasure at returning to the relative comfort 

of American detention, nevertheless faked a seizure 

within an hour of being returned to the camp. 

Having a designated observation area located in the 

detainee compound allows medical staff to bring the 

care to the detainee and limits the need for transport 

outside of the compound. In addition to observation, 

basic first aid, including suturing, bandaging, checking vital signs, administering medications, and other 

necessary interventions that do not require transport 

to the hospital can be done in the detainee compound. 

The designated area should be near the corrections 

staff command post or another area where detainees 

can be watched constantly but within their compound 

and as close to their living area as possible, so even 

direct contact with the behavioral health team can be 

limited if malingering to obtain such contact is suspected. TF MED 115 dealt with the increasingly selfinjurious behavior of one detainee by strictly limiting 

the patient’s access to the hospital, a treatment plan 

that required constant reassurance to the emergency 

medical teams that were called on to dress moderately 

severe self-inflicted injuries in the camp’s field setting. 

This strict restriction on access to the hospital eventually reduced the frequency of self-injurious behavior 

by the detainee, proving its value.

Medication Management and Distribution

Although some detainees with mental illness will 

not require medications, others will, and should be 

offered the appropriate medication to effectively 

treat their respective illness. Mental illnesses among 

detainees reflect those in the general population and 

include mood disorders, anxiety disorders, psychotic 

disorders, substance use disorders, personality disorders, and others listed in the Diagnostic and Statistical 
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Combat and Operational Behavioral Health

Manual of Psychiatric Disorders. Many medications commonly used and available in the United States are not 

available throughout the world, so cultural awareness 

can play an important role in prescribing appropriate 

medications. A given detainee may have been effectively treated on a psychotropic medication prior to 

being detained and should remain on that medication. 

Additionally, if the treatment is going to be necessary 

and continued after the detainee is released, selection 

of a medication that is available in the local economy 

should be strongly considered to facilitate accessibility 

and ongoing treatment. Otherwise, the indications, 

contraindications, side effects, and prescribing guidelines for a particular class of medications remain the 

same as in other settings.

Depending on the size of the detainee population 

and the number of detainees on medication, distribution can be a complicated and time-consuming process. 

Care must be given to prevent hoarding; consideration 

should be given to potential lethality or medical complications; and if possible selection of medications 

that can be taken daily, rather than more often, will 

increase compliance and decrease the demand on the 

staff distributing each medication. 

Each staff member responsible for distributing 

medication should be trained on the proper distribution technique. The technique is essentially the same 

as what is practiced in many US prisons: distributing 

each dose separately and watching closely to prevent 

deception and hoarding. A sequence of actions needs to 

take place to ensure that the right patient receives the 

medication, and actually swallows it (Exhibit 40-1).

This is required for each medication, and each 

detainee must be required to follow the procedure. 

Hoarding medications can be a serious problem, and 

abuse of psychotropics is endemic in this population. 

Medical staff, including behavioral health personnel, must be trained in this process, and leadership 

should make spot checks to ensure the process is being 

adhered to. Mental health personnel should take the 

lead in this process. Detainees may protest initially, 

but with continued practice most comply without 

hesitation. Furthermore, the process of interacting with 

detainees twice a day improves the therapeutic alliance: some detainees view the interaction as extremely 

supportive and benefit clinically from the interaction, 

although this process can be time consuming and 

very demanding on the medical staff member. Staff 

members can rotate administering medications. This 

also helps prevent burnout and helps the staff get to 

know the detainees.

Some detainees may be on other medications prescribed by different providers. It should be routine 

to review the medical record or to check with the 

pharmacy to get a list of all prescribed medications for 

each detainee to ensure there are no contraindications 

or overlaps in medication. Medical providers should 

discuss potential side effects for each medication with 

detainees and ensure each detainee has given informed 

consent prior to starting a medication. A medication 

education program is useful to prepare detainees for 

eventual release, when they will probably be provided 

a several-day supply of medication.

Communicating With Other Sites

Interacting with behavioral health staff at other 

detention sites should be facilitated early in the deployment. Detainees often are transferred from one site 

to another depending on the legal issues associated 

with their case. Communication between detention 

camps allows the effective transfer of detainees with 

behavioral health problems and enhances the continuation of treatment without interruption. The gaining 

facility should prepare by reviewing pertinent medical records, obtaining appropriate medications, and 

discussing any concerns with the staff members who 

have been treating the detainee. Without a working relationship between staff, detainees will be transferred 

EXHIBIT 40-1

MEDICATION DISTRIBUTION PROCESS 

FOR DETAINEES 

•	 Confirm the patient’s identity by comparing

the detainee’s identity card or armband to 

the person presenting for treatment (trading 

armbands for favors is not unknown); do not 

administer the medication if identification is 

not positive. 

	 •	 Administer each medication as a single dose;

do not give a detainee requiring medication 

twice a day both doses in the morning. 

	 •	 Ask the detainees to hold out their hand, and

then place the medication in their hand. 

	 •	 Ensure they have water to help with swallowing the medication. 

	 •	 Watch them carefully as they put the medication into their mouth and swallow. 

	 •	 After they swallow, have them open their

mouth and stick out their tongue to check for 

“cheeking” the medication. Have them open 

their hands with their fingers spread apart to 

ensure they don’t have the medication still 

in their hands. 

	 •	 After making sure they have actually swallowed the medication, the detainees can be 

excused from the area. 
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Behavioral Health Issues and Detained Individuals

and the gaining team can potentially be caught off 

guard and this may impact patient care. Communication between staff at different sites should occur on 

a regular basis, because moves often are sudden and 

unanticipated. The frequency can be determined based 

on patient acuity and need. Sometimes the gaining 

team receives information about transfers before the 

losing staff. Problems arise when detainees arrive at 

the new location and say they were taking psychiatric 

medications or receiving psychiatric treatment, and 

there is no record of the treatment. Often the detainee 

does not know what medications are being administered. Without the knowledge of current diagnosis 

and treatment, an effective treatment plan may be 

interrupted and the detainee will have to start the assessment and treatment process from the beginning, 

a frustration for both the detainee and the behavioral 

healthcare staff.

SPECIAL CLINICAL ISSUES

Common syndromes in detention care include 

situational reactions to capture and adjudication, fear 

of other detainees, distress related to being separated 

from family, and reactions to the inevitable inactivity 

associated with detention. Detainees often present 

with acute anxiety immediately after transfer to the 

facility or before trial. They often complain of insomnia, fatigue, or depressed mood, symptoms that on 

inquiry are related to poor sleep habits and inactivity. Awareness of these situational factors can reduce 

overdiagnosis and overuse of medication with this 

population.

Individuals in detention often attempt to assert control, gain special privileges, or reduce boredom in ways 

that bring them to the attention of the behavioral health 

team. Aggression toward others, unusual behavior 

such as bathing in sewage, and suicidal statements or 

parasuicidal behavior may be typical signs of mental 

illness, but in this context often are manipulative or 

testing behaviors. Hunger strikes, another behavior 

of significance seen in the detention population, are 

discussed in detail below because of their unusual 

political nature. Differential functional diagnosis and 

training of custodial staff in behavioral management 

are important tools in managing these potentially 

disruptive concerns. 

Cognitive disorders present a special challenge in 

military detainee care. Primary disorders that may 

present include the entire gamut of these illnesses: 

developmental disorders including mental retardation; acquired traumatic brain injury, acute or chronic; 

metabolic, vascular, or other invasive lesions from a 

medical cause; or age-related dementia. All represent 

special circumstances affecting the detainee’s ability to 

function and therefore trigger a special obligation on 

the part of the military caretaker. Unfortunately, most 

instruments designed to detect cognitive impairment 

are insensitive to cultural factors and to educational 

deprivation, making them unsuitable in this setting, 

even when effective, nonbiased translation services 

are available.

Privacy and confidentiality are recurring issues 

in behavioral health service systems. Although it is 

benevolent to argue that the detained individual has 

a right to confidentiality, in this setting even the right 

to refuse treatment may be arguable if detainees’ behavior causes substantial risk to themselves or others. 

Command has a legitimate interest in the mental state 

of detainees with serious emotional or cognitive issues, 

as do custodial staff responsible for the compound. It 

is likely that other residents of the compound will be 

aware of the patient’s behavioral health issues, especially if the behavior is disturbed. Interviews must be 

conducted in the public view, or at least with a guard 

present. Reasonable respect for human dignity and 

privacy is always indicated, but in this setting confidentiality in its strictest interpretation is unlikely and 

should not be promised.

Medical record management is another special 

clinical issue in the military detention setting. International standards require a single portable medical 

record that follows the patient and that can be accessed 

by the patient, his or her representative, or oversight 

agencies such as the International Red Cross. This 

apparently simple requirement is complicated by the 

typically dispersed nature of forward base detention 

settings: the record-keeping facility is likely to be in 

the hospital, not the camp, necessitating maintenance 

of a local working record in many instances. In the 

current conflict, detainees are identified by number, 

rather than by name, because of ambiguities in establishing identities and also to protect the individual. 

This makes matching the patient to the record difficult 

as well. Frequent movement of detainees for security 

or legal reasons further complicates compliance with 

medical record standards.

HUNGER STRIKES: A UNIQUE CLINICAL ISSUE

Behavioral health consultation to hunger strikes 

constitutes a special or command-directed assessment 

and as such requires the involvement of a doctorallevel behavioral health provider to meet the criterion of 
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Combat and Operational Behavioral Health

equivalent care to detainees. The military psychologist, 

psychiatrist, or doctoral social worker involved must 

be aware of international standards for the treatment 

of hunger strikers and the theater policy on hunger 

strikes; must be cognizant of cultural factors impinging 

on the detainee’s decision to fast; and if at all possible 

must consult with the facility commander, with Judge 

Advocate General staff, and with the detainee’s primary care provider to determine relevant contextual and 

situational issues before engaging with the detainee or 

making recommendations to command.

There is strong international sentiment in favor 

of hunger strikers, based on a history of their use to 

protest repressive political regimes. The international 

medical community supports self-determination by 

the detainee and proscribes forced feeding.6,7 Nevertheless, not all hunger strikes have the same degree 

of legitimacy.8 Reactive food refusers, much more 

common than political hunger strikers, are much more 

likely to rapidly terminate their fast without adverse 

consequences.

A typical hunger strike protocol9 requires the behavioral health provider to assess the competence of 

the fasting detainee at the outset of the hunger strike 

and daily thereafter. In addition to the complications 

created by the adversarial nature of a detention setting, 

the crosscultural aspects of assessment in a military 

context make this a challenging task. Because assessment will be ongoing throughout the hunger strike, 

the provider must be aware of the typical course of 

a hunger strike and of the impact of starvation on an 

individual’s emotional and cognitive status.

Assessment

The detainee engaging in a hunger strike is not allowed to refuse reasonable evaluations. The situation 

is analogous to evaluating a reluctant person suspected 

of dementia: the assessment is in the patient’s best 

interest. However, it is important to attempt to obtain 

informed consent for this and subsequent assessments, 

if only to establish a reasonable working relationship 

with the patient. The purpose, extent and limitations 

of evaluation, boundaries of the relationship with the 

provider, role conflicts that may develop, and issues 

of medical record confidentiality should be described. 

If the detainee refuses to be interviewed, observation 

and information from collateral sources become critical 

in establishing the person’s competence. In one such 

instance in theater, the attending physician was given a 

fixed interview protocol to follow that allowed assessment of immediate, delayed, and procedural memory, 

and was primed with specific questions to ask. The 

psychologist observed the interaction on closed-circuit 

television to allow clinical assessment of the patient’s 

cognitive status.

Relevant factors in determining initial competence 

to fast include the presence of a mental disorder affecting judgment and decision making; problems 

with impulse control leading to importune behavior; a 

cognitive disorder including mental retardation, brain 

injury, or dementia; coercion by or influence of others; 

and inaccurate situational information. Personal history, facility records, and clinical observation during 

the interview are essential tools in the assessment. 

Standard cognitive instruments are unlikely to be 

available, making psychometric evaluation of dementia or cognitive disorder difficult. The last two factors 

listed, coercion or influence by others and inaccurate 

situational information, are less accessible to historical 

review or direct assessment, but are important areas 

of concern. One incipient hunger strike during the TF 

MED 344 experience was avoided by clarifying the 

process of judicial review for the detainee.

The initial interview should clarify that the detainee 

does intend to engage in a hunger strike. Language 

problems and confusion on the battlefield can create 

inaccurate perceptions: one detainee transferred from 

a division internment facility to the tertiary internment 

facility or theater internment facility for a hunger strike 

protocol in early 2006 immediately denied intent to fast 

when interviewed in the emergency room and ate as 

soon as his gastrointestinal distress and nausea were 

treated. As part of clarifying intent, the behavioral 

health provider discusses with each detainee whether 

he plans to fast to death, or if he will accept medical 

advice and limit his hunger strike when his health is 

imperiled. 

The behavioral health provider is mandated to 

clarify the detainee’s reason for entering into a hunger strike. The provider does not, however, become 

engaged in negotiating with the detainee concerning 

demands, for a variety of reasons: maintaining a useful neutrality with the detainee separates the issue of 

refusal to eat from the issue that the detainee wishes to 

bring to public attention, an important strategy in managing the hunger strike situation. In one typical hunger 

strike situation, the detainee began every conversation 

with a request to see the combatant commander; each 

request was met with a response that the commander 

was aware of the request and the psychologist could 

do nothing to facilitate this matter.

Daily reassessment of the detainee’s emotional 

and cognitive status is required. A routine should be 

established with the primary care provider that allows 

the behavioral health provider to review any medical factors that may be affecting the detainee and to 

interview the primary care provider about his or her 
655

Behavioral Health Issues and Detained Individuals

interactions with the detainee. Initial reassessments are 

usually not fruitful except to help establish a pattern 

and a relationship, as cognitive and emotional changes 

are unlikely in the first week of the hunger strike.

Follow-up assessments include evaluation of subtle 

cognitive changes caused by altered nutritional status, 

such as a tendency to make more risky decisions, 

become irritable, and be increasingly oppositional, 

especially in situations involving confrontation.10

Minor memory or concentration problems that may 

signal the onset of delirium resulting from reduced 

metabolism, medications, altered nutrition, or organ 

dysfunction must be recognized early to avoid rapid 

cognitive deterioration. Hunger strikers with suicidal 

or morbid ideation, alteration in future orientation, 

or reduced interest in pleasurable activity, may be 

depressed—a condition for which they may allow 

treatment. The assessment also evaluates the detainee’s 

confidence in his physician, his understanding of the 

medical information he is provided, and his intent to 

persist in the hunger strike.

Cognitive measures are sensitive to educational and 

cultural factors (few instruments have been normed for 

use in different cultures) and are vulnerable to practice 

effects; repeated administration on a daily basis will 

invalidate their use just as the information they can 

provide becomes more critical. The behavioral health 

provider should design an observational protocol using routine interactions in the detention setting to assess memory, concentration, verbal fluency, and motor 

coordination rather than relying on tests.

Documentation of findings is critical. There are three 

possible outcomes of a hunger strike: the detainee 

ends the hunger strike voluntarily, the detainee is 

fed forcibly, or the detainee dies from complications 

related to not eating. Especially in the event of forced 

feeding or death, the basis for medical and subsequent 

administrative decisions about care must be clearly 

documented and communicated.

Intervention

The behavioral health provider cannot collaborate 

with coercive or deceptive strategies, nor agree to strategies that might be perceived as maltreatment of the detainee. Although it is reasonable to withdraw privileges 

or hold the detainee in isolation to prevent contagion 

or coercion, for example, it is not reasonable to restrict 

access to hygiene facilities or exercise. Exposing the 

patient to pleasant aromas and pleasing presentations 

of meals may be useful; deliberate exposure to others 

eating, taunting with food, or excessive exposure to food 

may constitute abuse and is likely to be counterproductive. Threats of forced feeding are counterproductive, 

create an adversarial atmosphere, and are considered 

coercive by the international community.

Psychological management of the hunger strike 

should focus on limiting unwarranted attention to the 

detainee during the hunger strike to reduce unintended reinforcement of the unwanted behavior. Medical 

management and administrative negotiations should 

be matter-of-fact and without emotional overlay. Effort 

should be made to separate treatment of the hunger 

strike and treatment of the concerns raised by the detainee: the decision-maker for the demands should be 

distinct from the medical and custodial personnel who 

work with the detainee. These two issues should never 

be linked during discussions with the detainee. 

Consultation 

The military behavioral health provider consults to 

the attending physician and to command regarding 

various aspects of the hunger strike situation, often 

in ways not anticipated by the command authority. 

It was the senior author’s experience that command 

expectations may exceed the role of the consultant: 

there may be an expectation that the behavioral health 

provider has greater insight into the hunger striker’s 

motivations than is possible, or that the provider may 

in some way be able to intervene and somehow induce 

the hunger striker to end the fast. Clear delineation of 

roles and capabilities is essential.

Healthcare providers do have a valuable role in 

protecting both the patient and the military command 

from the adverse consequences of the hunger strike. 

The careful balance between consulting to the care of 

the hunger striker, balancing competing ethical issues 

often associated with this situation, acknowledging 

international standards of care, and advising command regarding effective actions requires a thoughtful 

approach to this type of situation. 

The behavioral health provider discusses with the 

treating physician the available literature on hunger 

strikes, the ethics associated with managing both 

hunger strikers with a terminal goal and those willing 

to accede to medical advice, and the importance of 

avoiding an adversarial relationship with the patient. 

The physician should be encouraged to establish 

benchmarks for various decisions, including informing the patient of critical medical milestones and 

what findings to use to signal command that medical 

incapacity may be imminent.

Command is likely to consider forced feeding very 

early in the hunger strike, in part because the consequences of allowing the detainee to die in custody are 

extreme and in part because of limited knowledge 

about the likely time frame of the hunger strike. Keep-
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Combat and Operational Behavioral Health

ing the detainee alive through forced feeding, however, 

may simply prolong the hunger strike, carries its own 

medical risks, and is not likely to be necessary for 

health reasons in the first weeks of the strike. Good 

medical advice is critical to limiting the commander’s 

reactive responses, and effective consultation on approaches to the hunger striker will give command 

options other than coercive methods.

SUMMARY

Providing psychiatric care in a battle zone to an enemy combatant poses unique professional and personal 

challenges. There is no true civilian analogue to this 

situation. Because the mission is unique, it is important 

to develop a clear understanding of the clinical mission and its inherent systemic issues before entering 

the area of operations. It is vital to understand the full 

political and humanitarian impact of the behavioral 

healthcare provider’s role in this setting to appreciate 

the importance of the mission and to reconcile the 

accompanying complex and often contradictory emotions and reactions. 

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