"Very much in the middle"

How a military psychiatrist balanced treating Afghan detainees and U.S. troops

Thomas Fluent, M.D., clinical assistant professor of psychiatry at the Univeraity of Michigan Medical School and medical director of ambulatory psychiatric services at
U-M.

"There are certain situations that don't naturally appeal to what Lincoln called the "better angels of our nature," reflects Thomas Fluent, M.D., clinical assistant professor of psychiatry at the University of Michigan Medical School and medical director of ambulatory psychiatric services at U-M.

High on the list for him: the nine months he spent as chief of mental health services for more than 1,000 detainees at Bagram
Airfield in Afghanistan - while at the same time caring for the mental wellbeing of the U.S. soldiers tasked with guarding the often violent and dangerous men.

On a recent morning, Fluent, a captain in the U.S. Navy Medical Corps with more than 20 years of active duty and reserve service,

On a recent morning, Fluent, a captain in the U.S. Navy Medical Corps with more than 20 years of active duty and reserve service, reflected on being "very much in the middle" of such a challenging dynamic.

Fluent - a warm, energetic and self-effacing man who prefaces many of his insights with phases like, "Now this is going to sound corny, but..."-- explains in a dozen different ways over the course of an interview that for him the key was to never lose sight of the humanity of the people he was dealing with, nor of his own humanity. Fluent's job was to help detainees as they struggled with exactly the types of emotions you'd expect: homesickness, loneliness, sadness, trouble sleeping, worry about the safety of their families and uncertainty about what the future might hold.

"A cynic might say, "who cares, they're the enemy," he says. "But part of the mission was also to fight the insurgency by demonstrating to these men and their communities that our way was really the better way, our values the better values. In that sense, the mission was ennobling."

Still, Fluent had a responsibility to his fellow soldiers guarding the detainees, who were often on the receiving end of verbal abuse and, at times, had bodily substances thrown at them. The detainees were there for a reason, often for
harming or attempting to harm the soldiers' fellow Americans.

"My approach was to model that ambivalence, to respect the tension inherent in the situation," he says.

While doing his best to help the detainees in his capacity as a psychiatrist, Fluent also worked to maintain the respect of the guard force and not seem overly accommodating of the prisoners.

"It's definitely a fine line," he acknowledges.

Fluent quickly realized that as a highly visible, high-ranking officer, his behavior spoke volumes to both the detainees and guards.

"I tried to model behaviors that said, "This is what we're all about. This is the kind of behavior that Mom, Dad and everyone back home is going to be proud of,' " he says.

The tour marked his third mobilization since the attacks of Sept. 11, 2001.
After a difficult encounter with a detainee, he would try to demonstrate to other soldiers that it's perfectly natural to be angry and frustrated -- but he also wanted to show that those feeling didn't have to be channeled into negative behaviors.

"Wow," he would joke. "That guy was ridiculous! Do we need a bar in here or what?"

Fluent also found himself taking a similar approach to the detainees, telling them things like, "It has to be totally miserable in here for you. I'm sure being here makes you furious.I get it--or at least I'm trying to get it."

"It helped just to acknowledge the reality of the situation," he says.

His challenges as a psychiatrist were multiplied by linguistic and cultural differences. Having to speak through an interpreter robbed Fluent of some of the tools on which he frequently relies to put patients at ease: humor, intonation, playfulness, nuance.

"I found I focused a lot on my non-verbal communication, my eye contact and facial expressions," Fluent says. "I wanted my eyes to communicate warmth and humanity, but not 'I'm a fool.' "

Many of the detainees had very little experience with Western medicine, much less talk therapy. Their attitude seemed to be, the more medication you got, the better the doctor, he notes. Still, Fluent looks back at the mission with a sense of accomplishment.

"We did good things there," he says. "I know I made a difference, although it was the kind of mission where that sense was a little harder to wrap your arms around compared to my experience at Landstuhl," an earlier deployment to Landstuhl Regional Medical Center in Germany. There, Fluent mainly treated physically and psychologically injured Coalition troops fresh from the battlefield.

Fluent says he's grateful for the support he received while deployed. In July, U-M's Psychiatry Department received a Patriot Award from the Michigan Committee for Employer Support of the Guard and Reserve in recognition of its support for National Guard and Reserve forces.

RESOURCES
As more and more American troops return from Afghanistan and Iraq, and try to resume a civilian life, veteran patients and their families can take advantage of the following resources offered by U-M:

The Buddy-to-Buddy Program
The program pairs veterans readjusting to civilian life with a volunteer veteran - someone who's been through what they've been through - who can help them connect with resources and deal with the many challenges they face. More information is available at http://buddytobuddy.org or by calling 1-888-82-BUDDY (1-888-822-8339).

STRoNG Families
The STRoNG Families parenting group program is offered for military service members, their spouses or partners, and their children from birth to 8 years old, and provides a 10-week parent and child group experience designed to support and enhance the resilience of military families. For more information, contact Karen Smith, M.S.W., at 734-936-2627 or karenas@med.umich.edu.

Military Family Support Forum
The forum is a free monthly program for family members of Iraq and Afghanistan service members or veterans. Spouses, significant others, children, parents, siblings and other relatives are welcome. Topics covered include stress management, communication, understanding depression PTSD and substance abuse and relationship building. The forum is held one Saturday per month at the U-M Depression Center. For more information, Contact Kate Bullard at 734-763-4904 or krharris@umich.edu