The Darker Side of Military Mental Healthcare Part Two ...Learning historical lessons has always...

The Darker Side of Military Mental Healthcare Part Two: Five HarmfulStrategies to Manage Its Mental Health Dilemma

Mark C. Russell1 & Shawn R. Schaubel1 & Charles R. Figley2

Received: 15 September 2017 /Accepted: 15 December 2017 /Published online: 11 January 2018# Springer Science+Business Media, LLC, part of Springer Nature 2018

AbstractThis is the second part of our analysis of the military’s mental health care dilemma. Since the First World War, military andgovernment officials have been quite wary of mass psychiatric attrition and escalating pension costs fromwarzones. Specifically,the military worries about unknown repercussions should war stress injuries be de-stigmatized and treated equally as physicalwounds, as required per the military’s own documented lessons learned. Leaders fear that so-called evacuation syndromeswouldspread, thereby depleting the fighting force for invalid reasons, eroding unit morale, and providing an acceptable escape fromone’s military duties instead of the disapproval deserved, thus jeopardizing the military’s primary mission to fight and win wars,as well as risk possible financial strain in societies dealing with too many psychiatrically disabled veterans. Consequently, themilitary routinely admits to ignoring its war trauma lessons, resulting in a generational pattern of self-inflicted crises, includingsuicide epidemics. Moreover, besides neglecting such lessons, the military has adopted various approaches over time to reducethe possibility of evacuation syndromes by aggressively preventing psychiatric attrition, treatment, and disability pensions. Afteran extensive review of the war stress literature, we identified 10 overarching strategies the military has employed in order to resistfully learning from its lessons on the psychiatric realities of modern warfare by eliminating, minimizing, and/or concealing itsmental health problem. Part two of the article series examines the following avoidance strategies intended to prevent psychiatricattrition and disability pensions: (1) Cruel and Inhumane Handling; (2) Legal Prosecution, Incarceration, and Executions; (3)Weaponizing Stigma to Humiliate, Ridicule, and Shame into Submission; (4) Denying the Realities of Mental Health; and (5)Screening and Purging Weakness. We argue that by not accepting the realities of the combat stressors, no effective methods forassessment and treatment of the stress reactions, not to mention prevention methods, have emerged that contributes to alleviatingthe veteran suicide and mental health crises.

Keywords Mental health crisis .Military . Veterans .War stress . Policy . PTSD . Parity

BThose who cannot remember the past are condemnedto repeat it!^ George Santayana, 1905

Few would disagree with Santayana’s (1905) pronouncement-particularly those in the profession of defending the national trust.Learning historical lessons has always been viewed as an invalu-able and traditional staple for preparing future military leaders(e.g., U.S. Army Military History Institute, 1944). Wars are wonor lost—people may live or die—by how adeptly battlefield

lessons are incorporated. Thus, it has long been military doctrineto systematically and thoroughly analyze and integrate combatlessons by establishing Ba system for the collection, analysis, dis-semination, and implementation of combat, training, and materieltesting experiences with associated combat relevant lessonslearned into Department of the Army (DoA) doctrine^ (U.S.Army, 1989; p. i).

War Trauma Lessons and PreventableWartime Behavioral Health Crises

An extensive review of applicable material has identified 10interrelated foundational war trauma lessons, such as the needto adequately plan and prepare for large numbers of psychiat-ric casualties, to eliminate stigma, ensure large cadre of well-trained specialists, provide support to military families,

* Mark C. [email protected]

1 Antioch University Seattle, 2400 Third Avenue #200,Seattle, WA 98121-1814, USA

2 Tulane University, New Orleans, LA, USA

Psychological Injury and Law (2018) 11:37–68https://doi.org/10.1007/s12207-017-9311-9

http://crossmark.crossref.org/dialog/?doi=10.1007/s12207-017-9311-9&domain=pdf

mailto:[email protected]

establish an integrated organization with accountable leader-ship, and provide ready access to definitive treatment prior tomilitary discharge (Russell, Schaubel, & Figley, 2017). Theclearest proof of actual lessons learned would be the absenceof forgetting or ignoring basic tenets for meeting wartimemental health needs and preventing crisis. However, to thecontrary, it appears that the military has avoided to learn frompsychiatric realities of war, resulting in a pattern of largelypreventable behavioral health crises harming millions of vet-erans and their families since WWI, and thus leaving the U.S.military and its government vulnerable to future legal action(Russell & Figley, 2015a, b; Russell, Zinn, & Figley, 2016).

The Military’s Mental Health Dilemma

The burden of Service members deployed on our behalfincludes substantial psychological challenges. We in theDepartment of Defense Military Health System join thenation at large in our gratitude to all of our Servicemembers and their families. We are grateful for theirpersonal sacrifices and for their contributions to securityand freedom around the world. They have answered ourcall – we must answer theirs! [Assistant Secretary ofDefense for Health Affairs, William Winkenwerder(2005, p. 7)].

We describe the military’s mental health dilemma as achoice between two undesirable propositions: (1) facing therealities of the role of mental health decline during stressfuloperations involving high risk and limited rewards and chang-ing traditional preparation for and engagement in war to ac-commodate the loss; or (2) not facing the realities andpretending there is no systematic and predictable mentalhealth decline and continuation of the mental health crises.We argue and provide proof that millions of veterans and theirfamilies, as well as society are being harmed (e.g., Russellet al., 2017) because option 2 appears the choice being madeby the military.

Once a mental health crisis can no longer be denied,the military and government react with a flurry (Russell &Figley, 2015b). Each war generation candidly documentshaving to re-learn the previous generations’ war traumalessons after ignoring those realities at the outset of war(e.g., Russell & Figley, 2015b). Therefore, we see in thecurrent Afghanistan and Iraq Wars, just like in previousAmerican wars, significant increases in spending and re-sources for mental health specialists, training, research,treatment programs, family support, and anti-stigma rhe-toric (Russell & Figley, 2015a). However, as war windsdown, so too does national interest, and mental health

programs are often the first to erode away (Russell &Figley, 2015b).

The ending of war routinely marks the expiration of mili-tary and government commitment to learning the hard wonlessons of war trauma, resulting in a ‘national reset’ or returnto pre-war baseline of mental health neglect (Russell, Figley,& Robertson, 2015). Consequently, every war generationsince the twentieth century goes to war with grossly substan-dard mental health services completely incapable of meetingpeacetime, yet alone wartime needs-thus perpetuating self-inflicted crises (Russell & Figley, 2015a, b). This tragic cycleof ignoring and re-learning the psychiatric realities of war isopenly acknowledged by each war generation since WWI andreflects convictions of the military and government in terms ofthe mental health dilemma.

In Part I of our three-part analysis, we have described thecompeting demands and responsibilities placed on militarycommanders to look out for the welfare of individual servicemembers and their families, while being tasked to completetheir primary mission to fight and win wars (Russell et al.,2017). Additionally, the historical origins of the military’smental health dilemma have been reviewed, including theimportant constructs of evacuation syndromes and trauma-pension debates that shaped the military’s response to its men-tal health dilemma, along with the many distinguished accom-plishments of military mental healthcare (Russell et al., 2017).Underlying the military’s mental health dilemma is a profoundworry that acknowledging the psychological realities of warwill inevitably cause massive psychiatric evacuations thatwould deplete the fighting force and its will to fight, whilesimultaneously causing financial repercussions from ever-increasing attrition, treatment, and pension costs.

This is exemplified by the U.S. Army’s lessons learnedreport after WWI:Where the number of such cases increases to such anextent as to seriously threaten man power, then morethan ever do the war neuroses assume the dignity ofmilitary importance. Therefore, no statement of theproblem of the war neuroses can be made without con-sidering from the very beginning its military signifi-cance. Many of the errors made in attempting to solvethe problems of the war neuroses among soldiers mighthave been avoided if at all times the military point ofview had been kept in mind. This point of viewmight beexpressed as the effort toward returning such a patient tohis former status as a soldier with the basic assumptionthat this is a thing possible to accomplish (Salmon &Fenton, 1929, p. 369).

However, the military and government are also morally andlegally obligated to provide timely and high-quality healthcare

38 Psychol. Inj. and Law (2018) 11:37–68

to military populations, including mental health services (e.g.,Winkenwerder, 2005).

The Darker Side of Military Mental Healthcare

Ending the generational tragedy of preventable wartime men-tal health crises requires full-disclosure of a darker aspect ofthe military’s struggle to resolve its mental health dilemma,which, if continued unabated, will likely harm futureAmerican generations.

Five Harmful Strategies to Manage Its MentalHealth Dilemma

The greatest obstacle to neuropsychiatry in both civiland military practice has been the barrier that tends toseparate nervous and mental diseases from all other dis-eases, and it was thought by some that, in so far as theMilitary Establishment was concerned, the greatestgood, both to the practice of neuropsychiatry and tothe patients who were dependent upon it, would be ac-complished if a determined effort were made to breakthrough this barrier and to place the mental patient on apar with patients incapacitated by reason of other dis-eases (Bailey, 1929; pp. 42-43).

The military has employed 10 approaches aimed atavoiding learning from its war trauma lessons by punishing,eliminating, and/or concealing its mental health problem: (1)Cruel and Inhumane Handling; (2) Legal Prosecution,Incarceration, and Executions; (3) Weaponizing Stigma toHumiliate, Ridicule, and Shame into Submission; (4)Denying the Realities of Mental Health; (5) Screening andPurging Weakness; (6) Delay and Deception; (7) Bad PaperDischarges; (8) Diffusion of Responsibility and ErectingOrganizational Barriers to Care; (9) Appeasement, Half-Measures, and Other Temporary Fixes; and (10)Perpetuating Neglect and Self-Inflicted Crises. Collectively,these approaches carry on a 100-year-old tradition started dur-ingWWI to preserve the military’s short-term capacity to fightand win wars while protecting society and its’ governmentfrom financial repercussions (see Russell et al., 2017). Eachof the above strategies represents the military’s commitment toavoid full acceptance or permanent learning that mentalhealthcare is a legitimate component of military readiness de-serving equal priority as medicine. Due to the scope of ouranalysis, the latter five harmful strategies are covered in Partthree (Russell, Schaubel, & Figley, 2017).

Strategy One: Cruel and Inhumane Handling

Throughout military history and continuing to present day,there is a military tradition of extolling discipline to correctundesired behavior and send poignant warnings to the masses.Flogging, whipping, a cat-o-nine tails, solitary confinement,running the gauntlet, tar and feathering, and shackling were allfairly standard forms of physical punishment used by militaryleaders such as General George Washington to combat cow-ardice and mass desertions (e.g., Ward, 2006). For example,following the American war of 1812, the Deputy InspectorGeneral of Army Hospitals described medical examinationsfrom flogging: BI have seen several instances of men whohave received 500 lashes…and I am aware of one soldierwho received 700 lashes and drummed out of the corps^(Marshall, 1840; p. 30). However, other military leaders, in-cluding Washington’s Surgeon General, Benjamin Rush, ar-gued for more compassionate treatment of mentally ill com-batants (Baker, 2011).

Regarding corporal punishment of mentally ill soldiers,Marshall (1840) warned: Insanity has been frequently feignedby soldiers who wished to obtain their discharge… but it isalso true, and the fact is a melancholy one, that real insanityhas been mistaken for feigned, and the patients treated andpunished as imposters^ (p. 132). Marshall (1840) poignantlyrecalls the tragic case of an enlisted soldier with 11 years ofservice who developed symptoms of mental alienation(insanity) but was repeatedly accused of malingering to obtaina disability discharge and denied proper treatment. After fivecourts-martial convictions resulting in five incidents of severepublic flogging, the soldier’s untreated mental illness wors-ened. He eventually received a less than honorable discharge,but his mental health continued to deteriorate and shortlythereafter the veteran Bcommitted suicide by drinking a quan-tity of sulphuric acid^ (Marshall, 1840, p. 132).

During the U.S. Civil War and WWI, war stress casualtiesincapable or unwilling to continue to fight were often subjectto ‘Field Punishment One’ consisting of binding war stressedpersonnel accused of cowardice to a tree, fence post, orbarbed-wire fencing within an active battlefield to motivateothers to not shirk their duties (e.g., Holden, 1998). In addi-tion, over-stressed soldiers needing a respite were oftenassigned Boccupational therapy,^ consisting of grueling, te-dious, often distasteful labor (e.g., cleaning latrines) with theintention that combatants would view returning to the front-lines as imminently more desirable. Anecdotal reports ofphysical abuse of mental invalids in the military are abundant.Perhaps the most notorious incident was in 1946, in Palermo,Italy, when news reporters observedWWII legend, U.S. ArmyGeneral George C. Patton, repeatedly slapping and threaten-ing hospitalized Bbattle fatigued^ soldiers with a loaded re-volver for having the audacity to lay next to the Bhonorablywounded.^ While Patton’s exploits are clearly over the top

Psychol. Inj. and Law (2018) 11:37–68 39

even by military standards, he was expressing a widely heldantipathy toward mental health (e.g., Menninger, 1948).

Use of Cages for Psychiatric Patients A major finding byWWII army investigators was the confining of war-stressedcombatants in wire-meshed cages measuring six feet in lengthand three feet in height and width, thus prohibiting occupantsfrom sitting, which the official report labeled as Bquiteinhumane.^ The inspector general’s report further revealedthat Btransportation of this type of patient, understood so little,and feared so much, would be too difficult for medical andattendant personnel to control disturbed patients,^ so orderswere issued to use shock machines for ECT (electroconvul-sive therapy) (Kessler, 1966, p. 336). Kessler (1966) went onto report that official recommendations were made to removethe stigma created by the letters BNP^ (Neuropsychiatric) onpatient identification tags that Blooked upon men so designat-ed as social pariahs to the consequent grief and consternationof the psychiatric patients^ (p. 337). Unfortunately, the rec-ommendation was ignored as late as 1945, keeping in linewith the trend of neglect.

Deaths of Psychiatric Patients in Transit From April 1944through October 1944, a total of 2980 U.S. war veterans di-agnosed with war stress injury were transported via ship fromthe Pacific theater to San Francisco. In this group, there were19 deaths, all but one reportedly diagnosed as Bpsychotic^(Kessler, 1966). Causes of death were stated as: nine drowned(usually jumping overboard), one hanged himself, one died ofdiphtheria, three died of cardiac conditions, one died of mal-nutrition, one died of pyelonephritis, and two died of un-known causes (Kessler, 1966). The investigators concludedthat: BIn retrospect, it seems unconscionable that such abusesand inhumanities, as have already been enumerated, couldoccur in the first place (Kessler, 1966; p. 338). These abusesincluded severe overcrowding, lack of ventilation, lack of ac-cess to the decks, use of physical restraints, chains, and chron-ic exposure to air temperatures averaging 105 to 110F duringthe 14-day trip (Kessler, 1966).

Physical Isolation and Neglect During WWI, psychiatric ca-sualties were admitted to the: "isolation-insane buildingthat was a long rectangular building with windows anddoors heavily barred on the outside and heavily screenedon the inside, the interior broken into small cell-like struc-tures stoutly maintained^ (Salmon & Fenton, 1929; p.40). This practice continued in WWII, whereby combat-ants sacrificing their mental health for the military mis-sion were by policy labeled as psychiatric casualties andsystematically segregated from those with medicalwounds and sometimes subject to brutal, often inhumanetreatment leading to untimely deaths. (e.g., Kessler,1966). Tragically, combatants who sacrificed their mental

health for the military mission were abused. For example,Kessler (1966) reported WWII abuses of U.S. Marinesand Soldiers diagnosed with war stress injury during shiptransportation to San Francisco from the Pacific theater. In1943, an army investigator wrote BReturning Army trans-ports carried most of the mental cases and the latter wererelegated to an undesirable section of the ship which waspoorly lighted and ventilated… fundamentals of care suchas nutrition and water balance was neglected, morphinewas used as a sedative^ (Kessler, 1966; p. 336).

Evidence of Physical Maltreatment in the Twenty-FirstCentury In today’s wars, there is no widespread physical mal-treatment of war stress casualties, but isolated reports of abusestill emerge. For example, in 2010, the House OversightCommittee heard testimony about an Army Sergeant with12 years of military service who suffered migraine headaches,vision loss, anger episodes, and suicidal ideation following theconcussive effects of a mortar blast during an Iraq deploy-ment. His unremitting partial blindness was diagnosed ascaused by a preexisting personality disorder, subject to mili-tary discharge and potential loss of VA treatment benefits(Kors, 2010). After rejecting the diagnosis, the Sergeant wasallegedly confined in a closet, monitored around the clock byarmed guards who enforced sleep deprivation—keeping thelights on all night and blasting heavy metal music through thenight (Kors, 2010). When the sergeant tried to escape, he wasreportedly pinned down, injected with sleeping medication,and dragged back to the closet, and signed the personalitydisorder discharge papers after enduring a month of such treat-ment (Kors, 2010).

Strategy Two: Legal Prosecution,Incarceration, and Executions

Many of these soldiers witnessed horrible events; theysaw friends die; they lost limbs and faces; they wentwithout sleep or food for days at a time. They have dealtwith the same demons as the accused, and yet they haveresisted alcohol and drugs. The accused is asking you tohold him to a different standard. Send a message to theothers who have suffered. Give them a reason to stay thecourse and resist the temptation. Don’t let Sergeant Kuse PTSD as an excuse to violate the law and put othersat risk. This time, he damaged a wall. Next time, whoknows? The Government asks for a DishonorableDischarge and three years confinement, because justicedemands as much (Seamone, 2011, pp. 10-11; MilitaryLaw Review, Department of Army).


As illustrated by Seamone (2011), during times of war,military leaders are frequently confronted with a complicatedset of problems when it comes to disciplining personnel whoviolate military law (Uniformed Code of Military Justice,UCMJ) during or after deployments. At its core,Commanders are responsible for maintaining morale, disci-pline, and good-order within their units. Therefore, to allowcriminal misconduct to go unpunished may send an untenablemessage that could escalate into wide-spread indisciplinewithin the ranks. Historically, Commanders have often erredon setting an example of individuals who either cannot or willnot fight, and/or engage in other detrimental conduct byawarding excessive and harsh punishments, including execu-tions, as a means to intimidate and keep others in-line.

On the other hand, enlightened Commanders must alsoconsider whether misconduct is related to the subject’s combatexperiences (e.g., aggressive behavior after returning fromdeployment) and/or the result of a war stress injury (e.g.,PTSD, TBI). For instance, behaviors such as freezing underfire, desertion, excessive/inappropriate aggression, substanceabuse, social isolation, unkempt appearance, over-sleeping,recklessness, tardiness, and suicide attempts are common fea-tures of war stress injury such as PTSD, TBI, and depression,as well as frequent legal actions against military personnel.The Commander’s dilemma is greatly intensified when theoffender is an otherwise valuable, proven leader with an ex-emplary record of honorable service and no prior history ofdiscipline problems. Most Commanders appear to do a rea-sonable job of weighing factors such as the individual’s pastperformance, deployment history, and the nature and severityof the alleged offenses in determining a fair and proper legaldisposition. In fact, during WWI and WWII, the U.S. militaryimplemented highly successful progressive legal forms em-phasizing suspensions of sentences in favor of rehabilitation,treatment, and restoration to duty, predating today’s VeteransTreatment Courts (e.g., Seamone, 2011).

On the same token, there is ample evidence of themilitary’spropensity to abuse the legal system to manage its mentalhealth problem (e.g., GAO, 2017). For example, a recentYale law review article reported on a Vietnam War veteran’scivil suit to amend his discharge (Izzo, 2014). After complet-ing two honorable tours of duty, fighting in four separate cam-paigns in Vietnam, and earning an Air Medal with ValorDevice for heroism, John Doe was given an UndesirableDischarge (akin to Other-than-honorable) following a 1973conviction for threatening and hitting fellow soldiers (Izzo,2014). John Doe was later diagnosed with PTSD by a civiliantherapist; however, his Undesirable Discharge prohibits gov-ernment employment and VA benefits such as disability com-pensation, PTSD treatment, healthcare, education, and bene-fits for surviving family members (Izzo, 2014). Below, webriefly review themilitary’s legal system and options availableto Commanders in dealing with misconduct of war veterans.

Potential Legal Prosecutions Related to War StressInjury

The connection between war stress exposure and future crim-inality is the same as it has been in most major wars. In its2009 Porter v. McCollum opinion, the unanimous SupremeCourt bridged across time, citing early studies of this crimeconnection to war stress exposure in support of the Nation’sBlong tradition of according leniency to veterans in recogni-tion of their service, especially for those who fought on thefront lines.^ (p. 8).

Legal Prosecution for Cowardice

For instance, desertions and refusal to obey orders to attackcan jeopardize the effectiveness of fighting units. Marlowe(2001) highlighted the historical military dichotomy of humanadaptation to war stress as literally a ‘flight’ or ‘fight’ responsewith combatants either exhibiting constitutional weakness or‘cowardice’ and deserting the battlefield or the constitutional-ly ‘brave’who join the fight. Since the Napoleonic-era (1799–1815), massive modern militaries increasingly relied on citi-zen conscription, and although they became more adept atpreventing war stress-related escape behaviors (i.e., via battle-field execution, courts-martial, fostering unit cohesion) fromthe progressively destructive effects of industrial war, warstress injury incidence has trended upwards (i.e., Marlowe,2001). The numbers of ‘deserters,’ ‘malingerers’ (i.e., ‘rheu-matism fakers,’ self-inflicted wounds) and veterans executedwith war stress injury in any historic era is unknowable. Forexample, during the American Civil War (1861–1865), therewas an estimated 300,000 deserters between the Union andConfederate armies, with an unknown, but larger number of‘stragglers’ (Dean, 1997). How many soldiers that desertedthe battlefield had a war stress injury is pure speculation, butthere is ample historical evidence that many were battle-seasoned veterans, including senior enlisted and officers dur-ing the American Civil War (e.g., Lande, 2003) and the BoerWar (e.g., Finucane, 1900). During the Vietnam War,33,000 U.S. Army personnel deserted in 1971 alone, but prev-alence of war stress injury is unreported (e.g., Dean, 1997).

Throughout WWII, there were 1.7 million courts-martialsrepresenting a third of all criminal cases in the U.S. during1941–1946, including 21,000 cases of Bdesertion^ resulting inthe last American execution for desertion in 1945 of a combatsoldier diagnosed with Bpsychoneuroses^ (U.S. Army, 1975).Legal prosecution for cowardice is not relegated to only thosesoldiers who physically left the battlefield, but also pertains tothose who internally fled. Anecdotal reports of the so-calledfreeze response to extreme stress is readily apparent inmilitaryrecords, but is often called different names, such as war hys-teria, shell shock, conversion reaction, or dissociation disor-der. How many of these trembling, immobilized soldiers have


been prosecuted for cowardice is of course unknowable, butwe would rightly expect such overt demonstrations ofBweakness^ would be dealt harshly by the military.

Old Sergeant’s Syndrome

The dichotomy between cowardice and bravery in the face ofwar stress exposure is seriously undermined by what militaryphysicians and researchers call old sergeant’s syndrome(Sobel, 1949a). Throughout military history, there is ampledocumentation of chronic war stress injury within themilitary’s most battle-seasoned, highly-trained, and well-respected leaders (e.g., Da Costa, 1871). For example, Sobel(1949a) examined 100 WWII U.S. Army noncommissionedofficers ‘old’ in combat experience identified with old ser-geant syndrome or Guadalcanal twitch BFor these men wereamong the best and most effective of the trained and disci-plined combat infantry soldiers^ (p. 137). They developedabnormal tremulousness, excessive startle, severe anxiety,sweating, dyspepsia, depression, loss of self-confidence andguilt, with a highly uncharacteristic tendency to be the ‘first toget in and last to leave a foxhole.’ Military research on front-line psychiatry treatment of 100 cases of old sergeantsyndrome proved futile. 100% of those RTD relapsed withinless than 10 h to three combat days despite their excruciatingattempts to remain on the battlefront. This was long-term dis-position of reassignment to non-combat jobs in the backlinesor discharge (Sobel, 1949a). Battle-tested infantry leaderswere not the only vulnerable group. The aviator’s equivalentof old soldier’s syndrome was called flier’s fatigue or opera-tional fatigue as vividly illustrated in the 1949 movie ‘TwelveO’ Clock High’ depicting a combat seasonedWWII Army AirCorps bomber squadron commander succumbing to flier’sfatigue after replacing a fellow proven leader impaired bythe same affliction whom was previously viewed as constitu-tionally vulnerable. Flier’s fatigue and battle deaths werehighest for bomber crews, with fewer than 25% completinga full tour of duty and high relapse rates evident, with themajority requiring further treatment after their tour(Chermol, 1985). Yet, even these proven combat veteranswere not immune from accusations of Bbeing yellow^ oncethey succumbed to the effects of war stress (see TwelveO’Clock High, 1949).

Contemporary support of old sergeant’s syndrome isevident in reports of high prevalence of war stress injurylike PTSD even among the military’s most elite SpecialForces deployed to Iraq and Afghanistan (e.g., Hing,Cabrera, Barstow, & Forsten, 2012). These findings sug-gest that the severe and continuous deployments, danger-ous operations, and war cause mental health decline thatleads to medical decline and risk of a mental health crisis.The result is a danger to the soldier and others, and thiscan risk the military mission involved.

Legal Prosecution for Substance Use Disorders (SUD) Thestress of war has always been associated with high incidenceof SUD (Institute of Medicine (IOM), 2012), as well-documented by every generation, both during, but particularlyafter war. For example, alcoholism and opiate addiction weremajor concerns reported within the Union Army, with 5589soldiers hospitalized for inebriation, 110 of whom died due toalcohol poisoning; 3744 cases of delirium tremens, with 450fatal; and 920 cases of chronic alcoholism, with 45 fatalities(U.S. Army, 1888; p. 890). During WWI, 4170 deployed sol-diers were discharged for Balcoholism or drug addiction^(Salmon & Fenton, 1929); 43,339 in WWII (Glass &Bernucci, 1966); and incidence of SUD during Korea was alsoreported to be Bhigh,^ but unspecified (Jones, 2005).However, during Vietnam War, SUD was by far the mostextensive of any era. For example, Stanton (1976) reportedthat from 1967 to 1971, the proportion of enlisted soldierssmoking marijuana Bheavily^ (20 or more times) in Vietnamincreased from 7 to 34%, while the proportion of Bhabitual^users (200+ times) stabilized at 17 to 18% between 1969 and1971. The same holds true for contemporary veterans. Forinstance, the IOM (2012) reported that since the start ofOEF/OIF Balcohol abuse among returning military personnelhas spiked. In 2008, nearly half of active duty service mem-bers reported binge drinking^ (p. 2). In today’s cohort, from2000 to 2011, a reported 306,248 active military personnel(Armed Forces Health Surveillance Center, 2012) and200,923 VA treatment seeking OEF/OIF/OND vets (VA,2015) have been diagnosed with SUD.

Combat veterans struggling with SUD are extremely vul-nerable for legal prosecution under the UCMJ for a wide-arrayof behaviors [e.g., DUI, public intoxication, conduct unbe-coming, unauthorized absence (e.g., being late to work), illicitdrug use, prescription drug abuse]. The military’s zerotolerance policy for drug use results in nearly automaticGeneral or OTH discharges for first timers, regardless of rankand past performance, as do repeated alcohol-related inci-dents. For example, per the Department of Navy (2009):BThe Navy’s policy on drug abuse is Bzero tolerance.^ Navymembers determined to be using, possessing, promoting,manufacturing, or distributing drugs and/or drug abuse para-phernalia shall be disciplined as appropriate and processed forADSEP (Administratively Separated) as required^ (p. 5).

The actual number of current war veterans prosecuted forSUD is unknown. However, in 2007, National Public Radio(NPR) reported that since the Iraq invasion of 2003 the U.S.Army discharged almost 20% more soldiers for Bmisconduct,^including twice as many soldiers for drug abuse, than it did inthe same period before the war, (or Bhaving behavior issuesthat are potentially linked to PTSD)^ (Zwerdling, 2007).Furthermore, the number of enlisted soldiers prosecuted anddischarged out of the U.S. Army for drugs, alcohol, crimes,and other misconduct soared from 5600 at the peak of the Iraq


war in 2007 to more than 11,000 in 2013, while the number ofdischarged Army officers tripled to 387 in 2013 (Frizell,2014). Unfortunately, there is no hard data available on thenumber of Afghanistan or Iraq veterans prosecuted for SUD,nor how many of those may have had war stress injury.

Legal Prosecution for Post-traumatic Anger and InterpersonalViolence (IPV) Irritability and post-war anger problems havefrequently been reported in war veterans of every generation,and they can occasionally escalate into violence. In the contextof combat, anger and aggressive behaviors are normative re-sponses to threats of vulnerability (Forbes et al., 2008). Suchresponses are not only adaptive to war, but also have beenextensively modeled and reinforced through military training(Taft Vogt, Marshall, Panuzio, & Niles, 2007). Social re-integration transitions from deployment and after military dis-charge represent critical adjustment periods wherein violenceagainst self and/or others may arise, and therefore induce aheightened need for individual and family support. The U.S.government funded a study of the effects of the VietnamWar,BLegacies of Vietnam,^ and found 24% of vets who sawheavy combat were later arrested for criminal offenses, ascompared to 17% of other era veterans and 14% of non-vet-erans. A study by Jordan et al. (1992) found that approximate-ly one-third of Gulf War-era veterans with PTSD had perpe-trated interpersonal violence (IPV) in the previous year. Intoday’s cohort, an Army-wide study of 20,000 OEF/OIFSoldiers found length of deployment was positively correlatedwith the severity of self-reported IPV perpetration in the yearafter deployment (Klostermann, Mignone, Kelley, Musson, &Bohall, 2012).

Another study of OEF/OIF veterans with PTSD found self-reported irritability/anger as the highest symptom, with 29%of reports rated as Bquite a bit^ or Bextreme^ (Pietrzak,Goldstein, Malley, Rivers, & Southwick, 2010). Anotherstudy reported 70% of veterans with PTSD reported impulsiveaggressiveness compared to 29% of veterans without PTSD(Teten et al., 2010). Another more recent study estimated that33% of veterans seeking PTSD treatment reported perpetrat-ing partner violence (Taft, Weatherill, Woodward, et al.,2009). It is unknown how many of the aforementioned mili-tary personnel have an identifiable war stress injury and wereactually prosecuted for IPV.

Legal Prosecution of Misconduct Stress Behaviors TheDepartment of the Army (DoA, 2006) describes a range ofmaladaptive stress reactions from minor to serious violationsof military law and the Law of Land Warfare, most oftenoccurring in poorly trained soldiers, but the Bgood and heroic,under extreme stress may also engage in misconduct^ (p. 1–6)even in highly cohesive well-trained and led units. For exam-ple, according to previously classified ‘secret’ military docu-ments, the first-ever U.S. special forces unit was organized

during WWII and consisted of 2639 officers and enlisted per-sonnel (U.S. Army, 1944). On its first mission, 53 Rangerswere killed and 91% of this highly decorated unit receivedawards, including 1214 Purple Hearts, after 240 days of inten-sive, continuous combat (U.S. Army, 1944). However, afterdeployment, 10% or 266 of the military’s elite force wereconvicted of various misconduct: 87 summary courts martial;160 special courts martial, and 90 general courts martial (U.S.Army, 1944). Examples of misconduct stress behaviors in-cluded mutilating enemy dead, not taking prisoners, looting,rape, malingering, combat refusal, drugs, self-inflictedwounds, ‘fragging,’ desertion, torture, and intentionally kill-ing non-combatants (DoA, 2006).

In addition to predicting PTSD, high combat exposure wasshown to predict war-zone misconduct with participation inwar-zone violence empirically related to post military violenceto self, spouse, and others (Hiley-Young, Blake, Abueg,Rozynko, & Gusman, 1995). A 2010 study on psychosocialpredictors of military misconduct reported that 2274 out of asample of 20,746 Marines deployed to OEF/OIF between2002 and 2007 received either bad conduct discharges (3%;n = 548) or demotions in rank from misconduct (9%; n =1726) (Booth-Kewley, Highfill-McRoy, Larson, & Garland,2010). The most frequent reasons cited for bad conduct dis-charge were drug abuse (n = 340, 62%), frequent contact withcivil or military authorities (n = 88, 16%), and court-martialconvictions (n = 66, 12%) (Booth-Kewley et al., 2010).

The strongest predictor variables for bad conduct dischargewas age at first combat deployment (18–21 years) and psychi-atric diagnosis (Booth-Kewley et al., 2010). Moreover,Marines diagnosed with a psychiatric disorder after combatwere 9 times more likely to receive a bad conduct dischargethan Marines undiagnosed (Booth-Kewley et al., 2010). PerTable 2, there is clearly a trend of increasing number of OTHseparations for misconduct as the duration of a war increases.Similar data were not found for the other military (seeTable 2), but we assume the same holds true across themilitary.

Historical Precedents of Misconduct Stress Behavior DuringWWII, there were 82,754 general courts-martials in the U.S.Army alone for serious misconduct including murder, rape,and atrocities against civilians (U.S. Army, 1975) resultingin the execution of 70 soldiers deployed to Europe (Sullivan,1998). At least one of the executed soldiers had a documentedhistory of combat exhaustion (U.S. Army, 1975). There were101 reported homicides within the U.S. Army in Korea during1950–1953 (Reister, 1973), and an estimated 163 unarmedKorean women, children, and elderly refugees were killedby U.S. forces at No Gun Ri in 1950 (The Associated Press,1999). During Vietnam, Linden (1972) reported a progressiveincrease in the number of courts-martial for insubordinationand assaults (including murder), exemplified by Bfragging^


incidents increasing from 0.3/1000/year in 1969 to 1.7/1000/year in 1971 (Neel, 1991).

A reported 320 atrocities by American military personnelwere substantiated by an Army task force BThe Vietnam WarCrimes Working Group^ created after the 1968 My LaiMassacre, wherein victims numbered 347 to 504 unarmedVietnamese including many women and children (Nelson,2008). Research on VietnamWar veterans reported statistical-ly significant association between combat exposure and post-military antisocial behavior (Barrett et al., 1996; Resnick, Foy,Donahue, & Miller, 1989), along with exposure to war atroc-ities and subsequent IPV (Beckham, Feldman, & Kirby,1998). After the Persian Gulf War, a modest association be-tween combat experience and incarceration rates was found ina large sample (Black et al., 2005).

As in other wars, especially low-intensity (guerilla-type)warfare like in Iraq and Afghanistan, there has been a highincidence of misconduct stress behaviors by American per-sonnel ranging from inappropriate handling of American andenemy combatant dead, to prisoner torture and sexual abuse(e.g., 2004 Abu Ghraib incident), as well as several substan-tiated incidents of rape and homicide of unarmed civiliansincluding children. The total number of courts-martial, inci-dents of atrocity, and Bbad paper^ discharges related to mis-conduct stress behavior is unknown because the military doesnot track its legal prosecution of mentally-injured combatants.However, in 2014 the American Press reported a total of28,000 soldiers were discharged for misconduct since theIraq war (Baldor, 2014). During the same period of time be-fore the wars in Iraq and Afghanistan, the U.S. Armydischarged 20% more soldiers for Bmisconduct,^ 40% morefor personality disorder, and 50%more for drug abuse, includ-ing 11,000 enlisted soldiers in 2013 alone (Baldor, 2014). Wecan reasonably assume a large number of combat personnelhave been prosecuted and received punitive discharges forwar stress injuries like misconduct stress behaviors.

Military Discipline and Legal System

The historical foundation for U.S. military law lies in the 1774British Articles of War. The first legal codes, the AmericanArticles of War and Articles for the Government of the Navy,predated the Constitution and the Declaration ofIndependence. The American military’s current criminal code,Uniformed Code of Military Justice (UCMJ), was enacted in1950 and is a complete set of criminal laws, rules, and proce-dures contained in the Manual-for-Courts-Martial (MCM,2012). It includes many crimes punished under civilian law(e.g., murder, rape, drug use, larceny, drunk driving), but alsoit includes other conduct that affects good order and disciplinein the military. Those unique military crimes include, deser-tion, absence without leave, disrespect toward superiors, fail-ure to obey orders, dereliction of duty, wrongful disposition of

military property, drunk on duty, malingering, and conductunbecoming an officer (MCM, 2012). The purpose of militarylaw is to: Bpromote justice, to assist in maintaining good orderand discipline in the armed forces, to promote efficiency andeffectiveness in the military establishment, and thereby tostrengthen the national security of the United States^(MCM, 2012; p. i-1). Commanders are given significant rolesin the military justice system because discipline is essential tomission readiness. At the same time, there are safeguardsintended to protect against abuse of authority, such as the rightfor trial and appeal (MCM, 2012).

Discipline and Legal Proceedings and Disposition

There are essentially three avenues for Commanders to dealwith potentially war-stressed service members engaging inmisconduct: (1) informal resolutions, such as verbal repri-mands, extra-instruction or duties, temporary or permanentreassignment, chaplain referral, and/or referral for alcohol,medical, or mental health screening intended to rehabilitateoffenders depending on the nature/severity of the offenseand whether the offense occurred in operational versus a gar-rison setting; (2) formal administrative procedures, called non-judicial punishment, for minor offenses not severe enough towarrant referral for Courts-Martial; and 3) referral to Courts-Martial.

Non-judicial Punishment

The authority and guidelines for Non-Judicial Punishment(NJP) is contained in Article 15 of the MCM (2012). It is alsoknown as Office Hours and Captain’s Mast in different mili-tary branches. It is considered an invaluable leadership tool,providing Commanders with a prompt and essential means formaintaining good order and discipline for minor violations ofthe UCMJ without resorting to time-intensive and restrictiveCourts-Martial procedures. Service members subject to NJPmust waive their legal protective rights for trial by Courts-Martial, which most do because the penalties from Courts-Martial convictions are inherently more severe (see MCM,2012)-a fact military leaders greatly emphasize. Table 1 de-scribes the types and subsequent costs and benefits of sixtypes of separations from the US military across all branchesof service.

In most cases, NJP is the appropriate legal disposi-tion for disciplining service members with war stressinjury. However, NJP is an ‘administrative’ versus ‘le-gal’ proceeding; thus, there is no trial by peers or ad-herence to rules of evidence—the sole judge and jury isthe individual’s Commander (MCM, 2012). While mostCommanders exercise their Article 15 authority appro-priately, service members are at the mercy of less scru-pulous leaders, and this is where unjust practices arise


in the case of disciplining personnel with war stressinjury. NJP appeals are reviewed by the Commander’simmediate superior but, given the administrative natureof NJP, are rarely overturned. Legal dispositions forNJP can range from counseling, warnings to reductionin rank, fines, restriction, brief period of confinement,referral for alcohol or mental health treatment, and/oradministrative separation under General (e.g., alcoholrehab failure) or Other-than-honorable (e.g., pattern ofminor misconduct) conditions, also called Chapter 14.[A pattern of misconduct as evidenced by multipleNJP (even for relatively minor offenses), formal adversecounseling, and/or adverse performance evaluation re-ports.] Per Table 1, military personnel given an OTH

discharge face forfeiture of any military retirement ordisability pension and other VA benefits, regardless ofyears-in-service, as well as enduring civilian employ-ment restrictions (e.g., law enforcement, public safety,federal government agencies).

Courts-Martial

According to the MCM (2012), there are three levels ofCourts-Martial (Summary, Special, and General), which de-pend on the nature and severity of the alleged offenses anddesired punishment. The Summary Courts-Martial is used forlower level offenses similar to NJP, but the individual’sCommander believes warrant sterner punishment than

Table 1 Type of militaryseparation and discharge Type Description Benefits eligibility Negatively

impactscivilianemployment

Number ofdischargesFY2003-2013

VA

(health/pension)

GI Bill

(education)

Honorable Service member met thestandards of acceptableconduct andperformance

Yes Yes No 1,983,893

General When the service has beenhonest and faithful butthere are significantnegative aspects of theservice that outweigh thepositive aspects (e.g.,personality disorder;alcohol rehab failure;adjustment disorder)

Yes No Yes 172,125

Uncharacterized Applies to those separatedwithin 180 days

Yes No Yes 288,568

Other-than-honorable(OTH) conditions

Punitive administrativeseparation awarded bymilitary Commanderswithout full legal trial byeither non-judicial pun-ishment or SummaryCourts-Martial whenservice record reveals apattern of minor mis-conduct (e.g., drug use;disobedience, unautho-rized absence, disre-spect)

No No Yes 125,204

Bad conductdischarge (BCD)

Awarded by Judge afterSpecial or GeneralCourts-Martial trial &conviction for seriousoffense (e.g., assault)

No No Yes 19,054

Dishonorabledischarge (DD)

Awarded by Judge afterGeneral Courts-Martialtrial & conviction equiv-alent to felony in civiliancourt (e.g., murder, de-sertion)

No No Yes 1467


available via NJP including possible BCD. However, similarto NJP, the Commander acts as judge and jury, but more legaldue process protections are granted to individuals (MCM,2012). Special and General Courts-Martial each invoke fulllegal protections, rules of evidence, and procedures of a stan-dard trial, typically with military defense and prosecuting at-torneys presided by a military Judge. The difference betweenSpecial and General Courts-Martial pertains to the seriousnessof the offense and severity of punishment (see Table 1).

BBad Paper Discharges^

Military separation/discharges characterized as OTH, BCD,and DD are often referred to as ‘bad paper discharges’ becausethey result in loss of military pensions, VA benefits (e.g.,treatment, GI Bill) and can significantly impact future civilianemployment and other civil rights (see Table 1). However, theterm ‘bad paper discharges’ is also used for General (UnderHonorable) administrative separations that may have no legalcharges attached (e.g., personality disorder, adjustment disor-der, alcohol rehabilitation failure, sleep walking) yet can havethe same lifelong impact on war veterans as an OTH (seeTable 1). Some courts have found discharges other than hon-orable as punitive because they stigmatize the service-mem-ber’s reputation, impede their ability to gain employment, andserve as prima facie evidence against the service-member’scharacter, patriotism, and loyalty (e.g., Stapp v. Resor,1970). We will return to the issue of bad paper discharges ina later section.

Prosecution of Military Personnel with War StressInjury

Many of our returning veterans and Service membersexperience life-changing events, some of which maycause them to react in adverse ways and get into troublewith the law (Admiral Michael Mullen (2011),Chairman, Joint Chief of Staff)

Human adaptation to war stress is historically associatedwith a predictably broad spectrum of potential neuropsychiat-ric diagnoses (e.g., PTSD, TBI, substance use disorder), med-ically unexplained physical symptoms (e.g., chronic pain,sleep disturbances), behavioral/personality changes (e.g.,post-traumatic anger, interpersonal violence, suicide at-tempts), and misconduct stress behaviors (e.g., desertion, druguse, mistreatment of enemy) [see DoA, 2009; IOM, 2008;Russell & Figley, 2015a, b]. After a comprehensive reviewof the scientific literature on the long-term adverse health ef-fects and deployment-related stress, the IOM (2008)concluded:

In the brain, there is evidence of structural and function-al changes resulting directly from chronic or severestress. The changes are associated with alterations ofthe most profound functions of the brain: memory anddecision-making. They are also associated with symp-toms of fear and anxiety, and they might sensitize thebrain to substances of abuse and increase the risk ofsubstance-use disorders (p. 62).

Consequently, individuals returning from deployment towarzones are at significant risk for engaging in behaviors thatare often associated with exposure to war stress, but couldbecome the focus of legal difficulties. For instance, contem-porary frontline surveys revealed that deployed Soldiers andMarines diagnosed with mental health problems were morelikely to mistreat non-combatants in violation of the UCMJ(Mental Health Advisory Team, 2008), while another studyshowed that deployed Marines with PTSD were 11 timesmore likely to be discharged for misconduct than their peerswithout PTSD (Highfill-McRoy et al., 2010).

Surprisingly, the military does not routinely track orreport on the number of service members legally prose-cuted who are war veterans, or those who may also bediagnosed with a war stress injury (e.g., PTSD, TBI).However, the Army’s post-WWII analysis reveals thatfrom 1942 to 1945, 13,015 (56%) of 23,143 soldiers in-carcerated after courts-martial convictions were diagnosedwi th psych i a t r i c cond i t ions (Bernucc i , 1966) .Nonetheless, reports on the frequency of discipline andlegal dispositions of military personnel (e.g., Courts-Martial convictions, misconduct separations) for any his-torical era is inherently flawed because it is unknown howmany cases involved war veterans suffering from warstress injury. In addition, our presentation below in noway suggests that war veterans with or without war stressinjury should not have been disciplined or discharged.Readers are advised to refrain from over-generalizing thedata below as evidence of maltreatment and injustice. Atbest, all we can say is that there is a propensity for themishandling of at least some war veterans based on thefrequency of disposition.

The Military’s Unethical Legal Revolving Door

Many courts-martial are problem-generating—ratherthan problem-solving—courts when they preclude treat-ment considerations as tangential matters, lack a coher-ent framework for evaluating the benefit of treatmentversus incarceration, and result in punitive dischargesthat preclude offenders from future VA treatment(Seamone, 2011; p. 12).


The military justice system’s approach toward dealing withemotionally injured war veterans reflects the DoD’s avoidanceof learning war trauma lessons by its WWI and WWII prede-cessors. In short, the present-day policy disavows responsibilityfor provision of mental health treatment and rehabilitation ofveterans in the criminal justice system and foists the responsi-bility on the VA and private sector. Consequently, military per-sonnel and veterans with untreated mental health conditions areat significant risk for legal involvement (e.g., Highfill-McRoyet al., 2010), thus resulting in a revolving door.

A recent Seamone (2011) has summarized major ethicalconcerns over the military justice system’s punitive handlingof stress injured defendants: (1) accused service members withsuspected or confirmed mental conditions are referred to psy-chiatric sanity boards that focus only on fitness to stand trial andrarely make mental health treatment recommendations; (2) mil-itary conviction and incarceration generally prohibits access toadequate mental healthcare; (3) bad paper discharges (OTH,BCD, DD) bar the majority of emotionally-injured veteransfrom accessing critically needed VA treatment benefits and im-pact future employability; and (4) the Department of HomelandSecurity cited national security threats from discharged untreat-ed combat veterans (who have been taught to overcome instinc-tual resistance toward killing) who are actively being recruitedby homegrown terrorists.

Additional legal concerns involve sentencing standards usedby the current military justice system. They are significantlymore script-based versus individualized and heavily skewedtoward punishment versus treatment, thus raising serious ethicalworries in that:

First, even though an accused who has been cleared by asanity board may appreciate the wrongfulness of hisacts, this does not alleviate the concern that his mentalcondition contributed in some palpable way to the of-fense or that the offense would not have occurred in theabsence of the service-connected psychological influ-ence. Second, service-connected mental illness shouldmake commanders, military judges, and panels moreconcerned about the future than the past because itstrongly suggests that offenders will continue to findthemselves in the same circumstances that led to theoffense if they fail to obtain necessary cognitive tools^(Seamone, 2011; p.18).

Civilian Legal Problem-Solving and VeteransTreatment Courts

After more than a decade of sustained combat operations andrepeated combat deployments, the civilian justice system hasdeveloped Veteran Treatment Court (VTC) as a problem-

solving approach targeting mental health conditions underly-ing the veteran’s criminal conduct. VTCs use an interdisci-plinary treatment team that is presently absent in today’s mil-itary justice system (e.g., Seamone, 2011). Recent legal pre-cedents for VTC include Porter v. McCullum (2009), a unan-imous U.S. Supreme Court ruling on a Korean War veteranbridged across time: BOur Nation has a long tradition of ac-cording leniency to veterans in recognition of their service,especially for those who fought on the front lines as Porterdid. Moreover, the relevance of Porter’s extensive combatexperience is not only that he served honorably under extremehardship and gruesome conditions, but also that the jury mightfind mitigating the intense stress and mental and emotionaltoll that combat took on Porter^ (Seamone, 2011; pp. 23–24)In response to a crisis of discharged veterans with untreatedwar stress injury facing prosecution in civilian courts, JudgeRussell from Buffalo, New York, established the first VTC in2008 whose mission is:

To successfully habilitate veterans by diverting themfrom the traditional criminal justice system and provid-ing them with the tools they need in order to lead aproductive and law-abiding lifestyle. In hopes of achiev-ing this goal, the program provides veterans sufferingfrom substance abuse issues, alcoholism, mental healthissues, and emotional disabilities with treatment, aca-demic and vocational training, job skills, and placementservices. The program provides further ancillary ser-vices to meet the distinctive needs of each individualparticipant, such as housing, transportation, medical,dental, and other supportive services (Russell, 2009; p.364).

These courts adopt a therapeutic or problem-solving ap-proach to sentencing modeled after civilian drug and mentalhealth courts emphasizing interventions addressing the under-lying causes of legal transgressions. They suspend sentencesin favor of treatment and social support. In 2010, the BuffaloVTC diverted prosecution of a 32-year-old married Iraq/Afghanistan War veteran diagnosed with PTSD after threecombat tours, who was charged with assaulting VA staff andbecoming Bthe first criminal case nationwide to be transferredfrom federal court to a local veteran’s treatment court wherethe goal is to treat—rather than simply punish^ (Holbrook,2010; p. 1).

Moral, legal, and economic justification for VTCs alongwith their documented success in rehabilitating mentally illveterans led the military’s Commander-in-Chief, PresidentBarack Obama (2011), to recommend greatly expanding ci-vilian VTCs because of their tremendous value in addressingthe unique needs of returning veterans with PTSD andTraumatic Brain Injury (TBI). Similarly, the Chairman, Joint


Chief of Staff, Admiral Mullen (2011) pronounced: BVTCsare having a significant impact across the country. I have seenthese courts make a real difference, giving our veterans asecond chance, and significantly improving their quality oflife.^ However, the military’s strong public support of theVTC’s problem-solving approach begs the question why theDoD maintains a more punitive, problem-generating solutionto its mental health dilemma especially given highly success-ful legal predecessors to VTCs?

Precedents of Military Legal Problem-Solvingand Restoration Programs

Recent media and political attention to VTCs belie the factthat similar problem-solving legal approaches were institutedafter every major AmericanWar since the U.S. CivilWar (e.g.,Schaller, 2012). Notably, the military developed its first spe-cialized Courts-Martial rehabilitation programs, orDisciplinary Barracks (DB), including limited mental healthservices, during WWI, whereby convicted personnel receivedrehabilitative interventions in lieu of suspended sentences andbad paper discharges. Per the U.S. Army Judge AdvocateGeneral, the explicit purpose of the DB was: BTo give theman a certain period of time in which by positive action hecan evidence his reformation and be restored to the servicewithout the stigma of a dishonorable discharge appearing up-on his record^ (Bailey, 1929). Although the DB programswere open to the general military prison population, the influxof convicted veterans with war stress injury led to increasingaccess to mental healthcare. As the Army Surgeon Generalreported:

Fort Leavenworth Disciplinary Barracks. As a result ofthis, many cases of mental diseases were discoveredamong delinquents and the charges against them eitherwere dropped and discharged on disability initiated, or,if the case was tried and sentence imposed, the findingsof the court were approved, including discharge, andthe confinement was omitted. For example, during thesummer of 1918 the commanding officer of one of thecamps in the United States was facing serious difficul-ties on the charges of neglect of duty about to be broughtby the Inspector General of the Army. He had beenfrequently absent from his post, was lax in the enforce-ment of discipline, did not have the details of his com-mand well in hand, organized an excessive number ofentertainments, etc. Examination by a psychiatrist re-vealed a mild manic state, and upon the psychiatrist'sreport the charges were dropped and sick leave of sixmonths was granted, at the expiration of which thisofficer had made a perfect recovery. Had a psychiatristnot been available, the matter would have ended quite

differently, as the mental symptoms were not sufficientlypronounced to have justified the dropping of thecharges, except on the recommendation of an expert. Ifthe officer had been tried he would certainly have beenconvicted, which would have been a gross injustice tohim, and would have postponed his recovery indefinitely(Bailey, 1929, p. 131).

By most standards, the WWI-era legal problem-solvingapproach was successful, causing the Army Staff JudgeAdvocate to remark: BLike the Navy, in the great majority ofthese cases—Bover 80%^—the Army program worked, withmany restores later being discharged as non-commissionedofficers with a character ‘Excellent’^ (e.g., Strong, 1917; p.8). Overall, an estimated 20% of military prisoners sentencedto dishonorable discharge were restored to active-duty via theDB (e.g., Seamone, 2011). Although preventing personnelattrition was an important motivation for the WWI-era’s judi-cial problem-solving approach, the primary goal as reportedby the Navy Judge Advocate General, was to avoid: Bturning[a military offender] adrift without the credentials generallynecessary to secure honest employment in civil life^ (e.g.,Strong, 1917). Apparently, the same be said about the currentsystem.

WWII Service Command Rehabilitation Center (SCRC)

Following WWI, restoration-to-duty remained the objectiveof the military justice system via its DB or SCRC programs,but responsibility for restoration was split with local militaryprisons. As war stress casualties escalated during WWII, themilitary established Mental Hygiene Units (MHU) at SCRCs,with greater attention on understanding and rehabilitating wartrauma ensued including provision of group therapy (e.g.,Freedman, 1945). Near the end of WWII, the Army’s FifthSCRC instituted a progressive mental health program calledBtotal therapeutic push,^ it embodied the modern VTC philos-ophy of ‘therapeutic jurisprudence’ by seeking to maximizetherapeutic value in all phases of criminal justice for the ulti-mate betterment of both society and the offender (e.g., Knapp& Weitzen, 1945). Both officers and enlisted personnel pros-ecuted for misconduct after returning from combat received6 weeks of intensive therapy at SCRC MHUs, and were thenevaluated if they could be returned to duty, reclassified, ordischarged (e.g., MacCormick & Evjen, 1945). Accordingly,Bthe military justice system had the responsibility to Bdiffer-entiate between the cause and effect relationship^ and to basetreatment on Bsoundmental hygiene principles^ and dischargedecisions on more Bcareful study and analysis of the factorsinvolved^ in their offenses (Seamone, 2011, p. 94) Table 2.

Regarding program efficacy, an analysis of SCRC recordsbetween 1940 and 1946 indicate the Army restored over half(42,373) of 84,245 punitively discharged soldiers to


honorable active-duty status, with a recidivism rate of only12% (MacCormick & Evjen, 1945). The Navy and MarineCorps rehabilitated an additional 75% of 16,000 punitivelydischarged offenders to honorable service (Chappell, 1945).For all of these men, their discharges had been Bwiped clean,^helping not only the military, but ultimately the families andcommunities who depended on their future employability andgood name (MacCormick & Evjen, 1945). Per Seamone(2011): BIt is significant that, within this specialized correc-tional setting, trainees actually received more therapy timethan psychiatric battlefield casualties received during their re-habilitation period in mental hygiene units^ (p. 91). The im-portance of WWII lessons with judicial problem-solving isthat the military implemented these restorative-based princi-ples when the country was at war at a time when maintaininggood order and discipline were of utmost. Freedman andRockmore (1945) offered an example:

One soldier suffered shrapnel wounds and lost several ofhis Bclosest buddies^ in severe combat conditions in theNorth African Theater. He then lived in a state where, BIdidn’t give a damn whether I lived or not.^ Following aseries of unauthorized absences, alcohol-induced ram-pages, and an occasion when he pleaded for the militarypolice to shoot him, the Army adopted a treatment-based approach: BAfter a course of treatment this soldierwas returned to duty of a limited nature within the con-tinental limits of the United States.^ Accordingly, B[t]heArmy recognized [the relationship between his lack oftreatment and his criminal behavior] and treated him as asoldier-patient. The reward was that a combat-experienced soldier continued to render effective servicewhere otherwise a stockade prisoner might have beenthe only result (Freedman & Rockmore, 1945; p. 44).

Seamone (2011) identified two critical WWII legal lessons:(1) the use of therapeutic intervention and conditional sentenc-ing to address offenders’ underlying problems; and (2) theneed to expand and adapt court-martial procedure when ad-dressing offenders with combat trauma.

Legal Problem-Solving during the Vietnam War

In 1951, the U.S. Air Force established the 3320thCorrections and Rehabilitation Squadron, emphasizingtherapeutic environment over r igorous training.Throughout the early years of the Vietnam War, the3320th and other service Discharge Remission Programsplayed a central role in suspending punitive discharges ofconvicts with ‘combat fatigue/exhaustion’ in favor ofcomprehensive and individualized treatment (Seamone,2011). However, 1973 marked not only the end of the

military draft and beginning of the all-volunteer force,but also introduced the concept of Bquality force^(Seamone, 2011), or what today is oft referred to as thezero-defect military. The quality force doctrine essentiallyended the military justice system’s commitment toproblem-solving and restoration in favor of discharge.Consequently, the latter years of the Vietnam War sawpunitive discharges of veterans dramatically escalate fordrug use and other misconduct stress behaviors (e.g.,Camp, 2014). Today, only the Air Force maintains a via-ble legal restoration program (Seamone, 2011).

Death Penalty Sentences and Executions of MentallyIll Combatants

The military has long held the practice of executing soldiersfor cowardice as an example to others, regardless if the basisof their refusal to fight was a paralysis caused by a severeconversion reaction or an intentional act of disobedience. Inthe Union Army, there were a total of 267 executions, among900 courts-martial convictions, with more than 50% of sol-diers executed for any of the 200,000 estimated desertions andunknown number of stress casualties; 25% for homicide; and10% for rape or mutiny; and the rest for thievery or espionage(Lande, 2003). During WWI (1917–1918), the AmericanArmy executed 35 soldiers for rape and/or murder of civilians(Drimmer, 1992) and an unknown number for cowardice.

In addition, at least 3080 WWI British soldiers were sen-tenced to death for cowardice, desertion, or malingering, with306 actual executions (Holden, 1998; Iacobelli, 2013). Forinstance, Holden (1998) reported that a WWI soldier diag-nosed with ‘shell shock’ was being court-martialed, and hisevaluating army physician retorted: BI went to the trial deter-mined to give him no help of any sort, for I detest this type, Ireally hoped that he would be shot, as indeed anticipated by allof us^ (p. 84). Additionally, at least three of 23 executedCanadian soldiers had confirmed shell shock diagnosis(Iacobelli, 2013).

Throughout WWII, 40,000 U.S. soldiers were chargedwith desertion (U.S. Army, 1975). Of these, 2864 weretried by general courts-martial for desertion, resulting in49 death sentences with all but one commuted (U.S.Army, 1975). In sum, a total of 102 U.S. soldiers wereexecuted in WWII for rape and/or unprovoked murder ofcivilians (it is unknown how many suffered from warstress injury). In fact, the only U.S. service member exe-cuted solely for a military-related offense (desertion in theface of the enemy) since the U.S. Civil War and the lastever since, was 24-year-old U.S. Army Private Eddie D.Slovik (U.S. Army, 1975). Private Slovik was diagnosedby an Army division neuropsychiatrist with Bpsychoneu-roses^ (a precursor to PTSD) following an extended artil-lery bombardment during the Battle of the Bulge (Huie,


1954). Slovik had just arrived to his unit and after thebombardment proceeded to inform his Commander ofhis intent to desert if not reassigned (U.S. Army, 1975).Private Slovik explained during his two-hour GeneralCourts-Martial on 11 November 1944:

They were shelling the town and we were told to dig infor the night. The following morning they were shellingus again. I was so scared, nerves and trembling, that atthe time the other replacements moved out, I couldn’tmove (U.S. Army, 1975, p. 193).

However, Private Slovik’s psychiatric diagnosis did notconstitute a legal defense of insanity and so he was convictedand sentenced to death. Slovik’s military attorney appealed toGeneral Eisenhower who confirmed the execution order on 23December 1944, noting that it was necessary to discouragefurther desertions (U.S. Army, 1975). On 31 January 1945;Private Slovik was tied to a post, blindfolded, and shot multi-ple times by his fellow unit members and died slowly—thelast American soldier so executed since the U.S. Civil War,and the last known mentally injured service member put todeath.

Learning Legal War Trauma Lessons

As it relates to offenders with war stress injuries:

the military justice system is at odds with more thanVTCs; it is at odds with itself- in the way it underminesthe stated sentencing philosophy of rehabilitation of theoffender, the way it erodes the professional ethic bydenying core values, and the way it defies the moralobligation to advance the interests of both the veteranand the society he will rejoin (Seamone, 2011, p. 3).

In contrast to problem-solving courts like civilian VTC andthe military’s twentieth century diversionary treatment pro-grams that target underlying mental health conditions relatedto criminal conduct, the military justice system’s current ap-proach is problem-generating when it results in punitive dis-charges that preclude mental health treatment and intensifystigma. Unfortunately, the status of today’s military justicesystem harkens back to pre-WWI arguments againstproblem-solving programs: BThe Army is not a reformatoryfor its own criminals or for criminals from civil life, and itcannot be made one without doing great damage to theservice^ (Annual Report of the Adjutant General, 1910).

Strategy Three: Weaponizing Stigma to Humiliate,Ridicule, and Shame into Submission

The greatest weapon against the so-called "battle fa-tigue" is ridicule. If soldiers would realize that a largeproportion ofmen allegedly suffering from battle fatigue

Table 2 Principle US militaryoffenses and punishment in 1945 Principal military

offenseAll institutions Rehabilitation

centers (SCRC)Disciplinarybarracks (DB)

Federal institutions

Number Percent Number Percent Number Percent Number Percent

Absent withoutleave

9435 48.0 6058 50.7 3180 44.8 197 33.0

Desertion 5690 28.9 3549 29.7 1961 27.6 180 30.1

Mutiny or sedition 119 .6 28 .2 45 .6 46 7.7

Misbehavior beforethe enemy

155 .8 31 .3 123 1.7 1 .2

Discreditableconduct towardsuperior officer

2055 10.4 1117 9.3 912 12.8 26 4.4

Misbehavior ofsentinel

269 1.4 195 1.6 71 1.0 3 .5

Violation of arrestor confinement

1625 8.3 846 7.1 687 9.7 92 15.4

Committingdepredation orriot

103 .5 41 .3 59 .8 3 .5

Other 211 1.1 93 .8 69 1.0 49 8.2

Total 19,662 100.0 11,958 100.0 7107 100.0 597 100.0

Source: TABLE 50.-Distribution of 19,662 of 24,289 general prisoners, by place of confinement and principalmilitary offense in 1945 (Berlien, 1966; p. 515)


are really using an easy way out, they would be lesssympathetic. Any man who says he has battle fatigueis avoiding danger, and forcing on those who have morehardihood than himself the obligation of meeting it. Ifsoldiers would make fun of those who begin to showbattle fatigue, they would prevent its spread, and alsosave the man who allows himself to malinger by thismeans from an after-life of humiliation and regret(General George S. Patton Jr., 1947, p. 340).

Stigma is defined as a brand or stain. Researchers haveidentified three sources of mental health stigma: (1) institu-tional stigma caused by policies that either intentionally orunintentionally Brestricts opportunities and hinder the optionsof people with mental illness^ (Acosta et al., 2014; p. 9); (2)public stigma reflecting negative attitudes and bias towardmental health from family and broader society; and (3) self-stigma or the internalization of negative attitudes and beliefstoward oneself (Acosta et al., 2014).

Psychiatrically disabled veterans without visible warwounds have regularly been branded coward, yellow, crazy,lacking morale fiber, or deserter by the military. The conse-quence and purpose was to ridicule, shame, or punish thosewho might undermine military authority and illicit fear inthose who might contemplate following suite (e.g., Dean,1997; Holden, 1998). In addition, many debilitated veteranshave been characterized as having inherently defective, weakor unmanly personalities (i.e., male hysteric, psycho, section8, war hysteric, wussy, limp dick, personality disorder), asimmoral frauds attempting to avoid combat (i.e., evacuationneurotic, slacker,malingerer), or as profiteers seeking disabil-ity payment (i.e., goldbricker, pension neurotic, illness-seeker,dreg on society, leech; Dean, 1997); all of which sends anintimidating signal to the rank and file.

According to Brigadier General Menninger, the U.S.Army’s Chief Consultant of Neuropsychiatry during WWII:BThere was a tendency to stigmatize the neuropsychiatric pa-tient as being a failure. When the case was not physical, thenthe individual was variously regarded as perverse, subversive,unwilling, weak, dumb. He was likely to be labeled as a Bquit-ter,^ Ban eight-ball,^ Bgold brick,^ or any of numerous othervernaculars disparaging terms^ (Menninger, 1948, p. 20).

A recent attempt to compare stigma in the military andprivate sector led RAND investigators to conclude: BWithinthe military, stigma is largely conceptualized and assessed as abarrier to care^ thus making direct comparisons with the gen-eral population nearly impossible (Acosta et al., 2014, p. 25).It is important to recognize the effects of institutionalized stig-ma or ‘barriers to care’ not only deter individuals from seekingmental health treatment, but also from even disclosing symp-toms. Therefore, stigma-driven barriers to care in the militarywill predictably result in far greater numbers of service mem-bers diagnosed with war stress injury after military discharge,

which has indeed been the trend, resulting in accusations ofmass fraud (e.g., Russell & Figley, 2015b).

Recognizing the Need to Eliminate Mental HealthStigma

After wars end, the military customarily reflects on its psychi-atric lessons learned and invariably cites the need to eliminatethe disparity, prejudice, and stigma associated with mentalhealth difficulties. For example, the U.S. Army’s official les-sons learned fromWWI called upon the military to end mentalhealth stigma and disparity:

The greatest obstacle to neuropsychiatry in both civiland military practice has been the barrier that tends toseparate nervous and mental diseases from all other dis-eases, and it was thought by some that, in so far as theMilitary Establishment was concerned, the greatestgood, both to the practice of neuropsychiatry and tothe patients who were dependent upon it, would be ac-complished if a determined effort were made to breakthrough this barrier and to place the mental patient on apar with patients incapacitated by reason of other dis-eases (Bailey, 1929, pp. 42-43).

Similar conclusions were reached by U.S. Army afterWWII:

If medical practice is ever to progress to the ideal ofpsychosomatic medicine, it will require the reorientationof medical training and of all practitioners so that equalemphasis is placed upon the roles of the psyche and ofthe soma in all illness (Menninger, 1948, p. 163),

and repeated in 2004:

Reducing the perception of stigma and the barriers tocare among military personnel is a priority for researchand a priority for the policymakers, clinicians, andleaders who are involved in providing care to thosewho have served in the armed forces (Hoge et al.,2004, p. 21),

as well as 2007:

In the military, stigma represents a critical failure of thecommunity that prevents service members and theirfamilies from getting the help they need just when theymay need it most. Every military leader bears


responsibility for addressing stigma; leaders who fail todo so reduce the effectiveness of the service membersthey lead (DoD Task Force, 2007, p. 15).

In short, there is ample documentation of the military’sawareness to eliminate policies and practices that sustainharmful levels of stigma that prevent service members fromgetting needed support.

Weaponizing Stigma

The military’s episodic reflections on the need to eliminate theharmful effects of stigma is laudable; however, the recordshows the military is generally more invested in maintainingand intensifying stigma to deal with its mental health problem.Figley and Nash (2007) described the evolution of weaponiz-ing combat stress as the intentional development of weapons,tactics, and war-fighting strategies aimed primarily to demor-alize, terrorize, and debilitate the enemy with stress casualties.In a similar vein, the military has purposefully weaponizedstigma against internal threats posed by psychologically-injured warriors.

Lacking Moral Fiber (LMF) and Waverer DisposalPolicy

Reported usage of the derogatory WWII term BLMF^ withinthe twenty-first century U.K. military is a direct testament ofthe durability of the military’s weaponization of stigma toreduce the prevalence of war stress injury (e.g., Jones,2006). In 1940, the British Royal Air Force (RAF) adopteda formal policy to curb escalating psychiatric casualty ratesand disability pensions. They imposed severe penalties (e.g.,immediate transfer and/or discharge) and public shaming ofindividuals branded LMF (akin to cowardice) by their com-manders. Often this was done in front of their peers who wereunable or unwilling to fly without a valid medical reason (e.g.,Holden, 1998). Intended to be harsh and punitive toward mor-ally corrupt service members (e.g., LMF discharges are rough-ly equivalent to OTH separations today), the main purpose ofthe U.K.’s LMF policy was to intimidate the rest of the groupto avoid being next. For example, after reviewing the histori-cal records from the U.K.’s LMF policy, Jones (2006) con-cluded: BThe calculated use of stigma gave the policy force^(p. 443), as evidenced by a statement from the RAF’s AirCommodore Bthe dangers of too lenient treatment of failures,from whatever cause, owing to the possible undermining ef-fect on other officers striving to maintain their morale^ (Jones,2006, p. 444).

For instance, an RAF pilot who was labeled LMF afterexperiencing transient paralysis and mutism after his 20thcombat mission, described the reaction of his commander:

I was allowed no more contact with the crew and had topack all my kit for immediate departure. No goodbyes oranything, and these men were like my family. Beforeleaving I was summoned before the CO for the severestdressing down of my career when he left me in no doubtof the seriousness of the affair: I had let the side downand turned my back in the face of the enemy, an actionfor which soldiers had been shot in the First World War,he said (Holden, 1998, p. 110).

Enlisted aircrew members were often reassigned to groundcombat units, whereas officers were typically ordered to NotYet Diagnosed Neuropsychiatric (NYDN) centers originallyestablished in 1916 to eliminate psychiatric attrition fromWWI-era shell shock (e.g., Shepard, 2001). Upon admissionto NYDN hospitals, the LMF branded personnel would en-dure further ridicule and shaming by standing at attention infrom of unit members while their Flying Badges and rankmarkings were stripped from their uniforms (Jones, 2006). Ifpersonnel did not return to full duty after their Btreatment^ atNYDN centers, they would be given less than honorable dis-charges that significantly impacted future employment. Jones(2006) reported an annual rate of 160 to 240 LMF cases,resulting in a total of 2726 British aircrew personnel, mostlypilots, so classified. Near the end of WWII, the RAF eliminat-ed its LMF policy Bto avoid embarrassing the government^(Jones, 2006, p. 454). However, it remained a stigmatizinglabel through the 1960s and shows some persistence today.

In 2002, a group of British soldiers sued the Ministry ofDefense for inadequate mental healthcare. They also arguedthat the military had done little to change stigma. The HighCourt Justice apparently agreed: BNo doubt there could havebeenmore rapid change. No doubt more could have been doneto address the persistent stigma attaching to psychiatric/psychological disorder, particularly in the ranks^ (Owen,2003; cited in Jones, 2006, p. 455). However, Jones (2006)added: BOthers have argued that a measure of stigma is neededto prevent both conscious and unconscious resort to psycho-logical disorders as an exit from situations of personal danger^(pp. 455–456).

U.S. Military Policies and Weaponizing Stigma

Patton (1947) brazenly advocated for weaponizing stigmaduring WWII: BThe greatest weapon against the so-calledbattle fatigue is ridicule (p. 340). His pronouncement couldeasily be dismissed as unrepresentative of official militarypolicy. However, when the highest ranking military com-mander espouses similar biases toward the mental health ofsoldiers, there is a making of a trend. For instance, the U.S.Army’s WWII Chief of Staff, General George C. Marshall,(1943) explained:


To the specialists, the psychoneurotic is a hospital pa-tient. To the average line officer, he is a malingerer.Actually, he is a man who is either unwilling, unable,or slow to adjust himself to some or all phases of mili-tary life, and in consequence, he develops an imaginaryailment which in time becomes so fixed in his mind as tobring about mental pain and sickness^ (cited inMenninger, 1966, p. 132).

The stigma exacerbating attitudes of many of the military’stop leaders formally became institutionalized.

Frontline Psychiatry

Reducing exorbitant manpower attrition and costscaused by evacuations of psychiatric casualties duringWWI led to the military’s 100-year-old frontline psychi-atry or combat and operational stress control (COSC)doctrine to be permanently institutionalized after WWII(see Russell & Figley, 2017a, and section below onTreatment). In a nutshell, the military has designed apolicy that provides an echelon of brief restorative in-terventions for military emotional distress and strictlyprohibits psychiatric treatment and evacuation with theexplicit expectation that upwards to 95% of stress casu-alties will be returned-to-duty (RTD; Russell & Figley,2017a).

The military’s justification of its RTD policy is multi-faceted, but includes the prevention of harmful stigma inthat: BEvacuees had to deal with the stigma and shame ofevacuation out of the theater. However, if psychologicalcasualties were treated at forward locations with brief sup-portive therapy and the expectation of return to duty, be-tween 60% and 80% were able to continue as soldiers^(Cardona & Ritchie, 2007, p. 12). A recent review seri-ously undermines the military’s claim of stigma-reducingbenefits (Russell & Figley, 2017b), but more importantlyto our current purpose, is how does the military system-atically employ stigma to achieve its goals?

In short, the military’s weaponization of stigma to reducepsychiatric attrition is central to its frontline doctrine and thebedrock principle of ‘expectancy,’whereby medical and men-tal health practitioners are instructed to persuade the soldier-patient of certain Brealities^ of their situation, including thetransient, normal nature of their fear reactions and the certain-ty of their recovery and RTD after a brief respite period.Arguments are made as to why the soldier must be RTD toavoid the highly stigmatizing moral, personal, and social con-sequences. The samples below illustrate the military’s consis-tency in utilizing mental health stigma to persuade personnelaway from becoming labeled as cowardly, weak, dishonor-able, or immoral:

WWI

Persuasion Here the medical officer, having assured himselfthat the condition is functional, persuades the patient to makethe effort necessary to overcome the disability. In order to dothis, he uses his authority as an officer, he brings into play allthe moral suasion he can, appealing to the patient’s social self-esteem to make him co-operate and put forth a real effort ofwill. If moral suasion fails, then recourse may be had to moreforcible methods, and according to certain witnesses eventhreats were justified in certain cases (Report of the war officecommittee of enquiry into ‘shell-shock,’ 1928, p. 128).

WWII

Exhortation Exhortation ranges from an appeal to the soldierconcerning the necessity of aiding his comrades on the line toa form of plain talk in which he is asked whether he hasactually gone so far as to abandon them. The latter measureshould be used sparingly and judiciously, for it may exacer-bate an anxiety state.When these methods are used about 50%of all men presenting with anxiety were returned to duty with-in 1 to 6 h (Sobel, 1949b, p. 40).

Words with which the soldier was familiar and whosemeaning he understood proved more effective. The impor-tance of the war and the consequences of defeat to them andtheir families were stressed, and appeals were made to theirsense of duty, pride, and loyalty to comrades, unit, and country(Ludwig, 1949, p. 95).

Vietnam War

Reinforcement is given to the soldier’s softly heard voice ofconscience, which urges him to stay with his buddies, not tobe a coward, and to fulfill his soldierly duty. Encouragement isgiven to patriotic motivation, pride in the self and the unit, andto all aspects of one’s determination to go through with one’scommitment (Shaw, 1987, p. 131).

Not only the physician, but all treatment personnel shouldimmediately take the attitude that the patient will be returnedto duty. The patient is quite suggestible if he is treated early,and the desire to return to his group is reinforced. The ap-proach tends to minimize the patient’s symptoms in his owneyes. It should be pointed out that in a combat situation everysoldier is needed immediately if he can function. Not only ishe needed for the group to function, but in the long run it isbetter for both the patient and the group that he return to duty.This is based on the sound assumption that the successfulperformance of duty is more therapeutic than escape fromdanger with its concomitant chronic guilt reaction and thenecessity of maintaining symptoms indefinitely in order toassuage the guilt (Johnson, 1969, pp. 307–308).


Gulf Wars

Reassure At every echelon, give immediate, explicit reassur-ance to the soldier. Explain to him that he has BF (battlefatigue) and this is a temporary condition which will improvequickly. Actively reassure everyone that it is neither coward-ice nor sickness but rather a normal reaction to terribly severeconditions. Provide these soldiers with the expectation thatthey will be RTD after a short period of rest and physicalreplenishment and involve them in useful activities, as appro-priate (U.S. Army, 1998, p. 1–13).

Expectancy The individual is explicitly told that he is reactingnormally to extreme stress and is expected to recover andreturn to full duty in a few hours or days. A military leaderis extremely effective in this area of treatment. Of all the thingssaid to a Soldier suffering from COSR the words of his small-unit leader have the greatest impact due to the positive bond-ing process that occurs. A simple statement from the small-unit leader to the Soldier that he is reacting normally to COSRand is expected back soon have positive impact. Small-unitleaders should tell Soldiers that their comrades need and ex-pect them to return (DoA, 2006, p. 1–8).

American LMF Policy

Similar to WWI, the U.S. military in WWII quickly adoptedpolicies of European allies to deal with its mental health prob-lem. Per U.S. Army (1918) Circular No. 24:

It would seem then that we should profit as far as we canfrom the experience of the French in this matter. Checkthe development of neurosis by denying its existence atthe start. The treatment of the patients should be calm-ative and restorative and any appearance of such symp-toms as tremors, paralysis, etc., should be rigidly dis-couraged. This idea should run through the whole per-sonnel of the hospital. At first it should be effected bygentle persuasion, but if the patients persist in the pro-duction of hysterical symptoms sterner measures shouldbe resorted to (p. 297).

For instance, within 8 months after the U.S. Eighth ArmyAir Forces arrived in England and began bombing operationsover Germany, 35 LMF cases were identified as ‘psycholog-ical failure’ (Wells, 1992). The Eighth Army Air ForceCommand e r p r o po s ed a l e s s - p e j o r a t i v e l a b e lBTemperamental Unsuitability^ that was officially adoptedas U.S. Army Air Force policy in 1942 (U.S. Army AirForce, 1942). The initial U.S. policy emphasized treatmentand rehabilitation, eventually changing the label to an evenless stigmatizing term: ‘Primary Flying Fatigue’ (Wells,

1992). However, by the end of 1942, 255 new cases of emo-tionally disturbed aircrewwere identified, including 166 pilots(e.g., Wells, 1992).

From mid-1943 through the end of the war, some 2102American airmen became psychiatric casualties, resultingin the widespread use of the infinitely more stigmatizingterms LMF and ‘lack of intestinal fortitude’ within theU.S. military (Wells, 1992). In all, about 1230 Americanpilots and aircrew were branded as LMF. Dispositionsvaried from temporary reassignment, psychiatric treat-ment, and courts-martial. For example, a battle-tested,but then over-stressed American pilot in the 95th BombWing was sentenced to be confined at hard labor andgiven a less than honorable discharge after beingconvicted for ‘misbehaving before the enemy’ when herefused to fly, and an enlisted crewmember received2 years hard labor and a dishonorable discharge fordisobeying an order to fly soon after his unit sustainedheavy casualties (Wells, 1992). The legal case below pro-vides a telling example of the U.S. military’s weaponiza-tion of stigma and the silencing effect such punishmentswould expectedly have on military members as a wholewho may experience war stress injury:

Second Lieutenant, 412 Bombardment Squadron. This29-year-old navigator had 5 combat missions. He wasperforming satisfactorily until he was wounded in theright arm when his plane was badly damaging on the 5th

mission. He was hospitalized for three weeks, devel-oped tension symptoms, was unable to perform hisduties on subsequent practice missions and asked to begrounded. He was found to be tense, depressed, and toshow evidence of weight loss. He had an excellent re-cord, went to college for two years, held good jobs, waswell motivated towards flying and did well as a naviga-tor. The Central Medical Board qualified him in October1943 because it was not felt that he was suffering fromBoperational exhaustion.^ He was recommended for another than honorable discharge by the ReclassificationBoard (U.S. Army Air Force, 1944, p. 339).

After the war, U.S. Army Eighth Air Force CommandingGeneral boasted that only 1230 airmen were permanently re-moved from flying due to psychiatric reasons (Wells, 1992),prompting an American historian to quip: BEven more signif-icant, despite an overall casualty rate approaching 50%, muchless than 1% of flyers were grounded for alleged cowardice^(Wells, 1992, p. 306). From the military’s perspective, a suc-cessful mental health policy has always been measured interms of preserving manpower numbers, not improving themental health and well-being of war stressed combatants(Russell & Figley, 2017c).


Evidence of Twenty-First Century Weaponizationof Stigma

In today’s military, there are no overt policies employing stig-ma to manage the mental health problem. In fact, current DoDdirectives espouse considerable anti-stigma rhetoric.However, one must look at what the military is actually doingin regards to eliminating stigma and existing policies that re-inforce stigma and organizational barriers to seeking care thatcontradict the military’s public anti-stigma goals. We furtherassert the military’s weaponization of stigma is evident in itsproclivity to prosecute, incarcerate, and execute emotionallyinjured war veterans. This also includes, bad paper dischargesthat have significantly increased since the Vietnam War. Allthe stigma-enabling efforts send clear and powerful signalsthroughout the military of the potential dire repercussionsfor individuals with war stress injuries and their families.

Current Levels of Stigma and Organizational Barriers to Care

In 2004, U.S. Army researchers found 73% of soldiersreturning from Iraq who screened positive for a mental healthcondition like PTSD reported not seeking mental health treat-ment (Hoge et al., 2004). The landmark study seemingly in-dicated the effectiveness of the military’s stigmatizing policiesthat prohibit many from seeking needed mental health treat-ment or ‘barriers to care.’ Harmful organizational barriersfrom oppressive stigma levels are felt not only by returningwar veterans, but also by their spouses. For instance, 22% ofspouses and 77% of their active-duty partners reported theywould not seek mental health care for fear of being seen asweak, and 21% of spouses and 56.2% of their soldier partnerscited concerns about harm to the active-duty member’s career(Hoge, Castro, & Eaton, 2006).

In 2007, the DoD committed to reverse these harmfultrends:

Building resilient forces and families while reducingstigma are objectives closely tied with our first objectiverelated to leadership and culture. Our system of psycho-logical health leadership will help us to accomplish thisgoal by bringing together under one leadership functionall the related services to plan and carry out a programtailored to the needs of the Active and Reserve compo-nents. Anti-stigma campaign. Therefore, our Center ofExcellence will work with the Military Departments todevelop and execute an anti-stigma campaign, usingsome of the best and brightest minds in the Military,Federal family, and civilian professional community toensure the right tools are created and used to reducestigma associated with seeking mental health care when

needed and at the earliest possible time (DoD TaskForce, 2007, pp. 4-5).

Per Table 3, the military reports an encouraging trendwhereby levels of perceived stigma and barriers appear to begradually declining. For example, in 2013 ‘only’ 40% insteadof 50% of deployed soldiers screening positive for PTSD saidthey would not seek mental healthcare because it would harmtheir career. Since the DoD’s 2007 public pronouncement ofgiving up its weaponization of stigma, dozens of commis-sioned studies, DoD task forces, and government oversightinvestigations have been conducted, often with overlappingfindings and corrective actions for the military to achieve itsstated goal to eliminate stigma (see Russell, Butkus, & Figley,2016b).

Assessing the Military’s Commitment to Disarm and EliminateStigma Assessing the military’s true intent to honor its pledgeto unilaterally give-up its highly effective weapon forretaining control over the mental health problem requires ad-herence to the ‘trust, but verify’ dictum. To that end, in 2012the IOM reached the following conclusion about leadershipcommitment to actually eliminate stigma and organizationallyinduced barriers:

In DoD and each service branch, leaders at all levels ofthe chain of command are not consistently held account-able for implementing policies and programs to managePTSD effectively, including those aimed at reducingstigma and overcoming barriers to accessing care. Ineach service branch, there is no overarching authorityto establish and enforce policies for the entire spectrumof PTSD management activities (p. 6).

Most striking, 9 years after the DoD committed to its laudablegoal, the GAO (2016) reported:

DOD is not well positioned to measure the progress ofits mental health care stigma reduction efforts for severalreasons. First, DOD has not clearly defined the barriersto care it generally understands as Bmental health carestigma^ and does not have related goals or performancemeasures to track progress. Second, GAO’s reviewfound that multiple DOD- and service-sponsored sur-veys that contain questions to gauge stigma use incon-sistent methods, which precludes the analysis of trendsover time in order to determine effectiveness of stigmareduction efforts (p. i).

Moreover, both the GAO (2016) and an independentRAND study by Acosta et al. (2014) reported 203 specific


DOD policies serving as organizational barriers to seekingmental healthcare by promoting stigma, such as: Ban Armypolicy requires verification that a soldier has no record ofemotional or mental instability to be eligible for recruitingduty^ (GAO, 2016, p. i). The fact is, despite all the politicallycorrect pronouncements and incremental changes, militaryleadership appears uninterested in divesting itself from a strat-egy as effective as stigma; therefore: BNo single entity is co-ordinating department-wide efforts to reduce stigma^ (GAO,2016, p. i). Consequently, the likelihood that stigma and itsorganizational obstructions will be significantly reduced bythe military in the foreseeable future is remote:

Without a clear definition for Bmental healthcarestigma^ with goals and measures, along with a coordi-nating entity to oversee program and policy efforts anddata collection and analysis, DOD does not have assur-ance that its efforts are effective and that resources aremost efficiently allocated (GAO, 2016, p. i).

Why Has Military Mental Health Stigma Persisted?

Short answer is because stigma helps the all-volunteermilitary sustain a high level of readiness by protectingthe fighting force from exorbitant costs associated withpsychiatric attrition and treatment. Imagine a future timewhen military personnel feel completely unencumberedto disclose posttraumatic stress (PTSD) during and afterdeployments without any career repercussions. Insteadof shame, ridicule, and rejection, military leaders andhealthcare personnel openly encourage and positivelyreinforce health-seeking behaviors. In this utopia, mentalhealth and physical health are truly viewed as indispens-able sides of the same coin. Absolute parity is the normwith equal resources, priority, and practice when

problems arise. Sound ideal? Not from the military’sperspective. Instead, it worries that a slow trickle ofdeployed personnel leaving the frontlines would becomea torrid evacuation syndrome caused by mass hysteriaand liberal psychiatric evacuation policies. Who is goingto pay for treatment? Who will be left to fight? Howwill the morale and will of those remaining on thefrontlines be impacted? Eventually, even the hardiestand gung-ho would start to question whether its’ worthstaying and dying for when they see their friends leavethe battlefield, possibly with a Purple Heart and disabil-ity pension, given the modern-day trend of psychiatriccasualties far outpacing the total of combatants WIAand KIA (see Russell & Figley, 2017a). WarriorTransition Units back home are swelled beyond capacitywith divisions of temporary disabled personnel, andskyrocketing pension costs strain the financial stabilityof the country. This scenario is the military’s greatest offear.

Stigma Exists in Mainstream Culture

The recurring explanation or excuse used by the military forpersisting stigma is that such antiquated and prejudicial beliefsexist in mainstream culture (e.g., Acosta et al., 2014). Thetruism is rarely challenged. However, the logical implicationis that American society is responsible for taking the lead inchanging cultural bias against mental illness considers itself.However, the military has a long, storied tradition of assertive-ly working to eradicate undesirable and dysfunctional culturalbelief systems. For instance, there is a ‘zero tolerance’ policyin the military for drug use, racial discrimination, sexism, andsexual harassment (e.g., DoD, 2009). Per DoD’s (2009) direc-tive on diversity and civil right protection, it is DoD policythat: BPrograms or activities conducted by, or that receivefinancial assistance from, the Department of Defense shallnot unlawfully discriminate against individuals on the basis

Table 3 Military studies onstigma and organizational barriersto care (Russell & Figley, 2017b)

Survey question 2004 Army(Hoge et al., 2004)

Screened positivefor MH disorder-

Iraq

2013 Army(J-MHAT, 2013)

Screened positive for aMH disorder-Afghanistan

2013 Army(J-MHAT, 2013)

Not screened positive forMH disorder-Afghanistan

I would be seen as weak 65% 47% 23%

It would harm my career 50% 40% 17%

My unit leadership might treatme differently

63% 39% 22%

My leaders would blame mefor the problem

51% 36% 14%

There would be difficultygetting time off work fortreatment

55% 46% 17%


of race, color, national origin, sex, religion, age, or disability^(p. 2).

Not so for mental health stigma and discrimination;annually, the military strictly monitors compliance withits equal opportunity policies, and commanders are oftenheld accountable for non-adherence (DoD, 2009). In ad-dition, random drug testing and regular physical fitnesstesting reflect the military’s commitment to alter unpro-ductive cultural habits. What can be argued, and we haveshown, is that the military is not committed to changingthe culture around stigma and mental health.

Strategy Four: Denying the Psychiatric Realityof War

Denial is defined as the Brefusal to admit the truth or reality^(Merriam-Webster retrieved at: www.merriam-webster.com/dictionary/denial). In a psychiatric sense, Sigmund Freud(1924) described denial or Verleugnung as a primitive, uncon-scious defense mechanism instinctively employed by childrenand psychotics to protect the ego from internal and externalthreats. For Freud (1924), denial is used when an individualrejects a reality that is too uncomfortable to accept; insisting itis untrue despite overwhelming evidence to the contrary.Commonly, people and their organizations can utilize simpledenial, such as denying the reality of an unpleasant factaltogether, or engage in minimization which is to admit thefact, but deny its seriousness. In either case, Anna Freud(1936) considered denial as a mechanism of the immaturemind because its short-term benefit ultimately results inlong-term failure by prohibiting the ability to effectively learnfrom and thus adapt to reality.

Military Use of Denial to Cope with Its Mental HealthProblem

Each moment of combat imposes a strain so great thatmen will break down in direct relation to the intensityand duration of their exposure. Thus, psychiatric casu-alties are as inevitable as gunshot and shrapnel woundsin warfare (Appel & Beebe, 1946-U.S. Army, p. 185).

Historically, the military reflexively employed denial as aprimitive, yet central tactic in initially dealing with its mentalhealth dilemma. The military’s denial of the psychologicalrealities of war manifests in essentially four critical interrelat-ed ways: (a) denying the inevitability of large numbers ofpsychiatric casualties from modern warfare; (b) denying theinherent need to adequately plan and prepare to meet wartimemental health needs; (c) denying the primary etiological role

of exposure to war stress as causing a legitimate spectrum ofstress-injury; and (d) denying organizational responsibility tomeet mental health needs.

Denial that War Inevitably Causes Large Numbersof Psychiatric Casualties

Kay (1912) analyzed the impact of industrialized warfrom 1886 to 1908 for the British Army, finding signif-icant associations between increased rates of war stressinjury and duration of exposure: Bthe amount of theincrease is proportional to the duration of campaign^(Kay, 1912, p. 153) and intensity of combat: BThe con-ditions of modern warfare calling large numbers of meninto action, the tremendous endurance, physical andmental required, and the widely destructive effect ofmodern artillery fire,^ forewarning military leadersabout the future toxic effects of twentieth century war:Bwe shall have to deal with a larger percentage ofmental disease the hitherto^ (Cited in Jones &Wessely, 2005, p. 13). Kay’s (1912) prophetic warningis routinely ignored by war planners intent on denyingthe psychological realities of modern warfare: Bonly asmall percentage succumbs and takes flight intosickness^ (Gaupp, 1911; cited in Lerner, 2003, p. 40)- only to be re-learned by harsh realities:

The war has taught us and will continue to teach us (1) thatjust as before there are traumatic neuroses; (2) that they arenot always covered by the concept of hysteria; and (3) thatthey are really the product of trauma and not goal-oriented,well cultivated pseudo illness (Oppenheim, 1915; cited inLerner, 2003, p. 67).

The psychological realities of modern industrialized war-fare that Oppenheim (1915) and Appel and Beebe (1946)aptly summarized for their respective cohorts were clearlyevident long before WWI:

There is a strong suspicion that the high insanity rate inthe Spanish-American War and the Boer War, and per-haps in earlier conflicts, was due, in part at least, tofailure to recognize the real nature of the severe neuro-ses, which are grouped under the term "shell shock" inthis war (Salmon, 1917, p. 14).

And tragically repeated after WWII:

Undoubtedly, the most important lesson learned by psy-chiatry in World War II was the failure of responsiblemilitary authorities, during mobilization and earlyphases of hostilities, to appreciate the inevitability of


http://www.merriam-webster.com/dictionary/denial

http://www.merriam-webster.com/dictionary/denial

large-scale psychiatric disorders under conditions ofmodern warfare (Glass, 1966a, p. 736).

However, as Jones and Wessely (2007) asserted, prior tothe twentieth century: BThe idea that a soldier of previouslysound mind could be so emotionally disturbed by combatthat he could no longer function was not entertained; thathe might suffer long-term psychological consequences ofbattle was also dismissed^ (p. 165). Yet, psychiatric reali-ties could no longer be rationally denied by credible author-ities: BToday the enormous number of these cases amongsome of Europe's best fighting men is leading to a revisionof the medical and popular attitude toward functional ner-vous diseases^ (Salmon, 1917, p. 65).

Evidence of Military Denial in the Twenty-First Century

There is no other suitable term than denial to explain the U.S.military’s inability or unwillingness to appreciate the size andscope of wartime mental health needs. Efforts to minimize re-ality: BOf the 10 percent or so who have PTSD, most willrecover with time, patience and love. Some will need more^(Casscells, 2008, p. 2; Assistant Secretary of Defense HealthAffairs). Efforts to distort or even break from reality: as wararchitects prepared for the 2003 invasion of Iraq, the Army’ssenior psychiatrist Brigadier General recalled: Bwe were notallowed to talk of the unseen wounds of war-we were notallowed to prepare for the unseen wounds^ (Sutton, 2017).Observations subsequently validated by the DoD Task Force(2007) noted: BDespite the dedicated work of its members, thecurrent system is not structured to address these new chal-lenges, leaving many psychological health needs unmet.Without a fundamental realignment of services, this situationwill worsen^ (p. 6).

Evidence of how deeply entrenched the military’s use ofdenial is regarding fulfilling its promise to care for large num-bers of psychiatric casualties is demonstrated by its persistence.For example, the independently commissioned IOM (2014)concluded after 13 years of war:

PTSD management in DoD appears to be local, ad hoc,incremental, and crisis-driven with little planning devot-ed to the development of a long range, population-basedapproach for the disorder by either the Office of theAssistant Secretary of Defense for Health Affairs orany of the service branches (p. 5).

Denial of the Need to Adequately Plan and Prepare

Perhaps the most visible demonstration of the military’s pro-pensity to deny the factual realities of war stress injury is its

repeated post-hoc admission of abject failure to properly planand prepare for the predictable psychological outcomes of war.A certain degree of latitude can be given to WWI-era leaderswho failed to heed prior lessons of war trauma because thesheer magnitude of WWI psychiatric casualties was unprece-dented in human history. However, the documentation and dis-semination of those psychiatric realities began in earnest afterWWI, thus discrediting any future excuses: BFurther, and mostimportant, there was the documented history ofWorldWar I, aswell as accounts from other previous wars, which providedabundant evidence that combat would produce large numbersof psychiatric casualties^ (Glass, 1966a, p. 17).

Similarly, denial is evident in the following: BDespite theforegoing data that were available to responsible authorities,there was no effective plan or real preparation for the utilizationof psychiatry by the Army in World War II. Facilities for thecare and treatment of psychiatric cases were only barely suffi-cient for the small PEACETIME Army^ (Glass, 1966a, p. 18).Also, Glass noted that:

Defects in Preparation and Planning. As has been indi-cated already, psychiatric disorders proved to be a majorsource of manpower loss to the U.S. Army in World WarII. At the beginning of the war, a potential loss of thismagnitude was neither expected nor planned for by mil-itary authorities in general or the Medical Department inparticular. It was not until February 1942 that a psychia-trist was assigned to the Surgeon General’s Office (Glass,1966a, p. 18).

Perhaps the best illustration of the US Military’s failure tonot repeat the errors of the past lies in the massive, two-volumereport by the U.S. Army Surgeon General. It took 21 years towrite this 2038 page report about lessons learned from WW II.The report was data driven and focused on lessons from everyaspect of meeting wartime mental health needs (planning,staffing, training, treatment, prevention, organization, reintegra-tion, stigma, etc.). The purpose of these lessons learned was forthe explicit purpose of advising future leaders so they could nolonger deny the realities of war:

With this information so readily available, there can belittle excuse for repetition of error in future wars, shouldthey occur^ (Heaton (1966) U.S. Army SurgeonGeneral, cited in Glass & Bernucci, 1966, p. xiv).

Certainly no one expected the pattern of denial, crisis, andre-learning to continue after WWII. However, after the lastmajor American war of the twentieth century (Persian GulfWar), similar denial seemed evident about mental healthdifficulties:


They (mental health) were not adequately staffed,equipped or trained in peace-time to perform their war-time role. The world is a dangerous place and the Armymust be prepared today for tomorrow’s conflict. Ashighlighted here, lessons learned in SWA (SouthwestAsia) provide a reference point from which to preparefor this inevitability (Martin, 1992, pp. 40-44).

Perpetuating Military Denial in the Twenty-FirstCentury

On 16 June 2007, a congressionally mandated DoD TaskForce on Mental Health publicly unveiled its greatly delayedfindings depicting an urgent mental health crisis that militaryleaders unwaveringly denied as late as May 2007 (e.g.,Kilpatrick, 2007; Zoroya, 2007):

The Task Force arrived at a single finding underpinningall others: The Military Health System lacks the fiscalresources and the fully-trained personnel to fulfill itsmiss ion to suppor t psychological heal th inPEACETIME or fulfill the enhanced requirements im-posed during times of conflict (DoD Task Force, 2007,p. ES.2).^

The time for action is now. The human and financialcosts of un-addressed problems will rise dramaticallyover time. Our nation learned this lesson, at a tragic cost,in the years following the Vietnam War. Fully investingin prevention, early intervention, and effective treatmentare responsibilities incumbent upon us as we endeavorto fulfill our obligation to our military service members(DoD Task Force, 2007, p. 63).

Six years into the Afghanistan and Iraq wars, the DoDrevealed its repeated failure to adequately plan and pre-pare, with 99 corrective actions covering every fundamen-tal lesson of war trauma (e.g., staffing, training, treatment,prevention, stigma, reintegration, family support, etc.). Itthen pleaded for urgent action for neglected soldiers (DoDTF, 2007), and amid the military’s escalating rates ofPTSD, suicide, TBI, substance abuse, misconduct stressbehaviors, legal prosecutions, caregiver distress, etc.(Russell et al., 2016).

Denial that War Produces a Spectrum of LegitimateWar Stress Injury

In addition to grossly underestimating the inevitable highvolume of war stress casualties and forsaking proper plan-ning to meet wartime mental health needs, the military

also routinely denies the primary cause of war stress in-jury—exceeding exposure levels to toxic war stress: BItshould always be remembered that modern war producestwo unique types of casualties in large numbers; namely,injuries and psychiatric disorders, both of which arecaused by traumatic forces set forth by a changing andhostile environment^ (Glass, 1966a, b, p. 739), as wellas: BWhen finally, psychiatric casualties were regardedas legitimate consequence of battle stress and strain, itbecame possible to prepare adequately for their preven-tion and treatment^ (Glass, 1966a, p. 22).

These historical anecdotes have robust empirical support.For example, the IOM (2008) reported that

Activation of the stress response ensures survival in theshort term, but is maladaptive when its activation per-sists as a result of chronic, severe, or repeated stress.Chronic stress can lead to adverse health outcomes thataffect multiple body systems such as the CNS (centralnervous system) and the endocrine, immune, gastroin-testinal, and cardiovascular systems (p. 59).

And that:

In the brain, there is evidence of structural and function-al changes resulting directly from chronic or severestress. The changes are associated with alterations ofthe most profound functions of the brain: memory anddecision-making. They are also associated with symp-toms of fear and anxiety, and they might sensitize thebrain to substances of abuse and increase the risk ofsubstance-use disorders (p. 62).

In contrast, etiologic responsibility often is routinely assignedby the military to individual inherent weakness and predispo-sitions along with immoral pursuit of secondary gains (e.g.,evacuation from combat zones, receiving disability pension,(Department of Navy and U.S. Marine Corps, 2010; Glass,1966a) For instance, the U.S. Army’s top neuropsychiatrist inWWII reported the general sentiment toward war stressed sol-diers was that: BTo the line officer, he was a malinger^(Menninger, 1966; p. 132). Additionally, the U.S. Army’s cur-rent Textbook on War Psychiatry explains that PTSD iscaused:

in those with social and biological predispositions inwhom the stressor is meaningful when social supportsare inadequate. Other mechanisms such as positive re-inforcement (secondary gain in Freud’s model) seemmore important in the chronic maintenance of symp-toms (Jones, 1995, pp. 416-417),


However, in a period of honest reflection after WWII, theU.S. Army admitted to reliance on denial in managing itsmental health dilemma:

It was known that psychiatric disorders did occur in war-fare, for the World War I experience showed some160,000 admissions for neuropsychiatric conditions inthe Army. At the beginning of World War II, however,most military authorities and many psychiatrists, includ-ing civilian consultants to the armed services, believedthat psychiatric disorders did not occur to a significantextent in Bnormal^ persons, but arose primarily in theminority populations who were Bweaklings^ or whohad underlying emotional instability that predisposedthem to psychiatric illness (Glass, 1966a; p. 387).

And in even more clear terms:

Second, and again in retrospect, reliance upon psychiat-ric screening can be understood as a logical extension ofthe denial or the failure to appreciate the magnitude ofthe psychiatric problem in war (Glass, 1966a; p. 743).

Importantly, if the military truly has learned that war pro-duces a legitimate spectrum of war stress injury, we shouldexpect it would behave accordingly. There would be evidenceof adequate planning, staffing, and treatment similar to caringfor predictable physical wounds. Military clinicians and re-searchers would regularly screen and track the full spectrumof war stress injury, and not only a handful of conditions as itcurrently does (e.g., Russell & Figley, 2015a). Akin to medi-cine, there would be no toleration for stigma and barriers tocare and certainly no evidence of weaponizing stigma to re-duce help-seeking. Further evidence of denial is clearly dem-onstrated in the military’s efforts to eliminate war stress injuryby purging its mental health programs from the military aswell as purging any conceivable type of psychological weak-ness from joining the military (see section on PurgingWeakness). In other words, there is overwhelming evidencethe military has avoided learning its lesson that war stressinjury is a legitimate and predictable outcome from war.

Denial of Organizational Responsibility

Individuals or organizations using the stratagem of denial ofresponsibility are usually attempting to avoid potential harmor pain by shifting attention away from themselves (Ogden &Biebers, 2011). This type of denial involves avoiding personalresponsibility by: (a) blaming or shifting culpability; (b)attempting to minimize the effects or results of an action ap-pear to be less harmful than in actuality; (c) justifying actionsby attempting to make that choice look proper because of their

perception of what is right; and (d) acting in a regressive orchildish way (e.g., whining, temper tantrum).

Evidence of Blaming and Shifting Culpability

Historically, the military has frequently exercised thestrategy of shifting blame for war stress injury to everyfactor other than war itself. This approach is consistentwith the military’s denial of psychiatric realities of war.But the blame-shifting strategy includes but is not lim-ited to blaming: (a) individual predisposed weaknessand amoral pension-seeking; (b) disability compensationand pensions, or Bpension-seeking neurosis;^ (c) corro-sive influence of psychiatry and mental health providersin general (e.g.., Shepard, 2001); (d) weakening influ-ence of modern ‘culture of trauma and victimhood’(e.g., Shepard, 2001); (e) politically motivated anti-waradvocates and psychiatrists (Shepard, 2001); (f) overlylenient and ineffectual unit leaders; (g) inadequate mili-tary training and discipline; (h) sensationalized mediacoverage; (i) insufficient congressional support; and (j)shifting responsibility for treatment to the VA.

For example, the U.S. military’s policy of deferring respon-sibility for definitive mental healthcare to the VA or privatesector is well-documented (e.g., Brill, 1966b). In this regard,upon learning of the WWII crisis characterized by mass un-treated psychiatric casualties discharged by the military,President Franklin D. Roosevelt authored a December 4,1944 directive to the Secretary of War clarifying the military’sresponsibility it had stridently attempted to avoid (cited inBrill, 1966b, pp. 291–292):

My dear Mr. Secretary:I am deeply concerned over the physical and emotionalcondition of disabled men returning from the war. I feel,as I know you do, that the ultimate ought to be done forthem to return them as useful citizens-useful not only tothemselves but to the community.I wish you would issue instructions to the effect that itshould be the responsibility of the military authorities toinsure that no overseas casualty is discharged from thearmed forces until he has received the maximum bene-fits of hospitalization and convalescent facilities whichmust include physical and psychological rehabilitation,vocational guidance, prevocational training, andresocialization.

The then Commander-in-Chief’s order reflected a 180 de-grees reversal of the military’s policy and practice of essen-tially no treatment and discharge to Bmaximum benefit^ ofmental health treatment and retention before separation(Brill, 1966b; Menninger, 1948). However, toward the end


ofWWI, the U.S. military was also assigned responsibility fortreatment of its psychiatric casualties prior to discharge:

As the war proceeded it was considered desirable torequire that all mental cases be treated for a reasonableperiod in the military hospitals. Directions recommend-ed in June, 1918, sent out November 20, 1918, providedthat all except cases which were evidently incurableshould be treated in the military hospitals for a periodof at least four months, unless recovery took place soon-er (Salmon & Fenton, 1929, p. 147).

In the twenty-first century, President Obama’s ExecutiveOrder (2012) echoes his predecessor’s effort to compelthe military to accept its responsibility for caring ofmentally ill combatants:

Our efforts also must focus on both outreach to veteransand their families and the provision of high quality men-tal health treatment to those in need. Coordination be-tween the Departments of Veterans Affairs and Defenseduring service members' transition to civilian life is es-sential to achieving these goals.

Attempts to Minimize Harmful Effects

By far, the best example of this stratagem ofminimizing harm-ful effects is the military’s frontline psychiatry or combat op-erational stress control policy. This century-old policy pro-motes the military’s claim of the long-term health benefits todeployed personnel and their families of repeatedly returningtraumatized soldiers back to combat units. They are to remainin proximity to the war theater for treatment until they areeither severely incapacitated (e.g., psychotic) or present immi-nent danger to self or others (see Inadequate, Experimental,and Harmful Treatment).

Irrational Justification of Actions

A perfect illustration of this avoidance stratagem is when themilitary was confronted by the GAO in 2006 regarding itsPTSD prevention and treatment programs. The GAO (2006)reviewed the DoD’s PTSD screening policies that mandatepost-deployment health assessment (PDHA) screeningsintended for early identification and intervention. Per theGAO (2016), BA joint VA/DOD guideline states thatservice-members who respond positively to three or four ofthe questions may be at risk for PTSD^ (p. i). PDHA screen-ings are typically conducted by non-physicians (e.g., enlistedmedics), physician assistants, or general practitioners. Thesespecialties most often refer to specialists like neurology and

psychiatry for positive screenings of a high-risk health prob-lem like PTSD. However, the GAO (2006) found that themilitary failed to refer 78% of returning OEF/OIF veteranswho were at highest risk for PTSD (endorsing three to fourout of four symptoms) to a mental health specialist in compli-ance with the purpose of its screening policy. Keeping in mindthe mental health referral would evaluate if someone actuallyhad PTSD and warranted treatment.

When confronted, the military’s response to the GAO(2006) consisted of denying responsibility for the need to referhigh risk patients to a specialist, including:

Potential risks associated with false positives. No med-ical intervention is without risks. The general premise ofmedical practice is that the benefits should outweigh therisks. In terms of PTSD, the risks are associated withpotentially issuing a diagnosis of PTSD for an individ-ual who has no diagnosable mental health disorder (p.31).

In other words, the military prefers a non-physician or gener-alist assess a high-risk condition like PTSD versus its mentalhealth specialists, a seemingly backwards medical practice.Furthermore, the military attempts to covers its bases byoffering:

In making a clinical determination associated with amental health referral, the risks of false positive mustalways be weighed against the accuracy of clinicaljudgement. Watchful waiting may be more appropriatein situations in which the clinician is not sure about adiagnosis or the severity of symptoms (p. 31).

That is, the PDHA screener may never see the servicemember again, but is encouraged to wait versus refer to aspecialist. Therefore, it is entirely up to service members tore-engage the medical system when their symptoms worsen,they are in crisis, or they attempt suicide. This type of reac-tionary policy contradicts the entire reason for conductingproactive screenings in the first place, a tragic example ofinstitutional denial of responsibility.

Regressive Behavior

The closest example we can find of this stratagem is themilitary’s knee-jerk response to a whistleblower who filed agrievance with the DoD Inspector’s Office in 2005-06(Russell, 2006a, b) detailing a mental health crisis the militaryactively wanted to deny (see Delay, Deception, and Delaysection). In retaliation, top military officials disseminated aPublic Affairs Guidance (U.S. Navy, 2007) expressly


designed to refute claims of a crisis (e.g., staffing shortages,inadequate treatment), which were latter validated by the DoDTask Force (2007). They exacted retribution against saidwhistleblower’s military promotion and career (Zoroya,2007).

Why Deny Organizational Responsibility?

We are unaware of any previous investigations into themilitary’s reliance on denial as a protective defense mecha-nism in dealing with its mental health dilemma. To what ex-tent does the military’s propensity to deny the psychiatric re-alities of war reflect an unconscious or intentional process isopen to debate. Clearly there is an inexplicable disconnectbetween public knowledge that war results in psychiatric ca-sualties and the DoD’s systemic failure to provide even peace-time level of mental health services. The nature of the behav-ior by the military might be attributed to either denial or grossnegligence (Russell et al., 2016). Furthermore, for the militaryto endure repeated organizational embarrassment, shame,public disdain, and dishonor for failing to live by its moralcode to do right by millions of service personnel and theirfamilies, one could suggest that there must be serious advan-tages to use denial strategies.

At present, we offer the following conjecture about possi-ble motivations that may appear to justify (if true) themilitary’s use of denial strategies: (a) acknowledging the men-tal health difficulties of soldiers would lead to crippling themilitary’s capacity to fight and win wars due to attrition (e.g.,mass evacuation syndromes) and finances (e.g., costs requiredtomeet wartimemental health needs); (b) competing costs andresources for mental health services will fatally detract frommilitary readiness (e.g., weapon procurement); (c) expandingdisability pensions will strain society; (d) undermining mili-tary recruitment and retention efforts will result, as well as theability to sustain an all-volunteer force; and/or (e) there is anisrained culture antipathy and deeply held beliefs, biases, andfears toward the mental health field, in general, and its clien-tele and practitioners, in particular.

Strategy 5: Screening and Purging Weaknessto Prevent War Stress Injury

In the beginning of World War II, military authorities,both lay and medical, believed that psychiatric disordersoccurred only in predisposed individuals-weaklings.This led to the endorsement of and the reliance uponthe policy of psychiatric screening. As the warprogressed, these authorities discovered that most men-tal disorders occurred in "normal" men and that

screening was ineffective in preventing the occurrenceof such conditions (Appel, 1966, p. 414; Department ofArmy).

The military’s use seeming of denial to resolve its mentalhealth dilemma is effectively embodied by its insistence thatpredisposed weak personalities were the primary culprit forpsychiatric breakdown as opposed to the toxic effects of war-fare; despite ample evidence to the contrary. America’s briefinvolvement in WWI produced a total of 69,000psychiatrically-disabled veterans, costing the governmentover $1 billion in disability pensions (Berlien & Waggoner,1966). But who are what was blamed? Conclusions by inves-tigative commissions almost universally blamed pre-existingindividual weaknesses and the corrosive influence of psychi-atry (i.e., psychiatric diagnosing, disability pensions), as wellas inadequate military training, leadership, and unit morale(e.g., Report of the War Office Committee of Enquiry intoBShell Shock^, 1922).

Having diagnosed the problem, post-WWI military powersall took concerted action to eliminate psychiatry from its rankand file; BReference was made to the large amount of moneywhich was spent by the Government to provide care for neu-ropsychiatric patients after the war, and pleas were made toavoid getting involved again^ (Brill, 1966a; p. 207).Consequently, the U.S. militaryaggressively screened outand rejected the psychologically weak and predisposed,prevented or significantly reduced psychiatric disability pen-sions, as well as significantly ramping up military discipline,vigorous training, unit morale building, and leadership devel-opment in order to strengthen individual resistance against theerosive softening effects of modern culture that encouragescowardice, weakness, and pseudo-psychiatric illness.

Purging Mental Health Services

Consequently, European and American militaries disbandedtheir mental health services, including all frontline psychiatryprograms and personnel. The intent was to preventpredisposed war hysterics from infiltrating the armed forcesin that BProminent civil and military medical authorities point-ed out that World War I had demonstrated the necessity andfeasibility of psychiatric screening in eliminating overt andcovert mental disorders prior to entry in the military services^(Glass, 1966a, p. 7). From the military’s perspective, the onlyreal value of mental health specialists was to prevent theirfuture clientele from contaminating the military, and rigorousmilitary discipline, training, unit cohesion, and leadershipwould take care of the rest (e.g., Shepard, 2001). Having re-moved the morally corrosive influence of psychiatry from therank and file, the military now took concerted steps to end itsmental health dilemma.


Purging Predisposed War Hysterics

The U.S. military conducted psychiatric screenings duringWWI, resulting in 70,000 candidates rejected for enlistmentdue to emotional and intellectual risk factors (Berlien &Waggoner, 1966) (Table 4 provides an example of how, dur-ing wars, mental health-related screenings and disability dis-charges are managed. After WWI, the military decided todouble-down on its effort to screen out potential pensionersby significantly broadening the criteria for rejection to includein known or hypothesized potential risk factor. In 1941, HarryStack Sullivan was appointed as chief neuropsychiatric (NP)consultant to the Selective Service, and tasked to develop ascreening program consisting of different levels of medicaland psychiatric examinations. The latter included extensiverecord review (e.g., legal, medical, educational, family, psy-chiatric), standardized intelligence testing, and variouspsychiatric questionnaires all designed to reject anyone witha greater than average chance of NP breakdown. Orr (1941)reported the objectives of NP screenings was to disqualify theobviously ‘psychopathic’ or psychiatrically unfit then

eliminate further: (1) those men with more subtle per-sonality disorders missed by previous examiners; (2)men whose present personality makeup suggests thatthey may break under the special stresses and strainsof camp life; and even beyond these, (3) men whomay be expected to develop some type of neuropsychi-atric disorder at any time during the next eleven years(Cited in Berlien & Waggoner, 1966, p. 156).

The list of disqualifying predisposing or pre-existing riskfactors was extensive, from the reasonable (i.e., intellec-tual deficit, history of epilepsy, current or past psychiatrichistory, active substance abuse, incarceration history, en-uresis, current medical conditions, frequent medical ill-ness) to the absurd (e.g., any history of hospitalizations,shyness, history of speech impediment, extended familypsychiatric or substance abuse history, tendency to worry,repeating a grade or poor grades, parental divorce, adop-tion, school suspension, limited dating experiences, unsta-ble work history, or any other hypothesized ‘neurotic’tendencies), and with the cliché Bwhen in doubt reject^(Berlien & Waggoner, 1966, p. 162).

Considerable public consternation ensued, as large num-bers of patriotic volunteers were rejected because they ap-peared nervous or effeminate, had sweaty palms, tenseness,hand tremors, or answered affirmatively to questions like BDoyou worry?^ BAre you nervous?^ or BDo you have headachesor stomach troubles?^ As the war progressed, consequentmanpower shortages greatly alarmed military leaders, whothen authorized a series of revisions to selection standards(e.g., Berlien & Waggoner, 1966).

Results of Neuropsychiatric Predisposition Screenings

The military’s grand psychiatric experiment proved noth-ing short of a colossal failure and repudiation of the pre-dominant predisposed war hysteria formulation. For ex-ample, during the North African campaign (1941–1943),the American military supposedly devoid of inherentlypredisposed, constitutionally weak, defective service per-sonnel, were faced with grim unlearned lessons of thereality of twentieth century warfare when NP rates of20–34% of total casualties materialized, with only 3%RTD. Also, during the 1942 Guadalcanal invasion, 40%of 1st Division Marine evacuees were NP casualties. Inall, despite rejecting over 1,680,000 ‘predisposed’ or evenremotely defective inductees the rate of U.S. Army neu-ropsychiatric disability discharges during WWII was 7.6times higher than WWI (Glass, 1966a).By the end ofWWII, there were over 1,103,000 American Army and150,000 Navy/Marine Corps psychiatric hospital admis-sions, resulting in 504,000 (72%) supposedly non-defective Army and 110,000 (67%) Navy/Marine Corpspersonnel psychiatrically discharged (i.e., Brill &Kupper, 1966; Chermol, 1985). In September 1943 alone,more soldiers were discharged from the Army (112,500)tha entered active-duty (118,600), with the majority givenpsychiatric discharges. This prompted Chief of Staff,General Marshall to abandon the extensive predispositionscreening policy in 1943 because it was costing them thewar (e.g., Glass, 1966a).

Follow-up Studies on Previously Rejected PredisposedWWII Veterans

Significant modifications were made in selection criteria ofWWII soldiers, with many induction stations reexamining

Table 4 Prevalence ofneuropsychiatric screeningrejections and disabilitydischarges

War Total rejected ataccession

Total rejected atmobilization

Grand totalrejected

Total disabilitydischarges

WWI 70,158 15,247 85,405 43,706

WWII 1,846,000 Unknown 1,846,000 375,333

Source: Berlien & Waggoner, 1966


applicants they previously rejected. They found more than50% of prior rejections were acceptable (e.g., Cardona &Ritchie, 2007). Follow-up investigations into attrition ratesof these previously disqualified, ‘predisposed’ soldiers re-vealed 80% remained on active-duty after 1 year with manyserving for longer periods at satisfactory performance levels(Eanes, 1951). In another study, 413 of 732 (56%) previouslyrejected predisposed registrants were inducted, with a separatestudy of 248 veterans previously disqualified followed-up1 year after induction showing 209 (84%) still on active duty;32 discharged (2 accepting officer commissions) and 5 killedin action (Berlien & Waggoner, 1966).

Explanations for Failures to Screen out PredisposedAccessions

Various reasons have been offered for the failure of masspsychiatric screenings, including the lack of adequatelytrained psychiatric staff to conduct screenings, variabilityin screening instruments and procedures used, dishonestself-disclosures, and insufficient time to perform psychi-atric examinations (e.g., Berlien & Waggoner, 1966;Cardona & Ritchie, 2007). However, while the abovemay explain how some ‘false negatives’ or predisposedinductees later developing post war disorders could have‘slipped through the cracks,’ the following findings aretelling. 1,253,000 hospital admissions resulting in604,000 (48%) NP discharges passed excessively strin-gent inclusion criteria. This, along with the successfulperformance of the majority of previously rejected vet-erans identified with known or suspected predisposed riskfactors, appear to suggest that psychiatric screening of theBweak^ failed and attempts to purging the so-called weakwas misinformed.

Contemporary Military Psychiatric Screening Policy

After WWII, each military service continued to experimentwith different psychiatric screening or personality measuresto predict suitability for service, and all efforts in theseregards met similar outcomes. For example, Plag and Arthur(1965) followed 134 Navy recruits retained after beingscreened as psychiatrically predisposed and unfit for militaryduty, finding 70% were performing satisfactorily 2 years laterin comparison to 86% of a matched control group (i.e., reage,intellect). At present, the three components of psychiatricscreenings for military accession include: (1) estimates of in-tellectual potential via the Armed Services VocationalAptitude Battery (ASVAB), used since 1976; (2) measuresof educational achievement, high school graduation, or equiv-alent test; and (3) a review of medical screening forms andgeneral psychiatric examination during the entrance physicalevaluation at military induction centers intended to identify

and disqualify inductees only with clear psychiatric illness(e.g., Cardona & Ritchie, 2007). The military needs a morecomprehensive prescreening strategy of its volunteers, withthe limits of the assessments and their determinations noted,especially in light of the independent toxic effects of warzonecombat and stress. To avoid repeating past mistakes, the pur-pose of such screening is to establish baselines needed todetect potential changes caused by military service, as wellas early identification of high risk personnel requiring pre-emptive intervention and close monitoring.

Conclusion and Discussion

In summary, the military appears to have abandoned its effortto avoid learning the psychiatric realities of war via massivesystemic purging of weakness, opting instead for less costlyand dangerous strategy. We examine five additional avoidantstrategies in part three of the three-part series on the darkerside of military mental health care.

Compliance with Ethical Standards

Ethical Statement This study was unfunded and there are no conflicts ofinterests involving the authors.

References

Acosta, J. D., Becker, A., Cerully, J. L., Fisher, M. P., Martin, L. T.,Vardavas, R., Slaughter, M.E., & Schell, T. L. (2014).Mental healthstigma in the military. RAND prepared for the Office of theSecretary of Defense Center for Military Health Policy Research.Santa Monica, CA.

Annual Report of the Adjutant General. (1910).War Department AnnualReports 1910, at 176 (1910).Washington, DC.

Appel, J. W. (1966). Preventive psychiatry. In A. J. Glass & R. J.Bernucci (Eds.), Medical Department United States Army.Neuropsychiatry in World War II volume I: Zone of interior (pp.373–416). Washington, DC: Office of the Surgeon General,Department of the Army.

Appel, J. W., & Beebe, G. W. (1946). Preventive psychiatry: An epide-miologic approach. Journal of the American Medical Association,131(18), 1469–1475.

Armed Forces Health Surveillance Center. (2012). Substance use disor-ders in the U.S. Armed Forces, 2000–2011. Medical SurveillanceMonthly Report MSMR, November 2012 19(11), 11–16. Cited inServies, T., Hu, Z., Eick-Cost, A., & Otto, J. L. (2012). Substanceuse disorders in the US Armed Forces, 2000–2011.MSMR, 19(11),pp. 11–16.

Bailey, P. (1929). Provisions for care of mental and nervous cases. In P.Bailey, F. E. Williams, & P. O. Komora (Eds.), The MedicalDepartment of the United States Army in the World War: VolumeX Neuropsychiatry in the United States (pp. 39–55). Prepared underthe direction of Maj. Gen. M. W. Ireland, The Surgeon General.Washington, DC: U. S. Government Printing Office.

Baker, K. A. (2011). The effect of post-traumatic stress disorder on mil-itary leadership: An historical perspective. Fort Leavenworth:


United States Army Command and General Staff College, School ofAdvanced Military Studies.

Baldor, L. C. (2014).Misconduct forces more soldiers out. Associated Press.Barrett, D. H., Resnick, H.S., Foy, D.W., Dansky, B.S., Flanders, W. D.,

& Stroup, N.E. (1996). Combat exposure and adult psychosocialadjustment among U.S. Army veterans serving in Vietnam, 1965-1971. Journal of Abnormal Psychology, 105(4), 575–581.

Beckham, J. C., Feldman,M. E., &Kirby, A. C. (1998). Atrocities exposurein Vietnam combat veterans with chronic posttraumatic stress disor-der: Relationship to combat exposure, symptom severity, guilt, andinterpersonal violence. Journal of Traumatic Stress, 11(4), 777–785.

Berlien, I. C. (1966). Psychiatry in the army. In A. J. Glass, & R. J.Bernucci (Eds.), Medical Department United States Army.Neuropsychiatry in World War II volume I: Zone of interior (pp.491-522). Washington DC: Office of the Surgeon General,Department of the Army.

Berlien, I. C., & Waggoner, R. W. (1966). Selection and induction. In A.J. Glass & R. J. Bernucci (Eds.),Medical Department United StatesArmy. Neuropsychiatry in World War II volume I: Zone of interior(pp. 153–191). Washington, DC: Office of the Surgeon General,Department of the Army.

Bernucci, R. J. (1966). Forensic military psychiatry. In A. J. Glass & R. J.Bernucci (Eds.), Medical Department United States Army.Neuropsychiatry in World War II volume I: Zone of interior (pp.475–488). Washington, DC: Office of the Surgeon General,Department of the Army.

Black, D.W., Carney, C. P., Peloso, P.M., Woolson, R. F., Lettuchy, E., &Doebbeling, B. N. (2005). Incarceration and veterans of the firstGulf War. Military Medicine, 170(7), 612–618.

Booth-Kewley, S., Highfill-McRoy, R. M., Larson, G. E., & Garland, C.F. (2010). Psychosocial predictors of military misconduct. Journalof Nervous Mental Disease, 198(2), 91–98.

Brill, N. Q. (1966a). Hospitalization and disposition. InA. J. Glass&R. J.Bernucci (Eds.), Medical Department United States Army:Neuropsychiatry in World War II: Zone of interior (Vol. I, pp.195–253). Washington, DC: Office of the Surgeon General,Department of the Army.

Brill, N. Q. (1966b). Station and regional hospitals. In A. J. Glass & R. J.Bernucci (Eds.), Medical Department United States Army:Neuropsychiatry in World War II: Zone of interior (Vol. I, pp.255–295). Washington, DC: Office of the Surgeon General,Department of the Army.

Brill, N. Q., & Kupper, H. I. (1966). Problems of adjustment in return tocivilian life. In A. J. Glass & R. J. Bernucci (Eds.), MedicalDepartment United States Army. In Neuropsychiatry in World WarII: Zone of interior (Vol. I, pp. 721–733). Washington, DC: Office ofthe Surgeon General, Department of the Army.

Camp, N. M. (2014). U.S. army psychiatry in the Vietnam War: Newchallenges in extended counterinsurgency warfare. Fort Sam,Huston: Borden Institute, U.S. Army Medical Department Centerand School.

Cardona, R. A., & Ritchie, E. C. (2007). U.S. military enlisted accessionmental health screening: History and current practice. MilitaryMedicine, 172(1), 31–35.

Casscells, W. (2008). Rising to the challenges of PTSD. Pentagon NewsRelease by Assistant Secretary Health Affairs on August 18, 2008.

Chappell, R. A. (1945). Naval offenders and their treatment. FederalProbation, 9, 3–5.

Chermol, B. H. (1985). Wounds without scars: Treatment of battle fatiguein the U.S. armed forces in the Second World War.Military Affairs:The Journal of Military History, Including Theory and Technology,49, 9–12.

Da Costa, J. M. (1871). On irritable heart: A clinical study of a form offunctional cardiac disorder and its consequences. Reprinted DaCosta, J. M. (1951). On irritable heart: a clinical study of a form of

functional cardiac disorder and its consequences. The AmericanJournal of Medicine, 11(5), 559–567.

Dean, E. T. (1997). Shook over hell: Post-traumatic stress Vietnam andthe Civil war. Cambridge: Harvard University Press.

Department of Defense. (2009). Department of Defense Directive1020.02: Se management and equal opportunity (EO) in theDepartment of Defense of February 5. Retrieved from: www.deomi.org/DiversityMgmt/documents/DoD_Directive102002p.pdfwww.deomi.org /Divers i tyMgmt/documents /DoD_Directive102002p.pdf.

Department of Defense Task Force on Mental Health. (2007). An achiev-able vision: Report of the Department of Defense task force onmental health. Falls Church: Defense Health Board.

Department of Navy. (2009). OPNAV instruction 5350.4D: Navy alcoholand drug abuse prevention and control of 4 Jun 2009. Washington,DC: Office of the Chief of Naval Operations.

Department of Navy and U.S. Marine Corps. (2010). Combat and oper-ational stress control. U.S. Navy, NTTP 1-15M; U.S. Marine Corps,MCRP 6-11C. Washington, DC.

Department of the Army. (2006). Combat and operational stress control:Field manual (4–02.51) (FM 8–51). Retrieved from: http://armypubs.army.mil/doctrine/DR_pubs/dr_a/pdf/fm4_02x51.pdf.

Department of the Army. (2009). Field manual 6–22.5: Combat andoperational stress control manual for leaders and soldiers (p.111). Washington, DC: US Dept. of the Army.

Drimmer, F. (1992). Until you are dead: The book of executions inAmerica. New York: Pinnacle Books.

Eanes, R. H. (1951). Standards used by selective service and a follow-upon neuropsychiatric rejectees inWorldWar II. In L. Carmichael & L.C. Mead (Eds.), Selection of military manpower: A symposium (pp.149–156). Washington, DC: National Academy of Sciences –National Research Council.

Executive Order No. 13625, Federal Register, 77(172). (2012).Improving access to mental health services for veterans, servicemembers, and military families. Retrieved from: www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-22062.pdf.

Figley, C. R., & Nash, W. P. (Eds.). (2007).Combat stress injury: Theory,research, and management. New York: Routledge.

Finucane, M. I. (1900). General nervous shock, immediate and remote,after gunshot and shell injuries in the South African campaign. TheLancet, 156(4020), 807–809.

Forbes, D., Parslow, R., Creamer, M., Allen, N., McHugh, T., &Hopwood, M. (2008). Mechanisms of anger and treatment outcomein combat veterans with posttraumatic stress disorder. Journal ofTraumatic Stress, 21(2), 142–129.

Freedman, H. L. (1945). The mental-hygiene-unit approach toreconditioning neuropsychiatric casualties. Mental Hygiene,269(2), 269–302.

Freedman, H. L., & Rockmore, M. J. (1945). Mental hygiene frontiers inprobation and parole services. Social Correctives for Delinquency,44, 52–53.

Freud, S. (1924). The loss of reality in neurosis and psychosis. In A.Richards (Ed.), On psychopathology (pp. 219–226). London:Penguin Books.

Freud, A. (1936). The ego and the mechanisms of defense: The collectedworks of Anna Freud, Vol. 2. International Universities Press.

Frizell, S. (2014). U.S. army firingmore soldiers for misconduct: Numberdismissed for crime or misconduct doubled between 2007 and 2013.Time. Retrieved from: http://nation.time.com/2014/02/15/u-s-army-firing-more-soldiers-for-misconduct/.

Gaupp, R. (1911). Uber den Begriff der hysterie. ZgNP, 5, 457–466. Citedin Lerner, (2003) 38.

Glass, A. J. (1966a). Army psychiatry before WorldWar II. In A. J. Glass& R. J. Bernucci (Eds.), Medical Department United States Army.Neuropsychiatry in World War II volume I: Zone of interior (pp. 3–


http://www.deomi.org/DiversityMgmt/documents/DoD_Directive102002p.pdfwww.deomi.org/DiversityMgmt/documents/DoD_Directive102002p.pdf




http://armypubs.army.mil/doctrine/DR_pubs/dr_a/pdf/fm4_02x51.pdf

http://armypubs.army.mil/doctrine/DR_pubs/dr_a/pdf/fm4_02x51.pdf

http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-22062.pdf

http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-22062.pdf

http://nation.time.com/2014/02/15/u-s-army-firing-more-soldiers-for-misconduct/

http://nation.time.com/2014/02/15/u-s-army-firing-more-soldiers-for-misconduct/

23). Washington, DC: Office of the SurgeonGeneral, Department ofthe Army.

Glass, A. J. (1966b). Lessons learned. In A. J. Glass & R. J. Bernucci(Eds.),Medical Department United States Army. Neuropsychiatry inWorld War II volume I: Zone of interior (pp. 735–759). Washington,DC: Office of the Surgeon General, Department of the Army.

Glass, A. J., & Bernucci, R. J. (1966).Medical Department United StatesArmy. Neuropsychiatry in World War II volume I: Zone of interior.Falls Church: Office of the Surgeon General, Department of theArmy.

Government Accountability Office. (2006). Post-traumatic stress disor-der: DoD needs to identify the factors its providers use to makemental health evaluation referrals for service members. GAO-06-397 04: Washington, DC: Author.

Government Accountability Office. (2016). Human capital: Additionalactions needed to enhance DoD’s efforts to address mental healthcare stigma. GAO-16-404: Washington, DC: Author.

Government Accountability Office. (2017). Defense health care: Actionsneeded to ensure post-traumatic stress disorder and traumatic braininjury are considered in misconduct separations. GAO-17-260.Washington, DC: Author.

Heaton, L. D. (1966). Forward. In A. J. Glass & R. J. Bernucci (Eds.),Medical Department United States Army. Neuropsychiatry in WorldWar II volume I: Zone of interior (xiii-xiv). Washington, DC: Officeof the Surgeon General, Department of the Army.

Henry, K., & Zanuck, D. F. (1949). Twelve o’clock high [Motion picture].Los Angeles: Twentieth Century Fox.

Highfill-McRoy, R. M., Larson, G. E., Booth-Kewley, S., & Garland, C.F. (2010). Psychiatric diagnosis and punishment for misconduct:The effects of PTSD in combat-deployed marines. BMCPsychiatry, 10(1), 88.

Hiley-Young, B., Blake, D. D., Abueg, F. R., Rozynko, V., & Gusman, F.D. (1995). Warzone violence in Vietnam: An examination ofpremilitary, military, and postmilitary factors in PTSD inpatients.Journal of Traumatic Stress, 8(1), 125–141.

Hing, M., Cabrera, J., Barstow, C., & Forsten, R. (2012). Special opera-tions forces and incidence of post-traumatic stress disorder symp-toms. Journal of Special Operation Medicine, 12(3), 23–35.

Hoge, C. W., Castro, C. A., & Eaton, K. M. (2006). Impact of combatduty in Iraq and Afghanistan on family functioning: Findings fromthe Walter Reed Army Institute of research land combat study. In:Human dimensions in military operations—military leaders’ strate-gies for addressing stress and psychological support. MeetingProceedings RTO-MP-HFM-134, Paper 5. Neuilly-surSeine,France: RTO. 5.1–5.6.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., &Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, men-tal health problems, and barriers to care. New England Journal ofMedicine, 2004(351), 13–22.

Holbrook, J. G. (2010). Veterans’ courts and criminal responsibility: Aproblem solving history & approach to the liminality of combattrauma. Widener Law School Legal Studies Research Paper No.10–43. Forthcoming. In: D. C. Kelly, D. Gitelson, & S. H.Barksdale (Eds.), Young veterans: A resilient community of honor,duty & need. New York: Springer. Retrieved from https://ssrn.com/abstract=1706829

Holden, W. (1998). Shell shock. London, UK: Channel 4 Books.Huie, W. B. (1954). The execution of private Slovik. Yardley:

Westholme Publishing.Iacobelli, T. (2013).Death ordeliverance: Canadian courts martial in the

great war. Vancouver: UBC Press.Institute of Medicine. (2008). Gulf War and health: Physiologic, psycho-

logic and psychosocial effects of deployment-related stress 6,(1).Washington, DC: The National Academies Press.

Institute ofMedicine. (2012). Substance Use Disorders in the U.S. ArmedForces. Report Brief September, 2012. Washington, DC: TheNational Academies Press.

Institute of Medicine. (2014). Treatment for posttraumatic stress disorderin military and veteran populations: Final assessment. Washington,DC: The National Academies Press.

Izzo, R. (2014). In need of correction: How the army board for correctionof military records is failing veterans with PTSD. The Yale LawJournal, 123(5), 1118–1625.

Johnson, A. W. (1969). Combat psychiatry: Part I historical review.Medical Bulletin, U.S. Army Europe, 26(10), 305–308.

Joint Mental Health Advisory Team-8. (2013). Operation enduring free-dom 2013 Afghanistan. Washington, DC: Office of the SurgeonGeneral United States Army Medical Command and Office of theCommand Surgeon HQ, USCENTCOM and Office of theCommand Surgeon U.S. Forces Afghanistan (USFOR-A).

Jones, F. D. (1995). Psychiatric lessons of war. In F. D. Jones, L. R.Sparacino, V. L. Wilcox, J. M. Rothberg, J. W. Stokes, & J. W.(Eds.), Textbook of military medicine: War psychiatry (pp. 1–34). Washington, DC: Borden Institute, Office of the SurgeonGeneral, U. S. Army.

Jones, F. D. (2005). Military psychiatry after the first year of the KoreanWar. In A. J. Glass, F. D. Jones, L. R. Sparacino, & J. M. Rothberg(Eds.). Psychiatry in the U.S. Army: Lessons for communitypsychiatry (pp. 1–7). Bethesda, MD: Uniformed ServicesUniversity of the Health Sciences.

Jones, E. (2006). LMF: The use of psychiatric stigma in the royal air forceduring the second world war. The Journal of Military History, 70(2),439–458.

Jones, E., &Wessely, S. (2005). Shell shock to PTSD:Military psychiatryfrom 1900 to the Gulf War. New York: Psychology Press.

Jones, E., &Wessely, S. (2007). A paradigm shift in the conceptualizationof psychological trauma in the 20th century. Journal of AnxietyDisorders, 21(2), 164–175.

Jordan, B. K., Marmar, C. R., Fairbank, J. A., Schlenger, W. E., Kulka, R.A., & Hough, R. L. (1992). Problems in families of male Vietnamveterans with post-traumatic stress disorder. Journal of Consultingand Clinical Psychology, 60(6), 916–926.

Kay, A. G. (1912). Insanity in the army during peace and war, and itstreatment. Journal of the Royal ArmyMedical Corps, 18(1), 146–158.

Kessler, M. M. (1966). Troops in transit. In A. J. Glass & R. J. Bernucci(Eds.),Medical Department United States Army. Neuropsychiatry inWorld War II volume I: Zone of interior (pp. 320–348). Washington,DC: Office of the Surgeon General, Department of the Army.

Kilpatrick, M. E. (2007). Statement by Michael E. Kilpatrick, MDDeputy Director, Force Health Protection and Readiness Programs,Department of Defense. In U.S. Congress House of Representatives(2007), Invisible casualties: The incidence and treatment of mentalhealth problems by the U.S. military (pp. 63–79). Hearing before theU.S. Congress House of Representatives Committee on Oversightand Government Reform, First Session, May 24, 2007, Serial No.110–111. Washington, DC: U.S. Government Printing Office.

Klostermann, K., Mignone, T., Kelley, M. L., Musson, S., & Bohall, G.(2012). Intimate partner violence in the military: Treatment consid-erations. Aggression and Violent Behavior, 17(1), 53–58.

Knapp, L., & Weitzen, F. (1945). A total psychotherapeutic push methodas practiced in the fifth service command rehabilitation center, FortKnox, Kentucky. American Journal of Psychiatry, 102(3), 362–363.

Kors, J. (2010). Disposable soldiers: How the pentagon is cheatingwounded vets. The Nation, 290(16), 11–14.

Lande, R. G. (2003).Madness, malingering & malfeasance. Washington,DC: Blassey’s Inc..

Lerner, P. (2003). Hysterical men: War, psychiatry, and the politics oftrauma in Germany, 1890–1930. London: Cornell University Press.

Linden, E. (1972). The demoralization of an army: Fragging and otherwithdrawal symptoms. Saturday Review, 8, 12–17.


https://ssrn.com/abstract=1706829

https://ssrn.com/abstract=1706829

Ludwig, A. O. (1949). Psychiatry at the Army level. In F. R. Hanson, &U.S. Army Medical Department (Ed.), Combat psychiatry:Experiences in the North African and Mediterranean theaters ofoperation, American ground forces, World War II (pp. 74–104).Honolulu: University Press of the Pacific.

MacCormick, A. H., & Evjen, V. H. (1945). The Army’s rehabilitationprogram for military prisoners. Social Correctives for Delinquency,1, 8–11.

Manual of Courts-Martial. (2012). United States. Washington, DC: TheJoint Service Committee on Military Justice.

Marlowe, D. H. (2001). Psychological and psychosocial consequences ofcombat and deployment: With special emphasis on the Gulf War.(No. MR-1018/11-OSD). Santa Monica, CA: RAND.

Marshall, H. (1840). On the enlisting, discharging, and pensioning ofsoldiers: With the official documents on these branches of militaryduty. Philadelphia: A. Waldie.

Martin, J. A. (1992). Combat psychiatry: Lessons from the war inSouthwest Asia. Journal of the U.S. Army Medical Department,PB 89-2-1/2, 40–44.

Menninger, W. C. (1948). Reactions to combat. Psychiatry in a troubledworld. New York: MacMillan.

Menninger, W. C. (1966). Public relations. In A. J. Glass &R. J. Bernucci(Eds.),Medical department United States Army. Neuropsychiatry inworld war II volume I: Zone of interior (pp. 129–151). Washington,DC: Office of the Surgeon General, Department of the Army.

Mental Health Advisory Team-V. (2008). Mental health advisory team(MHAT-V). Operation enduring freedom 06–08. Washington, DC:Office of the Surgeon Multinational Force-Iraq & Office of theSurgeon General, United States Army Medical Command.

Mullen,M. G. (2011). Letter fromAdmiral Michael G.Mullen, Chairmanof the U.S. Joint Chiefs of Staff, to Hon. Eric K. Shinseki, Secretaryof the Department of Veterans Affairs (Feb. 15, 2011).

Neel, S. (1991). Vietnam studies: Medical support of the U. S. Army inVietnam 1965–1970. Washington, DC: Department of the Army.

Nelson, D. (2008). The war behind me: Vietnam veterans confront thetruth about U.S. war crimes. New York: Basic Books.

Obama, B. H. (2011). Strengthening our military families: MeetingAmerica’s commitment. Collingdale: Diane Publishing.

Ogden, S. K., & Biebers, A. D. (2011). Psychology of denial (1st ed.).New York: Nova Publishing.

Oppenheim, H. (1915). Der Krieg und die traumatischen Neurosen. InDer Krieg und die traumatischen Neurosen (pp. 3–28). Heidelberg:Springer Berlin Heidelberg.

Orr, D. W. (1941). Objectives of selective service psychiatric classifica-tion. Bulletin of Menninger Clinic, 5, 131–133.

Owen, J. (2003). Multiple claimants versus ministry of defence,May 2003, p. 166. Cited in Jones, 2006.

Patton Jr., G. S. (1947). War as I knew it. New York: Pyramid Books.Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., &

Southwick, S. M. (2010). Structures of posttraumatic stress disorderand psychosocial functioning in veterans of operation enduring free-dom and Iraqi freedom. Psychiatry Research, 178(2), 323–329.

Plag, J. A., & Arthur, R. J. (1965). Psychiatric re-examination of unsuit-able naval recruits: A two-year follow-up study. American Journalof Psychiatry, 122(5), 534–541.

Porter v. McCullum. (2009). 130 S. Ct. 447, 455, n.8.Reister, F. A. (1973). Battle causalities and medical statistics: U.S.

army experience in the Korea War. Washington, DC: TheSurgeon General, Department of the Army Report of the waroffice committee of enquiry into Bshell shock.^ (1922).London: Imperial War Museum.

Resnick, H. S., Foy, D. W., Donahue, C. P., & Miller, E. N. (1989).Antisocial behavior and post-traumatic stress disorder in Vietnamveterans. Journal of Clinical Psychology, 45(6), 860–866.

Russell, M. (2006a). Mental health crisis in the Department of Defense:DoD Inspector General Hotline Investigation #98829 submitted by

Commander Mark Russell, USN on 05JAN2006. Available uponrequest via Freedom of Information Act (FOIA) at Department ofDefense; Office of Freedom of Information, 1155 DefensePentagon; Washington, DC 20301–1155.

Russell, M. (2006b). The future of mental health care in the Departmentof Defense. Testimony before the Congressionally-mandatedDepartment of Defense Task Force on Mental Health, on 19–20October 2006, San Diego, CA.

Russell, R. T. (2009). Veterans treatment court: A proactive approach. NewEngland Journal on Crime and Civil Confinement, 35, 357–364.

Russell, M. C., & Figley, C. R. (2015a). Investigating recurrent genera-tional wartime behavioral health crises: Part one of a preliminaryanalysis. Psychological Injury and Law, 8(2), 106–131.

Russell, M. C., & Figley, C. R. (2015b). Generational wartime behavioralhealth crises: Part one of a preliminary analysis. PsychologicalInjury and Law, 8(2), 132–152.

Russell, M. C., & Figley, C. R. (2017a). Do the military’s frontlinepsychiatry/combat and operational stress control doctrine help orharm veterans?—Part one: Framing the issue. Psychological Injuryand Law, 10(1), 1–23.

Russell, M. C., & Figley, C. R. (2017b). Do the military’s frontlinepsychiatry/combat operational stress control programs benefit vet-erans? Part two: Systematic review of the evidence. PsychologicalInjury and Law, 10(1), 24–71.

Russell, M. C., & Figley, C. R. (2017c). Is the military’s century-oldfrontline psychiatry policy harmful to veterans and their families?Part three of a systematic review. Psychological Injury and Law,10(1), 72–95.

Russell, M. C., Figley, C. R., &Robertson, K. R. (2015). Investigating thepsychiatric lessons of war and pattern of preventable wartime be-havioral health crises. Journal of Psychology and BehavioralScience, 3(1), 1–16.

Russell, M. C., Zinn, B., & Figley, C. R. (2016a). Exploring optionsincluding class action to transform military mental healthcare andends the generational cycle of preventable wartime behavioral healthcrises. Psychological Injury and Law, 9(2), 166–197.

Russell, M. C., Butkus, S. N., & Figley, C. R. (2016b). Contribution ofmilitary organization and leadership factors in perpetuating genera-tional cycle of preventable wartime mental health crises: Part one.Psychological Injury and Law, 9(1), 55–72.

Russell, M. C., Schaubel, S. R., & Figley, C. R. (2017). The darker side ofmilitary mental healthcare. Part one: Understanding the military’smental health dilemma. In press. Psychological Injury and Law.

Salmon, T. W. (1917). Recommendations for the treatment of mental andnervous diseases in the United States Army. New York: NationalCommittee for Mental Hygiene.

Salmon, T. W., & Fenton, N. (1929). Neuropsychiatry in the Americanexpeditionary forces. In P. Bailey, F. E. Williams, P. A. Komora,T.W. Salmon, &N. Fenton (Eds.),Neuropsychiatry: TheMedicalDepartment of the United States Army in the World War (Vol. 10,pp. 271–474). Washington, DC: Office of The Surgeon General,US Army.

Santayana, G. (1905). Reason in common sense, volume 1 of the life ofreason. Mineola: Dover Publications.

Seamone, E. R. (2011). Reclaiming the rehabilitative ethic in militaryjustice: The suspended punitive discharge as a method to treat mil-itary offenders with PTSD and TBI and reduce recidivism. MilitaryLaw Review, 208(1), 1–212.

Schaller, B. R. (2012). Veterans on trial: The coming court battles overPTSD. Washington, DC: Potomac Books.

Shaw, J. A. (1987). Psychodynamic considerations in the adaptation tocombat. In G. Belenky (Ed.), Contemporary studies in combatpsychiatry (pp. 117–132). Wesport: Greenwood Press.

Shepard, B. (2001). A war of nerves: Soldiers and psychiatrists in thetwentieth century. Cambridge: Harvard University Press.


Sobel, R. (1949a). Anxiety-depressive reactions after prolonged combatexperience: The ‘old sergeant syndrome.’. In F. R. Hanson & U.S.Army Medical Department (Eds.), Combat psychiatry: Experiencesin the North African and Mediterranean theaters of operationAmerican ground forces, World War II (pp. 137–146). Honolulu:University Press of Pacific.

Sobel, R. (1949b). The battalion surgeon as psychiatrist. In F. R. Hanson& U.S. Army Medical Department (Eds.), Combat psychiatry:Experiences in the North African and Mediterranean theaters ofoperation, American ground forces, World War II (pp. 36–44).Honolulu: University Press of the Pacific.

Stanton, M. D. (1976). Drugs, Vietnam, and the Vietnam veteran: Anoverview. American Journal of Drug and Alcohol Abuse, 3(4),557–570.

Stapp v. Resor (1970). 314 F. Supp. 475 (S.D.N.Y. 1970).Strong, G. V. (1917). The administration of military justice at the United

States disciplinary barracks, Fort Leavenworth, Kansas. Journal ofAmerican Institute of Crime and Criminology, 8(3), 420–421.

Sullivan, D. (1998). A matter of life and death: Examining the militarydeath penalty's fairnesm. The Federal Lawyer, June, retrieved from:https://deathpenaltyinfo.org/us-military-death-penalty#overview

Sutton, L. (2017). Thank you for your service! Documentary film.Produced by Donahue, T.

Taft, C. T., Vogt, D. S.,Marshall, A. D., Panuzio, J., &Niles, B. L. (2007).Aggression among combat veterans: Relationships with combat ex-posure and symptoms of posttraumatic stress disorder, dysphoria,and anxiety. Journal of Traumatic Stress, 20(2), 135–145.

Taft, C. T., Weatherill, R. P., Woodward, H. E., Pinto, L. A., Watkins, L.E., Miller, M. W., & Dekel, R. (2009). Intimate partner and generalaggression perpetration among combat veterans presenting to a post-traumatic stress disorder cl inic. American Journal ofOrthopsychiatry, 79(4), 461–468.

Teten, A. L., Miller, L. A., Stanford, M. S., Petersen, N. J., Bailey, S. D.,Collins, R. L., Dunn, M. J., & Kent, T. A. (2010). Characterizingaggression and its association to anger and hostility among maleveterans with post-traumatic stress disorder. Military Medicine,175(6), 405–410.

The Associated Press. (1999). GI'S Tell of a USMassacre in KoreanWar.The New York Times. Retrieved from http://www.nytimes.com/1999/09/30/world/gi-s-tell-of-a-us-massacre-in-korean-war.html

U. S. Army. (1888). The medical and surgical history of the war ofthe republic: Part III, volume I. Washington, DC: GovernmentPrinting Office.

U.S. Army. (1918). Circular no. 24 American expeditionary forces,France. Published on April 23, 1918. Washington, DC: Office ofSurgeon, Headquarters, NATOUSA.

U.S. Army. (1943). Circular letter no. 17. neuropsychiatric treatment inthe combat zone. Published on 12 June 1943. Washington, DC:Office of Surgeon, Headquarters, NATOUSA.

U.S. Army. (1944).Headquarters first special service force. Memorandumby P. Mitchell, Captain, Assistant Adjutant 1st Sp. Sv. Force of 13November, 1944. Washington, DC: U.S. Army, APA 4994.

U.S. Army. (1975). The army lawyer: A history of the judge advocate gen-eral’s corps, 1775–1975. Honolulu: University Press of the Pacific.

U.S. Army. (1989). Army Regulation (A.R.) 11–33: Army Lessons LearnedProgram: System Development and Application. 10 October 1989.Washington, DC: Headquarters Department of the Army.

U.S. Army (1998). Combat stress control in a theatre of operations:Tactics, techniques and procedures. FM 8-51. Washington, DC:Headquarters, Department of the Army.

U.S. Army Air Force. (1942). Eighth Air Force Policy Letter 200.9x373of 29 October, AFHRA, London.

U.S. Army Eighth Air Force. (1944). The reclassification of personnel fail-ures in the Eighth Air Force of 16 October 1944, 520.742–4, AFHRA.

U.S. ArmyMilitary History Institute. (1944).Combat Lessons Number 5:Rank and file in combat-What they’re doing how they do it EO-10501 Restricted Report. Classified BUnrestricted^ on 5 August1986. Washington, DC: Combat Analysis Section, OperationsDivision, War Department.

U.S. Navy. (2007). Mental health public affairs guidance of 23 January2007. Unpublished document. U.S. Navy Medical Department,Navy Medicine West, Bureau of Medicine and Surgery,Washington, DC.

Veterans Administration. (2015). Analysis of VA health care utilizationamong Operation Enduring Freedom (OEF), Operation IraqiFreedom (OIF), and Operation New Dawn (OND) veterans.Released June 2015. Epidemiology Program. Post-DeploymentHealth Group. Office of Public Health. Veterans’ HealthAdministration. Washington, DC: Department of Veterans Affairs.Retrieved from http://www.publichealth.va.gov/epidemiology.

Ward, H. M. (2006). George Washington’s enforcers: Policing the conti-nental army. Carbondale: Southern Illinois University Press.

Wells, M. K. (1992). Aviators and air combat: A study of the U.S. Eighthair force and RAF bomber command. (No. AFIT/CI/CIA-92-136).Department of War Studies, King’s College. London, UK:University of London.

Winkenwerder, W. (2005). Mental health. Testimony of the AssistantSecretary of Defense for Health Affairs before the subcommitteeon military personnel armed services committee. U.S. House ofRepresentatives on July 26, 2005.

Zoroya, G. (2007). Navy Psychologist: Navy faces crisis. USA Today.Retrieved from http://usatoday30.usatoday.com/news/health/2007-01-16-ptsd-navy_x.htm.

Zwerdling, D. (2007, November 15). Army dismissals for mental health,misconduct rise. National Public Radio. Retrieved from: www.npr.org/templates/story/story.php?storyId=16330374.


https://deathpenaltyinfo.org/us-military-death-penalty#overview

http://www.nytimes.com/1999/09/30/world/gi-s-tell-of-a-us-massacre-in-korean-war.html

http://www.nytimes.com/1999/09/30/world/gi-s-tell-of-a-us-massacre-in-korean-war.html

http://www.publichealth.va.gov/epidemiology

http://usatoday30.usatoday.com/news/health/2007-01-16-ptsd-navy_x.htm

http://usatoday30.usatoday.com/news/health/2007-01-16-ptsd-navy_x.htm

http://www.npr.org/templates/story/story.php?storyId=16330374

http://www.npr.org/templates/story/story.php?storyId=16330374

The Darker Side of Military Mental Healthcare Part Two ...Learning historical lessons has always...

Documents

Transcript of The Darker Side of Military Mental Healthcare Part Two ...Learning historical lessons has always...