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

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

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

Abstract This is the second part of our analysis of the military’s mental health care dilemma. Since the First World War, military and government officials have been quite wary of mass psychiatric attrition and escalating pension costs from warzones. Specifically, the military worries about unknown repercussions should war stress injuries be de-stigmatized and treated equally as physical wounds, as required per the military’s own documented lessons learned. Leaders fear that so-called evacuation syndromes would spread, thereby depleting the fighting force for invalid reasons, eroding unit morale, and providing an acceptable escape from one’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, the military routinely admits to ignoring its war trauma lessons, resulting in a generational pattern of self-inflicted crises, including suicide epidemics. Moreover, besides neglecting such lessons, the military has adopted various approaches over time to reduce the possibility of evacuation syndromes by aggressively preventing psychiatric attrition, treatment, and disability pensions. After an extensive review of the war stress literature, we identified 10 overarching strategies the military has employed in order to resist fully learning from its lessons on the psychiatric realities of modern warfare by eliminating, minimizing, and/or concealing its mental health problem. Part two of the article series examines the following avoidance strategies intended to prevent psychiatric attrition 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 for assessment and treatment of the stress reactions, not to mention prevention methods, have emerged that contributes to alleviating the veteran suicide and mental health crises.

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

BThose who cannot remember the past are condemned lessons are incorporated. Thus, it has long been military doctrine to repeat it!^ George Santayana, 1905 to systematically and thoroughly analyze and integrate combat lessons by establishing Ba system for the collection, analysis, dis- Few would disagree with Santayana’s(1905) pronouncement- semination, and implementation of combat, training, and materiel particularly those in the profession of defending the national trust. testing experiences with associated combat relevant lessons Learning historical lessons has always been viewed as an invalu- learned into Department of the Army (DoA) doctrine^ (U.S. able and traditional staple for preparing future military leaders Army, 1989;p.i). (e.g., U.S. Army Military History Institute, 1944). Wars are won or lost—people may live or die—by how adeptly battlefield War Trauma Lessons and Preventable Wartime Behavioral Health Crises * Mark C. Russell [email protected] An extensive review of applicable material has identified 10 interrelated foundational war trauma lessons, such as the need 1 Antioch University Seattle, 2400 Third Avenue #200, to adequately plan and prepare for large numbers of psychiat- Seattle, WA 98121-1814, USA ric casualties, to eliminate stigma, ensure large cadre of well- 2 Tulane University, New Orleans, LA, USA trained specialists, provide support to military families, 38 Psychol. Inj. and Law (2018) 11:37–68 establish an integrated organization with accountable leader- programs are often the first to erode away (Russell & ship, and provide ready access to definitive treatment prior to Figley, 2015b). military discharge (Russell, Schaubel, & Figley, 2017). The The ending of war routinely marks the expiration of mili- clearest proof of actual lessons learned would be the absence tary and government commitment to learning the hard won of forgetting or ignoring basic tenets for meeting wartime lessons of war trauma, resulting in a ‘national reset’ or return mental health needs and preventing crisis. However, to the to pre-war baseline of mental health neglect (Russell, Figley, contrary, it appears that the military has avoided to learn from &Robertson,2015). Consequently, every war generation psychiatric realities of war, resulting in a pattern of largely since the twentieth century goes to war with grossly substan- preventable behavioral health crises harming millions of vet- dard mental health services completely incapable of meeting erans and their families since WWI, and thus leaving the U.S. peacetime, yet alone wartime needs-thus perpetuating self- military and its government vulnerable to future legal action inflicted crises (Russell & Figley, 2015a, b). This tragic cycle (Russell & Figley, 2015a, b; Russell, Zinn, & Figley, 2016). of ignoring and re-learning the psychiatric realities of war is openly acknowledged by each war generation since WWI and reflects convictions of the military and government in terms of The Military’s Mental Health Dilemma the mental health dilemma. In Part I of our three-part analysis, we have described the competing demands and responsibilities placed on military commanders to look out for the welfare of individual service The burden of Service members deployed on our behalf members and their families, while being tasked to complete includes substantial psychological challenges. We in the their primary mission to fight and win wars (Russell et al., Department of Defense Military Health System join the 2017). Additionally, the historical origins of the military’s nation at large in our gratitude to all of our Service mental health dilemma have been reviewed, including the members and their families. We are grateful for their important constructs of evacuation syndromes and trauma- personal sacrifices and for their contributions to security pension debates that shaped the military’s response to its men- and freedom around the world. They have answered our tal health dilemma, along with the many distinguished accom- call – we must answer theirs! [Assistant Secretary of plishments of military mental healthcare (Russell et al., 2017). Defense for Health Affairs, William Winkenwerder Underlying the military’s mental health dilemma is a profound (2005,p.7)]. worry that acknowledging the psychological realities of war will inevitably cause massive psychiatric evacuations that We describe the military’s mental health dilemma as a would deplete the fighting force and its will to fight, while choice between two undesirable propositions: (1) facing the simultaneously causing financial repercussions from ever- realities of the role of mental health decline during stressful increasing attrition, treatment, and pension costs. operations involving high risk and limited rewards and changing traditional preparation for and engagement in war to ac- commodate the loss; or (2) not facing the realities and This is exemplified by the U.S. Army’s lessons learned pretending there is no systematic and predictable mental report after WWI: health decline and continuation of the mental health crises. Where the number of such cases increases to such an We argue and provide proof that millions of veterans and their extent as to seriously threaten man power, then more families, as well as society are being harmed (e.g., Russell than ever do the war neuroses assume the dignity of et al., 2017) because option 2 appears the choice being made military importance. Therefore, no statement of the by the military. problem of the war neuroses can be made without con- Once a mental health crisis can no longer be denied, sidering from the very beginning its military signifi- the military and government react with a flurry (Russell & cance. Many of the errors made in attempting to solve Figley, 2015b). Each war generation candidly documents the problems of the war neuroses among soldiers might having to re-learn the previous generations’ war trauma have been avoided if at all times the military point of lessons after ignoring those realities at the outset of war view had been kept in mind. This point of view might be (e.g., Russell & Figley, 2015b). Therefore, we see in the expressed as the effort toward returning such a patient to current Afghanistan and Iraq Wars, just like in previous his former status as a soldier with the basic assumption American wars, significant increases in spending and re- that this is a thing possible to accomplish (Salmon & sources for mental health specialists, training, research, Fenton, 1929,p.369). treatment programs, family support, and anti-stigma rhetoric (Russell & Figley, 2015a). However, as war winds However, the military and government are also morally and down, so too does national interest, and mental health legally obligated to provide timely and high-quality healthcare Psychol. Inj. and Law (2018) 11:37–68 39 to military populations, including mental health services (e.g., Strategy One: Cruel and Inhumane Handling Winkenwerder, 2005). Throughout military history and continuing to present day, there is a military tradition of extolling discipline to correct The Darker Side of Military Mental Healthcare undesired behavior and send poignant warnings to the masses. Flogging, whipping, a cat-o-nine tails, solitary confinement, Ending the generational tragedy of preventable wartime men- running the gauntlet, tar and feathering, and shackling were all tal health crises requires full-disclosure of a darker aspect of fairly standard forms of physical punishment used by military the military’s struggle to resolve its mental health dilemma, leaders such as General George Washington to combat cow- which, if continued unabated, will likely harm future ardice and mass desertions (e.g., Ward, 2006). For example, American generations. following the American war of 1812, the Deputy Inspector General of Army Hospitals described medical examinations from flogging: BI have seen several instances of men who have received 500 lashes…and I am aware of one soldier Five Harmful Strategies to Manage Its Mental who received 700 lashes and drummed out of the corps^ Health Dilemma (Marshall, 1840; p. 30). However, other military leaders, including Washington’s Surgeon General, Benjamin Rush, argued for more compassionate treatment of mentally ill combatants (Baker, 2011). The greatest obstacle to neuropsychiatry in both civil Regarding corporal punishment of mentally ill soldiers, and military practice has been the barrier that tends to Marshall (1840) warned: Insanity has been frequently feigned separate nervous and mental diseases from all other dis- by soldiers who wished to obtain their discharge… but it is eases, and it was thought by some that, in so far as the also true, and the fact is a melancholy one, that real insanity Military Establishment was concerned, the greatest has been mistaken for feigned, and the patients treated and good, both to the practice of neuropsychiatry and to punished as imposters^ (p. 132). Marshall (1840)poignantly the patients who were dependent upon it, would be ac- recalls the tragic case of an enlisted soldier with 11 years of complished if a determined effort were made to break service who developed symptoms of mental alienation through this barrier and to place the mental patient on a (insanity) but was repeatedly accused of malingering to obtain par with patients incapacitated by reason of other dis- a disability discharge and denied proper treatment. After five eases (Bailey, 1929; pp. 42-43). courts-martial convictions resulting in five incidents of severe public flogging, the soldier’s untreated mental illness wors- The military has employed 10 approaches aimed at ened. He eventually received a less than honorable discharge, avoiding learning from its war trauma lessons by punishing, but his mental health continued to deteriorate and shortly eliminating, and/or concealing its mental health problem: (1) thereafter the veteran Bcommitted suicide by drinking a quan- Cruel and Inhumane Handling; (2) Legal Prosecution, tity of sulphuric acid^ (Marshall, 1840,p.132). Incarceration, and Executions; (3) Weaponizing Stigma to During the U.S. Civil War and WWI, war stress casualties Humiliate, Ridicule, and Shame into Submission; (4) incapable or unwilling to continue to fight were often subject Denying the Realities of Mental Health; (5) Screening and to ‘Field Punishment One’ consisting of binding war stressed Purging Weakness; (6) Delay and Deception; (7) Bad Paper personnel accused of cowardice to a tree, fence post, or Discharges; (8) Diffusion of Responsibility and Erecting barbed-wire fencing within an active battlefield to motivate Organizational Barriers to Care; (9) Appeasement, Half- others to not shirk their duties (e.g., Holden, 1998). In addi- Measures, and Other Temporary Fixes; and (10) tion, over-stressed soldiers needing a respite were often Perpetuating Neglect and Self-Inflicted Crises. Collectively, assigned Boccupational therapy,^ consisting of grueling, te- these approaches carry on a 100-year-old tradition started dur- dious, often distasteful labor (e.g., cleaning latrines) with the ing WWI to preserve the military’s short-term capacity to fight intention that combatants would view returning to the front- and win wars while protecting society and its’ government lines as imminently more desirable. Anecdotal reports of from financial repercussions (see Russell et al., 2017). Each physical abuse of mental invalids in the military are abundant. of the above strategies represents the military’scommitmentto Perhaps the most notorious incident was in 1946, in Palermo, avoid full acceptance or permanent learning that mental Italy, when news reporters observed WWII legend, U.S. Army healthcare is a legitimate component of military readiness de- General George C. Patton, repeatedly slapping and threaten- serving equal priority as medicine. Due to the scope of our ing hospitalized Bbattle fatigued^ soldiers with a loaded re- analysis, the latter five harmful strategies are covered in Part volver for having the audacity to lay next to the Bhonorably three (Russell, Schaubel, & Figley, 2017). wounded.^ While Patton’s exploits are clearly over the top 40 Psychol. Inj. and Law (2018) 11:37–68 even by military standards, he was expressing a widely held health for the military mission were abused. For example, antipathy toward mental health (e.g., Menninger, 1948). Kessler (1966) reported WWII abuses of U.S. Marines and Soldiers diagnosed with war stress injury during ship Use of Cages for Psychiatric Patients A major finding by transportation to San Francisco from the Pacific theater. In WWII army investigators was the confining of war-stressed 1943, an army investigator wrote BReturning Army trans- combatants in wire-meshed cages measuring six feet in length ports carried most of the mental cases and the latter were and three feet in height and width, thus prohibiting occupants relegated to an undesirable section of the ship which was from sitting, which the official report labeled as Bquite poorly lighted and ventilated… fundamentals of care such inhumane.^ The inspector general’s report further revealed as nutrition and water balance was neglected, morphine that Btransportation of this type of patient, understood so little, was used as a sedative^ (Kessler, 1966;p.336). and feared so much, would be too difficult for medical and attendant personnel to control disturbed patients,^ so orders Evidence of Physical Maltreatment in the Twenty-First were issued to use shock machines for ECT (electroconvul- Century In today’s wars, there is no widespread physical mal- sive therapy) (Kessler, 1966, p. 336). Kessler (1966)wenton treatment of war stress casualties, but isolated reports of abuse to report that official recommendations were made to remove still emerge. For example, in 2010, the House Oversight the stigma created by the letters BNP^ (Neuropsychiatric) on Committee heard testimony about an Army Sergeant with patient identification tags that Blooked upon men so designat- 12 years of military service who suffered migraine headaches, ed as social pariahs to the consequent grief and consternation vision loss, anger episodes, and suicidal ideation following the of the psychiatric patients^ (p. 337). Unfortunately, the rec- concussive effects of a mortar blast during an Iraq deploy- ommendation was ignored as late as 1945, keeping in line ment. His unremitting partial blindness was diagnosed as with the trend of neglect. caused by a preexisting personality disorder, subject to military discharge and potential loss of VA treatment benefits Deaths of Psychiatric Patients in Transit From April 1944 (Kors, 2010). After rejecting the diagnosis, the Sergeant was through October 1944, a total of 2980 U.S. war veterans di- allegedly confined in a closet, monitored around the clock by agnosed with war stress injury were transported via ship from armed guards who enforced sleep deprivation—keeping the the Pacific theater to San Francisco. In this group, there were lights on all night and blasting heavy metal music through the 19 deaths, all but one reportedly diagnosed as Bpsychotic^ night (Kors, 2010). When the sergeant tried to escape, he was (Kessler, 1966). Causes of death were stated as: nine drowned reportedly pinned down, injected with sleeping medication, (usually jumping overboard), one hanged himself, one died of and dragged back to the closet, and signed the personality diphtheria, three died of cardiac conditions, one died of mal- disorder discharge papers after enduring a month of such treat- nutrition, one died of pyelonephritis, and two died of un- ment (Kors, 2010). known causes (Kessler, 1966). The investigators concluded that: BIn retrospect, it seems unconscionable that such abuses and inhumanities, as have already been enumerated, could occur in the first place (Kessler, 1966;p.338).Theseabuses Strategy Two: Legal Prosecution, included severe overcrowding, lack of ventilation, lack of ac- Incarceration, and Executions cess to the decks, use of physical restraints, chains, and chronic exposure to air temperatures averaging 105 to 110F during the 14-day trip (Kessler, 1966). Many of these soldiers witnessed horrible events; they Physical Isolation and Neglect During WWI, psychiatric ca- saw friends die; they lost limbs and faces; they went sualties were admitted to the: "isolation-insane building without sleep or food for days at a time. They have dealt that was a long rectangular building with windows and with the same demons as the accused, and yet they have doors heavily barred on the outside and heavily screened resisted alcohol and drugs. The accused is asking you to on the inside, the interior broken into small cell-like struc- hold him to a different standard. Send a message to the tures stoutly maintained^ (Salmon & Fenton, 1929;p. others who have suffered. Give them a reason to stay the 40). This practice continued in WWII, whereby combat- course and resist the temptation. Don’tletSergeantK ants sacrificing their mental health for the military mis- use PTSD as an excuse to violate the law and put others sion were by policy labeled as psychiatric casualties and at risk. This time, he damaged a wall. Next time, who systematically segregated from those with medical knows? The Government asks for a Dishonorable wounds and sometimes subject to brutal, often inhumane Discharge and three years confinement, because justice treatment leading to untimely deaths. (e.g., Kessler, demands as much (Seamone, 2011, pp. 10-11; Military 1966). Tragically, combatants who sacrificed their mental Law Review, Department of Army). Psychol. Inj. and Law (2018) 11:37–68 41

As illustrated by Seamone (2011), during times of war, Potential Legal Prosecutions Related to War Stress military leaders are frequently confronted with a complicated Injury set of problems when it comes to disciplining personnel who violate military law (Uniformed Code of Military Justice, The connection between war stress exposure and future crim- UCMJ) during or after deployments. At its core, inality is the same as it has been in most major wars. In its Commanders are responsible for maintaining morale, disci- 2009 Porter v. McCollum opinion, the unanimous Supreme pline, and good-order within their units. Therefore, to allow Court bridged across time, citing early studies of this crime criminal misconduct to go unpunished may send an untenable connection to war stress exposure in support of the Nation’s message that could escalate into wide-spread indiscipline Blong tradition of according leniency to veterans in recogni- within the ranks. Historically, Commanders have often erred tion of their service, especially for those who fought on the on setting an example of individuals who either cannot or will front lines.^ (p. 8). not fight, and/or engage in other detrimental conduct by awarding excessive and harsh punishments, including execu- Legal Prosecution for Cowardice tions, as a means to intimidate and keep others in-line. On the other hand, enlightened Commanders must also For instance, desertions and refusal to obey orders to attack consider whether misconduct is related to the subject’scombat can jeopardize the effectiveness of fighting units. Marlowe experiences (e.g., aggressive behavior after returning from (2001) highlighted the historical military dichotomy of human deployment) and/or the result of a war stress injury (e.g., adaptation to war stress as literally a ‘flight’ or ‘fight’ response PTSD, TBI). For instance, behaviors such as freezing under with combatants either exhibiting constitutional weakness or fire, desertion, excessive/inappropriate aggression, substance ‘cowardice’ and deserting the battlefield or the constitutional- abuse, social isolation, unkempt appearance, over-sleeping, ly ‘brave’ who join the fight. Since the Napoleonic-era (1799– recklessness, tardiness, and suicide attempts are common fea- 1815), massive modern militaries increasingly relied on citi- tures of war stress injury such as PTSD, TBI, and depression, zen conscription, and although they became more adept at as well as frequent legal actions against military personnel. preventing war stress-related escape behaviors (i.e., via battle- The Commander’s dilemma is greatly intensified when the field execution, courts-martial, fostering unit cohesion) from offender is an otherwise valuable, proven leader with an ex- the progressively destructive effects of industrial war, war emplary record of honorable service and no prior history of stress injury incidence has trended upwards (i.e., Marlowe, discipline problems. Most Commanders appear to do a rea- 2001). The numbers of ‘deserters,’‘malingerers’ (i.e., ‘rheu- sonable job of weighing factors such as the individual’spast matism fakers,’ self-inflicted wounds) and veterans executed performance, deployment history, and the nature and severity with war stress injury in any historic era is unknowable. For of the alleged offenses in determining a fair and proper legal example, during the American Civil War (1861–1865), there disposition. In fact, during WWI and WWII, the U.S. military was an estimated 300,000 deserters between the Union and implemented highly successful progressive legal forms em- Confederate armies, with an unknown, but larger number of phasizing suspensions of sentences in favor of rehabilitation, ‘stragglers’ (Dean, 1997). How many soldiers that deserted treatment, and restoration to duty, predating today’s Veterans the battlefield had a war stress injury is pure speculation, but Treatment Courts (e.g., Seamone, 2011). there is ample historical evidence that many were battle- On the same token, there is ample evidence of the military’s seasoned veterans, including senior enlisted and officers dur- propensity to abuse the legal system to manage its mental ing the American Civil War (e.g., Lande, 2003) and the Boer health problem (e.g., GAO, 2017). For example, a recent War (e.g., Finucane, 1900). During the Vietnam War, Yale law review article reported on a Vietnam War veteran’s 33,000 U.S. Army personnel deserted in 1971 alone, but prev- civil suit to amend his discharge (Izzo, 2014). After complet- alence of war stress injury is unreported (e.g., Dean, 1997). ing two honorable tours of duty, fighting in four separate cam- Throughout WWII, there were 1.7 million courts-martials paigns in Vietnam, and earning an Air Medal with Valor representing a third of all criminal cases in the U.S. during Device for heroism, John Doe was given an Undesirable 1941–1946, including 21,000 cases of Bdesertion^ resulting in Discharge (akin to Other-than-honorable) following a 1973 the last American execution for desertion in 1945 of a combat conviction for threatening and hitting fellow soldiers (Izzo, soldier diagnosed with Bpsychoneuroses^ (U.S. Army, 1975). 2014). John Doe was later diagnosed with PTSD by a civilian Legal prosecution for cowardice is not relegated to only those therapist; however, his Undesirable Discharge prohibits gov- soldiers who physically left the battlefield, but also pertains to ernment employment and VA benefits such as disability com- those who internally fled. Anecdotal reports of the so-called pensation, PTSD treatment, healthcare, education, and bene- freeze response to extreme stress is readily apparent in military fits for surviving family members (Izzo, 2014). Below, we records, but is often called different names, such as war hys- briefly review the military’s legal system and options available teria, shell shock, conversion reaction, or dissociation disor- to Commanders in dealing with misconduct of war veterans. der. How many of these trembling, immobilized soldiers have 42 Psychol. Inj. and Law (2018) 11:37–68 been prosecuted for cowardice is of course unknowable, but Legal Prosecution for Substance Use Disorders (SUD) The we would rightly expect such overt demonstrations of stress of war has always been associated with high incidence Bweakness^ would be dealt harshly by the military. of SUD (Institute of Medicine (IOM), 2012), as well- documented by every generation, both during, but particularly Old Sergeant’s Syndrome after war. For example, alcoholism and opiate addiction were major concerns reported within the Union Army, with 5589 The dichotomy between cowardice and bravery in the face of soldiers hospitalized for inebriation, 110 of whom died due to war stress exposure is seriously undermined by what military alcohol poisoning; 3744 cases of delirium tremens, with 450 physicians and researchers call old sergeant’ssyndrome fatal; and 920 cases of chronic alcoholism, with 45 fatalities (Sobel, 1949a). Throughout military history, there is ample (U.S. Army, 1888; p. 890). During WWI, 4170 deployed sol- documentation of chronic war stress injury within the diers were discharged for Balcoholism or drug addiction^ military’s most battle-seasoned, highly-trained, and well- (Salmon & Fenton, 1929); 43,339 in WWII (Glass & respected leaders (e.g., Da Costa, 1871). For example, Sobel Bernucci, 1966); and incidence of SUD during Korea was also (1949a) examined 100 WWII U.S. Army noncommissioned reported to be Bhigh,^ but unspecified (Jones, 2005). officers ‘old’ in combat experience identified with old ser- However, during Vietnam War, SUD was by far the most geant syndrome or Guadalcanal twitch BFor these men were extensive of any era. For example, Stanton (1976)reported among the best and most effective of the trained and disci- that from 1967 to 1971, the proportion of enlisted soldiers plined combat infantry soldiers^ (p. 137). They developed smoking marijuana Bheavily^ (20 or more times) in Vietnam abnormal tremulousness, excessive startle, severe anxiety, increased from 7 to 34%, while the proportion of Bhabitual^ sweating, dyspepsia, depression, loss of self-confidence and users (200+ times) stabilized at 17 to 18% between 1969 and guilt, with a highly uncharacteristic tendency to be the ‘first to 1971. The same holds true for contemporary veterans. For get in and last to leave a foxhole.’ Military research on front- instance, the IOM (2012) reported that since the start of line psychiatry treatment of 100 cases of old sergeant OEF/OIF Balcohol abuse among returning military personnel syndrome proved futile. 100% of those RTD relapsed within has spiked. In 2008, nearly half of active duty service mem- less than 10 h to three combat days despite their excruciating bers reported binge drinking^ (p. 2). In today’s cohort, from attempts to remain on the battlefront. This was long-term dis- 2000 to 2011, a reported 306,248 active military personnel position of reassignment to non-combat jobs in the backlines (Armed Forces Health Surveillance Center, 2012)and or discharge (Sobel, 1949a). Battle-tested infantry leaders 200,923 VA treatment seeking OEF/OIF/OND vets (VA, were not the only vulnerable group. The aviator’s equivalent 2015)havebeendiagnosedwithSUD. of old soldier’s syndrome was called flier’sfatigueor opera- Combat veterans struggling with SUD are extremely vul- tional fatigue as vividly illustrated in the 1949 movie ‘Twelve nerable for legal prosecution under the UCMJ for a wide-array O’ Clock High’ depicting a combat seasoned WWII Army Air of behaviors [e.g., DUI, public intoxication, conduct unbe- Corps bomber squadron commander succumbing to flier’s coming, unauthorized absence (e.g., being late to work), illicit fatigue after replacing a fellow proven leader impaired by drug use, prescription drug abuse]. The military’s zero the same affliction whom was previously viewed as constitu- tolerance policy for drug use results in nearly automatic tionally vulnerable. Flier’s fatigue and battle deaths were General or OTH discharges for first timers, regardless of rank highest for bomber crews, with fewer than 25% completing and past performance, as do repeated alcohol-related inci- a full tour of duty and high relapse rates evident, with the dents. For example, per the Department of Navy (2009): majority requiring further treatment after their tour BThe Navy’spolicyondrugabuseisBzero tolerance.^ Navy (Chermol, 1985). Yet, even these proven combat veterans members determined to be using, possessing, promoting, were not immune from accusations of Bbeing yellow^ once manufacturing, or distributing drugs and/or drug abuse para- they succumbed to the effects of war stress (see Twelve phernalia shall be disciplined as appropriate and processed for O ’Clock High, 1949). ADSEP (Administratively Separated) as required^ (p. 5). Contemporary support of old sergeant’s syndrome is The actual number of current war veterans prosecuted for evident in reports of high prevalence of war stress injury SUD is unknown. However, in 2007, National Public Radio like PTSD even among the military’s most elite Special (NPR) reported that since the Iraq invasion of 2003 the U.S. Forces deployed to Iraq and Afghanistan (e.g., Hing, Army discharged almost 20% more soldiers for Bmisconduct,^ Cabrera, Barstow, & Forsten, 2012). These findings sug- including twice as many soldiers for drug abuse, than it did in gest that the severe and continuous deployments, danger- the same period before the war, (or Bhaving behavior issues ous operations, and war cause mental health decline that that are potentially linked to PTSD)^ (Zwerdling, 2007). leads to medical decline and risk of a mental health crisis. Furthermore, the number of enlisted soldiers prosecuted and The result is a danger to the soldier and others, and this discharged out of the U.S. Army for drugs, alcohol, crimes, can risk the military mission involved. and other misconduct soared from 5600 at the peak of the Iraq Psychol. Inj. and Law (2018) 11:37–68 43 war in 2007 to more than 11,000 in 2013, while the number of during WWII and consisted of 2639 officers and enlisted per- discharged Army officers tripled to 387 in 2013 (Frizell, sonnel (U.S. Army, 1944). On its first mission, 53 Rangers 2014). Unfortunately, there is no hard data available on the were killed and 91% of this highly decorated unit received number of Afghanistan or Iraq veterans prosecuted for SUD, awards, including 1214 Purple Hearts, after 240 days of inten- nor how many of those may have had war stress injury. sive, continuous combat (U.S. Army, 1944). However, after deployment, 10% or 266 of the military’s elite force were Legal Prosecution for Post-traumatic Anger and Interpersonal convicted of various misconduct: 87 summary courts martial; Violence (IPV) Irritability and post-war anger problems have 160 special courts martial, and 90 general courts martial (U.S. frequently been reported in war veterans of every generation, Army, 1944 ). Examples of misconduct stress behaviors in- and they can occasionally escalate into violence. In the context cluded mutilating enemy dead, not taking prisoners, looting, of combat, anger and aggressive behaviors are normative re- rape, malingering, combat refusal, drugs, self-inflicted sponses to threats of vulnerability (Forbes et al., 2008). Such wounds, ‘fragging,’ desertion, torture, and intentionally kill- responses are not only adaptive to war, but also have been ing non-combatants (DoA, 2006). extensively modeled and reinforced through military training In addition to predicting PTSD, high combat exposure was (Taft Vogt, Marshall, Panuzio, & Niles, 2007). Social re- shown to predict war-zone misconduct with participation in integration transitions from deployment and after military dis- war-zone violence empirically related to post military violence charge represent critical adjustment periods wherein violence to self, spouse, and others (Hiley-Young, Blake, Abueg, against self and/or others may arise, and therefore induce a Rozynko, & Gusman, 1995). A 2010 study on psychosocial heightened need for individual and family support. The U.S. predictors of military misconduct reported that 2274 out of a government funded a study of the effects of the Vietnam War, sample of 20,746 Marines deployed to OEF/OIF between BLegacies of Vietnam,^ and found 24% of vets who saw 2002 and 2007 received either bad conduct discharges (3%; heavy combat were later arrested for criminal offenses, as n = 548) or demotions in rank from misconduct (9%; n = compared to 17% of other era veterans and 14% of non-vet- 1726) (Booth-Kewley, Highfill-McRoy, Larson, & Garland, erans. A study by Jordan et al. (1992) found that approximate- 2010). The most frequent reasons cited for bad conduct dis- ly one-third of Gulf War-era veterans with PTSD had perpe- charge were drug abuse (n = 340, 62%), frequent contact with trated interpersonal violence (IPV) in the previous year. In civil or military authorities (n = 88, 16%), and court-martial today’s cohort, an Army-wide study of 20,000 OEF/OIF convictions (n = 66, 12%) (Booth-Kewley et al., 2010). Soldiers found length of deployment was positively correlated The strongest predictor variables for bad conduct discharge with the severity of self-reported IPV perpetration in the year was age at first combat deployment (18–21 years) and psychi- after deployment (Klostermann, Mignone, Kelley, Musson, & atric diagnosis (Booth-Kewley et al., 2010). Moreover, Bohall, 2012). Marines diagnosed with a psychiatric disorder after combat Another study of OEF/OIF veterans with PTSD found self- were 9 times more likely to receive a bad conduct discharge reported irritability/anger as the highest symptom, with 29% than Marines undiagnosed (Booth-Kewley et al., 2010). Per of reports rated as Bquite a bit^ or Bextreme^ (Pietrzak, Table 2, there is clearly a trend of increasing number of OTH Goldstein, Malley, Rivers, & Southwick, 2010). Another separations for misconduct as the duration of a war increases. study reported 70% of veterans with PTSD reported impulsive Similar data were not found for the other military (see aggressiveness compared to 29% of veterans without PTSD Table 2), but we assume the same holds true across the (Teten et al., 2010). Another more recent study estimated that military. 33% of veterans seeking PTSD treatment reported perpetrat- ing partner violence (Taft, Weatherill, Woodward, et al., Historical Precedents of Misconduct Stress Behavior During 2009). It is unknown how many of the aforementioned mili- WWII, there were 82,754 general courts-martials in the U.S. tary personnel have an identifiable war stress injury and were Army alone for serious misconduct including murder, rape, actually prosecuted for IPV. and atrocities against civilians (U.S. Army, 1975)resulting in the execution of 70 soldiers deployed to Europe (Sullivan, Legal Prosecution of Misconduct Stress Behaviors The 1998). At least one of the executed soldiers had a documented Department of the Army (DoA, 2006) describes a range of history of combat exhaustion (U.S. Army, 1975). There were maladaptive stress reactions from minor to serious violations 101 reported homicides within the U.S. Army in Korea during of military law and the Law of Land Warfare, most often 1950–1953 (Reister, 1973), and an estimated 163 unarmed occurring in poorly trained soldiers, but the Bgood and heroic, Korean women, children, and elderly refugees were killed under extreme stress may also engage in misconduct^ (p. 1–6) by U.S. forces at No Gun Ri in 1950 (The Associated Press, even in highly cohesive well-trained and led units. For exam- 1999). During Vietnam, Linden (1972) reported a progressive ple, according to previously classified ‘secret’ military docu- increase in the number of courts-martial for insubordination ments, the first-ever U.S. special forces unit was organized and assaults (including murder), exemplified by Bfragging^ 44 Psychol. Inj. and Law (2018) 11:37–68 incidents increasing from 0.3/1000/year in 1969 to 1.7/1000/ military property, drunk on duty, malingering, and conduct year in 1971 (Neel, 1991). unbecoming an officer (MCM, 2012). The purpose of military A reported 320 atrocities by American military personnel law is to: Bpromote justice, to assist in maintaining good order were substantiated by an Army task force BThe Vietnam War and discipline in the armed forces, to promote efficiency and Crimes Working Group^ created after the 1968 My Lai effectiveness in the military establishment, and thereby to Massacre, wherein victims numbered 347 to 504 unarmed strengthen the national security of the United States^ Vietnamese including many women and children (Nelson, (MCM, 2012; p. i-1). Commanders are given significant roles 2008). Research on Vietnam War veterans reported statistical- in the military justice system because discipline is essential to ly significant association between combat exposure and post- mission readiness. At the same time, there are safeguards military antisocial behavior (Barrett et al., 1996; Resnick, Foy, intended to protect against abuse of authority, such as the right Donahue, & Miller, 1989), along with exposure to war atroc- for trial and appeal (MCM, 2012). ities and subsequent IPV (Beckham, Feldman, & Kirby, 1998). After the Persian Gulf War, a modest association be- Discipline and Legal Proceedings and Disposition tween combat experience and incarceration rates was found in a large sample (Black et al., 2005). There are essentially three avenues for Commanders to deal As in other wars, especially low-intensity (guerilla-type) with potentially war-stressed service members engaging in warfare like in Iraq and Afghanistan, there has been a high misconduct: (1) informal resolutions, such as verbal repri- incidence of misconduct stress behaviors by American per- mands, extra-instruction or duties, temporary or permanent sonnel ranging from inappropriate handling of American and reassignment, chaplain referral, and/or referral for alcohol, enemy combatant dead, to prisoner torture and sexual abuse medical, or mental health screening intended to rehabilitate (e.g., 2004 Abu Ghraib incident), as well as several substan- offenders depending on the nature/severity of the offense tiated incidents of rape and homicide of unarmed civilians and whether the offense occurred in operational versus a gar- including children. The total number of courts-martial, inci- rison setting; (2) formal administrative procedures, called non- dents of atrocity, and Bbad paper^ discharges related to mis- judicial punishment, for minor offenses not severe enough to conduct stress behavior is unknown because the military does warrant referral for Courts-Martial; and 3) referral to Courts- not track its legal prosecution of mentally-injured combatants. Martial. However, in 2014 the American Press reported a total of 28,000 soldiers were discharged for misconduct since the Non-judicial Punishment Iraq war (Baldor, 2014). During the same period of time before the wars in Iraq and Afghanistan, the U.S. Army The authority and guidelines for Non-Judicial Punishment discharged 20% more soldiers for Bmisconduct,^ 40% more (NJP) is contained in Article 15 of the MCM (2012). It is also for personality disorder, and 50% more for drug abuse, includ- known as Office Hours and Captain’s Mast in different mili- ing 11,000 enlisted soldiers in 2013 alone (Baldor, 2014). We tary branches. It is considered an invaluable leadership tool, can reasonably assume a large number of combat personnel providing Commanders with a prompt and essential means for have been prosecuted and received punitive discharges for maintaining good order and discipline for minor violations of war stress injuries like misconduct stress behaviors. the UCMJ without resorting to time-intensive and restrictive Courts-Martial procedures. Service members subject to NJP Military Discipline and Legal System must waive their legal protective rights for trial by Courts- Martial, which most do because the penalties from Courts- The historical foundation for U.S. military law lies in the 1774 Martial convictions are inherently more severe (see MCM, British Articles of War. The first legal codes, the American 2012)-a fact military leaders greatly emphasize. Table 1 de- Articles of War and Articles for the Government of the Navy, scribes the types and subsequent costs and benefits of six predated the Constitution and the Declaration of types of separations from the US military across all branches Independence. The American military’s current criminal code, of service. Uniformed Code of Military Justice (UCMJ), was enacted in In most cases, NJP is the appropriate legal disposi- 1950 and is a complete set of criminal laws, rules, and proce- tion for disciplining service members with war stress dures contained in the Manual-for-Courts-Martial (MCM, injury. However, NJP is an ‘administrative’ versus ‘le- 2012). It includes many crimes punished under civilian law gal’ proceeding; thus, there is no trial by peers or ad- (e.g., murder, rape, drug use, larceny, drunk driving), but also herence to rules of evidence—the sole judge and jury is it includes other conduct that affects good order and discipline the individual’s Commander (MCM, 2012). While most in the military. Those unique military crimes include, deser- Commanders exercise their Article 15 authority appro- tion, absence without leave, disrespect toward superiors, fail- priately, service members are at the mercy of less scru- ure to obey orders, dereliction of duty, wrongful disposition of pulous leaders, and this is where unjust practices arise Psychol. Inj. and Law (2018) 11:37–68 45

Table 1 Type of military separation and discharge Type Description Benefits eligibility Negatively Number of impacts discharges VA GI Bill civilian FY2003- (health/ (education) employment 2013 pension)

Honorable Service member met the Yes Yes No 1,983,893 standards of acceptable conduct and performance General When the service has been Yes No Yes 172,125 honest and faithful but there are significant negative aspects of the service that outweigh the positive aspects (e.g., personality disorder; alcohol rehab failure; adjustment disorder) Uncharacterized Applies to those separated Yes No Yes 288,568 within 180 days Other-than-honorable Punitive administrative No No Yes 125,204 (OTH) conditions separation awarded by military Commanders without full legal trial by either non-judicial punishment or Summary Courts-Martial when service record reveals a pattern of minor misconduct (e.g., drug use; disobedience, unauthorized absence, disrespect) Bad conduct Awarded by Judge after No No Yes 19,054 discharge (BCD) Special or General Courts-Martial trial & conviction for serious offense (e.g., assault) Dishonorable Awarded by Judge after No No Yes 1467 discharge (DD) General Courts-Martial trial & conviction equivalent to felony in civilian court (e.g., murder, desertion) in the case of disciplining personnel with war stress discharge face forfeiture of any military retirement or injury. NJP appeals are reviewed by the Commander’s disability pension and other VA benefits, regardless of immediate superior but, given the administrative nature years-in-service, as well as enduring civilian employ- of NJP, are rarely overturned. Legal dispositions for ment restrictions (e.g., law enforcement, public safety, NJP can range from counseling, warnings to reduction federal government agencies). in rank, fines, restriction, brief period of confinement, referral for alcohol or mental health treatment, and/or Courts-Martial administrative separation under General (e.g., alcohol rehab failure) or Other-than-honorable (e.g., pattern of According to the MCM (2012), there are three levels of minor misconduct) conditions, also called Chapter 14. Courts-Martial (Summary, Special, and General), which de- [A pattern of misconduct as evidenced by multiple pend on the nature and severity of the alleged offenses and NJP (even for relatively minor offenses), formal adverse desired punishment. The Summary Courts-Martial is used for counseling, and/or adverse performance evaluation re- lower level offenses similar to NJP, but the individual’s ports.] Per Table 1, military personnel given an OTH Commander believes warrant sterner punishment than 46 Psychol. Inj. and Law (2018) 11:37–68 available via NJP including possible BCD. However, similar In the brain, there is evidence of structural and function- to NJP, the Commander acts as judge and jury, but more legal al changes resulting directly from chronic or severe due process protections are granted to individuals (MCM, stress. The changes are associated with alterations of 2012). Special and General Courts-Martial each invoke full the most profound functions of the brain: memory and legal protections, rules of evidence, and procedures of a stan- decision-making. They are also associated with symp- dard trial, typically with military defense and prosecuting at- toms of fear and anxiety, and they might sensitize the torneys presided by a military Judge. The difference between brain to substances of abuse and increase the risk of Special and General Courts-Martial pertains to the seriousness substance-use disorders (p. 62). of the offense and severity of punishment (see Table 1). Consequently, individuals returning from deployment to BBad Paper Discharges^ warzones are at significant risk for engaging in behaviors that are often associated with exposure to war stress, but could Military separation/discharges characterized as OTH, BCD, become the focus of legal difficulties. For instance, contem- and DD are often referred to as ‘bad paper discharges’ because porary frontline surveys revealed that deployed Soldiers and they result in loss of military pensions, VA benefits (e.g., Marines diagnosed with mental health problems were more treatment, GI Bill) and can significantly impact future civilian likely to mistreat non-combatants in violation of the UCMJ employment and other civil rights (see Table 1). However, the (Mental Health Advisory Team, 2008), while another study term ‘bad paper discharges’ is also used for General (Under showed that deployed Marines with PTSD were 11 times Honorable) administrative separations that may have no legal more likely to be discharged for misconduct than their peers charges attached (e.g., personality disorder, adjustment disor- without PTSD (Highfill-McRoy et al., 2010). der, alcohol rehabilitation failure, sleep walking) yet can have Surprisingly, the military does not routinely track or the same lifelong impact on war veterans as an OTH (see report on the number of service members legally prose- Table 1). Some courts have found discharges other than hon- cuted who are war veterans, or those who may also be orable as punitive because they stigmatize the service-mem- diagnosed with a war stress injury (e.g., PTSD, TBI). ber’s reputation, impede their ability to gain employment, and However, the Army’s post-WWII analysis reveals that serve as prima facie evidence against the service-member’s from 1942 to 1945, 13,015 (56%) of 23,143 soldiers in- character, patriotism, and loyalty (e.g., Stapp v. Resor, carcerated after courts-martial convictions were diagnosed 1970). We will return to the issue of bad paper discharges in with psychiatric conditions (Bernucci, 1966). a later section. Nonetheless, reports on the frequency of discipline and legal dispositions of military personnel (e.g., Courts- Prosecution of Military Personnel with War Stress Martial convictions, misconduct separations) for any his- Injury torical era is inherently flawed because it is unknown how many cases involved war veterans suffering from war stress injury. In addition, our presentation below in no way suggests that war veterans with or without war stress Many of our returning veterans and Service members injury should not have been disciplined or discharged. experience life-changing events, some of which may Readers are advised to refrain from over-generalizing the cause them to react in adverse ways and get into trouble data below as evidence of maltreatment and injustice. At with the law (Admiral Michael Mullen (2011), best, all we can say is that there is a propensity for the Chairman, Joint Chief of Staff) mishandling of at least some war veterans based on the frequency of disposition. Human adaptation to war stress is historically associated with a predictably broad spectrum of potential neuropsychiat- The Military’s Unethical Legal Revolving Door 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- Many courts-martial are problem-generating—rather tempts), and misconduct stress behaviors (e.g., desertion, drug than problem-solving—courts when they preclude treat- use, mistreatment of enemy) [see DoA, 2009; IOM, 2008; ment considerations as tangential matters, lack a coher- Russell & Figley, 2015a, b]. After a comprehensive review ent framework for evaluating the benefit of treatment of the scientific literature on the long-term adverse health ef- versus incarceration, and result in punitive discharges fects and deployment-related stress, the IOM (2008) that preclude offenders from future VA treatment concluded: (Seamone, 2011;p.12). Psychol. Inj. and Law (2018) 11:37–68 47

The military justice system’s approach toward dealing with solving approach targeting mental health conditions underly- emotionally injured war veterans reflects the DoD’s avoidance ing the veteran’s criminal conduct. VTCs use an interdisci- of learning war trauma lessons by its WWI and WWII prede- plinary treatment team that is presently absent in today’smil- cessors. In short, the present-day policy disavows responsibility itary justice system (e.g., Seamone, 2011). Recent legal pre- for provision of mental health treatment and rehabilitation of cedents for VTC include Porter v. McCullum (2009), a unan- veterans in the criminal justice system and foists the responsi- imous U.S. Supreme Court ruling on a Korean War veteran bility on the VA and private sector. Consequently, military per- bridged across time: BOur Nation has a long tradition of ac- sonnel and veterans with untreated mental health conditions are cording leniency to veterans in recognition of their service, at significant risk for legal involvement (e.g., Highfill-McRoy especially for those who fought on the front lines as Porter et al., 2010), thus resulting in a revolving door. did. Moreover, the relevance of Porter’s extensive combat ArecentSeamone(2011) has summarized major ethical experience is not only that he served honorably under extreme concerns over the military justice system’s punitive handling hardship and gruesome conditions, but also that the jury might of stress injured defendants: (1) accused service members with find mitigating the intense stress and mental and emotional suspected or confirmed mental conditions are referred to psy- toll that combat took on Porter^ (Seamone, 2011;pp.23–24) chiatric sanity boards that focus only on fitness to stand trial and In response to a crisis of discharged veterans with untreated rarely make mental health treatment recommendations; (2) mil- war stress injury facing prosecution in civilian courts, Judge itary conviction and incarceration generally prohibits access to Russell from Buffalo, New York, established the first VTC in adequate mental healthcare; (3) bad paper discharges (OTH, 2008 whose mission is: BCD, DD) bar the majority of emotionally-injured veterans from accessing critically needed VA treatment benefits and impact future employability; and (4) the Department of Homeland To successfully habilitate veterans by diverting them Security cited national security threats from discharged untreat- from the traditional criminal justice system and provided combat veterans (who have been taught to overcome instinc- ing them with the tools they need in order to lead a tual resistance toward killing) who are actively being recruited productive and law-abiding lifestyle. In hopes of achiev- by homegrown terrorists. ing this goal, the program provides veterans suffering Additional legal concerns involve sentencing standards used from substance abuse issues, alcoholism, mental health by the current military justice system. They are significantly issues, and emotional disabilities with treatment, aca- more script-based versus individualized and heavily skewed demic and vocational training, job skills, and placement toward punishment versus treatment, thus raising serious ethical services. The program provides further ancillary ser- worries in that: vices to meet the distinctive needs of each individual participant, such as housing, transportation, medical, dental, and other supportive services (Russell, 2009;p. First, even though an accused who has been cleared by a 364). sanity board may appreciate the wrongfulness of his acts, this does not alleviate the concern that his mental These courts adopt a therapeutic or problem-solving ap- condition contributed in some palpable way to the of- proach to sentencing modeled after civilian drug and mental fense or that the offense would not have occurred in the health courts emphasizing interventions addressing the under- absence of the service-connected psychological influ- lying causes of legal transgressions. They suspend sentences ence. Second, service-connected mental illness should in favor of treatment and social support. In 2010, the Buffalo make commanders, military judges, and panels more VTC diverted prosecution of a 32-year-old married Iraq/ concerned about the future than the past because it Afghanistan War veteran diagnosed with PTSD after three strongly suggests that offenders will continue to find combat tours, who was charged with assaulting VA staff and themselves in the same circumstances that led to the becoming Bthe first criminal case nationwide to be transferred offense if they fail to obtain necessary cognitive tools^ from federal court to a local veteran’s treatment court where (Seamone, 2011;p.18). the goal is to treat—rather than simply punish^ (Holbrook, 2010;p.1). Moral, legal, and economic justification for VTCs along Civilian Legal Problem-Solving and Veterans with their documented success in rehabilitating mentally ill Treatment Courts veterans led the military’s Commander-in-Chief, President Barack Obama (2011), to recommend greatly expanding ci- After more than a decade of sustained combat operations and vilian VTCs because of their tremendous value in addressing repeated combat deployments, the civilian justice system has the unique needs of returning veterans with PTSD and developed Veteran Treatment Court (VTC) as a problem- Traumatic Brain Injury (TBI). Similarly, the Chairman, Joint 48 Psychol. Inj. and Law (2018) 11:37–68

Chief of Staff, Admiral Mullen (2011)pronounced:BVTCs differently, as the mental symptoms were not sufficiently are having a significant impact across the country. I have seen pronounced to have justified the dropping of the these courts make a real difference, giving our veterans a charges, except on the recommendation of an expert. If second chance, and significantly improving their quality of the officer had been tried he would certainly have been life.^ However, the military’s strong public support of the convicted, which would have been a gross injustice to VTC’s problem-solving approach begs the question why the him, and would have postponed his recovery indefinitely DoD maintains a more punitive, problem-generating solution (Bailey, 1929,p.131). to its mental health dilemma especially given highly successful legal predecessors to VTCs? By most standards, the WWI-era legal problem-solving approach was successful, causing the Army Staff Judge Precedents of Military Legal Problem-Solving Advocate to remark: BLike the Navy, in the great majority of and Restoration Programs these cases—Bover 80%^—the Army program worked, with many restores later being discharged as non-commissioned Recent media and political attention to VTCs belie the fact officers with a character ‘Excellent’^ (e.g., Strong, 1917;p. that similar problem-solving legal approaches were instituted 8). Overall, an estimated 20% of military prisoners sentenced after every major American War since the U.S. Civil War (e.g., to dishonorable discharge were restored to active-duty via the Schaller, 2012). Notably, the military developed its first spe- DB (e.g., Seamone, 2011). Although preventing personnel cialized Courts-Martial rehabilitation programs, or attrition was an important motivation for the WWI-era’sjudi- Disciplinary Barracks (DB), including limited mental health cial problem-solving approach, the primary goal as reported services, during WWI, whereby convicted personnel received by the Navy Judge Advocate General, was to avoid: Bturning rehabilitative interventions in lieu of suspended sentences and [a military offender] adrift without the credentials generally bad paper discharges. Per the U.S. Army Judge Advocate necessary to secure honest employment in civil life^ (e.g., General, the explicit purpose of the DB was: BTo give the Strong, 1917). Apparently, the same be said about the current man a certain period of time in which by positive action he system. can evidence his reformation and be restored to the service without the stigma of a dishonorable discharge appearing up- WWII Service Command Rehabilitation Center (SCRC) on his record^ (Bailey, 1929). Although the DB programs were open to the general military prison population, the influx Following WWI, restoration-to-duty remained the objective of convicted veterans with war stress injury led to increasing of the military justice system via its DB or SCRC programs, access to mental healthcare. As the Army Surgeon General but responsibility for restoration was split with local military reported: prisons. As war stress casualties escalated during WWII, the military established Mental Hygiene Units (MHU) at SCRCs, with greater attention on understanding and rehabilitating war Fort Leavenworth Disciplinary Barracks. As a result of trauma ensued including provision of group therapy (e.g., this, many cases of mental diseases were discovered Freedman, 1945). Near the end of WWII, the Army’s Fifth among delinquents and the charges against them either SCRC instituted a progressive mental health program called were dropped and discharged on disability initiated, or, Btotal therapeutic push,^ it embodied the modern VTC philos- if the case was tried and sentence imposed, the findings ophy of ‘therapeutic jurisprudence’ by seeking to maximize of the court were approved, including discharge, and therapeutic value in all phases of criminal justice for the ulti- the confinement was omitted. For example, during the mate betterment of both society and the offender (e.g., Knapp summer of 1918 the commanding officer of one of the & Weitzen, 1945). Both officers and enlisted personnel pros- camps in the United States was facing serious difficul- ecuted for misconduct after returning from combat received ties on the charges of neglect of duty about to be brought 6 weeks of intensive therapy at SCRC MHUs, and were then by the Inspector General of the Army. He had been evaluated if they could be returned to duty, reclassified, or frequently absent from his post, was lax in the enforce- discharged (e.g., MacCormick & Evjen, 1945). Accordingly, ment of discipline, did not have the details of his com- Bthe military justice system had the responsibility to Bdiffer- mand well in hand, organized an excessive number of entiate between the cause and effect relationship^ and to base entertainments, etc. Examination by a psychiatrist re- treatment on Bsound mental hygiene principles^ and discharge vealed a mild manic state, and upon the psychiatrist's decisions on more Bcareful study and analysis of the factors report the charges were dropped and sick leave of six involved^ in their offenses (Seamone, 2011,p.94)Table2. months was granted, at the expiration of which this Regarding program efficacy, an analysis of SCRC records officer had made a perfect recovery. Had a psychiatrist between 1940 and 1946 indicate the Army restored over half not been available, the matter would have ended quite (42,373) of 84,245 punitively discharged soldiers to Psychol. Inj. and Law (2018) 11:37–68 49 honorable active-duty status, with a recidivism rate of only military draft and beginning of the all-volunteer force, 12% (MacCormick & Evjen, 1945). The Navy and Marine but also introduced the concept of Bquality force^ Corps rehabilitated an additional 75% of 16,000 punitively (Seamone, 2011), or what today is oft referred to as the discharged offenders to honorable service (Chappell, 1945). zero-defect military. The quality force doctrine essentially For all of these men, their discharges had been Bwiped clean,^ ended the military justice system’s commitment to helping not only the military, but ultimately the families and problem-solving and restoration in favor of discharge. communities who depended on their future employability and Consequently, the latter years of the Vietnam War saw good name (MacCormick & Evjen, 1945). Per Seamone punitive discharges of veterans dramatically escalate for (2011): BIt is significant that, within this specialized correc- drug use and other misconduct stress behaviors (e.g., tional setting, trainees actually received more therapy time Camp, 2014).Today,onlytheAirForcemaintainsavia- than psychiatric battlefield casualties received during their re- ble legal restoration program (Seamone, 2011). habilitation period in mental hygiene units^ (p. 91). The importance of WWII lessons with judicial problem-solving is Death Penalty Sentences and Executions of Mentally that the military implemented these restorative-based princi- Ill Combatants ples when the country was at war at a time when maintaining good order and discipline were of utmost. Freedman and The military has long held the practice of executing soldiers Rockmore (1945) offered an example: for cowardice as an example to others, regardless if the basis of their refusal to fight was a paralysis caused by a severe conversion reaction or an intentional act of disobedience. In One soldier suffered shrapnel wounds and lost several of the Union Army, there were a total of 267 executions, among his Bclosest buddies^ in severe combat conditions in the 900 courts-martial convictions, with more than 50% of sol- North African Theater. He then lived in a state where, BI diers executed for any of the 200,000 estimated desertions and didn’t give a damn whether I lived or not.^ Following a unknown number of stress casualties; 25% for homicide; and series of unauthorized absences, alcohol-induced ram- 10% for rape or mutiny; and the rest for thievery or espionage pages, and an occasion when he pleaded for the military (Lande, 2003). During WWI (1917–1918), the American police to shoot him, the Army adopted a treatment- Army executed 35 soldiers for rape and/or murder of civilians based approach: BAfter a course of treatment this soldier (Drimmer, 1992) and an unknown number for cowardice. was returned to duty of a limited nature within the con- In addition, at least 3080 WWI British soldiers were sen- tinental limits of the United States.^ Accordingly, B[t]he tenced to death for cowardice, desertion, or malingering, with Army recognized [the relationship between his lack of 306 actual executions (Holden, 1998; Iacobelli, 2013). For treatment and his criminal behavior] and treated him as a instance, Holden (1998) reported that a WWI soldier diag- soldier-patient. The reward was that a combat- nosed with ‘shell shock’ was being court-martialed, and his experienced soldier continued to render effective service evaluating army physician retorted: BI went to the trial deter- where otherwise a stockade prisoner might have been mined to give him no help of any sort, for I detest this type, I the only result (Freedman & Rockmore, 1945;p.44). really hoped that he would be shot, as indeed anticipated by all of us^ (p. 84). Additionally, at least three of 23 executed Seamone (2011) identified two critical WWII legal lessons: Canadian soldiers had confirmed shell shock diagnosis (1) the use of therapeutic intervention and conditional sentenc- (Iacobelli, 2013). ing to address offenders’ underlying problems; and (2) the Throughout WWII, 40,000 U.S. soldiers were charged need to expand and adapt court-martial procedure when ad- with desertion (U.S. Army, 1975). Of these, 2864 were dressing offenders with combat trauma. tried by general courts-martial for desertion, resulting in 49 death sentences with all but one commuted (U.S. Legal Problem-Solving during the Vietnam War Army, 1975). In sum, a total of 102 U.S. soldiers were executed in WWII for rape and/or unprovoked murder of In 1951, the U.S. Air Force established the 3320th civilians (it is unknown how many suffered from war Corrections and Rehabilitation Squadron, emphasizing stress injury). In fact, the only U.S. service member exe- therapeutic environment over rigorous training. cuted solely for a military-related offense (desertion in the Throughout the early years of the Vietnam War, the face of the enemy) since the U.S. Civil War and the last 3320th and other service Discharge Remission Programs ever since, was 24-year-old U.S. Army Private Eddie D. played a central role in suspending punitive discharges of Slovik (U.S. Army, 1975). Private Slovik was diagnosed convicts with ‘combat fatigue/exhaustion’ in favor of by an Army division neuropsychiatrist with Bpsychoneu- comprehensive and individualized treatment (Seamone, roses^ (a precursor to PTSD) following an extended artil- 2011). However, 1973 marked not only the end of the lery bombardment during the Battle of the Bulge (Huie, 50 Psychol. Inj. and Law (2018) 11:37–68

Table 2 Principle US military offenses and punishment in 1945 Principal military All institutions Rehabilitation Disciplinary Federal institutions offense centers (SCRC) barracks (DB)

Number Percent Number Percent Number Percent Number Percent

Absent without 9435 48.0 6058 50.7 3180 44.8 197 33.0 leave 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 before 155 .8 31 .3 123 1.7 1 .2 the enemy Discreditable 2055 10.4 1117 9.3 912 12.8 26 4.4 conduct toward superior officer Misbehavior of 269 1.4 195 1.6 71 1.0 3 .5 sentinel Violation of arrest 1625 8.3 846 7.1 687 9.7 92 15.4 or confinement Committing 103.541.359.83.5 depredation or riot 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 principal military offense in 1945 (Berlien, 1966;p.515)

1954). Slovik had just arrived to his unit and after the the military justice system is at odds with more than bombardment proceeded to inform his Commander of VTCs; it is at odds with itself- in the way it undermines his intent to desert if not reassigned (U.S. Army, 1975). the stated sentencing philosophy of rehabilitation of the Private Slovik explained during his two-hour General offender, the way it erodes the professional ethic by Courts-Martial on 11 November 1944: denying core values, and the way it defies the moral obligation to advance the interests of both the veteran and the society he will rejoin (Seamone, 2011,p.3). They were shelling the town and we were told to dig in for the night. The following morning they were shelling In contrast to problem-solving courts like civilian VTC and us again. I was so scared, nerves and trembling, that at the military’s twentieth century diversionary treatment pro- the time the other replacements moved out, I couldn’t grams that target underlying mental health conditions related move (U.S. Army, 1975,p.193). to criminal conduct, the military justice system’s current approach is problem-generating when it results in punitive dis- However, Private Slovik’s psychiatric diagnosis did not charges that preclude mental health treatment and intensify constitute a legal defense of insanity and so he was convicted stigma. Unfortunately, the status of today’s military justice and sentenced to death. Slovik’s military attorney appealed to system harkens back to pre-WWI arguments against General Eisenhower who confirmed the execution order on 23 problem-solving programs: BThe Army is not a reformatory December 1944, noting that it was necessary to discourage for its own criminals or for criminals from civil life, and it further desertions (U.S. Army, 1975). On 31 January 1945; cannot be made one without doing great damage to the Private Slovik was tied to a post, blindfolded, and shot multi- service^ (Annual Report of the Adjutant General, 1910). ple times by his fellow unit members and died slowly—the last American soldier so executed since the U.S. Civil War, Strategy Three: Weaponizing Stigma to Humiliate, and the last known mentally injured service member put to Ridicule, and Shame into Submission death.

Learning Legal War Trauma Lessons The greatest weapon against the so-called "battle fatigue" is ridicule. If soldiers would realize that a large As it relates to offenders with war stress injuries: proportion of men allegedly suffering from battle fatigue Psychol. Inj. and Law (2018) 11:37–68 51

are really using an easy way out, they would be less which has indeed been the trend, resulting in accusations of sympathetic. Any man who says he has battle fatigue mass fraud (e.g., Russell & Figley, 2015b). is avoiding danger, and forcing on those who have more hardihood than himself the obligation of meeting it. If Recognizing the Need to Eliminate Mental Health soldiers would make fun of those who begin to show Stigma battle fatigue, they would prevent its spread, and also save the man who allows himself to malinger by this After wars end, the military customarily reflects on its psychi- means from an after-life of humiliation and regret atric lessons learned and invariably cites the need to eliminate (General George S. Patton Jr., 1947,p.340). the disparity, prejudice, and stigma associated with mental health difficulties. For example, the U.S. Army’s official les- Stigma is defined as a brand or stain. Researchers have sons learned from WWI called upon the military to end mental identified three sources of mental health stigma: (1) institu- health stigma and disparity: tional stigma caused by policies that either intentionally or unintentionally Brestricts opportunities and hinder the options of people with mental illness^ (Acosta et al., 2014; p. 9); (2) The greatest obstacle to neuropsychiatry in both civil public stigma reflecting negative attitudes and bias toward and military practice has been the barrier that tends to mental health from family and broader society; and (3) self- separate nervous and mental diseases from all other dis- stigma or the internalization of negative attitudes and beliefs eases, and it was thought by some that, in so far as the toward oneself (Acosta et al., 2014). Military Establishment was concerned, the greatest Psychiatrically disabled veterans without visible war good, both to the practice of neuropsychiatry and to wounds have regularly been branded coward, yellow, crazy, the patients who were dependent upon it, would be ac- lacking morale fiber,ordeserter by the military. The conse- complished if a determined effort were made to break quence and purpose was to ridicule, shame, or punish those through this barrier and to place the mental patient on a who might undermine military authority and illicit fear in par with patients incapacitated by reason of other dis- those who might contemplate following suite (e.g., Dean, eases (Bailey, 1929, pp. 42-43). 1997;Holden,1998). In addition, many debilitated veterans have been characterized as having inherently defective, weak Similar conclusions were reached by U.S. Army after or unmanly personalities (i.e., male hysteric, psycho, section WWII: 8, war hysteric, wussy, limp dick, personality disorder), as immoral frauds attempting to avoid combat (i.e., evacuation neurotic, slacker, malingerer), or as profiteers seeking disabil- If medical practice is ever to progress to the ideal of ity payment (i.e., goldbricker, pension neurotic, illness-seeker, psychosomatic medicine, it will require the reorientation dreg on society, leech; Dean, 1997); all of which sends an of medical training and of all practitioners so that equal intimidating signal to the rank and file. emphasis is placed upon the roles of the psyche and of According to Brigadier General Menninger, the U.S. the soma in all illness (Menninger, 1948,p.163), Army’s Chief Consultant of Neuropsychiatry during WWII: BThere was a tendency to stigmatize the neuropsychiatric pa- and repeated in 2004: tient as being a failure. When the case was not physical, then the individual was variously regarded as perverse, subversive, unwilling, weak, dumb. He was likely to be labeled as a Bquit- Reducing the perception of stigma and the barriers to ter,^ Ban eight-ball,^ Bgold brick,^ or any of numerous other care among military personnel is a priority for research vernaculars disparaging terms^ (Menninger, 1948,p.20). and a priority for the policymakers, clinicians, and A recent attempt to compare stigma in the military and leaders who are involved in providing care to those private sector led RAND investigators to conclude: BWithin who have served in the armed forces (Hoge et al., the military, stigma is largely conceptualized and assessed as a 2004,p.21), barrier to care^ thus making direct comparisons with the general population nearly impossible (Acosta et al., 2014,p.25). as well as 2007: It is important to recognize the effects of institutionalized stigma or ‘barriers to care’ not only deter individuals from seeking mental health treatment, but also from even disclosing symp- In the military, stigma represents a critical failure of the toms. Therefore, stigma-driven barriers to care in the military community that prevents service members and their will predictably result in far greater numbers of service mem- families from getting the help they need just when they bers diagnosed with war stress injury after military discharge, mayneeditmost.Everymilitaryleaderbears 52 Psychol. Inj. and Law (2018) 11:37–68

responsibility for addressing stigma; leaders who fail to I was allowed no more contact with the crew and had to do so reduce the effectiveness of the service members pack all my kit for immediate departure. No goodbyes or they lead (DoD Task Force, 2007,p.15). anything, and these men were like my family. Before leaving I was summoned before the CO for the severest In short, there is ample documentation of the military’s dressing down of my career when he left me in no doubt awareness to eliminate policies and practices that sustain of the seriousness of the affair: I had let the side down harmful levels of stigma that prevent service members from and turned my back in the face of the enemy, an action getting needed support. for which soldiers had been shot in the First World War, he said (Holden, 1998, p. 110). Weaponizing Stigma Enlisted aircrew members were often reassigned to ground The military’s episodic reflections on the need to eliminate the combat units, whereas officers were typically ordered to Not harmful effects of stigma is laudable; however, the record Yet Diagnosed Neuropsychiatric (NYDN) centers originally shows the military is generally more invested in maintaining established in 1916 to eliminate psychiatric attrition from and intensifying stigma to deal with its mental health problem. WWI-era shell shock (e.g., Shepard, 2001). Upon admission Figley and Nash (2007) described the evolution of weaponiz- to NYDN hospitals, the LMF branded personnel would en- ing combat stress as the intentional development of weapons, dure further ridicule and shaming by standing at attention in tactics, and war-fighting strategies aimed primarily to demor- from of unit members while their Flying Badges and rank alize, terrorize, and debilitate the enemy with stress casualties. markings were stripped from their uniforms (Jones, 2006). If In a similar vein, the military has purposefully weaponized personnel did not return to full duty after their Btreatment^ at stigma against internal threats posed by psychologically- NYDN centers, they would be given less than honorable dis- injured warriors. charges that significantly impacted future employment. Jones (2006) reported an annual rate of 160 to 240 LMF cases, Lacking Moral Fiber (LMF) and Waverer Disposal resulting in a total of 2726 British aircrew personnel, mostly Policy pilots, so classified. Near the end of WWII, the RAF eliminat- ed its LMF policy Bto avoid embarrassing the government^ Reported usage of the derogatory WWII term BLMF^ within (Jones, 2006, p. 454). However, it remained a stigmatizing the twenty-first century U.K. military is a direct testament of label through the 1960s and shows some persistence today. the durability of the military’s weaponization of stigma to In 2002, a group of British soldiers sued the Ministry of reduce the prevalence of war stress injury (e.g., Jones, Defense for inadequate mental healthcare. They also argued 2006). In 1940, the British Royal Air Force (RAF) adopted that the military had done little to change stigma. The High a formal policy to curb escalating psychiatric casualty rates Court Justice apparently agreed: BNo doubt there could have and disability pensions. They imposed severe penalties (e.g., been more rapid change. No doubt more could have been done immediate transfer and/or discharge) and public shaming of to address the persistent stigma attaching to psychiatric/ individuals branded LMF (akin to cowardice) by their com- psychological disorder, particularly in the ranks^ (Owen, manders. Often this was done in front of their peers who were 2003; cited in Jones, 2006, p. 455). However, Jones (2006) unable or unwilling to fly without a valid medical reason (e.g., added: BOthers have argued that a measure of stigma is needed Holden, 1998). Intended to be harsh and punitive toward mor- to prevent both conscious and unconscious resort to psycho- ally corrupt service members (e.g., LMF discharges are rough- logical disorders as an exit from situations of personal danger^ ly equivalent to OTH separations today), the main purpose of (pp. 455–456). the U.K.’s LMF policy was to intimidate the rest of the group to avoid being next. For example, after reviewing the histori- U.S. Military Policies and Weaponizing Stigma cal records from the U.K.’s LMF policy, Jones (2006)concluded: BThe calculated use of stigma gave the policy force^ Patton (1947) brazenly advocated for weaponizing stigma (p. 443), as evidenced by a statement from the RAF’s Air during WWII: BThe greatest weapon against the so-called Commodore Bthe dangers of too lenient treatment of failures, battle fatigue is ridicule (p. 340). His pronouncement could from whatever cause, owing to the possible undermining ef- easily be dismissed as unrepresentative of official military fect on other officers striving to maintain their morale^ (Jones, policy. However, when the highest ranking military com- 2006,p.444). mander espouses similar biases toward the mental health of For instance, an RAF pilot who was labeled LMF after soldiers, there is a making of a trend. For instance, the U.S. experiencing transient paralysis and mutism after his 20th Army’s WWII Chief of Staff, General George C. Marshall, combat mission, described the reaction of his commander: (1943) explained: Psychol. Inj. and Law (2018) 11:37–68 53

To the specialists, the psychoneurotic is a hospital pa- WWI tient. To the average line officer, he is a malingerer. Actually, he is a man who is either unwilling, unable, Persuasion Here the medical officer, having assured himself or slow to adjust himself to some or all phases of mili- that the condition is functional, persuades the patient to make tary life, and in consequence, he develops an imaginary the effort necessary to overcome the disability. In order to do ailment which in time becomes so fixed in his mind as to this, he uses his authority as an officer, he brings into play all bring about mental pain and sickness^ (cited in the moral suasion he can, appealing to the patient’ssocialself- Menninger, 1966,p.132). esteem to make him co-operate and put forth a real effort of will. If moral suasion fails, then recourse may be had to more The stigma exacerbating attitudes of many of the military’s forcible methods, and according to certain witnesses even top leaders formally became institutionalized. threats were justified in certain cases (Report of the war office committee of enquiry into ‘shell-shock,’ 1928, p. 128).

Frontline Psychiatry WWII Reducing exorbitant manpower attrition and costs Exhortation Exhortation ranges from an appeal to the soldier caused by evacuations of psychiatric casualties during concerning the necessity of aiding his comrades on the line to WWIledtothemilitary’s 100-year-old frontline psychi- a form of plain talk in which he is asked whether he has atry or combat and operational stress control (COSC) actually gone so far as to abandon them. The latter measure doctrine to be permanently institutionalized after WWII should be used sparingly and judiciously, for it may exacer- (see Russell & Figley, 2017a, and section below on bate an anxiety state. When these methods are used about 50% Treatment). In a nutshell, the military has designed a of all men presenting with anxiety were returned to duty with- policy that provides an echelon of brief restorative in- in1to6h(Sobel,1949b,p.40). terventions for military emotional distress and strictly Words with which the soldier was familiar and whose prohibits psychiatric treatment and evacuation with the meaning he understood proved more effective. The impor- explicit expectation that upwards to 95% of stress casu- tance of the war and the consequences of defeat to them and alties will be returned-to-duty (RTD; Russell & Figley, their families were stressed, and appeals were made to their 2017a). sense of duty, pride, and loyalty to comrades, unit, and country The military’s justification of its RTD policy is multi- (Ludwig, 1949,p.95). faceted, but includes the prevention of harmful stigma in that: BEvacuees had to deal with the stigma and shame of evacuation out of the theater. However, if psychological Vietnam War casualties were treated at forward locations with brief supportive therapy and the expectation of return to duty, be- Reinforcement is given to the soldier’s softly heard voice of tween 60% and 80% were able to continue as soldiers^ conscience, which urges him to stay with his buddies, not to (Cardona & Ritchie, 2007, p. 12). A recent review seri- be a coward, and to fulfill his soldierly duty. Encouragement is ously undermines the military’s claim of stigma-reducing given to patriotic motivation, pride in the self and the unit, and benefits (Russell & Figley, 2017b), but more importantly to all aspects of one’s determination to go through with one’s to our current purpose, is how does the military system- commitment (Shaw, 1987,p.131). atically employ stigma to achieve its goals? Not only the physician, but all treatment personnel should In short, the military’s weaponization of stigma to reduce immediately take the attitude that the patient will be returned psychiatric attrition is central to its frontline doctrine and the to duty. The patient is quite suggestible if he is treated early, bedrock principle of ‘expectancy,’ whereby medical and men- and the desire to return to his group is reinforced. The ap- tal health practitioners are instructed to persuade the soldier- proach tends to minimize the patient’s symptoms in his own patient of certain Brealities^ of their situation, including the eyes. It should be pointed out that in a combat situation every transient, normal nature of their fear reactions and the certain- soldier is needed immediately if he can function. Not only is ty of their recovery and RTD after a brief respite period. he needed for the group to function, but in the long run it is Arguments are made as to why the soldier must be RTD to better for both the patient and the group that he return to duty. avoid the highly stigmatizing moral, personal, and social con- This is based on the sound assumption that the successful sequences. The samples below illustrate the military’sconsis- performance of duty is more therapeutic than escape from tency in utilizing mental health stigma to persuade personnel danger with its concomitant chronic guilt reaction and the away from becoming labeled as cowardly, weak, dishonor- necessity of maintaining symptoms indefinitely in order to able, or immoral: assuage the guilt (Johnson, 1969, pp. 307–308). 54 Psychol. Inj. and Law (2018) 11:37–68

Gulf Wars 1992). However, by the end of 1942, 255 new cases of emotionally disturbed aircrew were identified, including 166 pilots Reassure At every echelon, give immediate, explicit reassur- (e.g., Wells, 1992). ance to the soldier. Explain to him that he has BF (battle From mid-1943 through the end of the war, some 2102 fatigue) and this is a temporary condition which will improve American airmen became psychiatric casualties, resulting quickly. Actively reassure everyone that it is neither coward- in the widespread use of the infinitely more stigmatizing ice nor sickness but rather a normal reaction to terribly severe terms LMF and ‘lack of intestinal fortitude’ within the conditions. Provide these soldiers with the expectation that U.S. military (Wells, 1992). In all, about 1230 American they will be RTD after a short period of rest and physical pilots and aircrew were branded as LMF. Dispositions replenishment and involve them in useful activities, as appro- varied from temporary reassignment, psychiatric treat- priate (U.S. Army, 1998,p.1–13). ment, and courts-martial. For example, a battle-tested, but then over-stressed American pilot in the 95th Bomb Expectancy The individual is explicitly told that he is reacting Wing was sentenced to be confined at hard labor and normally to extreme stress and is expected to recover and given a less than honorable discharge after being return to full duty in a few hours or days. A military leader convicted for ‘misbehaving before the enemy’ when he is extremely effective in this area of treatment. Of all the things refused to fly, and an enlisted crewmember received said to a Soldier suffering from COSR the words of his small- 2 years hard labor and a dishonorable discharge for unit leader have the greatest impact due to the positive bond- disobeying an order to fly soon after his unit sustained ing process that occurs. A simple statement from the small- heavy casualties (Wells, 1992). The legal case below pro- unit leader to the Soldier that he is reacting normally to COSR vides a telling example of the U.S. military’s weaponiza- and is expected back soon have positive impact. Small-unit tion of stigma and the silencing effect such punishments leaders should tell Soldiers that their comrades need and ex- would expectedly have on military members as a whole pect them to return (DoA, 2006,p.1–8). who may experience war stress injury:

American LMF Policy Second Lieutenant, 412 Bombardment Squadron. This Similar to WWI, the U.S. military in WWII quickly adopted 29-year-old navigator had 5 combat missions. He was policies of European allies to deal with its mental health prob- performing satisfactorily until he was wounded in the lem. Per U.S. Army (1918) Circular No. 24: right arm when his plane was badly damaging on the 5th mission. He was hospitalized for three weeks, developed tension symptoms, was unable to perform his It would seem then that we should profit as far as we can duties on subsequent practice missions and asked to be from the experience of the French in this matter. Check grounded. He was found to be tense, depressed, and to the development of neurosis by denying its existence at show evidence of weight loss. He had an excellent re- the start. The treatment of the patients should be calm- cord, went to college for two years, held good jobs, was ative and restorative and any appearance of such symp- well motivated towards flying and did well as a naviga- toms as tremors, paralysis, etc., should be rigidly dis- tor. The Central Medical Board qualified him in October couraged. This idea should run through the whole per- 1943 because it was not felt that he was suffering from sonnel of the hospital. At first it should be effected by Boperational exhaustion.^ He was recommended for an gentle persuasion, but if the patients persist in the pro- other than honorable discharge by the Reclassification duction of hysterical symptoms sterner measures should Board (U.S. Army Air Force, 1944,p.339). be resorted to (p. 297). After the war, U.S. Army Eighth Air Force Commanding For instance, within 8 months after the U.S. Eighth Army General boasted that only 1230 airmen were permanently re- Air Forces arrived in England and began bombing operations moved from flying due to psychiatric reasons (Wells, 1992), over Germany, 35 LMF cases were identified as ‘psycholog- prompting an American historian to quip: BEven more signif- ical failure’ (Wells, 1992).TheEighthArmyAirForce icant, despite an overall casualty rate approaching 50%, much Commander proposed a less-pejorative label less than 1% of flyers were grounded for alleged cowardice^ BTemperamental Unsuitability^ that was officially adopted (Wells, 1992, p. 306). From the military’s perspective, a suc- as U.S. Army Air Force policy in 1942 (U.S. Army Air cessful mental health policy has always been measured in Force, 1942). The initial U.S. policy emphasized treatment terms of preserving manpower numbers, not improving the and rehabilitation, eventually changing the label to an even mental health and well-being of war stressed combatants less stigmatizing term: ‘Primary Flying Fatigue’ (Wells, (Russell & Figley, 2017c). Psychol. Inj. and Law (2018) 11:37–68 55

Evidence of Twenty-First Century Weaponization needed and at the earliest possible time (DoD Task of Stigma Force, 2007, pp. 4-5).

In today’s military, there are no overt policies employing stig- Per Table 3, the military reports an encouraging trend ma to manage the mental health problem. In fact, current DoD whereby levels of perceived stigma and barriers appear to be directives espouse considerable anti-stigma rhetoric. gradually declining. For example, in 2013 ‘only’ 40% instead However, one must look at what the military is actually doing of 50% of deployed soldiers screening positive for PTSD said in regards to eliminating stigma and existing policies that re- they would not seek mental healthcare because it would harm inforce stigma and organizational barriers to seeking care that their career. Since the DoD’s 2007 public pronouncement of contradict the military’s public anti-stigma goals. We further giving up its weaponization of stigma, dozens of commis- assert the military’s weaponization of stigma is evident in its sioned studies, DoD task forces, and government oversight proclivity to prosecute, incarcerate, and execute emotionally investigations have been conducted, often with overlapping injured war veterans. This also includes, bad paper discharges findings and corrective actions for the military to achieve its that have significantly increased since the Vietnam War. All stated goal to eliminate stigma (see Russell, Butkus, & Figley, the stigma-enabling efforts send clear and powerful signals 2016b). throughout the military of the potential dire repercussions for individuals with war stress injuries and their families. Assessing the Military’s Commitment to Disarm and Eliminate Stigma Assessing the military’strueintenttohonoritspledge to unilaterally give-up its highly effective weapon for Current Levels of Stigma and Organizational Barriers to Care retaining control over the mental health problem requires adherence to the ‘trust, but verify’ dictum. To that end, in 2012 In 2004, U.S. Army researchers found 73% of soldiers the IOM reached the following conclusion about leadership returning from Iraq who screened positive for a mental health commitment to actually eliminate stigma and organizationally condition like PTSD reported not seeking mental health treat- induced barriers: ment (Hoge et al., 2004). The landmark study seemingly in- dicated the effectiveness of the military’s stigmatizing policies that prohibit many from seeking needed mental health treat- In DoD and each service branch, leaders at all levels of ment or ‘barriers to care.’ Harmful organizational barriers the chain of command are not consistently held account- from oppressive stigma levels are felt not only by returning able for implementing policies and programs to manage war veterans, but also by their spouses. For instance, 22% of PTSD effectively, including those aimed at reducing spouses and 77% of their active-duty partners reported they stigma and overcoming barriers to accessing care. In would not seek mental health care for fear of being seen as each service branch, there is no overarching authority weak, and 21% of spouses and 56.2% of their soldier partners to establish and enforce policies for the entire spectrum cited concerns about harm to the active-duty member’scareer of PTSD management activities (p. 6). (Hoge, Castro, & Eaton, 2006). In 2007, the DoD committed to reverse these harmful Most striking, 9 years after the DoD committed to its laudable trends: goal, the GAO (2016)reported:

Building resilient forces and families while reducing DOD is not well positioned to measure the progress of stigma are objectives closely tied with our first objective its mental health care stigma reduction efforts for several related to leadership and culture. Our system of psycho- reasons. First, DOD has not clearly defined the barriers logical health leadership will help us to accomplish this to care it generally understands as Bmental health care goal by bringing together under one leadership function stigma^ and does not have related goals or performance all the related services to plan and carry out a program measures to track progress. Second, GAO’sreview tailored to the needs of the Active and Reserve compo- found that multiple DOD- and service-sponsored sur- nents. Anti-stigma campaign. Therefore, our Center of veys that contain questions to gauge stigma use incon- Excellence will work with the Military Departments to sistent methods, which precludes the analysis of trends develop and execute an anti-stigma campaign, using over time in order to determine effectiveness of stigma some of the best and brightest minds in the Military, reduction efforts (p. i). Federal family, and civilian professional community to ensure the right tools are created and used to reduce Moreover, both the GAO (2016) and an independent stigma associated with seeking mental health care when RAND study by Acosta et al. (2014) reported 203 specific 56 Psychol. Inj. and Law (2018) 11:37–68

Table 3 Military studies on stigma and organizational barriers Survey question 2004 Army 2013 Army 2013 Army to care (Russell & Figley, 2017b) (Hoge et al., 2004) (J-MHAT, 2013) (J-MHAT, 2013) Screened positive Screened positive for a Not screened positive for for MH disorder- MH disorder- MH disorder-Afghanistan Afghanistan Iraq

I would be seen as weak 65% 47% 23% It would harm my career 50% 40% 17% My unit leadership might treat 63% 39% 22% me differently My leaders would blame me 51% 36% 14% for the problem There would be difficulty 55% 46% 17% getting time off work for treatment

DOD policies serving as organizational barriers to seeking problems arise. Sound ideal? Not from the military’s mental healthcare by promoting stigma, such as: Ban Army perspective. Instead, it worries that a slow trickle of policy requires verification that a soldier has no record of deployed personnel leaving the frontlines would become emotional or mental instability to be eligible for recruiting a torrid evacuation syndrome caused by mass hysteria duty^ (GAO, 2016, p. i). The fact is, despite all the politically and liberal psychiatric evacuation policies. Who is going correct pronouncements and incremental changes, military to pay for treatment? Who will be left to fight? How leadership appears uninterested in divesting itself from a strat- will the morale and will of those remaining on the egy as effective as stigma; therefore: BNo single entity is co- frontlines be impacted? Eventually, even the hardiest ordinating department-wide efforts to reduce stigma^ (GAO, andgung-howouldstarttoquestionwhetherits’ worth 2016, p. i). Consequently, the likelihood that stigma and its staying and dying for when they see their friends leave organizational obstructions will be significantly reduced by the battlefield, possibly with a Purple Heart and disabil- the military in the foreseeable future is remote: ity pension, given the modern-day trend of psychiatric casualties far outpacing the total of combatants WIA and KIA (see Russell & Figley, 2017a). Warrior Without a clear definition for Bmental healthcare Transition Units back home are swelled beyond capacity stigma^ with goals and measures, along with a coordi- with divisions of temporary disabled personnel, and nating entity to oversee program and policy efforts and skyrocketing pension costs strain the financial stability data collection and analysis, DOD does not have assur- of the country. This scenario is the military’s greatest of ance that its efforts are effective and that resources are fear. most efficiently allocated (GAO, 2016,p.i). Stigma Exists in Mainstream Culture

Why Has Military Mental Health Stigma Persisted? The recurring explanation or excuse used by the military for persisting stigma is that such antiquated and prejudicial beliefs Short answer is because stigma helps the all-volunteer exist in mainstream culture (e.g., Acosta et al., 2014). The military sustain a high level of readiness by protecting truism is rarely challenged. However, the logical implication the fighting force from exorbitant costs associated with is that American society is responsible for taking the lead in psychiatric attrition and treatment. Imagine a future time changing cultural bias against mental illness considers itself. when military personnel feel completely unencumbered However, the military has a long, storied tradition of assertive- to disclose posttraumatic stress (PTSD) during and after ly working to eradicate undesirable and dysfunctional cultural deployments without any career repercussions. Instead belief systems. For instance, there is a ‘zero tolerance’ policy of shame, ridicule, and rejection, military leaders and in the military for drug use, racial discrimination, sexism, and healthcare personnel openly encourage and positively sexual harassment (e.g., DoD, 2009). Per DoD’s(2009)direc- reinforce health-seeking behaviors. In this utopia, mental tive on diversity and civil right protection, it is DoD policy health and physical health are truly viewed as indispens- that: BPrograms or activities conducted by, or that receive able sides of the same coin. Absolute parity is the norm financial assistance from, the Department of Defense shall with equal resources, priority, and practice when not unlawfully discriminate against individuals on the basis Psychol. Inj. and Law (2018) 11:37–68 57 of race, color, national origin, sex, religion, age, or disability^ of exposure to war stress as causing a legitimate spectrum of (p. 2). stress-injury; and (d) denying organizational responsibility to Not so for mental health stigma and discrimination; meet mental health needs. annually, the military strictly monitors compliance with its equal opportunity policies, and commanders are often held accountable for non-adherence (DoD, 2009). In ad- Denial that War Inevitably Causes Large Numbers dition, random drug testing and regular physical fitness of Psychiatric Casualties testing reflect the military’s commitment to alter unpro- ductive cultural habits. What can be argued, and we have Kay (1912) analyzed the impact of industrialized war shown, is that the military is not committed to changing from 1886 to 1908 for the British Army, finding signif- the culture around stigma and mental health. icant associations between increased rates of war stress injury and duration of exposure: Bthe amount of the increase is proportional to the duration of campaign^ Strategy Four: Denying the Psychiatric Reality (Kay, 1912, p. 153) and intensity of combat: BThe con- of War ditions of modern warfare calling large numbers of men into action, the tremendous endurance, physical and Denial is defined as the Brefusal to admit the truth or reality^ mental required, and the widely destructive effect of (Merriam-Webster retrieved at: www.merriam-webster.com/ modern artillery fire,^ forewarning military leaders dictionary/denial). In a psychiatric sense, Sigmund Freud about the future toxic effects of twentieth century war: (1924) described denial or Verleugnung as a primitive, uncon- Bwe shall have to deal with a larger percentage of scious defense mechanism instinctively employed by children mental disease the hitherto^ (CitedinJones& and psychotics to protect the ego from internal and external Wessely, 2005,p.13).Kay’s(1912) prophetic warning threats. For Freud (1924), denial is used when an individual is routinely ignored by war planners intent on denying rejects a reality that is too uncomfortable to accept; insisting it the psychological realities of modern warfare: Bonly a is untrue despite overwhelming evidence to the contrary. small percentage succumbs and takes flight into Commonly, people and their organizations can utilize simple sickness^ (Gaupp, 1911; cited in Lerner, 2003,p.40) denial, such as denying the reality of an unpleasant fact - only to be re-learned by harsh realities: altogether, or engage in minimization which is to admit the The war has taught us and will continue to teach us (1) that fact, but deny its seriousness. In either case, Anna Freud just as before there are traumatic neuroses; (2) that they are (1936) considered denial as a mechanism of the immature not always covered by the concept of hysteria; and (3) that mind because its short-term benefit ultimately results in they are really the product of trauma and not goal-oriented, long-term failure by prohibiting the ability to effectively learn well cultivated pseudo illness (Oppenheim, 1915; cited in from and thus adapt to reality. Lerner, 2003,p.67). The psychological realities of modern industrialized war- Military Use of Denial to Cope with Its Mental Health fare that Oppenheim (1915) and Appel and Beebe (1946) Problem aptly summarized for their respective cohorts were clearly evident long before WWI:

Each moment of combat imposes a strain so great that There is a strong suspicion that the high insanity rate in men will break down in direct relation to the intensity the Spanish-American War and the Boer War, and per- and duration of their exposure. Thus, psychiatric casu- haps in earlier conflicts, was due, in part at least, to alties are as inevitable as gunshot and shrapnel wounds failure to recognize the real nature of the severe neuro- in warfare (Appel & Beebe, 1946-U.S. Army, p. 185). ses, which are grouped under the term "shell shock" in this war (Salmon, 1917,p.14). Historically, the military reflexively employed denial as a primitive, yet central tactic in initially dealing with its mental And tragically repeated after WWII: health dilemma. The military’s denial of the psychological realities of war manifests in essentially four critical interrelated ways: (a) denying the inevitability of large numbers of Undoubtedly, the most important lesson learned by psy- psychiatric casualties from modern warfare; (b) denying the chiatry in World War II was the failure of responsible inherent need to adequately plan and prepare to meet wartime military authorities, during mobilization and early mental health needs; (c) denying the primary etiological role phases of hostilities, to appreciate the inevitability of 58 Psychol. Inj. and Law (2018) 11:37–68

large-scale psychiatric disorders under conditions of repeated post-hoc admission of abject failure to properly plan modern warfare (Glass, 1966a,p.736). and prepare for the predictable psychological outcomes of war. A certain degree of latitude can be given to WWI-era leaders However, as Jones and Wessely (2007)asserted,priorto who failed to heed prior lessons of war trauma because the the twentieth century: BThe idea that a soldier of previously sheer magnitude of WWI psychiatric casualties was unprece- sound mind could be so emotionally disturbed by combat dented in human history. However, the documentation and dis- that he could no longer function was not entertained; that semination of those psychiatric realities began in earnest after he might suffer long-term psychological consequences of WWI, thus discrediting any future excuses: BFurther, and most battle was also dismissed^ (p.165).Yet,psychiatricreali- important, there was the documented history of World War I, as ties could no longer be rationally denied by credible author- well as accounts from other previous wars, which provided ities: BToday the enormous number of these cases among abundant evidence that combat would produce large numbers some of Europe's best fighting men is leading to a revision of psychiatric casualties^ (Glass, 1966a,p.17). of the medical and popular attitude toward functional ner- Similarly, denial is evident in the following: BDespite the vous diseases^ (Salmon, 1917, p. 65). foregoing data that were available to responsible authorities, there was no effective plan or real preparation for the utilization Evidence of Military Denial in the Twenty-First Century of psychiatry by the Army in World War II. Facilities for the care and treatment of psychiatric cases were only barely suffi- There is no other suitable term than denial to explain the U.S. cient for the small PEACETIME Army^ (Glass, 1966a,p.18). military’s inability or unwillingness to appreciate the size and Also, Glass noted that: scope of wartime mental health needs. Efforts to minimize reality: BOf the 10 percent or so who have PTSD, most will recover with time, patience and love. Some will need more^ Defects in Preparation and Planning. As has been indi- (Casscells, 2008, p. 2; Assistant Secretary of Defense Health cated already, psychiatric disorders proved to be a major Affairs). Efforts to distort or even break from reality: as war source of manpower loss to the U.S. Army in World War architects prepared for the 2003 invasion of Iraq, the Army’s II. At the beginning of the war, a potential loss of this senior psychiatrist Brigadier General recalled: Bwe were not magnitude was neither expected nor planned for by mil- allowed to talk of the unseen wounds of war-we were not itary authorities in general or the Medical Department in allowed to prepare for the unseen wounds^ (Sutton, 2017). particular. It was not until February 1942 that a psychia- Observations subsequently validated by the DoD Task Force trist was assigned to the Surgeon General’sOffice(Glass, (2007)noted:BDespite the dedicated work of its members, the 1966a,p.18). current system is not structured to address these new challenges, leaving many psychological health needs unmet. Perhaps the best illustration of the US Military’sfailureto Without a fundamental realignment of services, this situation not repeat the errors of the past lies in the massive, two-volume will worsen^ (p. 6). report by the U.S. Army Surgeon General. It took 21 years to Evidence of how deeply entrenched the military’s use of write this 2038 page report about lessons learned from WW II. denial is regarding fulfilling its promise to care for large num- The report was data driven and focused on lessons from every bers of psychiatric casualties is demonstrated by its persistence. aspect of meeting wartime mental health needs (planning, For example, the independently commissioned IOM (2014) staffing, training, treatment, prevention, organization, reintegra- concluded after 13 years of war: tion, stigma, etc.). The purpose of these lessons learned was for the explicit purpose of advising future leaders so they could no longer deny the realities 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-based With this information so readily available, there can be approach for the disorder by either the Office of the little excuse for repetition of error in future wars, should Assistant Secretary of Defense for Health Affairs or they occur^ (Heaton (1966) U.S. Army Surgeon any of the service branches (p. 5). General, cited in Glass & Bernucci, 1966,p.xiv).

Certainly no one expected the pattern of denial, crisis, and Denial of the Need to Adequately Plan and Prepare re-learning to continue after WWII. However, after the last major American war of the twentieth century (Persian Gulf Perhaps the most visible demonstration of the military’spro- War), similar denial seemed evident about mental health pensity to deny the factual realities of war stress injury is its difficulties: Psychol. Inj. and Law (2018) 11:37–68 59

They (mental health) were not adequately staffed, also routinely denies the primary cause of war stress in- equipped or trained in peace-time to perform their war- jury—exceeding exposure levels to toxic war stress: BIt time role. The world is a dangerous place and the Army should always be remembered that modern war produces must be prepared today for tomorrow’s conflict. As two unique types of casualties in large numbers; namely, highlighted here, lessons learned in SWA (Southwest injuries and psychiatric disorders, both of which are Asia) provide a reference point from which to prepare caused by traumatic forces set forth by a changing and for this inevitability (Martin, 1992, pp. 40-44). hostile environment^ (Glass, 1966a, b, p. 739), as well as: BWhen finally, psychiatric casualties were regarded as legitimate consequence of battle stress and strain, it Perpetuating Military Denial in the Twenty-First became possible to prepare adequately for their preven- Century tion and treatment^ (Glass, 1966a,p.22). These historical anecdotes have robust empirical support. On 16 June 2007, a congressionally mandated DoD Task For example, the IOM (2008)reportedthat Force on Mental Health publicly unveiled its greatly delayed findings depicting an urgent mental health crisis that military Activation of the stress response ensures survival in the leaders unwaveringly denied as late as May 2007 (e.g., short term, but is maladaptive when its activation per- Kilpatrick, 2007;Zoroya,2007): sists as a result of chronic, severe, or repeated stress. Chronic stress can lead to adverse health outcomes that affect multiple body systems such as the CNS (central The Task Force arrived at a single finding underpinning nervous system) and the endocrine, immune, gastroin- all others: The Military Health System lacks the fiscal testinal, and cardiovascular systems (p. 59). resources and the fully-trained personnel to fulfill its mission to support psychological health in And that: PEACETIME or fulfill the enhanced requirements imposed during times of conflict (DoD Task Force, 2007, p. ES.2).^ In the brain, there is evidence of structural and functional changes resulting directly from chronic or severe The time for action is now. The human and financial stress. The changes are associated with alterations of costs of un-addressed problems will rise dramatically the most profound functions of the brain: memory and over time. Our nation learned this lesson, at a tragic cost, decision-making. They are also associated with symp- in the years following the Vietnam War. Fully investing toms of fear and anxiety, and they might sensitize the in prevention, early intervention, and effective treatment brain to substances of abuse and increase the risk of are responsibilities incumbent upon us as we endeavor substance-use disorders (p. 62). to fulfill our obligation to our military service members (DoD Task Force, 2007,p.63). In contrast, etiologic responsibility often is routinely assigned by the military to individual inherent weakness and predispo- Six years into the Afghanistan and Iraq wars, the DoD sitions along with immoral pursuit of secondary gains (e.g., revealed its repeated failure to adequately plan and pre- evacuation from combat zones, receiving disability pension, pare, with 99 corrective actions covering every fundamen- (Department of Navy and U.S. Marine Corps, 2010;Glass, tal lesson of war trauma (e.g., staffing, training, treatment, 1966a) For instance, the U.S. Army’s top neuropsychiatrist in prevention, stigma, reintegration, family support, etc.). It WWII reported the general sentiment toward war stressed sol- then pleaded for urgent action for neglected soldiers (DoD diers was that: BTothelineofficer,hewasamalinger^ TF, 2007), and amid the military’s escalating rates of (Menninger, 1966; p. 132). Additionally, the U.S. Army’scur- PTSD, suicide, TBI, substance abuse, misconduct stress rent Textbook on War Psychiatry explains that PTSD is behaviors, legal prosecutions, caregiver distress, etc. caused: (Russell et al., 2016).

Denial that War Produces a Spectrum of Legitimate in those with social and biological predispositions in War Stress Injury whom the stressor is meaningful when social supports are inadequate. Other mechanisms such as positive re- In addition to grossly underestimating the inevitable high inforcement (secondary gain in Freud’s model) seem volume of war stress casualties and forsaking proper plan- more important in the chronic maintenance of symp- ning to meet wartime mental health needs, the military toms (Jones, 1995, pp. 416-417), 60 Psychol. Inj. and Law (2018) 11:37–68

However, in a period of honest reflection after WWII, the perception of what is right; and (d) acting in a regressive or U.S. Army admitted to reliance on denial in managing its childish way (e.g., whining, temper tantrum). mental health dilemma: Evidence of Blaming and Shifting Culpability

It was known that psychiatric disorders did occur in war- Historically, the military has frequently exercised the fare, for the World War I experience showed some strategy of shifting blame for war stress injury to every 160,000 admissions for neuropsychiatric conditions in factor other than war itself. This approach is consistent the Army. At the beginning of World War II, however, with the military’s denial of psychiatric realities of war. most military authorities and many psychiatrists, includ- But the blame-shifting strategy includes but is not lim- ing civilian consultants to the armed services, believed ited to blaming: (a) individual predisposed weakness that psychiatric disorders did not occur to a significant and amoral pension-seeking; (b) disability compensation extent in Bnormal^ persons, but arose primarily in the and pensions, or Bpension-seeking neurosis;^ (c) corro- minority populations who were Bweaklings^ or who sive influence of psychiatry and mental health providers had underlying emotional instability that predisposed in general (e.g.., Shepard, 2001); (d) weakening influ- them to psychiatric illness (Glass, 1966a;p.387). ence of modern ‘culture of trauma and victimhood’ (e.g., Shepard, 2001); (e) politically motivated anti-war And in even more clear terms: advocates and psychiatrists (Shepard, 2001); (f) overly lenient and ineffectual unit leaders; (g) inadequate mili- Second, and again in retrospect, reliance upon psychiat- tary training and discipline; (h) sensationalized media ric screening can be understood as a logical extension of coverage; (i) insufficient congressional support; and (j) the denial or the failure to appreciate the magnitude of shifting responsibility for treatment to the VA. the psychiatric problem in war (Glass, 1966a;p.743). For example, the U.S. military’s policy of deferring responsibility for definitive mental healthcare to the VA or private Importantly, if the military truly has learned that war pro- sector is well-documented (e.g., Brill, 1966b). In this regard, duces a legitimate spectrum of war stress injury, we should upon learning of the WWII crisis characterized by mass un- expect it would behave accordingly. There would be evidence treated psychiatric casualties discharged by the military, of adequate planning, staffing, and treatment similar to caring President Franklin D. Roosevelt authored a December 4, for predictable physical wounds. Military clinicians and re- 1944 directive to the Secretary of War clarifying the military’s searchers would regularly screen and track the full spectrum responsibility it had stridently attempted to avoid (cited in of war stress injury, and not only a handful of conditions as it Brill, 1966b, pp. 291–292): currently does (e.g., Russell & Figley, 2015a). Akin to medicine, there would be no toleration for stigma and barriers to care and certainly no evidence of weaponizing stigma to re- My dear Mr. Secretary: duce help-seeking. Further evidence of denial is clearly dem- I am deeply concerned over the physical and emotional onstrated in the military’s efforts to eliminate war stress injury condition of disabled men returning from the war. I feel, by purging its mental health programs from the military as as I know you do, that the ultimate ought to be done for well as purging any conceivable type of psychological weak- them to return them as useful citizens-useful not only to ness from joining the military (see section on Purging themselves but to the community. Weakness). In other words, there is overwhelming evidence I wish you would issue instructions to the effect that it the military has avoided learning its lesson that war stress should be the responsibility of the military authorities to injury is a legitimate and predictable outcome from war. insure that no overseas casualty is discharged from the armed forces until he has received the maximum bene- Denial of Organizational Responsibility fits of hospitalization and convalescent facilities which must include physical and psychological rehabilitation, Individuals or organizations using the stratagem of denial of vocational guidance, prevocational training, and responsibility are usually attempting to avoid potential harm resocialization. or pain by shifting attention away from themselves (Ogden & Biebers, 2011). This type of denial involves avoiding personal The then Commander-in-Chief’s order reflected a 180 de- responsibility by: (a) blaming or shifting culpability; (b) grees reversal of the military’s policy and practice of essen- attempting to minimize the effects or results of an action ap- tially no treatment and discharge to Bmaximum benefit^ of pear to be less harmful than in actuality; (c) justifying actions mental health treatment and retention before separation by attempting to make that choice look proper because of their (Brill, 1966b; Menninger, 1948). However, toward the end Psychol. Inj. and Law (2018) 11:37–68 61 of WWI, the U.S. military was also assigned responsibility for psychiatry for positive screenings of a high-risk health prob- treatment of its psychiatric casualties prior to discharge: lem like PTSD. However, the GAO (2006) found that the military failed to refer 78% of returning OEF/OIF veterans who were at highest risk for PTSD (endorsing three to four As the war proceeded it was considered desirable to out of four symptoms) to a mental health specialist in compli- require that all mental cases be treated for a reasonable ance with the purpose of its screening policy. Keeping in mind period in the military hospitals. Directions recommend- the mental health referral would evaluate if someone actually ed in June, 1918, sent out November 20, 1918, provided had PTSD and warranted treatment. that all except cases which were evidently incurable When confronted, the military’s response to the GAO should be treated in the military hospitals for a period (2006) consisted of denying responsibility for the need to refer of at least four months, unless recovery took place soon- high risk patients to a specialist, including: er (Salmon & Fenton, 1929,p.147).

In the twenty-first century, President Obama’s Executive Potential risks associated with false positives. No med- Order (2012) echoes his predecessor’s effort to compel ical intervention is without risks. The general premise of the military to accept its responsibility for caring of medical practice is that the benefits should outweigh the mentally ill combatants: risks. In terms of PTSD, the risks are associated with potentially issuing a diagnosis of PTSD for an individ- Our efforts also must focus on both outreach to veterans ual who has no diagnosable mental health disorder (p. and their families and the provision of high quality men- 31). tal health treatment to those in need. Coordination between the Departments of Veterans Affairs and Defense In other words, the military prefers a non-physician or gener- during service members' transition to civilian life is es- alist assess a high-risk condition like PTSD versus its mental sential to achieving these goals. health specialists, a seemingly backwards medical practice. Furthermore, the military attempts to covers its bases by offering: Attempts to Minimize Harmful Effects

By far, the best example of this stratagem of minimizing harm- In making a clinical determination associated with a ful effects is the military’s frontline psychiatry or combat op- mental health referral, the risks of false positive must erational stress control policy. This century-old policy pro- always be weighed against the accuracy of clinical motes the military’s claim of the long-term health benefits to judgement. Watchful waiting may be more appropriate deployed personnel and their families of repeatedly returning in situations in which the clinician is not sure about a traumatized soldiers back to combat units. They are to remain diagnosis or the severity of symptoms (p. 31). in proximity to the war theater for treatment until they are either severely incapacitated (e.g., psychotic) or present immi- That is, the PDHA screener may never see the service nent danger to self or others (see Inadequate, Experimental, member again, but is encouraged to wait versus refer to a and Harmful Treatment). specialist. Therefore, it is entirely up to service members to re-engage the medical system when their symptoms worsen, Irrational Justification of Actions they are in crisis, or they attempt suicide. This type of reac- tionary policy contradicts the entire reason for conducting A perfect illustration of this avoidance stratagem is when the proactive screenings in the first place, a tragic example of military was confronted by the GAO in 2006 regarding its institutional denial of responsibility. PTSD prevention and treatment programs. The GAO (2006) reviewed the DoD’s PTSD screening policies that mandate Regressive Behavior post-deployment health assessment (PDHA) screenings intended for early identification and intervention. Per the The closest example we can find of this stratagem is the GAO (2016), BA joint VA/DOD guideline states that military’s knee-jerk response to a whistleblower who filed a service-members who respond positively to three or four of grievance with the DoD Inspector ’s Office in 2005-06 the questions may be at risk for PTSD^ (p. i). PDHA screen- (Russell, 2006a, b) detailing a mental health crisis the military ings are typically conducted by non-physicians (e.g., enlisted actively wanted to deny (see Delay, Deception, and Delay medics), physician assistants, or general practitioners. These section). In retaliation, top military officials disseminated a specialties most often refer to specialists like neurology and Public Affairs Guidance (U.S. Navy, 2007) expressly 62 Psychol. Inj. and Law (2018) 11:37–68 designed to refute claims of a crisis (e.g., staffing shortages, screening was ineffective in preventing the occurrence inadequate treatment), which were latter validated by the DoD of such conditions (Appel, 1966,p.414;Departmentof Task Force (2007). They exacted retribution against said Army). whistleblower’s military promotion and career (Zoroya, 2007). The military’s use seeming of denial to resolve its mental health dilemma is effectively embodied by its insistence that Why Deny Organizational Responsibility? predisposed weak personalities were the primary culprit for psychiatric breakdown as opposed to the toxic effects of war- We are unaware of any previous investigations into the fare; despite ample evidence to the contrary. America’sbrief military’s reliance on denial as a protective defense mecha- involvement in WWI produced a total of 69,000 nism in dealing with its mental health dilemma. To what ex- psychiatrically-disabled veterans, costing the government tent does the military’s propensity to deny the psychiatric re- over $1 billion in disability pensions (Berlien & Waggoner, alities of war reflect an unconscious or intentional process is 1966). But who are what was blamed? Conclusions by inves- open to debate. Clearly there is an inexplicable disconnect tigative commissions almost universally blamed pre-existing between public knowledge that war results in psychiatric ca- individual weaknesses and the corrosive influence of psychi- sualties and the DoD’s systemic failure to provide even peace- atry (i.e., psychiatric diagnosing, disability pensions), as well time level of mental health services. The nature of the behav- as inadequate military training, leadership, and unit morale ior by the military might be attributed to either denial or gross (e.g., Report of the War Office Committee of Enquiry into negligence (Russell et al., 2016). Furthermore, for the military BShell Shock^,1922). to endure repeated organizational embarrassment, shame, Having diagnosed the problem, post-WWI military powers public disdain, and dishonor for failing to live by its moral all took concerted action to eliminate psychiatry from its rank code to do right by millions of service personnel and their and file; BReference was made to the large amount of money families, one could suggest that there must be serious advan- which was spent by the Government to provide care for neu- tages to use denial strategies. ropsychiatric patients after the war, and pleas were made to At present, we offer the following conjecture about possi- avoid getting involved again^ (Brill, 1966a; p. 207). ble motivations that may appear to justify (if true) the Consequently, the U.S. militaryaggressively screened out military’s use of denial strategies: (a) acknowledging the men- and rejected the psychologically weak and predisposed, tal health difficulties of soldiers would lead to crippling the prevented or significantly reduced psychiatric disability pen- military’s capacity to fight and win wars due to attrition (e.g., sions, as well as significantly ramping up military discipline, mass evacuation syndromes) and finances (e.g., costs required vigorous training, unit morale building, and leadership devel- to meet wartime mental health needs); (b) competing costs and opment in order to strengthen individual resistance against the resources for mental health services will fatally detract from erosive softening effects of modern culture that encourages military readiness (e.g., weapon procurement); (c) expanding cowardice, weakness, and pseudo-psychiatric illness. disability pensions will strain society; (d) undermining military recruitment and retention efforts will result, as well as the ability to sustain an all-volunteer force; and/or (e) there is an Purging Mental Health Services israined culture antipathy and deeply held beliefs, biases, and fears toward the mental health field, in general, and its clien- Consequently, European and American militaries disbanded tele and practitioners, in particular. their mental health services, including all frontline psychiatry programs and personnel. The intent was to prevent predisposed war hysterics from infiltrating the armed forces Strategy 5: Screening and Purging Weakness in that BProminent civil and military medical authorities point- to Prevent War Stress Injury ed out that World War I had demonstrated the necessity and feasibility of psychiatric screening in eliminating overt and covert mental disorders prior to entry in the military services^ (Glass, 1966a, p. 7). From the military’s perspective, the only In the beginning of World War II, military authorities, real value of mental health specialists was to prevent their both lay and medical, believed that psychiatric disorders future clientele from contaminating the military, and rigorous occurred only in predisposed individuals-weaklings. military discipline, training, unit cohesion, and leadership This led to the endorsement of and the reliance upon would take care of the rest (e.g., Shepard, 2001). Having re- the policy of psychiatric screening. As the war moved the morally corrosive influence of psychiatry from the progressed, these authorities discovered that most men- rank and file, the military now took concerted steps to end its tal disorders occurred in "normal" men and that mental health dilemma. Psychol. Inj. and Law (2018) 11:37–68 63

Purging Predisposed War Hysterics Considerable public consternation ensued, as large numbers of patriotic volunteers were rejected because they ap- The U.S. military conducted psychiatric screenings during peared nervous or effeminate, had sweaty palms, tenseness, WWI, resulting in 70,000 candidates rejected for enlistment hand tremors, or answered affirmatively to questions like BDo due to emotional and intellectual risk factors (Berlien & you worry?^ BAre you nervous?^ or BDo you have headaches Waggoner, 1966)(Table4 provides an example of how, dur- or stomach troubles?^ As the war progressed, consequent ing wars, mental health-related screenings and disability dis- manpower shortages greatly alarmed military leaders, who charges are managed. After WWI, the military decided to then authorized a series of revisions to selection standards double-down on its effort to screen out potential pensioners (e.g., Berlien & Waggoner, 1966). by significantly broadening the criteria for rejection to include in known or hypothesized potential risk factor. In 1941, Harry Results of Neuropsychiatric Predisposition Screenings Stack Sullivan was appointed as chief neuropsychiatric (NP) consultant to the Selective Service, and tasked to develop a The military’s grand psychiatric experiment proved noth- screening program consisting of different levels of medical ing short of a colossal failure and repudiation of the pre- and psychiatric examinations. The latter included extensive dominant predisposed war hysteria formulation. For ex- record review (e.g., legal, medical, educational, family, psy- ample, during the North African campaign (1941–1943), chiatric), standardized intelligence testing, and various the American military supposedly devoid of inherently psychiatric questionnaires all designed to reject anyone with predisposed, constitutionally weak, defective service per- a greater than average chance of NP breakdown. Orr (1941) sonnel, were faced with grim unlearned lessons of the reported the objectives of NP screenings was to disqualify the reality of twentieth century warfare when NP rates of obviously ‘psychopathic’ or psychiatrically unfit then 20–34% of total casualties materialized, with only 3% RTD. Also, during the 1942 Guadalcanal invasion, 40% of 1st Division Marine evacuees were NP casualties. In eliminate further: (1) those men with more subtle per- all, despite rejecting over 1,680,000 ‘predisposed’ or even sonality disorders missed by previous examiners; (2) remotely defective inductees the rate of U.S. Army neu- men whose present personality makeup suggests that ropsychiatric disability discharges during WWII was 7.6 they may break under the special stresses and strains times higher than WWI (Glass, 1966a).By the end of of camp life; and even beyond these, (3) men who WWII, there were over 1,103,000 American Army and may be expected to develop some type of neuropsychi- 150,000 Navy/Marine Corps psychiatric hospital admis- atric disorder at any time during the next eleven years sions, resulting in 504,000 (72%) supposedly non- (Cited in Berlien & Waggoner, 1966,p.156). defective Army and 110,000 (67%) Navy/Marine Corps personnel psychiatrically discharged (i.e., Brill & The list of disqualifying predisposing or pre-existing risk Kupper, 1966; Chermol, 1985). In September 1943 alone, factors was extensive, from the reasonable (i.e., intellec- more soldiers were discharged from the Army (112,500) tual deficit, history of epilepsy, current or past psychiatric tha entered active-duty (118,600), with the majority given history, active substance abuse, incarceration history, en- psychiatric discharges. This prompted Chief of Staff, uresis, current medical conditions, frequent medical ill- General Marshall to abandon the extensive predisposition ness) to the absurd (e.g., any history of hospitalizations, screening policy in 1943 because it was costing them the shyness, history of speech impediment, extended family war (e.g., Glass, 1966a). psychiatric or substance abuse history, tendency to worry, repeating a grade or poor grades, parental divorce, adop- Follow-up Studies on Previously Rejected Predisposed tion, school suspension, limited dating experiences, unsta- WWII Veterans ble work history, or any other hypothesized ‘neurotic’ tendencies), and with the cliché Bwhen in doubt reject^ Significant modifications were made in selection criteria of (Berlien & Waggoner, 1966,p.162). WWII soldiers, with many induction stations reexamining

Table 4 Prevalence of neuropsychiatric screening War Total rejected at Total rejected at Grand total Total disability rejections and disability accession mobilization rejected discharges discharges WWI 70,158 15,247 85,405 43,706 WWII 1,846,000 Unknown 1,846,000 375,333

Source: Berlien & Waggoner, 1966 64 Psychol. Inj. and Law (2018) 11:37–68 applicants they previously rejected. They found more than and disqualify inductees only with clear psychiatric illness 50% of prior rejections were acceptable (e.g., Cardona & (e.g., Cardona & Ritchie, 2007). The military needs a more Ritchie, 2007). Follow-up investigations into attrition rates comprehensive prescreening strategy of its volunteers, with of these previously disqualified, ‘predisposed’ soldiers re- the limits of the assessments and their determinations noted, vealed 80% remained on active-duty after 1 year with many especially in light of the independent toxic effects of warzone serving for longer periods at satisfactory performance levels combat and stress. To avoid repeating past mistakes, the pur- (Eanes, 1951). In another study, 413 of 732 (56%) previously pose of such screening is to establish baselines needed to rejected predisposed registrants were inducted, with a separate detect potential changes caused by military service, as well study of 248 veterans previously disqualified followed-up as early identification of high risk personnel requiring pre- 1 year after induction showing 209 (84%) still on active duty; emptive intervention and close monitoring. 32 discharged (2 accepting officer commissions) and 5 killed in action (Berlien & Waggoner, 1966). Conclusion and Discussion Explanations for Failures to Screen out Predisposed Accessions In summary, the military appears to have abandoned its effort to avoid learning the psychiatric realities of war via massive Various reasons have been offered for the failure of mass systemic purging of weakness, opting instead for less costly psychiatric screenings, including the lack of adequately and dangerous strategy. We examine five additional avoidant trained psychiatric staff to conduct screenings, variability strategies in part three of the three-part series on the darker in screening instruments and procedures used, dishonest side of military mental health care. self-disclosures, and insufficient time to perform psychiatric examinations (e.g., Berlien & Waggoner, 1966; Compliance with Ethical Standards Cardona & Ritchie, 2007). However, while the above may explain how some ‘false negatives’ or predisposed Ethical Statement This study was unfunded and there are no conflicts of inductees later developing post war disorders could have interests involving the authors. ‘slipped through the cracks,’ the following findings are telling. 1,253,000 hospital admissions resulting in 604,000 (48%) NP discharges passed excessively strin- References gent inclusion criteria. This, along with the successful performance of the majority of previously rejected vet- Acosta, J. D., Becker, A., Cerully, J. L., Fisher, M. P., Martin, L. T., erans identified with known or suspected predisposed risk Vardavas, R., Slaughter, M.E., & Schell, T. L. (2014). Mental health factors, appear to suggest that psychiatric screening of the stigma in the military. RAND prepared for the Office of the B ^ Secretary of Defense Center for Military Health Policy Research. weak failed and attempts to purging the so-called weak Santa Monica, CA. was misinformed. Annual Report of the Adjutant General. (1910). War Department Annual Reports 1910, at 176 (1910).Washington, DC. Contemporary Military Psychiatric Screening Policy 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. After WWII, each military service continued to experiment 373–416). Washington, DC: Office of the Surgeon General, with different psychiatric screening or personality measures Department of the Army. to predict suitability for service, and all efforts in these Appel, J. W., & Beebe, G. W. (1946). Preventive psychiatry: An epide- regards met similar outcomes. For example, Plag and Arthur miologic approach. Journal of the American Medical Association, 131(18), 1469–1475. (1965) followed 134 Navy recruits retained after being Armed Forces Health Surveillance Center. (2012). Substance use disor- screened as psychiatrically predisposed and unfit for military ders in the U.S. Armed Forces, 2000–2011. Medical Surveillance duty, finding 70% were performing satisfactorily 2 years later Monthly Report MSMR, November 2012 19(11), 11–16. Cited in in comparison to 86% of a matched control group (i.e., reage, Servies, T., Hu, Z., Eick-Cost, A., & Otto, J. L. (2012). Substance – intellect). At present, the three components of psychiatric use disorders in the US Armed Forces, 2000 2011. MSMR, 19(11), pp. 11–16. screenings for military accession include: (1) estimates of in- Bailey, P. (1929). Provisions for care of mental and nervous cases. In P. tellectual potential via the Armed Services Vocational Bailey, F. E. Williams, & P. O. Komora (Eds.), The Medical Aptitude Battery (ASVAB), used since 1976; (2) measures Department of the United States Army in the World War: Volume – of educational achievement, high school graduation, or equiv- X Neuropsychiatry in the United States (pp. 39 55). Prepared under the direction of Maj. Gen. M. W. Ireland, The Surgeon General. alent test; and (3) a review of medical screening forms and Washington, DC: U. S. Government Printing Office. general psychiatric examination during the entrance physical Baker, K. A. (2011). The effect of post-traumatic stress disorder on mil- evaluation at military induction centers intended to identify itary leadership: An historical perspective. Fort Leavenworth: Psychol. Inj. and Law (2018) 11:37–68 65

United States Army Command and General Staff College, School of functional cardiac disorder and its consequences. The American Advanced Military Studies. JournalofMedicine,11(5), 559–567. Baldor, L. C. (2014). Misconduct forces more soldiers out. Associated Press. Dean, E. T. (1997). Shook over hell: Post-traumatic stress Vietnam and Barrett, D. H., Resnick, H.S., Foy, D.W., Dansky, B.S., Flanders, W. D., the Civil war. Cambridge: Harvard University Press. & Stroup, N.E. (1996). Combat exposure and adult psychosocial Department of Defense. (2009). Department of Defense Directive adjustment among U.S. Army veterans serving in Vietnam, 1965- 1020.02: Se management and equal opportunity (EO) in the 1971. Journal of Abnormal Psychology, 105(4), 575–581. Department of Defense of February 5. Retrieved from: www. Beckham, J. C., Feldman, M. E., & Kirby, A. C. (1998). Atrocities exposure deomi.org/DiversityMgmt/documents/DoD_Directive102002p. in Vietnam combat veterans with chronic posttraumatic stress disor- pdfwww.deomi.org/DiversityMgmt/documents/DoD_ der: Relationship to combat exposure, symptom severity, guilt, and Directive102002p.pdf. interpersonal violence. Journal of Traumatic Stress, 11(4), 777–785. Department of Defense Task Force on Mental Health. (2007). An achiev- Berlien, I. C. (1966). Psychiatry in the army. In A. J. Glass, & R. J. able vision: Report of the Department of Defense task force on Bernucci (Eds.), Medical Department United States Army. mental health. Falls Church: Defense Health Board. Neuropsychiatry in World War II volume I: Zone of interior (pp. Department of Navy. (2009). OPNAV instruction 5350.4D: Navy alcohol 491-522). Washington DC: Office of the Surgeon General, and drug abuse prevention and control of 4 Jun 2009. Washington, Department of the Army. DC: Office of the Chief of Naval Operations. Berlien, I. C., & Waggoner, R. W. (1966). Selection and induction. In A. Department of Navy and U.S. Marine Corps. (2010). Combat and oper- J. Glass & R. J. Bernucci (Eds.), Medical Department United States ational stress control. U.S. Navy, NTTP 1-15M; U.S. Marine Corps, Army. Neuropsychiatry in World War II volume I: Zone of interior MCRP 6-11C. Washington, DC. (pp. 153–191). Washington, DC: Office of the Surgeon General, Department of the Army. (2006). Combat and operational stress control: Department of the Army. Field manual (4–02.51) (FM 8–51). Retrieved from: http:// Bernucci, R. J. (1966). Forensic military psychiatry. In A. J. Glass & R. J. armypubs.army.mil/doctrine/DR_pubs/dr_a/pdf/fm4_02x51.pdf. Bernucci (Eds.), Medical Department United States Army. Department of the Army. (2009). Field manual 6–22.5: Combat and Neuropsychiatry in World War II volume I: Zone of interior (pp. operational stress control manual for leaders and soldiers (p. 475–488). Washington, DC: Office of the Surgeon General, 111). Washington, DC: US Dept. of the Army. Department of the Army. Drimmer, F. (1992). Until you are dead: The book of executions in Black, D. W., Carney, C. P., Peloso, P. M., Woolson, R. F., Lettuchy, E., & America. New York: Pinnacle Books. Doebbeling, B. N. (2005). Incarceration and veterans of the first Eanes, R. H. (1951). Standards used by selective service and a follow-up Gulf War. Military Medicine, 170(7), 612–618. on neuropsychiatric rejectees in World War II. In L. Carmichael & L. Booth-Kewley, S., Highfill-McRoy, R. M., Larson, G. E., & Garland, C. C. Mead (Eds.), Selection of military manpower: A symposium (pp. F. (2010). Psychosocial predictors of military misconduct. Journal 149–156). Washington, DC: National Academy of Sciences – of Nervous Mental Disease, 198(2), 91–98. National Research Council. Brill, N. Q. (1966a). Hospitalization and disposition. In A. J. Glass & R. J. Executive Order No. 13625, Federal Register, 77(172). (2012). Bernucci (Eds.), Medical Department United States Army: Improving access to mental health services for veterans, service Neuropsychiatry in World War II: Zone of interior (Vol. I, pp. members, and military families. Retrieved from: www.gpo.gov/ 195–253). Washington, DC: Office of the Surgeon General, fdsys/pkg/FR-2012-09-05/pdf/2012-22062.pdf. Department of the Army. Figley, C. R., & Nash, W. P. (Eds.). (2007). Combat stress injury: Theory, Brill, N. Q. (1966b). Station and regional hospitals. In A. J. Glass & R. J. research, and management.NewYork:Routledge. Bernucci (Eds.), Medical Department United States Army: Finucane, M. I. (1900). General nervous shock, immediate and remote, Neuropsychiatry in World War II: Zone of interior (Vol. I, pp. after gunshot and shell injuries in the South African campaign. The 255–295). Washington, DC: Office of the Surgeon General, Lancet, 156(4020), 807–809. Department of the Army. Forbes, D., Parslow, R., Creamer, M., Allen, N., McHugh, T., & Brill, N. Q., & Kupper, H. I. (1966). Problems of adjustment in return to Hopwood, M. (2008). Mechanisms of anger and treatment outcome civilian life. In A. J. Glass & R. J. Bernucci (Eds.), Medical in combat veterans with posttraumatic stress disorder. Journal of Department United States Army. In Neuropsychiatry in World War Traumatic Stress, 21(2), 142–129. II: Zone of interior (Vol. I, pp. 721–733). Washington, DC: Office of Freedman, H. L. (1945). The mental-hygiene-unit approach to the Surgeon General, Department of the Army. reconditioning neuropsychiatric casualties. Mental Hygiene, Camp, N. M. (2014). U.S. army psychiatry in the Vietnam War: New 269(2), 269–302. challenges in extended counterinsurgency warfare.FortSam, Freedman, H. L., & Rockmore, M. J. (1945). Mental hygiene frontiers in Huston: Borden Institute, U.S. Army Medical Department Center probation and parole services. Social Correctives for Delinquency, and School. 44,52–53. Cardona, R. A., & Ritchie, E. C. (2007). U.S. military enlisted accession Freud, S. (1924). The loss of reality in neurosis and psychosis. In A. mental health screening: History and current practice. Military Richards (Ed.), On psychopathology (pp. 219–226). London: Medicine, 172(1), 31–35. Penguin Books. Casscells, W. (2008). Rising to the challenges of PTSD. Pentagon News Freud, A. (1936). The ego and the mechanisms of defense: The collected Release by Assistant Secretary Health Affairs on August 18, 2008. works of Anna Freud, Vol. 2. International Universities Press. Chappell, R. A. (1945). Naval offenders and their treatment. Federal Frizell, S. (2014). U.S. army firing more soldiers for misconduct: Number Probation, 9,3–5. dismissed for crime or misconduct doubled between 2007 and 2013. Chermol, B. H. (1985). Wounds without scars: Treatment of battle fatigue Time. Retrieved from: http://nation.time.com/2014/02/15/u-s-army- in the U.S. armed forces in the Second World War. Military Affairs: firing-more-soldiers-for-misconduct/. The Journal of Military History, Including Theory and Technology, Gaupp, R. (1911). Uber den Begriff der hysterie. ZgNP,5,457–466. Cited 49,9–12. in Lerner, (2003) 38. Da Costa, J. M. (1871). On irritable heart: A clinical study of a form of Glass, A. J. (1966a). Army psychiatry before World War II. In A. J. Glass functional cardiac disorder and its consequences. Reprinted Da & R. J. Bernucci (Eds.), Medical Department United States Army. Costa, J. M. (1951). On irritable heart: a clinical study of a form of Neuropsychiatry in World War II volume I: Zone of interior (pp. 3– 66 Psychol. Inj. and Law (2018) 11:37–68

23). Washington, DC: Office of the Surgeon General, Department of Institute of Medicine. (2012). Substance Use Disorders in the U.S. Armed the Army. Forces. Report Brief September, 2012. Washington, DC: The Glass, A. J. (1966b). Lessons learned. In A. J. Glass & R. J. Bernucci National Academies Press. (Eds.), Medical Department United States Army. Neuropsychiatry in Institute of Medicine. (2014). Treatment for posttraumatic stress disorder World War II volume I: Zone of interior (pp. 735–759). Washington, in military and veteran populations: Final assessment. Washington, DC: Office of the Surgeon General, Department of the Army. DC: The National Academies Press. Glass, A. J., & Bernucci, R. J. (1966). Medical Department United States Izzo, R. (2014). In need of correction: How the army board for correction Army. Neuropsychiatry in World War II volume I: Zone of interior. of military records is failing veterans with PTSD. The Yale Law Falls Church: Office of the Surgeon General, Department of the Journal, 123(5), 1118–1625. Army. Johnson, A. W. (1969). Combat psychiatry: Part I historical review. – Government Accountability Office. (2006). Post-traumatic stress disor- Medical Bulletin, U.S. Army Europe, 26(10), 305 308. der: DoD needs to identify the factors its providers use to make Joint Mental Health Advisory Team-8. (2013). Operation enduring free- mental health evaluation referrals for service members. GAO-06- dom 2013 Afghanistan. Washington, DC: Office of the Surgeon 397 04: Washington, DC: Author. General United States Army Medical Command and Office of the Government Accountability Office. (2016). Human capital: Additional Command Surgeon HQ, USCENTCOM and Office of the actions needed to enhance DoD’s efforts to address mental health Command Surgeon U.S. Forces Afghanistan (USFOR-A). care stigma. GAO-16-404: Washington, DC: Author. 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. Government Accountability Office. (2017). Defense health care: Actions (Eds.), Textbook of military medicine: War psychiatry (pp. 1– needed to ensure post-traumatic stress disorder and traumatic brain 34). Washington, DC: Borden Institute, Office of the Surgeon injury are considered in misconduct separations. GAO-17-260. General, U. S. Army. Washington, DC: Author. Jones, F. D. (2005). Military psychiatry after the first year of the Korean Heaton, L. D. (1966). Forward. In A. J. Glass & R. J. Bernucci (Eds.), War. In A. J. Glass, F. D. Jones, L. R. Sparacino, & J. M. Rothberg Medical Department United States Army. Neuropsychiatry in World (Eds.). Psychiatry in the U.S. Army: Lessons for community War II volume I: Zone of interior (xiii-xiv). Washington, DC: Office psychiatry (pp. 1–7). Bethesda, MD: Uniformed Services of the Surgeon General, Department of the Army. University of the Health Sciences. ’ Henry, K., & Zanuck, D. F. (1949). Twelve o clock high [Motion picture]. Jones, E. (2006). LMF: The use of psychiatric stigma in the royal air force Los Angeles: Twentieth Century Fox. during the second world war. The Journal of Military History, 70(2), Highfill-McRoy, R. M., Larson, G. E., Booth-Kewley, S., & Garland, C. 439–458. F. (2010). Psychiatric diagnosis and punishment for misconduct: Jones, E., & Wessely, S. (2005). Shell shock to PTSD: Military psychiatry The effects of PTSD in combat-deployed marines. BMC from 1900 to the Gulf War.NewYork:PsychologyPress. Psychiatry, 10(1), 88. Jones, E., & Wessely, S. (2007). A paradigm shift in the conceptualization Hiley-Young, B., Blake, D. D., Abueg, F. R., Rozynko, V.,& Gusman, F. of psychological trauma in the 20th century. Journal of Anxiety D. (1995). Warzone violence in Vietnam: An examination of Disorders, 21(2), 164–175. premilitary, military, and postmilitary factors in PTSD inpatients. Jordan, B. K., Marmar, C. R., Fairbank, J. A., Schlenger, W. E., Kulka, R. Journal of Traumatic Stress, 8(1), 125–141. A., & Hough, R. L. (1992). Problems in families of male Vietnam Hing, M., Cabrera, J., Barstow, C., & Forsten, R. (2012). Special opera- veterans with post-traumatic stress disorder. Journal of Consulting tions forces and incidence of post-traumatic stress disorder symp- and Clinical Psychology, 60(6), 916–926. toms. Journal of Special Operation Medicine, 12(3), 23–35. Kay, A. G. (1912). Insanity in the army during peace and war, and its Hoge, C. W., Castro, C. A., & Eaton, K. M. (2006). Impact of combat treatment. Journal of the Royal Army Medical Corps, 18(1), 146–158. duty in Iraq and Afghanistan on family functioning: Findings from Kessler, M. M. (1966). Troops in transit. In A. J. Glass & R. J. Bernucci the Walter Reed Army Institute of research land combat study. In: (Eds.), Medical Department United States Army. Neuropsychiatry in Human dimensions in military operations—military leaders’strate- World War II volume I: Zone of interior (pp. 320–348). Washington, gies for addressing stress and psychological support.Meeting DC: Office of the Surgeon General, Department of the Army. Proceedings RTO-MP-HFM-134, Paper 5. Neuilly-surSeine, Kilpatrick, M. E. (2007). Statement by Michael E. Kilpatrick, MD France: RTO. 5.1–5.6. Deputy Director, Force Health Protection and Readiness Programs, Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Department of Defense. In U.S. Congress House of Representatives Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, men- (2007), Invisible casualties: The incidence and treatment of mental tal health problems, and barriers to care. New England Journal of health problems by the U.S. military (pp. 63 –79). Hearing before the Medicine, 2004(351), 13–22. U.S. Congress House of Representatives Committee on Oversight Holbrook, J. G. (2010). Veterans’ courts and criminal responsibility: A and Government Reform, First Session, May 24, 2007, Serial No. – problem solving history & approach to the liminality of combat 110 111. Washington, DC: U.S. Government Printing Office. trauma. Widener Law School Legal Studies Research Paper No. Klostermann, K., Mignone, T., Kelley, M. L., Musson, S., & Bohall, G. 10–43. Forthcoming. In: D. C. Kelly, D. Gitelson, & S. H. (2012). Intimate partner violence in the military: Treatment consid- – Barksdale (Eds.), Young veterans: A resilient community of honor, erations. Aggression and Violent Behavior, 17(1), 53 58. duty & need. New York: Springer. Retrieved from https://ssrn.com/ Knapp, L., & Weitzen, F. (1945). A total psychotherapeutic push method abstract=1706829 as practiced in the fifth service command rehabilitation center, Fort – Holden, W. (1998). Shell shock. London, UK: Channel 4 Books. Knox, Kentucky. American Journal of Psychiatry, 102(3), 362 363. Kors, J. (2010). Disposable soldiers: How the pentagon is cheating Huie, W. B. (1954). The execution of private Slovik. Yardley: wounded vets. The Nation, 290(16), 11–14. Westholme Publishing. Lande, R. G. (2003). Madness, malingering & malfeasance. Washington, Iacobelli, T. (2013). Death or deliverance: Canadian courts martial in the DC: Blassey’sInc.. great war. Vancouver: UBC Press. Lerner, P. (2003). Hysterical men: War, psychiatry, and the politics of Institute of Medicine. (2008). Gulf War and health: Physiologic, psycho- trauma in Germany, 1890–1930. London: Cornell University Press. logic and psychosocial effects of deployment-related stress 6,(1). Linden, E. (1972). The demoralization of an army: Fragging and other Washington, DC: The National Academies Press. withdrawal symptoms. Saturday Review, 8,12–17. Psychol. Inj. and Law (2018) 11:37–68 67

Ludwig, A. O. (1949). Psychiatry at the Army level. In F. R. Hanson, & Commander Mark Russell, USN on 05JAN2006. Available upon U.S. Army Medical Department (Ed.), Combat psychiatry: request via Freedom of Information Act (FOIA) at Department of Experiences in the North African and Mediterranean theaters of Defense; Office of Freedom of Information, 1155 Defense operation, American ground forces, World War II (pp. 74–104). Pentagon; Washington, DC 20301–1155. Honolulu: University Press of the Pacific. Russell, M. (2006b). The future of mental health care in the Department MacCormick, A. H., & Evjen, V. H. (1945). The Army’s rehabilitation of Defense. Testimony before the Congressionally-mandated program for military prisoners. Social Correctives for Delinquency, Department of Defense Task Force on Mental Health, on 19–20 1,8–11. October 2006, San Diego, CA. Manual of Courts-Martial. (2012). United States. Washington, DC: The Russell, R. T. (2009). Veterans treatment court: A proactive approach. New Joint Service Committee on Military Justice. England Journal on Crime and Civil Confinement, 35,357–364. Marlowe, D. H. (2001). Psychological and psychosocial consequences of Russell, M. C., & Figley, C. R. (2015a). Investigating recurrent genera- combat and deployment: With special emphasis on the Gulf War. tional wartime behavioral health crises: Part one of a preliminary (No. MR-1018/11-OSD). Santa Monica, CA: RAND. analysis. Psychological Injury and Law, 8(2), 106–131. Marshall, H. (1840). On the enlisting, discharging, and pensioning of Russell, M. C., & Figley, C. R. (2015b). Generational wartime behavioral soldiers: With the official documents on these branches of military health crises: Part one of a preliminary analysis. Psychological duty. Philadelphia: A. Waldie. Injury and Law, 8(2), 132–152. Martin, J. A. (1992). Combat psychiatry: Lessons from the war in Russell, M. C., & Figley, C. R. (2017a). Do the military’s frontline Southwest Asia. Journal of the U.S. Army Medical Department, psychiatry/combat and operational stress control doctrine help or – PB 89-2-1/2,40 44. harm veterans?—Part one: Framing the issue. Psychological Injury Menninger, W. C. (1948). Reactions to combat. Psychiatry in a troubled and Law, 10(1), 1–23. world. New York: MacMillan. Russell, M. C., & Figley, C. R. (2017b). Do the military’s frontline Menninger, W. C. (1966). Public relations. In A. J. Glass & R. J. Bernucci psychiatry/combat operational stress control programs benefit vet- (Eds.), Medical department United States Army. Neuropsychiatry in erans? Part two: Systematic review of the evidence. Psychological – world war II volume I: Zone of interior (pp. 129 151). Washington, Injury and Law, 10(1), 24–71. DC: Office of the Surgeon General, Department of the Army. Russell, M. C., & Figley, C. R. (2017c). Is the military’s century-old Mental Health Advisory Team-V. (2008). Mental health advisory team frontline psychiatry policy harmful to veterans and their families? – (MHAT-V). Operation enduring freedom 06 08. Washington, DC: Part three of a systematic review. Psychological Injury and Law, Office of the Surgeon Multinational Force-Iraq & Office of the 10(1), 72–95. Surgeon General, United States Army Medical Command. Russell, M. C., Figley, C. R., & Robertson, K. R. (2015). Investigating the Mullen, M. G. (2011). Letter from Admiral Michael G. Mullen, Chairman psychiatric lessons of war and pattern of preventable wartime be- of the U.S. Joint Chiefs of Staff, to Hon. Eric K. Shinseki, Secretary havioral health crises. Journal of Psychology and Behavioral of the Department of Veterans Affairs (Feb. 15, 2011). Science, 3(1), 1–16. Neel, S. (1991). Vietnam studies: Medical support of the U. S. Army in Russell, M. C., Zinn, B., & Figley, C. R. (2016a). Exploring options Vietnam 1965–1970. Washington, DC: Department of the Army. including class action to transform military mental healthcare and Nelson, D. (2008). The war behind me: Vietnam veterans confront the ends the generational cycle of preventable wartime behavioral health truth about U.S. war crimes.NewYork:BasicBooks. crises. Psychological Injury and Law, 9(2), 166–197. Obama, B. H. (2011). Strengthening our military families: Meeting Russell, M. C., Butkus, S. N., & Figley, C. R. (2016b). Contribution of America’s commitment. Collingdale: Diane Publishing. military organization and leadership factors in perpetuating genera- Ogden, S. K., & Biebers, A. D. (2011). Psychology of denial (1st ed.). tional cycle of preventable wartime mental health crises: Part one. New York: Nova Publishing. Psychological Injury and Law, 9(1), 55–72. Oppenheim, H. (1915). Der Krieg und die traumatischen Neurosen. In Der Krieg und die traumatischen Neurosen (pp. 3–28). Heidelberg: Russell, M. C., Schaubel, S. R., & Figley, C. R. (2017). Thedarkersideof ’ Springer Berlin Heidelberg. military mental healthcare. Part one: Understanding the military s Orr, D. W. (1941). Objectives of selective service psychiatric classifica- mental health dilemma. In press. Psychological Injury and Law. tion. Bulletin of Menninger Clinic, 5,131–133. Salmon, T. W. (1917). Recommendations for the treatment of mental and Owen, J. (2003). Multiple claimants versus ministry of defence, nervous diseases in the United States Army. New York: National May 2003, p. 166. Cited in Jones, 2006. Committee for Mental Hygiene. Patton Jr., G. S. (1947). WarasIknewit. New York: Pyramid Books. Salmon, T. W., & Fenton, N. (1929). Neuropsychiatry in the American Pietrzak,R.H.,Goldstein,M.B.,Malley,J.C.,Rivers,A.J.,& expeditionary forces. In P. Bailey, F. E. Williams, P. A. Komora, Southwick, S. M. (2010). Structures of posttraumatic stress disorder T. W. Salmon, & N. Fenton (Eds.), Neuropsychiatry: The Medical and psychosocial functioning in veterans of operation enduring free- Department of the United States Army in the World War (Vol. 10, – dom and Iraqi freedom. Psychiatry Research, 178(2), 323–329. pp. 271 474). Washington, DC: Office of The Surgeon General, Plag, J. A., & Arthur, R. J. (1965). Psychiatric re-examination of unsuit- US Army. able naval recruits: A two-year follow-up study. American Journal Santayana, G. (1905). Reason in common sense, volume 1 of the life of of Psychiatry, 122(5), 534–541. reason. Mineola: Dover Publications. Porter v. McCullum. (2009). 130 S. Ct. 447, 455, n.8. Seamone, E. R. (2011). Reclaiming the rehabilitative ethic in military Reister, F. A. (1973). Battle causalities and medical statistics: U.S. justice: The suspended punitive discharge as a method to treat mil- army experience in the Korea War. Washington, DC: The itary offenders with PTSD and TBI and reduce recidivism. Military Surgeon General, Department of the Army Report of the war Law Review, 208(1), 1–212. office committee of enquiry into Bshell shock.^ (1922). Schaller, B. R. (2012). Veterans on trial: The coming court battles over London: Imperial War Museum. PTSD. Washington, DC: Potomac Books. Resnick, H. S., Foy, D. W., Donahue, C. P., & Miller, E. N. (1989). Shaw, J. A. (1987). Psychodynamic considerations in the adaptation to Antisocial behavior and post-traumatic stress disorder in Vietnam combat. In G. Belenky (Ed.), Contemporary studies in combat veterans. Journal of Clinical Psychology, 45(6), 860–866. psychiatry (pp. 117–132). Wesport: Greenwood Press. Russell, M. (2006a). Mental health crisis in the Department of Defense: Shepard, B. (2001). A war of nerves: Soldiers and psychiatrists in the DoD Inspector General Hotline Investigation #98829 submitted by twentieth century. Cambridge: Harvard University Press. 68 Psychol. Inj. and Law (2018) 11:37–68

Sobel, R. (1949a). Anxiety-depressive reactions after prolonged combat U.S. Army. (1944). Headquarters first special service force. Memorandum experience: The ‘old sergeant syndrome.’.InF.R.Hanson&U.S. by P. Mitchell, Captain, Assistant Adjutant 1st Sp. Sv. Force of 13 Army Medical Department (Eds.), Combat psychiatry: Experiences November, 1944. Washington, DC: U.S. Army, APA 4994. in the North African and Mediterranean theaters of operation U.S. Army. (1975). The army lawyer: A history of the judge advocate gen- American ground forces, World War II (pp. 137–146). Honolulu: eral’s corps, 1775– 1975. Honolulu: University Press of the Pacific. University Press of Pacific. U.S. Army. (1989). Army Regulation (A.R.) 11–33: Army Lessons Learned Sobel, R. (1949b). The battalion surgeon as psychiatrist. In F. R. Hanson Program: System Development and Application. 10 October 1989. & U.S. Army Medical Department (Eds.), Combat psychiatry: Washington, DC: Headquarters Department of the Army. Experiences in the North African and Mediterranean theaters of U.S. Army (1998). Combat stress control in a theatre of operations: – operation, American ground forces, World War II (pp. 36 44). Tactics, techniques and procedures. FM 8-51. Washington, DC: Honolulu: University Press of the Pacific. Headquarters, Department of the Army. Stanton, M. D. (1976). Drugs, Vietnam, and the Vietnam veteran: An U.S. Army Air Force. (1942). Eighth Air Force Policy Letter 200.9x373 overview. American Journal of Drug and Alcohol Abuse, 3(4), of 29 October, AFHRA, London. 557–570. U.S. Army Eighth Air Force. (1944). The reclassification of personnel fail- Stapp v. Resor (1970). 314 F. Supp. 475 (S.D.N.Y. 1970). ures in the Eighth Air Force of 16 October 1944, 520.742–4, AFHRA. Strong, G. V. (1917). The administration of military justice at the United States disciplinary barracks, Fort Leavenworth, Kansas. Journal of U.S. Army Military History Institute. (1944). Combat Lessons Number 5: – Rank and file in combat-What they’re doing how they do it EO- American Institute of Crime and Criminology, 8(3), 420 421. B ^ Sullivan, D. (1998). A matter of life and death: Examining the military 10501 Restricted Report. Classified Unrestricted on 5 August death penalty's fairnesm. The Federal Lawyer, June, retrieved from: 1986. Washington, DC: Combat Analysis Section, Operations https://deathpenaltyinfo.org/us-military-death-penalty#overview Division, War Department. Sutton,L.(2017).Thank you for your service! Documentary film. U.S. Navy. (2007). Mental health public affairs guidance of 23 January Produced by Donahue, T. 2007. Unpublished document. U.S. Navy Medical Department, Taft, C. T., Vogt, D. S., Marshall, A. D., Panuzio, J., & Niles, B. L. (2007). Navy Medicine West, Bureau of Medicine and Surgery, Aggression among combat veterans: Relationships with combat ex- Washington, DC. posure and symptoms of posttraumatic stress disorder, dysphoria, Veterans Administration. (2015). Analysis of VA health care utilization and anxiety. Journal of Traumatic Stress, 20(2), 135–145. among Operation Enduring Freedom (OEF), Operation Iraqi Taft, C. T., Weatherill, R. P., Woodward, H. E., Pinto, L. A., Watkins, L. Freedom (OIF), and Operation New Dawn (OND) veterans. E., Miller, M. W., & Dekel, R. (2009). Intimate partner and general Released June 2015. Epidemiology Program. Post-Deployment aggression perpetration among combat veterans presenting to a post- Health Group. Office of Public Health. Veterans’ Health traumatic stress disorder clinic. American Journal of Administration. Washington, DC: Department of Veterans Affairs. Orthopsychiatry, 79(4), 461–468. Retrieved from http://www.publichealth.va.gov/epidemiology. Teten, A. L., Miller, L. A., Stanford, M. S., Petersen, N. J., Bailey, S. D., Ward,H.M.(2006).George Washington’s enforcers: Policing the conti- Collins, R. L., Dunn, M. J., & Kent, T. A. (2010). Characterizing nental army. Carbondale: Southern Illinois University Press. aggression and its association to anger and hostility among male Wells, M. K. (1992). Aviators and air combat: A study of the U.S. Eighth veterans with post-traumatic stress disorder. Military Medicine, air force and RAF bomber command. (No. AFIT/CI/CIA-92-136). 175(6), 405–410. Department of War Studies, King’s College. London, UK: The Associated Press. (1999). GI'S Tell of a US Massacre in Korean War. University of London. The New York Times. Retrieved from http://www.nytimes.com/ Winkenwerder, W. (2005). Mental health. Testimony of the Assistant 1999/09/30/world/gi-s-tell-of-a-us-massacre-in-korean-war.html Secretary of Defense for Health Affairs before the subcommittee U. S. Army. (1888). The medical and surgical history of the war of on military personnel armed services committee. U.S. House of the republic: Part III, volume I. Washington, DC: Government Representatives on July 26, 2005. Printing Office. Zoroya, G. (2007). Navy Psychologist: Navy faces crisis.USAToday. U.S. Army. (1918). Circular no. 24 American expeditionary forces, Retrieved from http://usatoday30.usatoday.com/news/health/2007- France. Published on April 23, 1918. Washington, DC: Office of 01-16-ptsd-navy_x.htm. Surgeon, Headquarters, NATOUSA. Zwerdling, D. (2007, November 15). Army dismissals for mental health, U.S. Army. (1943). Circular letter no. 17. neuropsychiatric treatment in misconduct rise. National Public Radio. Retrieved from: www.npr. the combat zone. Published on 12 June 1943. Washington, DC: org/templates/story/story.php?storyId=16330374. Office of Surgeon, Headquarters, NATOUSA.