Afghan killings by soldier lead to questions about TBI, PTSD, and combat stress

Speculation about why U.S. Army Staff Sgt. Robert Bales killed 17 Afghan civilians, including nine children, in the early morning of March 11, centers around traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), multiple deployments, and family and financial problems faced by the 38-year-old officer.

The case has led some to ask broader questions about the stresses of being in combat and how the Army should and would respond to psychic suffering in someone who is serving “in theater.” Two points are clear: you don’t have to be mentally ill to be shaken by combat, and the Army discourages diagnosing mental illness when the cause of the symptoms is combat stress.

“It’s hard to diagnose someone with PTSD because so many symptoms are adaptive,” said Bret A. Moore, Psy.D. ,a former Army captain and psychologist who co-authored Wheels Down: Adjusting to Life After Deployment. And he doesn’t think TBI would cause aberrant behavior because hundreds of soldiers have experienced it and not gone on to commit any atrocities.

Many of the PTSD-like “symptoms” displayed in deployed settings are adaptive, including hypervigiliance and sleep disturbance, said Moore. “These help keep service members on their toes, where they need to be,” he said. “No matter how resilient you are, combat is a stressful environment.” So soldiers with these symptoms – and others – are not diagnosed with mental illness.

Serious mental illness is another story, however. If someone is diagnosed with a severe mental illness such as bipolar disorder or schizophrenia, or exhibits signs of suicidality, he or she is not kept in the field, but sent home – probably for good – said Moore. The loss of the military career is another reason that the patient himself, as well as the doctor and the soldier’s commander, are unwittingly collaborating to cover up problems that can lead to suicide and homicide. Moore has diagnosed deployed soldiers with major psychiatric disorders. “You have to get those individuals out,” he said.

COSR, not PTSD

In a March 15 Time article, Mark Thompson wrote that the Army Field Manual instructs mental-health professionals not to declare soldiers mentally ill. In a section titled “Combat and Operational Stress Control: Defer Diagnosis of Behavioral Disorders,” the manual encourages a diagnosis of combat stress (combat and operational stress reaction, or COSR, a diagnosis not in the DSM) instead of a pathological diagnosis. From the manual:

During assessment, COSC [combat and operational stress control] personnel must always consider BH [behavioral health] disorders that resemble COSR [combat and operational stress reaction], but defer making the diagnosis. The COSC personnel favor this default position to preserve the Soldier’s expectations of normalcy … This is also done to avoid stigma associated with BH disorders and to prevent the Soldier identifying with a patient or sick role. Deferral is also preferred because some diagnoses require extensive history collection or documentation that is unavailable during deployment situations.

Thompson’s sources told him they thought these rules might have contributed to Bales’ actions, although there is no proof of this. “The uncomfortable truth is that the military mental-health system is designed to avoid recognizing manic symptoms or delusions — symptoms that put someone at increased risk for suicide or homicide,” the expert told Thompson.

The COSR manual allows for medication, but discourages treating soldiers with combat stress as if they are patients:

It is both inappropriate and detrimental to treat Soldiers with COSR as if they are a BDP [behavioral disordered patient]. A therapeutic relationship may promote dependency and foster the “patient” role. Likewise, medication therapy and the highly structured treatment modalities imply the “patient” role. Medication for transient symptom relief (insomnia or extreme anxiety) may not be detrimental if there is no expectation that medication will continue to be prescribed.

There is also the fact that active duty troops are stretched thin. Sending some troops to medical facilities – from which they usually do not return to the battleground – would likely mean more or longer deployments for other troops. And to date, there is no agreement about how many deployments are too many.

Repeated deployments

The 38-year-old Bales was on his fourth deployment. The day before he shot the Afghan civilians, he had seen his friend devastatingly injured. So the question: Do repeated deployments and exposure to violence to close buddies lead soldiers to develop mental problems?

“I wish it were that simple,” said Moore, who did one 12-month tour and one 15-month tour back-to-back in Iraq, from 2005-2006 and 2007-2008. “Most people are fairly hardy and resilient and can make it through a 12-month deployment,” he said. Some people – most likely those with pre-existing problems – find it more difficult to adjust to repeated deployments. “Those are the people, the more severe cases, who have to be removed from theater,” to adjust, he explained. “There’s less risk for someone getting hurt.”

Moore doesn’t buy into the concept of “snapping” due to combat stress alone, as some people have suggested Bales did. “But if you look at people who have had three, four, or five deployments, and who commit horrific crimes, you’re going to find financial struggles, relationship problems, different factors that combined to create this perfect storm,” he said. “Maybe it’s a 22-year-old guy whose high-school sweetheart is going to leave him; that might be enough for one person.”

Carrying weapons is the norm for service members, said Moore. “Violence is the norm.” This does make it easier to for the person to use weapons – the stigma is gone. “Common sense tells me that it is easier for a service member to carry out violence.” That begs the question, he said, of what the Army is doing right – because most service members do not “snap.”

“I would imagine most service members at some point have felt fear; I had those thoughts myself,” he said. “But pulling the trigger is different.”

Resilience and training

So what is the Army doing right? Moore credits the training received by soldiers prior to deployment. “The training is what separates the soldier from the average citizen,” he said.

Basic principles for the management of combat stress dictate that soldiers focus on resilience instead of pathology, said Moore. “If you put a soldier in a sick role, you’re going to lose that person,” he said. “You’re saying, ‘You’re broken, you’re weak, there’s something wrong with you.’” If, instead, the soldier is told “‘This is something we expect to happen, but you have internal and external resources, and you will overcome this,’ the soldier has a chance to recover. As soon as you put someone in a sick role, the problems get worse, because they fall into that sick role,” he said. “Instead, you want to focus on what they’re doing well.”

Still, the military has to deal with the issue of stigma, said Moore. “There is a pervasive culture within the military that if you seek mental health treatment or have mental health issues it is a sign of weakness,” he said. It’s true that a serious psychiatric disorder, or repeated hospitalizations for suicidal ideation, will have an adverse effect on a military career. “But there is this belief that if you seek mental health treatment it will automatically impact your career. It won’t.”

Soldiers don’t have to acknowledge that they have even been to mental health counseling anymore, which is a change for the better, said Moore.

Maybe war awakens demons in normal, healthy people. Maybe it should. As Bales’ lawyer told reporters, hinting at a key strategy in the defense of his client, “I’m not putting the war on trial, but it is on trial.”

Aging film documents WWII-era treatment

The Army has a history of not wanting the world to know about psychological scars of battle. In the 1940s, the Army commissioned a film in which director John Huston focused on battle-scarred veterans. This documentary, called “Let There be Light,” was not seen until 35 years after it was made, because military police seized the film minutes before it was supposed to be shown for the first time at the Museum of Modern Art in 1945. The Army didn’t want it to be seen, claiming that the producers had not obtained the necessary waivers from patients. Huston, however, insisted that the waivers had been obtained.

In 1946, James Agee, who had seen it, called it “a fine, terrible, valuable non-fiction film about psychoneurotic soldiers” and said that if dynamite was necessary to reverse the decision to ban it, so be it. In 1981, when the film was finally screened under pressure from the organizers of a John Huston film festival, film critic Andrew Sarris wrote:

“Nothing in Agee’s elegantly-lean critiques had prepared me for the sheer conventionality and unoriginality of the work. Why on earth would the top brass object to a film which attributed to an army psychiatrist the combined talents and powers of Mandrake the Magician and Bernadette of Lourdes? Indeed, ‘Let There Be Light’ could be subtitled ‘The Song of Sigmund’ as it depicts a series of Freudian-faith-healing sessions as so many clinical epiphanies crossing over from the medical to the miraculous.” 

See John Huston's1945 film, Let There Be Light, an account of early treatment for what we now know of as PTSD at  https://bit.ly/JBurqT