War Atrocities in Afghanistan: Who Is Blameworthy?

Institutional military medicine is deserving of at least some liability for the steady drum beat of war stress injuries and misconduct stress behaviors.
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As the nation reels from the latest war atrocity, articles like "Robert Bales, Afghan Killing Suspect, Plagued By Money And Job Strife" attempt to explain why on March 11, 2012, 17 Afghanistan civilians, nine of whom were children, were allegedly murdered in the sanctity of their homes by U.S. Army Staff Sergeant Robert Bales, a decorated 38-year-old, married father of two young children with 10 years of honorable service.

Senior military and political officials reflexively assign full accountability to the isolated, deranged acts of a lone, troubled killer. Some mention the cumulative effects of a fourth combat tour for this seasoned, battle-tested leader since 2003, who was wounded twice, including a mild traumatic brain injury (TBI) during his last deployment. Others suggest triggers for the uncharacteristic rampage involve the alleged consumption of alcohol after witnessing a unit member losing a leg from a recent fire fight, disgruntlement over being passed for promotion, financial difficulties, and family strain due to an unanticipated deployment. Still others infer that a 2002 guilty plea for assault, a dismissed hit-and-run in 2008, and financial problems diagnose the accused murderer as a predisposed, morally-flawed "bad apple," or sociopath. Has to be, right? No "normal" person could commit such heinous acts, right?

Preventing War Atrocity and Other Misconduct Stress Behaviors

As reported in my Jan. 27, 2012 blog, "Preventing Military Misconduct Stress Behaviors," war atrocities are called "misconduct stress behaviors" by the military, which have always befallen in war, even at the hands of otherwise decent people. There have been dozens, if not hundreds of new stories within the past few years alone regarding military suicides, sexual assaults, homicides, etc. In hindsight, nearly every incident is preceded by occasions for early identification and intervention that could have prevented tragedy. In Bales' case, there were certainly plenty of opportunities whereby effective intervention might have diverted catastrophe. However, with exception of anger management in 2002, it is unknown what mental health services, if any, Bales received between 2003 and 2012.

What we do know is that Bales now sits alone in the isolation of his jail cell at Fort Leavenworth, Kan., contemplating a futureless, guilt-ridden existence, with the senseless blood-taking of 17 innocents allegedly on his hands. As a society, we collectively search for answers and compulsively seek to assign blame and responsibility when the seemingly-inexplicable happens. Confirmation of a monster becomes a national priority.

Who Is to Blame for War Atrocity?

First and foremost, the perpetrator(s) -- after all, they pulled the trigger. But the national finger pointing doesn't and shouldn't stop there. Other potential sources of culpability mentioned in the press are a possible anti-PTSD climate at Joint Base Lewis-McChord in Tacoma, Wash., where Bales was stationed, questions over deployment of a struggling SSGT after TBI, the Afghanistan base commander's alcohol policy, and so on. At the end of the day, however, it is likely that none of above may be revealed as legitimate contributing factors, leaving many with the unsettling feeling that certainly someone other than the accused screwed-up and must be held accountable.

Reality Check

We should never allow the unspeakable acts of a few to color the many. More than 2 million men and women have deployed and served their country honorably over the past 10 years, and 99.9 percent did not commit war atrocity. However, history has taught us time and again that individuals adapt differently to the effects of chronic war stress. Some experience positive effects, or even post-traumatic growth. Yet most, given a certain dosage or level of exposure, will and have experienced some sort of physical and/or psychological breakdown in the form of PTSD, depression, suicide, medically-unexplained symptoms, substance abuse, military sexual trauma, interpersonal violence, etc.

War and Societal Guilt

The most inconvenient of truths, however, is that every U.S. citizen above the age of 18 years bears some responsibility for such travesties, particularly the politicians and ruling elite. Bales and his family are just the latest of a long string of members of the warrior class that have unjustly born the burden of fighting an 11-year war. For instance, more than 107,000 military personnel have been deployed at least three times, while the vast majority of society remains comfortably insulated and complicity silent. No million-person marches or protests occur as long as the weight of war fighting conveniently falls upon an all-voluntary force comprised of fewer than one-half of 1 percent of the less-privileged members of society.

Yet, this story too will rapidly fade from the public eye -- especially when our conscience is tweaked by an uneasy, unrecognized sense of guilt as media accounts from Bales' military supervisors, co-workers, high school teachers, neighbors, friends, and family members don't paint a portrait of a crazed psychopath, but rather someone eerily like us, excluding of course the reported past transgressions and alleged financial miscalculations. How could a "caring, good-natured, family man and loving father" suddenly break and commit such unconscionable, mortal sin? There must be a monster inside, else wise what does it say about us? Do we bear any obligation for permeating the conditions well-known to break even the strongest and most resilient of human beings?

Culpability of Institutional Military Medicine

Additionally, institutional military medicine is deserving of at least some liability for the steady drum beat of war stress injuries and misconduct stress behaviors, starting with its public deception and gross negligence in preparing and responding to wartime mental health needs that led to a transparent but unacknowledged mental health crisis until as late as June 2007 (see G. Zoroya, Psychologist: Navy faces crisis and An Achievable Vision: Report of the Department of Defense Task Force on Mental Health, June 2007 ). Similar to Wall Street and banking barons whose unethical behavior subverted the U.S. economy, senior military leaders betrayed the public trust with impunity when it came to managing military mental health care.

A recent but token example is Department of Veteran's Affairs (DVA) and Department of Defense (DoD) policymakers' continued restriction of war veterans' access to eye movement desensitization and reprocessing (EMDR), one of the most effective, evidence-based PTSD treatments available, according to the VA/DoD clinical practice guidelines for managing post-traumatic stress, the American Psychiatric Association's practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder, and every major international PTSD treatment guideline. [1]

When Politics Trumps Science in Military Mental Health Care

In January 2011, the Government Accountability Office (GAO) investigated the DVA's indefensible decision to limit veterans' access to two of its homegrown PTSD treatments --Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) -- while excluding external competitors, like EMDR, developed outside the DVA. For instance, despite billions of dollars spent by the DVA/DoD to research PTSD treatments (e.g., massage, art therapy, marijuana derivatives, etc.), no EMDR research has been conducted since the wars began -- a blatant disregard of military medicine's mission to ensure that all war veterans have unrestricted access to the highest quality mental health treatment possible.

Scientific and personal bias should never enter into the equation. The status quo is even more inexplicable when in February, 2012, the DVA informs the Congressional Budget Office that only 40 percent of VA PTSD patients successfully complete PTSD treatment -- a 60 percent wash-out rate!

In stark contrast, randomized controlled trials of EMDR in 1998 with Vietnam combat veterans demonstrated that 77 percent of veterans no longer had PTSD diagnosis after 12 sessions -- with no drop-out [2]. Promising results; however, 1998 marked the last EMDR research trial the DVA has funded.

Why Should Military Personnel and Veterans Have Access to EMDR?

According to the DVA's National Center for PTSD public advice for military patients seeking PTSD treatment, "Experts are still learning how EMDR works [just not DVA or DoD experts]. Studies have shown that it may help you have fewer PTSD symptoms. But research also suggests that the eye movements are not a necessary part of the treatment."

Not a ringing endorsement for a VA/DoD-identified evidence-based therapy. The DoD and DVA also deceptively omit the fact that approximately two dozen controlled studies have show eye movements have positive effects, including decreases in the vividness of negative imagery and emotions that at a minimum can make treatments of traumatic memories more tolerable. Yet, if we take the DVA/DoD at their word, EMDR is still designated as an evidence-based PTSD treatment (see: VA/DoD, 2010) despite using meaningless eye movements and violating every known principle of talk therapy and trauma-focused treatment (see: Russell, 2008), such as:

•requiring little client self-disclosure and minimal therapist input

•not compelling clients to repetitively retell vivid details of trauma events

•requiring no homework, as compared to 40-60 hours of CBT homework completion

•not requiring teaching of coping skills, cognitive restructuring, or rational disputation

•a single protocol shown to simultaneously treat symptoms associated to PTSD, depression, anger, dissociation, traumatic grief, guilt, and medically unexplained symptoms including phantom limb pain

•effectiveness with both acute and chronic stress injuries

•better tolerated by clients than exposure therapies (e.g., PE)

•generally more rapid treatment effects than standard talk therapies

The real question ought to be: "Why are the DVA and DoD not researching EMDR?" Even more conspicuous, considering a 2007 National Institute of Mental Health-funded random controlled study where EMDR significantly outperformed Prozac (the frontline medication for PTSD and depression) and a placebo control in treating adults with PTSD [3]. At follow-up, 100 percent of those suffering from adult onset trauma no longer had PTSD.

Concluding Remarks

Of course it's impossible to know whether EMDR might have actually altered the horrific trajectory, had it been widely accessible to soldiers like Bales earlier. We will never know. It could also be that Bales received EMDR therapy before deploying and it did not prevent the ensuing massacre. Nonetheless, failure to do the right thing, for the right reasons, especially during wartime, constitutes an unnecessary self-inflicted wound and breach of trust raising serious questions of societal and institutional military medicine intent to keep faith with the warrior class.

Again, the EMDR issue is not the main point here, but a symptom of the bigger underlying problem regarding military mental health care and why after every major war since 1918 we experience mental health crisis and tragedies like the alleged Bales incident. No time to go into that here. For now, readers are urged to contact their congressional members and request that DVA and DoD end the political gaming and ensure that EMDR research, training, and treatment utilization is immediately made available on par with DVA-favored treatments. In sum, there is plentiful cause for a nation to self-reflect in its pursuit of social justice.


[1] Russell, M.C. (2008). Scientific resistance to research, training, and utilization of EMDR therapy in treating post-war disorders. Social Science and Medicine, 67(11), 1737-1746].

[2] (Carlson, et al. (1998). Eye movement desensitization and reprocessing for combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3-24.

For more by Mark C. Russell, Ph.D., ABPP, click here.

For more on PTSD, click here.

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