An Enduring Argument against Counterinsurgency.docx-1 by dandanhuanghuang


									                       An Enduring Argument against Counterinsurgency

       American troops have departed Iraq. The drawdown has begun in Afghanistan. The

Pentagon’s latest strategy document focuses on the Asia-Pacific region and the great power

challenges therein. The Army and Marines prepare to grow smaller, while the Navy and Air

Force increase capabilities for anti-access, area denial environments. Big war is back and

counterinsurgency (COIN) is out.

       Yet with almost 100 percent certainty, a time will come when the works of T.E.

Lawrence and David Galula will again be dusted off and lessons from Vietnam, Afghanistan and

Iraq reviewed. That generation of Americans will find themselves confronted by the latest

strategic surprise which will summon the ghosts of COIN past. The drums will beat, once more

calling us to intervene in a foreign insurgency.

       This article offers an enduring argument against involving American forces in COIN, an

argument which has little to do with today’s budgetary woes or wary eyes towards China. The

argument suggests successfully countering insurgencies in weak and failed states, which is where

the United States has and will often fight them, is almost impossible. This difficulty is driven, in

part, by the high rate of mental disorders among the host-nation population. Said another way,

the main effort of the counterinsurgency—the host nation government and security force—as

well as the population, whose allegiance the counter-insurgent seeks, are both beset by mental

disorders. And, just as mental disorders have a deleterious effect on the individual, as the rates

rise among the population they will have an increasingly deleterious effect on the state, too.

       Central to the argument is the assertion that a nexus exists between weak and failed states,

insurgencies and prevalence of mental disorders (this paper focuses on two: Post-traumatic Stress

Disorder (PTSD) and Major Depressive Disorder (depression)). Furthermore, this nexus is such
that each of the three characteristics can drive changes in the others. For example, as a state

becomes increasingly weak and failed, the likelihood of insurgency increases. As insurgencies

and the trauma associated with them intensify, the rates of mental disorders among the

population will also increase. As rates of mental disorders increase, the likelihood of a state

remaining in its weak and failed status also increases. It is difficult to break free from this sticky


        This article is divided into four sections. The first examines the nexus between weak and

failed states, insurgencies and prevalence of mental disorders. The second section discusses the

impact of mental disorders on the individual and society. The interaction between mental

disorders and the use of military force follows. The final section offers recommendations for

senior leader consideration.

The Nexus between Weak and Failed States, Insurgencies and Mental Disorders

        Weak governance is frequently cited as a common precondition for insurgencies, as it

makes insurgency more attractive.1 The governments of weak and failed states have, by

definition, become ineffective, illegitimate or a combination of both. As a result, the

population’s grievances become more widespread, intense and legitimate. Additionally, “when

states fail, those with power employ it to extract resources from those without power. The latter

flock to those who offer them security, albeit often for a price…Political predation from the top

is thus accompanied by the militarization of civic society below.”2

        Afghanistan provides an example of such a militarized civic society. Frequently,

“Taliban” is incorrectly used to denote the various groups fighting against the Afghan

government and the International Security Assistance Force. The Haqqani Network, Hizb-i-

Islami, drug runners, and other criminal elements all represent examples of a militarized civic

society in Afghanistan.

        The study of weak and failed states began in earnest in 1994 with the advent of the

Political Instability Task Force (PITF). The PITF was funded by the Central Intelligence

Agency and comprised of scholars from a number of leading research institutions.3 Since that

time, George Mason University (GMU), the Center for Systemic Peace (which had a long-

standing affiliation with GMU) and the Fund for Peace in conjunction with Foreign Policy

magazine, have become the prominent organizations to quantitatively study weak and failed

states over time. The Center for Systemic Peace’s State Fragility Index is the most

comprehensive with a full dataset available from 1995 to present.4 By way of comparison, the

Fund for Peace’s Failed State Index dataset starts in 2005.

        The State Fragility Index is comprised of an array of security, political, social and

economic measures of both a state’s legitimacy and effectiveness. Similarly, the Failed State

Index looks at 12 key indicators across the political, social and economic arenas which are

further supported by more than 100 sub-indicators.

        Once a state becomes weak and failed, it is very difficult to break free. In 1995, the first

year of available data, there were 20 states listed as extremely fragile—the worst category of

state fragility. As Figure 1 shows, over the 15 years of available data, one state (i.e., Guatemala)

almost made it into the top 50%, while the overwhelming majority remain in the bottom 20%.

Seven of the 20 also remain at war. Further, once hostilities cease, 40% will again return to civil


        Figure 1, Tracking extremely fragile states over time6

        In terms of the propensity for weak and failed states to be at war, the data is equally

dismal. Of the eight nations identified as extremely fragile in the most recent State Fragility

Index, seven are at war.7 That compares with only one of the 42 states assessed as having little-

or-no fragility being at war (i.e., the United States).8 Eighty-eight percent of extremely fragile

states are at war as opposed to 2% of states with little-or-no fragility. As Figure 2 indicates, this

relationship holds true throughout the last decade, with 64% of extremely fragile states at war

during that period. That compares with 15% of highly fragile states being at war during the same

time period, with the percentages dropping off for each successive category until just 2% of

little-or-no fragility states being at war in the last decade.

                           States at War, 2000-2010

                      60                                                           High

   % States at War                                                                 Serious

                      40                                                           Moderate

                                          Level of State Fragility

Figure 2, Average percentage of states at war each year by level of state fragility9

        This led the authors of Global Report 2009 to observe that the worst category of weak

and failed states appears to be “synonymous with nearly perpetual warfare.”10 Other researchers

obtained similar findings at the regional level. Ndulu et al found that failed states in Africa from

1970 to 1995 were embroiled in civil wars 60% of the time. And, viewed from the reverse

direction, of all civil wars that occurred during that time in Africa, 70% took place in failed


        The majority of insurgencies occur in weak and failed states. Therefore, if the United

States seeks to support a foreign government in countering its insurgency, in the majority of

cases it will be in a weak and failed state.

        Mental disorders, such as PTSD and depression, are found in much higher rates among

the populations of weak and failed states than among those of stable states.12 The Journal of the

American Medical Association published a meta-analysis of 181 surveys designed to examine

the “prevalence of depression or PTSD among refugee, conflict-affected populations or both.”13

Although the criterion for survey inclusion was not specifically weak and failed states, but rather

those states subject to “armed conflict or widespread organized violence”, there is a strong

correlation between state fragility and armed conflict as discussed previously. Additionally, a

comparison of the countries from the 181 surveys alongside the State Fragility Index data

revealed that weak and failed states were significantly overrepresented. For example, while

extremely fragile states normally represent only 6% of the world’s nations, 38% of the surveys

were conducted within those populations. Conversely, little-or-no fragility states typically

represent 26% of the world’s nations, yet none of the surveys were done among these

populations. Finally, notable weak and failed states where American ground forces have fought

were also included in the surveys (i.e., Afghanistan, Iraq, and Somalia).

       The meta-analysis showed substantially higher rates of PTSD and depression among

refugee and/or conflict-affected populations. The 145 surveys which addressed PTSD revealed

an overall weighted prevalence of 30.6%.14 This compares with an estimated prevalence rate of

5% across the entire range of populations.15 The populations of weak and failed states cohere,

therefore, with PTSD rates 500% greater than those found across the collective populations of all

states. The results for the presence of depression were nearly identical. Of the 117 surveys

focused on depression, the weighted prevalence rate was 30.8%.16

       In terms of causation, mental disorders such as PTSD and depression are strongly

correlated with traumatic events. A traumatic event is defined in the American Psychiatric

Association's Diagnostic and Statistical Manual of Mental Disorders as a situation where “the

person experienced, witnessed, or was confronted with an event where there was the threat of or

actual death or serious injury. The event may also have involved a threat to the person's physical

well-being or the physical well-being of another person. The person responded to the event with

strong feelings of fear, helplessness or horror.”17 Examples of traumatic events include combat,

forced relocation from one’s home, victimization in the form of torture and rape, and natural


        Depression, aptly described as an end-product of failed adaptation to chronic emotional

stress, is frequently present among those with PTSD.18 Research indicates 30-50% of those with

PTSD also display “significant depressive symptomatology.”19 Conversely, there are those who

will have depression but will not have PTSD. In the aggregate, though, a significant portion of

those with either PTSD or depression will also have the other, particularly in the context of weak

and failed states where exposure to trauma is recurring.

        The likelihood of a person having PTSD and/or depression, as well as the intensity of that

disorder, is correlated with the severity of traumatic experience, the number of traumatic

experiences they were exposed to, and the time elapsed since exposure; though experts debate

the contribution of each and some only focus on one or two of the variables.20 Cumulative

exposure to traumatic events has the strongest association for depression.21 For PTSD, previous

experiences of torture, which is defined as the “deliberate…infliction of physical or mental

suffering…to force another person to yield information…or for any other reason,” has the

strongest correlation.22 For example, while the overall weighted prevalence of PTSD in conflict-

torn nations is 30.6%, that number jumps to 53.5% when filtering for those with the highest

exposure rates to torture within three years since conflict termination.23 Temporal proximity to

the conflict, as suggested, also impacts the likelihood of PTSD and depression, with rates

declining as time elapses from conflict termination. For instance, the surveys done while the

conflict was on-going or had been terminated for less than a year yielded 39.9% rates of PTSD,

while those surveys conducted two to six years after conflict termination demonstrated 23% of

the affected population still had PTSD.24

       As Figure 3 indicates, PTSD rates climb dramatically in populations that are conflict-

affected and/or become refugees. Additionally, these rates climb even higher when populations

are confronted with high rates of terror.

           PTSD Rates across Different Populations
                                                               Avg of All Populations

                                                               Conflict-affected and/or
                     30                                        Refugee Populations
   % of population
     with PTSD
                                                               High Terror Populations
                     10                                        (NOTE: Iraq meets this
                                                               criterion since 1983,
                                                               Afghanistan since 1979 [1990
                      0                                        and 2003 excepted])
                                 Population Segment

Figure 3, Prevalence of PTSD among different populations25

       The severity of the traumatic experience, cumulative exposure to traumatic events, and

time since exposure to the trauma all contribute to the likelihood of a person having PTSD or

depression. Weak and failed states provide such environments, with dramatically high rates of

PTSD and depression to show for it. And, in those weak and failed states also beset with high

terror rates, PTSD levels climb to more than 50%. Weak and failed states are home to

disproportionally high rates of PTSD and depression.

Impact of Mental Disorders on the Individual and Society

       Those with PTSD or depression, by the APA’s definition, have an array of cognitive and

behavioral symptoms that impair their social, occupational or other area of functioning.26 In the

case of PTSD, symptoms often include persistent re-experiencing of the traumatic event,

increased anxiety, a numbing of general responsiveness, “deliberate efforts to avoid thoughts,

feelings…about the traumatic event and to avoid…situations and people who arouse

recollections of it,” loss of meaning, and substance abuse.27 Symptoms for depression typically

include depressed moods or lack of interest in normal activities lasting for two weeks or longer

and a “diminished ability to think or concentrate;” the depressed person may also feel intensely

threatened.28 Additionally, a large body of literature indicates traumatic stress impairs learning

and memory processes, which has profound implications for weak and failed states wrestling

with effectiveness and legitimacy issues.29

       Of particular concern for quelling insurgencies is learned helplessness, which is strongly

correlated to both PTSD and depression.30 Learned helplessness typically occurs after exposure

to uncontrollable events and results in a person disassociating their own actions from

achievement of a positive outcome.31 They no longer perceive themselves as having control over

future outcomes, so they no longer try. As a person learns that their situation is uncontrollable,

cognitive, motivational and emotional deficits occur. In the cognitive domain, future learning is

impaired. The person has difficulty seeing how A causes B. Motivationally, voluntary initiation

of activity decreases. And emotionally, the person’s interest levels decrease.32

       PTSD and depression, like the statuses of weak and failed states, are persistent, even

when medically treated. In the case of depression, the literature is fairly unified—remission

occurs only in the minority of cases.33 For example, a meta-analysis of 34 studies involving drug

treatment indicated an overall remission rate of 38%.34 For PTSD, the literature is more

ambiguous, with remission rates recorded from less than 20% to 100%. However, a meta-

analysis of 55 studies yielded a 56% remission rate for those who received treatment.35

       In sum, mental disorders impair the individual’s functioning. Interpersonal relationships

are disrupted. Cognitive deficits decrease capability. Finding and keeping a job gets more

difficult.36 And, the prognosis for recovery is quite challenging. The toll on the individual and

their loved ones can be immense. When, however, the incidence rates skyrocket to 30% in the

case of conflict-affected nations, or beyond 50%, as is the case in high terror states, society writ

large endures the negative effects.

       Weak and failed states face additional challenges since treatment is typically limited.

Additionally, there is little hope of effective treatment if the person continues to be exposed to

the same traumatic experiences that caused the mental disorder.

Military Force and Mental Disorders

       In traditional war, where nation-states fight in force-on-force military operations, military

force is used in concert with the other instruments of national power to defeat, destroy or seize.37

Each of those three words from joint doctrine—defeat, destroy and seize—superbly captures the

negative atmosphere of traditional war, an atmosphere so deteriorated that each instrument of

power is increasingly used in a coercive manner. It is a downward slide, with the use of military

force brought in to accelerate the run to the bottom where, finally, the enemy’s fielded force has

been defeated or the will of the population or decision-makers has been sufficiently shocked that

they opt for surrender. In traditional war, mental disorders among the opposing population or its

fielded force arguably work to our advantage. As we seek to accelerate the downward slide,

increased prevalence of mental disorders further destabilizes the opposing state and its

population, and destabilizing fits well with efforts to defeat, destroy and seize.

       Countering insurgencies, however, is quite dissimilar. It is contained under the umbrella

of irregular warfare (IW), and joint doctrine defines IW as a “violent struggle…for legitimacy

and influence over the relevant population.”38 Deleterious terms such as destroy, defeat and

seize give way to the more gainful vocabulary of legitimacy and influence. Whereas traditional

war is a downward slide accelerated by military force until the conflict is resolved, in COIN

military force is used to arrest the downward slide. Accordingly, the majority of military force is

dedicated to providing security for the population and increasing the capacity of host-nation

security forces, while only a minority is focused on killing and capturing insurgents. According

to joint doctrine, “COIN requires joint forces to both fight and build.”39

       Joint doctrine goes on to say that what makes IW “’irregular’ is the focus of its operations

– a relevant population – and its strategic purpose – to gain or maintain…the support of that

relevant population…”40 And therein is the problem. Both the population and the government

of weak and failed states suffer from such high rates of mental disorders, that accomplishing

positive objectives becomes almost impossible. Increasing government capability and

legitimacy, and gaining the population’s support, are remote indeed when the main effort—the

host nation government and security force—and the focus of operations—the population—are

beset with PTSD and depression.

       For the insurgents, however, the high rates of PTSD and depression provide a benefit in

much the way they do in traditional war. The high rates inhibit positive growth in government

legitimacy and capability, while making the population more susceptible to intimidation and the

belief that they themselves are incapable of changing things for the better. While this does not

endear the insurgents to the population, it does keep the environment unstable and insecure over

time, which is typically an insurgent goal.

       If an American unit had PTSD and depression rates of 30% or higher, it would be

declared combat ineffective. When we conduct COIN in weak and failed states, we are

supporting a government and security force that is likewise combat, or perhaps more

appropriately, mission ineffective. Mentoring and training them to a sufficient level of

legitimacy and effectiveness is incredibly difficult, particularly so in the timeframes likely

required by domestic political considerations at home.


       1. Do not conduct COIN unless absolutely necessary. Since the populations of weak

and failed states are beset with mental disorders, stability and growth are strongly inhibited. As a

result, the resources required for successful COIN, in terms of time and capital, are profound.

Evidence from Vietnam, Iraq and Afghanistan suggests we severely underestimated the

resources required to successfully conduct COIN in those weak and failed states.

       2. Include a psychological estimate/analysis of the host nation in any COIN OPLAN

and ensure sufficient mental health capability to address the mental disorders of the host

nation population. Since 2001, the military has done a significant amount of learning and

adapting. Ensuring attention is paid to the host nation culture, language and history represent

such examples, but the same cannot be said of the psychological component. By way of

comparison, Joint Publication 3-24, Counterinsurgency Operations, refers to culture and its

importance nearly 100 times, while psychological considerations of the population go

unmentioned.41 Furthermore, just as we recognize the need to secure the population, we should

now recognize the need to secure the psychological domain of the population. It is not

compassion that drives this point, rather it is the assertion that a population temporarily secured

will again give way to insurgency and continued weak and failed state status if the high rates of

mental disorders are not addressed.

       3. Consider slowing the speed at which sovereignty is returned to the host nation

government. Joint doctrine presents a model of governance across a range of state fragility.42

Optimally, the host nation government is in charge, and this typically corresponds with nations

that are in “recovery.” When the state is “failing,” a transitional civilian government will often

be in place, and when it is “failed,” a transitional military government may very well need to be

in charge. While a transitional military government is described as undesirable, joint doctrine

acknowledges that less desirable forms of government may be required during periods of

increased fragility. As an example, Afghanistan has had an elected president since 2004, though

Afghanistan was and remains in the worst fragility category (i.e., extreme). Joint doctrine

suggests, and Afghanistan’s current status appears to corroborate, that such weak and failed

states are incapable of legitimately and effectively governing their people.

       4. Only enter areas where security will be provided 24/7. While enduring security is

optimal, no security or presence is preferable from the population’s perspective to only having

some security and presence. Touch-and-go US or host nation presence sets the population up for

increased insurgent intimidation—Are you working with the government? What information did

you give them? Did you ask them to come?—which results in more traumatic events. PTSD and

depression rates will likely rise in response, making the situation worse than if there had been no

US/host nation presence.

       5. Vigorously debate the use of force in COIN. Doctrine currently recommends to

“limit the use of force to the minimum necessary.”43 It is tied to American ideals, the Law of

Armed Conflict and the belief such discretion enhances government legitimacy. Conversely,

though, in both Afghanistan and Iraq we are confronted by the fact that insurgency and violence

became rampant only after we intervened. Our removal of two reprehensible regimes and

subsequent inability to provide adequate security unwittingly ushered in the conditions necessary

for the insurgencies and spiraling rates of violence, which contribute to higher rates of mental

disorder. Perhaps a less limited use of force might have yielded different results. The history

books are yet to be written, but it will be interesting to see how the average Afghan and Iraqi

ends up assessing the costs and benefits of their respective regime changes, new found freedoms

and insurgencies.

        6. Commission studies to further examine the impact of mental disorders in COIN.

Achieving America’s objectives is the focus of our military. In COIN settings, mental disorders

and the broader psychological component have been largely ignored. This negatively impacts

our ability to achieve America’s objectives. Utilizing the expertise of academia and think tanks

would likely assist in this area.


        This article suggests there is an enduring argument against America conducting COIN.

Specifically, the argument is that insurgencies occur in weak and failed states, and weak and

failed states are home to disproportionately high rates of mental disorders such as PTSD and

depression. The interrelationship between weak and failed states, insurgencies and mental

disorders is such that they reinforce one another, resulting in weak and failed states tending to

remain weak and failed, with high rates of mental disorders and violence among the population.

As a result, victory from the counterinsurgent’s perspective becomes almost impossible.

1 Seth Jones, “The Rise of Afghanistan’s Insurgency: State Failure and Jihad,” International Security (2008), 8.
See also James Fearon and David Laitin, “Ethnicity, Insurgency, and Civil War,” The American Political Science
Review 97 (2003), 75.
2 Robert Bates, “State Failure,” Annual Review of Political Science (2008), 9.
3 Center for Global Policy, State Failure - Political Instability Task Force (19 Jan 2010), available at
4 Early work on the State Fragility Index was done through GMU’s Center for Global Policy.
5 Bates, 9.
6 Data extracted from Marshall & Cole’s Global Report 2010 and State Fragility Index and Matrix 2010, as well

as Marshall & Gurr’s Peace and Conflict 2005, Gurr et al’s Peace and Conflict 2001, and Marshall’s Major
Episodes of Political Violence 1946-2011.
7 Monty Marshall and Benjamin Cole, State Fragility Index and Matrix 2010 (2011a), available at, 1.
8 Marshall and Cole (2011a), 34-35. To be at war, a state must have at least 500 "directly-related" fatalities

and sustain a base rate of 100 "directly-related deaths per annum." Therefore, of all ISAF nations, only the US
is at war in Afghanistan.
9 Data compiled from Global Report 2011, 2009, 2008, 2007; Peace and Conflict Report 2005, 2003, 2001; as

well as the State Fragility Index, 1995-2010.
10 Marshall and Cole (2009), 22.
11 Bates, 3.
12 Zachary Steel et al, “Association of Torture and Other Potentially Traumatic Events With Mental Health

Outcomes Among Populations Exposed to Mass Conflict and Displacement A Systematic Review and Meta-
analysis,” Journal of the American Medical Association 302:5 (2009), 540, 543. See also Aziz Yasan et al,
“Trauma Type, Gender, and Risk of PTSD in a Region Within an Area of Conflict,” Journal of Traumatic Stress
22:6 (2009) 663; and American Psychiatric Association, American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition, Text Revision. (Washington, DC: American Psychiatric
Association, 2000), 466.
13 Steel et al, 538.
14 Steel et al, 540.
15 Yasan et al, 663; American Psychiatric Association, 466.
16 Steel et al, 544.
17 American Psychiatric Association, 466.
18 Louisa Burriss et al, “Learning and Memory Impairment in PTSD: Relationship to Depression,” Depression

and Anxiety 25:2 (2008), 155. See also Charles Nemeroff et al, “Posttraumatic stress disorder: A state-of-the-
science review,” Journal of Psychiatric Research 40:1 (2006), 5, 8, 10; and Jon Elhai et al, “Testing whether
posttraumatic stress disorder and major depressive disorder are similar or unique constructs,” Journal of
Anxiety Disorders (2011), 404-5.
19 Duncan Campbell et al, “Prevalence of Depression–PTSD Comorbidity: Implications for Clinical Practice

Guidelines and Primary Care-based Interventions,” Journal of General Internal Medecine 22:6 (2007), 712.
20 Patrick Vinck, “Exposure to War Crimes and Implications for Peace Building in Northern Uganda,” Journal of

the American Medical Association 298:5 (2007), 543. See also Denise Michultka, Edward Blanchard and Tom
Kalous, “Responses to Civilian War Experiences: Predictors of Psychological Functioning and Coping,” Journal
of Traumatic Stress 11:3 (1998), 571, 575-6; as well as Kaz de Jong et al, “The Trauma of War in Sierra Leone,”
The Lancet 355:9220 (2000), 2067; and Howard Johnson Andrew Thompson, “The development and
maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A
review,” Clinical Psychology Review 28 (2008), 40-2.
21 Steel et al, 547.
22 World Medical Assembly, WMA Declaration of Tokyo - Guidelines for Physicians Concerning Torture and

other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment
(1975), preamble, available at; Steel et al, 547-8.

23 Steel et al, 543. See also the Political Terror Scale at which uses US
Department of State and Amnesty International data to ascribe a rating to each country based on the extent to
which the government and/or its agents use political violence and terror against the population. Data is
available from 1976 onwards.
24 Steel et al, 540-1.
25 Data compiled from Steel et al, 540, 543; Yasan et al, 2009), 663; American Psychiatric Association, 466;

and the Political Terror Scale.
26 American Psychiatric Association, 349, 463; Nemeroff et al, 5.
27 American Psychiatric Association, 463-4; Josh Cisler et al, “PTSD symptoms, potentially traumatic event

exposure, and binge drinking: A prospective study with a national sample of adolescents,” Journal of Anxiety
Disorders 25:7 (2011), 978. See also Raymond Flannery and Mary Harvey, “Psychological Trauma and
Learned Helplessness: Seligman's Paradigm Reconsidered,” Psychotherapy 28:2 (1991), 374.
28 American Psychiatric Association, 345, 356, 465.
29 Burriss et al, 150. See also J. Douglas Bremner et al, “Functional Neuroanatomical Correlates of the Effects

of Stress on Memory,” Journal of Traumatic Stress 8:4 (1995), 529; Charles Morgan III et al, “Stress-Induced
Deficits in Working Memory and Visuo-Constructive Abilities in Special Operations Soldiers,” Biological
Psychiatry 60:7 (2006), 726; and Slawomira Diener et al, “Learning and Consolidation of Verbal Declarative
Memory in Patients with Posttraumatic Stress Disorder,” Journal of Psychology 218:2 (2010), 139.
30 Bargai, Ben-Shakhar and Shalev, 272, 274.
31 Neta Bargai, Gershon Ben-Shakhar and Arieh Shalev, “Posttraumatic Stress Disorder and Depression in

Battered Women: The Mediating Role of Learned Helplessness,” Journal of Family Violence 22 (2007), 268.
See also Steven Maier, “Exposure to the Stressor Environment Prevents the Temporal Dissipation of
Behavioral Depression/Learned Helplessness,” Biological Psychiatry (2001), 763.
32 Lyn Abramson and Martin Seligman, “Learned Helplessness in Humans: Critique and Reformulation,”

Journal of Abnormal Psychology 87 (1978), 50.
33 George Papakostas, Maurizio Fava and Michael Thase, “Treatment of SSRI-Resistant Depression: A Meta-

Analysis Comparing Within- Versus Across-Class Switches,” Biological Psychiatry 63:7 (2008), 699. See also
Raymond Lam, “Priorities in treating depression only,” International Journal of Psychiatry in Clinical Practice
8:suppl 1 (2004), 26.
34 Nemeroff et al, 426-7.
35 William Berger et al, “Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: A

systematic review,” Progress in Neuro-Psychopharmacology & Biological Psychiatry 33:2 (2009), 170. See also
Kathryn Ponniah and Steven Hollon, "Empirically supported psychological treatments for adult acute stress
disorder and posttraumatic stress disorder: a review," Depression & Anxiety 26 (2009), 1090-1100.
36 Jennifer Vasterling et al, "Attention, learning, and memory performances and intellectual resources in

Vietnam veterans: PTSD and no disorder comparisons," Neuropsychology 16:1 (2002), 10-12. See also
Karsten Paul and Klaus Moser, "Unemployment impairs mental health: Meta-analyses." Journal of Vocational
Behavior 74 (2009), 278; and Arne Mastekaasa, "Unemployment and Health: Selection Effects," Journal of
Community and Applied Social Psychology 6 (1996), 189, 199, 203; and Holly Prigerson, Paul Maciejewski and
Robert Rosenheck, "Population attributable fractions of psychiatric disorders and behavioral outcomes
associated with combat exposure among US men," American Journal of Public Health 92 (2002), 60.
37 Joint Chiefs of Staff, Joint Publication 1: Doctrine for the Armed Forces of the United States (Washington, D.C.:

Joint Chiefs of Staff, 2007/updated 2009), I-6.
38 Joint Chiefs of Staff (2007), I-1.
39 Joint Chiefs of Staff, Joint Publication 3-24, Counterinsurgency Operations (Washington, D.C.: Joint Chiefs of

Staff, 2009), I-14.
40 Joint Chiefs of Staff (2007), I-7.
41 Psychological or a variant is used in JP 3-24, but the use is limited to psychological operations or isolating

the insurgents from the population both physically and psychologically.
42 Joint Chiefs of Staff (2009), I-5.
43 Joint Chiefs of Staff (2009), III-10.


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