STRESS, COPING, AND RECRUITMENT Exploring the relationship between recruitment standards and stress-related disorders in the U.S.

military veteran population

Interdisciplinary Research Senior Thesis

Patrick Edward O’Toole

University of California at Berkeley May, 2015

Thesis Advisor: Gary Wren, Ph.D.

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- PTSD - Also known as PTSD, Post traumatic stress, Post traumatic stress disorder, Post traumatic stress, Post traumatic stress disorder Parent disease Anxiety disorder, Mental disorder Symptoms Nightmare, Insomnia, Anger, Irritability, Hyper vigilance, Self-destructive behavior, Flashback, Suicide, Violence, Depression Causes Psychological trauma, Major trauma, Incident stress Treatments Exposure therapy, Cognitive therapy, Eye movement desensitization and reprocessing, Cognitive behavioral therapy, Anxiolytic, Tricyclic antidepressant, Mood stabilizer, Selective serotonin reuptake inhibitor, Lamotrigine, Tranylcypromine Risk factors Combat, sexual abuse, auto accidents, divorce, physical abuse, emotional abuse, socioeconomic stressors, parental drug and alcohol use, single-parent upbringing, financial stress, bullying, isolation, childhood abandonment, adoption, parental incarceration, etc. Medical specialties Psychiatry Diseases with this risk factor Major trauma

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Table of Contents

1. Introduction………………………………………………………………………….3

2. An Overview of Stress Theory……...………………...…….……………………….5

3. Historical Context…………………………………………………………………...9

4. Research Background

a. the role of pre-existing trauma…………………….…..……………………..15

b. current research on the biology of stress…………...………………………..19

c. the effects of post-employment policies……………………………………..26

5. Theoretical Context………………………………………………………………….33

6. Conclusions and Recommendations………………………………………………....41

7. Work Cited…………………………………………………………………………...44

8. Sources Consulted……………………………………………………………………47

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Introduction

This research project asserts that most of the trauma, dislocation, and self-harm observed

in the Veteran population is not combat-related, having more to do with the enlistment strategies

of the Military including a lack of screening for pre-existing trauma, and biological variations in

individual ability to cope with stress. The general military is not staffed with well-educated,

well-adjusted, mature, effectively screened employees and represents, nationally, higher levels of

“at risk” potential for stress-related issues.

The enlisted ranks of the U.S. Military represent a concentration of already at-risk

employees. The unusually high levels of problems and issues expressed by the Veteran

population should be seen, at least to some degree, as expected outcomes of bad-fit hires who are

not well suited to stress. There is a driving need to implement effective methods of determining

biological dispositions to stress as the first boundary in the recruitment process. Emphasis must

be equally placed on the possibility of pre-existing stress and trauma, individual biological

ability to manage and cope with stress, and the effects of transitioning out of the military

paradigm into civilian culture. Of the 22 million veterans in America, over 80 percent were

never exposed to combat. The high levels of self harm that are observed in the Veteran

population cannot all be due to combat-specific stress, and this assumption distracts from the

reality of low-quality enlistment standards that target demographics more likely to have

employment problems, substance abuse issues, domestic violence and divorce- regardless of

military service.

Research for this paper will focus on the life-cycle of non-combat veterans described as

(1) the presence and effects of pre-existing trauma in entry-level applicants; (2) current research

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on the biology of stress-coping abilities; (3) the attachment trauma experienced when personnel

exit the military and engage in non-military environments. This project will not focus on stress-

related issues due to direct combat as it is neither original or in deficit.

This thesis will draw on academic and medical research as well as interviewing

academic-experts who work, study, and publish on Veteran-specific issues. I will directly

compare the levels of stress-related issues between officer and enlisted staff. The officer core is

assumed to have higher levels of education, maturity, and social fitness with resulting greater

abilities to deal with stress- a selection process that is quantitatively more rigorous than that of

regular enlistment.

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An Overview of Stress Theory

The reader will notice the use of a particular language throughout this paper- the

language of human resources, of personnel and employees, contexting the discussion of Veterans

to a conversation of hiring, employment, screening, candidate quality and manpower. It is

helpful to remember that a large percentage of the veteran population were government

employees, doing regular jobs, stationed in the U.S., dealing with the realities of day-to-day

bureaucracy, marriage, family, and finance.

This paper critically questions the higher-than- average self-harm, suicide, drug and

alcohol use, divorce, homelessness, etc., that is documented in the Veteran population, as being

the result of war and combat trauma alone, suggesting a higher-than-average level of pre-existing

trauma in the socioeconomic and psychological profiles of entry-level recruits. As the title page

suggests, this research is about stress and the ability to cope with it, looking to socioeconomic

influences, biological indicators, and the stress-related dynamics of attachments that are broken

upon entry and again upon exit from military employment, as systemic processes that deeply

influence the character of the Veteran population According to Mercer (2010) “Two concepts

are central to any psychological stress theory: individuals' evaluation of the significance of what

is happening for their well-being, and coping, i.e., individuals' efforts to manage specific

demands.”1 This concept- that people experience stress and must rely on personal ability to deal

with it, is the key context of this research. Veterans are simply people who experience stress and

deal with it as best they can. According to Krohne (2011), “this definition points to two

processes as central mediators within the person–environment transaction: cognitive appraisal

1 Mercer 2010, in Emotional Beliefs." Scribd. N.p., n.d. Web. 28 Feb. 2015.

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and coping”, suggesting that stress is a transaction between the individual and her environment,

quantified by emotional responses. “These appraisals, in turn, are determined by a number of

personal and situational factors. The most important factors on the personal side are motivational

dispositions, goals, values, and generalized expectancies.”2 The existing quality of the

individuals life-situation, then, as it informs personal motivation and expectation, desires, goals,

and education, forms the instrument through which stress is negotiated and contested: the

individuals coping mechanism- her ability to cope with stress. There are many classifications

used to describe coping methods regarding stress, each representing varying levels of

engagement and avoidance, repression and anxiety. These basic categorical approaches

represent quantitative differences in how an individual will experience stress. These coping

strategies explain why some veterans are able to experience stress without incurring stress-

related trauma.

Social Stress Theory is a sociological examination of how social environments expose

people to stress (the impact of disadvantaged social experiences), recognizing the potential stress

and trauma that comes with lower socioeconomic status. Social stress theory is central to this

research, as it is precisely this parameter of the U.S. population that looks to military service as a

vehicle for social integration and opportunity. This parameter, however, is statistically more

likely to have dealt with divorce, single-parent households, drug and alcohol exposure, physical,

emotional, and sexual abuse, financial strain, prejudice, and lower educational performance- all

of which create emotional scarring that can be triggered by high-stress environments with

2 Krohne, Heinz Walter. "Stress and coping theories." The international encyclopedia of the social and behavioral sciences 22 (2011): 15163-15170.

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resultant stress-related disorders3, a claim which is supported throughout this paper with peer-

reviewed data from academic and military research experts.

Research on gene-specific correlations points to indicators which support a biological

hypothesis, like Post-Traumatic Stress Disorder Comorbidity. According to the Cornelis (2010)

“PTSD is highly comorbid with other psychiatric disorders. A positive family history of

psychiatric disorders is a consistent risk factor for development of PTSD. Preexisting psychiatric

disorders may also increase PTSD risk, suggesting that PTSD represents a generalized

vulnerability to psychopathology following trauma. Twin studies have demonstrated that genetic

influences common to major depression, generalized anxiety disorder, panic disorder, or

substance dependence account for up to 60% of PTSD.”4 There is also strong indications that

dopamine-regulating genes that specifically deal with stress and fear vary widely, which would

account for dramatically divergent experiences of people with similar exposure to stress.5

Amazingly, there is also conclusive evidence that handedness, both in people and their parents,

plays an unbelievable role in the development of stress-related disorders.6 Brain lateralization

and the centering of language are a significant variables, if not causal factors, in who develops

stress-related disorders.

Attachment theory describes how human beings cope with life based on the quality and

nature of the attachments formed with adult caregivers throughout childhood, specifically

3 Meyer, Ilan H., Sharon Schwartz, and David M. Frost. "Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources?." Social science & medicine 67.3 (2008): 368-379. 4 Cornelis, Marilyn C. "Genetics of Post-Traumatic Stress Disorder: Review and Recommendations for Genome-Wide Association Studies." Current Psychiatry Reports. U.S. National Library of Medicine, 12 Aug. 2010. Web. 26 Feb. 2015. 5 Yehudaa, Rachel, PhD, and Karestan C. Koenenb, PhD. "The Role of Genes in Defining a Molecular Biology of PTSD." The Role of Genes in Defining a Molecular Biology of PTSD. Hindawi Publishing Corporation, Feb.-Mar. 2011. Web. 27 Feb. 2015. 6 Coren, Stanley, and Diane F. Halpern. "Left-handedness: a marker for decreased survival fitness." Psychological bulletin 109.1 (1991): 90.

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regarding trust. Breakdowns in attachment occur as avoidance pattern in adults- who experience

intense environments in as threatening- a disadvantaged coping style for stress. Four different

attachment classifications have been identified in children which are very similar to the

classifications discussed in “Stress and Coping Theory”, and may be highly correlated. There is

strong evidence that the quality of caregiving shapes the development of the neurological

systems which regulate stress in the developing child.7 This research asserts that there is a

significant parameter in the military population that comes to the military with pre-existing

attachment trauma, and find themselves in high-stress environments with less than desirable

coping styles. The military experience involves systematic attachment-breaking: from civilian

life when entering to re-assignments, losing friends and familiarity over time, to end with yet

another break in belonging upon release from service, leading to significant breakdowns over

time.

7 Fox NA, Hane AA (2008). "Studying the Biology of Human Attachment". In Cassidy J, Shaver PR. Handbook of Attachment: Theory, Research and Clinical Applications. New York and London: Guilford Press. pp. 811–29. ISBN 978-1-59385-874-2.

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Historical Context

“Management of the enlisted force has ostensibly been going on since the late 1700s when the nation first established permanent forces. However, for much of this 200+ year period, the concept of consciously managing a force- planning, organizing, and controlling the functions of accessing, developing, promoting, and transitioning, to achieve objectives- simply did not exist. Instead, forces happened as a result of events and reactions to events. For good reason, enlisted force management before the 1950s has been labeled "free flow." Only with the advent of large standing forces after World War II were attempts made to manage the enlisted force systematically.”

Members of the U.S armed forces are active in more than 150 countries. As of 2012,

approximately 66,000 are stationed in Europe; approximately 80,000 in East Asia and the Pacific

region; over 5,000 in North Africa, Southwestern and South Asia; over 1,700 in the Americas;

less than 400 in Sub-Saharan Africa; and less than 100 in states of the former Soviet Union.8 The

pie graph below9 displays in detail the distribution of U.S. forces throughout the world.

The Army has the largest number of personnel with 546,057 members, followed by the

Air Force with 328,812 members, the Navy with 314,339 members, and the Marine Corps with 8 Lynn E. Davis; Stacie L. Pettyjohn; Melanie W. Sisson; Stephen M. Worman; Michael J. McNerney (2012). "U.S. Overseas Military Presence: What Are the Strategic Choices?". Project Air Force. RAND Corporation. Retrieved 6 November 2012. 9 2012 Demographics Report - Military OneSource." 2013. 2 Mar. 2015

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198,820 members. Overall, 85.4 percent of Active Duty members are men and 14.6 percent of

Active Duty members are women. The U.S. Military and associated government agencies offer

hundreds of different jobs and career paths to its employees, all over the world. The variety of

available jobs reflects the different missions, tools, equipment, training, and expectations of this

industrialized, technological conglomeration of organizations, from flipping eggs and washing

dishes to underwater tours in submarines and cold-weather training in ice and snow.

How enlisted members are accessed, trained, promoted, and transitioned has changed

significantly over the years. Aptitude testing was used by the Army during WW I, designed to

measure ability and assign recruits to jobs. The Army General Classification Test (AGCT)

replaced the earlier tests during World War II, but after the war, each service developed its own

separate aptitude tests. The first all-services standardized aptitude test was developed in 1906,

called the Armed Forces Qualification Test (AFQT). The AFQT was designed as a screening

device to measure both the individual's "general mental ability to absorb military training within

a reasonable length of time and his potential general usefulness in the service, if qualified on the

tests"10. These standards were basic at best.

In 1974, the Department of Defense decided on a single test battery for screening

enlistees and for occupational assignment. The Armed Service Vocational Aptitude Battery

(ASVAB) was created to assist in this purpose. The ASVAB soon became (1976) the accepted

aptitude test of enlistment eligibility for all branches of the military (Army, Navy, Air Force,

Marines). The test consists of multiple sections that assess a potential recruit's ability in math,

word knowledge, number operations, and English comprehension. The modern ASVAB

provides the military with a highly useful tool to assess and rate current abilities and future 10 "Karpinos, B.S. [WorldCat Identities]." 2015. 2 Mar. 2015

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potential. The chart below is a breakdown of the scoring system used to classify ASVAB results

by category, out of a potential score of 100.11

“Categories I-IIIA constitute the upper half of the AFQT distribution and are generally viewed as

high quality. Individuals scoring in Category V—who generally read at a 5th to 7th grade level—

are excluded from military service and the proportion of Category IV recruits is limited to 20

percent by law.”12 The modern military, aware of the need for smarter soldiers, has set staffing

standards and thresholds for employment. More desirable jobs and career paths require better

scores and higher display of aptitude. Although enlist qualifications have varied from service to

service, current requirements are standardized between the Branches.13

● You must be a U.S. citizen or resident alien. ● You must be at least 17 years old. ● You must (with very few exceptions) have a high school diploma. ● You must pass a physical medical exam.

Military protocols, however, have little resilience in the face of military need. Consider

the following. “Following the end of the war, peacetime enlistment standards were raised and

the 1948 draft law set an aptitude standard somewhat more restrictive than before (corresponding

to a score of 13 on the current AFQT). Just before the start of the Korean War, the minimum

11 "Official ASVAB: Understanding ASVAB Scores - Asvab.com." 2007. 22 Mar. 2015 12 Fiscal Year 2001 National Defense Authorization Act 13 "Are You Eligible to Join the Military? | Military.com." 2012. 13 Mar. 2015

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aptitude standard was raised to 31 on the AFQT; this dropped to 13 and later to 10 as the conflict

continued and a larger number of potential conscripts were needed. During the period between

the Korean War and the Vietnam conflict, each service set its own minimum standards based on

its needs and the trend was in the direction of raising standards to improve the caliber of the

recruits. During the course of the Vietnam conflict, aptitude and education standards were

lowered four times.”14 This calls into question the extent to which the U.S. military and veteran

populations were subject to existing recruitment thresholds and role this plays in the

psychological breakdowns and personal struggles observed in both populations.

The Psychological screening of recruits dates back to World War I, following trends in

psychological testing and assessment that had become popular by the end of the 19th century.

“Intelligence testing became linked with the prediction of future performance and adopted during

World War I for testing military recruits.”15 The military tests inspired similar testing in schools

and workplace, as managers (and officers) found it highly useful in placing troops and assigning

duties. As early as WW I, however, it was already apparent that the need to identify precursors

for psychiatric issues was essential. “Neuropsychiatric casualties were always a major problem,

accounting for approximately 10% of disabilities. A large percentage of these casualties had

symptoms present several years before service induction. Medical care and disability from the

war cost $1 billion for more than 2.3 million World War I veterans.” 16 It was understood that a

mentally healthy armed force was a strong force, but there were doubts about the medical

communities capacity to detect mental illness.

14 Kirby, Sheila N., and Harry J. Thie. Enlisted Personnel Management: A Historical Perspective. No. RAND/MR-755-OSD. RAND CORP SANTA MONICA CA, 1996. 15 Cardona, Robert, and Elspeth Cameron Ritchie. "Psychological screening of recruits prior to accession in the US military." Recruit medicine (2006): 297-309. 16 Menninger WC. Psychiatry in a Troubled World. New York: The MacMillan Company; 1948: 267.

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By the end of WWII psychiatric evaluation was integrated into the general medical

examination “with the intention of identifying and disqualifying only gross psychiatric

disabilities.”17 However effective this was at basic screening, it did little to detect precursors and

pre-dispositions for mental breakdown and personality disorders that were not immediately

obvious. From 1945-1975 the US Military created, implemented, revised, and tested various

assessment methods used for mental health screening. A 1988 study of 340 U.S. enlisted

soldiers was evaluated by McCraw and Bearden to identify causal factors that might influence

the inability of military personnel’s to adapt, integrate, and perform in capacity. They

emphasized the need for early identification and separation of unsuitable recruits to minimize

increasing technical training costs. “These soldiers were described as unresponsive to therapeutic

interventions. Early indications of reduced adaptability were present in mental health

evaluations even while in basic training.”18 There is strong evidence that low-adaptive recruits

are cycled into active service regardless, which is alarming considering the implications of bad-

fit outcomes in the high-stress environments endemic to military service.

Fortunately, the past several decades has seen major advances in aptitude testing. In

1998 The Presidential Review Directive established a Recruit Assessment Program (RAP) “to

develop and maintain health and risk factor information on all recruit and officer accessions.”19

Increased measures for enlistment, like ASVAB scoring and high school graduation, have

provided immediate standards that noticeably increased the quality of recruitment. Mental health

17 US General Accounting Office. U.S. Senate Committee on Armed Services, Subcommittee on Personnel, Military Attrition: DoD Needs to Better Understand Reasons for Separation and Improve Recruiting Systems. Washington, DC: GAO; March 1998. GAO Testimony T-NSIAD-98-109. 18 McCraw, Ronald K, and Dwight L Bearden. "Motivational and demographic factors in failure to adapt to the military." Military medicine (2008). 19 "A National Obligation Presidential Review Directive 5." 2011. 2 Mar. 2015

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screening, however, does not provide the same measure of objectivity. According to Robert

Cardona, MD and Elspeth C. Ritchie MD, “Military history has demonstrated limited success in

predicting draftee performance by estimating independent personal qualities; functional

assessment with psychological testing is difficult to do.”20 Interestingly, the 2012 report by

Robert Cardona, MD (Captain, Medical Corps, US Army; Chief, Department of Behavioral

Health) and Elspeth C. Ritchie MD (Program Director, Mental Health Policy and Women’s

Issues, The Pentagon, Washington) “Psychological Screening Of Recruits Prior To Accession In

The US Military” ends with a rather bold and potentially alarming conclusion. “There is not an

available screening tool with adequate predictive validity and reliability to identify individuals at

high-risk before they enter military training and service.”21 What is interesting, and what leads

directly into the main body of this research, is this reflection in the summary of their report, a

report that served as a 2012 medical benchmark situational report for the Department of Defense

regarding the health and welfare of U.S. Military Personnel. “The best predictor of success in

the military is still a high school diploma, or 2 or more years of college.”22

20 "Recruit Medicine: Front Matter - U.S. Army Medical ..." 2012. 2 Mar. 2015 21 Cardona, Robert, and Elspeth Cameron Ritchie. "Psychological screening of recruits prior to accession in the US military." Recruit medicine (2006): 297-309. 22 Cardona, Robert, and Elspeth Cameron Ritchie. "Psychological screening of recruits prior to accession in the US military." Recruit medicine (2006): 297-309.

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Research Background “the role of pre-existing trauma”

“To define why some recruits do well and others do poorly, a model of individual

behavioral health is necessary to explain and predict resiliency- or the lack of it.”23 The word

Veteran is used in association with 22 million Americans who are alive and who served in some

capacity for one of many (fifteen) branches of the military or associated organizations24. This

term is, in fact, highly misleading in that it signals a unified set of experiences that are associated

with combat and war: associations which have nothing to do with the experience of the vast

majority of current and former military personnel alive today. In WWII, less than 35% of

military personnel were involved in combat25. In Vietnam, only one million of the nine million

active duty members who served in the armed forces between 1964-1975 were engaged in direct

combat, bring the number of direct combat veterans for that period to 11%26. Of the 540,000

American troops (active and reserve forces27) who served in the 1991 Persian Gulf War period,

fewer than 100,000 were actually involved in combat situations, making the percentage of

combat veterans from this period 3.7% of the total armed forces. Although the total number of

service members who have served in Afghanistan has reached 831,576 (and now number

68,000)28, this means that, on average over the past 14 years, 2%-3% of US Military forces were

involved in combat situations in Afghanistan at any given time.

23 "Textbooks of Military Medicine: Recruit Medicine." 2 Mar. 2015 24 Moulta-Ali, U. ""Who is a Veteran?" -- Basic Eligibility for Veterans' Benefits." 2014. 25 "Structuring the Active and Reserve Army for the 21st Century." 2011. 28 Mar. 2015 26 "Sobering Statistics." 2009. 28 Mar. 2015 27 "The Persian Gulf War - Infoplease." 2003. 28 Mar. 2015 28 Cooper, Helene (17 February 2012). "Putting Stamp on Afghan War, Obama Will Send 17,000 Troops". The New York Times. Retrieved 6 September 2012.

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There are hundreds of occupational possibilities available for military personnel, most of

them having nothing to do with combat or combat exposure. “In fact, about 91 percent of

today’s enlisted military jobs are non-combat. Such positions support the fighting forces, aid in

disaster relief, construct infrastructure, provide medical care and legal help and much more.

Essentially, any job you can find in a major city, you can find in the U.S. Military.”29 How then

to resolve the great disparity of mental health and stress-related disorders of the Veteran

population as compared to the general population of the United States? One assumption would

be that the Veteran population is a statistical sample of the general population of the United

States which has been subjected to destructive combat-related stress, and the suicide, drug and

alcohol abuse, homelessness, and general mental disorders observed are the natural and very

unfortunate result of this kind of exposure. However, less than 15% of the 22 million living

veterans have been involved in combat. This paper offers a different hypothesis which will be

addressed in detail in the follow chapter, which will present the intervention and thesis of this

research.

Reflecting back to the claims of the preceding this chapter that a high-school diploma or

2 years of college were still the best benchmark for quality recruitment, this research compares

enlisted veterans to that of officer veterans, which represents the differences of education,

privileged, socio economics, and pre-hire validation of capacity and character. Officers are

hired from a different parameter of the general population using much more rigorous standards.

These parameter differences: age, maturity, education, military training in college, and better

socioeconomics, creates an employee-selection process that recruits people with better stress

resilience, and less manifestations of stress-related problems.

29 "Types of Military Service - MyFuture." 2010. 13 Mar. 2015

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On August 20, 2013 the Journal of the American Medical Association published a

seminal article on suicide30 to include cross variant data from studies that compared age, rank,

and gender, to suicide as the dependent variable. According to this study, suicide rates are

negatively correlated with age, being an office, increased rank, and Reserve Status (this is

important as Reservists are statistically older and possess higher levels of education than their

Active Duty counterparts).31 While there are observable differences in the different military

branches, the figures that stand out come from age, rank, and officer status. This report as well

documents that deployment and combat exposure in not a unique causal factor in suicide. “At

the height of the Iraq war, the military enlisted troops with low levels of education and physical

fitness, and tried to prevent troops from leaving through a deeply unpopular program called

“stop-loss.” But the study found that neither policy pushed up the suicide rate. Instead, it found

that a third of soldiers who attempted suicide had mental health disorders before they enlisted.”32

In a similar manner, the Whitehall studies of British civil servants 33 on stress related

disorders “have found that workers who have little control over their jobs- meaning they have

minimal say over what tasks are performed or how they are carried out- have significantly higher

mortality rates than other workers in the civil service with more decision-making authority.”34 In

the military, authority, autonomy, and decision making the facets of control- are positively

correlated with rank, which is positively correlated with education, aptitude, and tests scores that

determine military occupation. The least successful and the least educated military employees 30 LeardMann, Cynthia A et al. "Risk factors associated with suicide in current and former US military personnel." Jama 310.5 (2013): 496-506. 31 "2013 Demographics - Military OneSource." 2014. 15 Mar. 2015 32 "Five myths about military suicides - The Washington Post." 2014. 14 Mar. 2015 33 Marmot, Michael G et al. "Health inequalities among British civil servants: the Whitehall II study." The Lancet 337.8754 (1991): 1387-1393. 34 "Naked Economics." 2005. 16 Mar. 2015, pp 185

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come from the civilian populations with the lowest educational achievements, representing the

highest at risk factors for preconditioned stress and trauma, ending up in stressful environments

with low decision-making authority.

According to a 2011 Pew Research study of transitioning difficulties out of military

service, there were four positive variables associated with re-integration.35 College graduation,

understanding of mission, being an Officer, and religious affiliation. This presents another

variable in understanding the Veteran population.

Homelessness, unemployment, substance abuse,

legal problems- are not only correlated, but also

indicative of certain socioeconomic demographics.

Age, education, perspective, and maturity are the

social buffers missing in a large percentage of the

Veteran population (at their time of service).

“Unemployment rates are lower for people who have a

bachelor's degree or higher. In 2010, both Persian

Gulf War and Iraq/Afghanistan vets who had a

bachelor's degree had an unemployment rate of 4.1 percent, much lower than for those with some

college -- 10 percent -- or high school graduates --12.5 percent.”36

35 "The Difficult Transition from Military to Civilian Life | Pew ..." 2011. 25 Mar. 2015 36 "U.S. Veterans: By the Numbers - ABC News." 2011. 14 Mar. 2015

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Research Background “current research on the biology of stress”

PTSD is used specifically as it is the current catchall term used to blanket a large array of

problems, disorders, and breakdowns that are observed and diagnosed in the veteran population.

This research wishes to unpack basic assumptions that come with this. It is not uncommon,

when former military employees are observed in breakdown to make two understandable and

concurrently egregious assumptions. (1) The individual in questions is suffering from PTSD that

has (2) something to do with their military experience. Whereas the last section hypothesized

pre-existing trauma and disposition due to social-stress conditions, we here examine biological

markers as pre-determinant factors. The hypothesis here is that biology- which in this case has

to do with grit, resilience, brain and cortisol responses to stimuli- constitutes a hierarchy of

coping abilities that are ingrained and innate, that can and must be tested for, and should, like

education, constitute a threshold for acceptance into military service. Most importantly, PTSD is

highly correlated with other mental disorders, and is usually the result of pre-existing conditions-

in the matter of military personnel, conditions that predated their service and any military-based

stress exposure. “PTSD is highly comorbid with other psychiatric disorders. A positive family

history of psychiatric disorders is a consistent risk factor for development of PTSD. Preexisting

psychiatric disorders, particularly conduct disorder, major depression, and nicotine dependence,

also increase PTSD risk, suggesting that PTSD represents a generalized vulnerability to

psychopathology following trauma. Twin studies have demonstrated that genetic influences

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common to major depression, generalized anxiety disorder, panic disorder, or substance

dependence account for up to 60% of PTSD.”37

As has been stated throughout this paper, the U.S. military has long-standing awareness

of and policies to screen for existing and potential mental problems. “During the 20th century,

US military psychiatrists tried reducing the debilitating impact of psychiatric syndromes by

implementing screening programs to detect factors that predispose individuals to mental

disorders. The success of screening has proven disappointing, the effects unclear, and the results

of treatment are mixed.”38 This being said, the employment of the ASVAB, medical screening,

background checks, and educational requirements has greatly increased military capacity over

the past 50 years. For all of this, however, there still remains an almost enigmatic disparity

between the problems and issues of the Veteran population and the greater American population

from which is it selected. A recent large, nationally representative study reports that 60% of men

and 50% of women experience a traumatic event at some point in their lives. And yet this same

study finds that estimates of lifetime posttraumatic stress disorder (PTSD) are 5% for men and

10% for women. “Research indicates that only one half of those who have an episode of PTSD

develop chronic symptoms of the disorder. These data underscore a central problem – although

trauma is a common element of many if not most lives, why do only a certain minor proportion

of individuals exposed to the various forms of trauma develop chronic pathological reactions of

37 Cornelis, Marilyn C. "Genetics of Post-Traumatic Stress Disorder: Review and Recommendations for Genome-Wide Association Studies." Current Psychiatry Reports. U.S. National Library of Medicine, 12 Aug. 2010. Web. 26 Feb. 2015. 38 Pols, H. "WAR & Military Mental Health." 2007.

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mind and body to catastrophic life events?”39 There is significant research that is being

conducted to determine the influence of biology on stress and stress-related pathology (PTDS).

Genetic Risk Factors: Brain development is highly sensitive to environmental

conditions. Nutrition, stability, financial security of caregiver, mental/emotional/physical health

of caregiver, will all affect the development of the various features of the central nervous system.

Simply put, “the overwhelming stress of maltreatment in childhood is associated with adverse

influences on brain development”.40 There is significant research to suggest that social activities

like expression, communication, attachment, and control over spontaneity, are linked to brain

development which is highly correlated to quality of childhood experience, specifically in

regards to stress and lack thereof. It is very important to understand the depth that family history

and socio economic stress affects the primary human output: the children raised in these

conditions, many of whom do less well socially and academically. In this regard do higher-level

educational requirements screen out potential breakdowns as they are positively correlated with

academic and social achievement.

But not all children are traumatized and not all traumatized children join the military. It

would be false to assert childhood trauma alone as the causal mechanism for stress-related

disorders in the Veteran population. A more responsible assertion is an acknowledgment that

biology defines coping levels, independent of environment, and that people may, because of their

biology, be less-fit for certain kinds of stress-related exposure. There are strong indications that

dopamine-regulating genes that specifically deal with stress and fear vary widely in function,

39 Schore, Allan N. "Dysregulation of the right brain: a fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder." Australian and New Zealand Journal of Psychiatry 36.1 (2012): 9-30. 40 De Bellis MD, Baum AS, Birmaher B et al. Developmental traumatology. Part I, Biological stress systems. Biological Psychiatry 1999; 45:1259–1270. (p.1281)

O’Toole 22

which would account for dramatically divergent experiences of people with similar

environmental exposure to stress. “According to such studies is the observation from

epidemiological studies that not all trauma survivors develop this disorder. Furthermore,

neuroendocrine findings suggest pre-existing hormonal alterations that confer risk for PTSD.”41

Breakthroughs in understanding stress as a varying experience came from research by H.D.

Kessler in several 1998-2000 studies of cortisol levels in PTSD afflicted test cases. The results

directly suggested “that PTSD does not represent a universal response to a major environmental

event” but a biological response to environmental stressors that do not permit, or in fact directly

impair, reinstatement of physiologic homeostasis or recovery from trauma.”42 PTSD then, is not

an event nor a condition, but a failure to recover from the normal effects of trauma, a failure that

is directly indicated with brain functioning. Low cortisol levels are correlated with PTSD. The

individual may not be able to re-establish proper levels, or, may have a lower threshold of

cortisol levels in general, putting them at great risk for developing PTSD pathology.

Interestingly, other scientists43 have speculated that lowered cortisol levels result from previous

trauma the individual never recovered from. Cortisol testing is key to understanding the

biological aspects of stress.

Brain lateralization: There is fascinating and conclusive evidence that handedness, both

in people and their parents, plays an unexpected role in the development of stress-related

disorders, demonstrating that left handed people, and those raised by them, are significantly at-

41 Yehudaa, Rachel, PhD, and Karestan C. Koenenb, PhD. "The Role of Genes in Defining a Molecular Biology of PTSD." The Role of Genes in Defining a Molecular Biology of PTSD. Hindawi Publishing Corporation, Feb.-Mar. 2011. Web. 27 Feb. 2015. 42 N. Breslau, R.C. Kessler, H.D. Chilcoat, L.R. Schultz, G. Davis and P. Andreski, Trauma and posttraumatic stress disorder: The 1996 Detroit area survey of trauma, Arch Gen Psychiatry 55 (1998), 626–632. 43 A. Perkonigg, R.C. Kessler, S. Storz and H.U. Wittchen, Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity, Acta Psychiatr Scand 101 (2000), 46–59.

O’Toole 23

risk for PTSD44. The human brain is a paired organ: two halves that look somewhat the same.

The term lateralization means that the two halves of the human brain are not alike. Each

hemisphere has functional specializations: some function whose mechanisms are localized in one

half of the brain. “In most people the left hemisphere of the brain is dominant for language.

Because of the increased incidence of atypical right-hemispheric language in left-handed

neurological patients, a systematic association between handedness and dominance has long been

suspected.”45 The hypothesis for this was well stated by researchers Claude Chemtob. Ph.D. and

Kristin Taylor Ph.D. in 2003. “This neuropsychological hypothesis asserted that the right

hemisphere plays a key role in the identification of threat and the regulation of emotion and that

right-handed people with reduced cerebral lateralization for language as indexed by female

gender, mixed-handedness, and familial left-handedness, would be more sensitive to threat and

prone to experience emotion more intensely, because their cerebral organization was

hypothesized to give greater relative primacy to right hemisphere contributions to ongoing

cognitive processing.”46

According to this research, there were significantly higher manifestations of PTSD in

U.S. combat veterans who are left handed or mix-handed or who were raised by left-handed or

mix-handed parents. While this is indeed surprising- and the exact reasons unknown- this

phenomena is cross-culturally verified through many studies reaching back to Viet Nam era

studies of PTSD. Veterans were divided into three groups based on lateral preferences, and the

indications for PTSD were astounding. “There was a significant difference in the proportion of

44 Coren, Stanley, and Diane F. Halpern. "Left-handedness: a marker for decreased survival fitness." Psychological bulletin 109.1 (1991): 90. 45 "972 - Brain." 2015. 25 Mar. 2015 46 Chemtob, Claude M, and Kristen B Taylor. "Mixed lateral preference and parental left-handedness: possible markers of risk for PTSD." The Journal of nervous and mental disease 191.5 (2003): 332-338.

O’Toole 24

participants with PTSD for three groups: participants with parental left-handedness and mixed

lateral preference (100% PTSD), participants with parental left-handedness or mixed lateral

preference (70% PTSD), and participants with neither parental left-handedness nor mixed lateral

preference (44% PTSD).47 Researchers Stanley Coren and Diane Halpern have offered an

evolutionary explanation for this, hypothesizing that left-handedness and its concordant

lateralization is an evolutionary trait that is atavistic and has been fading from human evolution

as humans have evolved. They suggest elevated mortality, coordination issues, and lower

academic achievements as representing a level of functioning and disposition that is no longer

adaptive in modern, right brain lateralized societies.48 Left-handedness is as such a genetic

marker associated with stress. “The specific linkage between lateral preference and stress is

based upon (an) earlier suggestion that the left cerebral hemisphere is more subject to damage

than is the right hemisphere of the brain.”49 Since brain lateralization, which is to say, the brain

half that is dominate, is directly associated with handedness, the suggestions in that left handed

and both-handed veterans will experience more stress trauma since the side of the brain that is

dominate in left-handed people is more at-risk for stress trauma and damage. Related research

lists neuropathology, birth stress, immune deficiencies, lower testosterone, and higher rates of

substance abuse, in left handed persons. Left-handed people- which is to say, those with a lateral

disposition to the right half of the brain, were 3x a likely to develop smoking and alcohol

addictions, with a 50% reduction in ability to recovery.50

47 Lovibond, Peter F, and Sydney H Lovibond. "The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories." Behaviour research and therapy 33.3 (1995): 335-343. 48 Coren, Stanley, and Diane F. Halpern. "Left-handedness: a marker for decreased survival fitness." Psychological bulletin 109.1 (1991): 90. 49 (Hecaen & Ajuriaguerra, 1964). 50 Smith, Vann, and Conrad Chyatte. "Left-handed versus right-handed alcoholics; an examination of relapse patterns." Journal of Studies on Alcohol and Drugs 44.03 (1983): 553.

O’Toole 25

In researching brain lateralization/handedness amongst Israeli veterans, researcher

Baruch Spivak with the Ness Ziona Medical Center, Israel, found that mixed lateral preference to

be associated with increased susceptibility to PTSD. According to this research, “Mixed-handed

combat soldiers had a 65% likelihood of having PTSD.”51

Brain lateralization, like cortisol testing, as a biological indicator of risk, is one of many

important examples of the relationship between biology and stress. The process of assessing

“enlistment-readiness” needs fundamental change that recognizes the reality of predisposition to

stress and coping. By adding “handedness of both applicant and parent”, and engaging

technologies to test for biological stress-responses, the enlistment process will have more

effective screening layers, to be complemented with other important research that address the

biology of stress, coping, and disposition.

51 Spivak, Baruch, et al. "Diminished suicidal and aggressive behavior, high plasma norepinephrine levels, and serum triglyceride levels in chronic neuroleptic-resistant schizophrenic patients maintained on clozapine." Clinical neuropharmacology 21.4 (1998): 245-250.

O’Toole 26

Research Background

“the effects of post-employment policies”

This section is specifically interested in the effects of detachment, as military personnel

leave their service organization to re-integrate to civilian life. Attachments- and Attachment

Theory- might seem out of place for adults, yet the impact of security and trust, however deep in

one’s past, has lasting effects for military personnel. This sections’ hypothesis is that a large

percentage of the veteran population came to the military with pre-existing attachment trauma,

seeking to form missing, or repair damaged, primary attachments, only to re-experience

attachment trauma upon release from service. The Washington Post published a startling article

about social adjustment and veteran (mental) health and social success. “Veterans also face

multiple stressors as they try to adjust to a civilian world that many barely recognize or

understand. They may struggle financially, with relationships, and with drug or alcohol

addiction. Meanwhile, the military medical system is so short-staffed that, too often, doctors give

troops prescriptions for powerful medications and simply send them on their way. Under stress,

without sufficient support — it can be a lethal combination.”52

The Israeli army conducted a study to assess the impact of attachment style on the way

young adults react to the stress combat training, having each soldier in the test complete an

attachment assessment during training. The reader may recall from the section on theoretical

considerations that an individual's attachment process manifests itself as a coping strategy that

represents their ability to manage stress. Each soldiers appraisal of the training

“involved their ways of coping with it, and peer evaluations of their leadership ability were assessed. Ambivalent persons reported more emotion-focused coping, appraised the training in more threatening terms, appraised themselves as less capable of coping with

52 "Five myths about military suicides - The Washington Post." 2014. 14 Mar. 2015

O’Toole 27

the training, and were evaluated by their peers as less fitting for military leadership. Avoidant persons reported more distancing coping and less support seeking and appraised the training in more threatening terms.”53

Although this section is more interested in what happens to veterans after the break in

belonging that occurs post-employment, the above research example is very helpful in contexting

the need for more insightful, more effective, pre-screening of recruits. As was stated in an

earlier section, “Attachment theory describes how human beings cope with life based on the

quality and nature of the attachments formed with adult caregivers throughout childhood,

specifically regarding trust. Breakdowns in attachment occur as avoidance pattern in adults- who

experience intense environments as threatening- a primary disadvantaged coping style for

stress.”54 As with brain lateralization and cortisol levels, depth screening for attachment-style

and testing for poor-fit coping styles might be another key element to avoid the financial and

emotional costs of personal breakdowns and lowered performance that comes with stress-related

disorders from bad-fit hires.

A similar study conducted with Israeli POW’s, sought to measure hardiness- the ability to

cope/deal/recover from stress- as a correlative of ‘positive attachment formation’ as a function of

their current quality of attachments, i.e. the level of trust and safety experienced in the present by

veterans exposed to high-stakes stress while in service. “Results showed that among both

combat veterans and ex-POWs greater hardiness and secure attachment style were separately

associated with reduced vulnerability to PTSD and the associated symptoms of depression,

anxiety and somatization. Military personnel with healthy attachment styles continue to create

53 Mikulincer, Mario, and Victor Florian (2005). "Appraisal of and coping with a real-life stressful situation: The contribution of attachment styles." Personality and Social Psychology Bulletin 21, no. 4 (2005): 406-414. 54 Fox NA, Hane AA (2008). "Studying the Biology of Human Attachment". In Cassidy J, Shaver PR. Handbook of Attachment: Theory, Research and Clinical Applications. New York and London: Guilford Press. pp. 811–29. ISBN 978-1-59385-874-2.

O’Toole 28

and accept healthy relationships- relationships of trust and security in which the soldier- now a

veteran- feels a measure of control.”55

A longitudinal study from German researchers in 2013 documented the relationship of

ambivalence and PTSD in German veterans: “Emotional ambivalence and post-traumatic stress

disorder (PTSD) in soldiers during military operations.”56 This study observed startling

relationship between emotional expression and stress-related trauma, specifically in regards to

emotional ambivalence- the cornerstone of positive or negative childhood attachment formation.

The correlations between emotional ambivalence on the one hand and the specific post-traumatic

stress on the other are not only statistically significant but may be relevant as risk factors.

Soldiers who are unable to express their feelings in a social context (competence ambivalence) or

do not want to do so (effect ambivalence) “thus have an increased risk of post-traumatic stress

disorder. It is conceivable that the selection procedure of the German military grants access to

the occupation of a soldier to persons with a personality structure that permits little insight into

their own mental processes and low sensitivity to emotional stress.”57

In this study, as with the study of Israeli veterans mentioned prior, attachment formation,

the ability to trust, to feel secure, to feel some measure of control, is essential to the coping

mechanisms needed to cope with stress, in any fashion and regardless of the context of exposure.

The German researchers adopted the use of the Harvard Trauma Questionnaire (HTQ) and the

Ambivalence over Emotional Expressiveness Questionnaire (AEQ-G18) to quantify the levels of

ambivalence and stress in the veterans they surveyed. They even predicted that “the AEQ-G18 55 Zakin, Giora, Zahava Solomon, and Yuval Neria. "Hardiness, attachment style, and long term psychological distress among Israeli POWs and combat veterans." Personality and Individual Differences 34.5 (2003): 819-829. 56 Marzabadi, Azad. "The Effectiveness of Mindfulness Training in Improving the Quality of Life of the War Victims with Posttraumatic stress disorder (PTSD)." Iranian journal of psychiatry 9.4 (2014): 228-236. 57 Marzabadi, Azad. "The Effectiveness of Mindfulness Training in Improving the Quality of Life of the War Victims with Posttraumatic stress disorder (PTSD)." Iranian journal of psychiatry 9.4 (2014): 228-236.

O’Toole 29

values could be considered predictors of the risk of developing symptoms of PTSD.”58 These

assessment technologies could well be employed during the recruitment process, to assess

attachment style as a predictor of coping strategy and capacity, hopefully screening out bad-fit

candidates before stress-exposure creates lasting problems and costs for the U.S taxpayer,

leaving the military blamed for damaging its employees, rather than an organization that suffers

from unsatisfactory hiring standards and practices- as reflected by its low-thresholds for

employment.

Yet- this research is not about combat veterans. As has been repeatedly stated throughout

this paper, a vast majority of the veteran population is not combat-exposed. What, then, explains

the larger than average (compared to the general American population) percentage of veterans

that engage in self-harming activities or display the effects of PTSD pathology? This section

makes observations regarding vast majority of service members who complete their service

contract and move back into the civilian population. What’s happens to them at the end of their

life cycle as active duty military personnel?

Jason Deitch, Ph.D., U.C. Berkeley, is a Veteran’s Affairs Consultant and the founder of

the U.C. Berkeley Veteran’s Group, who served as an Army medic for 10 years. In preparation

for this research, the author spoke with Dr. Deitch about military culture and re-integration into

the civilian population after end of contract. Dr. Deitch offered this perspective. “The military

does an unparalleled job in liquidating the cultural ties and associations of its service members.

The whole point of boot-camp, of the military culture of rules and regulations (not to mention the

impact of living in remote locals with geographic and social separation from regular, every-day

58 Albani C, Blaser G, Völker J, Geyer M, Schmutzer G, Bailer H, Grulke N, Brähler E, Traue HC Psychosoc Med. 2007 Sep 10.

O’Toole 30

society) is to install a new orientation and perspective- a process which is highly effective.”59

According to Deitch, the effects of this enculturation is lasting, leaving many veterans feeling

dislocated and out-of sync, even after years of civilian living. Former military personnel often

have a “two-places at once” experience after release from service. A part of their orientation is

stamped with their military experience, while they are physically and emotionally engaged in a

new environment and a new cultural context.

According to veteran Mike Ergo,

MSW, U.C. Berkeley, and Readjustment

Counseling Specialist with the Concord

Veteran Center, the adjustment process for

Veterans can be very challenging,

regardless of stress exposure or specific

military experience. The Veteran

population, all else aside, had some aspects

of their personality changed and altered as a

result of the enculturation process of being

in the military.60 Mike’s experience

working with the veteran population has let

him (like Dr. Deitch) to believe that the

process of leaving the military is nothing

short of traumatic for many veterans. As

59 Deitch, J., PhD, (Jan-Feb, 2015) 60 Ergo, M., MSW, Interview Jan-Feb 2015

O’Toole 31

Dr. Deitch said “how could they not be traumatized on some level after what they experienced,

being re-conditioned to an orientation so different from civilian life.”61

These conversations were supported by veteran Nathan D. Johnson, MSW, U.C.

Berkeley, and County Veterans Service Officer with the Contra Costa Veterans Administration.

For Nathan, “the very experience of being a military person causes significant shifts away from

civilian functioning. Military personnel are often isolated from civilian society. Think of boot

camp. Think of the remote bases in deserts and all around the globe. All of this is designed to

make fundamental shifts in personality and orientation- and it works”62 According to Nathan, it

works all too well. “They come back, not fitting in, torn between here and there.”63

Our military spends years enculturation its employees, and does this efficiently. The result is a

force-ready organization with its own organizational patterns, normative expectations, learning

styles, and intensive system of rewards and punishments. This is not to suggest that there is an

epidemic of readjustment issues, but to highlight another point of stress in the stress-chain that is

part of the life cycle of military employment. “Veterans who were commissioned officers and

those who had graduated from college have an easy time readjusting than enlisted personnel and

those who are high school graduates. Veterans who had a clear understanding of their missions

experienced fewer difficulties transitioning into civilian life than those who did not fully

understand their duties or assignments.”64

61 Deitch, J., PhD, Interview Jan-Feb 2015 62 Johnson, N., MSW Interview Jan-Feb 2015 63 Johnson, N., MSW Interview Jan-Feb 2015 64 "The Difficult Transition from Military to Civilian Life | Pew ..." 2011. 24 Mar. 2015

O’Toole 32

The military seems to lack an exit strategy for its end-of-contract soldiers. It front-loads

its employee focus on enculturation, reformatting its employees to its specific needs, using time-

tested techniques to instill values and patterns that are effective within the various sub-

organizations of the DoD. What happens after is not the focus of the training. As former Naval

Officer and Korean War Veteran Thomas P. O’Toole, J.D65, who spent his post-naval career as a

public defender who worked for years defending Alameda County veterans with criminal and

substance abuse problems “The military takes people from wherever they can get them, and

when its done, dumps them back on the street.” While harsh, this observation is reflected by the

Veteran coordinators and academics interviewed for this research. The author observed a strong

consensus that the military was lacking in post-employment services, with nominal release

practices that are more procedural than influential.

To what degree is the separation training and procedures effective, and how does this

compare with the effort and effectiveness of the doctrinal training of military enculturation?

Considering the growing numbers of trauma-based claims and observable effects of

maladjustment- not to mention the societal costs involved with life-time mental and physical

benefits- the military would be well served to find solutions, creating de-conditioning practices,

and implement procedures that support effective re-integration (and even better served to employ

multi-dimensional screening practices and raise the thresholds for employment, to avoid the

back-end costs that stem from unidentified pre-existing problems and maladaptive coping

mechanisms that are ill-suited to an environment with significant opportunities for stress-

exposure and high-stakes mission objectives.

65 O’Toole, Thomas P. LT U.S. Navy, JD St John’s: January 2015

O’Toole 33

Theoretical Context

The purpose of the preceding chapters were to highlight commonly held views about the

demographics that constitute the U.S. veteran population, and to present specific and valid

research which offers a significantly differing set of conclusions as to the casual factors

surrounding the unfortunately high manifestations of psychopathology, self harm, and substance

abuse- to include PTSD and suicide- that are present in the veteran population. The point was

made and will be restated, that there is no attempt being made to minimize the intensity and harm

that comes with combat exposure; rather, to point out that there is a disconnect between the <

10% of the veteran population that has combat exposure, and the x10 rates of PTSD, suicide, and

social adjustment problems facing the veteran population, compared to the general population

from which it comes. The assertion is straightforward, and attempts to debunk and overturn the

inaccurate and widely held belief that combat exposure is the causal factor responsible for the

rampant PTSD in the U.S. military; that PTSD is not an unavoidable outcome of a military

career.

The press, government officials, and most of the public believes in a myth that suicide

and self-harm in former military personnel are the result of combat and emotional trauma

experienced during service. This is decidedly not true. My argument suggests that problemed

veterans (and current military employees) bring the pre-disposition, if not the outright condition,

into their military employment, conditions that are common to the sociodemographics which

look to the military, and to which the military targets as entry level recruits, who are less likely to

resist stress and/or have lower resilience and abilities to cope. The relationship between combat

O’Toole 34

and stress is well established, but as has been explained, too few U.S. soldiers have participated

in combat for this to explain the quantitative realities of veteran PTSD, a number that grows

yearly, with ever increasing financial burden to the United States taxpayer.

This paper favors a far different assumption of the causal factors responsible for PTSD

and suicide; that the Veteran population, far from being a representative sample of the U.S.

general population, is a concentrated population of stress-disposed applicants who were hired to

fill entry-level positions, and that the higher-than-average (as compared to the greater US

population) manifestations of stress-related and mental disorders are a reflection of the quality of

person allowed into military service via the screening requirements for employment. Some of

these hires were already “at risk” for stress-related disorders when they enlisted, and the

subsequent suicides, substance abuse, and mental health problems observed in the Veteran

population is highly correlated with the expected outcomes of the populations from which it was

recruited. Consider the following quote from the 2014 joint research study from the U.S. Army

and the National Institute of Health. “Findings from The Army Study to Assess Risk and

Resilience in Service members (Army STARRS ) include: the rise in suicide deaths from 2004 to

2009 occurred among soldiers never deployed; half of soldiers who reported suicide attempts

indicated their first attempt was prior to enlistment and reported higher rates of ADHD,

intermittent explosive disorder (recurrent episodes of extreme anger or violence), and substance

abuse disorder than in the civilian population.”66

Fundamentally, the current enlistment standards for entry-level military personally are far

too low; in fact, they are sub-standard. On March 14th and 15th of 2015, the author’s 14 year

old son completed a set of three (full) practice ASVAB tests, scoring a 92 out of 100 for the 66 "Suicide in the Military: Army-NIH Funded Study Points to Risk." 2014. 14 Mar. 2015

O’Toole 35

mean average of the three tests. That a 14 year old child in his first year of high school can score

90%+ on a cognitive assessment exam, and that the ASVAB requirements for enlistment are a

minimum of 30 for the Army and 31 for the Marine Corps, calls into question the threshold the

U.S. military employees for assessing and accepting mental capacity and educational abilities. I

find the requirement of a (1) high school diploma or GED, (2) no obvious medical issues, (3) no

major felonies and (4) the ability to score 30 on the ASVAB test- (all of which can be waived) as

the current thresholds for enlistment, to be alarmingly low. I directly question the

accomplishments these minimal thresholds offers in terms of verifying and validating the

character and capacity of the applicant’s overall fitness for service in regards to a resiliency to

stress and its associated disorders The military employs low thresholds for enlistment which

provides inexpensive entry-level employees, but pays for it, extensively, with an at-risk

population entitled to lifetime financial and medical benefits. According to a 2013 study

published in the Journal of the American Medical Association “The increase in military suicides

is the result of untreated mental illness (depression, bipolar disorder) and substance abuse rather

than combat experience or number of deployments”67 The current military recruiting standards

are neither fair to under-qualified applicants, or the society who must pay for it.68

67 "JAMA Network | JAMA | Home." 2012. 13 Mar. 2015 68 "Expenditure quick facts - US Department of Veterans Affairs." 2011. 13 Mar. 2015

O’Toole 36

Why there is such a remarkably higher quantity of stress-related disorder than there is in

the general U.S. population? A percentage that far outstrips the percentage of combat-exposed

members? Repeated tours through the war zones of Iraq and Afghanistan are often cited as a

primary reason so many troops take their own lives. But the statistics don’t support that

explanation. A study published in the Journal of the American Medical Association69 in the

summer of 2013 found that longer deployments, multiple deployments and combat experience

didn’t elevate suicide risk. In fact, more than half the troops who had taken their lives had

never deployed. A separate, massive Army study70 found that, while suicide rates for soldiers

who had deployed to Iraq or Afghanistan more than doubled, the rate for those who had never

spent time in the war zones nearly tripled.”71

69 LeardMann, Cynthia A et al. "Risk factors associated with suicide in current and former US military personnel." Jama 310.5 (2013): 496-506. 70 "Suicide in the Military: Army-NIH Funded Study Points to Risk." 2014. 14 Mar. 2015 71 "Five myths about military suicides - The Washington Post." 2014. 14 Mar. 2015

O’Toole 37

Most importantly, this is not a unique breakdown within the U.S. military, or a temporary

staffing issue. The effects of recruitment standards are supported by longitudinal, cross-cultural

studies throughout the world. The New Zealand Journal of Psychiatry compared U.K., U.S.,

Australian and New Zealand soldiers from Vietnam to Afghanistan over the past 50 years.

“Research has demonstrated that elite forces and officers, who are better trained and more

cohesive, have better fitness and higher motivation, and have significantly lower levels of PTSD

than lower ranks.”72 As long as the United States maintains an active staff of combat-ready

forces that will be subject to a variety of combat and non-combat related stressors, and, as long

as these forces have life-time financial and medical guarantees, it is essential that higher

thresholds for enlistment that prevent the employment of candidates who are unsuited for stress

and contain the pre-conditioners for PTSD pathology.

The significance of my hypothesis is well supported from the theories of social stress

presented in the earlier sections of this paper. The social stress framework is based on

longitudinal studies of the effects of social circumstances and stress exposure, providing clear

evidence of the strong correlation of socio economics and stress; in fact, it can be seen as a

socioeconomic stress theory. There is strong correlation between economic hardship and stress,

between low parental education and stress, between parental substance abuse and child

substance-use, between low parental education and financial hardship and low child-performance

in regards to education, and sexual, emotional and physical abuse that is more manifest in lower

social-opportunity demographics- all of which create stress and trauma in these communities.

These are the demographics that do less well in school, display lower performance on

standardized tests, are at higher risk for criminal-legal activities and substance abuse. 72 Richardson, Lisa K, B Christopher Frueh, and Ronald Acierno. "Prevalence estimates of combat-related posttraumatic stress disorder: critical review." Australian and New Zealand Journal of Psychiatry 44.1 (2010): 4-19.

O’Toole 38

“First, poverty is associated with increased levels of parental stress, depression, and poor health – conditions which might adversely affect parents’ ability to nurture their children. Low-income parents report a higher level of frustration and aggravation with their children, and these children are more likely to have poor verbal development and exhibit higher levels of distractibility and hostility in the classroom. Our baseline estimates imply that every $1,000 increase in (family) income raises math test scores by 2.1 percent and reading test scores by 3.6 percent of a standard deviation.”73

High Schools are compelled by current educational pressures to graduate their students.

“Over the last 15 years, 15 million students have graduated from high school reading at below

the basic level (Bottoms, 2004). Only 16% of Black high school seniors and 20% of Hispanic

high school seniors scored at or above proficient on the 2005 NAEP reading test and only 43%

of Caucasian students (NCES, 2007).”74 That a student is able to get a diploma or a GED and

score a minimum of 30 on the ASVAB provides no barrier to entry that would screen out the

demographics with higher-than-average pre-disposition to future stress, to stress related

disorders, to PTSD and mental health issues.

Officer selection offers a perfect comparison. In order to become an officer, the applicant

has to have, at minimum, a bachelor’s degree from an accredited university, which puts the

applicant, on average, at 22-24 years old. This applicant must be eligible for a secret security

clearance, which means they must pass a rigorous background process that far exceeds anything

performed for enlisted personnel. The officer corps has a “100% bachelors degree rate, a 40%

graduate degree rate, and a 10% professional/doctoral rate.”75 In order for a college grad to

73 Dahl, GB. "The Impact of Family Income on Child Achievement ..." 2010. 74 Rutenberg, David. "High School Literacy: A Quick Stats Fact Sheet." National High School Center (2009). 75 "2013 Demographics Report - Military OneSource." 2013. 14 Mar. 2015

O’Toole 39

become an officer76, they must be selected for, qualify for, and complete a rigorous Officer

Candidate School, with intense levels of physical, mental, and academic exposure. At least 25%

of all military officers come form College ROTC programs, where they receive years of ongoing

training, evaluation, academic review, and are held to very high performance standards and

expectations throughout college, where they are trained to be leaders.77 Other military officers

either receive a direct commissioned into the military because of excellence in their given

profession (lawyers, doctors, academics, etc.) or are graduates of elite military colleges like West

Point and Annapolis, which enroll and graduate top performing academics. This process reflects

high barriers to entry and high selection criterion. In alignment with the previous discussion on

enlisted criterion, becoming an officer requires a significantly greater display of pre-existing

social and academic accomplishments that far exceed the low threshold requirements for entry-

level enlisted applicants.

It has been easy to find studies and research that support the major themes and hypothesis

of this project. The correlation between variables presented is so extensively documented, and

populous in number, as to support the theoretical connections and claims made. Consider this

statement from Richardson, Frueh and Acierno in 2010, that “the expression of PTSD is

mediated by genetic factors. Other relevant pre-deployment factors include age and education at

time of deployment, gender, race, early conduct problems, intelligence, childhood adversity,

family history of psychiatric disorder, pre-deployment psychological, poor social support after a

trauma, and personality pathology.”78 The quote offer comes from the Australian and New

76 "Become an Officer”." 2010. 14 Mar. 2015 77 "West Point versus other sources of commission - John T. Reed." 2011. 14 Mar. 2015 78 Richardson, Lisa K, B Christopher Frueh, and Ronald Acierno. "Prevalence estimates of combat-related post-traumatic stress disorder: critical review." Australian and New Zealand Journal of Psychiatry 44.1 (2010): 4-19.

O’Toole 40

Zealand Journal of Psychiatry in 2010, where researchers conducted a study of western nation

soldiers: American, Dutch, Australian, New Zealand, U.K.- from Viet Nam through Desert

Storm, Iraqi Freedom and Operation Enduring Freedom, looking for the causes and correlations

for PTSD. Findings indicated higher rates of PTSD “among personnel who were younger, less

educated, enlisted, current smokers, and problem drinkers”79, with a reminder that smoking and

drinking were correlated with lower education and lower rank. It requires only a small extension

to move from this, to the primary assertion of my research paper, that the unusually high

percentage of problems, issues, self-harm, and PTSD observed in the veteran population is

reflection of the parameters of the general population from which it was recruited- that in fact,

the low hiring thresholds allow the exact demographics which are younger, less educated,

enlisted, current smokers, problem drinkers, most prone to early conduct problems, childhood

adversity, family history of psychiatric disorder, pre-deployment psychological problems, poor

social support, and personality pathology, to become entry-level/enlisted employees who later

constitute the veteran population. What we are observing in the veteran population is a

concentrated demographic of Americans who are predisposed to stress-related problems,

undiluted by their healthier, more able counterparts who have better opportunities available due

to their higher level of social achievement.

79 Richardson, Lisa K, B Christopher Frueh, and Ronald Acierno. "Prevalence estimates of combat-related post-traumatic stress disorder: critical review." Australian and New Zealand Journal of Psychiatry 44.1 (2010): 4-19.

O’Toole 41

Conclusions and Recommendations

John Vandiver is a Stars and Stripes contributor, and published an article on July 23,

2014, about child abuse and military employment. This article referred to findings by the

Journal of the American Medical Association80, which suggest that those who have served in the

military are “more likely to have suffered childhood abuse or to have lived in homes where there

was violence than their non military counterparts.”81 The article by Vandiver and the research

from the American Medical Association offers strong agreement with the main premise of my

research- that exposure to childhood trauma was linked to post-traumatic stress disorder,

substance abuse, and risk for suicide- noting that “nearly half of suicides among active-duty

personnel have been among people who have never deployed to war zones”82, according to the

study, which cited a Defense Department report from 2011. More interesting than any

agreement, however, was the closing remarks of the Stars and Stripes article. The study’s

authors had also compared military service during the all-volunteer era to the pre-1973 draft era.

Beginning with the all-volunteer era, “men with military service have had a higher prevalence of

“adverse childhood events” in all 11 categories examined- than those without military service.

Meanwhile, during the draft era, the only difference among men was in household drug use,

where men with military service had a lower prevalence than men without military

service.”83

80 Blosnich, John R., Melissa E. Dichter, Catherine Cerulli, Sonja V. Batten, and Robert M. Bossarte. "Disparities in adverse childhood experiences among individuals with a history of military service." JAMA psychiatry 71, no. 9 (2014): 1041-1048. 81 "Study: Military a refuge for those exposed to childhood abuse." 24 Mar. 2015 82 Blosnich, John R., Melissa E. Dichter, Catherine Cerulli, Sonja V. Batten, and Robert M. Bossarte. "Disparities in adverse childhood experiences among individuals with a history of military service." JAMA psychiatry 71, no. 9 (2014): 1041-1048. 83 "Suicide in the military - Stripes." 2010. 25 Mar. 2015

O’Toole 42

The recommendations of this research are that, to dilute the higher-than-average

concentration of less-fit applicants in entry-level recruits, several measures must be

operationalized. (1) Mandatory draft. This would require all citizens to offer a period of service

unless otherwise disqualified. (2) Significantly higher thresholds for selection, to include raising

the minimum age and ASVAB/cognitive requirements combined with rigorous biological and

psychological testing, to screen out lower-end candidates who lack the biological, psychological,

and cognitive capacities needed to perform in high-stress environments. (3) Make these profiles

public domain, to ensure that draftees will not opt to malinger or falsify behavior to avoid

service. (4) Tie in federal financial aid to the honorable completion of the service requirements,

to make performance and service part of social mobility and education. There is significant

evidence that the disparity of U.S. soldiers with PTSD compared to its western equivalents has to

do with the compensation structures offered by the U.S. Government. Recently there has been

concern that health-care systems and disability policies encourage psychiatric illness claims.

“In fact, some argue that the U.S. VA system has failed to benefit from the lessons of 20th century military psychiatry regarding social expectations and incentives.84 Certainly recent administrative trends regarding PTSD disability claims are troubling. Among the relatively small subset of veterans seeking mental health treatment in VA clinics, most (up to 94%) also concurrently apply for PTSD disability benefits.85 Further, the number of veterans receiving VA disability payments for PTSD increased 79.5% from 1999 to 2004, while all other disabilities increased only 12.2% during that same period.86 Different compensation and support structures for veterans of non-US armed forces may partly explain different estimates of PTSD prevalence.”87

As long as the U.S. military engages in stress-positive environments, and allows

84 Hotopf M, Wessely S. Can epidemiology clear the fog of war? Lessons from the 1990-91 Gulf War. Int J Epidemiol 2005; 34:791–800. 85 Frueh BC, Elhai JD, Gold PB et al. Disability compensation seeking among veterans evaluated for posttraumatic stress disorder. Psychiatr Serv 2003; 54:84–91. 86 Frueh BC. PTSD and Vietnam veterans. Science 2007; 315(5809):184–187. 87 Baggaley M. ‘Military Munchausen’s’: assessment of fictitious claims of military service in psychiatric patients. Psychiatr Bull 1998; 22:153–154.

O’Toole 43

for bad-fit hires, there will be a wide variance of coping skills and hardiness within the military

population- with expected outcomes of long and short-term stress-related issues in the veteran

population. This is offered in no way to devalue the real and expected trauma suffered by

soldiers exposed to the hardships and horrors of combat. There is, however, such conclusive

evidence that PTSD pathology is deeply influenced by social, biological and educational

variables that it would be unconscionable to continue what is nothing less than a staffing crisis,

with claims and costs rising every year (see graph pg. 26). Considering the low probability of a

draft, the author would provide these baseline recommendations for the continuance of an all-

volunteer force.

Minimum age: 20 Minimum Education: 2 year of college/AA degree Minimum ASVAB Score: 60 Rigorous background check & no use of waivers Advanced psychological profiling Cortisol Testing Ambivalence testing The Harvard Trauma Questionnaire (HTQ) Ambivalence over Emotional Expressiveness Questionnaire (AEQ-G18) Brain Lateralization testing and mandatory exclusion

To conclude: age, education, lateralization, cognitive abilities, attachment style, biology,

and socio economics are each significant variables in determining individual coping styles

regarding stress, and pre-dispositions to the pathology of PTSD. There is troubling data to

support that the prevalence of PTSD in U.S. soldiers comes from pre-existing conditions that can

be anticipated, and that the benefits structure from current V.A. policies is conducive to PTSD

claims. Current hiring thresholds, and a lack of sophisticated screening techniques, facilitates the

employment of bad-fit and lower-end candidates, and the resultant claims, and costs, of stress-

related disorders observed in the Veteran population, is a direct result.

O’Toole 44

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