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 along with lessons from Vietnam, Afghanistan and Iraq. A new generation of Americans will find themselves confronted by the latest strategic surprise, calling us to intervene in a foreign insurgency.
This article offers an enduring argument against involving American forces in COIN, based on a crucial factor that has hitherto received little attention: the mental health of the populations in weak and failed states. This argument suggests that successfully countering insurgencies in weak and failed states such as Afghanistan, Iraq, and a number of African nations will nearly always be doomed to failure. This position is buttressed by the high rate of pre-existing mental disorder among the populations of failed states. Said another way, the main effort of the counterinsurgency—the host nation government and security force—as well as the population, whose allegiance the counterinsurgent seeks, are both beset by mental disorder.
Central to this argument is the assertion that a nexus exists between weak and failed states, insurgencies and the 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 disorder among the population will also increase. As rates of mental disorder increase, the likelihood increases that a state will remain in its failed status. It is difficult to break free from this “sticky” situation.
This article examines the nexus between weak and failed states, insurgencies and prevalence of mental disorder; the impact of mental disorders on the individual and society; and the interaction between mental disorders and the use of military force. Finally, recommendations will be offered for senior leader consideration.
The Nexus between Weak and Failed States, Insurgencies, and Mental Disorders
The governments of weak and failed states have, by definition, become ineffective, illegitimate or both. As a result, the population’s grievances become more widespread, intense and legitimate. Weak governance is, therefore, frequently cited as a common precondition for insurgency. 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.”
Afghanistan provides an example of such a militarized civic society. Frequently, “Taliban” is incorrectly used as a catch-all 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), funded by the Central Intelligence Agency and comprised of scholars from a number of leading research institutions. Since that time, George Mason University (GMU), the Center for Systemic Peace and the Fund for Peace in conjunction with Foreign Policy magazine, have become the prominent organizations to study weak and failed states over time.
The Center for Systemic Peace’s State Fragility Index (hereinafter “Index”) is the most comprehensive, with a full dataset reflecting 1995 to present. The Index is comprised of an array of security, political, social and economic measures of a state’s legitimacy and effectiveness utilizing data from the World Bank and United Nations, among others.
The Index suggest that once a state becomes weak and failed, it is extremely difficult to break free. In 1995, the first year for which data are available, 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, only one state, Guatemala, almost made it into the top 50%, while the overwhelming majority remain in the bottom 20%. Seven of the 20 remain at war. Further, once hostilities cease, it appears 40% fall back into civil war within the first decade.
Figure 1, Tracking extremely fragile states over time
The data is equally dismal in terms of the propensity for weak and failed states to be at war. Of the eight nations identified as extremely fragile in the most recent Index, seven are presently at war, compared to only one, the United States, of the 42 states assessed as having 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, compared with just 2% of little-or-no fragility states.
Figure 2, Average percentage of states at war each year by level of state fragility
The authors of Global Report 2009 concluded that the worst category appears to be “synonymous with nearly perpetual warfare.” Other researchers reached similar conclusions 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. Further, of all civil wars that occurred during that time, 70% took place in failed states.
The evidence is strong that the majority of insurgencies will occur in weak and failed states. Therefore, if the United States seeks to assist a foreign government in countering its insurgency, in the majority of cases it will be doing so in weak and failed states.
Perhaps not surprisingly, the populations of weak and failed states tend to reflect mental disorders, such as PTSD and depression, at significantly higher rates than those of stable states. In 2009, the Journal of the American Medical Association published a meta-analysis of 181 surveys to examine the “prevalence of depression or PTSD among refugee, conflict-affected populations or both.” 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”, as noted above, there is a strong correlation between state fragility and armed conflict. Additionally, a comparison of the countries from the 181 surveys with those in the Index, revealed that weak and failed states were significantly overrepresented. For example, while extremely fragile states 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, included in the surveys were weak and failed states where American ground forces have fought, notably, 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%, compared with an estimated prevalence rate of 5% across the entire range of populations., The populations of weak and failed states, therefore, have PTSD rates approximately 500% greater than those of the average nation. The results for the presence of depression were nearly identical, with a weighted prevalence rate of 30.8% for the 117 surveys focused on depression.
In terms of causation, mental disorders such as PTSD and depression are strongly correlated with traumatic events, defined in the American Psychiatric Association's (APA) 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.” Examples of traumatic events include combat, forced relocation from one’s home, victimization in the form of torture and rape, and natural disasters.
Depression, aptly described as an end-product of failed adaptation to chronic emotional stress, is frequently present among those with PTSD. Research indicates 30-50% of those with PTSD also display “significant depressive symptomatology.” 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 focus on only one or two of the variables. Cumulative exposure to traumatic events has the strongest correlation for depression. 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. 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. 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 completed while a 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 reflected that 23% of the affected population still had PTSD.
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, defined as political violence and terror so pervasive, that it affects the “majority of the population.”
Figure 3, Prevalence of PTSD among different populations
Weak and failed states provide the ideal environments—severe traumatic events, recurring and cumulative exposure, and little time since last exposure to trauma—to create dramatically high rates of PTSD and depression. And, in those weak and failed states also beset with high terror rates, PTSD levels climb to more than 50%.
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. 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. 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. 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.
Of particular concern for quelling insurgencies is learned helplessness, which is strongly correlated to both PTSD and depression. Learned helplessness typically occurs after exposure to uncontrollable events and results in a person disassociating their own actions from achievement of a positive outcome. 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.
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 for less than half of those who receive treatment. For example, a meta-analysis of 34 studies involving drug treatment indicated an overall remission rate of 38%. 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.
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. 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 as a whole endures the negative effects.
Weak and failed states face additional challenges. Medical treatment is typically limited in the best of times and will be severely disrupted during conflict. 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 in the first place.
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. 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 every instrument of power is increasingly used in a coercive manner. War is a downward slide, with the use of military force applied to accelerate the run to the bottom where, ultimately, 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), which joint doctrine defines as a “violent struggle…for legitimacy and influence over the relevant population.” Deleterious terms such as destroy, defeat and seize give way to the more constructive 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.”
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…” And therein lies 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 extremely difficult. Increasing government capability and legitimacy, and gaining the population’s active support are quite problematic when the government, security force and 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 often an insurgent goal.
If an American unit had PTSD and depression rates of 30% or higher, it would likely 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.
1. Conduct COIN only when absolutely necessary. In populations beset with mental disorders, stability and growth are strongly inhibited, while the resources required for successful COIN, in terms of time and capital, are profound. Evidence from Vietnam, Iraq and Afghanistan suggests US policy-makers 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 their population. Since 2001, the military has done a significant amount of learning and adapting, including ensuring attention is paid to the host nation culture, language and history. The same cannot be said of the psychological component. Joint Publication 3-24, Counterinsurgency Operations, refers to culture and its importance nearly 100 times, while psychological considerations of the population go unmentioned. Furthermore, just as we recognize the need to secure the population, we should also 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 temporarily secured population will inevitably give way to insurgency and a continued weak and failed status if the high rates of mental disorders are not addressed.
3. Slow 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. 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 stuck in the worst fragility category. 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 government presence appears to be preferable from the population’s perspective to only having some security and presence. Touch-and-go US or host nation presence sets up the population as targets for increased insurgent intimidation: Are you working with the government? What information did you give them? Did you ask them to come? This results in even 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.” This is tied to American ideals, international laws and treaties, and the belief such discretion enhances government legitimacy. In Afghanistan and Iraq, however, widespread insurgency and rampant violence occurred only after we intervened. The removal of two reprehensible regimes and the subsequent inability of the host-nations/international community to provide adequate security unwittingly ushered in the conditions necessary for the insurgencies and spiraling rates of violence. Perhaps a less limited use of force might have yielded different results.
6. Study 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 largely been ignored, negatively impacting our ability to achieve America’s objectives. Studies could be commissioned among the medical community, academia and think tanks; entities which have the expertise to better understand the presence and impact of mental disorders among weak and failed state populations. Such studies would better inform the planning and execution of future COIN operations.
This article suggests there is an enduring argument to be made against America conducting COIN. Specifically, the argument is that insurgencies often occur in weak and failed states, which are home to disproportionately high rates of mental disorders such as PTSD and depression. This results in a problematic cycle of violence and traumatic events which drive higher rates of mental disorder which, in turn, place additional pressure on a failed state to remain in that category. As a result, victory from the counterinsurgent’s perspective becomes almost impossible.
 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.
 Robert Bates, “State Failure,” Annual Review of Political Science (2008), 9.
 Center for Global Policy, State Failure - Political Instability Task Force (19 Jan 2010), available at http://globalpolicy.gmu.edu/pitf/.
 By way of comparison, the Fund for Peace’s Failed State Index dataset starts in 2005. Additionally, it should be noted that early work on the State Fragility Index was done through GMU’s Center for Global Policy.
 Paul Collier, Anke Hoeffler, and Mans Soderbom, “Post-Conflict Risks,” Journal of Peace Research 45:4 (2008), 465.
 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.
 Monty Marshall and Benjamin Cole, State Fragility Index and Matrix 2010 (2011a), available at http://www.systemicpeace.org/SFImatrix2010c.pdf, 1.
 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.
 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.
 Marshall and Cole (2009), 22.
 Bates, 3.
 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.
 Steel et al, 538.
 Steel et al, 540.
 Yasan et al, 663; American Psychiatric Association, 466.
 Steel et al, 544.
 American Psychiatric Association, 466.
 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.
 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.
 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.
 Steel et al, 547.
 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 http://www.wma.net/en/30publications/10policies/c18/; Steel et al, 547-8.
 Steel et al, 543. See also the Political Terror Scale at http://politicalterrorscale.org/ 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.
 Steel et al, 540-1.
 Steel et al, 543.
 Data compiled from Steel et al, 540, 543; Yasan et al, 2009), 663; American Psychiatric Association, 466; and the Political Terror Scale.
 American Psychiatric Association, 349, 463; Nemeroff et al, 5.
 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.
 American Psychiatric Association, 345, 356, 465.
 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.
 Bargai, Ben-Shakhar and Shalev, 272, 274.
 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.
 Lyn Abramson and Martin Seligman, “Learned Helplessness in Humans: Critique and Reformulation,” Journal of Abnormal Psychology 87 (1978), 50.
 Diane Warden et al, “The STAR*D Project Results: A Comprehensive Review of Findings” Current Psychiatry Reports 9 (2007), 449, 451. See also Madhukar Trivedi et al, “Evaluation of Outcomes With Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice,” American Journal of Psychiatry 163 (2006), 33; A. John Rush et al, “Selecting Among Second-Step Antidepressant Medication Monotherapies: Predictive Value of Clinical, Demographic, or First-Step Treatment Features,” Archives of General Psychiatry 65:8 (2008), 870; 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; and Raymond Lam, “Priorities in treating depression only,” International Journal of Psychiatry in Clinical Practice 8:suppl 1 (2004), 26.
 Charles Nemeroff et al, “Comprehensive analysis of remission (COMPARE) with venlafaxine versus SSRIs,” Biological Psychiatry 63:4 (2008), 426-7.
 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.
 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.
 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.
 Joint Chiefs of Staff (2007), I-1.
 Joint Chiefs of Staff, Joint Publication 3-24, Counterinsurgency Operations (Washington, D.C.: Joint Chiefs of Staff, 2009), I-14.
 Joint Chiefs of Staff (2007), I-7.
 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.
 Joint Chiefs of Staff (2009), I-5.
 Joint Chiefs of Staff (2009), III-10.