Sgt. Robert Bales and multiple tours of duty: How many is too many?

“I am well aware of the necessity for hardness and toughness on the battlefield,” Eisenhower admonished. “But this does not excuse ... abuse of the ‘sick.’ ” Congress concurred, stepping in to delay a command promotion for Patton.

Attempts have increased to understand war trauma and to use psychiatry to pinpoint which troops will suffer inordinately from what they have seen and done, but they remain primitive, military officials say. “There’s going to be lots of soul-searching and teeth-gnashing, but the reality is that we can’t tell when somebody is going to snap,” says Ronald Smith, director of psychiatry at Walter Reed National Military Medical Center in Bethesda, Md.

Dr. Smith recalls doing screenings for Antarctica missions. “I’m supposed to be pretty good at this, but you’d say that somebody’s going to have a terrible time, and they’d do great. Another guy you’d think would cruise through it would come apart,” he adds.

The bottom line is that war is a gruesomely powerful and ultimately unwieldy force that has the capacity to change the people who fight it in ways large, small, or negligible – but nearly always unpredictable. “Horrible, wretched tragedies that brook no understanding can in fact happen at war because you threaten people’s survival,” Smith, a Navy captain, says. The solution for preventing such tragedies, he adds, “is that our appetite for war should go away – and we should only do it when everything else fails.”

In the meantime, psychiatrists must often grapple in cases like Bales’s with “that sickening feeling [that] we don’t know and we can’t explain it,” he adds. “That will be up to a jury of his peers. But there’s not to my knowledge a neuropsychologist in the world who can say this was predictable.”

It is a frustration echoed by Gen. Peter Chiarelli, who, as the Army’s second-ranking officer, spearheaded the service’s mental-health outreach efforts until he retired this year. “We have no reliable diagnostics,” he says. “That was the frustrating thing for me for 3-1/2 years.”

Chiarelli, now chief executive officer for One Mind for Research, is pushing for collaborative research that he hopes will ultimately help troops who have been fighting the longest wars in American history. For now, however, the tools remain limited.

“The military is the only organization I know of that screens its people when they enter the service, before they deploy, while they are deployed, when they return, and six months after they return,” Chiarelli says. “If we had reliable tools, don’t people think we’d use them?”    

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