Gen Rhonda Cornum States: Dr. Malik-Hasan’s Violence Not Predictable

Brig. Gen Rhonda Cornum, the recently named head of the, “Comprehensive Soldier Fitness Program”, stated that the violence at Ft. Hood was no more predictable then previous episodes of violence against other soldiers in garrison. I was stationed at Fort Rucker, Alabama in flight surgeon training when then Maj. Cornum, herself a Flight Surgeon, returned from the Gulf War in 1991, one of two females captured in that war. She was taken prisoner when her helicopter was shot down during an attempt to rescue a downed F-16 pilot. After three days of beatings and humiliations, she was released from Iraqi prison. Her resilience and heroism as a prisoner of war convinced many in the Pentagon at the time that women could indeed serve on the front lines. And now, as a general officer, she is an authoritative voice on this violence issue.

But, Maj. Nidal Malik Hasan is not, and was not, just a soldier. Prior to his assault on fellow troops his behavior was disruptive, his performance lacking, fitting the description of what is now called “Disruptive Physician Behavior”, a syndrome that I have written about elsewhere (see http://www.medscape.com/When Behavior Disrupts the Physician-Healer). The function of these physicians deteriorates under stress due to personality structure, mental, and physical disorders. Malik-Hasan, impaired as evidanced by a preoccupation with a precived conflict between his faith and his duty, regardless of the specifics, exhibited disruptive behavior well before his violent rampage. Even Cornum acknowledges “hidden traumas” for soldiers.

What, then, are we to make of her statement that, “…one individual act of murdering tells me (nothing) about the fitness of the 1.1 million people in the force”? It tells us the culture in the military regarding mental health that, if not examined, will allow such catastrophes to happen again. Demographic and situational correlates such as base rate of such instances, age, gender, race, socio-economic status, availability of weapons and victims, job stability, peer relations, and family systems can, and should be considered when a homicidal or violent individual acts (Monahan, 1981; Meloy, 1987a). Even the civil courts now affirm the admissibility of demographic information as “character evidence” in capital cases.

The usual “good order and disipline” in the military may have delayed the wider use of such data concerning the dangerousness of such individuals in the past, but, in a country waging two wars for almost a decade, and, with multiple deployments now the norm, the multitude of situational and individual variables that may precipitate homicidal and violent behavior must be assassed.

Careful study of the pattern, or instance, of target selection in this and other cases of violence against fellow soldiers can make reasonable inferences about the nature of the individual and how they, and others like them, might behave when stressed and confronted with their most primitive and aggressive impulses. In this case, the pattern of target selection seems predictable and, given the size of the potential victim pool (the 1.1 million service members Gen. Cornum mentioned) demands an assessment of any one individual’s dangerousness.

So, if what I say is true, what can we observe about Dr. Malik-Hasan’s behavior and, by inference, his state of mind, on that fateful day? First it is clear that violent and homicidal behavior occur in primitive mental states, in most cases, when individuals are regressed due to stress in individuals who lack mature coping mechanisms. Psychoanalytic theory tells us that three factors are important in determining such states-of-mind of murderers at the time of a killing: First, he perceives important relationships to have failed him, or, feels compelled to right past wrongs previously repressed. Second, he losses touch with reality, misperceiving threats in his environment, and, third he reacts to his experience of internalized aggression. Analysis of these three factors can generate empirical evidence that reflects the state of mind at the time of the murder (Maloy, J.R. 1988). Translating this into predictive data is a bit tricky, but not impossible, and it is this fact that has lead to a movement to identify Disruptive Physician Behavior, find the cause and treat it before the physician, or anyone else suffers. In episodes of violence, the individuals mental picture of important relationships may be inferred by the pattern, or instance, of target selection, and, proactively, but observed relationships with authority figures, subordinates, and colleagues.

In Malik-Hasan’s case, the Army, the community he had defied his parents to join, the caretakers who had given him so much in terms of education, prestige, rank, and social standing, seemed to have failed him. How could this institution fail to recognize the deep personal conflict with which he believed himself to be confronted by? We know he expressed it to superiors; we know he tried to get out; we know his performance suffered; we know he was transferred and ordered to war. And, we know he killed the one’s he was trained to protect. In regard to his ability to test reality, how could he think, after the Army invested so much in him, that they would just let him go? How could he ultimately seem his colleagues as enemies or threats? These errors of mental processing influenced both his motivation and his perceptual-conceptual experience (Meloy, 1985); Reality testing has both distinguishing and evaluating properties. The distinguishing property, a sensory-perceptual task, is most useful in determining the individual’s capacity to separate interoceptive and exteroceptive stimuli, that is, what’s going on inside his head versus what’s going on in the environment.

It is not, as some might think, intuitively obvious that what was going on in Malik-Hasan’s head was more important then what was going on in the environment. Doesn’t everybody think that way? No. In point of fact it is a significant misperception of reality, a break down of the psychodynamic most akin to determining the individual’s ability to distinguish right from wrong. In assessing Malik-Hasan at the time of the alleged violence, there are three possibilities: He did not know, he did not care, or, the thought what he did was right. Third, we must consider his mode of aggression can be classified as either affective (I feel angry) or predatory aggression (Cold and calculating). The two general categories of aggression have distinctive neuro-anatomical pathways and are controlled by different sets of neurotransmitters (Eichelman, Elliott, and Barchas, 1981).

Affective aggression is the result of external or internal threatening stimuli that evoke an intense and patterned activation of the autonomic nervous system, accompanied by threatening vocalizations and attacking or defending postures. If this was present in Malik-Hasan, it has not been reported and, it is my guess, that those around him would have reacted much differently to his overtures had this been evident.

This was not a crime of passion.

It is true that many of the pathways in the brain that control this type of aggression are tied closely to the spinothalamic tract and the periaquaductal gray which closely links affective aggression to pain responses (Eichelman et al., 1981). It is not too much of a stretch to imagine that Malik-Hasan was frightened and in pain. More likely, however, in this case is that Malik-Hasan was in the throws of predatory aggression in humans, which explains the international occurrence of war, is the hallmark of the violent seen in this case. Predatory aggression requires intent, planning, and emotional detachment. Any one act of predatory aggression in a pattern of violent behavior significantly increases the likelihood that a psychopathic character disturbance exists, a problem that is identifiable before manifest violence, if one is inclined to look for it.

So, what could have been done and should be done going forward? The person needs to be talked with, and listened to. Such clinical investigation should focus on the individual’s conceptions of others. Is there sufficient evidence through his reminiscence, evaluation, judgment, and affective responses that he conceptualizes others as three-dimensional, whole, and separate individuals? Or does he reflect, a narcissistic self-absorption, or worse, a callous disregard for the thoughts and feelings of others? Assessment of reality testing through the use of a projective technique like the Rorschach that is dependent upon indices of perceptual distortions (Exner, 1986) is not enough. The interpersonal history is critical to understand the individual’s perspective, his perceptions of others, and his reality testing. The individual’s capacity to suspend empathic regard, to plan and carry out an act that inflicts suffering on another, and to decide that this is the best course of action among all other actions can not exist without telltale signs that can and should be taken note of and accounted for.

It is my experience having assess, treated and returned to productive practice many individuals whose behavior was identified as disruptive, that such a program of identification, intervention, and treatment to, “Conserve the Fighting Strength”, as stated in the motto of my former Regiment, can and should be instituted in the military. Careful analysis of these variables in the military settings should be based upon clinical interviews, a reliable and corroborated history, and psychological testing.

Meloy, J.R. (1988). Violent and Homicidal Behavior in Primitive Mental States.

http://usacac.army.mil/CAC2/cgsc/Events/CSF/images/cornum.jpgJ. Amer. Acad. Psychoanal., 16:381-394