Abstract
The relationship between military absenteeism and mental health problems has been noted; however, factors affecting military absenteeism by enlisted personnel have not been studied systematically. In a medical center in Taiwan, we performed a chart review of 26 forensic psychiatric evaluations of enlisted personnel who were absent without leave (AWOL) or deserted their service from 1994 to 2014. The findings showed that many of these recruits had a lower level of education (50.00% had just nine years of education), intellectual disability (46.15%), depressive disorders (30.76%), and suicidal ideation (53.85%). Depressive disorder was overrepresented in comparison with findings in a previous study. Further study is needed to confirm whether psychiatric screening before service enlistment and early psychiatric intervention for service members with mental illness or emotional disturbance could help in the prevention of desertion or going AWOL.
Military absenteeism, including absence without official leave (AWOL) and its more severe form, desertion (permanent leave without authorization) influences manpower, discipline, leadership, and morale in military service.1,–,3 The behavior is often regarded as a military crime, and may result in court-martial prosecutions.4,5 Criminal prosecutions in courts-martial may result in forensic evaluations in these cases.1,3,6,–,9 Taiwan maintains armed forces to face the challenging international security concerns in East Asia.10 Therefore, it is important to study the question of forensic psychiatric evaluation of enlisted personnel who commit military absenteeism in Taiwan for the influences of desertion or AWOL on manpower, discipline, leadership, and morale in military service.1,–,3 There are several studies in the United States and other countries of military personnel who have committed desertion or been AWOL.11,–,16 However, there are no psychiatric studies on the forensic psychiatric evaluation of enlisted personnel who have committed military absenteeism in Taiwan.
Taiwan's criminal court system is an inquisitorial system, in which the accused, his relatives, guardians, or the lawyers can try to persuade the judges or prosecutors to request psychiatric evaluations, based on the psychiatric history, records of psychopathology or unusual behaviors in the criminal behaviors reported by witnesses, with or without insanity pleas.17,18 Forensic psychiatric evaluations in Taiwan's inquisitorial legal system are court ordered by judges or, in some rare cases, ordered by the prosecuting attorneys, with or without insanity pleas by the evaluees before the court proceedings. The judge or prosecutor could appoint a psychiatrist or even a psychiatric team to perform the evaluations.19 The courts-martial adopted the same procedures. According to the Criminal Code of the Republic of China, the definition of legal insanity is that an offense is “committed by a person who [has a] mental disorder…and, as a result, is unable or less able to judge his act or lack[s] the ability to act according to his judgment.” Similar to some other countries,20,–,24 diminished responsibility, or partial criminal responsibility, is the definition of an offense committed “as a result of obvious reduction in the ability [to exercise good] judgment.”25 For legal insanity, the offense is not punishable, and for diminished responsibility, the punishment may be reduced.25
The accused are sent for evaluation to a medical center department of forensic services on a scheduled day, or, in some complicated cases, hospitalized for a short period. While the service member is there, psychiatric diagnostic interviews, mental and physical examinations, psychological assessments, routine laboratory workups, and sometimes brain imaging studies, such as computed tomography, or even electroencephalograms, are administered. Two board-certified psychiatrists, or one 3rd- or 4th-year psychiatry resident, under the supervision of a senior board-certified psychiatrist, perform or supervise the performance of the workup. A final report is issued after each case is discussed at biweekly forensic psychiatry conferences in the psychiatry department of the medical center and then is mailed to the courts or attorneys' office. This procedure is similar to other forensic psychiatric evaluations in Taiwan.19,26,27
The report is then sent to the court as an official document. In 2003, cross-examination was adopted from the adversarial system; however, the forensic evaluations are still court-appointed in most criminal cases, and the judge decides whether attorneys from both sides can cross-examine the evaluators as expert witnesses.28 In courts-martial or common criminal courts in cases involving substitute servicemen (defined below), or sometimes in the military or local prosecuting attorneys' offices, the presence of “suspected mental problems needing evaluation” mandates a forensic psychiatric assessment for enlisted personnel who are accused of going AWOL or deserting.10,30,39
The relationship between military absenteeism and mental health problems has been studied. Even though some political and cultural reasons may prevent these data from being published or discussed in many countries, there are several reports in the literature discussing military absenteeism, after Western wartime experiences from the two world wars in the 20th century.2,11,–,13,29,31,32,–,36 Studies of forensic psychiatric evaluations for persons who engaged in military absenteeism after those wars are few.
There is obligatory military service duty for male nationals above 18 years of age in Taiwan.10 The person who chooses not to fulfill his military service for religious or conscientious reasons can choose a substitute service in other uniformed services, such as constabulary police troops, fire brigades, correction services, environmental protection service, or other public sections.10,30,37
We sought to find out which psychiatric diagnosis or problems were present in those servicemen who committed desertion or AWOL and were referred for forensic psychiatric evaluation. Consequently, we conducted a chart review of individuals who were guilty of absenteeism from the military in a relatively peaceful time and underwent assessment by members of the forensic psychiatric department of a medical center in Taiwan, using a retrospective method that is similar to other studies for analyzing forensic psychiatric evaluations.38,39 Unlike other studies performed in wartime33,–,35 or countries deploying troops during regional conflicts, Taiwan has been in a relatively peaceful state since several conflicts with mainland China in the 1950s.2,4,16 We could only collect forensic reports from this peaceful time. We also reviewed relevant literature to provide a more comprehensive picture of this topic.
Subjects and Methods
The 26 persons who went AWOL or deserted were referred by the judges of the courts-martial for forensic psychiatric evaluations between 1994 and 2014. All 26 forensic psychiatric assessment files were archived in the medical record database of our military medical center and were reviewed by the authors.
The authors read all the forensic psychiatric reports and confirmed the evaluees' age, sex, years of education, psychiatric diagnosis, and psychiatric symptoms at the time that they were AWOL. Demographic data, psychiatric diagnoses, psychopathology, and other manifestations of mental illness were recorded and then analyzed. The forensic psychiatrists' professional opinions about legal insanity or diminished responsibility were also obtained from these forensic reports.
Ethics
This study was conducted in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). The Institutional Review Board of Tri-Service General Hospital approved the study and waived the need for individual written informed consents (No. 2-102-05-044).
Statistics
Simple descriptive statistics were used.
Results
From 1994 to 2014, 26 persons who had enlisted in the military or engaged in alternative civil service had gone AWOL or deserted. They were sent to the forensic psychiatric service at our military medical center for evaluation of their “mental problems” and included 23 (88.4%) who were fulfilling their compulsory or military obligation as soldiers, 2 (7.7%) who were lower-rank officers (both second lieutenants), and 1 (3.8%) who was a substitute serviceman in a correctional institute. None was a career soldier, such as regular armed forces officer, noncommissioned officer, or soldier. All were men, average age 23 ± 3.75 years. Thirteen (50%) of them had completed only nine years of compulsory education in Taiwan.
Psychiatric diagnosis, psychopathology, and characteristics found in the charts upon review of the AWOL incident were as follows. Intellectual disability (intelligence quotient < 70) and borderline intellectual functioning were diagnosed in 12 (46.15%) of the men: 8 of the men had mild developmental disability and 4 had borderline intellectual functioning. Depressive disorders were diagnosed in eight (30.76%): two with major depressive disorder, three with dysthymic disorder, and three with depressive disorder not otherwise specified. For all the persons with depression, depression diagnoses were present both at the desertion/AWOL and the time of evaluation. Five (19.23%) had schizophrenia (four paranoid type and one disorganized type). Five (19.23%) had personality disorders (two antisocial, one borderline, and one schizotypal). Fourteen (53.85%) had thought about suicide, and nine (34.62%) had attempted it. Two of the latter nine had experienced some form of dissociation during the period of AWOL. In 2 cases, the desertion occurred while they were under the direct influence of psychotic symptoms (auditory hallucinations or persecutory delusions); the remaining 24 reported maladjustment and inability to tolerate the stress of military training and duties. Twenty-four (92.30%) were AWOL within half a year after enlistment. Four (15.38%) repeated their AWOL attempts. Three (11.53%) committed other crimes: for example, theft and assault.
In Taiwan, the courts frequently ask forensic psychiatrists to provide professional opinions about the offenders' criminal responsibility, including impairment of responsibility or being legally insane (discussed below). Of the professional opinions that our center provided for the courts in the forensic psychiatric evaluation reports, 16 (61.53%) subjects had partial impairment of responsibility. Among these, three (11.54%) were legally insane and thirteen (50%) were regarded as having a diminished sense of responsibility. Ten (38.47%) accepted full responsibility for their malfeasance as deserters and did not raise the question of diminished responsibility.
The findings noted above were obtained from forensic reports, not the court's decisions. The courts-martial decisions or sentences were not all available to the authors, and few judges felt it necessary to notify the forensic psychiatry service about sentences or court decisions, even when requested to do so. Therefore, the court's decision about criminal responsibility was not included in the results.
Discussion
Psychiatric or psychological problems related to desertion are rarely discussed. We believe that our study may be the first attempt to examine the forensic assessment of military or substitute service members in peacetime. Psychiatric evaluations in the military are commonplace for purposes such as pre-enlistment screening, medical discharge, criminal investigation, and re-evaluation of erroneous diagnoses.41,–,43 Sometimes, service members develop a mental illness after they serve for a time and need further psychiatric assessment for discharge from the military.25,44 Generally speaking, the proportion of those with depressive disorders and intellectual disability is higher among enlisted personnel who receive forensic psychiatric evaluations than among others in Taiwan and those in the military in other countries who are under criminal investigation.19,40,41,45
In 1917, Tausk, in reference to the wartime Austro-Hungarian Empire, divided war deserters into seven categories: 1) hysterical or epileptic disturbances, 2) restless or wandering souls, 3) fear of punishment, 4) inability to stand the strain of duty, 5) anxiety or obsessional ideas, 6) homesickness, and 7) “war neurosis.” His was a psychoanalytic viewpoint, and he argued that desertion during war is a manifestation of Freud's theory of a “disturbed father–son relationship.”13
Several authors have discussed the psychological factors rather than psychiatric diagnoses related to desertion. In these studies, mostly of World War II experiences of military personnel who were AWOL or deserted, the researchers found problems with emotions, personality, intelligence, or adjustment to military life (Table 1). U.S. Army research in 2004 reported that “(t)he primary reasons cited for going AWOL centered on dissatisfaction with Army life (40%), family problems (39%), homesickness (37%), feelings that promises made upon enlistment were not kept (27%), a lack of motivation (26%), and unfair treatment (21%).2 A senior military police officer in Taiwan reported that stressors found in 2,072 military draftees who were AWOL in 2001–2003, ranked as personal stressors (44%), family stressors (22%), social relations stressors (18%) and military stressors (16%).31 Difficulties related to mental disorders or disadvantageous psychological traits and consequent maladjustment seemed to be related more to AWOL. In our study, only two persons deserted under the direct influence of psychotic symptoms; all others (n = 24) reported maladjustments and an inability to tolerate the stress of military training and duty; these findings were compatible with those in previous studies. Zuring et al.1 studied desertions from the Dutch Army during the Indonesian colonial wars (1945–1949) and found that 65 percent of the evaluees, were neurotic, 35 percent psychopathic, 43.5 percent had intellectual disability, and 29.2 percent normal, according to an assessment by the colonial Army Division Board. We found intellectual disability in 12 (46.15%) and personality disorders in 5 (19.23%) cases in our study, rates similar to those found in the wartime Dutch Army; however, in our study, the frequency of depressive disorder was higher (30.76%).
Comparison of Previous Research on Military AWOL in Different Military Samples: Experiences From Western Wars
Dieckhofer and Vogel7 showed that about one-third of all persons with so-called “poriomania” (a passion for wandering or journeying away from home) were “feebleminded.” Such persons were more inclined to fraud, pseudologia, abuse of alcohol, prostitution, and suicide (15%). The personalities of men with poriomania were characterized by unsteadiness, instability, and a tendency to engage in wishful thinking. In our study, only 12 (46.15%) had intellectual disability, 14 (53.85%) had suicidal ideation, and 9 (34.62%) had attempted suicide. It is difficult to compare our findings with those of the previous study because of the different populations.
A study by Mazurczyk8 of psychiatric evaluations for general military delinquency in the Polish army indicated that the environment and the perpetrator's personality traits and intelligence determined whether typical military crimes, such as AWOL or desertion, were committed. We found intellectual disability in 12 (46.15%) and personality disorders in 5 (19.23%) cases, rates similar to those found in the Polish Army. Kolb et al.46 showed that rates of unauthorized absence and desertion increased significantly from before to after treatment for alcohol abusers. In our sample, depressive disorders and mental insufficiency are overrepresented. Since the prevalence of alcohol and other substance use disorders is lower in the general populations in Taiwan and other Asian countries, this finding may correlate with the military population.47,48 Chuang et al.25 studied 152 military draftees with mental disorders who got suspensions from the military: 7 (4.6%) had gone AWOL, 48 (31.6%) had thought about it, and 23 (15.1%) had specific plans to be AWOL, but there was no discussion about psychiatric diagnoses and actual or contemplated AWOL. None of these studies involved forensic subjects.
The Criminal Codes for military and substitute service members contain articles pertaining to desertion or AWOL in Taiwan.10,29 Those who desert the battlefield or frontline can be sentenced to up to life in prison or even death; however, most deserters are given short-term punishment, months to one year in prison, and, in peacetime, most single attempters are actually given probation. As in other military systems, our service aims to provide accurate forensic psychiatric information about service members who desert or go AWOL as a result of suspected mental health problems.39,42,45
Taiwan has an inquisitorial system in the criminal courts, which differs from the adversarial system in Common Law countries, and the courts frequently request that forensic psychiatrists provide professional opinions about the offenders' criminal responsibility. However, the judges have the final authority on whether to accept the forensic psychiatrists' professional opinions by ruling on the offenders' criminal responsibility. In our study, we found that our center provided professional evaluations for the courts opining that 16 of 26 (61.53%) subjects had partial impairment of criminal responsibility, as 3 (11.54%) were legally insane and 13 (50%) had diminished responsibility.
This study has some limitations. First, the number of AWOLs from peacetime Taiwan military units was low and the small sample may limit the generalization of the results. Second, the results were collected by retrospective chart review in one hospital and may not represent the entire population of military absentees. Third, the final court decisions were not always available, and we did not know whether the courts accepted the conclusions of our evaluations, but the acceptance rate of forensic psychiatric evaluation reports by the criminal courts for civilians is high in Taiwan. One Taiwan study reported a consistency rate of 93.6 percent between criminal records and corresponding court sentences in 84 cases at a psychiatric hospital over a 3-year period.39 For Australian Vietnam draftees, AWOL charges during service were one of the factors related to post-Vietnam death rates.14 We were unable to follow those evaluees in our study who were acquitted or discharged, and we were unable to determine whether there was a similar factor regarding death rates. Finally, few recent articles about this topic approached the discussion from a contemporary viewpoint.
Conclusions
In this study, among 26 evaluees who have committed desertions and received forensic psychiatric evaluations, depressive disorders and mental insufficiency were overrepresented. We reviewed several reports in the literature about mental health, diagnosis, and evaluations of the personnel who committed desertions. Since the retrospective study performed in peacetime is limited in number of cases and by the difficulty in following up the judges' verdicts and the outcomes of the evaluees, further study is needed to confirm whether psychiatric screening before any military or civil substitute service enlistment and early psychiatric intervention for service members with mental illness or emotional disturbance would help in the prevention of desertion or AWOL.
Footnotes
This article was funded by a grant from the Tri-Service General Hospital (Research Fund: MAB-102-69).
Disclosures of financial or other potential conflicts of interest: None.
- © 2016 American Academy of Psychiatry and the Law
