A New Home for Nightmare Treatment

by Barry Krakow, MD

A new home for nightmare treatment

Military personnel returning from wars in Afghanistan and Iraq show increasing rates of post-traumatic stress disorder (PTSD) and post-traumatic nightmares. Media coverage of these two vexing mental health conditions is also intensifying and raising public awareness about the need for more effective therapeutic options. With growing attention focused on patients with nightmares, sleep centers have an opportunity to engage these patients. Successfully doing so hinges on applying a standard of care for nightmare assessment and treatment through behavioral sleep medicine specialists.

MENTAL HEALTH VIEW OF NIGHTMARES

Traditionally, nightmares reflect emotional turmoil that needs venting through the process of dreaming. This psychological perspective fuels the entrenched and enduring focus on dream interpretation therapy as one of two core treatments for this potent sleep disrupter. The other primary approach known as exposure therapy is gaining ascendency in the mental health community because of the prevailing view that PTSD—the cause of the disturbing dreams—must be treated first. As the theory goes, the nightmares will resolve when their cause is treated. Yet, both these treatment paradigms (dream interpretation and exposure) trigger treatment avoidance among nightmare patients because of their fear of unmasking unpleasant mental health issues. Although this paradox creates an opening for nightmare patients to seek help outside of mental health facilities, it is rare for sleep medicine clinics to encounter patients seeking treatment exclusively for nightmares.

SLEEP MEDICINE PROFESSIONALS

To date, the sleep medicine profession has not applied a standard of care for nightmare assessment and treatment. While recent practice parameters published in the Journal of Clinical Sleep Medicine spell out efficacious treatment strategies for chronic nightmares, no evidence suggests these standards are widely adopted. To make treatment options more readily available, the sleep medicine community, particularly the field of behavioral sleep medicine, must embrace the emerging model of "nightmares as an independent sleep disorder," a paradigm described in the scientific literature for more than 20 years and now inferred by the new practice parameters.

In the practice parameters, imagery rehearsal therapy (IRT) is a Level A treatment and a relatively simple instruction that seems to alter the dreaming cycle by taking advantage of the fact that waking imagery influences sleeping imagery. The technique is no more complicated than asking someone to recall a recent bad dream, change this dream's content into a "new dream" while awake, and then spend a few minutes each day rehearsing the images from the new dream. For nightmare patients without complex comorbidities such as anxiety, depression, or PTSD, one clinic appointment is sufficient to teach IRT. Treatment is more involved among nightmare patients with PTSD who may require as much as 5 to 15 hours of clinical follow-up through individual appointments or group programs, primarily because they need extensive coaching to reach the point of receptivity to, interest in, and comfort with the imagery technique.

TAKING THE LEAD

In order to more firmly root sleep medicine professionals as leading care providers for this patient population, the next logical step will be facilitating and marketing the role of behavioral sleep medicine specialists as therapists for nightmare patients. The most expedient ways to develop this market include internal development and external outreach. At the most basic level, introducing a few key questions into the sleep center's intake process such as "How often do you suffer from nightmares?" and "Do your nightmares disturb your sleep?" has proven highly reliable in identifying patients likely to be interested in nightmare treatment. Outreach may be straightforward if your sleep center resides in a locale that also houses military installations.
At Maimonides Sleep Arts & Sciences, the single largest source of treatment-seeking nightmare patients is the US Air Force and US Army. The second most useful resource is outpatient mental health clinics or therapists, who routinely see patients with chronic nightmares yet often do not provide effective treatment programs for disturbing dreams. Many of these therapists are frustrated with their inability to resolve the nightmares in their patients, and therefore, they tend to be very receptive to programs such as IRT.
To maximize clinical efforts toward nightmare patients in our PTSD Sleep Clinic, we combine individual patient encounters with a self-help workbook and audio series, Turning Nightmares into Dreams (2002), developed at Maimonides Sleep Arts & Sciences. We believe the workbook not only reinforces treatment efforts, but in the majority of cases it decreases the total number of follow-up appointments.
In clinic, we have also seen that nightmares serve as a marker for much more complex sleep disturbances. Our PTSD Sleep Clinic experience demonstrates that nightmare patients almost always suffer from insomnia and a sizeable proportion (70% or greater) suffer from obstructive sleep apnea (OSA). When testing is conducted for upper airway resistance syndrome, upwards of 90% or more of our nightmare patients suffer diagnosable sleep-disordered breathing. Thus, both cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure therapy (PAP-T) for OSA are important treatments to be considered for nightmare patients seeking help at sleep medical centers.
Other nightmare treatment programs have also been tested, many of which use components of IRT: Burgess, Marks, and Gill (2001) published Self-Help for Nightmares, a manual that uses self-exposure therapy; Davis (2008) recently published Treating Post-Trauma Nightmares, which combines elements of IRT and exposure therapy. In the 1990s, Krakow and Neidhardt published Conquering Bad Dreams & Nightmares (1992), the first book on IRT; Cartwright and Lamberg published Crisis Dreaming (1992), an innovative dream interpretation approach to nightmares; and Lansky published Posttraumatic Nightmares (1995), an authoritative work on the psychodynamic approach.
By embracing and applying a standard of care for nightmare patients, sleep medicine physicians and psychologists are likely to emerge as leading care providers in offering solutions and treatments for afflicted individuals. And as military personnel return from wars in the Middle East and the media expands coverage of related mental health issues, our profession has an opportunity to serve these soldiers and others who need treatment for chronic nightmares.

Barry Krakow, MD, is the author of Sound Sleep, Sound Mind, principal investigator at Sleep & Human Health Institute, and medical director at Maimonides Sleep Arts & Sciences Ltd (www.sleeptreatment.com), and blogs at www.sleepdynamictherapy.com. He can be reached at sleepeditor@allied360.com.
We have seen that nightmares serve as a marker for much more complex sleep disturbances.

I Miss Iraq. I Miss My Gun. I Miss My War.

Mosul, Iraq 2004 -2005

Busa and I on FOB Marez 2004-2005

The "Deuce" in the many news publications

I found this in Esquire and the sentiment he talks about are grounded in truth. The feelings of exhilaration when creeping through the streets at night prior to a raid can't be explained. I too miss it......

By Brian Mockenhaupt
A few months ago, I found a Web site loaded with pictures and videos from Iraq, the sort that usually aren't seen on the news. I watched insurgent snipers shoot American soldiers and car bombs disintegrate markets, accompanied by tinny music and loud, rhythmic chanting, the soundtrack of the propaganda campaigns. Video cameras focused on empty stretches of road, building anticipation. Humvees rolled into view and the explosions brought mushroom clouds of dirt and smoke and chunks of metal spinning through the air. Other videos and pictures showed insurgents shot dead while planting roadside bombs or killed in firefights and the remains of suicide bombers, people how they're not meant to be seen, no longer whole. The images sickened me, but their familiarity pulled me in, giving comfort, and I couldn't stop. I clicked through more frames, hungry for it. This must be what a shot of dope feels like after a long stretch of sobriety. Soothing and nauseating and colored by everything that has come before. My body tingled and my stomach ached, hollow. I stood on weak legs and walked into the kitchen to make dinner. I sliced half an onion before putting the knife down and watching slight tremors run through my hand. The shakiness lingered. I drank a beer. And as I leaned against this kitchen counter, in this house, in America, my life felt very foreign.
I've been home from Iraq for more than a year, long enough for my time there to become a memory best forgotten for those who worried every day that I was gone. I could see their relief when I returned. Life could continue, with futures not so uncertain. But in quiet moments, their relief brought me guilt. Maybe they assume I was as overjoyed to be home as they were to have me home. Maybe they assume if I could do it over, I never would have gone. And maybe I wouldn't have. But I miss Iraq. I miss the war. I miss war. And I have a very hard time understanding why.
I'm glad to be home, to have put away my uniforms, to wake up next to my wife each morning. I worry about my friends who are in Iraq now, and I wish they weren't. Often I hated being there, when the frustrations and lack of control over my life were complete and mind-bending. I questioned my role in the occupation and whether good could come of it. I wondered if it was worth dying or killing for. The suffering and ugliness I saw disgusted me. But war twists and shifts the landmarks by which we navigate our lives, casting light on darkened areas that for many people remain forever unexplored. And once those darkened spaces are lit, they become part of us. At a party several years ago, long before the Army, I listened to a friend who had served several years in the Marines tell a woman that if she carried a pistol for a day, just tucked in her waistband and out of sight, she would feel different. She would see the world differently, for better or worse. Guns empower. She disagreed and he shrugged. No use arguing the point; he was just offering a little piece of truth. He was right, of course. And that's just the beginning.
I've spent hours taking in the world through a rifle scope, watching life unfold. Women hanging laundry on a rooftop. Men haggling over a hindquarter of lamb in the market. Children walking to school. I've watched this and hoped that someday I would see that my presence had made their lives better, a redemption of sorts. But I also peered through the scope waiting for someone to do something wrong, so I could shoot him. When you pick up a weapon with the intent of killing, you step onto a very strange and serious playing field. Every morning someone wakes wanting to kill you. When you walk down the street, they are waiting, and you want to kill them, too. That's not bloodthirsty; that's just the trade you've learned. And as an American soldier, you have a very impressive toolbox. You can fire your rifle or lob a grenade, and if that's not enough, call in the tanks, or helicopters, or jets. The insurgents have their skill sets, too, turning mornings at the market into chaos, crowds into scattered flesh, Humvees into charred scrap. You're all part of the terrible magic show, both powerful and helpless.
That men are drawn to war is no surprise. How old are boys before they turn a finger and thumb into a pistol? Long before they love girls, they love war, at least everything they imagine war to be: guns and explosions and manliness and courage. When my neighbors and I played war as kids, there was no fear or sorrow or cowardice. Death was temporary, usually as fast as you could count to sixty and jump back into the game. We didn't know yet about the darkness. And young men are just slightly older versions of those boys, still loving the unknown, perhaps pumped up on dreams of duty and heroism and the intoxicating power of weapons. In time, war dispels many such notions, and more than a few men find that being freed from society's professed revulsion to killing is really no freedom at all, but a lonely burden. Yet even at its lowest points, war is like nothing else. Our culture craves experience, and that is war's strong suit. War peels back the skin, and you live with a layer of nerves exposed, overdosing on your surroundings, when everything seems all wrong and just right, in a way that makes perfect sense. And then you almost die but don't, and are born again, stoned on life and mocking death. The explosions and gunfire fry your nerves, but you want to hear them all the same. Something's going down.
For those who know, this is the open secret: War is exciting. Sometimes I was in awe of this, and sometimes I felt low and mean for loving it, but I loved it still. Even in its quiet moments, war is brighter, louder, brasher, more fun, more tragic, more wasteful. More. More of everything. And even then I knew I would someday miss it, this life so strange. Today the war has distilled to moments and feelings, and somewhere in these memories is the reason for the wistfulness.
On one mission we slip away from our trucks and into the night. I lead the patrol through the darkness, along canals and fields and into the town, down narrow, hard-packed dirt streets. Everyone has gone to bed, or is at least inside. We peer through gates and over walls into courtyards and into homes. In a few rooms TVs flicker. A woman washes dishes in a tub. Dogs bark several streets away. No one knows we are in the street, creeping. We stop at intersections, peek around corners, training guns on parked cars, balconies, and storefronts. All empty. We move on. From a small shop up ahead, we hear men's voices and laughter. Maybe they used to sit outside at night, but now they are indoors, where it's safe. Safer. The sheet-metal door opens and a man steps out, cigarette and lighter in hand. He still wears a smile, takes in the cool night air, and then nearly falls backward through the doorway in a panic. I'm a few feet from him now and his eyes are wide. I mutter a greeting and we walk on, back into the darkness.


Read more: http://www.esquire.com/features/essay/ESQ0307ESSAY#ixzz1l3Hj7D2C

In Afghan war, rate of post-injury survival rises

By David Brown

Army Spec. Bryce MacBride, wounded in Afghanistan in late 2010, waits in the hallway of a hospital at Bagram Airfield. (Linda Davidson — The Washington Post) There has probably never been a war in which there has been as much on-the-job improvement in the care of the wounded than there has been in the United States’ war in Afghanistan. Of course, at 10 years and counting, there has been a lot of time for practice.
That truth is evident in a recent report by the Congressional Research Service, “Afghanistan Casualties: Military Forces and Civilians.” It sketches out the remarkable ability of military physicians and nurses to save the lives of grievously wounded troops.
Last year, 415 American men and women died in Afghanistan, while 5,159 were wounded and survived.
That ratio — 12.4 survivors for every fatality — marked a record high over the past decade. In fact, the ratio has been growing almost every year since 2001.
In 2007, the first year in which battlefield deaths in Afghanistan surpassed 100, there were only 6.4 survivors for every fatality. The ratio dipped slightly in 2008 but has increased ever since.
How much better are doctors, nurses, medics, corpsmen and technicians in this war than in previous ones?
That’s hard to answer with precision. Comparisons are tricky because the quality of medical care isn’t all that changes between conflicts. Indeed, the nature and hazards of combat can evolve during the course of a war.
For example, a study of military personnel killed in Iraq and Afghanistan in the second half of 2006 found that 76 percent of fatalities were caused by explosions. Earlier in the wars (2003-04), that “mechanism of injury” was responsible for 56 percent of deaths.
In previous wars, blast injuries accounted for less than 10 percent of battle injuries.
That said, there is plenty of evidence that troops wounded today have a far better chance of survival than ever before.
In 2006, approximately 9.8 percent of wounded service members died either on the battlefield or after leaving it in Afghanistan and Iraq. During the Vietnam War, that figure, the “case fatality rate,” was 16 percent. During World War II, it was 19 percent.
These days, if you make it to a hospital alive, your chances of surviving are extremely good.
During the first eight years of the wars in Iraq and Afghanistan, 4.6 percent of troops who got to the trauma bay of a hospital eventually died. (During the 2007 “surge” in Iraq, that number was 3.2 percent ). Furthermore, the number has stayed low even as the severity of injuries has worsened.
Many factors have produced this story of survival.
They include consistent use of body armor; fire-retardant uniforms; the timely application of tourniquets (every service member carries two); battlefield bandages loaded with clot-forming powder; the use of whole blood (or its equivalent in components) in resuscitating patients; less use of IV fluids on the battlefield and in helicopter evacuation; a strategy of many short operations (“damage-control surgery”) in treating victims of poly-trauma; the placement of neurosurgeons in forward hospitals; and the improvement that comes with experience and multiple deployments.
“None of these kids would have survived in the civilian world,” Col. Jay Johannigman, an Air Force surgeon, said in late 2010 at Bagram Air Base in Afghanistan after a weekly meeting in which doctors review what has happened to critically injured troops after they return to the United States.
“And we never would have saved them five years ago.”

Plan would help military families take leave

The best medicine for recovery is having loved ones around. I remember after coming back from Iraq in 2005 I was moved to Boise to serve in an ROTC billet. With no friends, family or any aquantences I found it the hardest transition I had ever had to do and very nearly fell into depression. This would really help Soldiers and their families and also allow family memebrs to be there without the reprecussions of losing their jobs.

By SAM HANANEL
Associated Press

WASHINGTON (AP) -- The Obama administration proposed new rules Monday to help military families care for service members when they are called to active duty or become injured.

The proposal expands eligibility under the Family and Medical Leave Act, which allows employees to take unpaid leave for certain medical or family reasons.

First lady Michelle Obama joined Labor Secretary Hilda Solis to announce the plan, which would allow caregivers to take leave to care for family members up to five years after they leave the military. Current law only covers family members of those currently serving in the military.

"We want to recognize the extraordinary dedication, sacrifice and service of our nation's caregivers, not simply with words but with deeds," Obama said during a Labor Department ceremony attended by dozens of military members and their families.

The rules would also expand leave to cover family members of those in the regular armed forces, not just families of National Guard members and reservists.

"Many service members come home stressed, ill and injured," Solis said. "They need attention, care and support from the people that love them most."

The proposal would let family members take up to 12 weeks of leave from work to help a service member deployed on short notice. Family caregivers could attend military functions, deal with child care issues, or make financial and legal arrangements without fear of losing their jobs.

It would also give family members up to 26 weeks of leave to care for recent veterans who were injured or became ill in the line of duty. That includes conditions that don't arise until after a veteran has left military service.

The plan expands from five days to 15 days the amount of time an employee can take off work to spend with a service member who is on leave to rest or recuperate.

Combat Call Center

Sunset on FOB Ramrod, Afghanistan

The Combat Call Center (1-877-WAR-VETS) is a confidential hotline staffed by combat Veterans from all eras and spouses of Vets. The call center is for Veterans and their families—offering you someone you can connect with that might have had a similar experience as you. The hotline is staffed 24 hours a day and is free.
This is a blessing to help those vets in need.

Ending Nightmares Caused By PTSD

Ending Nightmares Caused By PTSD

Amy Standen

January 16, 2012, 12:01 AM

Everyone has nightmares sometimes. But for people with PTSD, it's different.
Sam Brace doesn't want to talk about what he saw when he was a soldier in Iraq eight years ago. In fact, it's something he's actively trying not to dwell on. But what he can't control are his dreams.
They're almost always about the same explosion. "When I was overseas, we'd hit an IED," Brace says. "When I have a nightmare, normally it's something related to that."
Healthy dreams seem kind of random, according to Steven Woodward, a psychologist with the National Center for PTSD at the VA Medical Center in Menlo Park, Calif. "They're wacky," he says. "They associate lots of things that are not normally associated."
PTSD dreams are the same real-life event played over and over again like a broken record. "Replicative nightmares of traumatic events ... repeat for years," Woodward says. "Sometimes 20 years."

Scientists wanted to find out the reason why people with PTSD can't sleep and dream normally. One theory comes from Matthew Walker, a psychology researcher at the University of California, Berkeley. His particular interest lies in rapid eye movement, or REM. It's the time during sleep when a lot of dreaming occurs.
It's also a time when the chemistry of the brain actually changes. Levels of norepinephrine — a kind of adrenaline — drop out completely. REM sleep is the only time of day when this happens. That struck Walker as a mystery. "Why would rapid eye movement sleep suppress this neurochemical?" he asks. "Is there any function to that?"
Walker found that in healthy people, REM sleep is kind of like therapy. It's an adrenaline-free environment where the brain can process its memories while sort of stripping off their sharp, emotional edges. "You come back the next day, and it doesn't trigger that same visceral reaction that you had at the time of learning."
Emotions are useful, he says. They show us what really matters to us. "But I don't think it's adaptive to hold onto that emotional blanket around those memories forever," he says. "They've done their job at the time of learning, then it's time to hold on to the information of that memory, but let go of the emotion."
Walker's theory suggests that in people with PTSD, REM sleep is broken. The adrenaline doesn't go away like it's supposed to. The brain can't process tough memories, so it just cycles through them, again and again.
So, what if you could make the adrenaline just go away? Enter prazosin.
Pfizer Inc. introduced the drug under the brand name Minipress in the 1970s to treat high blood pressure. Dr. Murray Raskind, a VA psychiatrist in Seattle, says the drug, now generic, can cost anywhere between 5 and 15 cents. And, actually, it's not terribly effective as a blood pressure medication, he says.
But what prazosin does do is make people less sensitive to adrenaline. About a decade ago, Raskind starting giving prazosin to some of his PTSD patients, including one Vietnam War veteran.
"He had this recurrent nightmare of being trapped by the Vietcong forces in a landing zone and having his best friend killed in front of his eyes by a mortar round," Raskind says.
After a few weeks of treatment with prazosin, the veteran came in for a follow-up appointment. Raskind says the veteran told him that he wasn't sure the medication was working. He was still having the same dream over and over — just about something else. He told Raskind that in the new dream he was in his fifth grade classroom and there was a test. If he didn't pass the test, he wasn't going to be promoted to the next grade. But he never even got the assignment.
"I said, 'That's my nightmare!' " Raskind says.
Indeed, the veteran's new dream was the stress dream of a healthy brain trying to work things out, Raskind says.
This year, the VA is expected to finish up its trial for prazosin. It's already prescribing the drug to about 15 percent of its PTSD patients. Raskind, of course, would like to see that number rise.
"To us, it's a simple thing that works," he says.

Strykers: Did attitude lead to Afghan killings?

Another instance when the leaders are held responsible for the action (or in actions) of its subordinates. I worked with 2nd Battalion, 1st Infantry and had better leaders and a better time than I did with my own unit 1st Battalion, 17th Infantry. Don't always judge a unit by the poor decisions of some of its Soldiers.

Strykers: Did attitude lead to Afghan killings?

CRAIG WHITLOCK; The Washington Post

Published: 10/14/1012:05 am | Updated: 10/14/10 6:49 am

When a Stryker brigade from Joint Base Lewis-McChord arrived in Afghanistan last year, its leader, Col. Harry Tunnell, openly sneered at the U.S. military’s counterinsurgency strategy. The old-school commander barred his officers from even mentioning the term and told shocked U.S. and NATO officials that he was uninterested in winning the trust of the Afghan people.

Instead, he said, his soldiers from the 5th (Stryker) Brigade, 2nd Infantry Division would simply hunt and kill as many Taliban fighters as possible, as dictated by the brigade’s motto, “Strike and Destroy.”

What resulted was a year of tough fighting in territory fiercely defended by the Taliban. The brigade also carried home a dark legacy that threatens to overshadow its hard-won victories and sacrifices on the battlefield. In some of the gravest war-crime charges to arise from the Afghan conflict, five soldiers have been accused of killing unarmed Afghan men, apparently for sport, and desecrating their corpses.

Seven other platoon members have been charged with other crimes, including smoking hashish – which some soldiers said happened on a near-daily basis – and assaulting an informant.

As sordid accounts of the platoon’s activities continue to emerge, critics inside and outside the Army are questioning whether the brigade’s get-tough strategy, which emphasized enemy kills over civilian relations, could have influenced the behavior of the accused.

Questions also persist about why the 5th Brigade’s chain of command did not intervene earlier, given that soldiers from the platoon are charged with crimes alleged to have taken place over a roughly six-month period, beginning in November 2009.

Interviews and records obtained by The Washington Post indicate that commanders received multiple warnings of trouble brewing in the 3rd Platoon, Bravo Company, 2nd Battalion, 1st Infantry Regiment.

Some soldiers have since told investigators that their company commander became furious after learning that the platoon had killed a second unarmed Afghan in January. But rather than referring the incident up the chain of command, he demanded that soldiers find evidence that would allow the Army to justify the shooting.

In March, the platoon’s first lieutenant and sergeant were removed from their posts because their soldiers had been caught shooting at dogs, according to Army investigative records. In contrast, no disciplinary action was taken after platoon members shot and killed four Afghan men, who were allegedly unarmed, in as many incidents. (Three of those shootings are now the focus of murder investigations.)

“It’s obvious that willful blinders came into play, because this unit clearly was stepping in it,” said Eric Montalvo, an attorney for one of the soldiers charged with murder.

Tunnell, the brigade commander, is not implicated in the shootings. There has been no indication that he was aware that soldiers were allegedly killing for sport until special agents from the Army’s Criminal Investigations Command opened an investigation in May.

According to brigade members, however, Staff Sgt. Calvin Gibbs, the alleged ringleader of the self-described “kill team,” was assigned to Tunnell’s personal security detail from July until November 2009, right before the first of the atrocities was allegedly carried out.

Gibbs, 25, was reassigned to 3rd Platoon for reasons that remain unclear. Army officials declined to say why he was transferred, citing the criminal investigation.

Within days of the transfer, other soldiers have said in statements to investigators, Gibbs confided to his new platoon mates that he had gotten away with “stuff”during his previous deployments. They also said he talked about how easy it would be to stage the killings of innocent Afghans. Investigators are now examining Gibbs’ involvement in the killing of an Iraqi family in 2004.

Through a spokeswoman at Fort Knox, Ky., where he now works for the U.S. Army Accessions Command, Tunnell acknowledged that Gibbs served on his security detail “for a brief time,” but declined to answer other written questions for this article.

When asked in July about the killings, he told The Seattle Times that the fact that his brigade had opened the investigation by itself was “a good comment on how the system is supposed to work.”

In February 2009, while the brigade was undergoing mission rehearsal exercises in California, evaluators warned Tunnell that his open disdain for counterinsurgency would cause troubles in Afghanistan, but the brigade commander ignored them, said Richard Demaree, a retired lieutenant colonel who served as a battalion commander for the 5th Stryker Brigade.

“Everybody was astonished he has this war-fighting philosophy toward Iraq or Afghanistan that was totally out of sync with the Army,” Demaree said.

Tunnell, who served in Iraq and was badly wounded there, was a devotee of counter-guerrilla strategy, which places more emphasis on raids and other aggressive tactics but had been rejected as a doctrine by the Army in the aftermath of the Iraq insurgency. According to Demaree, Tunnell barred his soldiers from using the term COIN, shorthand for counterinsurgency.

Demaree, who says he was later forced to relinquish his battalion command because of personal conflicts with Tunnell, said many officers worried that Tunnell’s contempt for counterinsurgency would interfere with their mission in Afghanistan. “I believed it would put soldiers’ lives unnecessarily at risk,”he said.

Tunnell’s mindset also alarmed NATO and U.S. officials shortly after the 5th Brigade arrived in Kandahar, according to a State Department official who was present in Kandahar. At the time, military and civilian leaders in NATO’s Regional Command South had embraced counterinsurgency.

“We all said, ‘This is going to be a disaster. This is the exact opposite of what we need,’ “ said the official, who spoke on the condition of anonymity because agency rules forbid him from giving unauthorized interviews.

U.S., Dutch and Canadian officials asked Army Brig. Gen. John Nicholson, the then-deputy commander of Regional Command South, to intervene with Tunnell. Nicholson agreed to talk to the brigade commander, but the chat had little effect, the State Department official said. Nicholson did not respond to an e-mail seeking comment.

“Tunnell was just apparently totally unimpressed by what he was told,” the official said. “He spoke to us and said, ‘Some of you might think I’m here to play this COIN game and just pussyfoot with the enemy. But that’s not what I’m doing.’”

Tunnell’s Strike and Destroy approach contrasted with official guidelines issued by Gen. Stanley McChrystal, then the top U.S. commander in Afghanistan, which read:“Protecting people is the mission. The conflict will not be won by destroying the enemy.”

As the 5th Brigade began sustaining heavy casualties, however, some officers and enlisted soldiers openly grumbled that Tunnell’s strategy was backfiring.

On Jan. 28, members of the 3rd platoon fatally shot an Afghan man along Highway 1 in Kandahar. Some soldiers said they thought the man could have been a suicide bomber. He was unarmed.

When Capt. Matthew Quiggle, the platoon’s company commander, heard of the incident, he turned “furious,” according to one soldier, Cpl. Emmitt Quintal, who later gave a statement to Army investigators. The platoon had shot and killed another unarmed Afghan man two weeks earlier, so Quiggle told the soldiers “they needed to search until they found something” that would justify the shooting, according to the statement. Quiggle did not respond to a request for comment submitted through the Army.

In response, Gibbs and other members of the unit planted a magazine from a contraband AK-47 rifle next to the corpse “to give the appearance the Afghan was an insurgent,” according to an Army investigator’s report. The shooting was subsequently ruled justified and no one was disciplined.

Members of the platoon would kill two more unarmed Afghans, according to charging documents.

Army criminal investigators learned about the killings in May as they were scrutinizing hashish use in the 3rd Platoon. In June, they charged Gibbs and four other soldiers with murder.