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War inflicts psychological damage behind the lines as well as in the thick of the fight, study finds

November 10, 2016

For more information, contact: Ben Haimowitz , (718) 398-7642,

War inflicts psychological damage behind the lines

as well as in the thick of the fight, study finds

But comforts and routines from home may only make things worse  

I question my loss of humanity out here  

That is my worry, that is my fear.

According to a new study, this little rhyme, penned by a surgical-team member at a military field hospital, sums up much that is lacking in the current public discussion of the psychological toll of contemporary warfare, a toll that, the U.S. Department of Veterans Affairs estimates, has affected 20% to 30% of returnees from Iraq and Afghanistan.  

The research, reported in the December issue of the Academy of Management Journal, focuses on the six-week deployment to Afghanistan of a surgical team who, despite superb skills in caring for severely injured victims, "all experienced some psychological distress upon arrival back home."  

This occurred in spite of the fact that 1) team members had volunteered to serve, 2) had had prior experience treating combat injuries, and 3) functioned behind the lines rather than in the thick of the fighting. Their distress strikes the study's co-authors as "particularly surprising, as it is combat exposure specifically that has repeatedly been shown to impact adversely on mental health."  

This surprise leads co-authors Mark de Rond of the University of Cambridge and Jaco Lok of the University of New South Wales to "explore sources of psychological distress other than the extreme threat of death or injury to self that is widely considered to be a leading cause of psychological injury from war." 

They find these sources of distress in "repeated experiences of senselessness, futility, and surreality that are known to characterize the experience of war...When these experiences are sustained, they can dislocate people's institutionalized sense of the meaningful, the good, and the normal to the point where they experience an existential threat to their sense of being in the world." 

Unfortunately, the most common response to this disjointed reality – introducing normal or familiar elements into the environment – is not only largely ineffective, the professors conclude, but may make matters worse. 

Thus does the paper bring a new dimension to research on war-related psychological injury, which "to date has largely focused on determining the psychological and/or neurological factors that make some people more prone to psychological injury than others as a result of exposure to traumatic events" (the view reflected in Donald Trump's recent comment that some people are "strong and...can handle it" while others can't). 

In contrast, the new study shows that “the specific cultural, professional, and organizational contexts in which people who work at war are embedded can play a central role in the experience of emotional distress, regardless of whether they are directly exposed to combat...because these contexts can trigger and amplify repeated experiences of senselessness, futility, and surreality."  

    Senselessness, the professors explain, refers to the needless cruelty that are part and parcel of war – as seen in the fate of a little girl who, after being arduously nursed back to health by caring medical professionals, was starved to death by her family because they judged her too ugly to get married and too handicapped to work. 

   Futility describes the many times protocol required doctors to turn over patients they had stabilized to ill-equipped local facilities where chances for recovery were severely compromised. 

   Surreality refers to the disoriented, deamlike quality of the war environment, such as when the coordinator of the operating room received the delivery in a cardboard food box of two legs blown off a soldier six hours earlier and dispatched by his buddies in the misguided belief they could be re-attached. 

How to cope with such disjointed realities? As indicated above, the way most commonly used is not only largely ineffective but may actually prove to be counterproductive. In the words of the study, "attempts to normalize the war environment as much as possible through importing home comforts, rituals and routines, may be responsible for amplifying rather than reducing the experience of senselessness, futility, and surreality at war by increasing the contrast between life at home and life at war...Reliance on them may also permanently damage the existential function of home comforts when troops return home." 

As an example, the authors cite an incident when a team member carrying an amputee's leg for disposal in an incinerator ran into two colleagues walking the other way, dressed in bunny ears and carrying Easter eggs. That surreal experience, they observe, "may permanently damage the future ability of Easter rituals to provide a sense of familiarity and existential grounding after returning home." Noting the presence of a Pizza Hut and Kentucky Fried Chicken in a trailer on the premises, they write that "to consume chicken wings after [performing open-chest surgery for a gunshot wound] may forever taint any future experience of KFC by invoking memories of war." 

They add: "Imports are soiled by being experienced in a particular context such that the two may become difficult to subsequently untangle. As a result, people may become estranged from both life at war and life at home, which may increase the likelihood of permanent psychological injury." 

Yet, if trying to introduce some elements of normality to a disjointed reality doesn't help, what does? 

The professors suggest much of the answer when they observe that the team's pre-deployment training "was exclusively technical in nature...This context socializes medical professionals at war into understanding their identities as professionals...who can maintain composed detachment at all times. This context informed how members of the team viewed themselves and their work, amplifying the dissonance between what they expected and desired as normal practice on the one hand and, on the other, what they actually experienced on the ground...The futility and boredom they experienced...challenged their sense of self as highly agentic beings whose positive impact on other people's lives was embodied in their medical skills." 

Indeed, similar hazards await many others in the military and beyond. As the study notes, "Disaster-relief organizations, aid organizations, the field of medicine, NGOs and the police often rely on this sense of calling to attract people to jobs that will likely expose them to pervasive human suffering, and even to the threat of (psychological) injury or death...Yet, these are the very organizations in which people are likely to face real constraints to their ability to make the kind of purposeful impact they desire because they face the enormous challenge of turning the never-ending tide of human suffering. We have shown that a profound sense of purpose and an equally profound sense of futility may thus become two sides of the same coin." 

As to what can be done, the study notes that "the medical profession has long shared [an] impassive approach to problem-solving with the military, producing a culture of silence around emotional distress among both doctors and military personnel....Just what exactly the role of the military is in helping to prevent, alleviate, or cause post-traumatic stress disorder in different groups of military personnel is still an open question." 

To which Prof de Rond adds: "Military training has always featured abundant realism about the physical dangers and hardships of combat but very little, if any, about the psychological ones. Senselessness, futility, and surreality, to the extent they are dealt with at all, are matters of sarcasm and humor – often grim humor. Our study suggests that's not enough. There seems to be more willingness now than in the past to be open about psychological problems once they occur, which is all well and good. But maybe there needs to be more awareness of the dangers up front, in the training people receive, not just after the damage has happened." 

The study, "Some Things Can Never Be Unseen: The Role of Context in Psychological Injury at War" is in the December issue of the Academy of Management Journal, published every other month by the Academy, which, with more than 18,000 members in 125 countries, is the largest organization in the world devoted to management research and teaching. The research discussed above is also the basis for a book, Doctors at War: Life and Death in a Field Hospital," to be published in March 2017 by Cornell University Press. 



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