Have we misunderstood post-traumatic stress disorder?
In understanding war-related post-traumatic stress disorder, a person's cultural and professional context is just as important as how they cope with witnessing wartime events, which could change the way mental health experts analyse, prevent and manage psychological injury from warfare.
It's long been assumed that war-related post-traumatic stress disorder (PTSD) stems from how well a person copes psychologically with exposure to violence or the threat of violence. A new study, published in the Academy of Management Journal, finds that this is only half the story, however.
The researchers behind the study say that the context through which war is experienced – based on a person's cultural, professional and organisational background – may be equally important in determining how warfare can be traumatic for some and not for others.
The research focused on military doctors in Afghanistan, and found that the "dissonance" between what the medics experienced on the ground and their values as dedicated professionals resulted in "senselessness, futility and surreality" – factors that can lead to PTSD and other mental health problems.
"This understanding of the connection between PTSD and the context of those who suffer from it could change the way mental health experts analyse, prevent and manage psychological injury from warfare," said Mark de Rond of University of Cambridge Judge Business School, who co-authored the study with Jaco Lok of the University of New South Wales Business School in Australia.
"The study highlights the urgent and serious nature of dealing with PTSD – beyond the very real impact on many veterans, to others who work in the theatre of war, such as medical personnel," says Lok.
Between 20 and 30 per cent of the 2.7 million US troops sent to Iraq or Afghanistan between 2001 and 2011 returned with some form of psychological injury, says the US Department of Veterans Affairs, while the British charity Combat Stress reported a four-fold increase in former service personnel seeking help for mental disorders in the past 20 years. In 2013, a former commander of Australian forces in the Middle East warned of a "large wave of sadness coming our way."
The new study is based on fieldwork by de Rond, Reader in Strategy & Organisation at Cambridge Judge Business School, who was "embedded" with a team of military surgeons at Camp Bastion in Afghanistan for six weeks in 2011 – and includes tales both harrowing and tragi-comic.
"The doctors I was embedded with were known as Rear Located Medics, who don't have a combat role, so they have less reason to fear for their lives than frontline personnel," says de Rond. "Studying this group was an excellent way to look beyond psychological reaction to the horrors of warfare in order to also analyse contextual elements that lead to PTSD."
For example, the Camp Bastion army medics were particularly disturbed by rules of the camp's small 50-bed field hospital that required the quick transfer of badly mutilated children (often double amputees due to Improvised Explosive Devices encountered while playing) and other Afghan civilians to inferior local hospitals, often within 48 hours, to make way for new battlefield casualties. This was a specific, local organisational requirement.
"(It was) difficult for them to come terms with rules, practices and experiences on the ground that appeared contradictory to their purpose and values, thus amplifying feelings of senselessness," the study says.
As an example of the surreal hopelessness faced by the medics, the study relates a conversation between two medics: "They talked about the frustration of bringing a stable, anesthetised patient over to some hospital only to be met by an empty van, having to hand over a wired-up patient to someone with no equipment at all."
This practice tore at the fabric of their professional purpose and responsibility and highlighted the contrast between the medics' actual experience in a warfare setting with their professional expectations as doctors – a life of "the meaningful, the good and the normal."
The doctors' real names are not used, but the study instead substitutes the names of characters such as "Trapper," "Hawkeye" and "Potter" from the hit TV show "M*A*S*H". Among de Rond's field notes chronicled in the study, some incidents seem like they could have come out of the "M*A*S*H" gallows-humour playbook:
"One of the theatre nurses told me of an experience over Easter weekend, when a double amputee had come in… One of his legs had come off, and (the nurse) was asked to please take it to the mortuary (and from there to the incinerator). As he crossed the ambulance bay carrying a yellow (container) with a leg, he ran into the Commanding Officer and a TNC (Travel Nurse Corps) nurse walking the other way, dressed in bunny ears and carrying Easter eggs."
Such a contrast "between the human gravity of the situation on the one hand, and the casual nature of everyday rituals and routines on the other" can have a very disorienting effect, the study says.
When such disorientation is sustained over time, it can also permanently damage the ability of everyday rituals and routines to provide a sense of meaning and predictability to life back home. This may be one important reason why many war veterans find it so difficult to adjust back to home life.
Camp Bastion, which was constructed in 2005 and handed over to Afghan forces in 2014, was the largest British overseas military camp since World War II, accommodating 32,000 people. The field hospital was staffed by mostly British and American doctors, with some Danes and Estonians, many of them "battle-hardened" by previous deployments to other war zones such as Bosnia and Sierra Leone.