Have we misunderstood post-traumatic stress disorder?

A clash of standards and organisational protocols is a potent source of anguish

Witnessing the terrible suffering and cruelty innate in war is commonly believed to cause psychological distress, such as post-traumatic stress disorder (PTSD), but recent research suggests there may be other causes as well.

While these events are undoubtedly traumatic, the context in which they are experienced is just as important, according to new research, in findings that could have implications for the way work-related PTSD is minimised and treated.

In Some Things Can Never Be Unseen: A Contextual Perspective on Psychological Injury at War, published this month by the Academy of Management, authors Mark de Rond from Cambridge University, and Jaco Lok from UNSW Business School, move away from present psychological theories on the causes of PTSD which rely on universal triggers and universal predisposition to PTSD. 

Instead, they look at context – and find that repeated experiences of senselessness, futility and surreality are particularly distressing.

"Context was directly implicated in this experience through the dissonance it produced between professional and cultural values and practice expectations on the one hand, and actual lived experience on the ground on the other," the researchers write.

In other words, they claim the specific professional and cultural expectations through which people filter their experience of war can influence whether and how they experience war as psychologically traumatic.

'If you eat KFC chicken wings in the desert after you've just done a horrible operation on a child, those chicken wings at home may forever remind you of the horrors of war'

JACO LOK

  'A large wave of sadness'

Symptoms of PTSD may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. In 2013, Major General John Cantwell, former commander of Australian forces in the Middle East, warned the parliamentary defence sub-committee of  "a large wave of sadness coming our way".

The committee also heard that PTSD can lie dormant for up to 30 or 40 years and it can be assumed that 15% to 20% of the veterans of recent conflicts may develop PTSD at some point in their lives.

The researchers took as their starting point an examination of PTSD rates among damage control surgery staff at Camp Bastion Field Hospital in Afghanistan. Medical surgeons are trained for many years to deal with graphic injuries, which suggests it's not just the exposure to the blood and guts of war that causes PTSD, especially as their own lives are not under threat. In fact, PTSD rates among rear-located medical military personnel are on par with those of battlefield soldiers.

De Rond, an ethnographer at Cambridge, travelled to Afghanistan and lived with the medical staff for the duration of a typical tour of duty to better understand their experience.

The authors posed a question: "What types of experiences at war are actually experienced as traumatic and why? Maybe it's not the obvious reasons of just being under threat yourself or seeing other people suffer. Maybe we should look into this a little bit more carefully," says Lok, associate head of the school of management at UNSW Business School.

Sources of distress

Lok and de Rond noted that medical personnel regarded themselves as professionals with a higher sense of purpose. But the context of war amplified 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 organisational context appeared to force them to compromise on patient care, and the cultural context appeared blind to the inhumanity they encountered. This specific context gave rise to three types of distressing experiences. 

One experience was senselessness:

The researchers write: "One of the general surgeons, 'Hawkeye', talked about a little girl they nursed for six weeks during his last deployment to Afghanistan before discharging her to her family. Having done so, they subsequently learned that she had been starved by her family as she apparently was considered too ugly to ever get married and too handicapped ever to be able to work and provide."

(Surgeons' identities were disguised with nicknames from the television show MASH)

The researchers say that while treating children is difficult in any circumstance, this difficulty was compounded by an inability to find any sensible place for them in war, thus pointing to the role of cultural expectations in the experience of war.

Another distressing experience was futility:

"In the Doctors' Room this evening, I strike up a conversation with Hawkeye about (…) and when only palliative care should be provided. Hawkeye says that the merciful thing would be to take a pillow and shoot the boy through the head. It is hard to reconcile this statement with the kindness he showed the boy 30 minutes ago, unless one assumes that letting the boy die is actually the kind thing to do," write the researchers

Lok and de Rond show that this experience of futility was directly related to some of the treatment limits that were imposed on the war surgeons, particularly in relation to Afghans, thus highlighting a clash between professional standards and organisational protocol as an important source of distress.

'[Present treatments and interventions are] assuming that there's something universal going on, whereas we're saying that the nature of war trauma is specific'

JACO LOK

Limits of the rituals and routines

A third type of distressing experience was surreality:

"One of the theatre nurses told of an experience over Easter weekend, when a double amputee had come in. During the log roll, 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 bucket with a leg, he ran into the commanding officer and a TNC nurse walking the other way, dressed in bunny ears and carrying Easter eggs," the researchers write.

The distressing experience of surreality – of doubting the nature of reality itself – is caused by "the stark contrast between the human gravity of the situation that medical surgeons deal with – for example, walking around with body parts – versus the casual everyday nature of the rituals and routines that are brought in to try and normalise the environment as much as possible, such as Easter," Lok says.

Surreality exposes the limits of the rituals and routines that people use in their everyday lives to ground themselves, to make life predictable and get a sense of meaning.

"Those break down there. Rituals and routines that we all use in everyday life cannot really repair the extreme nature of the environment there and may be forever damaged when they go home," he says.

As a result, personnel can become estranged not only from the traumatic war environment, but may become permanently estranged from the everyday routines that ground them back home.

"If you eat KFC chicken wings in the desert after you've just done a horrible operation on a child, those chicken wings at home may forever remind you of the horrors of war," says Lok.

Alarm system

Jay Spence, a Sydney clinical psychologist with experience in treating patients from the military and emergency services, says there has been little research into the organisational factors in PTSD, "but I heard about it all the time from the patients I was treating".

One issue is the conflicting messages personnel receive from their organisation. The medical staff within the organisation tell them they want to support them and help with PTSD, "and then, they're getting an entirely different message that comes from the training programs they're in which is, at all costs, do not show vulnerability or weakness because someone else's life might depend on it," says Spence.

He explains the typical PTSD response in layman's terms. The brain has an "alarm system" that normally only triggers when something bad is happening, but in PTSD sufferers the alarm system is over-sensitised and it starts firing at a very low threshold, which triggers the typical PTSD symptoms.

Spence also explains how day-to-day events can trigger PTSD symptoms. Because the brain is built to survive, it memorises anything related to extremely stressful events and pairs together things that shouldn't be paired.

Lok says the research might ultimately lead to better treatment of PTSD.

The authors suggest there is a need for research into PTSD that shifts the focus from the individual psychological response to war to considering the institutional context and its unique interactive effects with individual psychology as a possible additional site of intervention.?

The effectiveness of present treatments and interventions "has been very mixed and we're arguing that the reason for this may be because they're all assuming that there's something universal going on, whereas we're saying that the nature of war trauma is specific to specific groups who filter their experience of war through specific cultural, professional, and organisational contexts," Lok says.