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From shell shock to moral injury: a hundred years of psychological war trauma
10/11/2018

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The century since the end of the First World War has seen significant development in thinking around war trauma. We explore what the current lack of recognition of moral injury and the part it plays in mental health says about our attitude to war and serving personnel.

 

'I have spent a quick life and my run is finished,' wrote Machine Gunner Frank Leyes, aged seventeen, at Parkhurt, Isle of Weight, before shooting himself in the barrack room. The deceased joined up when fifteen, and had been sent to the Western front, where he was gassed... The jury returned a verdict of suicide whilst temporarily insane.' The Sunday Post, 18 February 1917.

'Dreams mainly of dead Germans... Got terribly guilty conscience over having killed Huns.' Medical Case Note from Lennel Auxiliary Hospital, a private convalescent home for officers during WW1.(1)

 

These stories are just a few among many soldiers returning from the First World War suffering from severe mental trauma. The horror they endured, from daily death and injury, to poisonous gas, to killing other humans, led to the development of symptoms like nightmares, tremors, impaired sight and hearing, fugue states (confused wandering) and an inability to function. It was known as shell shock.

To begin with, physicians connected the symptoms with physical brain injury from exposure to repeated explosions;* but before long military and medical authorities saw the predominant problem as 'nervous' or psychological, and many considered this to be a sign of individual weakness.

One notorious form of treatment involved snapping people out of their condition by torturing them, for example with electric shocks and burns, as well as other forms of discipline and punishment.(2) However, some medical professionals and facilities increasingly developed psychotherapy and occupational therapy.(3)

Shell shock was a pressing problem for the British Army by the winter of 1914, a few months into the war, and when its ending had once been anticipated.(4) The war would in fact last until 1918, by which time at least 80,000 men were diagnosed with some form of shell shock.(5)

The number may in fact be much larger as many soldiers were not treated, and when it became clear shell shock was not always directly related to brain injury, use of the diagnosis was increasingly reduced.(6) The psychological theory was preferred by the British Army to the brain injury theory, because it was easier to return 'uninjured' soldiers to active duty; and they were increasingly short of front-line troops.(7)

The 11th Borders Battalion, for example, suffered one of the highest casualty rates of the Somme when they went over the top one day, and the survivors refused to go again a few days later as so many of them were traumatised. They were accused of being cowards and lacking 'any soldierly qualities', were humiliated and disciplined, and their medical officer was sent home in disgrace for saying they were suffering from shell shock.(8)

By the end of the Battle of the Somme, the Royal Army Medical Corps banned medical officers from using the term shell shock – they were instead to be classed as 'Not Yet Diagnosed Nervous' before being diagnosed by doctors in specialist centres.(9) In 1917, medical authorities 'deliberately discouraged use of the term [shell shock] and suggested an association with malingering.'(10)

Many people suffering shell shock may even have been executed; 306 British and Imperial soldiers were shot for running away or refusing to keep fighting.(11)

Renaming the trauma

During the Second World War, medical understanding of shell shock developed further. Even though British authorities banned the term when the war began (there were fears that shell-shock was 'contagious' and damaged morale; and also led to expensive war pensions claims and costly treatment initiatives), soldiers continued to present with a range of trauma symptoms.(12) This was termed 'battle fatigue' or 'combat fatigue.'

With concerns about invalid claims, units would retain soldiers in the armed forces but offer occupational therapy and vocational training. The aim was to return them to service without being too concerned about what had caused the symptoms.(13)

As in World War One, there was a lot of stigma in World War Two around mental illness within the Armed Forces, and military psychiatrists were viewed with suspicion with concerns that they could 'undermine the fighting spirit.' Soldiers were reluctant to report their symptoms, and after the end of the war, records of officers who had been treated for psychological disorders were destroyed in order to protect their reputations. (14)

Nearly 40 years later, there are still significant limitations to the research, and under-reporting of psychological ill-health in military groups.

Since the Vietnam War, mental health research around military populations has developed further and in 1980, the American Psychiatric Association recognised Post Traumatic Stress Disorder (PTSD). However, nearly 40 years later, there are still significant limitations to the research, and under-reporting of psychological ill-health in military groups. Much of the quantitative research in the UK is directly funded by the Ministry of Defence, which constrains its scope. (Gee, Last Ambush, p. 1 and 16**)

Accepted understanding of mental health risks today

Limitations aside, the available research shows that while the British armed forces have not engaged in a 'world' war with enormous levels of trauma and loss of life for many decades, there are some mental health related problems which remain a serious problem; these include alcohol use and post-deployment violent behaviour. (Gee, Last Ambush, p. 1, 8, 18 and more)

Common mental disorders have also been shown to be higher in the armed forces than the general population. (Gee, Last Ambush, p. 6 and 2). However, likely because of the healthy worker effect, wherein general population figures include higher rates of people suffering from ill-health or various vulnerabilities, the prevalence of self-reported self-harm and suicide have often been equal or lower in the armed forces than in the general population.

If personnel don’t have individual risk factors (exposure to warfare when deployed, and pre-Service vulnerabilities such as a socio-economically disadvantaged background, childhood trauma and young age at enlistment), they are likely to have good mental health. The majority of British armed forces personnel today are not typically exposed to traumatic stressors. (Gee, Last Ambush, p. 8)

The prevalence of mental health problems in military populations is also likely to be substantially under-estimated due to research methodology weaknesses, under-reporting due to continued stigma around mental illness, and non-anonymous conditions for taking part in research. The latter could explain why, alongside differences in combat intensity, recent PTSD rates in the UK military have so far been found to be lower than those in the US – the major US military health research institute typically does not ask participants for identifying personal information. (Gee, Last Ambush, p.14)

Some groups within the forces are more affected; socio-economic disadvantage, childhood adversity, a history of anti-social behaviour and/or under-achievement in school all predispose vulnerability to mental health problems

However, some groups within the forces are more affected; socio-economic disadvantage, childhood adversity, a history of anti-social behaviour and/or under-achievement in school all predispose vulnerability to mental health problems. Younger age groups in the contemporary British military have been shown to be more likely to commit suicide and drink at harmful levels when compared to their civilian counterparts. (Gee, Last Ambush, p. 3 and 26)

The most potent risk factor for mental health-related problems, however, is exposure to warfare when deployed. Personnel deployed to Iraq and/or Afghanistan, as could be expected, showed a 20% increase in PTSD prevalence compared to the general population. (Gee, Last Ambush p. 2)

Furthermore, it is those who carry the highest levels of pre-service vulnerability (young people from the most disadvantaged backgrounds) who are also more likely to be in close combat roles that expose them to traumatic stress. For some veterans the risks are elevated by a lack of social support networks. (Gee, Last Ambush, p. 3)

Historical analysis of wars from the 19th century to the present day shows that there is a constant relationship between the number killed or wounded and the number of psychiatric casualties. (Gee, Last Ambush, p. 9) The hotter the conflicts personnel find themselves in, the likelier they are to suffer high rates of mental trauma. While some individuals are more vulnerable to long-term mental trauma (which casts a shadow over the ethics of targeting those individuals for recruitment), any soldier can be psychologically damaged by war.

In our submission to this year’s inquiry into military mental health (15) we wrote:

‘We are concerned about a report that suggests that, as part of investigating compensation claims, the Ministry of Defence has hired psychologists to look into the childhoods of veterans, to try to show that childhood trauma is at the root of their PTSD rather than experiences on the battlefield alone. There needs to be more understanding of the fundamental impact of the unique rigours of military life on mental well-being, whatever pre-existing factors may or may not exist. Furthermore, it is unethical to use pre-enlistment vulnerabilities to avoid compensation, while continuing to target and recruit the groups of people most likely to have these vulnerabilities.’

Developing new understanding of moral injury

There is a growing understanding that war trauma is a normal response to the abnormality of war.

While in World War One, and still in World War Two, many considered those suffering from shell shock to be morally feeble, in fact there is a growing understanding that war trauma is a normal response to the abnormality of war.

This includes a new development in our understanding of war trauma, which is to focus on how morality fits in with the picture of military mental health. Psychiatrist Peter Marin noted in 1981 the ‘moral pain’ with which many Vietnam War veterans were living, saying it may be both highly stressful and the healthy response of a morally functioning individual. (Gee, Last Ambush, p. 15)

To suppress empathy and override moral convictions during war might protect individuals from trauma reactions which negatively impact health, but suppressed conscience and empathy are not in themselves healthy things. Although studies show the link between feelings of shame and PTSD symptoms, there is yet to be research into the role of conscience, empathy and shame in war trauma. Removing this moral aspect risks pathologising what is in fact a normal and healthy response to warfare, as well as stifling the consequent moral critique. (Gee, Last Ambush, p. 15)

The war trauma symptoms experienced by Vietnam veterans actually led to the coining of a new term – moral injury, by psychiatrist professor Jonathan Shay. His definition is that 'moral injury is present when (i) there has been a betrayal of what is morally right, (ii) by someone who holds legitimate authority and (iii) in a high-stakes situation.’(16) The feeling that one has been obliged to betray a moral position is linked with psychological damage.

Moral injury theory encapsulates symptoms related to guilt, shame, anger and disgust – while PTSD focuses on fear-related symptoms. It is yet to be widely understood and recognised – and advancements in this area are much further along in the United States than in the UK.

The US Department of Veterans Affairs (VA) acknowledges moral injury, although the US Department of Defense does not. The VA describes it as:

A construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events… The key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational and group-based rules about fairness, the value of life, and so forth. In the context of war, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations.’(17)

A US study published in 2017 found that 11% of combat-exposed veterans admitted perceived moral transgressions on the battlefield, a quarter witnessed perceived moral transgressions by others, and a quarter felt morally betrayed by their peers or leaders, or by others. (18)

There have yet to be any detailed empirical studies of moral injury in a UK military context. The recent Defence Committee report of inquiry into Armed Forces and Veterans Mental Health failed to mention it. (19)

There have yet to be any detailed empirical studies of moral injury in a UK military context.

Could the reluctance of the British military mental health establishment to adopt an understanding of moral injury, be influenced by the moral judgement on the actions of the military which is implicit in this theory?

This would be in fitting with a hundred years of military priorities constraining, whenever deemed necessary or useful, our understanding of war trauma and our reactions to it as a society: from demonising shell shock as weakness, to banning the term, to refusing to acknowledge the moral aspect of people’s reactions to warfare.

If moral injury is to be increasingly recognised, it is important that the emphasis does not become how the military and society can ‘fix’ the problem by making soldiers less likely to experience it, regardless of what they take part in or witness.

There has in fact been some commentary about how moral injury impacts an army's ability to fight – in Moral Injury, towards an international perspective (2017) Brad Allenby and Tom Frame write:

A strong warrior identity is particularly important in a high stress, high performance domain such as military operations, but has not entirely evolved to keep pace with the demands proliferating and increasingly stringent current environments generate. The result is not just a proliferation of moral injury, but also a new and exploitable military weakness with the potential to become a long-term deficiency in American, Australian, and British ability of project national power. Our first observation is, therefore, that moral injury is not only a serious issue requiring respect and mitigation at the individual level; it constitutes a systemic challenge that demands institutional responses. Inability to adapt to profoundly different value systems on the part of individual warriors becomes not just an exploitable weakness; it is a growing threat to mission success and a continuing liability for the entire society in terms of continuing veteran care.’(20)

In Respecting Moral Injury, Brad Allenby went further:

The practical constraints of the military mission and environment, civilians entering service must be trained to become more psychologically flexible and adaptive warriors, without lowering ethical standards or condoning simplistic relativism. Warriors need strong values given the tasks, such as killing other human beings, that they are asked to do, but inflexible psychologies are more prone to break, rather than adapt, when challenged at the limits.'(21)

The idea that we should be creating more ‘psychologically flexible’ soldiers to help them kill more easily without suffering moral injury, feels rather like the plot of a Black Mirror episode. Military training is already developed to overpower inhibitions to killing by dehumanising the opponent, stimulating aggression and antagonism, and indoctrinating obedience – which may strengthen a fighting force but can also be mentally harmful.(22) How much further can it go?

The idea that we should be creating more ‘psychologically flexible’ soldiers to help them kill more easily without suffering moral injury, feels rather like the plot of a Black Mirror episode.

Rather, should we not view human susceptibility to moral injury as a strength rather than a military weakness; a sign of our innate empathy and conscience which, even when repressed through rigorous training to re-wire the brain, cause us to psychologically resist the brutality and injustice of warfare?

Military mental health researcher David Gee writes:

Veterans who experience moral injury do so because their conscience is strong, not because their mental health is weak.'(23)

While it is good that support for those suffering with moral injury is being developed in the US, surely such a condition should cause us to closely question the ethics of what the military were and are doing?

Their lack of recognition of moral injury aside, the British military and its establishment allies are concerned (as they have been for a hundred years), to minimize and distract from military mental ill-health. There has been a concerted recent effort to 'prove' despite limited research, that being in the military is either good for your mental health, or no different from being a civilian.

Our inability to honestly interrogate moral injury in our own soldiers speaks to our inability to wrestle with the ethics of our militarised and imperial foreign policy.

This is a very problematic narrative, particularly as there have recently been growing concerns about a rise in PTSD and suicide among British military veterans, most affecting those who were in combat roles in Iraq or Afghanistan.(24, 25)

With the widespread controversy about the meta-level morality of those wars, let alone the murky individual experiences of moral wrongdoing, it is likely that the officially unrecognised condition of moral injury plays a powerful role in the lives of contemporary British personnel and veterans, and will continue to do so.

Our inability to honestly interrogate moral injury in our own soldiers speaks to our inability to wrestle with the ethics of our militarised and imperial foreign policy, and to the powerful PR efforts of the military and related interests. In this regard, much is the same today as it was one hundred years ago.

Michael Castellana, a psychotherapist at the U.S. Naval Medical Center in San Diego, sees the damage among dozens of his Marine patients: an erosion of moral certainty, or the confidence in their sense of right and wrong:

'We are beginning...to venture into what I think is the kernel of combat trauma: the transformative capacity of what happens when we send our children into a war zone and say, “Kill like a champion”.'(26)

Notes

* A contemporary focus in personnel and veterans' mental health is a return to Mild Traumatic Brain Injury (MTBI) – similar to how shell-shock was initially viewed in World War One. There is increasing understanding that physical and psychological injury often coexist and cannot always be clearly distinguished.

**Gee D, 2013, The Last Ambush: Aspects of mental health in the British armed forces – referenced multiple times, in brackets.

References

1. World War 1: 100 Years Later, Smithsonian Magazine, 2010.

2. Psychological Sequelae of Torture, SW. Turner and C Gorst-Unsworth, 1993, p.9

3. See 1.

4. Shell Shocked, E Jones, Monitor on Psychology, 2012.

5. Shell Shock during World War One, Professor Joanna Bourke, BBC History, 2011.

6. WW1 dead and shell shock figures 'significantly underestimated', The Telegraph, 16/01/2014 and Shell Shock and Mild Traumatic Brain Injury, A Historical Review by E Jones et al, American Journal of Psychiatry, 2007, pp.1642-1643.

7. Shell Shock and Mild Traumatic Brain Injury; A Historical Review, pp.1642-1643, as above.

8. How shell-shock shaped the Battle of the Somme, The Telegraph, 16/04/2016.

9. See 8.

10. Shell Shock and Mild Traumatic Brain Injury; A Historical Review, p.1644-1643, as above.

11. Shot at Dawn, Heritage of the Great War

12. Psychological Trauma: A historical perspective, E Jones and S Wessely, Elsevier 2006, p.218 and see ref. 6

13. See 7.

14. The injured mind in the UK Armed Forces, N Greenberg et al, in Philosophical Transactions, 2011.

15. ForcesWatch submission to the Defence Committee's Armed Forces and Veterans Mental Health Inquiry, 2018

16. Moral Injury, by J Shay, in Psychoanalytic Psychology, 2014, p.183.

17. See 15.

18. Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study, by BE Wisco et al, in Depress Anxiety, 2017.

19. Mental Health and the Armed Forces, Part One: The Scale of mental health issues, House of Commons Defence Committee, 2018.

20. What is to be Done? Brad Allenby with Tom Frame, in Moral Injury: Towards an International Perspective, p.56.

21. War and Moral Injury: A Reader, Small Wars Journal, 2018.

22. See more on this in First Ambush and Last Ambush by David Gee, and in On Killing: The Psychological Cost of Learning to Kill in War and Society by David Grossman.

23. Rewiring the Human Brain to Train it for Obedience and Violence: The Psychological Reality of Military Training, by David Gee, 2017, Karnacology.

24. Post-traumatic stress disorder rising among British military veterans, study suggests, The Telegraph, 08/10/2018.

25. 'A national emergency': suicide rate spikes among young US veterans, The Guardian, 26/09/2018.

26. The Recruits: When right and wrong are hard to tell apart, David Wood, Huffington Post, 2014.

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