The first half of Shay's presentation at the Presidential Symposium of APsaA's 2009 National Meeting was printed in the previous issue of The American Psychoanalyst. The second half is included here. In part I, Shay reviewed how he came to work with veterans and was inspired by their Homeric narratives. He reviewed the origins of psychological wounds of war and how they might be prevented. He discussed the shortcomings of current diagnostic nomenclature and reviewed the necessary components of a therapeutic milieu and a therapeutic alliance. Here he continues by describing psychological complications of the initial wartime injury and the effect of the injury on the family, workplace, and community in which the veteran lives.
…So the complications of the primary injury, just like hemorrhage and infection, deserve our most vigorous efforts toward prevention and early recognition and treatment. And I'm here to say that I am deeply optimistic that it is possible to both prevent and treat the most dreadful of the complications.
Now, you'll discover momentarily that when I say that the worst complications can be prevented and treated, I'm running directly afoul of very longstanding and very prestigious and very entrenched philosophic positions which we can trace visibly back to Plato and through the Stoics, to Emmanuel Kant and through Emmanuel Kant and the Stoics to Freud, and independently without Freud from Plato, the Stoics, and Kant. You can read all of that in that Institute of Medicine rant (iom.edu). I worked hard on getting the writing and the voice engaging and interesting, so you won't find it painful to read in terms of the writing. But in any case, I have advocated for the concept in prevention, that the main way you prevent the complications is by ethical leadership, expert ethical and properly supported leadership at all levels. But this is very heavy lifting in many military organizations to actually bring that about, but that's another matter.
The dreaded and dreadful complications are alcohol and drug abuse, suicide, criminal involvements, and danger seeking. All of these are potentially fatal and disastrous to the veteran and to the family and to the community. As to danger seeking or living on the edge, line and support leaders on military bases are painfully aware of the holocaust of young men in single vehicle motor accidents. It's catastrophic.
Some of this can be understood as the direct continuation of valid survival adaptations, such as veering across four lanes of high-speed traffic to avoid a parked car. That was a valid survival adaptation in theatre to avoid a roadside bomb, but now potentially fatal to the veteran and whoever is in the car with him, in the civilian context it is an illustration of “primary injury.” Danger seeking behavior—some people refer to this by the ad hominem term, “thrill-seeking”—like fast motorcycle riding, is a complication. Remember this is not a stereotype invented by the Vietnam era press. T.E. Lawrence, the most famous veteran of WWI, Lawrence of Arabia, died in a motorcycle accident and in his own words described riding his motorcycle at 90 mph through the lanes of Oxfordshire at a time when the other traffic was moving at 25 mph. And it killed him.
My claim is that the functional and ethical qualities of leadership especially are critical in preventing these complications. To begin with, when I speak of preventing psychological moral injury, I'm referring mainly to the complications to the destruction of trust and to all of these horrible downstream complications of the primary injuries.
What we're doing is physiological, it is psychological, it is social, it is cultural, at every instant. None of those four avatars of the human critter has ontologic priority. It's not that this brain of ours is the really, really real and everything else is merely epiphenomenal. They are each other's environments and they must exchange with each other as environments. They co-evolved during the Upper Paleolithic and were all fully present when the modern human first appeared. There has never been a human with half a mind or a quarter of a culture.
Jonathan Shay, M.D., is a Veterans Administration psychiatrist, author of Achilles in Vietnam and Odysseus in America, and was awarded a MacArthur Foundation (Genius) Award. He is internationally renowned for his groundbreaking work on the psychological sequellae of war.
Moral injury, something that I have studied my whole career now in psychiatry, is what happens when there is a high stakes violation of what's right; the what's right is in the realm of culture by someone who holds legitimate authority. Legitimation and authority are both in the social system. And the stakes here, such as the love that this marine has for that marine he went through boot camp with and out to the fleet with, and shared the same fighting hole in Iraq—this love is in the mind, the social system, and the culture.
When moral injury happens, it's massively physiological. You know that from your own experience, that when there is a high stakes violation of what's right by someone with legitimate authority, it's a kick in the stomach. There is a profound physiological reaction; it is psychologically momentous. Such violations purely in the moral world are coded by the body as physical attack and will create a full-fledged post-traumatic picture, with intrusions, and numbing, and the rest.
But that's not the most important thing about moral injury. That is the deforming effect on good character, caused by betrayal of what's right in a high stakes situation by someone who holds authority. Character is formed and reformed throughout life, primarily by every individual's interaction with the ecology of power.
Now I want to particularly address the handful of you who are mental health administrators. Working with severely traumatized people is an occupationally hazardous activity. Secondary trauma is not a secondary issue in doing this work. It's an OSHA issue; it's an occupational safety and health issue that has to be taken care of in the workplace. If you were talking to a coalmine operator about black lung and that coalmine operator said, “Oh, black lung, it's terrible, terrible. We have this wonderful respiratory therapy clinic down the street from the pit and anybody who starts to cough, we refer them to it on their own time and their own money. You go get that shit pounded out of your chest.” We would look at that coalmine operator like he was a moral moron. We would say, “No, you have to supply dust respirators to the miners at your expense. You have to install misters in the mine galleries to knock that stuff out of the air.” And yet in the mental health workplace there's a long tradition that if you can't hack it, little girl, you must need more therapy, at your own expense on your own time, or go sell shoes. You should pick another occupation. The prevention of secondary trauma in the workplace—no matter how well trained or how perfectly you have been psychoanalyzed—is something that critically depends on the qualities of community in the workplace. And community in the workplace requires time. It requires that the people who are on the clinical teams have time to meet together to struggle safely together. A key to preventing psychological injury is the capacity for safe struggle among the team, which prevents splitting.
Two things cumulatively damage the mind and spirit of the health professional working with trauma survivors: first, is being made a witness to atrocity over and over again by hearing the trauma narratives; and second, being subjected to the repeated and ingenious tests of trust, which most often take the form of splitting.
People who can struggle safely together cannot be split, or the splits are so very quickly healed that they don't do major damage; but all of this takes time and the administrators have to include it in their business model. If you want to do this work in your institution, you have to include the resources for people to take care of themselves.
One last thing before I stop: Sleep—that's a self-care item for all of you, but it's also a huge prevention issue in war, starting right from the terrible things that happen as the result of leaders making bad decisions and losing their self-restraint. Sleep is fuel for the frontal lobes of the brain. If you're out of gas in your frontal lobes you lose ethical self-restraint and you lose emotional self-restraint. Both of those are catastrophic in military units. A paper on this is one of the references in your handout, and it's on the Web. It was in the Army War College Quarterly more than 10 years ago. It's mainly about commanders' sleep and the need for commander self-care to be seen as critical to military leaders fulfilling their own ideals of winning fights and taking care of their troops. If they get too sleep deprived they will screw up and people that they are responsible for will die and they will not complete their missions.
So it's a big matter, but sleep is not very sexy. The military culture has not yet embraced sleep discipline in the way it has embraced water discipline. The culture fights it—you hear boasts today about going without sleep the same way that 25 years ago you'd hear boasts about running 20k in the heat and coming back with full canteens. I hope you will read this military paper to see how, culturally speaking, we got where we are today, treating sleep as questionable self-indulgence, rather than ethically obligatory self-care. It applies to mental health professionals as much as to military professionals. You need your frontal lobes!
I am out of time, so I'm going to stop and listen to your comments, questions, ideas, and criticisms.
Thank you.