From Shell Shock to Moral Injury

Instructor: David L. Fisher, Ph.D.

Goals and Objectives

Hermann Oppenheim in 1884 published Die Traumatischen Neurosen wherein he observed that victims and observers of industrial and train accidents often developed symptoms of disassociation. Two decades later, shellshock was the term first given to similarly observed phenomena in combat veterans.  Since that time, we have seen a litany of words to describe the effects of war on its combatants: irritable heart syndrome, soldier’s heart, war neuroses, combat exhaustion, post-traumatic stress disorder (PTSD), and traumatic brain injury (TBI). 

The astute observer will notice that many of these terms are diametrically opposed: some of them declare the problem to be biological, others psychological.  For instance, shell shock and TBI both ascribe symptoms to biological responses to repeated concussion; in contrast, war neuroses, combat exhaustion, and PTSD are psychological in nature and treatment.  There are several explanatory reasons why these models keep switching between the physical and psychological.  On one hand, if it can be shown that they are simply psychological, it is easier to dismiss veterans’ problems due to the fact they have a ‘weak character’ or are ‘defective mentally’ in some way.  In this manner, one can deny medical pensions, treatments, and sweep the debilitating effects of war under the rug.  If one uses the biological or physical model however, then it can be ‘proven’ that it is a physical injury and thus treatment, pensions, and recognition are warranted.  Another lens to view these competing models is through the medicalization of terms and the advancement of technology.  Heidegger recognized the problem of technology and how it separates us from the phenomenology of human experiences.  Secondly, the relentless notion that as technology advances that everything, including subjective experience, can be explained by rational science: which is a rejection of the notion of German romanticism and its phenomenological roots.

As should be clear from the Foundations in Moral Injury course, the notion of moral injury is not new, nor is it exclusively applied to the domain of combat veterans.  There is a rich notion of moral injury running through both philosophy and theology that has only recently broken through into the psychology literature.  Even so, as Shay points out, the Veterans Administration (VA) in the United States, has co-opted and medicalized the term in order to fit it into their evidence-based outcomes mode.  As Roger Brooke points out, “the medicalization of psychological life is the most pressing aspect of something that is more general and insidious in the field of (clinical) psychology. It is, as Heidegger described in his essay, The question concerning technology, our compulsion to set upon everything in our world with appropriating agendas.”  Further, “it is widely taken for granted that we are here to help patients fix their problems, get rid of their symptoms, become more functional and happier, think more rationally, be more congruent and in touch with their feelings, make better object choices, enjoy sex more, be more individuated, get over their trauma, and work through their grief.”  In short, rather than simply be a witness to someone’s suffering there is a propensity to try and “fix” someone.  Parker J. Palmer in Let your Life Speak: Listening to the voice of Vocation describes how, in a deep depression, it was a friend, who would just sit and listen, that helped him the most.  Those who tried to give advice or get him out of his funk provided little succor. 

This course lays out the groundwork for understanding how we have come from trauma-based models to understanding moral injury, particularly as it relates to the sequela of war.  It will also set the groundwork for understanding the telos of moral injury.  Finally, it should call into question certain epistemologies.  As James Hillman pointed out, we have had a hundred years of psychotherapy and things are getting worse: we could change that to we have over a hundred years describing modern theories of what war does to the human psyche and still veterans suffer.

Methodology, Objectives, and Evaluation

The course is composed of required reading, recommended reading, lecture, and small group discussion.  The Socratic method will be used to guide discussions and challenge all participants’ understanding of the material.  The student/practitioner is expected to have read required readings before each session; a complete understanding of each reading is not required, nor expected, but the student/practitioner should arrive with questions or thoughts stimulated by the readings.  These questions and thoughts can take the form of requests for clarity, amplification, or challenge. 

Recommended readings expand the epistemological grounding of the topic.  Depending upon the interests of the student/practitioner these provide a ready-made reference for further learning focused on their interests.  While not required, some allusion to recommended reading content will inform certain lecture components.

We will meet four times in three-hour sessions.  The sessions are held every two weeks to give participants the chance to prepare for the session and complete the readings.

All readings, with the exception of two books, will be available as PDFs for download by registered attendees.  There is also a list of books with links to Amazon on the Moral Injury Institute website if you choose to purchase the full book(s).  Full disclosure, these are affiliate links that provide a small commission to the Institute to help fund ongoing operations and keep the price of classes low.

Objectives

  • Be able to articulate a definition of trauma.
  • Describe the history and schools of thought around definitions of trauma.
  • Be able to give a cogent history of models used to describe the sequela of war in the human psyche.
  • Differentiate between medical and moral injury languages as they apply to the human condition.
  • Describe the various constituents and their motivations to apply one model over the other in the history of dealing with war veterans.
  • Delineate the different approaches used to help the war veteran return to civilization, particularly the differences in ancient versus modern approaches.
  • Understand the problems with technology, particularly as it applies to the human condition.

Evaluation

  • Course attendance: miss no more than one three-hour block, or three hours over the course. 
  • Class participation: students are expected to participate in class to the best of their ability and comfort.  It is understood that some students are more comfortable speaking in a group than others.  The rubric is not one of domination of discourse, but thoughtful participation that demonstrates a facility of the readings and lecture content.
  • A written paper, at least eight pages on an aspect of the history or treatment of war veterans.  No formal style need be followed (such as APA, Chicago, or MLA) but the student/practitioner should indicate through citation, footnote, or other device that they are quoting or paraphrasing others’ writing or thinking.  The paper should be double spaced, use a 12 point font, and have one inch margins all around.  A specific font is not required, but should be easily readable (no specialty fonts). This paper will be graded on a pass/fail basis.  The evaluation rubric is delineated below:
    • Pass: demonstrates knowledge of the language and writings of moral injury; cites at least four readings/references; demonstrates practical application to a case study.
    • Fail: fails to turn in paper within 7 days of the last class; demonstrates no or a misapplication of the language or writings of moral injury; fails to cite the work of others (plagiarizes); fails to demonstrate connection between moral injury and case study.
  • Students/practitioners must achieve a pass on the final paper, meet attendance requirements, and participate in class in order to receive credit for class leading to the Certificate in Moral Injury (this is class two of three).

Course Outline

Please begin reading The Road Back by Remarque in preparation for discussing this book in our final session.

Session One

“I’m saying that when your child goes off to war, you will never get him back.  Not as he was, not the same boy.  Changed, if he comes back at all” (Card, 2008, p. 3)  In this session, we focus on the early theories of trauma.  Freud is introduced, followed by Jung, then Kalsched.

Required reading:

Total reading commitment: 114 pages.

Session Two

Phillip Gibbs, speaking of World War I veterans noted, “but all was not right with the spirit of the men who came back.  Something was wrong.  They put on civilian clothes again, looked to their mothers and wives very much like the young men who had gone to business in the peaceful days before the August of ‘14.  But they had not come back the same men” (1920, p. 547).  In this session, we examine the first psychological approaches to the sequela of war: notably, two different diagnoses with serious import as to how returning veterans were viewed and treated by both doctors and civilians, dependent on their diagnoses.

Total reading commitment: 163 pages.

Session Three

“I am afeared there are few die well that die in battle; for how can they charitably dispose of anything when blood is their argument” (Henry V 4.1.6).  After the Great War, the interest in shellshock and the war neuroses gradually faded, except for the question of who deserved a pension and who was malingering.  As World War II began though, the psychiatric problems came back, albeit now listed as combat fatigue, combat stress reaction, or combat exhaustion.

Total reading commitment: 172 pages.

Session Four

“One soldier back from Afghanistan wrote on his deployment questionnaire, ‘I have a moral injury, a betrayal of what is right’” (Tick, 2014, p. 93).  In this last session, we will make the transition to moral injury.  Post Vietnam, the signature psychological injury was PTSD, however, it recent times, moral injury is emerging in the discourse.  This section covers that transition in the literature.

Total reading commitment: 84 pages + finish reading ReMarque.

Required Readings

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Bartemeier, L. H., Kubie, L. S., Menninger, K. A., Romano, J., & Whitehorn, J. C. (1946). Combat exhaustion. Journal of Nervous and Mental Disease104, 358–389. doi:10.1097/00005053-194610000-00002

Breuer, J., & Freud, S. (1953). On the psychical mechanism of hysterical phenomena: Preliminary communication. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1–18). London, United Kingdom: Hogarth Press. (Original work published 1893)

Bogousslavsky, J. & Tatu, L. (2013). French neuropsychiatry in the great war: Between moral support and electricity. Journal of the History of the Neurosciences, 22:144-154.

Brison, S. J. (2002). Aftermath: Violence and the Remaking of a Self. Princeton University Press: Princeton, NJ.

Crocq, M. A., & Crocq, L. (2000). From shell shock and war neurosis to posttraumatic stress disorder: A history of psychotraumatology. Dialogues in Clinical Neuroscience, 2(1), 47–55.

Currier, J. M., Drescher, K. D., & Harris, J. I. (2014). Spiritual functioning among veterans seeking residential treatment for PTSD: A matched control group study. Spirituality in Clinical Practice, 1, 3–15.

Freud, S. (1953). The neuro-psychoses of defence. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 3, pp. 45–61). London, United Kingdom: Hogarth Press. (Original work published 1894)

Freud, S. (1953). The aetiology of hysteria. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 3, pp. 191–221). London, United Kingdom: Hogarth Press. (Original work published 1896)

Freud, S. (1953). Introduction to psychoanalysis and the war neuroses. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 17, pp. 205–210). London, United Kingdom: Hogarth Press. (Original work published 1919)

Grossman, D. L., & Siddle, B. K. (2010). Psychological effects of combat. In G. Fink (Ed.), Stress of war, conflict, and disaster (2nd ed., pp. 440–450). Sydney, Australia: Academic Press.

Gunther, M. S., & Trosman, H. (1974). Freud as expert witness; Wagner-Juaregg and the problem of war neuroses. The Annual of Psychoanalysis, 2, 3-23.

Jung, C. G. (1961). Freud’s theory of hysteria: A reply to Aschaffenburg (R. F. C. Hull, Trans.). In H. Read et al. (Series Eds.), The collected works of C. G. Jung (Vol. 4, 2nd ed., pp. 3–9). Princeton, NJ: Princeton University Press. (Original work published 1906)

Jung, C. G. (1961). The therapeutic value of abreaction (R. F. C. Hull, Trans.). In H. Read et al. (Series Eds.), The collected works of C. G. Jung (Vol. 16, 2nd ed., pp. 108–115). Princeton, NJ: Princeton University Press. (Original work published 1928)

Jung, C. G. (1961). A review of the complex theory (R. F. C. Hull, Trans.). In H. Read et al. (Series Eds.), The collected works of C. G. Jung (Vol. 8, 2nd ed., pp. 92–106). Princeton, NJ: Princeton University Press. (Original work published 1948)

Kalsched, D. (1996). The inner world of trauma: Archetypal defenses of the spirit. New York, NY: Routledge.

Linden, S. C., Jones, E., & Lees, A. J. (2013). Shell shock at Queen square: Lewis Yealland 100 years on. Brain, 136(6), 1976–1988.

Maguen, S., & Litz, B. T. (n.d.). Moral injury in veterans of war. US Department of Veterans Affairs, retrieved from https//www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp

Mott, F. W. (1919). War, neuroses, and shell shock. London, UK: Oxford Univeristy Press.

Pols, H. (2011). The Tunisian campaign, war neuroses, and the reorientation of American psychiatry during World War II. Harvard Review of Psychiatry, 19, 313–320.

Pols, H., & Oak, S. (2007). War & military mental health: The US psychiatric response in the 20th century. American Journal of Public Health97(12), 2132–2142. http://doi.org/10.2105/AJPH.2006.090910

Remarque, E. M. (2013). The road back. In A. W. Wheen (Trans.). New York, NY: Random House Trade Paperbacks. (Original work published 1931)

Sgarzi, J. A. (2009). Healing a warrior world. Spring, 81, 243–263.

Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York, NY: Scribner.

Shephard, B. (2001). A war of nerves. Cambridge, MA:  Harvard University Press, 55-68.

Williams, S. (n.d.). Walking alone.  Retrieved from: http://www.vietvet.org/walkingalone.pdf.

Recommended Readings

Herman, J. (1992). Trauma and recovery: The aftermath of violence—From domestic abuse to political terror. New York, NY: Basic Books.

Jung, C. G. (1961). The collected works of C. G. Jung (Vol. 4). Princeton, NJ: Princeton University Press.

Jung, C. G. (1961). The collected works of C. G. Jung (Vol. 8). Princeton, NJ: Princeton University Press.

Jung, C. G. (1961). The collected works of C. G. Jung (Vol. 16). Princeton, NJ: Princeton University Press.

Kalsched, D. (1996). The inner world of trauma: Archetypal defenses of the spirit. New York, NY: Routledge.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1988). Contractual report of findings from the national Vietnam veterans’ readjustment study: Volume 1. Research Triangle Park, NC: Research Triangle Institute.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1988). Contractual report of findings from the national Vietnam veterans’ readjustment study: Volume 2. Research Triangle Park, NC: Research Triangle Institute.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1988). Contractual report of findings from the national Vietnam veterans’ readjustment study: Volume 3. Research Triangle Park, NC: Research Triangle Institute.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1988). Contractual report of findings from the national Vietnam veterans’ readjustment study: Volume 4. Research Triangle Park, NC: Research Triangle Institute.

Lifton, R. J. (1973). Home from the war. New York, NY: Simon and Schuster.

Martens, W. H. (2005). Multidimensional model of trauma and correlated antisocial personality disorder. Journal of Loss and Trauma, 10, 115–129.

Pearlman, L. A., & Saakvitne, K. W. (1995). Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 150–177). New York, NY: Brunner Mazel.

Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner.

Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York, NY: Scribner.

Shephard, B. (2001). A war of nerves. Cambridge, MA:  Harvard University Press.

Sutker, P. B., & Allain, A. J. (1996). Assessment of PTSD and other mental disorders in World War II and Korean conflict POW survivors and combat veterans. Psychological Assessment, 8(1), 18–25. doi:10.1037/1040–3590.8.1.18

Sutker, P. B., Winstead, D. K., Galina, Z. H., & Allain, A. N. (1991). Cognitive deficits and psychopathology among former prisoners of war and combat veterans of the Korean conflict. The American Journal of Psychiatry148(1), 67–72. doi:10.1176/ajp.148.1.67

Tick, E. (2005). War and the soul: Healing our nation’s veterans from post-traumatic stress disorder. Wheaton, IL: Quest Books Theosophical Publishing House.

Tick, E. (2014). Warrior’s return: Restoring the soul after war. Boulder, CO: Sounds True.