r Academy of Management Journal

2016, Vol. 59, No. 6, 1965–1993.

http://dx.doi.org/10.5465/amj.2015.0681

SOME THINGS CAN NEVER BE UNSEEN: THE ROLE OF

CONTEXT IN PSYCHOLOGICAL INJURY AT WAR
MARK DE ROND
University of Cambridge

JACO LOK
University of New South Wales

Recent wars in Iraq and Afghanistan have reignited debates on how to prevent and
manage psychological injury among returning troops. These debates point to the psy-
chological cost of war as a grand challenge whose scale and complexity stretch far
beyond the already large and growing number of veterans affected. We use a unique
ethnography of a military medical team’s tour of duty in Camp Bastion, Afghanistan, to
explore the role of institutional context as a contributing factor to psychological injury
from war. We find that exposure to war and its consequences invokes sustained expe-
riences of senselessness, futility, and surreality that are partially rooted in cultural
expectations, professional role identity, and organizational protocol, and can threaten
people’s existential grounding in this institutional context. We argue that what makes
work at war traumatic for some and not others is likely affected by the specific context
through which people filter, frame, and cope with their experience. A contextual un-
derstanding of psychological injury at war that is based in organizational research can
thus form an important part of better addressing this grand challenge.

War can be deeply traumatizing, even for those not exceeding U.S. combat deaths in 2012. Similarly,
in the firing line, because it tears at the fabric of what the U.K. charity Combat Stress (2015) has reported
it is to be human. Yet there is little indication of war’s a fourfold increase in ex-service personnel seeking
remission: the 20th century, for all its progress in help for mental disorders over the past 20 years, and
medicine, technology, and education, was also the a 25% increase in referrals for post-traumatic stress
most murderous in recorded history. Recent wars in disorder (PTSD) during 2014–2015 alone. These es-
Iraq, Afghanistan, Syria, Yemen, and the Ukraine timates do not take into account deployments from
show no abatement in the trend. Leaving aside the the other 42 countries that made up the International
direct cost of war, the psychological costs of de- Security Assistance Force (ISAF).
ployment are becoming ever more apparent. Of the The Western media’s emphasis on PTSD among
2.7 million U.S. troops sent to Iraq or Afghanistan veterans risks neglecting the incidence of psy-
between 2001 and 2011, 20–30% returned with chological injury among civilians, estimated by
some form of psychological injury (U.S. Department Afghanistan’s Ministry of Health to be double that
of Veteran Affairs, 2015). While correlation need not of combat veterans (Canadian Women for Women in
imply causation, according to a 2008 Congressional Afghanistan, 2015; Cardozo et al., 2004). Moreover,
report, military veterans account for 10% of U.S. PTSD is only one of several war-related disorders
adults, yet 20% of suicides, with Pentagon figures that constitute psychological injury, which also in-
showing active-duty suicides among U.S. troops cludes depression, anxiety, and substance abuse. In
addition, psychological injury is rarely a private af-
We wish to thank Scott Sonenshein and three anony- fair, with employers and colleagues, friends and
mous referees for their uncompromising efforts in helping family on the receiving end of depressive bouts, vi-
us shape this paper. We also thank Barbara Czarniawska,
olence, and alcohol misuse. Given this scale and
John Dunne, Jennifer Howard-Grenville, Elizabeth Maitland,
Richard O’Quinn, Simon Wessely, Hugh Willmott, Dvora
complexity, the psychological cost of war is a grand
Yanow, participants at the PROS symposium, and mem- societal challenge that has captured the popular
bers of OT discussion groups at Cass Business School, imagination—cinema blockbusters such as The Hurt
University of Edinburgh Business School, UMEA, and Locker, American Sniper, and Good Kill all revolve
UNSW Business School, for their input. around psychological injury from war. It has also
1965
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1966 Academy of Management Journal December

become an acute political issue. In 2015, Barack groups. We may also gain a better appreciation of
Obama signed a bill to help prevent suicide among how particular institutional arrangements can exac-
war veterans, and legal experts have suggested that erbate, and possibly even create, certain types of
the U.S. criminal justice system should treat veterans psychological injury in organizations more generally.
suffering from PTSD differently from other crimi- For this study we draw on an ethnography of a
nals, including an exemption from the death penalty. military medical team in Helmand, Afghanistan, in
Yet, despite the prevalence and scale of mental 2011. Our case study is particularly well suited to
health legacy issues among military personnel, we still exploring factors that can play a role in psychological
know relatively little about their underlying causal injury at war over and above those typically con-
mechanisms. This is because most research to date has sidered in PTSD research for a number of reasons.
either exclusively focused on the psychological fac- We focus on the specific case of damage control
tors involved in psychological injury from war, or surgery (DCS) team members that, as rear located
on the effectiveness of different treatment methods. medics (RLM), do not typically have a combat role.
The general attribution in this research of causality to Because DCS staff generally have less reason to fear
a person’s exposure to (the aversive effects of) a trau- for their lives than frontline troops do, they enable us
matic event assumes that the likelihood of psycho- to explore sources of psychological distress other
logical injury depends primarily on how well a person than the extreme threat of death or injury to self that
can cope with such events psychologically. Why and is widely considered to be a leading cause of psy-
how war is experienced as traumatic in the first place chological injury from war. Moreover, as a group
are questions that have received much less attention, they should be particularly apt at coping with treat-
possibly because the answers may seem obvious given ing severe injuries in others: most are highly expe-
the intrinsically violent nature of combat. Yet, by re- rienced and “battle hardened,” and their medical
ducing the problem of psychological injury to a psy- training is designed to make them especially resilient
chological response to (the threat of) violence, we risk (Firth-Cozens, Midgley, & Burges, 1999; Weinberg
losing sight of important contextual factors that can and Creed, 2000). Yet, despite these factors, PTSD
affect how war is experienced, and what makes this rates among rear located medical military personnel
experience traumatic for some, and not others. are on par with those of battlefield soldiers (Cawkill
In this paper, we explore new pathways for better et al., 2015). This is particularly surprising, as it is
understanding and managing the grand challenge of combat exposure specifically that has repeatedly
psychological injury from war through a contextual been shown to impact adversely on mental health
analysis of the lived experience of deployed person- (Pietrzak, Pullman, Cotea, & Nasveld, 2012, 2013).
nel. We ask: What role do cultural, professional, and Thus, how is it that DCS staff are prone to psycho-
organizational contexts play in the experience of logical distress, and what may this tell us about the
psychological distress at war? This research question drivers of psychological injury at war more broadly?
aims to broaden the scope of current understanding Our study shows that the specific cultural, pro-
of psychological injury from war by examining the fessional, and organizational contexts in which people
institutional context in which these injuries are who work at war are embedded can play a central role
allowed to occur. Seen through the lenses of organi- in the experience of emotional distress, regardless of
zational, occupational, and institutional scholarship, whether they are directly exposed to combat. Our
the “context” of psychological injury at war involves findings suggest that this is because these contexts can
more than likely exposure to (the threat of) violence trigger and amplify repeated experiences of senseless-
and human suffering. Rather, it includes the cultural, ness, futility, and surreality that are known to charac-
professional, and organizational meaning structures terize the experience of war for many who are exposed
and practices through which people experience, in- to it. We argue that when these experiences are sus-
terpret, and cope with such exposure. Thus, the mil- tained, they can dislocate people’s institutionalized
itary as an organization is not merely a means by sense of the meaningful, the good, and the normal to the
which people become exposed to traumatic events at point where they experience an existential threat to
war; as a workplace it forms a specific context that is their sense of being in the world (Heidegger, 1962).
likely to be consequential for the way people experi- We show how institutional context is implicated in
ence, and cope with, psychological distress. By ex- this distressing experience in three ways. First, it can
plicitly considering the role of this context, we may produce repeated dissonance between people’s in-
be able to develop better explanations for dif- stitutionalized expectations of the meaningful, the
ferential rates of psychological injury in different good, and the normal on the one hand, and, on the
2016 de Rond and Lok 1967

other, their experiences on the ground. For example, threats or injuries. It incorporates disorders such as
we show how the heightened sense of purpose and major depressive episodes, acute stress disorder,
agency of DCS staff, which is rooted in their pro- substance abuse disorder, a propensity for violence,
fessional context, can contrast sharply with the care a myriad of other less-defined anxiety and de-
constraints that military protocol places on them, pressive reactions, and PTSD. The most recent
resulting in a profound sense of futility that is partic- edition of the DSM, used by U.S. clinicians and
ularly distressing for people who have been socialized researchers to identify mental disorders, suggests
to “make a difference.” Second, we show how this that PTSD is triggered by “exposure to actual or
same context can form an impediment to coping with threatened death, serious injury or sexual violation”
such distressing experiences when it denies people (APA, 2013), either in the form of direct experience
the cultural resources needed to resolve the disso- (e.g., seeing others get killed or injured, being shot
nance they experience. Third, we show that, as a re- at), or indirect experience (e.g., exposure to aversive
sult, doctors and nurses rely on improvised coping details of the traumatic event, or learning that the
strategies to deal with their distress. We argue that traumatic event occurred to a close family member or
these are generally ineffective, and may even exacer- friend). Regardless of the specific trigger event, PTSD
bate distress, because they fail to fully address the causes “clinically significant distress or impairment
institutional sources underlying the experience of in the individual’s social interactions, capacity to
senselessness, futility, and surreality that, we suggest, work or other important areas of functioning” (APA,
lie at the heart of psychological distress at war. 2013). Symptoms that accompany PTSD include:
These findings form the basis for two key contribu- reexperiencing (dreams or flashbacks of the trau-
tions. First, we develop a contextual explanation for matic event), avoidance (distressing memories or
psychological distress at war that is intended to com- reminders), negative cognitions and mood (feelings
plement and deepen current understanding of the that range from a distorted sense of blame to es-
causes of psychological injury. Our focus on how trangement), and arousal (aggressive, reckless, or
context contributes to psychological distress at war self-destructive behaviors). Neither PTSD specifi-
enables us to make some tentative suggestions about cally, nor psychological injury generally, are con-
new possible ways of approaching this grand chal- fined to the military, even if they are popularly
lenge. Second, we contribute to organizational re- associated with it. For example, with its primary
search by showing how “context theory” (Johns, 2006) interest in veterans, the media has largely ignored
may be developed in such a way that it is practically the psychological impact of war on civilians, even
relevant. Specifically, our study shows how and why though they constitute an estimated 90% of all war
the very contexts that can look most promising to casualties (Summerfield, 1996).
people who derive a strong sense of purpose and In the military, related concepts, such as “shell
agency from a particular “calling” (Wrzesniewski, shock” and “irritable heart,” have been around since
2011) may be inherently prone to produce the oppo- World War I (and “soldier’s heart” since the U.S.
site: an overwhelming sense of futility and meaning- Civil War), and have had an enduring literary
lessness that is difficult to recover from because it can presence (e.g., Conrad’s Heart of Darkness and
permanently taint the institutional structures that Hemingway’s A Farewell to Arms). Yet, it was not
normally ground people in everyday life. until after Vietnam that veterans were formally di-
We begin by specifying psychological injury, and agnosed as suffering chronic, adverse psychological
what we know about its causes, before presenting the effects from war (Jones & Wessely, 2007). Prior to
methods and findings of our study. We close with this—and to some extent still today—psychological
a discussion of the implications for understanding injury was looked upon as a form of disgrace
psychological injury at war, highlighting the role (Greenberg, Jones, Jones, Fear, & Wessely, 2011). Such
a contextual perspective rooted in organizational re- was the stigma that, in the post-1945 period, ad-
search may play in addressing this grand challenge. missions registers and case notes for officers treated
for psychological disorders were systematically
PSYCHOLOGICAL INJURY AT WAR destroyed to protect their identity (Greenberg et al.,
2011), and their doctors colloquially referred to as
The Nature and Prevalence of Psychological
“shrinks,” “trick-cyclists,” or “nut-pickers” (Shepard,
Injury at War
2000).
Psychological injury refers to a stress-related emo- It is now well established that psychological in-
tional condition that results from real or imagined jury from deployment is a significant problem, with
1968 Academy of Management Journal December

20–30% of Iraq or Afghanistan veterans showing specific situated reasons why and how people
PTSD symptoms (U.S. Department of Veteran Af- experience certain events as traumatic, and not
fairs, 2015).1 Data on psychological injury in medical others, it may remain difficult to develop targeted
personnel at war is harder to come by insofar as and tailored interventions that can help prevent
this particular group is understudied in relation psychological injury at war for specific groups of
to psychological injury (Palgi, Ben-Ezra, Langer, & people.
Essar, 2009). One study of U.K. military health pro- In order to better understand these situated rea-
fessionals estimated 35% to suffer psychological sons, we believe it is important to begin considering
injury (Jones et al., 2008), while Cawkill et al. (2015) the specific contexts in which psychological injury
found it to be equivalent to other deployed military at war occurs. The military is not merely a vehicle
staff. The latter study also found no significant dif- through which people become exposed to traumatic
ference when comparing forward located medics events at war; it is also a place of work for millions of
with RLM, despite RLMs being much further re- people around the world. It thus forms a specific
moved from combat. context that may be consequential for the way people
One explanation for the comparatively high in- experience, and cope with, the violence they in-
cidence of psychological injury among military evitably encounter at war. We know that organiza-
medics—even taking into account their training, tions can have a very significant effect on people’s
experience, and non-combat role—is that they are psychological well-being, not only in the workplace,
typically assembled in groups only weeks before but in their lives as a whole (Danna & Griffin, 1999;
their deployment, as compared to combat units who Warr, 1999). This is not surprising given that people
can spend up to a year training together (Jones et al., increasingly seek, and expect, meaning and purpose
2008). This is relevant in that high team morale and from their work (Wrzesniewski, LoBuglio, Dutton, &
good interpersonal relationships have been found to Berg, 2013).
provide some protection against serious adverse re- Not only can organizations provide a context in
actions to traumatic experiences (Hatch et al., 2013; which such meaning and purpose may be found,
Jones et al., 2008). Yet, relatively little is known they can also contribute to profound emotional dis-
about the precise nature of the traumatic psycho- tress, particularly when they deny the fulfillment of
logical experiences that team morale can help pro- a person’s calling (e.g., Creed, DeJordy, & Lok, 2010),
tect against. or compel them to engage with traumatic events
while at the same time denying them the means to
cope (e.g., Keats, 2010). For this reason, research
Toward a Contextual Understanding
in the area of disaster management has explicitly
of Psychological Distress at War
included the role of organizational factors in its un-
One reason why we know relatively little about the derstanding of the psychological responses of di-
experiences that make war psychologically dis- saster workers to trauma exposure (Paton, Smith, &
tressing may be that the literature on psychological Violanti, 2000). Research has also shown that the
injury at war predominantly centers around the rel- broader institutional context in which organizations
ative psychological (in)ability to cope with direct or are embedded can affect what aspects of their work
indirect exposure to (threats of) traumatic events. practices people experience as fulfilling or distress-
Questions as to how and why particular events are ing. This is because the meaning people construct
experienced as traumatic have received limited around their experiences at work is directly tied
attention. After all, traumatic event triggers of psy- to the institutional context through which they un-
chological injury, including PTSD, can seem rela- derstand this work (Zilber, 2002). Their internal-
tively unproblematic considering the nature of war. ization of the societal values through which different
Research to date has largely focused on determining types of work practices are judged can thus affect
the psychological or neurobiological factors that whether they experience a sense of pride or shame
make some people more prone to psychological in- in relation to their work (Ashforth & Kreiner, 1999,
jury as a result of exposure to traumatic events than 2002).
others. Yet, without a better understanding of the The question is how this understanding of the
role and importance of context in people’s well-
1
There is literature on veterans inventing narratives of being at work can be applied to the military context
distress, a useful review of which is provided in Jones and in a way that informs a better understanding of
Milroy (2016). psychological injury. What role does this context
2016 de Rond and Lok 1969

play in the lived experience of work at war as psy- Camp Bastion’s field hospital. Camp Bastion’s
chologically distressing? And what may this tell us 50-bed field hospital was the most successful of any
about possible contributing causes of psychological hospital in any prior war. Of 6,386 admissions be-
injury from war, over and above direct or indirect tween April l, 2006, and July 31, 2013, it achieved
exposure to the intrinsic violence of war? Below, we a survival rate for U.K. Armed Forces personnel of
address these important questions by analyzing the 99.2%. Led by British forces, Camp Bastion’s hos-
role of context in the lived experience of work at pital was staffed by a combination of Americans
war by members of a DCS medical team in Camp and Britons in more or less equal proportion, and
Bastion. a handful of Danes and Estonians. Over the years,
injury patterns had evolved such that the signature
injury of the insurgency during the study period was
RESEARCH SITE AND METHODS
the double amputation, inflicted by improvised ex-
Empirical Context plosive devices (IEDs) (see Figure 2). The study pe-
riod comprised the hospital’s bloodiest and busiest:
Camp Bastion. Camp Bastion was, from its con-
174 casualties were admitted during the first week
struction in 2005 until its handover to Afghan forces
of fieldwork alone, with some requiring upwards of
in October 2014, the largest British overseas military
100 pints of blood each (an adult contains about 10
camp since World War II. Four miles long and two
pints of blood). A record-setting 3,100 pints of blood
miles wide, it accommodated some 30,000 people
had been used the previous month. The most seri-
and incorporated a smaller U.S. base, Fort Leather-
ous ISAF casualties would typically arrive in the
neck. It housed a Role 3 field hospital and an airfield
early morning—victims to IEDs on daily, predawn
that, at its peak, handled 600 flights each day. It was,
patrols—or just after evening patrols. About half of
as then-Prime Minister Tony Blair said in 2006, an
the casualties were locals, often members of the
“extraordinary piece of desert . . . where the fate of
Afghan National Army or Afghan National Police.
world security in the early 21st century [would] be
About 20–25% of Afghan casualties were children.
decided” (Brown, 2006).
With the outside temperature regularly exceeding
Everything in the camp was bought and sold using
115 degrees Fahrenheit, the DCS doctors spent their
American dollars. Change came in the form of paper
“downtime” between the gym and Doctors’ Room.
coins, about an inch in diameter, varying in color
The latter featured a leather sofa and plastic desk
depending on value. These could be traded for
chairs (one without its metal frame and bolted to an
soda pop, food, candy, coffee, toiletries, and knick-
upside-down soda-pop crate instead), long-out-of-
knackery in a small market square that featured
date newspapers and magazines, a PC with internet
a Pizza Hut–KFC combo, operating out of a 40-foot
access, an old television, a games console and DVD
shipping container (see Figure 1). There was a coffee
player, medical journals, a bookshelf full of long-life
shop, a games room, and a general store. Higher
foodstuffs, a small fridge containing “near beer,” and
ticket items, “near beer” (alcohol free), and elec-
tronics were sold in a PX on the U.S. base.
FIGURE 2
FIGURE 1 One of Many Double Amputees
The Pizza Hut–KFC Combo
1970 Academy of Management Journal December

a heavily used coffee machine. It might have looked insight into the private world of DCS staff. Those
a jumble, but the room was well used, and was the attending MOST would go to a local pub for drinks
doctors’ to do with as they pleased. (always the George IV on Portugal Street, London),
followed by dinner elsewhere. Helped by the alcohol
and informality, it was here that they would reflect
Data Sources
on their personal experience of war, as per the
Ethnographic data were collected over 16 months, fieldnotes:
between April 2010 and August 2011, by one of the
As The George gives generously, those due to deploy
authors (referred to here as “the ethnographer”), and
get a chance to socialise, and as the alcohol does the
included predeployment training over the course of
inevitable, stories begin to flow of deployments past,
several months, as well as a six-week “tour of duty”
things fair and unfair, surreal but oh so real at the
in Afghanistan. The ethnographer was granted per-
same time. They may hate war but war reminds them
mission to deploy with a DCS team to Camp Bastion of why they went into medicine in the first place . . .
for the duration of a typical tour from June 14 to July It is as Chris Hedges wrote: war is what gives life
29, 2011. He had unrestricted and unsupervised meaning. Those who choke up take a hike to return
access to all areas of the hospital. The DCS team a little while later to more merriment, to tales of na-
comprised, at any one time, around 4–5 general ked generals and toilet seats and illicit sex on board
surgeons, 6–7 orthopedic surgeons, 1 plastic sur- a ship, all the while working the night into a cre-
geon, and 5–6 anesthetists, alongside operating de- scendo more intoxicating and affecting than any
partment practitioners, theater nurses, and theater drug could. For of course at the end it is the cama-
coordinators. raderie that matters . . . the sense of brotherhood that
Fieldnotes from predeployment training and from wins small wars.
the six-week deployment in Camp Bastion comprise
Those about to deploy had typically been on sev-
the bulk of the empirical data used for this study. The
eral previous tours, and were keen to recommend
ethnographer’s account is composed of thick de-
books that they felt best conveyed their own experi-
scriptions of observations, with particularly rich
ence of war: M*A*S*H, Catch-22, My War Gone By
detail on personal reflections on the experience of
war, as related by informants before, during, and af- I Miss It So, The Bang Bang Club, Emergency Sex,
ter their deployment (see de Rond, 2017, for a de- What it is Like to go to War, On Killing, Meditations
tailed account). The empirical data also contain in Green, and Heart of Darkness. We carefully read
reflections in the form of poetry written and shared these, and others like them, in preparation for this
by DCS staff, a post-tour report by a DCS member of paper. Those who know this literature will be fa-
a 12-month embedded tour of duty in an Afghan miliar with their explicit raw potency and surreal-
hospital, a post-tour report by a DCS member cov- ism, which is reflective of our primary data as well.
ering the study period, data on hospital admissions To foster reflexivity in data analysis, the ethnog-
and triage, data from weekly morbidity and mortality rapher also kept a personal journal of “headnotes,” in
meetings, and some 1,000 useable photographs taken which he recorded his own experiences, anxieties,
by the ethnographer. Many of these photographs fea- and reflections. While the focus in this paper is
ture the DCS teams at work, and were used to help squarely on the lived experience of members of the
elicit new data by prompting conversations post- DCS team, we have included occasional references
procedure, mostly because it was not usually possible to these headnotes to help locate the researcher in the
to engage in conversations during emergency pro- context of his fieldwork, and to show that the eth-
cedures (see Harper, 2002). nographer was not inoculated from the effect of what
Predeployment training for surgeons and anes- he, and the DCS staff, bore witness to daily, as we
thetists included three core components in addition explain below.
to weapons handling: a five-day military operational
surgical training (MOST) course, a three-day hospi-
Data Analysis
tal exercise course, and a 10-day operation, test, and
evaluation command (OPTEC) course. The ethnog- One of the challenges of writing ethnography is
rapher attended each course (except for weapons that of drawing inferences from observations such
handling), as well as OPTEC’s civilian counterpart. that they stack up to a credible theoretical claim
The informal socialization during predeployment (Ketokivi & Mantere, 2010; Locke & Golden-Biddle,
training proved to be a particularly rich source of 1997). This inference process necessarily involves
2016 de Rond and Lok 1971

what Langley (1999: 707) refers to as “inspiration:” were shared by members of the DCS team. First, we
creating new and plausible connections between systematically compared the content of the ethnog-
formal data, experience, a priori theory, and com- rapher’s headnotes and fieldnotes, noting experi-
mon sense. For us, this process consisted of sys- ences that appeared unique to the ethnographer.
tematically and repeatedly interrogating the data, Second, the coauthor played an important re-
and examining them against the ethnographer’s flexive role by actively questioning the valid-
preunderstanding based on his immersion in the ity of emerging insights in ongoing discussions
setting, as well as against extant theory (Mantere & about data interpretation and theory develop-
Ketokivi, 2013). Throughout this cyclical process, ment. This helped us attain the critical distance
we actively and continually called into question our required for moving from data to general theo-
emerging theoretical understanding by exposing it retical explanation (Alvesson, Hardy, & Harley,
to further data analysis (Alvesson & Kärreman, 2008; Cunliffe, 2010).
2007), until a deeper, empirically grounded expla- Analyzing themes in distressing experiences of
nation of psychological distress at war emerged. work at war. In order to establish the main themes
Thus, rather than focusing on general empirical that ran across the lived experience of war as
tendencies as a basis for inducing new theory (see distressing, we decided to focus on events—i.e.,
Gioia, Corley, & Hamilton, 2013), we followed the observations of actual events, or stories of events
interpretive research tradition (Mantere & Ketokivi, from current or past deployments—that were as-
2013). This involved actively using the ethnogra- sociated with direct expressions of distress, or
pher’s preunderstanding of the setting as an entry appeared purposely chosen to convey the extremi-
point into our data analysis, and focusing on the ties of war as distressing without necessarily express-
contextual authenticity of our reasoning in light of ing such distress directly. Both authors independently
the data (Ketokivi & Mantere, 2010). Rather than coded the fieldnotes for these events as a basis for
presuming that the ethnographer’s experience was discussions on particularly striking examples, and
necessarily shared by the DCS team, we used his what they might tell us about the lived experience of
personal account to sensitize us to plausible themes war across informants. For example, we discussed
and theories that may help us structure and interpret medics having to unhook a very sick Afghan patient
the data. from potentially lifesaving equipment (antibiotics,
This process began with a series of discussions oxygen, analgesics), and hand him over to a driver with
about the nature of the ethnographer’s own experi- no medical expertise for transfer to a local hospital. “He
ences, and their possible relation to those of the will die of pneumonia,” the doctor in charge of the
DCS medics with whom he was embedded. These handover had told the ethnographer, admitting to
initial discussions produced a number of themes, having resigned himself to the futility implied by these
including: the dream-like, surreal nature of the eth- handovers.
nographer’s deployment experience; the suppressing In our discussions, we aggregated and connected
of emotions during deployment, yet surprise at the such examples to five emerging themes in the lived
absence of guidance on how to cope with distressing experience of work at war as distressing: horror (as-
events during predeployment training; the flash- sociated with [unnecessary] suffering); contradic-
backs and anger that followed deployment several tion (between the obligation to provide the best
weeks later; feelings of powerlessness in the face of possible care and the military protocol of handing
suffering; the realization of the brutality, absurdity, local Afghan patients over to the local healthcare
and futility of war; the absence of a meaningful nar- system as soon as possible); futility (related to the
rative; profound existential boredom upon return; pointlessness of treating patients who would likely
and a general lack of zest for life (see de Rond, 2012). die), strangeness (of the contrast between daily rou-
Insofar as these themes were also reflected in the tines and the human gravity of the situation); and
fieldnotes, we decided to use them as entry points boredom (medics struggled to deal with the long
into our subsequent systematic data analysis. In spells of inactivity when waiting for new patients to
this way, we sought to get as close as possible to the come in).2 In reflecting on these themes, it became
lived experience of the research subjects, which is
a key strength of ethnography (Spradley, 1996; Van 2
Boredom has also been shown to have a profound,
Maanen, 2011). distressing effect on frontline soldiers, some of whom
We used two means to verify the extent to, and ways “prayed for contact [with the enemy] as farmers pray for
in which the ethnographer’s personal experiences rain” (Hetherington, 2010: 15).
1972 Academy of Management Journal December

clear that some were closely related. For example, and normalization (Ashforth & Kreiner, 1999, 2002;
the experience of boredom was intricately related Ashforth, Kreiner, Clark, & Fugate, 2007) to sensi-
to the experience of futility, with the former exac- tize us to the presence of coping strategies in our
erbating the latter. For the sake of parsimony, we data.3 This enabled us to code for the presence of
therefore aggregated the five themes into three well-known coping strategies (e.g., avoiding, denial,
overarching ones, going back to the data to identify behavioral or mental disengagement, attempts to
the most direct expressions of each of these three improve the situation), while leaving room for ad-
themes. For reasons outlined below, we also de- ditional coping strategies that appeared more unique
cided to change the heading for our original theme to our setting (e.g., acts of creation, such as baking
of “horror” into “senselessness.” This produced the bread). Both authors coded the fieldnotes indepen-
three themes illustrated in Table 1: senselessness, dently for the presence of coping strategies, paying
futility, and surreality. particular attention to striking examples as a basis for
Analyzing the role of institutional context. In anal- defining different coping types. Codes and categories
yzing the role of institutional context in the lived ex- were then compared, and differences reconciled in
perience of war, we first divided our contextual data ongoing discussions between the ethnographer and
into three temporal brackets—predeployment, de- the coauthor.
ployment, and post-deployment (Langley, 1999)— As a basis for judging which of the behaviors
and developed lists of institutionally prescribed identified through this process could plausibly be
practices, rules, norms, and values that were sa- interpreted as coping responses to the distress of
lient during each of these phases. We differen- war, we deployed abductive reasoning (Mantere &
tiated between the medical profession and the Ketokivi, 2013) to isolate behaviors that were diffi-
military as different sources of these institutional cult to explain other than as coping strategies. For
prescriptions, creating a third category for where example, we observed DCS medics repeatedly using
they overlapped. various tricks and excuses to get out of the moral
As a second step, we systematically related these obligation to attend formal repatriation services for
lists to the specific instances of implicit or explicit troops that had died in battle and had to be flown
emotional distress that we coded in our analysis of home. We determined this to be an “avoiding” cop-
the three lived experience themes discussed above. ing strategy based on the following line of (abduc-
We reviewed these for the presence of institutionally tive) reasoning: first, the literature on psychological
prescribed practices, norms, and values, as a basis for coping has suggested that escape coping through
building an emerging understanding of the role of avoidance is a common way for people to attempt to
context in the lived experience of war. Figure 3 cope with a stressor (Carver, Scheier, & Weintraub,
presents an illustration of this analysis. 1989); second, we have empirically established that
This process led us to identify specific ways the lived experience of work at war is distressing,
through which the cultural, professional, and orga- and explanations provided by those directly in-
nizational contexts played a role in expressions of volved in avoiding repatriation services provided
distressing experiences. During this analysis we also some confidence that this behavior was specifically
noticed that the role of context was not only marked aimed at avoiding distressing confrontations with
by its presence in expressions of distress, but also by the human cost of war; and third, there was no
its absence. This absence was particularly felt in the evidence in the data to suggest that medics were
lack of purpose that the military organization pro- eschewing repatriation services for alternative rea-
vided other than “doing a job,” and in a professional sons, suggesting that this was indeed a coping re-
culture that made it extremely difficult to talk about sponse. Through this process we settled on five
the moral ambiguity and strong emotions that distinct coping strategies that were prevalent in the
marked the lived experience of work at war. The data: avoiding, bracketing, humor, recovering fa-
inability to rely on the organizational and profes- miliarity, and reclaiming control, as illustrated in
sional context to cope with the distressing nature of Table 2.
work at war was particularly evident in the preva-
lence of improvised coping strategies in our data, 3
We consider the normalization strategies that Ashforth
which we discuss next. and Kreiner (1999, 2002), and Ashforth, Kreiner, Clark and
Analyzing coping strategies. We used the litera- Fugate (2007) identify to be coping strategies in the sense
ture on psychological coping (Bleich, Gelkopf, & that they are designed to alleviate the stress caused by
Solomon, 2003; Mikulincer, Florian, & Weller, 1993) stigmatization or shame.
2016 de Rond and Lok 1973

TABLE 1
Themes in the Lived Experience of War in Relation to Contextual Expectations
Experience themes
Contextual expectations Source Actual lived experience due to dissonance

Children are innocent; Culture The ward nurses talk of the sadness and frustration Senselessness
symbols of hope they feel at the cruelty of the methods employed
by the Taliban, and relate the example of them
stuffing a donkey full of explosive and letting it
be led by a young boy to its target, killing both in
the process.
All patients are created equal; Profession When a U.S. marine dies on the operating table, the Senselessness
there is only the technical effect on the team is palpable. Some of the
theater staff are badly affected, such that one
broke out in tears and another choked up when
realizing that very soon, the man’s parents will
get a knock on their door to tell them that their
most precious possession has just died. As he
said at the time: “I really don’t know why this
case affected me so much, but it did. Maybe it
was the culmination of so many cases, I don’t
know, but it certainly affects me quite badly . . .”
To provide the best possible Profession or military In the Doctors’ Room they discussed whether pain Futility
care for patients relief should be continued for this Afghan double
amputee and so many others like him? He was on
a dose of opiates his local health care system
would never in a gazillion years match, and
would be discharged within the next few days
with nothing stronger than Paracetamol. So why
raise his hopes? Southwark suggested they wean
him off the most powerful opiate twenty-four
hours before discharge to ease his reentry into
Afghan care, only for his suggestion to be
dismissed by one of the nurses. His pain would
be so awful, she said, that he would lie howling
on the ward, which would be distressing to all the
other patients, and to her staff, and so why not
give him a handful of opiates when releasing him
to the care of this terrible country just to carry
him over for a couple of days?
To make a difference Culture or profession When relating the day’s experience, he laughed Futility
and jokingly replied: “You don’t mean to say that
our work is futile, do you?” as if they knew
something I hadn’t caught on to yet.
Children’s songs are pure; not Culture During the evening, a 13-year old arrived with Surreality
associated with pain shrapnel wounds from an IED. Small ball
bearings penetrated the skin behind his ear, and
his arm, while shrapnel entered his neck,
buttock and hand. The child sang all the while in
rhesus while an older man (perhaps his father?)
stood over him with a stuffed, cuddly toy. His
voice was high and pitch-perfect, even as he
must be in pain.
Taxis are used to transport Culture Two badly burned Afghans arrived yesterday Surreality
living people afternoon. One died shortly after (with 48%
burns), the other was expected to follow suit but,
refusing to go to Boost (a local hospital in
Lashkar Gah) asked if the hospital could please
arrange for a taxi to take him and his dead friend
back home.
1974 Academy of Management Journal December

FIGURE 3
Example of Analysis of the Role of Context in the Lived Experience of War
Data Sample
Coding of Data Sample
1 Futility
Sunday,10 July: Had breakfast with Blake, an intensivist, and
Potter, a primary care doctor. They spoke about the sense of
2 Senselessness
futility 1 of what they do: “we torture a casualty (by injuring
them), then make them better, then torture them again (by
handing them over to some local hospital).” 2 They talked 3 Primacy of patient care
about the frustration of bringing a stable, anesthetized patient
over by CCAST to BOST or some other hospital only to be met 4 Military protocol
by an empty van, 3 having to hand-over a wired-up patient to
someone with no equipment at all. 4 “Today we are flying a 5 Suffering of children
little girl over to BOST so she can die there of sepsis”, Blake
said. “A slow and painful death” 5 , Potter responded. (...) “This 6 Dissonance
isn’t normal”, Blake says. “No it isn’t”, 6 Potter concurs. “We
are not normal”, Blake says. “We’re barking mad”, 7 Potter 7 Existential threat to self
replies.

Schematic Illustration of Interpretation of Data Sample

Institutional Context Lived Experience of War Existential Dislocation

Professional Values Cultural Values

3 Primacy of patient care 5 Suffering of children

2 Senselessness
6 Dissonance produces produces Existential threat
7
to self
1 Futility

Organizational Context

4 Military protocol

Theorizing the role of context in psychological institutional sources—and the actual experience
distress. As a final step, we proceeded to theorize the of war on the other, as the key to better understand-
interrelations between the main elements of our ing the role of context in psychological distress.
empirical analysis by engaging the literature on ex- This enabled us to develop the model depicted in
istentialism (e.g., Camus, 1942, 1955; Kafka, 1915). Figure 4, around which we structure our interpretive
In this literature, themes of surreality and estrange- account below.
ment, as characteristic of lived experience in general, We begin by describing themes in the lived expe-
are particularly prevalent, and directly related to rience of war, and, in the next section, link these to
context. We were particularly drawn to the concept the cultural, professional, and organizational con-
of “absurdity” as a possible root cause of psycho- texts in which the DCS team were embedded. We
logical distress at war: “a sense that one’s estab- then argue why and how the sustained experience of
lished social worlds are hopelessly alien from one’s senselessness, futility, and surreality by members of
conception of the good, the expected, and the ‘nor- the DCS team posed an existential threat. Finally, we
mal’” (Lyman and Scott, 1970: 192). This concept describe their improvised coping responses to this
pointed us to the importance of the contrast be- threat, in relation to the (lack of) coping resources on
tween (expectations of) the meaningful, the good, offer in their professional and organizational con-
and the normal on the one hand—including their text. All names used are pseudonyms.
2016 de Rond and Lok 1975

TABLE 2
Types of Coping Strategies Prevalent in the Fieldnotes
Data segments Coping types

I attended the Wednesday evening vigil for two fallen British soldiers. (. . .) Hawkeye didn’t want to come, Avoiding
as did several of the other surgeons, so he had arranged for someone to page him shortly after his
departure for the services just so he could make his excuses and return to the hospital.
“But I couldn’t work on the wards,” she volunteered, as “this is where they become people again.”
Had a chat with one of the operating theater coordinators. He told me that he forces himself to look Bracketing
at—and be shocked by—the injuries coming in: “I still want to be shocked by wounds coming in to
remind myself that this is not normal, that there is a normal world out there.”
“When I arrived, I was [told] “Take your brain out. I’ll show you how to deal with these injuries.””
Watched new casualties arrive from behind the yellow line. Every conversation was heavy with innuendo. Self-distancing through humor
The orthopods, as usual, were engaging in banter. They were taking bets on whether the amputee is
a single or double amputee, left or right leg. At stake was a pizza.
Hunnicutt asked me if I wanted to see a burns casualty. I followed him into the theater where the soldier is
sedated and his dead skin is being removed. “Can you smell that?” Hunnicutt asked me, “Oh, I love
that smell.”
Tonight is pizza night—like every Friday night, if only to break the monotony of one day seeping into Recovering the familiar
another, and I put in my $10 (and another $10 for Hawkeye).
A U.S. “orthopod” receives a package from home, including glazed pecans, a journal, and an oral hygiene
package, including toothpaste, a toothbrush, floss, and bottle of Listerine. Looking at me, he says: “You
know what the Listerine secret is? It’s vodka with green food colouring (smiling).”
Kellye is rooting through the drawers of a small desk in the DR, looking for an electric toothbrush. We look Reclaiming agentic control
at him confused. He needs it, he says, to cross-pollinate his tomato plants since there are no
bumblebees.
Hawkeye, having closed up two laparotomies this morning was asked to close a shoulder one day early for
a Danish soldier who was to be flown home with his dead dog. (. . .) Hawkeye said he had no patience for
things like this, and doesn’t want to see “someone whining about a dog who is going to be flown home to
be put in the burning pit. That’s more than we do for our lads.”

THE LIVED EXPERIENCE OF WAR feelings of senselessness associated with near-daily

BY THE DCS TEAM encounters with the inhumanity, and, in its more
extreme form, the cruelty that characterized this war:
Many of the DCS team had encountered severe
trauma on prior tours to Iraq, Bosnia, Kosovo, The loss of your limbs and abuse of your youth / We’re
Macedonia, Sierra Leone, and Northern Ireland. One left with more questions, no sign of the truth / What
might reasonably expect such “battle-hardened” kind of father allows his child to lay bombs / Money to
medics to have become relatively impervious to war feed families to which you belong / The death of these
trauma, and yet the data bears out quite a different pic- children is nothing but waste / And makes it much
ture. Many expressed emotional reactions to the na- harder to cope with this place / Take all my wages for
ture and extent of the injuries they faced, with the the rest of my days / To stop these kids dying, to allow
strength of these reactions often depending on the them to play / I question my loss of humanity out here /
age, gender, and nationality of the victim. Others ex- That is my worry, that is my fear.
pressed guilt and confusion about feeling emotion- What is particularly notable in our coding of as-
ally numb in the face of events that they knew should sociated experiences of revulsion and moral outrage
have triggered stronger emotions in them. In both is how often these involved children: badly burned,
cases, the lived experience of work at war was char- drowned, or mutilated by landmines or IEDs stum-
acterized by a profound and sustained sense of sense- bled upon while playing. The poem’s references to
lessness, futility, and surreality. Below, we discuss “We’re left with more questions, no sign of the truth,”
each of these in turn, followed, in the next section, by and “The death of these children is nothing but
an analysis of the role of context in these experiences. waste,” suggests that one of the reasons these expe-
riences were so unsettling is the absence of any ra-
Senselessness
tional account to make sense of them. Hence, our use
A handwritten poem given to the ethnographer of the category of “senselessness” to characterize
by a member of the DCS team captures widespread these experiences is informed by its frequent use in
1976 Academy of Management Journal December

FIGURE 4
Conceptual Framework of the Lived Experience of Work at War by DCS Staff

dissonance dissonance
Cultural Professional Organizational
Institutional context Context Role Identity Context

Amplifies

Lived experience of war Senselessness Futility Surreality

Threaten

Reason and Purpose and Familiarity and

Existential pillars of the self
Hope Agentic Control Predictability

Aim to protect

Passive Coping Active Coping

Personal coping strategies

Reclaiming Recovering the

Avoiding Bracketing Humor
Control Familiar

the Western media in relation to the killing of women works on his right arm before beginning the grue-
and children as “senseless,” as a way of conveying some job of removing his eye. “I don’t mind it so much
that such killing is considered needless, cruel, with- in adults but I hate it in children. It’s just wrong.”
out reason, and therefore unjustifiable. The following 3. One of the general surgeons, Hawkeye, talked
are three examples from the ethnographer’s fieldnotes about a little girl they nursed for six weeks during
(see Table 1 for more examples). his last deployment to Afghanistan before dis-
charging her to her family. Having done so, they
1. Hunnicutt, the only plastic surgeon here, and
subsequently learned that she had been starved by
a veteran of many wars, spoke of an experience
her family as she apparently was considered too
during his last tour of Afghanistan. A bus full of
ugly to ever get married and too handicapped ever to
school children had been targeted in an ambush,
be able to work and provide.
and everyone shot and killed. The authorities had
wanted to know whether the bullets were “local” These experiences were deeply distressing, as
or fired by coalition forces. Since Camp Bastion evidenced by references to “waking up in cold sweat”
does not have a pathologist, he had been asked to and “I hate it in children.” While treating children
go into the container where the bodies of the can be difficult even in Western hospitals (Marsh,
school children were laid out, “in a heap,” and to 2014), this difficulty was compounded by the in-
go recover the bullets. He described it as a memory ability to find any sensible place for them in war; their
that still makes him wake up in cold sweat. deaths experienced as “nothing but waste.”
2. At 1730 a Dustoff [helicopter] delivers at 13-year
old boy from Forward Operating Base Eddie en
Futility
route to Kandahar. (. . .) The boy is a double-amputee
who has already had a thoracotomy. I take some As “signatories” to the Geneva conventions
photos while six surgeons work on him. Hunnicutt and Hippocratic oath, and socialized into a “caring
2016 de Rond and Lok 1977

profession,” DCS staff found themselves increas- of the anesthetists explained: “Everyone wants to go
ingly unable to live up to their own expectations as home with a sense of pride;” this could only be
they tired of compassion. Circumstances forced achieved if they felt they could use their skills to
them to decide on treatments without the benefit of optimum effect. When bored, they expressed feel-
full information or time, to consign Afghans to a po- ings of guilt for hoping for new work to come in (for it
tentially grim spell in local hospitals, and to find implied that someone had to get hurt), became crit-
themselves complicit in a controversial war. This ical of each other’s clinical decisions or technique,
produced strong feelings of futility, defined here as and sought out ways to be assigned more “interesting”
pointlessness, or the antonym of doing something casualties. As one of the surgeons said: “I hope they
worthwhile or purposeful. For example, one of the all get wrapped up with those testicles so I can have
nurses, when asked if she needed anything, replied the next case all for myself.”
in exasperation: “a reason to live.” The following are
empirical vignettes from the fieldnotes that illustrate Surreality
some of these experiences (see Table 1 for more
A third category of experience is that of the surreal,
examples).
defined here as an incongruous juxtaposition be-
1. Spent some time with the nurses in intensive care tween the familiar and the real. Surreal experiences
today. One of them said they are tired of nursing typically have the disorienting, hallucinatory quality
Afghans with no clear explanation of why that is of dreams, and, as is evident from Table 1, are often
important or even valuable. After all, they came triggered by observations that—because they are so
here to treat “their boys.” (. . .) So it appears to be unfamiliar—give one the impression of being bizarre
the sense of futility associated with having to treat or strange. Daily life within the field hospital had its
Afghans who will invariably be passed to local fair share of surreal experiences.
hospitals where their chances of successful re-
1. Had a chat with Burns, who coordinates the op-
covery and/or survival are greatly comprised.
erating room. He told me about an incident yes-
2. In the Doctors’ Room this evening, I strike up
terday when a U.S. double amputee, courtesy of an
a conversation with Hawkeye about the (. . .) and
IED, had been brought in. Meanwhile, his fellow
when only palliative care should be provided.
soldiers had located his legs. Burns received a call
Hawkeye says that the merciful thing would be to
wondering if they could deliver the legs to the
take a pillow and shoot the boy through the head. It
hospital, thinking that if they did so within six
is hard to reconcile this statement with the kind-
hours of the explosion, that they might be able to
ness he showed the boy thirty minutes ago, unless
reattach them. Burns knew that would be impos-
one assumes that letting the boy die is actually the
sible but didn’t have the heart to say so, and the
kind thing to do.
legs were already on their way in any case. When
3. Blake and Potter spoke about the sense of futility of
Burns was called to reception a few hours later,
what they do: “we torture a casualty [by injuring
a soldier was awaiting him, handing him a card-
them], then make them better, then torture them
board food box with legs inside it. Burns didn’t
again” [by handing them over to some local hos-
know what to do, he said, and so called the morgue
pital]. They talked about the frustration of bringing
and asked a colleague to walk them over and dis-
a stable, anesthetized patient over to some hospital
pose of them there. He told me he could not get the
only to be met by an empty van, having to hand-
surreality of the experience out of his mind.
over a wired-up patient to someone with no
2. An Afghan casualty was returned to Bastion after
equipment at all. “Today we are flying a little girl
a short visit to the neurosurgeon in Kandahar.
over to Boost [a local hospital] so she can die there
He originally arrived on Thursday with a hole in
of sepsis,” Blake said. “A slow and painful death,”
the head requiring neurosurgery. Problem is that
Potter responded. (. . .) “This isn’t normal,” Blake
Kandahar forgot to send the relevant piece of skull
says. “No it isn’t,” Potter concurs. “We are not
back with him, and so he lies in bed, looking around
normal,” Blake says. “We’re barking mad,” Potter
wildly. His skull piece was flown back into Bastion
replies.
at 0100 this morning, upon which one of the or-
This shared sense of futility was amplified by oc- thopedic surgeons (who happened to be asleep on
casional but prolonged spells of boredom, which the the sofa in the Doctors’ Room) stuck it into the small
vast majority of DCS staff experienced as deeply fridge where they keep their near-beer, chocolate,
unpleasant for the unproductivity it implied. As one and soft-drinks. It’s a good thing the piece survived
1978 Academy of Management Journal December

as apparently one of the pilots nearly sat on it, not often framing their decision to pursue a career in
knowing what was in the small plastic bag. medicine in terms of “making a difference.” They
3. One of the theater nurses told me of an experience also referred to tours of duty as a positive break from
over Easter weekend, when a double amputee had the “lifestyle diseases” they treat in their ordinary
come in. During the log roll one of his legs had work back home. As one of the surgeons explained, to
come off, and he was asked to please take it to the deploy to war reminded them of why they had pursued
mortuary (and from there to the incinerator). As he a medical career in the first place. Hence, the meaning
crossed the ambulance bay carrying a yellow bin they hoped to find in deployment was closely related
liner with a leg, he ran into the Commanding Officer to their sense of self as wishing to make a positive dif-
and nurse walking the other way, dressed in bunny ference. As we explain below, this made it difficult for
ears and carrying Easter eggs. them to come to terms with rules, practices, and ex-
periences on the ground that appeared contradictory to
What characterizes each of these experiences is
their purpose and values, thus amplifying feelings of
the contrast between the human gravity of the situ-
senselessness, futility, and surreality.
ation on the one hand, and the casual nature of ev-
eryday rituals and routines on the other.4 As Berger
and Luckmann (1967) explained, these surreal ex- The Role of Professional Context in Shaping
periences can have a profoundly disorienting and Self-Understanding
dislocating effect because they temporarily expose
The medical profession is broadly seen as “noble,”
people’s inability to “put everything in its right place,”
in that it concerns itself squarely with improving
suggesting that “all is not right” with the way they
the health of mankind, as Wakin (2000: 103) made
normally understand the world. People are shocked
clear: “It is because we view life to be so precious
by the revelation that the world does not appear to
that we can so readily agree that the profession
care, as it marches on through its rituals and routines
whose principal function is to preserve life deserves
regardless (Camus, 1955).
our approbation.” As a result, it is not uncommon
for medical professionals to experience their profes-
THE ROLE OF CONTEXT IN THE LIVED sion as a “calling” that serves a higher purpose than
EXPERIENCE OF WAR careerism. The medical profession channels this
higher calling into a number of values and principles
Several of the first-hand accounts of war recounted
that medical professionals are expected to uphold.
by the DCS suggest that this experience of sense-
For example, medical professionals are socialized
lessness, futility, and surreality is shared by many of
into prioritizing the patient’s interests above all else
those who bear witness to it (e.g., Hedges, 2003;
(Wright, Zammuto, & Liesch, 2015). These values
Loyd, 2000; Marlantes, 2011). Yet, we find that the
and principles are set out in the United Kingdom’s
specific nature of these experiences by DCS staff
General Medical Council’s “Good Medical Practice”
is directly related to the particular cultural, pro-
guide, and in the United States’s “Guide to Good
fessional, and organizational contexts in which they
Medical Practice.” Among other things “making the
were embedded. These contexts caused a number of
care of your patients your first concern,” “providing
tensions through which their lived experience of war
a good standard of practice and care,” and “comply
as psychologically distressing can be better un-
with systems to protect patients” are key principles
derstood. Specifically, DCS staff strongly identified
that medical professionals expect to enact (General
with their role identities as medical professionals,
Medical Council, 2013).
The latter principle refers to a professional culture
4
A photojournalist who provided extensive coverage of that takes systems, protocol, and technique very se-
the war in Afghanistan wrote that while he “expected that riously. This was particularly evident in the nature of
war would make no sense, [he] was surprised that this predeployment training for surgeons and anesthe-
madness expressed itself in such an off-balance, weird and
tists, which was exclusively technical in nature. This
at times even comical way” (Bangert, 2016: 1). His recent
general technical focus is designed in part to de-
“Hello, Camel” provides photographic evidence of war’s
surreality. Many of those who have experienced war first- sensitize doctors to emotions that may interfere with
hand have likewise described its surreality, including their ability to provide the best possible patient care.
soldiers, medics, journalists, and those working for non- In medical training, emotions have long been con-
governmental organizations (NGOs), typically in first- sidered potential impairments to decision making
hand published accounts. and the effective exercising of one’s duty. Thus,
2016 de Rond and Lok 1979

through technical training the medical profession’s hospital had limited capacity (50 beds) and was
higher purpose of acting in the interest of patient designed principally to provide support for forward
care becomes embodied in a medical professional’s operations, Afghans were expected to be transferred
technical ability to heal people. This provides them to a local hospital as soon as it was deemed safe to do
with a clear sense of purpose and agency that is so, and often within 48 hours. However, given that
singularly focused on the patient, and embodied in the local healthcare system was widely considered
systems, protocol, and technique. inferior to Camp Bastion’s, and since transferring
The medical profession has long shared this im- casualties meant taking them off oxygen, antibiotics,
passive approach to problem solving with the mili- and powerful analgesics not available locally, to do
tary (Becker, Geer, Hughes, & Strauss, 1961; Shem, so often jeopardized an Afghan patient’s chances of
1979), producing a culture of silence around emo- recovery. This caused psychological distress among
tional distress among both doctors and military several of the deployed doctors and nurses re-
personnel (Green, Emslie, O’Neill, Hunt, & Walker, sponsible for their treatment. Occasionally, admin-
2010). For example, when, on one occasion, a meet- istrative procedures would also appear inhumane, as
ing was called to discuss the death of a young U.S. in the case of a severely injured detainee who was
marine on the operating table, the ensuing discussion kept alive long enough so as to give those in charge
was entirely technical, void of any reference to what sufficient time to declassify him and, in doing so, to
many had clearly experienced as emotionally upset- ease any further administrative procedures.
ting. From the fieldnotes: Many expressions of senselessness, futility, and
surreality explicitly related to this unique organiza-
Trapper: “How do you think the debrief went?”
tional context, which formed a stark contrast to their
Hawkeye: “Fine. But it might be worthwhile having everyday experience of medical practice back home.
a coffee with the lads.” Specifically, the high levels of distress that often
accompanied expressions of futility can be under-
Trapper: “You’re too soft. There’s nothing but
stood in relation to the DCS team’s highly agentic
technical.”
role identities, in combination with their profes-
Hawkeye (to the ethnographer): “Did you hear that? sional commitment to good patient care. These re-
There’s nothing but technical.” quired a positive, lasting impact on patient health,
making it unpalatable to hand over patients to in-
Taken together, this context socializes medical
ferior care that would likely compromise their
professionals at war into understanding their role
chances of recovery. The organizational protocol of
identities as professionals who pursue a higher, no-
passing local Afghans on to local hospitals as soon
ble purpose; who are there “to make a difference;”
as it was safe to do also amplified the experience of
who achieve technical mastery through hard work
senselessness, as the consequences of this protocol
and protocol; and who can maintain composed de-
could appear coldhearted. Moreover, the human
tachment at all times. This context informed how
drama that often unfolded in front of their eyes as
members of the DCS team viewed themselves and
a result of this inhumanity contrasted with the often
their work, amplifying the dissonance between what
casual nature in which patients appeared to be
they expected and desired as normal practice on the
treated by the local healthcare system, thus exacer-
one hand, and, on the other, what they actually ex-
bating the sense of surreality that also characterized
perienced on the ground. This was particularly the
their lived experience.
case in relation to the organizational context that
appeared to force them to compromise on patient
care, and the cultural context that appeared blind to Dissonance Between Medical Role Identity and
the inhumanity they encountered. Cultural Context
The humane values of care that are central to the
medical profession not only jarred with the organi-
Dissonance Between Medical Role Identity and
zational context in which they were expected to be
Organizational Context
practiced, but also contrasted with the broader cul-
While protocols for triage and treatment were tural context, both inside and outside Camp Bastion,
generally similar to those in many emergency rooms, fueling the experience of senselessness and surreal-
one unique protocol related to the treatment of ity in particular. Inside the Camp, the importance of
Afghans beyond damage control surgery. As the care and respect for patients that is central to the
1980 Academy of Management Journal December

medical profession played an important role in the his application of this perspective to war trauma,
many reported experiences of surreality. These often Pitchford (2009) argued that war can shift people’s
involved a sharp contrast between the human gravity sense of meaning and purpose to the point at which
of the situation on the one hand, and the imported, they are no longer able to take part in the feelings
cultural routines and rituals designed to normalize and thoughts of others. This can trigger a profound
life in the camp on the other, such as consuming sense of meaninglessness and isolation that can only
“near beer” at the end of the day, or browsing the be healed through helping them reconnect to others,
trivia of Facebook after emergency surgery on a badly and, through this process, rediscover themselves.
injured child. Not only were the DCS team’s contextually em-
Outside of the Camp, the cultural context of Af- bedded experiences of senselessness, futility, and
ghan society also appeared to jar with the medics’ surreality profound and sustained, they were also
professional and cultural values, particularly in inescapable: the DCS team was confined to life at
relation to children. In contemporary Western so- Camp Bastion without recourse to direct, embodied
ciety, childhood is often associated with innocence exposure to more “normal” social realities, such as
(Holland, 2004), and the culturally specific idea that family life. The lived experience of work at war
childhood innocence should be preserved and pro- thus formed a radical, collective disjuncture from
tected has been pervasive here since the late 19th the ontological certitudes that normally grounded
century (Gittins, 1998; Kehily, 2004). In the con- their everyday existence. Many social theorists
text of armed conflict, the child is also often a socie- have argued that such threats to people’s existential
tal symbol of peace and hope in many cultures grounding in everyday life can “swamp” them with
(Greenbaum, 2006). This Western cultural context anxiety that, when sustained over time, can lead to
through which the DCS staff interpreted the suffering a regressive loss of a sense of sanity and agency
of children played an important role in their dis- (e.g., Berger & Luckmann, 1967; Giddens, 1984;
tressing experience of senselessness. Goffman, 1961). Below, we discuss the nature of this
Thus, the primary way in which cultural, pro- existential threat, followed in the next section by an
fessional, and organizational aspects affected the analysis of people’s coping strategies in response
lived experience of war as distressing was to cause to it.
dissonance between professional and cultural val-
ues, practices, and expectations on the one hand,
Senselessness as a Threat to Reason and Hope
and actual organizational practice experience on the
ground on the other. This dissonance triggered pro- According to Berger and Luckmann (1967), the
found and sustained feelings of senselessness, futil- ability to attribute and provide reasons for the ac-
ity, and surreality that were experienced as highly tions of oneself and others is fundamental to our
distressing. Below, we argue that this is because the sense of being in the world (see also Giddens, 1984).
sustained experience of senselessness, futility, and When those reasons cannot easily be provided, life
surreality can dislocate people’s institutionalized can quickly begin to feel meaningless, arbitrary, and
sense of the meaningful, the good, and the normal to unjust (Berger & Luckmann, 1967). Camus (1955)
the point at which they experience an existential argued that when people are confronted with such
threat to their sense of being in the world. meaninglessness, their primary recourse tends to be
to invest themselves in hope: “everything that makes
man work and get excited utilizes hope.” We suggest
THE LIVED EXPERIENCE OF WAR AS
that the sustained experience of senselessness by the
EXISTENTIALLY THREATENING
DCS team, particularly in relation to the suffering of
In his review of the construct of meaning in psy- children, threatened both reason and hope as exis-
chology, Baumeister (1991) asserted that people re- tential pillars of the self. Not only does first-hand
ceive their meaning from cultural context, and that experience of children’s suffering violate the sym-
the fulfillment of a universal need for such meaning bolic values that society places on them, it can also
has a stabilizing effect on people. It follows that directly threaten the existential self, insofar as chil-
a threat to such meaning can be destabilizing, and dren represent “an extension of the adult self, a sym-
therefore distressing. The field of existential psy- bolic link with one’s own childhood” (Kehily, 2004: 2;
chology has likewise recognized that a general sense see also Steedman, 1995). Kehily and Montgomery
of meaninglessness is a growing psychological prob- (2004) pointed out that the idea of “childhood in-
lem that has social cultural roots (Yalom, 1980). In nocence” is an “adult” ideal in that it says more about
2016 de Rond and Lok 1981

adults than children. The “senseless” (or reasonless) Surreality as a Threat to Familiarity and
destruction and suffering of children therefore not Predictability
only threatens the hope placed in them by society,
Finally, in addition to reason, hope, and pur-
but also the deeply personal sense of hope people
poseful agency, the familiarity and predictability of
require to ground themselves existentially. A par-
routinized everyday life are of existential impor-
ticularly cruel example of this can be found in his-
tance to human beings (Giddens, 1984), because
torical records of the 1978 Jonestown massacre,
they allow them to suspend doubts of its “realness”
where survivors reported that after having been
(Berger & Luckmann, 1967). Repeated and profound
made to kill their own children, many felt that they
experiences of surreality can threaten this normalcy
had no choice but to take their own lives because all
by endowing it with dream-like qualities: meeting
hope was lost (Nelson, 2006). It is in this sense that
the Easter bunny while walking to the incinerator
experiences of the senseless destruction and suf-
with a human leg wrapped in yellow plastic; being
fering of children can symbolically produce our
asked to arrange a taxi for a dead man and his dying
own existential death through the extinction of
friend; or being handed boxed up legs by a marine,
the hope and innocence that is symbolically vested
who went to the trouble of collecting them from
in them.
the battlefield in the misplaced hope they might
be reattached. Such surreal experiences can be a
Futility as a Threat to Purpose and Agentic Control source of what Berger and Luckmann (1967) call
“marginal situations” that can threaten one’s sanity
Just as people need reasons to help them un-
by making the routines and rituals that ground
derstand the death and suffering of others, they also
people in their everyday lives appear strange and
need a narrative to help them make sense of their
alien. It is this (momentary) realization of the ab-
own experience as “actors” here to enact a “role”
normality of institutionalized routines and rituals
(Alvesson & Willmott, 2002; Berger & Luckmann,
in the face of human tragedy that can thus be exis-
1967). Even though such actorhood is a distinctly
modern phenomenon (Meyer & Jepperson, 2000), the tentially threatening, puncturing them as a “shield
capacity to exercise control over one’s life through against [existential] terror” (Berger & Luckmann,
a sense of purposeful agency is broadly seen to be 1967: 119). This terror can pull us into the “horror of
central to a sense of meaningful existence. Indeed, aloneness” (1967:119), such that we are no longer
Bandura (2001: 1, italics added) claimed that “(t)he able to leverage such everyday contextual means
capacity to exercise control over the nature and as routines and rituals to sustain a meaningful
quality of one’s life is the essence of humanness,” existence.
and Giddens (1984) considered the ability to main-
tain some sphere of personal control in daily life
COPING WITH THE EMOTIONAL DISTRESS OF
essential for human survival. Positive organizational
EXISTENTIAL THREAT AT WAR
scholarship likewise has pointed to the importance
of a sense of purpose and impact for people’s well- The military organization was aware of the un-
being at work (Quinn & Wellman, 2011). usually severe nature of injury patterns of war
It follows that the prolonged sense of futility and casualties, as well as the possibility of psycho-
boredom that members of the DCS team experienced logical distress in response to them, as evident in
can profoundly threaten the human desire for pur- its two main support channels for medical staff:
poseful agency that is essential for meaningful exis- predeployment training and on-the-ground mental
tence (Baumeister, 1991). As discussed above, this is health support. While the technical predeployment
especially the case for medical professionals who training helped medical staff get to grips with the
derive their sense of self largely from their pro- technical challenges they were likely to face, it did
fessional roles as people who are there to “make not also help them prepare for the experiences of
a difference.” In our case, the futility and boredom senselessness, futility, and surrealism. For example,
they experienced was not only difficult to reconcile at no point in predeployment training, or during
with their expectation of doing something more deployment, was the issue of psychological distress,
worthwhile than treating “lifestyle diseases” at let alone PTSD, ever raised. Moreover, the military
home, it challenged their sense of self as highly never explained, or offered up for discussion, the
agentic beings whose positive impact on other peo- point of the war effort to attempt to provide a sense of
ple’s lives was embodied in their medical skills. purpose. While, in private, many of the DCS staff
1982 Academy of Management Journal December

were highly critical of the war, they never expressed Instead of being able to rely on cultural, pro-
this publicly. Questions as to the purpose of their fessional, or organizational means to cope with
deployment would typically be answered with an such distress, the doctors and nurses developed
“it’s my job” reply, leaving the issue of purpose to a range of improvised coping strategies. These fell
politicians. As an ex-Royal Air Force officer ex- into two general categories, namely: (1) passive
coping strategies that appeared primarily oriented
plained, questions of purpose are not openly dis-
at coping with senselessness; and (2) active coping
cussed for fear of eroding morale, which cannot be
strategies that appeared primarily oriented at cop-
put at risk in battle.
ing with futility and surreality. We discuss these
The military organization also made available next.
several mental health support resources: a trauma
risk management (TRiM) team, designed to provide
peer-to-peer support from non-medical colleagues Passive Coping Strategies: Escaping Senselessness
trained in psychological first-aid; a field mental
“Avoidance coping” and “escape coping” are well-
health team (FMHT), comprising three mental health
known coping strategies through which people
nurses to provide clinical assessment, as well as
avoid dealing with a particular stressor in an attempt
psychotherapeutic interventions; and a “church”
to protect themselves from psychological anguish
and chaplain (see Figure 5). Yet, the ethnographic (Zeidner & Endler, 1995). These coping strategies are
data contain just one reference to TRiM, where one of
considered passive in that they generally involve
the surgeons suspected an operating theater nurse to
a distancing of the self from potential psychological
have consulted with TRiM after a particularly trau-
stressors. This means that, by their very definition,
matic death, and none at all as regards FMHT, church
they are unable to help resolve the psychological
services, or clergy. While it is true that people may be
injury that triggers them, because they can only offer
reluctant to admit to having sought help onsite, none
a temporary escape. Yet, passive coping strategies
of these facilities were ever promoted internally. As
were very apparent in our data, particularly in re-
such, they reflected and reinforced the culture of lation to the experience of senselessness.
silence on the psychological impact of work in
Avoiding. Each Wednesday night was marked
a warzone. As a result, any admissions to the psy-
by a repatriation service that all troops stationed
chological distress experienced from work at war
in Camp Bastion, including hospital staff, were
would always be private. Thus, the very culture of
expected to attend. It was here that fallen North
emotional control and focus on the technical that
Atlantic Treaty Organization troops were remembered
enabled doctors and nurses to be effective in their
before being sent home for burial. Many would have
work at war denied them the resources needed to
arrived at the hospital already dead, meaning that
make sense of, and cope with, the emotional distress DCS medics would not have been involved. Even so,
involved in this work (see Keats, 2010).
several of them took pains to avoid attending the
service; for example, by asking colleagues to page
them while en route to give them an excuse to return
FIGURE 5 to the hospital. And while they might be expected to
Church in Camp Bastion have a professional interest in checking up on their
patients during quiet times, it was rare to see a sur-
geon on the wards outside of the required twice-daily
rounds. These ward rounds were a frequent source of
complaint by ward nurses who thought them noisy
and unruly, with surgeons and anesthetists paying
little attention to patients, other than those they were
expected to give an opinion on. Through this lack of
engagement with the living and the dead, DCS staff
attempted to avoid reconnecting with the sharp end
of conflict.
What is of interest here is that these consistent at-
tempts to avoid emotional engagement often co-
incided with a simultaneously expressed concern
about not being more deeply affected emotionally by
2016 de Rond and Lok 1983

what they bore daily witness to, as is evident from the their experience of war, except with each other. As
following excerpts. an operating room coordinator put it: “Sometimes I
try telling my family some of these things but they
1. Ran into Mike, one of the American anaesthetists,
don’t understand.” It is often not until they meet
and struck up a conversation. (. . .) He told me
again post-deployment, usually over drinks, that
about his worries about feeling callous that he is
deployments are remembered and tales told and
not affected by deaths. He loses no sleep over it,
retold.
and worries that this is not normal.
Self-distancing through humor. Attempts to cre-
2. Colin, one of the orthopedic surgeons, says what
ate distance between the self and the lived experi-
personally affects him more than what he sees
ence of working in a warzone also included the use of
here is the recent death of his Staffordshire terrier
humor to deflect or make manageable what might
that had to be put down a couple of weeks ago.
otherwise be experienced as emotionally upsetting
3. Surgeon to ethnographer: “Don’t feel any guilt
or traumatic. Humor is a well-documented response
about not feeling emotion. If we got emotional
to hospital trauma (Becker et al., 1961; Henman,
about what we have just done or seen we would
2001; Wear, Aultman, Varley, & Zarconi, 2006). For
never be able to do it again or live with ourselves.”
example, Hedges (2003: 3) wrote that “[war] domi-
Post-deployment conversations with several mem- nates culture, distorts memory, corrupts language,
bers of the DCS, as well as the ethnographer’s and infects everything around it, even humor, which
personal experience, make it clear that they all ex- becomes preoccupied with the grim perversities of
perienced some psychological distress upon arrival smut and death.”
back home, suggesting any emotional numbness Much of DCS’s humor was directed at Afghan ca-
experienced in Camp Bastion was temporary, and sualties whose injuries were either self-inflicted
likely to be a defensive mechanism against the (fear (e.g., deliberately shooting themselves in the foot)
of) being overwhelmed by potentially debilitating or the result of incompetence (e.g., accidentally
emotions related to the lived experience of work shooting themselves). Targeting these people with
at war. black humor as “fair game” served the dual purpose
Bracketing. In addition to avoiding potentially of distancing the self from the human misery of war,
painful confrontations with the human side of war, and to differentiate “us” from “them.” Such “other-
some people engaged in a form of mental escape from ing” can be experienced as pleasurable in and of
the reality of the situation by framing their de- itself (Lok & Willmott, 2014), and terror management
ployment as a temporary state of affairs, contrasting theorists have shown that derogatory “othering” is
it with the “normal” to which they soon hoped to a common way to defend the validity of the values on
return, as in the following excerpt. which one’s worldview is based, especially in the
face of increased death awareness (Greenberg et al.,
Had a chat with one of the operating theatre co-
1990).
ordinators. He told me that he forces himself to look at
the injuries coming in: “I still want to be shocked by
wounds coming in to remind myself that this is not Active Coping Strategies: Recovering Agentic
normal, that there is a normal world out there.” Control and the Familiar
Self-reminders of a more “normal” world out there In addition to these passive coping strategies, we
served to bracket the reality of the Afghanistan ex- observed more active coping strategies, known as
perience as something exceptional and temporary, “approach coping” (Carver et al., 1989). These were
and, as such, not reflective of true, “normal” reality. primarily aimed at recovering some sense of famil-
As such, it can be considered a form of “denial,” iarity to counter experiences of surreality, and some
which is a common passive coping response to dis- degree of agentic control to counter experiences of
tressing events, and was one of Anna Freud’s original futility.
defense mechanisms (Freud, 1937). This coping re- Reclaiming the familiar. What are perhaps most
sponse appeared oriented at temporally containing easily observable are the various routines and rituals
the senselessness, futility, and surreality of the de- that appear to have been invented, or imported, by
ployment experience sufficiently for it not to bleed the DCS medics so as to try and establish enclaves of
into, or otherwise affect, life back home. It may partly normality, familiarity, and home comfort. Despite
be for this desire to compartmentalize that returning every day being like any other (in that there was no
medics are often reluctant to speak openly about real distinction between weekdays and weekends,
1984 Academy of Management Journal December

workwise), the beginning to every weekend was to sustain at war amid the lack of private spaces, the
marked by a “Friday night pizza night,” and each unpredictability of casualty arrivals, and the expe-
Sunday morning by a pancake breakfast. By the same rience of futility. In response, members of the DCS
token, theater nurses would organize movie nights, team attempted to reclaim agentic control in a num-
while the Estonian contingent built themselves an ber of ways. For example, many made elaborate
authentic sauna in the desert. The “near beer” was efforts to construct private spaces inside shared
always in plentiful supply, and something to look pods, usually by draping linens, towels, or flags over
forward to on quieter nights, much like one might washing lines, to create almost entirely enclosed
relax over beer after work back home. There were spaces (see Figure 6). People would turn to these
poker evenings and sports days. Everyday comforts areas for respite so as to maintain some personal
were valued commodities that were shared, and space away from work at war, and derive a sense of
typically sealed in packages sent from home. Thus, agentic control from their ability to construct their
significant effort was expended in trying to generate privacy. Such attempts are consistent with Lyman
a sense of normalcy by importing into the hospital and Scott’s (1970) argument that territorial strategies
the sort of routines and rituals that structure every- form an important means of controlling the absurd
day lives back home. Except for the Doctors’ Room circumstances of life.
and Internet, none of the above were formally orga- The desire for an increased sense of control in the
nized or sponsored by the military organization. face of the futility of work at war also found creative
However, even though these active attempts to expression in the form of an attempt by one of the
reclaim the familiar were aimed at staving off the intensivists to try and grow sunflowers and tomatoes
surreal through normalization, they also became in the desert sands behind the Doctors’ Room, tend-
constant reminders that this alien environment was ing to his patch religiously (see Figure 6). Others, in
not like home: e.g., watching the film Apocalypse a subsequent deployment, baked their own sour-
Now on movie night against the background of dough bread:
Apache fighter helicopters taking off on similar mis-
sions, tending to a flower garden in a barren desert, or As in the series MASH, the counterpoint to the tales of
enjoying Pizza Hut in the midst of a war zone. At best, blood, heroism, and medical miracles was the hu-
mour and the humanity that punctuated the bloody
importing home comforts could therefore only offer
routine of daily life; but, instead of a potato distillery
a temporary escape from, instead of a resolution of,
brewing alcohol, we made bread. (. . .) In the end, the
the lived experience of war. At worst, this strategy
legacy of this club of five military consultants (. . .) is
may actually have contributed to feelings of surreal-
embodied in their Bastion tour T shirt: “Make bread
ity by increasing the contrast between the reality of not war.” (Arul, Bree, Sonka, Edwards, and Reavley,
war and reminders of life back home. 2014: 16–17)
Reclaiming a sphere of agentic control. Giddens
(1984) argued that the sense of a sphere of agentic The “Make bread not war” T-shirt symbolizes the
control is of fundamental importance for people’s sometimes defiant or slightly rebellious nature of
ontological security. However, this sense is difficult attempts to reclaim a sphere of agentic control. For

FIGURE 6
Coping Responses: Acts of Creation and Private Spaces
2016 de Rond and Lok 1985

example, individual attempts at defiant agentic of these findings for both research on psychological
control consisted of refusals to engage with “trivial” injury from war, as well as organization research.
cases, such as an Afghan who suffered temporary
impotence, and a request to operate on a Danish
Implications for the Understanding of
soldier one day early so that he could accompany his
Psychological Distress and Injury at War
dead sniffer dog on its flight home:
The evidence for the efficacy of interventions to
Hawkeye said he had no patience for things like this,
help prevent or treat PTSD is mixed (Mulligan et al.,
and doesn’t want to see “someone whining about
a dog who is going to be flown home to be put in the
2010). Recent reviews of the effectiveness of pre-
burning pit. That’s more than we do for our lads.”
deployment stress briefings, and the high-profile
Comprehensive Soldier and Family Fitness program
As was the case for attempts to reclaim familiarity, concluded that their impact is marginal (Sharpley,
it is doubtful that these efforts to reclaim agentic Fear, Greenberg, Jones, & Wessely, 2008; Wang,
control resolved the sense of futility that often char- 2014). There is also evidence to suggest that debriefs
acterized the lived experience of work at war. This is during deployment that are specifically designed to
because the attempt to channel a sense of purpose minimize acute emotional distress and the onset of
into acts of creation or resistance did not, and could PTSD may actually increase PTSD rates (Wessely,
not, address the main source of distress associated Bisson, & Rose, 2000; Wessely & Deahl, 2003), Evi-
with the experience of futility: feeling unable to dence of the effectiveness of post-deployment
make a difference to many patients’ lives. At best, psycho-educational interventions is also mixed.
they therefore offered a temporary escape from the For example, the Battlemind program proved bene-
debilitating feeling of being involved in something ficial to U.S. armed forces, but showed no improve-
futile, or brought temporary excitement to punctuate ment in mental health when trialed on their U.K.
the boring monotony of daily life at war. counterparts (Mulligan et al., 2012). What charac-
terizes most of these interventions is not just their
mixed success, but also the universalizing assump-
DISCUSSION
tions regarding causes of PTSD that inform them.
In this paper, we set out to examine the role of The general attribution of causality to a person’s
cultural, professional, and organizational contexts in exposure to (the aversive effects of) a traumatic event
the experience of psychological distress at war in appears to assume that the likelihood of psycholog-
order to broaden the scope of current understanding ical injury depends primarily on how well a person
of psychological injury from war. We took as our can cope with such events psychologically or phys-
subject DCS staff who, as RLMs, are less susceptible ically. Research under this rubric includes studies of
to the oft-cited triggers of psychological injury, be- traumatic brain injury (e.g., Huber et al., 2013), and
cause they are not usually exposed to the high level of those into the neurobiological foundations of PTSD
threat to life or limb faced by front-line soldiers, and (e.g., Sherin & Nemeroff, 2011).
because they are usually vastly experienced in deal- In order to complement this understanding, we
ing with catastrophic injury and death, including in have taken a contextual approach as a basis for ar-
war zones. Our analysis showed that repeated expe- guing that psychological distress at war cannot be
riences of senselessness, futility, and surreality were adequately understood without also taking into
particularly distressing. Context was directly impli- consideration the specific, situated context in which
cated in this experience through the dissonance it it occurs. For example, our findings suggest that it is
produced between professional and cultural values not exposure to physical trauma in others per se that
and practice expectations on the one hand, and ac- is psychologically distressing to medical doctors.
tual lived experience on the ground on the other. This Their technical training has taught them to deploy
same context also made it very difficult for medics to their skills to optimum effect, and, in our case, sur-
reground themselves existentially, forcing them to geons would often compete for the most complex
rely on largely ineffective improvised coping strate- and challenging injury patterns. Rather, we have
gies. These could only offer a temporary escape at shown that what was particularly distressing to them
best, and may even have further exacerbated the very was the specific local organizational requirement to
existential threat they were designed to alleviate hand over local Afghan patients as soon as they were
by increasing the dissonance between life at war and stabilized. This practice tore at the fabric of their
life back home. Next, we discuss the implications sense of professional purpose and responsibility,
1986 Academy of Management Journal December

which they derived from their ability and obligation in helping to prevent, alleviate, or cause PTSD in
to heal and care for their patients. Moreover, our data different groups of military personnel is still very
suggest that even the distress experienced around much an open question. Our research suggests that
this particular organizational protocol could differ while PTSD rates between frontline troops and RLM
depending on whether the patients were, for exam- staff (including DCS staff) may be comparable, the
ple, Afghan children, or male adults who had injured specific reasons for this must be different, because
themselves. Whereas children’s cultural association the institutional context that helps shape what is
with innocence and hope triggered a profound feel- considered traumatic for medical personnel is highly
ing of senselessness when they were brought in specific and situated. This implies that the most ef-
injured, enemy combatants were considered “fair fective ways in which psychological injury from war
game” in black humor that helped to distance medics can be treated, or even prevented, are likely to be
from the human tragedy of war. specific to the particular nature of the cultural, pro-
Hence, we argue that it is not necessarily exposure fessional, and organizational contexts in which spe-
to aversive details of traumatic events in and of itself cific groups are embedded.
that can trigger psychological injury. Rather, our A second important way our study can act as
analysis has highlighted some important ways in a basis for future research on psychological injury
which institutional context can become implicated from war is through an increased focus on the ways
in the psychological distress experienced at war. in which the very coping strategies people rely on to
Specifically, we have shown how particular cultural alleviate psychological distress at war may actually
and professional contexts can socialize military per- have the opposite effect. Specifically, our study
sonnel into specific values, practices, and expecta- suggests that attempts to normalize the war envi-
tions that existentially ground their sense of the ronment as much as possible through importing
meaningful, the good, and the normal. We have ar- home comforts, rituals, and routines may be re-
gued that this grounding can begin to break down sponsible for amplifying, rather than reducing, the
through repeated practice experiences on the ground experience of senselessness, futility, and surreality
that sharply contrast with these professional and at war by increasing the contrast between life at home
cultural expectations. We also suggest that this exis- and life at war. Existentialist theory has pointed to
tentially dislocating experience can be further am- the fragile nature of the institutional structures
plified by the very coping strategies that are designed through which people ground themselves exis-
to alleviate distress, especially in an environment tentially in everyday life (Camus, 1955; Berger &
that leaves little room for alternative ways of coming Luckmann, 1967). We have argued that this fragil-
to terms with the lived experience of war. Our anal- ity can become particularly evident in life at war,
ysis thus highlights the power of shifting research because war exposes some of the intrinsic limits of
focus from the individual psychological response to home comforts, routines, and rituals in normalizing
war as the primary site of possible improvement, to lived experience.
considering the institutional context, and its unique Importantly, these limits may not just render peo-
interactive effects with individual psychology, as ple’s reliance on them largely ineffective as a coping
a possible additional site of intervention. strategy for psychological distress at war. In addition,
We highlight two specific ways in which we be- we suggest that reliance on them may permanently
lieve this contextual perspective may be deployed in damage the existential function of home comforts
future research to help improve both the prevention when troops return from war, making it much more
and treatment of psychological injury from war. First, difficult for them to adjust back to civilian life. For
a contextual perspective can be deployed to enable example, the surreal experience of bumping into the
a more systematic analysis of the differences in the Easter Bunny on the way to the incinerator to dispose
nature and extent of psychological injury between of a body part may permanently damage the future
different groups within the military. For example, ability of Easter rituals to provide a sense of famil-
reservists (or part-timers) and people who leave the iarity and existential grounding after returning home.
military shortly after deployment have been shown to Similarly, consuming chicken wings after a clam-
be at increased risk of PTSD as compared to regular shell thoracotomy on a gunshot wound to the chest
troops (Hotopf et al., 2006; Samele, 2013), because may forever taint any future experience of KFC
they do not have access to the same support networks by invoking memories of war. Imports are “soiled”
within the military (Iversen & Greenberg, 2009). by being experienced in a particular context, such
However, just what, exactly, the role of the military is that the two may become difficult to subsequently
2016 de Rond and Lok 1987

untangle. As a result, people may become estranged organizations (Suddaby, 2010), yet has simulta-
from both life at war and life at home, which may neously been criticized for lacking practical rele-
increase the likelihood of permanent psychological vance. For example, Dover & Lawrence (2010: 305)
injury such as PTSD. Thus, while context may not argued that its insights “remain locked within
directly cause psychological injury such as PTSD per academic circles, (. . .) with attempts to explore
se, we suggest that its role in contributing to psy- practical implications confined to cursory final
chological distress both during and after deployment paragraphs.” In parallel, organizational behavior
may be more significant than current theories are able research is seeing a shift toward explicitly in-
to allow for. We believe future research that further corporating “context” into its theories, following
unpacks this role could form the basis for developing critiques that its impact on micro-level phenomena
new intervention methods that are better tailored to is not sufficiently appreciated (Johns, 2006). Our re-
the contextually situated nature of psychological search sits at the nexus of these two concerns: the
distress at war. Rather than searching for universal recognized need in organizational research to de-
triggers and psychological factors that predict the velop practically relevant context theory through
likelihood of psychological injury in general, we which both “macro” and “micro” approaches can be
draw attention to the situated nature of psychological advanced.
distress in relation to the specific institutional con- Specifically, our study draws attention to the role
text through which certain events are experienced as context can play in triggering and amplifying exis-
existentially traumatic. tential psychological distress in organizations such
as the military. Figure 7 offers a theoretical model
that captures this role in three ways. First, through
Implications for Organization Research
socialization, institutional context produces in peo-
Institutional theory has been described as one of the ple expectations of the meaningful, the good, and the
most dominant “macro” approaches to understanding normal. These expectations can clash with actual

FIGURE 7
The Role of Context in the Experience of Existential Threat in Organizations

INSTITUTIONAL SOCIALIZED ACTUAL

CONTEXT produces EXPECTATIONS clash EXPERIENCE
The Meaningful The Meaningless
The Good The Immoral
triggers

The Normal The Abnormal

Values
Norms
Beliefs DISSONANCE

Practices
can block
resolution of
when unresolved
and sustained
embedded in

EXISTENTIAL
can amplify

THREAT
Culture Senselessness
Futility
Profession Surreality
Organization
triggers fails to
resolve

IMPROVISED
acts as source for COPING
Attempt to import
normality to block
out existential threat
1988 Academy of Management Journal December

lived experience in organizations—especially in meaningful, the good, and the normal. We have
extreme environments such as war—when people shown how this can produce profound emotional
encounter meaninglessness, immorality, and/or distress that can trigger a number of improvised
abnormality in their work. This can produce disso- coping responses through which people’s practice
nance, which people attempt to resolve through engagement is significantly altered. Specifically, in
sensemaking resources that are embedded in their our case, practice engagements often became dis-
cultural, professional, and organizational contexts ruptive of normal organizational practice as a result
(see Lok & de Rond, 2013). However, these contexts of coping strategies; e.g., unruly patient contact,
may not be conducive to such a resolution, espe- avoiding repatriation ceremonies, refusing to treat
cially when the very cultural resources they offer are certain patients, denigrating the medical skills of
part of the reason why dissonance is experienced. others, etc. Thus, our study builds on, and extends,
Thus, the second way in which context can play research that has highlighted the importance of
a role is by blocking the possible resolution of dis- “breakdowns” for the nature of practice engagement
sonance between contextual expectations and actual in organizations (Lok & de Rond, 2013; Sandberg &
experience. Our analysis suggests that this can pro- Tsoukas, 2011). It shows that in extreme environ-
duce repeated experiences of senselessness, futility, ments, breakdowns may accumulate to the point
and surreality that can form a threat to people’s sense of posing an existential threat, which can produce
of being in the world. To deal with this threat, people coping responses that may disrupt practice. Thus, by
rely on improvised coping strategies through which highlighting the role of existential desires and anxi-
they try to block out, or cover over, existential dis- eties in people’s engagement with their organiza-
tress. In addition to avoidance strategies, we have tional lives, our study offers a new possible pathway
shown that this can involve attempts to normalize for future research on the relations between emo-
lived experience by superimposing a sense of nor- tions, institutions, and practice engagement.
mality through, for example, importing home com- Normalization research. Our contextual per-
forts and rituals. Hence, the third and final way in spective also contributes to micro-level organizational
which context can play a role in existential distress research by pointing to the limits of normalization
in organizations is as an important source for im- in helping people cope with contextual sources of
provised coping strategies that are aimed at nor- distress at work. Ashforth and Kreiner (2002: 228)
malization. We suggest that these normalization theorized that under extreme circumstances, nor-
attempts are likely to fail when they merely cover malization strategies “may not be able to fully re-
over the existential threat. They may actually end up store a sense of order,” and therefore suggest that
amplifying dissonance by increasing the contrast they are “likely to be most effective in the broad
between expectations of normality and actual lived mid-range of emotionality.” Our study of a setting
experience. Next, we discuss some of the implica- in which work experiences were extreme in their
tions of this theoretical model for both macro and emotional charge offers empirical support for this
micro approaches to organization research. proposition. It also extends this theoretical insight
Organizational institutionalism. Recent work in by suggesting that when the distress experienced
organizational institutionalism has begun to focus on involves an existential threat, some normalization
emotions as a basis for better understanding “how strategies may not only be ineffective, they may
people experience the institutional arrangements end up amplifying the very distressing experiences
that (. . .) make their lives meaningful and prime how they are meant to alleviate.
they think and feel” (Voronov & Yorks, 2015: 579). We believe that the reason we did not observe more
This new research interest is based on the un- typical normalization attempts—such as a reframing
derstanding that people derive “high existential of role identity and associated ideology in such a way
stakes of life and meaning” from institutions (Creed, that it reduces distress—is because this simply was
Hudson, Okhuysen, & Smith-Crowe, 2014: 281, not feasible for DCS medics. Indeed, the very nor-
italics added). Yet, despite this reference to the ex- malization mechanisms through which medical
istentialist dimension of institutions, its significance professionals learn to cope with treating severe in-
for both institutional and psychological stability has juries in their medical training (emotional distance
rarely been discussed (Willmott, 2011). Our study from patients, composure under pressure, and an
shows that lived experience in extreme environ- exclusive focus on technique and protocol in the in-
ments can threaten the institutional foundations of terest of the patient), prevented them from openly
everyday life through a breakdown of the sense of the discussing the psychological distress they experienced
2016 de Rond and Lok 1989

and collectively recasting it in a different light. The kind of purposeful impact they desire, because
technocratic culture into which they were socialized they face the enormous challenge of turning the
denied that there was a problem in the first place, and never-ending tide of human suffering. We have
no alternative ideology was available to help nor- shown that a profound sense of purpose, and an
malize their experience. This produced what could equally profound sense of futility, may thus be-
be called a “normalization vacuum:” a context in come two sides of the same coin. The fact that
which it is impossible to normalize existentially people in these organizations persist in their work
dissonant experiences, because the only cultural regardless, doing the best they can to care for
resources available for normalizing these experi- others in extremely challenging circumstance,
ences are those that cause the dissonance. Future deserves nothing but our unreserved admiration.
research is needed to explore whether and how such We owe them our support through developing
normalization vacuums are prevalent in other orga- more effective ways to help alleviate, or even
nizational environments, as a basis for better speci- prevent, the psychological costs involved in their
fying some of the limits of normalization as a response work.
to contextual sources of dissonance.
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