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Risks facing soldiers in war zones are countless, and the mental impact of war on soldiers, as well as the risk of post-traumatic stress disorder (PTSD), is well known.

But recent research suggests that the traumas that most impact a soldier’s psychological state may not be what was previously expected.

The study of Norwegian soldiers in Afghanistan found that soldiers who experienced suffering and death without personally being in danger experienced far greater symptoms of post-traumatic stress than those who were in life-threatening situations themselves.

The study was led by Psychologist Andreas Espetvedt Nordstrand who is the clinical psychologist of the Combat Stress Management Team of the Norwegian Armed Forces. It was his own experience with soldiers and veterans that inspired the study.

“In the course of my clinical work I noticed that a lot of soldiers and veterans had depressive symptoms, shame-based issues and interpersonal difficulties related to incidents that did not meet the classical conceptions of traumatic stress. Of course I would encounter classical fear-based PTSD reactions related life threatening events, however, more commonly soldiers would report growth after such experiences. In contrast, many veterans would have a hard time digesting encounters with the cruelty war can inflict on civilians, particularly when it happened to children,” he told Theravive.

“Sometimes mistakes happen in war, and soldiers end up causing suffering in people they didn’t intend to hurt. Mistakenly directing fire on people who turn out to be civilians, is unfortunately sometimes a consequence of modern warfare. At the same time, the enemy of the modern battlefields often do not subscribe to the Geneva convention and the rules of war. Experiencing first hand such atrocities may also be hard to reconcile with.”

Of the 7000 Norwegian soldiers who participated in the war in Afghanistan between 2001 and 2011, 4053 of them participated in the study. The research is part of a broader project to determine how veterans are coping after their time in Afghanistan.

Trauma can be categorised into either danger or non-danger based stressors. Soldiers often experience danger-based trauma when being attacked. Non-danger based trauma is more complex and takes two forms: witnessing the suffering or even death of another person, without personally being in danger, or witnessing or performing an action that is contrary to a person’s own moral beliefs (called moral injury).

An example of witnessing suffering may involve soldiers helping to clean up in the aftermath of a suicide bomb that killed children or civilians. Whilst a moral injury may involve a soldier shooting a civilian thought to be a suicide bomber, but who in fact wasn’t. It is these kinds of non-danger based stressors the researchers found were most deeply impacting soldiers.

“We found that so called non-danger based experiences actually had a more negative impact on the mental health of soldiers, when we compared such incidents to having been in life-threatening situations. Such non-danger based incidents included experiences such as seeing dead and dismembered people, witnessing atrocities, and committing or witnessing acts that deeply transgress one's moral beliefs,” Nordstrand said.

Both danger and non-danger based stressors lead to an increase of symptoms of PTSD. Such symptoms may include poor sleep patterns, flashbacks to past events, or being hyper alert or jumpy.

But the researchers found that non-danger based stressors were likely to result in more symptoms of distress.

“Being shot at or similar life-threatening experiences is not the only type of incidents that can lead to post traumatic suffering. We actually find that certain non-danger based traumas are worse with respect to psychological distress and personal development after deployment,” Nordstrand told Theravive.

“I hope that the current findings will increase the emphasis on recognizing and caring for people who have been exposed to non-danger based traumas. The current understanding of both trauma and trauma reactions may have to broaden. I also hope that our findings will encourage further investigating into effective treatment protocols, specifically designed to alliterate suffering after exposure to Moral Injury and witnessing experiences.”

Although Nordstrand’s research concerned Norwegian soldiers, he says US commanders and soldiers who were in Afghanistan could also benefit from the study.

“All of them had been part of the NATO operations in Afghanistan. The war zone exposures they experienced would not be particularity different from that of US troops. Both the US and Norway are liberal democracies who appreciates humanist values, therefore it is likely that similar assumptions about the world and how people should treat each other will come under pressure from non-danger based traumas,” he said.

Nordstrand is hopeful the research will be used to help better prepare soldiers for some of the non-danger based traumas they may experience whilst deployed.

“I think it is important to recognize that western soldiers have some fundamental assumptions about the world and how people interact that can stand in stark contrast to the realities of war. In a nut shell these types of experiences makes the suffering of the world real. Not something abstract you see on television. Acknowledging this fact, and facilitating the construction of new realistic, but not nihilistic, assumptions is an important process,” he told Theravive. 

“This process can be facilitated both through pre deployment training, the culture of a unit, the officers and we who serve as mental health professionals. Finally, I think that we as a society have a responsibility. Many veterans feel that they cannot tell their civilian friends or family about these experiences, often because they have a real fear of causing discomfort in others by fracturing perceptions they have about the world. This can lead to veterans feeling ostracized and distant from their home community.“