Denne artikel er et engelsk bidrag til årets første temanummer om stresspåvirkninger under FN-tjeneste. Artiklen er skrevet a f major lan Palmer MB. ChB. MRCPsych. RÅMC. Senior Specialist in Military Psychiatry. Department o f Psychiatry, QEMH, Stadium Road, Woolwich, London. SEIB 4QH.
In the minds of many UN duties are seldom as stressful as 'real' war. There is little doubt that we are unlikely to see cases of Battle-shock (the old Shell-shock of W.W.I). We are however seeing cases of Post-Traumatic Stress Reactions (PTSR) from such theatres. Most of these are self limiting witjiin 4- 6 weeks, but a few develop full blown Post-Traumatic Stress Disorder (PTSD) a condition characterised by intrusive, disturbing recollections of the event(s); avoidance of reminders; emotional withdrawal; irritability; disturbed sleep & other symptoms of over-arousal occurring in response to events that are both extremely unpleasant & cause intense fear or helplessness in the individual concerned. (Table. 1 ) Whilst the psychological response is a product of the individual's personality; the traumatic event & the environment into which the soldier returns, the worse the event, the more likely a serious psychological reaction is to occur. There are of course the practical problems we all face when deploying on any operation. These include separation from children, sorting out money supply for partners, what to tell the children & so forth. I shall not cover these here but would point out that it is these areas which nearly always give rise to problems on a deployment. It is vital to ensure that a trusted & efficient team is in charge of the rear-party & that, wherever possible, communications are up & running from the moment the soldiers land in country. I shall therefore concentrate on issues around deployment to difficult zones drawing upon my experiences in Bosnia & Rwanda. The aim of the psychiatric services must be to undertake an assessment of the levels of psychological threat upon the troops & accordingly organise psychological support to cover areas of potential difficulties & to target vulnerable individuals & groups. There are 3 psychological phases to any Operation, namely:
In high profile deployments most soldiers, partners & families will form their expectations about the deployment from information gleaned from the media. Whilst these opinions can in part be modified by good briefs it is important to give this information to the families as well, if lurid tales & photographs are not to misinform those left behind.
Wherever possible whole units should deploy with as few additions as possible. Such deployments are group experiences & it is vital to have good unit morale & cohesion in order to counter-balance the effects of the stresses of the tour. This is equally important on return \Æien the unit should remain together for a week or two as the troops re-adjust to life at home afterwards. Any deployment should have build-up training to enhance cohesion & focus effort.
It is vital for soldiers (& their families) to understand (a) why they are deploying (b) their actual rather than imagined role in countiy (c) rules of engagement (d) the political constraints of the mission. The best teachers are drawn from those on previous deployments (where possible). On new deployments it is best to be wary of overplaying the psychological aspects of the deployment as this may 'prime' individuals & even allow the message to be marginalised. Seldom is it possible to present matters psychological in a form other than a lecture which is of little value to anyone. It is better to say "after consideration of all the available information the problems 'may' be x, y or z but this will be assessed once in countiy ; & dealt with accordingly." It is my experience that if you can undertake tailored presentations in small groups in theatre then these are well received & accepted.
On any deployment a soldier's world constricts so it is vital that attention is paid to the provision of good food, regular mail deliveries, telephone, recreational facilities etc. especially in situations where accommodation is cramped & there is little prospect of rest & recreation locally.
The level of personal threat, either direct or incidental, acts to raise individual's levels of anxiety. It is important to get the actual threat into perspective. This is not always possible for those left at home, who have to rely on the media. However the provision of videos made by the soldiers in country &, shown to families at home can prove particularly helpftil & reassuring. The unpredictability of a threat is stressftil as is understanding the political constraints of reacting in difficult situations, especially early in the deployment. Not knowing who the enemy is particularly galling to many & of course soldiers are trained to be men of action, not inaction! It is requires a fair degree of psychological sophistication to be impartal in these conflicts. It is therefore vital that everyone concerned with the deployment understand the political, historical, cultural, moral, political & social background in the conflict & how the local people react to the situation in which they find themselves. Also how they perceive the role of the UN troops. It is easy to project your own value system onto others in an endeavour to understand what is happening - seldom is this helpful to either party. Being bystanders in someone else's war is difficult for many soldiers, especially as they often perceive that they have the training & equipment to 'sort things out'. "After all surely we're here to stop all this fighting?" as one soldier put it to me. There is the impotence at seeing a people dispossessed & traumatised by genocide yet being unable to help without your efforts being used by one side or the other for the purposes of propaganda. This is especially painful when those considered most vulnerable in our society seem to suffer most of the hardships. At times soldiers may become pawns in the wars around them for example it is not unusual for UN troops to be taken hostage. Perhaps worst of all is being seriously injured by bullet, bomb, mine or simple accident whilst 'trying to help'. I have often heard comments such as "there's nothing worth dying for out here". These comments are commonest when morale falls - the commonest cause of which in my experience if failure of the mail to get through.
Unfortunately soldiers will occasionally witness atrocities. Media coverage can lead those at home to the belief that this is the norm, that eveiyone sees these horrors - seldom is this true thankfully. On the other hand however when such events are not covered in the press it may devalue this experience for those involved. There is a natural human fascination with death, which when it comes to gruesome death borders on the voyeuristic. Some soldiers are directed to such sites as part of their job e.g. those involved in documentation for war crimes, grave diggers & so on. The numbers involved in going to such sites/sights should be kept to a minimum, & the medics should not be specifically 'targeted' for such objectionable duties. All who visit these scenes are inevitably changed by the experience. I therefore believe that casual visiting should be strongly discouraged. Those who have to be involved in the line of duty should ideally receive some psychological preparation before starting work on a site. All, without exception, should be debriefed as a group following the work. This should focus on the emotional aspects of the work & how they coped. These individuals should be informed as to the likely psychological sequelae & the time course of any possible upsets. Follow-up should be offered as required & a note of the work made in their personal or medical files. The reason for this is that we have little way of predicting who will be effected by what & when.
Sport. Eveiy effort should be made to ensure that competitive sport occurs. It is vital to allow the aggression bom of the frustrations on such deployment to be displaced. Locals. Nothing has ever been able to stop soldiers meeting up with members of the opposite sex when abroad. There are numerous reasons for this & even the threat of HIV/AIDS is not sufficient deterrent for some soldiers. ALL deployments should have a clear AIDS policy with facility for baseline testing in country. ALL soldiers should be clear about this. It may be considered sensible to involve partners in sexual-health briefs prior to deployment in an endeavour. But alcohol is often at the root of this problem.
A clear policy must be set & adhered to from the outset. Many will accept a 'dry' tour if adhered to by all ranks, including officers! However black-markets are always bound to spring up. If there is to be no alcohol then strenuous efforts should be expended in providing adequate alternative methods of relieving stress. Often it is a choice between treating soldiers like children by withholding alcohol or by allowing access & dealing with the child-like behaviour when the get drunk. There is always the added problem of fights with other nationals & the possibility of diplomatic incidents occurring.
This is seldom a problem for junior ranks but this can be particularly stressful for senior NCOs & Officers who may unconsciously impose their own value-system on those with whom they are negotiating. Much maturity, common sense, diplomacy, tact, patience & intelligence is required when dealing with individuals who range from criminals through psychopaths to the simply desperate. Working with interpreters brings its own stress. Information may be 'altered' in the translating process. The relationship between the interpreter & his/her fellow countiyman may be veiy threatening & difficult. Intense relationships can build up between soldiers & the interpreters, especially those of the opposite sex. Comrades may become jealous of those with access to women & in small isolated communities gossip can become a real problem.
It is essential to have facilities in theatre to deal with the psychological sequelae of traumatic events i.e. Psychological Debriefmg (PD). It is also wise to have a psychiatric presence to deal with the more common, less visible & more chronic stresses we encounter on such tours. Units should deploy with a Padre. However the old adage 'it's the Will, or an Act of God' cuts little ice with many soldiers if not coupled with practical psychological help. As an occupational medical service we therefore have a duty of care here & close co-operation with the Padre is highly desirable. After a traumatic event the aim of psychological interventions is to ”normalise ” the individual & group reaction to it. Nearly all settle within 4-6 weeks & the process of healing is helped by talking, especially to those with whom the experience was shared. PD is basically a military debrief but with the emphasis on what an individual DID, THOUGHT & FELT (in that order) at the time of the trauma. We do not yet know if PD prevents long term problems, but it can highlight potential difficulties for individuals & make them more aware of what help is on offer should the need arise in future. It may also de-stigmatise getting psychological help in an individual's mind. However as mentioned at the outset the PTSR is a product of 3 variables personality & previous life experiences; the traumatic event & the 'healing' environment (which PD aims to promote). Families are often the ones who first notice changes in personality & unfortunately often bear the brunt of the difficulties engendered by PTSR.
Any new experience needs to be assimilated & accommodated in order to become part of long-term memoiy & our emotional experience. This process causes change which may be minimal or lifechanging, it may confirm our predjuces or change our world view. But change we will - so will our partners & children in our absence. They have had to adjust to life without us. I hear many men talk of just "picking up" where they left off 3-6 months earlier. This is unrealistic & a denial of what has happened. It is important to validate the experience for those involved in the group 'experience' of a deployment. Those involved have shared a unique experience. On return they can feel alienated if they separate too quickly from this group - especially if the changes caused by the tour are denied. Just as they had expectations of the impending deployment, they surely have expectations & fantasies of their return. Some will not match those of their partners! Repatriation groups of upto 10 soldiers are a useftil way of exploring the highs & lows of the deployment, what they will take away etc. & looking forward to the return home, examining aspects of change & expectations in themselves, partners, children. Seldom does separation resolve outstanding problems !
For the majority it is a welcome & enjoyable experience. We have found that soldiers & their famihes benefit from a period of readjustment following operational tours. By returning to duty in camp for 7- 10 days before going on leave continuity is restored. Soldiers are not at home 'all at once' so the family 'system' has a bit of time to readjust to their return. The soldier also has a break from home where he may have difficulty in dealing with his/her partner's worries which may seem quite pathetic when compared to what he/she has been through - especially if the experience has not yet been assimilated At work he/she has the opportunity to talk things over with those with whom the experience was shared. Going straight on leave should be resisted - despite the pressure from the top downwards to 'give them the leave they deserve'. Those cases of PTSD we see are likely to have gone straight on leave & have not received a period of readjustment. This is especially so when units are formed simply for a specific task. Here soldiers really are alone & isolated from the group. Others may also be envious of their achievements which adds to their difficulties. Single soldiers can feel particularly isolated & alienated & a number drink heavily at this time.
Summary of the Stresses of UN Operations
UN deployments are stressful. The actual stress depends upon the particular operation. Battle-shock is unlikely to be seen. Experience to date reveals that whilst PTSRs are common PTSD is not. Most reactions are self limiting in 4-6 weeks This process is aided by discussion amongst those involved & to encourage this regular debriefing is recommended after work/missions & is essential following major incidents. Families need impartial information if they are not to be upset by sensationalistic media coverage of the deployment.
The political constraints on intervention with resultant feelings of impotence. Isolation of Units. Units formed on an individual reinforcement basis, resulting in decreased unit cohesion. Cramped accommodation, minimal privacy, little recreational opportunity. Unpredictability of local response to troops' actions. Rapidly changing, unpredictable & confusing political situation. 'Culture Shock' Working with dispossessed, desperate & damaged people & communities. Intense media attention with rapid transfer of images back home. Career pressures on Commanders by political constraints. Unprepared for the tasks involved in the deployment e.g. atrocity work, riot control etc. Logistic difficulties.
Role of Military Psychiatry
Any new UN deployment requires a full assessment of the psychological threats on the soldiers. I believe this is best undertaken by a Military Psychiatrist who, by reason of his qualifications, is best placed to cross the Medical/Command divide. He/she should be a Command resource with much of the day to day psychological work being camed out by RMO/GP/Community Psychiatric Nurses. The following are legitimate areas of concern & interest for military psychiatric services:
Assessment of psychological threat.
Education of all ranks about PTSR & its relationship with leadership qualities. Provision of PD.
Provision of psychological advice to:
In theatre Commanders, Doctors etc.
Home Command sponsoring the deployment.
Other UN Units in theatre.
Local psychiatric services dealing with PTSR in civihans touched by the conflict
Provision of routine psychiatric care.
Running re-patriation roups.
Negotiations - Transcultural issues & personalities.
Table I The symptoms of Post Traumatic Stress following exposure to a traumatic event.
Re-experiencing the event:
Intrusive, distressing images, thoughts, perceptions. Recurring dreams of the event. Acting/feeling "as if the event was happening again. Intense distress if reminded of the event in some way. Avoidance phenomena: Elforts to avoid thoughts, feelings, associated with event. Avoidance of 'triggers' e.g. places/activities/people. Amnesia for important aspects ofthe trauma. Emotional detachment. Loss of interest in previously enjoyed activities. Inability to feel emotions as before trauma.
Sense of a foreshortened future. Arousalphenomena: Sleep problems. Irritability & angry outbursts. Difficulty in concentrating. Over aroused/jitteiy