The stresses of UN duties
Denne artikel er et engelsk bidrag til årets første temanummer om stresspåvirk- ninger under FN-tjeneste. Artiklen er skrevet af major lan Palmer MB. ChB. MRCPsych. RÅMC. Senior Specialist in Military Psychiatry. Department of 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:
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 Æ\ ien 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.
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.
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.
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.
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.
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.
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.
- 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.
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:
Education of all ranks about PTSR & its relationship with leadership qualities.
Provision of PD.
- 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.
Running re-patriation roups.
Negotiations - Transcultural issues & personalities.
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.
- 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.
- Sleep problems.
- Irritability & angry outbursts.
- Difficulty in concentrating.
- Over aroused/jitteiy.
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