Archives

by Dr. Narme F. Wickremesinghe

In the month of October it is usual to declare a National Mental Health Week and for mental health organizations to concentrate on a specific theme. Then in the month of November there is an International Remembrance Week to remember those who sacrificed life and limb in the defence of the nation.

But never the twain have met, i.e. mental health organizations have hardly thought of the mental effects of strife on those defending the nation and their families, and the massive impact the 18-year-old strife will have on the thousands of war affected minds in the years to come. Perhaps this is because it is generally thought that death and injury to body and mind is an expected occupational hazard of a soldier with no effects on the population later. This is far from the truth.

Terminology of battle stress

During World War I, when high explosives and shells were used for the first time in war, persons without any physical injuries became numbed, frightened blinded, dumb semi-paralysed, in a state of stupor and helplessness, withdrawn, often unable to remember the past or having nightmares of killings, unexplained anger and irritability with colleagues, crying for nothing, unnatural ways of walking lack of concentration, fatigue, inability to function, attempt and ideas at suicide, and unable to sleep etc. It astonished the doctors at the front as well as those seeing these patients back in England.

The Cambridge Psychologist Dr. C. S. Myers working in a military base in France coined the term 'shell shock' for this unknown reaction to war. This peculiar reaction was later dubbed as an illness called 'war neurosis' emphasizing a predisposing personality defect'. This resulted in large numbers being brought back from the warfront during World War II and then being unable to return to battle. To curtail evasion, and since in most cases it was a short-term reaction, military leaders ordered a short rest at the front itself and then returned to duty.

Hence the World War 11 term 'combat fatigue.' But after Vietnam (1973), it was seen that even those unscathed at war together with the injured, later developed a variety of different types of emotional and physical symptoms making them psychiatric cripples in civilian society, forcing the American Psychiatric Association in 1980 to include new diagnostic criteria for what it termed 'Post Traumatic Stress Disorder'.

Around the same time, Israeli psychiatrists and psychologists with direct experience both at the front in Lebanon and at the Yom Kippur War and later at Israeli hospitals, such as Drs. Shabtai Noy, Zahava Solomon, Tuvia Yitzhaki and others realized that the initial effects of experiencing the pathos of war are a normal reaction to stress that needs immediate recognition and intervention, without which many go on to a chronic stage, or years later develop crippling symptoms of an illness, preventing normal life.

The Israeli Defence Forces have Jumped all stages together in a broader term called 'Combat Stress Reactions' (CSR). The problem of CSR is that it reduces fighting human resources, weakens military strength, and then prolongs the human suffering of a war.

The war maybe lost due to the number of CSR dropouts.

During World War II in the Pacific Area, it was found that mental health casualties far surpassed the wounded in action. In the 1973 Yom Kippur war and the 1982 long drawn out Lebanon war 30% more than the wounded had Combat Stress Reactions. Of the Vietnam War veterans 33% continued to walk the streets as psychiatric cripples.

CSR has been found to cross cultural barriers (except for a few reactions). In Sri Lanka in the years to come, the effects of strife could affect many thousands. According to newspaper reports over 400,000 have joined the Armed Services and Police, with an equal number of families in acute anxiety and fear for years on end; around 10,000 have been permanently physically maimed with mental effects on themselves and their families; 18,000 have sacrificed their lives (killed or missing) with an equal number or more of grieving widows, mothers, and families - many of them unable to get on with life because of unresolved grief.

This strife affects every segment of the population throughout the length and breadth of Sri Lanka - not only in the North and East. We are told that there are over 20,000 deserters from the Forces, some involved in criminal acts, but conversations with a few indicate that they mainly deserted because of social problems and CSR with no prior knowledge of the law and poor training together with factors of poor relationships in their respective fighting units.

In addition to CSR, war can bring out various forms of serious mental illnesses with long periods of hospitalisation or inability to take responsibility in the Armed Services and Police, and also drug abuse - a problem already slowly creeping in even now in Sri Lanka. Ill defined chronic vague psychological and physical features have also been seen in combatants in every modern war from the Second World War to the Gulf War - preventing their living a normal life after the war.

Causation and mitigation

The primary cause for CSR is the combatant's perception of the imminent threat to life Unlike in the normal stresses in civilian life, in battle it is impossible to deny or ignore the possibility of annihilation of self and buddies. Stress is too mild a term for what real combatants experience. This is further enhanced by the severity of battle, the troops evaluation of losing, poor leadership, disorganization of the unit, inability to endure any longer, a soft personality unable to cope with physical exertion, hunger, thirst, sleeplessness, and lack of communication with supporting troops and relatives.

But perception to survive can be enhanced by many factors Training must be made realistic, rigorous, ingrained, continuous and most importantly it must be team training into a new military culture and value system in the newly acquired family or team, and more so for Officers and Non - Commissioned Officers. Continuous motivation must be made to develop a fighting spirit to overcome fear and promote courage, similar to that of the terrorist, emphasizing self esteem through the elements of the psychology of the cause and of the psychology of the comrades (-the new family).

But the most important mitigating factors are social support from the efficiency and care of the immediate leader, the cohesiveness and competence of the group/team (-comrades), the assurance of support and care in practice from the wider family - the Unit, the Regiment, the Force, and other Forces (e.g. Air support), and the perception that ones own side has a greater probability of kill through superior and lethal weapons and other resources. Without unit cohesiveness and social support the war is lost. The encouragement from one's biological family is also crucial in the Sri Lanka setting.

Leaders must be alert to indication of fatigue, poor discipline, reduced morale, isolation etc. before a cumulative effect causes collapse of the Unit. They must offset adverse publicity given in the sensational media about inefficiency and corruption of military and political leaders and other false rumour-mongering supported by the enemy.

Their's is a singular mission to defend the nation - the demoralizing actions or not of others or of the pacifists is not their business. They must emphasize how the majority of the population and the organisations such as the Rana Viru Seva Authority (RVSA) are one with them and support them in facing the rigors of strife.

All combatants must be taught to realise that their immediate or delayed reactions are part of a normal threat to life. They should not suppress such feelings but let it out in the open, discussing it in groups and sharing one another's experiences and believe that it is a temporary normal event, not an illness requiring medical intervention. They should recognize CSR happening in their buddies and allow them to talk about it.

As Robert Leach has remarked recently, CSR is far too important to be left to health care professionals and arm chair strategists. It is an issue for the leadership and comrades at the front itself. It is time that military leaders lean less heavily on medical services.

After all, CSR should never be labelled as an illness - only a normal stress reaction to be over come by self and buddies.

Families behind the lines

Similar problems of continued wartime stress significantly affects the families of combatants - living, missing, killed or maimed. The anxiety for the security of the loved one is far more real and far more prolonged than the usual perception of anxious times and depression in civilian society. When I went to hand over a new house to a soldier's family in Monaragala, the mother started howling, thinking that I was an Army high-up bearing bad news of the son at the strife front.

Wives and mothers of those missing in action are in uncertainty, unresolved grief for years and yet clutching with hope at any news that the hero is alive (including the views of light-readers, prophets, and media sensationalists). They are always crying, frustrated, depressed and yet intensely hopeful - a continuing yo-yo changes of mood vacillating form the deepest despair to the highest hope, which is extremely stressful.

The retired disabled is similar - a prolonged extreme stress. Grieving for loss of a part, denying that it has happened, uncontrollable anger, bargaining and making unfair demands on family and society for having sacrificed the best years of life, suspicion, abnormal jealousy, guilt, depression, isolation, rage, alienation, sleep disturbances, nightmares, and obsessive episodes of reliving combat experiences - all features of post traumatic stress disorder and grief. But many disabled do come to terms with loss and get involved with social life and self-employment.

Children too are not told of a lost one, and wait for the return of the father and the older ones kept in ambiguity. The ability of children to cope with extreme stress is a reflection of their mother's ability to cope effectively. They are often neglected-no father nor an effective mother.

Loss, separation, isolation and humiliation are common experiences of these families of combatants and the retired combatants.

They are indeed combat casualties who remain at home - a significant civilian population uncared by society, untouched by the NGOs, and only recently assisted by Government-in a strife situation involving modern lethal weapons that has gone on for an unprecedented 18 years.

The effects on the mind in the families within the strife torn areas could only be described as disastrous uncertainty - not to speak of the physical damage by cross fire, mines, unexploded devices and inaccurate bombings.

What to do

Without the experience of such a long conflict in the 20th century one can only try out solutions attempted in shorter armed conflicts in the world - and even these are experiments and incomplete.

Within the Armed Services and the Police, there must be a realization that armed strife causes untold effects on mental health which is not only immediate but goes on for years to come. Armies abroad have had Psychiatrists and Psychologists since World War 1 to plan strategies for the benefit of those sacrificing life, mind and limb for the nation.

There are no such mental health professionals (except volunteers to treat illness in the rear hospitals) in Sri Lanka.

The Defence Services should immediately send score's of young graduates grilled in the military culture to train as Clinical Psychologists abroad - and recruit more patriotic Psychiatrists into its cadre. (Even in civil society there are only 8 clinical Psychologists and around 30 Consultant Psychiatrists - 22 of whom are in the Western and Central Provinces, and no Occupational Physicians).

But that is a long-term measure, and immediate action should be taken to train barefoot counsellors and befrienders from amongst the personnel at the front including the medical corpse personnel.

Meanwhile Field Commanders need to be kept informed of developing coping skills and enhancing the prevalent skills of leadership, unit cohesiveness, communication strategies (including debrief at every possible event), rest and recreation arrangements etc. In the rear and in hospitals, arrangements for counselling as well as forming groups to discuss and rationalize each others experiences would be crucial to minimize future distress. Governmental and NGO intervention to train Psychologists, counsellors and befrienders in all concerned Ministries and Organizations is a long term necessity.

Interestingly there is no cadre for Psychologists and counsellors in the Public Service! An immediate necessity is for the training of barefoot befrienders in civil society to talk to the families at regular intervals and to arrange self-help support groups among themselves.

These fora should be arranged at village level giving an opportunity to vent their frustrations, decrease their feelings of isolation, as well as to obtain encouragement from better adjusted long experienced families.

Sharing of emotions is essential for coping. The Service authorities should regularly meet with these groups, giving any news, even when there is nothing special about the missing person.

'Missing - but presumed dead' category after one year may be helpful.

Families must be encouraged to overcome guilt, blame, anger, bargaining and depression to get on with their lives with skills training/employment or self-employment.

They should be challenged to manage the home and control feelings - and to return to family routines including celebrations e.g. New Year. For the families of those missing in action, without seeing the body or being able to have the final dhane (almsgiving), the final stage of grieving which is acceptance of the reality of loss is exceedingly difficult if not impossible, and life comes to a standstill. We can only try to encourage the strong family bonds in Sri Lanka and group support from others to enable them to cope.

Let us not forget these patriots and their families, and help them in every way possible to be comfortable in civil society - and let the effects of strife cease with this generation. Please care for those who dare!

News | Business | Features | Editorial | Security
Politics | World | Letters | Sports | Obituaries |

Produced by Lake House
Copyright 2001 The Associated Newspapers of Ceylon Ltd.
Comments and suggestions to :Web Manager