By Ruwan M. Jayatunge -
The Eelam War in Sri Lanka has produced a large number of veterans with complex physical and psychological traumas over the last three decades. The war trauma has created potent barriers to their lives and these barriers obstruct recovery and personal growth. Combatants with war trauma experience problems in their living, working, learning, and social environments. The Psychosocial well-being of these combatants were not adequately addressed during the war and in the postwar period. The veterans who became the casualties of the Eelam War need effective Psychosocial Rehabilitation to acquire functionality, recovery and reintegration.
In the aftermath of the Eelam War a large number of combatants sustained physical and psychological wounds. The most common psychological injuries experienced by soldiers were Adjustment Disorder, Posttraumatic Stress Disorder and major depression. Combat related psychological ailments increased over the past three decades in Sri Lanka. According to the 2008 The World Health Organisation report and survey that was conducted with the help of the Ministry of Health revealed a high incidence of mental illness in Sri Lanka. The Mental Health experts suspect a strong correlation between the armed conflict and surge of mental illnesses. A large number of Sri Lankan combatants have experienced the profound effects of war trauma that drasticaly impacted their metal health and long-term functioning.The four year study on Sri Lankan soldiers who experienced war trauma reveals that PTSD is emerging among the combatants. (Fernando & Jayatunge, 2011).
Post war researches of the Vietnam, Iraq and Afghanistan wars have shown that the combat exposure could negatively affect the mental health of the combatants. Hoge et al.(2004) indicate that exposure to combat results in considerable risk of mental health problems, including PTSD, major depression, substance abuse, impairment in social functioning, an inability to work, and the increased use of health care services.
Combat Related PTSD among the Sri Lankan Combatants
The studies have shown that PTSD could be a disabling condition that affects the war veterans. Norris et al. (2002) indicate that Posttraumatic Stress Disorder (PTSD) represents a common, if not the most prevalent, mental health problem in community studies in post-conflict areas.
The prolonged war in Sri Lanka has triggered widespread psychological trauma among the soldiers. Unlike the soldiers of WW2 , Korea or Vietnam the Sri Lankan combatants experienced combat for a longer period. Some soldiers were constantly in the operational areas for over 10 years. The psychological wounds of the Eelam War were underestimated for a long time and it took many years for the Sri Lankan Military Authorities to recognize the impact of combat trauma especially the PTSD. Based on rough estimations 8-12 % of Sri Lankan combatants are suffering from combat related PTSD (Jayatunge, 2010). Many victims experience intrusive thoughts, flashbacks, nightmares, intense rage, apathy, cynicism, alienation, depression, mistrust and reduced life interests. These psychological scars affect in their daily lives making them dysfunctional and vulnerable.
Combat Trauma and the Social Impact
The Eelam War had immense effects on society and it has wreaked the social fabric. For nearly three decades the entire nation experienced the bitter realities of the war. The traumatic events of the Eelam War emotionally touched most of the members of the society. The armed conflict in Sri Lanka created a collective trauma. Fear, grief, sorrow: have become the overriding emotions of war.
Complex situations that follow war and natural disasters, have a psychosocial impact on not only the individual, but also on the family, community and society., Just as the mental health effects on the individual psyche, can result in non-pathological distress as well as a, variety of psychiatric disorders like Post Traumatic Stress Disorder (PTSD); massive and widespread, trauma and loss can impact on family and social processes, causing changes at the family, community and, societal levels (Somasundaram, 2010).
The impact of fear, physiological arousal, horror, survival guilt and hopelessness in combat cannot be underestimated. It has a long lasting effect and sometimes these destructive feelings could be transformed on to the society by the combatants. When violence seeps into everyday life, then there is always the possibility that as a society comes out of conflict the residue of violence will remain. Violence generally continues to exist within the social fabric of societies coming out of conflict for decades to come (Hamber , 2004). The war trauma has made the combatants dysfunctional and opened doors for various psychosocial problems. These psychosocial problems have domino effects that can last for many years.
War Trauma and Stigma
The combatants with war trauma have self-blame and guilt that always work against their psychosocial wellbeing. The heart of trauma is shame, guilt rejection and isolation. The soldiers with PTSD and other combat related stress conditions feel highly subjugated over their symptoms. Many feel that these symptoms are signs of weakness, cowardice and no longer are they able to perform military duties with honor and dignity. Howell (2006) of the view that many combatants affected by the war trauma tend to conceal their condition for fear of retribution in the form of intolerance, stigmatization and job loss.
Stigma refers to negative attitudes (prejudice) and negative behavior (discrimination) toward combatants with battle trauma. Stigmatization is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and avoidance. Combatants with battle stress feel ashamed of themselves and become highly sensitive to the comments by their buddies and commanding officers. The stigma is worse than the illness itself. The stigma is a serious obstacle and it prevents them seeking treatment. Many officers and soldiers with combat stress conditions take deliberate efforts to hide their posttraumatic symptoms such as hyper vigilance, nightmares and avoidance.
Creamer & Sing (2004) argue that the diagnosis of PTSD provided a degree of legitimacy for sufferers of postwar mental health problems and reduced the need for pejorative terms such as, “inadequate personality” or non-specific descriptors such as, “anxiety neurosis” that were used widely until then. Nevertheless many combatants with PTSD find that there is a huge stigma associated with PTSD. Therefore some experts insist to use the term Posttraumatic Injury (PTI) instead of Posttraumatic Stress Disorder (PTSD) to eliminate the sigma and prejudices. Tick (2005) of the view that the psychiatric construction of PTSD that itself turns combat trauma into a chronic condition, and burdens the individual veteran with the consequences of political decisions to go to war. By jettisoning communal responsibility, it exacerbates the veteran’s sense of communal alienation and personal dehumanisation, and it leaves him or her with the shame of being weak.
The officers and the soldiers who suffer from physical and psychological ailments of battle trauma can experience low self-worth, low self-esteem and and sense of inability to command their subordinates. Fairweather & Garcia (2007 ) identifies stigma as a potential negative impact to service member’s career, paired with shame and fear of judgment is a concerning barrier to treatment and rehabilitation. Stigma inhibits service members from seeking and receiving treatment and rehabilitation. Tull (2011) provides the results of one study that was done with the United States service members returning from Bosnia, 61% strongly agreed with the idea that disclosing a psychological problem would harm their career. In addition, 43% strongly believed that admitting a psychological problem would cause other people to not want to be around them.
The Post War Period and Psychosocial Health
The World Health Organization (WHO) defines mental health as “a state of well-being in which the individual realizes his or her own abilities can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community. War trauma negatively affects the mental health parameters. Odenwald et al. (2007) have shown that consequences of war-related trauma cause enormous suffering and problems adjusting to post-war life in many parts of the world.
After facing traumatic combat events the soldiers experience hopelessness, low self-fulfillment, rage, guilt, sense of emptiness, alienation and whole range of negative emotions. War has a catastrophic effect on the health and well-being of nations (Murthy& Lakshminarayana, 2006). Wars can change the psychological makeup of the combatants making them vulnerable to psychological disorders. Recent research suggests that military employees are at risk for acquiring PTSD (Danckwerts & Leathem, 2003).
The armed conflict in Sri Lanka ended in 2009 and the Sri Lankan Armed Forces militarily defeated the LTTE. But the military victory came with a huge human and social cost. Over 300,000 members of the Sri Lanka Armed Forces (including the Police Force) had been directly or indirectly exposed to combat situations during these three decades. Following the thirty year armed conflict in Sri Lanka many combatants underwent traumatic battle experiences that caused immense physical, emotional, and psychological distress. These experiences were events outside the range of usual human experience. Some combatants were diagnosed with combat related PTSD and other battle related psychological trauma. It has been estimated that there are a large number of combatants with undiagnosed combat related psychological ailments and many are without any kind of treatment. Stigma, lack of information, lack of resources etc. have prevented them getting professional help. For many veterans the combat stress has become an insidious disease – existing without marked symptoms but ready to become active upon some slightest psychological trigger.
War is profoundly political and social, yet terms such as, “trauma” tends to medicalize and individualize the problem (Martín-Bar”, 1994; Punamäki, 1989)., The armed conflict in Sri Lanka became extremely political and political decisions overruled the military decisions. Hence the war became a part of the political power struggle and war trauma naturally became an under discussed subject. There was no National strategy to address combat trauma.
The Sri Lankan military authorities delayed to recognize the psychological impact of the Eelam War. Combat related PTSD was not regarded as a disabling condition that could affect the soldiers. Although the armed conflict started in way back in 1980s until 2005 the Sri Lanka Army did not give a medical discharge based on the diagnostic criteria “PTSD”. There were no strong socio political voices to address the psychological repercussions of the armed conflict. The Health Ministry had less power and minimal access to treat the soldiers with battle trauma. The health care providers did not receive adequate training to identify combat related symptoms among the combatants. These hindering factors have increased the psychological casualties among the armed forces.
Post-war situations are often characterized by the traumatization of large groups. In war, situations, people become victims of violence, destruction and displacement. Some have, experienced violence personally, others have lost relatives and friends, all, however, continue to live in an environment still marked by war and its consequences, even after, the end of the war (Scherg, 2003). The sequence of the, survivors’ post-war experiences usually, follows a pattern that includes a profound disorientation; despair and lust, for revenge (sometimes denied and/or, turned upon themselves); a process of, deep but incomplete mourning; the tentative reaching out for emotional solace in the form of new relationships and the rebuilding of a family world (Wolberg &Aronson,1975).
During the post war period in Sri Lanka delayed combat related posttraumatic reactions surfaced. Some extreme reactions manifested as self-harm, suicides and social violence. According to the Military Spokesperson of the Sri Lanka Army from 2009 to 2012 postwar period nearly 400 soldiers had committed suicide.
War related psychological symptoms could last for many years affecting individuals, their families and society. Van der Kolk et al. (1996) identified the significance of dissociation, affect, dysregulation, and somatization as “associated features” of PTSD. According to Van der Kolk and colleagues these associated features lasted for years even after full-blown, PTSD symptoms, subside. The combatants with affect dysregulation have persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or inhibited anger, compulsive or inhibited sexuality. Therefore Posttraumatic Mental Health of the combatants should be addressed appropriately. Evidence-based care system has to be introduced to increase and improve the post war psychosocial health.
Veterans affected by war trauma have a re-traumatization risk. Re- traumatisation is defiend as a situation, attitude, interaction, or environment that replicates the events or dynamics of the original trauma and triggers the overwhelming feelings and reactions associated with them. Dutton et al.( 2005) elucidate that sometimes the term “revictimization” rather than “retraumatization” is used to, designate re-experiencing interpersonal trauma again, especially later in life after an, earlier trauma.
Combat involves multiple types of life-and-death experiences associated with strong and wide-ranging emotional reactions. The emotional scars of the war remain for a long period. Traumatized veterans are a vulnerable group and measures would be needed to prevent them from re-traumatization. Many traumatized people expose themselves, seemingly compulsively, to situations reminiscent of the original trauma. These behavioral reenactments are rarely consciously understood to be related to earlier life experiences (van der Kolk, 1989).
Redeployment , working in adverse environments could trigger past traumatic memories. When the working environment becomes adverse or less supportive, there is a high tendency for the soldiers to become AWOL. A large number of Sri Lankan soldiers have become deserters over the past few decades. The numbers are exceeding over 50, 000 (AFP, 2011). Many deserters were exposed to battle events and they still relive with traumatic combat memories. A large number of traumatized combatants have joined the underworld gangs and committed crimes. Some have joined with local politicians and engaged in election related violence: the irony is many veterans who had got honorable military discharges have rejoined as security officers in private firms. van der Kolk (1987) indicates that some traumatized people remain preoccupied with the trauma at the expense of other life experiences. Effective measures must be implemented to minimize the re traumatization of combatants who underwent gruesome realities of the Eelam War.
Combatants with Traumatic Brain Injuries
Many combatants sustained traumatic brain injuries during the Eelam war due to gun short injuries and blast injures. Traumatic Brain Injuries (TBI) had become one of the signature injuries of the Eelam War. A significant number of soldiers diagnosed with PTSD and posttrumatic epilepsy during the past three decades. Frain et al.(2010) claim that veterans, as a group, face numerous problems due to the, common injuries of war. Posttraumatic stress, traumatic brain, injury, and polytrauma can all result in diminished problem-solving skills and poor self-care.
The combatants with traumatic brain injuries experience irritability , emotional liability, sensory impairments, neuro- cognitive deficits , difficulty sustaining concentration or dividing attention , word-finding or naming difficulty (anomia) , diminished verbal fluency , dysarthria ,limited capacity for insight and reasoning, Impairment of organizational and problem-solving skills. These combatants would be benefited by psychosocial rehabilitation.
Alcohol and Substance Abuse
According to the Harvard Medical School addiction is characterized by frequent use of a substance/process (usually daily) and by the fact that a, great deal of the individual’s behavior is focused on using the object of their addiction, obtaining the object and talking about the object or paraphernalia associated with the object’s use. Jacobsen et al. (2001) point out that 22-43% of people living with PTSD have a lifetime, prevalence rate of substance use disorders and the rate for, veterans is as high as 75%. The studies based on Vietnam and Afghan veterans in the US reveal that alcohol and substance abusers could be potential health hazards that go hand in hand with combat trauma. Analysis of data collected in a 1977 U.S. national epidemiologic study of substance abuse revealed that Vietnam veterans had substantially higher levels of alcohol consumption and binge drinking, than comparable groups of Vietnam “era” veterans with no Vietnam service other veterans and non-veterans (Boscarino, 1981).
Alcohol, tobacco and cannabis abuse are most prevalent problems among the Sri Lankan combatants and these practices lead to a significant health risk. Many veterans use alcohol and other substances to reduce the impact of intrusive memories, nightmares and break the social isolation. Alcohol and substance abuse have caused intense health, economical and family problems and the veterans need effective coping strategies to overcome the negative influence. Psychosocial rehabilitation can reduce the harm caused by alcohol and substance abuse and increase abstinence.
Sri Lankan women generally enjoy a higher degree of gender equality than, many women in other countries in the region (UN- Human, Development Report 2001). However in the recent past there have been upsurge in acts of domestic violence and violence against women in Sri Lanka. The impact of the armed conflict on women in Sri Lanka has been felt in different ways by women of different ethnicities and social classes and by, women living in different areas of the country (OMCT 2002). According to the Police Women and Child Protection Bureau of Sri Lanka anywhere from 8,000 to 10,000 cases of domestic violence are reported to police annually. Domestic violence has become a pervasive societal problem in Sri Lanka with the Eelam War.
Combat trauma is a collective ordeal and both soldiers and their families face the psychosocial repercussions of war. Often the families experience frustration, anxiety, marital problems, and behavioral problems. When the stress is overwhelming spouses emotionally distancing themselves from their husbands creating a deep void in the family communication. Combat trauma has created significant unhappiness, stress and conflict in marriages and families. Many spouses and children have become the secondary victims of the war.
Many studies have shown that combat trauma linked to domestic violence. A number of studies have found that veterans’ PTSD symptoms can negatively impact family relationships and that family relationships may exacerbate or ameliorate a veteran’s PTSD and comorbid conditions (Price & Stevens, 2010). Jordan et al. (1992) indicate that Male veterans with PTSD are more likely to report marital or relationship problems, higher levels of parenting problems, and generally poorer family adjustment than veterans without PTSD.
Combat Trauma and Alteration in Self Perception
Complex posttraumatic conditions (Malignant PTSD) often develop in the aftermath of chronic cumulative trauma. During the War the soldiers were exposed to insidious traumatization. There are a number of Sri Lankan combatants diagnosed with Malignant PTSD or DESNOS (Disorder of Extreme Stress Not otherwise Specified) and they have affect dysregulation, pathological dissociative symptoms ,somatic effects etc.
Many experts agree that trauma disrupts the development of self, capacities such as boundary regulation, affect modulation and tolerance, and, identity. Combatants with battle trauma often have altered self-perception. The victims feel a sense of helplessness, shame, guilt, and stigma. Many post combat reactions lead to drastic personality changes among the soldiers. They experience a paralysis of initiative, a sense of defilement with alienation. They preoccupy with morbid and traubled relationships sometimes thinking of revenge. They have mistrustful attitude toward the world and lack of trust cut them from reaching the support services and mental health care providers. Social withdrawal, feelings of emptiness and estrangement make them disconnected from the family and loved ones. There can be marked personality changes in which Horowitz (1986) described “post-traumatic character disorder that is resulted following long term exposure to trauma. Combat trauma has many residual effects that change their self-perception. Combat trauma could leave permanent scars. Solomon (1993) concluded that the trauma of combat leaves marked stress residues among combatants; hence war becomes internalized and continues to cast a shadow on the lives of veterans.
Psychosocial Rehabilitation of the Combatants
A combat veteran’s transition to civilian society from combat is fraught with complications in familial and interpersonal relations, vocational endeavors, and, at times, adherence to societal and legal boundaries (Fairweather & Garcia, 2007). In Sri Lanka a large number of ex combatants transited to civil society without any prier screening process. Many of them have readjustment problems. Psychosocial rehabilitation of the war veterans have been recognized as a crucial component in Sri Lanka. A range of social, educational, occupational, behavioral and cognitive interventions would be needed to address the needs of the combatants who were affected by the war.
Rehabilitation is an ecological approach that aims at the long term recovery and maximum self-sufficiency. In 1996 the World Health Organization came out with a consensus statement on psychosocial rehabilitation. The WHO defined psychosocial rehabilitation as a process that facilitates for individuals who are impaired, disabled or handicapped by a mental disorder to reach an optimal level of independent functioning in the community. Many physically and psychologically traumatized combatants need psychosocial rehabilitation to recover. Warren (2002) of the view that addressing the broader emotional, social and economic needs of survivors is a critical aspect of the rehabilitation process. Support survivors in becoming reintegrated into all aspects of community life, including education, employment, recreation, and social and political activities. Psychosocial Rehabilitation practices help war veterans re-establish normal roles in the community, independence and their reintegration into community life. These interventions should help to manage behaviors, perceptions and reactions to the physical / psychological injury or condition which may hold back the process of recovery or maintenance of the veteran’s well-being.
Often the combatants with disturbing battle memories find it difficult to achieve a complete recovery. They are troubled by whole range of negative emotions that affect their cognition and behavior. The traumatized veterans easily go in to negative stress coping methods such as alcohol and substance abuse. Frequently the physical and psychological wounds that they had received from the battle ground make them highly dysfunctional. These traumas create various barriers making the veterans vulnerable. Inability to reintegrate and connect with the families and communities generate a sense of isolation and mistrust. The combatants feel that they are unable to find peace with themselves. These factors hinder their recovery.
Psychosocial rehabilitation helps the veterans to move towards recovery. Recovery is a journey of healing and transformation enabling the wounded veteran to live a meaningful life in a community of his choice while striving to achieve his or her full potential. Anthoney et al. (2012) defines recovery as a deeply unique process of changing one’s attitudes, values, feelings, goals, skills, and or roles.
Almost every traumatized veteran is capable of recovery. Studies show that in the West 60-90% of trauma victims can help themselves, by balancing the, protective factors (e.g. normal living conditions, social and cultural support mechanisms) and risk factors, (e.g. length of traumatic experiences, being wounded) in their lives (Kleber & Brom, 1992). Although in Sri Lanka mental health services are not advanced like in the developed countries culture and traditional healing systems acted as strong catalysts for recovery. The recovery process depends on several factors and individual resilience, support services and post combat environment play an important role. It is widely acknowledged that recovery from trauma is facilitated by emotional disclosure within a socially supportive environment (Pennebaker, 1992).
Adding Case Management Services
A case management service has been introduced into Veteran’s rehabilitation programs in a number of Armies. In general terms Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality costeffective outcomes. Case management address the concerns regarding the wider psychosocial needs of veterans and their families. Case management helps to coordinate the community services for veterans by allocating a professional to be responsible for the assessment of need and implementation of care plans. It provides ongoing support in areas such as housing, employment, social relationships, and community participation.
Using ACT Teams
Assertive Community Treatment is a team treatment approach designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness. It was implemented by Dr. Arnold Marx in the late 1960s. The US Department of Veterans Affairs has implemented ACT across the United States to help the veterans and ACT teams are closely working with the soldiers. This multi-disciplinary Team is composed of a psychiatrist, nurses, social workers, mental health workers, a peer support worker, a program assistant, an occupational therapist, a general practitioner, and a team leader who provide a range of comprehensive and integrated community-based treatment, rehabilitation and support services assisting clients toward their recovery. Its a timely requirement that the health authorities should start using such multidisciplinary team to heal the Sri Lankan combatants who were affected by war trauma.
The Impact of Culture in the Process of Recovery in War Trauma
The culture plays a key role in the recovery process. Culture is the full range of learned human behavior patterns and it is a powerful human tool for survival. In psychosocial rehabilitation culture has been identified as a powerful tool that promotes recovery. Culture plays an important role in recovery as sources of strength and enrichment for the person and the services. Sri Lankan traditional culture does not outcast the mentally wounded. Combat trauma has been identified in the ancient history of Sri Lanka.
In every culture special attention is given to the soldiers who fought in battles. The psychological wounds of war are a universal human experience, and that, as we discover in traditional warrior cultures, there is a common structure to the requirements and processes of healing. These wounds have been named in all cultures, and described in our own western culture more than two-and-a-half thousand years ago (Brooke, 2012).
The traditional Sri Lankan culture is enriched with Buddhist Philosophy that views the human suffering in more existential perspective. Incorporating traditional cultural beliefs and values the recovery process could be accelerated. The war veterans who struck by psychological trauma archive a great personal growth.
In traditional warrior cultures combat experience sets the returning warrior on a different path of psychological development, which continues through the life span. He (or, now, she) can never return to the time of innocence and will never be “merely” a civilian again. Instead, he or she is called to take up this experience as a spiritual task in which moral character, self-sacrifice, humility, strength, and wisdom are recognizable themes. The transformation of combat trauma into spiritual meaning is the warrior’s archetypal calling ((Brooke, 2012).
In Sri Lanka the combatants are treated with drug therapy ( anti depressants, mood stabilisers , anti psychotics , pain killers etc.) psychotherapy (CBT , EMDR , Rogerian therapy) traditional healing methods ( Thovilay the ancient ritual , Dehi Kapima – chasing the evil spirits) Spiritual Therapy and mediation (mindfulness and the Methha mediation or the meditation of loving kindness ). These therapeutic processes help to minimise the symptomatology that is caused by the combat trauma.
For psychosocial rehabilitation alleviating of symptoms are essential. Rehabilitation is an integrated program of interventions that empower individuals with disabilities and chronic health conditions to achieve “personally fulfilling, socially meaningful, and functionally effective interaction” in their daily contexts ( Riggar& Maki 2004). Physical and psychological symptoms related to combat trauma often affect the veterans in massive proportions. These symptoms make them dis-empowered. Alleviating the effects of physical and emotional trauma is a significant part of psychosocial rehabilitation.
Traumatic stress and PTSD are often associated with physical (i.e. somatic) complaints such as headaches, stomach problems, body pain, dizziness or palpitations, etc., that do not actually relate to a physical, malfunction or disorder (McFarlane, Atkison, Rafalowicz & Papay, 1994; Van der Kolk et al., 1996). The residuals of combat trauma could become detriment to the functionality and well being of the combatants. War trauma can be cumulative and create vicious cycles. Many combatants experience war related intrusions, negative feelings, chronic tension, hyper arousal, insomnia, fatigability, medically unexplained somatic pain , emotional anesthesia, and various other symptoms. Alleviating symptoms associated with war trauma is highly essential to eliminate the functional and environments barriers that are created by war trauma.
Research, indicates that the duration and the frequency of traumatic experiences negatively influences physical, mental, and spiritual coping mechanisms (e.g. Kleber & Brom, 1992). Veterans affected by war trauma experience drastic limitations in human intractions, professional situations and have problems coping with stress.
Seligman (2002) identifies strong connection between a self-defeating pessimistic attitude and susceptibility to PTSD and identifies a phenomenon which is called “post-traumatic growth,” that could affect the combatants. Soldiers with battle trauma feel disempowered and defenseless. Building strengths help the combatants to fight back their war related symptoms. Psychosocial Rehabilitation interventions build on the strengths of each person. Strengths Based practice uses peoples’ personal strengths to aid in recovery. Discovering and using individual strengths accelerates the process of recovery. Building strengths is an effective way of empowering the combatant and they can live in the community with the least amount of professional support.
Creating Supportive Working Environment
Employment is an integral component of recovery. Employment has been seen to correlate with self-esteem and decreased stress and income has often been correlated with, disability (Richardson et al, 2002). Soldiers with war related trauma need extra support to perform their military duties. There are specific military duties that can trigger past trauma in war affected soldiers. Handling human remains, working in combative environment with fire arms can further escalate their trauma fixated memories. Therefore proper assessments have to be done to find the triggering factors. The military duties should not re traumatise the veteran who is profoundly affected by the combat stress. Rough and harsh way of handling traumatized combatants without offering administrative support could damage their psychosocial wellbeing. Healthy and empathetic working environments help war affected combatants to achieve speedy recovery.
Very often physically and psychologically wounded soldiers cannot perform normal military duties and they need special vocational rehabilitation. Vocational rehabilitation helps maintain work activities and reduce negative symptoms. The aim of vocational rehabilitation is to provide the soldiers with the new skills and knowledge necessary to work in the military. The vocational training they master could help them after leaving the military.
Premature retirement from the military following disability conditions could lead to financial constrains. Some ex combatants find it extremely difficult to enter in to the civilian job market since they have no marketable civilian job skills. Difficulties in transition and reintegration experienced by veterans can lead to financial distress resulting from inability to maintain employment (Fairweather & Garcia, 2007). The ex combatants need to learn new skills to find a suitable employment that does not trigger their traumatic memories. The vocational training and supportive employment could help them to overcome these barriers and find meaningful jobs.
To address ex-combatants’ economic concerns, income-generating and capacity-building activities would be needed. Providing vocational skills training; and on-the-job training help them to become employable. A number of studies have now demonstrated that supported employment is an effective rehabilitation approach (Burns, Catty & Becker, et al, 2007; Bond, et al, 2008). Meaningful employment leads to improved social integration, normalized peer relationships and a source of identity (Warner, 2009). In addition vocational training and supportive employment gives them a sense of safe place and prevents re-traumatization.
Family Involvement in the Rehabilitation Process
A large number of combatants who are affected by combat stress have dysfunctional family systems. Family members often have difficulties to understand the combatant who is experiencing battle stress. Irritability and rage—angry outbursts disintegrate the family ties. The entire family is profoundly affected by the trauma based behavior of the combatant. They repeatedly focus their anger and frustration on family members. The family members may experience fear, anger, and sometimes disgust. The family members start to distance themselves from the victim. This creates a pathological style of family communication system and it adversely affects the combatant’s recovery process.
In Psychosocial Rehabilitation family is considered as a strong ally in the process of recovery. Supportive family involvement was found to be an important aspect of a soldier’s rehabilitation. Family members need help, psycho education and skill training to communicate with the combatant. Trained and empathetic family members are inimitable resources for the combatant who is suffering from war trauma. Research investigating the predictors of outcome of chronic, illness and disability has increasingly recognized the importance, of families, both in terms of their influence on the recovery of the, individual, and the effects of the illness or disability on other family members (Degeneffe & Lynch, 2006; Storer, Frate, Johnson, &, Greenberg, 1987)
Bowlby (1973) notes that human beings are strongly dependent on social support for a sense of safety, meaning, power, and control. Supportive relationships are essential in the recovery process. Family members, relatives, friends, colleagues at the work place play a key role in combatant’s emotional wellbeing. An examination of long-term stress reactions among these Vietnam veterans revealed that differences in family stability and the amount and intensity of combat experiences interacted to affect veterans to different degrees. Supportive relationships with others were found to have a significant effect in reducing the incidence and severity of stress, reactions for all veterans, regardless of amount of, combat experience (Stretch, 1995).
Supportive Housing for the Combatants
Housing is a key determinant of health. Supportive Housing provides community living for the veterans affected by combat trauma promoting recovery. To address the housing needs the Sri Lankan Rehabilitation Authorities implemented the Ranaviru (War Hero) villages. However this concept has not resolved many issues faced by the combat veterans.
The concept of Ranaviru (War Hero) villages was introduced as a part of the rehabilitation process in early 90 s when the number of disabled soldiers increased. The Sri Lankan Army rehabilitation authorities decided to create such villages concentrating physically wounded men in to satellite areas. This helped them to do the administration work more efficiently. But this Ranaviru village concept sometimes worked as a hindering factor for self-growth. When physically and psychologically wounded soldiers and their families put in one place many social issues began to emerge. Interactions among the individuals as well as the families created relentless issues in these villages. Sometimes violence and unhealthy social infarctions reported in the Ranaviru villages. Some combatants felt that their social integration was decelerated and they lost some of the supports that they used to receive from the relatives. Some expressed their concern to live among the relative where they received more material and emotional support.
Social Skills Training
Some researchers suspect negative associations between social skills and negative life events such as war trauma. According to the social skills deficit stress generation hypothesis people who possess poor social skills have been hypothesized to experience negative events and consequently become vulnerable to psychosocial problems (Sergin 2001). Strengthening of the social skills are essential for the soldiers who experienced traumatic combat events. Rage and social isolation have deteriorated their social skills and it pushes the combatant in to a vicious cycle. Social skills training are important innovations for the veteran’s rehabilitation program. Social skills training involves teaching how to act and interact in various social situations effectively. and it helps to revive and strengthen existing social structures and capacities of the target community.
Full Community Integration
In the aftermath of the thirty year war, Sri Lanka faces greater challenges in dealing with disintegration of communities and individuals. Activities and programs should be implemented to promote community integration that uplifts social well-being. Psycho social rehabilitation include a variety of strategies to increase the community integration and independence of veterans with combat trauma. Socially disconnected veterans are largely benefitted by social and community integration that acts positively in their journey of recovery. Community Integration is the opportunity to live in the community and be valued for one’s uniqueness, and abilities, like everyone else. (Salzer, 2006). Community integration encompasses of supportive housing, supportive employment, supportive education and civic engagement. Community integration creates an environment that facilitates the combatant’s well-being.
Introducing Club House Model for the War affected Combatants
The Clubhouse model play an important part in psychosocial rehabilitation. Combatants with battle trauma would be benefited from Club houses. The club house model is still not widely used in Sri Lanka and it is a timely requirement to implement a such model to help the soldiers.
Clubhouses are community-based rehabilitation programs for people with psychiatric disability offering vocational opportunities, planning for housing, problem-solving groups, case management, recreational activities, and academic preparation. Individuals can learn or regain skills necessary to live a productive and empowering life. The Clubhouse Model provides for the societal, occupational, and interpersonal needs of the person as well as medical and psychiatric needs (Fountain House, 1999). The Club houses help people with mental illness to, stay out of hospitals while achieving social, financial, educational and vocational goals. Clubhouse is a place that offers respect and opportunity to its members. The Clubhouse has an independent board of directors, or if it is affiliated with a sponsoring agency, has a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support and advocacy for the Clubhouse. (International Standards for Clubhouse Programs). Bond (1995) states that the Clubhouse Model is a comprehensive group approach that focuses on practical issues in informal settings.
Using Sports as a Tool of Reintegration and Rehabilitation
Sports provide important opportunities for social reintegration and rehabilitation. The experience in Liberia, Sierra Leone, Mozambique and South Africa coincide that sports can be used as a powerful rehabilitation tool for the ex-combatants. Sports play a significant part in Sri Lankan Culture. Although volley ball is the national sport Sri Lanka is world famous for cricket. Among the other sports Elle (similar to baseball), Rugby, Football etc. are popular among the people. Sports provide a sense of comradeship and it crates social bonds. The combatants with battle trauma find sports as a soothing method to achieve catharsis. Sports provide socially-acceptable and structured patterns of behavior to the combatants affected by war trauma.
Veteran’s Self Help Groups
Self-help groups are composed of peers who share similar mental, emotional, or physical problems. Veteran’s Self-help groups share a common desire to overcome the impact of combat trauma. Self-help groups provide traumatized people with an opportunity to talk about their, experiences with others who have experienced similar situations. In an atmosphere of, trust, social support and common experience, many people find it easier to speak, about painful and humiliating experiences and the feelings associated with them (Olsen et,al 2006).
Solomon(2004) concur that self-help groups are effective for helping people cope with, and recover from, a wide variety of problems. In addition members demonstrate improved coping skills, greater acceptance of their illness, improved medication adherence, decreased levels of worry, higher satisfaction with their health, improved daily functioning and improved illness management. Participation in self-help groups for mental health encourages more appropriate use of professional services, making the time spent in care more efficient. The amount of time spent in the programs, and how proactive the members are in them, has also been correlated with increased benefits.
Healthy Transformation after Facing Combat Events
Partly because PTSD is the most widely known impact of trauma but also for other complex reasons, trauma’s impact is often seen in terms of symptoms of psychological disorders. Dissociation, flashbacks, and nightmares that are among the diagnostic criteria of PTSD are not the only symptoms associated with experiencing violence designated by mental illness diagnoses. Diagnoses of depression, anxiety and panic disorders, obsessive compulsive disorder, psychotic disorders, and eating disorders are commonly given to individuals who have experienced violence (Allen, Huntoon, & Evans, 1998; Briere & Elliott, 1994; Browne & Finkelhor, 1986; Margolin & Gordis, 2000). Living through traumatic events changes the ways the self and the world are experienced. Kemmerer & Mazelis (2006) indicate that numerous studies suggest that experiencing trauma heightens vulnerability to other traumatic events. These traumatic events transform the victims.
Although negative transformation following combat related psychological trauma have been reported throughout the world sometimes veterans use these traumatic experiences to achieve positive transformation and self-growth. The story of the Emperor Ashoka of India (273 – 232 BC) discloses the positive transformation after facing traumatic battle events. The Emperor Ashoka was devastated by the events that occurred during the Great Kalinga battle. He used these psychologically devastating events to achieve a complete positive transformation. Admiring Asoka’s character the British Historian H.G Wells wrote ” Ashoka the greatest of Kings.
The modern wars and armed conflicts have produced a number of combatants with positive transformation after facing traumatic battle events. Sergeant Alvin Cullum York (WW1), the Soviet Fighter Pilot Alexey Maresyev (Red Army WW2), First Lieutenant Audie Murphy, (US Army WW2) General Denzil Kobbekaduwa (Sri Lanka Army ), General Romeo Dallaire (Canadian Army who served in the Rwandan Peace Keeping Mission) etc. were able to turn their bad combat experiences in to positive life energy. Every combatant is capable of positive transformation despite the distressing combat events that he / she underwent. They can turn these adverse life experiences in to meaningful and productive outcomes.
Sri Lanka is challenged by the adverse effects of the Eelam War. A large number of combatants were exposed to the traumatic battle events for over three decades. Various trauma related ailments such as PTSD , Adjustment Disorders, Depression , Somatization etc have found among the combatants. Many combat stress reactions are still undiagnosed and a large percentage of war affected soldiers do not receive any kind of treatment. Combat trauma has caused significant harm to the veterans , their families and to the society. Effective Psychosocial Rehabilitation measures should be implemented to help the veterans of the Eelam War. These Psychosocial Rehabilitation measures include individual and family therapy, addiction services , supportive employment, supportive housing etc. The Psychosocial rehabilitation should reflect the concepts of recovery with the ability to live a full and meaningful life .
1) Nancy Pingel : Program Instructor – Psychosocial Rehabilitation Humber Lakeshore Campus Canada
2) Professor Daya Somasundaram -University of Adelaide Australia
3) Dr Hamasen De Silva – Board Certified Psychiatrist : Colmary-O’Neil Veterans Affairs Medical Center Kansas USA
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