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SWEDISH SOLDIERS IN PEACEKEEPING OPERATIONS: STRESS REACTIONS FOLLOWING MISSIONS IN CONGO, LEBANON, CYPRUS, AND BOSNIA Tom Lundin, M.D., Ph.D., & Ulf Otto, M.D., Ph.D. Just a few weeks after arrival in Bosnia in October 1993, a group of young and relatively inexperienced soldiers from the first Swedish battalion in former Yugoslavia, found the bodies of 19 murdered women and children in the village Stupni Do. This tragic discovery illustrates the situation for many UN soldier might be exposed to an unexpected and overwhelming traumatic situation. To witness the effects of a massacre on innocent civilians - and not being capable to prevent or retaliate, might result in intense traumatic stress reactions. UN soldiers from several countries have been trying to prevent extensive suffering among civilians in towns with names, that we now associate with genocide, atrocities, concentration camps, and ethnic cleansing: Bihac, Banja Luka, Vitez, Sarajevo, Srebrenica, Gorazde. These names also should remind us that peacekeeping soldiers will be exposed to both cognitive and emotional stressors specific to peacekeeping missions (Table 1). Table. 1. Cognitive and emotional stressors by peacekeeping soldiers Cognitive Information: too much, too little Sensory overload vs deprivation Ambiguity, uncertainty, isolation Time pressure vs waiting Unpredictability Rules of engagement, difficult discriminations Organizational dynamics Hard choices vs no choices Emotional fear and anxiety-producing threats (of death, injury, failure and loss) grief-producing losses (bereavement) resentment, anger, and rage-producing frustration, threat and loss boredom-producing inactivity conflicting motives (worries about home, divided loyalties) spiritual confronting or tempting causing loss of faith interpersonal feeling More than 60,000 Swedish military personnel have been in UN-service since the operations in Greece 1951-52. The first study on Swedish UN soldiers, who had been exposed to combat during the hostilities in the Congo in 1961, was the study by Kettner (1). One question was whether participation in military combat affects the health and social adjustment in the long run, regardless of the immediate consequences and if certain background factors affects the risk of combat exhaustion in the short-and long-term outcome. Kettner compared the 1082 Swedish soldiers serving in combat-exposed UN battalions in the Congo (combat veterans) with 1242 other Swedish UN soldiers (non-combat veterans). Data were collected on morbidity, income, and alcohol offenses during the years preceding the UN service as well as during the 3-4 years after the service. The combat veterans did not differ from the non-combat veterans in morbidity or psychiatric morbidity after their UN service. On the other hand, the combat veterans were significantly more prone to accidents during the first years after their service. They also had a significantly lower income than the non-combat veterans. They did not differ from the non-combat veterans in number of alcohol offenses after the UN service. Kettner also compared 35 Swedish UN soldiers succumbing to combat exhaustion (patients) with an Table 2. Differences between patients and controls among former UN-soldiers, concerning frequencies of symptoms Symptom "Patients" Matched controls SIGN. (N=35) (N=35) _____________________________________________________________________________________ Extreme fatigue 51.4% 62.9% NS Nervousness 34.3% 22.9% NS "Nervous stomach" 45.7% 60.0% NS Sleep disorders 28.6% 22.9% NS Tendency to worry 45.7% 34.3% NS OCD-traits 20.0% 28.6% NS meticulousness(anxiousness) 5.7% 28.6% p<0.05 equal number of soldiers from the same battalions exposed to the same combat stress but not breaking down (Table 2). Men under 21 suffered from combat exhaustion significantly more than older soldiers (Table 3). The soldiers who broke down more often had parents Table 3. Acute psychiatric combat reactions in 12th and 14th battalion in UN service in Congo, 1961 Age N= Psychiatric breakdown in per cent _____________________________________________ 17-20 220 6.8% 21-24 474 2.5% 25-28 178 1.7% 29-32 89 4.5% 33- 121 0 Total 1082 3.1% with a psychiatric history, were more often divorced, and were on average, of lower intellectual level, than those who did not break down. The long-term follow-up did not show that combat exhaustion worsens the social or medical outcome. The mission and the stress-load following the military situation was quite different for the Congolese-soldiers compared with most later UN-missions: in Congo, the soldiers were directly exposed to and actively participating in combat activities. The stress situation for UN soldiers will therefore often differ from the situation for soldiers in other military operations. The UN-soldier might be scared by his own aggressiveness, because of his limited opportunities to use his weapons. The mission for the UNIFIL hospital in Naqoura, a few kilometers north of the Israeli border, is to provide the UN forces (5000-6000 soldiers) with hospital care and specialized medical services. Three contingents (N=340) have been studied by means of questionnaires, self-rating scales, and personal interviews during a three year period (Tables 3 & 4). The personal interviews were structured and performed in the last month of service for each contingent. All the interviews took place within the Swedish UN hospital area in South Lebanon (2). A study of mental adjustment was carried out by means of a questionnaire with one Swedish UN logistic battalion in South Lebanon at the end of its period of service (3). The results showed a generally good adjustment. The frequency of stress-related symptoms was, however, relatively high. Some respondents experienced the service as being monotonous. Two Swedish rifle battalions serving as UN-soldiers in Cyprus (UNFICYP) have been investigated with respect to their demographic background and motives for application for UN service. The comparison of symptoms of stress in general, of posttraumatic stress disorder (PTSD) specifically, and some other variables of reaction with various studies of Swedish UN soldiers in different settings has given the following results (Tables 4 & 5). Very few interviewees experienced "personal nervous breakdown" (0.5%). The soldiers reported in general very few psychological or psychosomatic complaints in the short time perspective. There seemed, however, to be two groups of persons at risk, namely those who were repatriated and those with a high consumption of alcohol (4). The soldiers of one Swedish logistic battalion experienced the Gulf War during the last month of their mission in South Lebanon. A representative sample was studied using the same methodology as with earlier Swedish UN troops. The results have not yet been published, but there seemed to be no significant differences compared with previous studies (Tables 4 & 5). Table 4. Self-rated symptoms and reactions related to peacekeeping stress Item UNIFIL/Hospital UNFICYP UNIFIL/Gulf War SA01 (N=340) (N=605) (N=459) (N=368) _____________________________________________________________________________________ Depression 9.4 8.6 6.6 7.5 Sleep disturbances 7.1 6.6 5.5 1.7 Nightmares 1.2 1.5 1.3 - Anxiousness/ restlessness 10.6 13.7 16.7 1.2 A need for isolation 24.1 16.2 - 2.8 Unpleasant feelings 7.1 7.6 18.7 - at work Muscular tension 1.5 1.2 1.5 - Table 5. UNIFIL/Hospital, UNFICYP, and UNIFIL/Gulf War reactions to UN peacekeeping service UNIFIL/Hospital UNFICYP UNIFIL/Gulf War Item (N=340) (N=649) (N=459) ____________________________________________________________________________________________ Subjective estimation of "personal nervous break down" 5.6 0.5 0 Possibilities for personal support 82.9 77.4 - Too high use of alcohol (self rated) 24.7 9.6 3.5 Considered leaving UN-service 19.2 9.0 - Feelings of monotony at work 51.3 63.6 40.7 Homesickness for age-group 20-29 53.1 30.7 52.2 During the Gulf War, a field hospital (SA01) for the acute treatment of combat injuries was organized by Swedish authorities. The hospital was located in Saudi Arabia. Towards the end of the mission, the frequencies of stress-related symptoms were assessed by help of the same methodology that had been used previously with other Swedish UN soldiers. Remarkably low frequencies of symptoms were reported (Table 5). Practical and Clinical Aspects Conclusions from Kettner's (1) study are that personality factors do less to cause mental breakdown during battle than they do in other circumstances of military life and that the soldiers should be older than 21 years of age. The interviewed health care personnel of three Swedish UNIFIL contingents had different backgrounds and experiences. During UN service the living accommodation is relatively primitive in most aspects. On the other hand, no one has to worry about household duties. In spite of very unusual circumstances concerning cultural and social factors and the threat from surrounding war, it was noted that stress reactions were not prominent. Living far away from home might result in a constantly heightened worry about significant others. Most UN soldiers seemed, however, to manage quite well. A great many people wanted to continue their UN service for another six-month period (2). The soldiers of the studied groups had no combat experiences. They developed few psychological or psychosomatic problems in the short time perspective. There were, however, in all three groups persons at risk (e.g. cases of repatriation and heavy drinkers), who might develop psycho-social problems or psychiatric disorders with a delayed onset (4). As a result of the work reported here, we have identified a number of cognitive and emotional variables that may serve as stressors for peacekeeping soldiers (Table 1). In order to prevent physical, mental or social after-effects among Swedish military personnel in UN-service in Bosnia-Herzegovina, the demobilization procedure was revised and expanded. Before 1994, the demobilization procedure (in general) consisted of a short program, with an emphasis on logistic and administrative end-of mission routines. In 1994, the procedure was extended to include stress debriefing, an official ceremony, and home-coming information about the physical and psychological stress-mechanisms. Furthermore, a post-demobilization psychosocial support system has begun to develop (6). References 1. Kettner, B. (1972). Combat strain and subsequent mental health. A follow-up study of Swedish soldiers serving in the United Nations forces 1961-62. Acta Psychitrica Scandinavica; Suppl 230. 2. Lundin, T., & Otto, U. (1989). Stress reactions among Swedish health care personnel in UNIFIL, South Lebanon 1982-1984. Stress Medicine, 5, 237-46. 3. Calstrom, A., Lundin, T., & Otto, U. (1990). Mental adjustment of Swedish UN soldiers in South Lebanon in 1988. Stress Medicine, 6, 305-10. 4. Lundin, T., & Otto, U. (1992). Swedish UN soldiers in Cyprus, UNFICYP: Their psychological and social situation. Psychotherapy and Psychosomatics, 57 (4), 187-93. 5. Westling, G. (1995). Swedish UN-personnel demobilization procedures and support apparatus: Experiences limitations and possible development. Presentation at the 4th European Conference on Traumatic Stress, Paris. Tom Lundin and Ulf Otto are at the Department of Psychiatry, Karolinska Hospital, Box 1366, S-172 27 SUNDYBERG, Sweden.
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