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Psychological Adjustment After Military Operations: The Utility of Postdeployment Decompression for Supporting Health Readjustment

Authors:
  • De Weg Wijzer

Abstract

This chapter provides a literature review of postdeployment stressors and their effects and explores the potential value of adding a transition period between the operational environment and the “home front”. The organized transition period between the end of a military operation and the homecoming is known as Third Location Decompression (TLD), a promising means of providing better psychosocial support to troops returning from difficult dangerous and potentially traumatic operation theatres. TLD programs aim to combine postmission debriefing, psychosocial adjustment, mental and physical relaxation, sense giving, and mental health psychoeducation in a location that is safe and comfortable. This chapter will focus on the key features of various TLD programs utilized with troops that have been deployed in different theatres in Afghanistan. We also review the antecedents, correlates, and outcomes of postmission adjustment during and after military peacekeeping or war operations, with a focus on the role of traumatic stress and posttraumatic stress disorder in readjustment and readaptation of troops after long-term deployment. Last, we will discuss the implementation of TLD programs in several NATO countries (i.e. Belgium) and assess the evidence for their effectiveness in facilitating healthy adjustment and homecoming.
89
© Springer International Publishing AG 2017
S.V. Bowles, P.T. Bartone (eds.), Handbook of Military Psychology,
DOI 10.1007/978-3-319-66192-6_7
Psychological Adjustment After
Military Operations: The Utility
of Postdeployment
Decompression for Supporting
Health Readjustment
Erik De Soir
This chapter provides a literature review of post-
deployment stressors and their effects and
explores the potential mitigating value of adding
a transition period between the operational envi-
ronment and the “homefront”. The organized
transition period between the end of a military
operation and the homecoming, is currently
known as Third Location Decompression (TLD),
which is under study by the Belgian Defence
department as a means of providing better
psychosocial support to troops returning from
difficult, dangerous, and potentially traumatic
operation theatres.
The TLD, referred to in Belgium and France
as “Sas d’Adaptation” (Adaptation Lock), has
been developed by several NATO countries and
can be an important preventive tool to foster post
operational stress management and adjustment
in returning soldiers and their spouses or part-
ners. These programs usually combine postmis-
sion debriefing, psychosocial adjustment, mental
and physical relaxation, sense giving, and men-
tal health psychoeducation in a safe and com-
fortable location. There remains some
disagreement regarding inclusion criteria—i.e.,
who needs a TLD—and whether or not civilian
facilities should be used. With the exception of a
few studies on perceived utility, up to now there
is little empirical evidence regarding the benefits
of TLD on postmission health and its usefulness
regarding trauma screening and prevention (De
Soir, 2011). This chapter will focus on the key
features of various TLD programs with troops
that have been deployed in different theaters in
Afghanistan. The ingredients of what seems to
be the ideal TLD program will be discussed in
the light of the perceived benefits obtained in
other NATO countries.
We begin by reviewing research regarding the
antecedents, correlates, and outcomes of post-
mission adjustment during and after military
(peacekeeping or war) operations. Traumatic
stress and posttraumatic stress disorder (PTSD)
play a prominent role in scientific research about
readjustment and readaptation of troops after
long-term deployment. Next, we discuss the
implementation of Third Location Decompression
programs in several NATO countries including
Belgium and assess the evidence for their effec-
tiveness in facilitating healthy adjustment and
homecoming.
E. De Soir (*)
Royal Higher Institute of Defence,
Bruxelles, Belgium
e-mail: erik.desoir@mil.be
7
Portions of this chapter were drawn from E. De Soir
(2011) NATO Technical Report “The Belgian end of mis-
sion transition period: Lessons learned from third location
decompression after operational deployment,” Defense
Technical Information Center Accession Number
ADA582836.
90
Psychological Adjustment
During Deployment
PTSD-Related Adjustment
Of the various mental health problems that soldiers
may experience during and after deployment,
PTSD has probably received the most attention.
Many studies have attempted to ascertain preva-
lence rates for PTSD in soldiers. For example, a
recent review of 49 different studies in Canada,
the United Kingdom, and the United States found
PTSD prevalence rates of 11.3–14.4% among
military personnel returning from the Iraq war
(Hines, Sundin, Rona, Wessely, & Fear, 2014).
The same study found somewhat lower rates in
personnel returning from the Afghanistan war,
4.6––9.6%. In earlier research, PTSD rates varied
from a very low 0.5% (Lundin & Otto, 1992) up
to a high of 25.8% (Seedat, le Roux, & Stein,
2003) and were certainly lower than the 15.2% of
PTSD found in a sample of Vietnam veterans
(Kulka, Schlenger, Fairbank, & Cranston, 1990).
Ramchand, Schell, Osilla, Burns, and Caldarone
(2010) report how different ways of defining or
measuring PTSD can result in very different
prevalence estimates.
First of all, it is important to take a look at the
antecedents of PTSD in military cohorts. Many
studies have been done that examine at PTSD and
other psychological reactions among military
personnel involved in peacekeeping operations.
Importantly, several sociodemographic variables
seem to play a significant role in the prediction of
PTSD. Risk of developing PTSD is higher for
younger peacekeepers (Bolton, Litz, Britt, Adler,
& Roemer, 2001; Kettner, 1972; Hotpof et al.,
2003), women (Hotpof et al., 2003, Litz, Orsillo,
Friedman, Ehlich, & Batres, 1997), servicemen
of lower rank (Bolton et al., 2001; Hotpof et al.,
2003), those with lower income (Kettner, 1972),
those unemployed before enrolment (Ballone
et al., 2000), divorced (Kettner, 1972), unmarried
(Bolton et al., 2001), having a large family
(Ballone et al., 2000), reporting a lack of athletic
activities (Ballone et al., 2000), and those with
less education (Bolton et al., 2001; Hotpof et al.,
2003, Kettner, 1972; Litz, Orsillo et al., 1997).
Contrary to some of these findings, older studies
found that men were more prone to develop
PTSD (Lundin & Otto, 1989), or found no differ-
ences between men and women (Lundin & Otto,
1992). Interestingly, Britt, Adler, and Bartone
(2001) found that women reported more benefits
as a result of deployment than did male soldiers.
Research on stress during peacekeeping mis-
sions has found that some personality variables
predispose servicemen to develop stress-related
problems, including PTSD. Soldiers having
parents with a psychiatric history (Kettner, 1972),
or having themselves a psychiatric history
(Ward, 1997) were more prone to develop PTSD.
Servicemen expressing hostility, paranoid
ideation or psychoticism were also more at risk
for PTSD (Bolton et al., 2001). Looking at medi-
cal units deployed during the Persian Gulf War,
Bartone (1999) found that soldiers low in person-
ality hardiness reported more stress related PTSD
symptoms.
In addition to personality, situational variables
seem to play a considerable role in the prediction
of PTSD. Factors associated with PTSD include
being a victim of war-zone violence (Litz, 1996),
having been deployed previously in a peacekeep-
ing operation (Hotpof et al., 2003), having par-
ticipated in a mission of 6 months or longer
(Ballone et al., 2000), being deployed on “com-
bat duty” (Hotpof et al., 2003; Litz, Orsillo et al.,
1997), being exposed to potentially traumatic
events (Bolton et al., 2001; Hotpof et al., 2003),
and personal discomforts during the mission
(Litz, Orsillo et al., 1997). Other associated
factors are witnessing serious injury or illness
(Bolton et al., 2001) witnessing violence or the
aftermath of violence (Litz, 1996), witnessing
atrocities against civilians without the opportu-
nity to help (Litz, Orsillo et al., 1997; Weisæth,
Mehlum, & Mortensen, 1996), witnessing the
effects of starvation (Litz, 1996), and being fired
upon without permission to return fire (Weisæth
et al., 1996). Litz (1996) found that the interac-
tion between exposure to war-zone stress (e.g.,
going on a dangerous patrol) and frustration with
the peace enforcement mission (e.g., restrictive
rules of engagement) was the best predictor of
PTSD severity. A measure reflecting events,
E. De Soir
91
circumstances or contexts experienced as fulfill-
ing, pleasing, or uplifting for military personnel
was associated with fewer PTSD symptoms
(Litz, Orsillo et al., 1997). Interestingly, Hotpof
et al. (2003) found no evidence for previous
deployment as a predisposing or a protective fac-
tor. Contrary to earlier research, the study of Litz,
Orsillo et al. (1997) found no relationship
between PTSD and the need to restrain the use of
force when faced with life-threatening circum-
stances. It seems therefore that soldiers who
experienced greater frustration tended to also
benefit psychologically from their humanitarian
role. In contrast, exposure to traditional combat
was negatively related to positive aspects of
peacekeeping, suggesting that more intensive
levels of stress or threat to life may attenuate the
potential rewards or gratification that would oth-
erwise result from humanitarian duties associated
with modern peacekeeping.
Beyond PTSD: Other Psychological
Adjustment Problems
During Deployment
In addition to PTSD, researchers have noted a
number of physical and mental health problems
experienced by troops engaged in peacekeeping
operations. Buma, van Ameijden, and Huyboom
(1999) reported interesting results about morbid-
ity surveillance among 2283 Dutch peacekeepers
in Cambodia. Findings indicated that the medical
services were consulted by 1356 personnel
(59.4%). The three main problems were all phys-
ical: tropical disorders (24.8%), musculoskeletal
disorders and injuries (23.9%), and dermatologi-
cal disorders (22.7%). Eight percent of the ser-
vicemen consulted for neurological and
psychiatric disorders reasons. Contrary to these
findings, in an older study, Lønnum, Kluge, and
Malm (1982) found that the majority of repatria-
tions in UNIFIL (United Nations Interim Force in
Lebanon) operation between 1978 and 1980
(31.3%) were due to neuropsychiatric disorders,
including headaches, anxiety, depression, and
insomnia. Interestingly, Croft, Hoad, and Dales
(1999) found that 6% of the 4400 hospitaliza-
tions of British troops deployed to Bosnia were
due to psychiatric disease. Finally, Brundage,
Kohlhase, and Gambel (2002) found that military
personnel having been hospitalized for mental
health reasons before deployment were at higher
risk than those who were not hospitalized to be
again hospitalized during the mission and after
the end of the operation. At least, these three
studies indicate that mental health is an important
issue for military personnel and that it deserves
attention.
Indeed, psychological problems were reported
quite frequently by military personnel in the early
peacekeeping operations in the nineties
(Baggaley, Piper, Cumming, & Murphy, 1999;
Weisaeth & Sund, 1982). Although Lundin and
Otto (1992) found a low incidence of depression,
sleep disorders, nightmares, and muscular
tension among peacekeepers, Ward (1997)
reported that a substantial proportion of young
veterans reported persisting problems with anger,
irritability, intrusive thoughts, exaggerated startle
response, and bodily aches and pains. Orsillo,
Roemer, Litz, Ehlich, and Friedman (1998) found
that more than one-third of Somalia peacekeep-
ers reported significant symptomatology on the
dimensions of hostility, psychoticism, depres-
sion, and paranoid ideation. Women were more at
risk for depression and anxiety (Lundin & Otto,
1989), and were more likely to have a higher
score on scales of interpersonal sensitivity and
psychoticism.
Several researchers have included control
groups to better identify specific problems peace-
keepers are confronted with. Compared to con-
trols, veteran peacekeepers expressed higher
levels of somatization (somatization) lower
scores on a measure of general health (Ward,
1997). Moreover, peacekeepers report higher lev-
els of fatigue (Hotpof et al., 2003). In comparison
with soldiers stationed in Italy, more stress was
reported by Italian peacekeepers in Bosnia, and
they also showed more insomnia, a tendency for
solitude, neurovegetative symptoms, and reelab-
oration of traumatic events (Ballone et al., 2000).
Hotpof et al. (2003) found in a study of peace-
keepers deployed in Bosnia between 1992 and 1996
that four symptoms (irritability and outbursts of
7 Psychological Adjustment After Military Operations: The Utility of Postdeployment…
92
anger, avoiding doing things, night sweats, and
unintended weight gain) were significantly
more common in the Bosnia group than in the
control group.
Interestingly, peacekeepers on missions in
Somalia and Haiti saw their roles changed at the
end of the mission, and at that time reported over-
all good mental health, even if maladjustments
were noted in terms of misconduct and nonadap-
tive or abusive behaviors (e.g., fighting, disciplin-
ary problems, and recklessness; Hall, Cipriano,
& Bicknell, 1997).
Moderators of the Relation
Between Stressors and Adjustment
Two hypothesized buffers of stress have been fre-
quently studied: social support and coping strate-
gies. Regarding social support, Carlström,
Lundin, and Otto (1990) found that two-thirds of
soldiers had someone to talk about their prob-
lems with during the mission. Other studies
found a substantial number had a tendency to iso-
late from others (Ballone et al., 2000; Ward,
1997) or felt isolated (Bartone et al., 1998).
Looking at military medical personnel on a
humanitarian mission, Britt and Adler (1999)
found that respondents were less likely to use
adaptive coping strategies, and reported drinking
more alcohol to deal with problems. In a similar
vein, Hotpof et al. (2003) showed that peace-
keepers deployed in Bosnia between 1992 and
1996 consumed significantly more alcohol than a
control group. The association with alcohol
decreased after controlling for demographic vari-
ables but was still present. Studies have also
shown that cigarette smoking increases during
peacekeeping deployments (Britt & Adler, 1999).
Asmundson, Stein, and McCreary (2002)
investigated how PTSD symptoms may influence
health status of deployed peacekeepers and non-
deployed military personnel. Results for deployed
personnel show that PTSD symptoms influence
directly health status, controlling for the effects
of depression and alcohol use. PTSD symptoms
also had an indirect influence on health through
alcohol. Britt and Bliese (2003) found evidence
that engagement in work can serve as a buffer of
negative effects associated with lack of sleep.
Another relevant study examined special
operations soldiers deployed to Iraq and
Afghanistan, and found that 15% (N = 201)
screened positive for alcohol misuse following
their return home (Skipper, Forsten, Kim, Wilk,
& Hoge, 2014). When looking at the different
types of combat exposure experienced by this
group, results showed that alcohol abuse was
higher for soldiers who reported greater exposure
to atrocities, threats to self, and fighting. A more
recent study looking at U.S. soldiers returning
from a war-zone deployment to Afghanistan also
found that combat exposure was related to
increased risk for alcohol abuse in the early
homecoming period (Bartone et al., 2015).
Interestingly, this study also found that soldiers
who were high in psychological hardiness were
at lower risk for stress-related alcohol problems.
Family Problems of Deployed Troops
Several studies have found that peacekeepers
often long for home (Carlström et al., 1990).
Orsillo et al. (1998) found that participants
reported quite a bit of distress regarding general
frustrations associated with separation from fam-
ily and friends. Once deployed, servicemen were
generally eager to contact their families to con-
firm and verify that all was well at home and to
let their families know that they had arrived
safely (Bartone, Adler, & Vaitkus, 1998). Bell,
Schumm, Knott, and Ender (1999) found that the
most popular means of communication was the
telephone. Interestingly, these authors found that
stress of peacekeeping deployment was signifi-
cantly predicted by having had problems of com-
munication, in turn predicted by time to contact,
mobilization readiness, and the unit returning
earlier. The quality of the current communication
means have increased dramatically with the
appearance of smartphones and the quasi-
permanent availability of social media. The dis-
advantage of this evolution is that soldiers on
deployment carry a greater burden of accumu-
lated small home front problems on their
E. De Soir
93
shoulders. Before, contact with the homefront
was only made on periodically calculated
moments or in crisis situations.
Soldiers preparing to deploy often underesti-
mate the stressors they will likely encounter
during operations. For example, Britt and Adler
(1999) found the following stressors were expe-
rienced more than expected: trouble communi-
cating, feeling far away from things that are
familiar, travel restrictions, isolation. When sol-
diers reported a large amount of family-related
stress, those who were more engaged in their
jobs showed lower levels of psychological dis-
tress than those who were disengaged (Britt &
Bliese, 2003). In a study assessing the changes
in marital satisfaction over time for soldiers
who had deployed overseas on a peacekeeping
mission, Schumm, Bell, and Gade (2000) found
that among those who remained married, mari-
tal quality did not appear to change. This sug-
gests that if separation reduced marital
satisfaction moderately, it did not reduce sol-
diers’ basic confidence in the intrinsic quality of
the marriage. The authors also found that mari-
tal instability was not uncommon among
deployed soldiers over a 2-year period, although
it appeared to be highest for those who said that
their marriage was in trouble a few months
before deployment.
Organizational Stressors
Social and organizational factors can also influ-
ence stress and vulnerability for deployed sol-
diers. Ballone, Valentino, Occhiolini, Di Mascio,
Cannone, and Schioppa (2000) conducted a study
about the factors influencing the psychological
stress level of Italian peacekeepers in Bosnia.
Compared to a group of soldiers stationed in
Italy, a higher proportion of peacekeepers had
lower socioeconomic status. Also, more peace-
keepers enrolled for economic reasons and were
unemployed before the mission. The major fac-
tors associated with stress for this group of peace-
keepers were: a mission lasting for 6 months or
more, unemployment before enrolment, having a
large family, and lack of physical activity.
Moreover, witnessing atrocities against civil-
ians without the opportunity to help, and being
subject to (close fire) incidents without the per-
mission to return fire seemed to represent severe
trauma for peacekeepers in comparison with tra-
ditional combat soldiers (Weisæth et al., 1996).
The lack of a clear return date (Hall et al., 1997;
Ritchie, Anderson, & Ruck, 1994), restricted
local travel (Hall et al., 1997), changing rules of
engagement (Ritchie et al., 1994), a lost sense of
the mission (Hall et al., 1997), lack of meaning-
ful activities in which to engage (Bartone et al.,
1998), poor communication with home (Hall
et al., 1997), boredom (Bartone et al., 1998;
Ritchie et al., 1994), and determining work unit
and section relationships are considered as
stressors by peacekeepers. Indeed, Bartone et al.
(1998) showed that virtually every work team in
the U.S. peacekeeping unit they studies was
composed of military personnel who had not
worked together previously.
Nevertheless, most of the peacekeepers con-
sidered their jobs to be relevant and important to
maintain peace. In their study of 35 medical per-
sonnel on a six-week humanitarian mission to
Kazakstan, Britt and Adler (1999) found that sol-
diers believed they were gaining valuable profes-
sional experience that would be relevant to other
missions including combat. On the other hand, if
peacekeepers felt they were engaged in a lot of
irrelevant activities, they expressed concern that
their jobs skills were degrading through inactiv-
ity (Britt & Adler, 1999).
Positive Aspects of Deployment
In addition to negative effects of peacekeeping
deployments, a number of researchers have found
some positive effects. Litz, Orsillo et al. (1997)
found that participants reported positive aspects
of their mission activities, although traditional
military duties were seen as more rewarding than
humanitarian duties. Men were more exposed
than women to traditional war zone stressors, and
women were more affected by both peacekeeping-
related stressors and low-magnitude stressors.
Still, women reported feeling more positive about
7 Psychological Adjustment After Military Operations: The Utility of Postdeployment…
94
their humanitarian duties. This suggests that the
subject of postmission satisfaction and posttrau-
matic growth are important topics for psychoso-
cial support activities.
Litz, King, King, Orsillo, and Friedman
(1997) reported that exposure to traditional com-
bat and negative aspects of peacekeeping
appeared to influence PTSD severity. The most
compelling results relate to the feature of peace-
keeping that is particularly difficult to reconcile
for combat-trained military personnel: the need
to restrain the use of force when faced with pos-
sibly life-threatening circumstances. However,
the restraint variable was not linked to PTSD,
directly or indirectly. Positive aspects of peace-
keeping were strongly negatively related to
PTSD. It seems that soldiers who experienced
greater frustration tended to also benefit psycho-
logically from their humanitarian role. In con-
trast, exposure to traditional combat was
negatively related to positive aspects of peace-
keeping, suggesting that intensive levels of stress
or threat to life may attenuate the potential
rewards or gratification that would otherwise
result from humanitarian duties associated with
modern peacekeeping. At any rate, these feelings
and frustrations need to be ventilated before the
homecoming in order to avoid the cumulative
effect of such emotions, which can lead to acting
out and disturbed readjustment on the
homefront.
Britt et al. (2001) studied the role of engage-
ment in meaningful work and hardiness as pos-
sible variables playing a role when peacekeepers
derive benefits from stressful events. They found
that there was a strong link between personality
hardiness (commitment, challenge, and control),
and the tendency to perceive meaning in the
deployment (soldier engagement, job impor-
tance, and peacekeeper identity). Interestingly,
the location influenced both the contextual expe-
riences and the perceived benefits peacekeepers
felt. That is, servicemen who deployed to rela-
tively safe areas in Hungary reported fewer expe-
riences and perceived benefits than soldiers
deployed to the more dangerous Bosnia and
Croatia. Results also showed that contextual
experiences mediated the link between the loca-
tion and the perceived benefits felt by peacekeep-
ers. Last, it appeared that women reported more
benefits as a result of deployment than male
soldiers.
If adjustment during deployment influences
postdeployment adjustment, it is important to
carefully track its evolution during the deploy-
ment and shortly before the homecoming.
Weisaeth et al. (1996) studied stress among
Swedish peacekeepers who served in South
Lebanon. A considerable proportion of soldiers
increased their consumption of alcohol during
the service term (roughly 45%). Other problems
included unemployment, higher divorce rate,
deterioration of financial status, and legal prob-
lems. However, positive outcomes were also
reported by peacekeepers. Specifically, they
believed that their stress-tolerance and self-
reliance had improved. In another relevant study,
MacDonald, Chamberlain, Long, Pereira-Laird,
and Mirfin (1998) examined mental, physical
health, and stressors reported by 277 New
Zealand peacekeepers. Results showed that at
predeployment, well-being was relatively low,
decreased further during deployment period,
increased postdeployment, and decreased again
at follow-up. Psychological distress was quite
high at predeployment, was relatively low during
the deployment period and immediately after the
deployment, and it increased sharply at follow-
up. The mean level of depression increased
steadily from pre-deployment through mid-
deployment, increased at postdeployment, and
increased further at follow-up. Results demon-
strate that the periods that most affected the men-
tal health of the personnel were predeployment
(preparation and anticipation of the deployment)
and follow-up (adjustment to an altered routine).
Postdeployment Adjustment
PTSD-Related Issues
A number of studies have identified higher levels
of PTSD in the period after soldiers return home
from peacekeeping duties. Melhum and Weisæth
(2002) investigated the predictors of PTSD
E. De Soir
95
reactions in Norwegian U.N. peacekeepers
7 years after service. About half of the veterans
reported that their alcohol consumption increased
during their stay in Lebanon. The main reasons
given for this increase were that alcohol was
cheap, easily accessible or both. Significantly
more members of the repatriated veterans
reported tension, anxiety, and stress as reasons
for the increased use of alcohol. Just 10 percent
of the subjects were found to have PTSD. Finally,
PTSD symptoms were related to both stressful
life events, and the perceived lack of meaningful-
ness in the military mission. Moreover, the more
comfortable the respondent was with U.N. ser-
vice, the fewer PTSD symptoms reported.
Increased alcohol consumption in the aftermath
of the service was likewise linked to more PTSD
symptoms.
Han and Kim (2001) examined psychiatric
symptoms reported by international peacekeep-
ing personnel in the Western Sahara Desert.
Stressors included exposure to the hot, sandy
environment and homesickness. Only 5% of
respondents complained about anxiety, and most
of them had no trouble sleeping but 8.4% com-
plained of general fatigue. Sleep difficulties were
associated with thoughts about family, work
responsibilities, and noise (air conditioner,
generator, TV, etc.). Interestingly, none of the
respondents showed signs of clinically signifi-
cant psychopathic or depressive problems.
Furthermore, no significant discrepancies in
symptoms or stress levels were noted in terms of
team site, age, mission duration, or number of
missions. MacDonald, Chamberlain, Long,
Pereira-Laird and Mirfin (1998) report only three
cases of PTSD (1%) in a sample of 277 New
Zealand Defence Force peacekeepers.
Mental Health Issues
Two studies deal specifically with this issue. In
the first study, Weisaeth et al. (1996) studied
stress among Swedish peacekeepers who served
in South Lebanon. A considerable proportion of
soldiers increased their consumption of alcohol
during the service term (roughly 45%). Other
problems included unemployment, higher
divorce rate, deterioration of financial status, and
legal prosecution. However, positive outcomes
were also reported by peacekeepers. Specifically,
they believed that their stress-tolerance and self-
reliance had been improved.
Greenberg et al. (2003) investigated the issue
of self-disclosure among a sample of 1002 peace-
keepers after return from deployment. They
found that 44% of servicemen wanted to talk
about their experience with someone, and
approximately two-thirds did. Results indicate
that women talked more than men, and those who
disclosed reported lower scores on the GHQ-12
(Goldberg, 1972), and on a measure of PTSD
symptomatology (PCL-M, Davidson et al.,
1997). Peacekeepers speaking with their spouse/
partner were more likely to be married, male, and
older. Women were more likely to have spoken to
other family members, and older personnel were
more likely to speak with military friends/peers
(deployed or not) or the chain of command.
Speaking with more persons was associated with
lower scores of both GHQ-12 and PCL-
M. Interestingly, those who spoke to medical ser-
vices had higher scores on both PCL-M and
GHQ-12 that those who did not.
Readjustment Problems: Conclusion
As should be clear by now, existing literature on
peacekeeping, peace enforcing, and combat oper-
ations shows that military personnel returning
from operational deployments may experience a
range of stress-related adjustment and mental
health problems. PTSD-related issues, as a func-
tion of the type of exposure and the characteris-
tics of the mission (boredom, frustration, combat
exposure, witnessing atrocities, length of the
deployment, etc.), organizational stressors (qual-
ity of leadership, meaning making, cohesion, pre-
dictability of return date, etc.), health problems,
and family concerns may cause significant stress
in returning troops. Considering this, it makes
sense for policy makers to include a transitional
phase between the operational theatre and the
return home for military personnel. This transition
7 Psychological Adjustment After Military Operations: The Utility of Postdeployment…
96
phase can serve as a screening tool and also
catalyst for adequate coping with the typical
homecoming challenges.
TLD as a Tool for Post Mission
Readjustment
TLD refers to the procedures allowing troops to
“unwind” or “to wash off the mission” after long-
term deployments in difficult and dangerous
operational theatres such as Iraq or Afghanistan.
The question of a possible evaluation of such
decompression programs was first raised in
Belgium in spring of 2010 by the Chief of
Defence. The literature review above makes it
clear that postoperational stress management can
be an important aspect of psychosocial support
for soldiers and their significant others. Although
other NATO countries use the term TLD, a work-
ing group of Belgian operational stress special-
ists chose to rename this transition period as an
“adaptation period”, inspired by the French “sas
d’adaptation” (literally translated as “transition
lock”). Decompression aims to achieve “a grad-
ual reduction in pressure” or “the release from
compression or stress.” The so-called “third loca-
tion” refers to a place that is neither the opera-
tional theatre nor home, somewhere in between
the deployment zone and the home front. It is a
place where a combined program of rest, relax-
ation, psychoeducation, and postmission debrief-
ing can take place. The theoretical rationale for
these programs is based upon the combat motiva-
tion literature, which holds that the morale and
effectiveness of any individual depends upon his
or her membership in a close-knit social group. It
is thought to be important to ensure reintegration
within the primary group that was exposed to
operational or combat stressors (Hacker Hughes
et al., 2008).
Decompression has been seen throughout his-
tory as time away from the warfront, being tem-
porarily away from combat, taking time for
relaxation and physical recovery (De Soir, 2011).
However, this kind of decompression or “rest and
relaxation” (R&R) did not prepare soldiers to
adapt to civilian life, and did not provide the nec-
essary time to unwind before returning to their
families. After some armed conflicts, the decom-
pression effect might have occurred somewhat by
accident. For example, Freedman (2005)
describes how troops returned from the Falklands
war by sea or by air. Interestingly, those who
sailed all the way home (a lengthy journey)
appeared to adjust better psychologically than
those who sailed only part of the journey.
Presumably, this is because the former had more
time available to “debrief” each other, to unwind
and decompress. Even if these experiences can-
not be seen as strong empirical evidence, they
now appear as a starting point in the development
of postdeployment decompression leave for sol-
diers following combat (Cobb, 1976).
Reflecting this growing awareness, a special
conference was held in Portsmouth, UK, in
order to review the existing decompression pro-
grams in Canada, the Netherlands, the United
Kingdom, and the United States (Castro,
Greenberg, & Vigneulle, 2009). Participants at
the meeting, military mental health profession-
als from a variety of NATO countries, reviewed
and compared existing TLD programs, and
sought to determine if such programs really do
lead to improvements in mental health for
returning troops. This was the first attempt to
arrive at a consensus among participating
nations on the key questions surrounding TLD
programs. Following extensive review and dis-
cussion, participants agreed that based on early
positive evidence, TLD programs should be
made available to all deploying personnel. As to
content and format, it was thought best for TLD
programs to include a combination of psycho-
education, rest, and recreation, and that there
should be plenty of mental health professionals
and chaplains or padres available for informal
interactions. TLDs should provide opportunities
and encouragement for informal discussions to
take place regarding the operational experiences
encountered during the deployment. The pro-
gram should net be viewed as one of trauma
(PTSD) or suicide prevention, although it may
reduce the sense of stigma often associated with
seeking help for mental health problems (Castro
et al., 2009).
E. De Soir
97
The concept of TLD is still quite new in
Belgium, and continues to be studied and tested.
France is also making use of TLD programs in
something of an experimental manner. The expe-
riences of an elite French unit (8ième Régiment
Parachutiste), which had been ambushed in
Afghanistan resulting in 10 fatalities, convinced
the French armed forces to expand their post mis-
sion counseling for returning troops. A TLD was
first organized somewhat “on the fly,” and took
place on a US military base in Bagram. But a
number of practical problems there convinced the
EMAT (Etat-Major de l’Armée de Terre) to fol-
low the lead of several other NATO countries,
who placed their TLD programs at a hotel resort
in Cyprus.
Although TLD programs clearly show prom-
ise, it is important to note that to our knowledge,
no study has yet provided high quality empirical
evidence that TLD is beneficial. Also, it is still
not clear whether and how much a TLD should
be linked to the nature and intensity of the opera-
tions returning soldiers experienced during
deployment. Most of the data that do exist on
TLD programs are basically satisfaction reports,
rather than hard evidence on the psychological
benefits. Countries that are considering imple-
menting TLD programs should be aware of these
limitations. At the current time there is an absence
of definitive evidence that decompression results
in improved post mission mental health out-
comes, or conversely that lack of decompression
is associated with worsening mental health.
There is a clear need for additional study.
Goals of the Decompression Program
The primary and overarching goal of decom-
pression is restore and preserve the resiliency of
soldiers after long-term deployment under diffi-
cult conditions. During deployments, a broad
range of operational stressors, to include combat
exposure, length of the mission, physical fatigue,
and separation from the family, can negatively
influence the troops’ psychological fitness.
Therefore, the goals of TLD programs (Table 7.1)
should include physical rest and recreation in a
safe environment, facilitating reintegration into
civilian and family life, promoting wellness
through relaxation and reflection, increasing rec-
ognition of potential mental health programs,
encouraging help-seeking behaviors, and reduc-
ing stigma surrounding postmission adaptation
problems. Importantly, decompression programs
should not primarily aim at the prevention of
psychiatric disorders such as PTSD or depres-
sion, or at reducing suicide. Although these may
be desirable outcomes, they should not be the
explicit aim of the program. Rather, TLD pro-
grams should be presented and seen as a reward-
ing compensation for troops after long and
difficult deployments, as well as a recognition
for the sacrifices they have made.
Key Elements in Decompression
Programs
Although existing decompression programs vary
with respect to location, duration, structure, and
content, there is nevertheless broad agreement
across NATO countries as to the key components
Table 7.1 Goals of TLD programs
Facilitating and easing the transition from combat-life
to noncombat life: reducing the stress associated with
return reintegration and readjustment in family life.
Promoting wellness and mental hygiene through rest,
relaxation, recreation, and reflection: stimulate
positive connotation about operational experience
through individual reflection and group discussion of
operational experience.
Increasing awareness of mental health symptoms and
ways to address them: provide tools to work through
difficult experiences and ways to recognize
uncommon reaction (coping with anger).
Addressing command closure: achieve closure for the
felt responsibility towards those who served.
Stimulate information exchange of operational
experience: informal mental health interventions,
during recreational activities and rest, helping the
normalization process, taking away the stigma on
help-seeking.
Reducing the stress associated with return,
reintegration and readjustment in family life: coping
with (young) children, spouses, meeting the
expectations on both sides, working on the mindset of
both sides.
7 Psychological Adjustment After Military Operations: The Utility of Postdeployment…
98
to include. Typical features of decompression
programs are (1) giving returning soldiers a short
break from the operation theatre before home-
coming; (2) psychoeducation, i.e., counseling on
coping and adaptation strategies; (3) rest and rec-
reation; (4) gradual exposure to alcohol con-
sumption; (5) some degree of choice about how
to spend time during the TLD program; and (6)
structured opportunities to share experiences and
engage in reflection on their experiences.
Location and Duration Most NATO nations
appear to agree that decompression is best car-
ried out in a third, neutral location. Therefore, a
location which is half way between the operation
theatre and the home-front is the best possible
choice. For troops returning from Afghanistan to
Europe, this could mean for example Malta,
Cyprus, or Crete. Also, the weather conditions
can play an important role and should be consid-
ered. A transition period in a cold and cloudy
country would likely be more stressful that a
sunny tourist destination.
Although Canada, France, Belgium, and the
Netherlands prefer to use hotel resort facilities,
the United States and the UK seem to prefer mil-
itary bases. This might offer a better control of
the troops and keep journalists away (instead of
letting them book rooms in the same hotel
resort). It is acceptable that soldiers prefer civil-
ian facilities and that even from the organiza-
tional point of view (simply being away from the
strictly military environment should be relax-
ing), but yet (to our knowledge) no empirical
data are available to point at the differences in
effectiveness regarding the rest and recreational
(R&R) aspect of the program.
The experiences of the Armée de Terre of
France suggest that a three-day TLD program is
the optimum. If the program is any shorter than
this, there may not be sufficient time to rest,
adapt and to recuperate, nor to carry out the
educational and social activities. Several days
are needed to adapt to a normal (holiday) envi-
ronment. However, if the TLD goes beyond
3 days, soldiers can begin to get bored and start
to looking for action again, increasing the risk
for misbehavior.
Structure TLD programs typically alternate
between planned, mandatory activities and free
time. The shift from the intense activity of mili-
tary operations to R&R should be smooth. There
should be a clear indicator provided to mark the
end of the formal operational part of the mission,
and the start of the TLD.
Similarly, the TLD structure should be quite
clear and allow for adequate rest and physical
recuperation alongside the more active and edu-
cational program ingredients. Again, the purpose
of the TLD is to facilitate recovery, reinsertion
and transition in normal life. Therefore, it is rec-
ommended that returning soldiers be exposed to
the various aspects of normal life, with plenty of
free choice of relaxation time. TLD psycholo-
gists of the French Armée de terre argue that it is
senseless to separate soldiers from civilians in the
resort where the program is carried out. Their
viewpoint is that during a TLD soldiers will act
like they would once on the home front. The best
solution thus seems to be one in which soldiers
are exposed to a structured program with a bal-
ance between mandatory elements and free
choice or elective sessions. Although the wake-
up time in the morning has to be early enough to
ensure a disciplined beginning of the day pro-
gram, it still has to be different from what it was
in the operation zone.
Canadian service members remove their com-
bat battledress, kit, and military gear before arriv-
ing in Cyprus, where they wear shorts and t-shirts.
French soldiers usually arrive in full battle dress,
but hand them over to the TLD staff upon arrival
in the hotel resort. During the TLD, they wear
their official military sports clothes, which help
them to be recognizable by both the TLD and the
hotel staff. For the French armed forces, this is an
important part of the program. Although being
allowed to rest and recuperate, the wear of offi-
cial unit colors in their sports clothes reminds
them that the TLD is really considered as “on
duty.” Their battle uniforms are laundered by per-
sonnel of the hotel resort, and they will wear
them again when returning home.
A typical TLD day starts with a late wake up
and breakfast, some mandatory session (psycho-
education session, mental relaxation, postmission
E. De Soir
99
debriefing, etc.), followed by free sports and rec-
reation, lunch, and a similar program in the after-
noon. Most nations agree that soldiers should
have some choice between different kinds of rec-
reational and sports activities, but consider the
mental health activities as mandatory. However,
some workshops might also be optional, for
example those addressing problems with young
children after the homecoming, or anger manage-
ment. Religious services should also be available
but never made mandatory. Religious services
may be even more important for units which have
experienced fatalities or severely wounded casu-
alties during the deployment.
Opportunities for Rest and Recreation
(R&R) Although most TLD programs include
rest and recreation, forced physical training
activities should be avoided. This is especially
true for group sports with a competitive edge.
The soldiers’ aggression levels, which were
functional during the deployment, are still too
high and carry risks for acting out behavior while
on the playing fields. This is also true for risky
sports such as jet-skiing, parasailing, canoeing,
etc. Because risk-taking behavior is typical for
soldiers who have been exposed to constant dan-
ger, it would be dangerous for them take part in
these activities. It would be especially sad to see
accidents with wounded casualties during the
TLD program.
Although some nations organize diverse tour-
ist activities during the TLD (e.g., France,
Netherlands), others keep soldiers busy with a
strict military regime. A French SAS de fin de
mission may begin with a relaxing boat trip dur-
ing which a band plays popular songs and sol-
diers are allowed to swim in the open sea. It may
also contain a cultural visit to an ancient Roman
mosaic site during the last day. With this cultural
activity, the French army aims at a gradual expo-
sure to normal leisure and tourist activities.
Another interesting element in the French pro-
gram is massage. Each soldier receives at least
one massage session, and everyone is examined
by an osteopathic specialist. Six months in com-
bat dress, carrying the military kit and gear, is
potentially harmful to the back and lower limbs.
The French armed forces consider it as crucial
that every soldier returns home in a relaxed mus-
cular condition.
Current TLD programs for NATO forces con-
sider access to alcohol in a safe, controlled envi-
ronment to be an important aspect of TLD,
although the degree of access to alcohol differs
varies. For some countries, such as the
Netherlands, alcohol was freely available. For
other such as the UK, the timing and amount of
alcohol was more carefully controlled. In some
cultures, alcohol is typically consumed as part of
social function or part of the “table culture” or
gastronomy, as for example France and Belgium.
During the French TLD, soldiers were allowed to
drink wine or beer with their meals starting at
7 pm, and bars closed at 1 am.
Although alcohol policies vary from country
to country, it is nevertheless clear that military
commanders are still responsible for the return-
ing soldiers. Abuse of alcohol during the TLD is
a strict disciplinary problem, and should be
treated in the same way as it would be during the
operation. Alcohol consumption during social
events or parties at the TLD should be based on
the principle of “mutual coercion mutually
agreed upon.” This means they everyone in the
TLD program agrees to control his buddy over a
reasonable and restricted use of alcohol during
the time-off, and is clearly briefed on this at the
beginning of the TLD. Together with a buddy
system in which everyone “watches the back of
someone else,” good leadership should prevent
any form of abuse. There is still some uncer-
tainty regarding how much freedom of move-
ment to allow soldiers during the TLD. Some
armies will allow their soldiers to leave the hotel
facilities, whereas other nations such as France
and Belgium prefer to restrict soldiers to the
hotel facilities.
Psychoeducational Components Although
there is variability here as well, all the current
TLD programs include form of mental health
(MH) activities. These sessions typically aim at
(1) reducing the stigma associated with MH
7 Psychological Adjustment After Military Operations: The Utility of Postdeployment…
100
support although informing soldiers on the
availability of support; (2) facilitating social
sharing and mutual support during collective
group sessions (preferably in the same groups
that operated together); (3) informing soldiers
about the normal thoughts, reactions, and emo-
tions they may experience after returning from
long term deployments; and (4) facilitating and
stimulating the normal working through and
psychological integration process. Post mission
debriefing sessions might also focus on the most
difficult or frightening parts of the tour of duty.
These sessions can vary from the well-known
protocols on psychological debriefing and do
not primarily aim at emotional disclosure and
ventilation. But they should always allow for
direct support for all the possible reactions.
These sessions are typically carried out by uni-
formed psychologists and are also valuable for
identifying those at higher risk for long-term
psychological problems.
Deciding who should Participate
in TLD Programs
There is still some debate on whether to include
in the TLD program military personnel who
had to leave the mission prematurely for psy-
chological, medical, or social reasons. Canada
does not bring injured service members back in
for the TLD, although some have requested it.
It remains unclear what benefits this might have
for the injured soldiers themselves or their
colleagues.
In contrast, the UK brings their injured sol-
diers to the TLD if they are fit to transport and do
not place an undue burden on those in Cyprus. To
date, reactions of both the individuals and the
units have been positive. Most was it as valuable
in promoting the recovery process. For the US,
allowing injured soldiers to return to the unit for
the post mission activities, starting with a TLD
activity, is not part of a general policy. For
Belgium and France, this issue has not been
raised until very recently, and is still under
consideration.
Common Problems during the TLD
A frequent problem with the organization of a
TLD is found with the policies on alcohol and
freedom of movement during this transition
phase. Restrictions on alcohol use are perceived
by many troops as “childish,” or showing a lack
of trust. During the Netherlands TLD, soldiers
receive a fixed number of tickets allowing them
to purchase alcohol. Nevertheless, some soldiers
do get drunk, and they are cared for by the TLD
staff. Canada takes a somewhat different
approach. They use a nonrestrictive policy that
also applies control measures to mitigate the
potential for misconduct. Soldiers are relied upon
to use their own judgment and any misconduct is
treated on a disciplinary basis. In contrast, the
UK does not provide alcohol during the first day
at the beach. Alcohol is later available after din-
ner, with limit of five drinks per person. The UK
seeks to prevent “tribalizations” of close-knit
units, and the related potential for clashes
between differing units as a result of alcohol
overconsumption. Belgium also follows the
French policy with respect to alcohol during the
SAS: no alcohol is permitted during the day (until
7 pm), and all hotel bars must close at 1 am sharp.
Also, there is no stocking of alcohol in the hotel
rooms.
Evaluation of Decompression
Programs
There have been some attempts to evaluate the
TLD programs of several NATO countries, but
thus far these studies have not gone beyond
assessing levels of soldier satisfaction with the
programs. There is still no hard evidence regard-
ing the mental health outcomes of TLD. What
currently exists is limited to expert opinions and
anecdotal evidence on the usefulness and success
of these adaptation programs. These subjective
reports indicate a high level of support for the
utility of TLDs.
As to the right length for a TLD, the consen-
sus view seems to be between 36 and 72 h.
E. De Soir
101
The majority of those who experienced TLD
were satisfied with the training received, includ-
ing those cases that included so-called
“BATTLEMIND” training (Castro, Hoge, &
Cox, 2006). The psychoeducational components
were reported to be satisfactory both during the
TLD and 16–24 weeks later. Soldiers with low
combat exposure report a greater degree of satis-
faction with the TLD. Leaders attitudes toward the
benefits of TLD appear to be somewhat mixed.
It is surprising that so many troops seem to be
against participation in a TLD prior to attending
the program, and yet show high levels of satisfac-
tion with it afterwards. The role of combat expo-
sure as related to the perceived usefulness of
TLDs remains largely unclear, and merits further
investigation.
Conclusions
At this early stage, the majority of NATO coun-
tries consider TLD to be a valuable component of
post mission counseling and psychosocial adjust-
ment. However, many questions remain to be
answered. Even if the TLD can be perceived as a
reward to the service members, it is important to
be sure that no additional harm is done while
bringing soldiers together and in some respect
making them talk about their experiences.
With the limited available research data cur-
rently available, it is impossible to draw scientific
conclusions about the mental health outcomes of
TLD. There may even be potential risks with
these decompression programs, comparable to
the risks associated with psychological debrief-
ing. Also, expectations might still be unreason-
ably high and military commanders might view
TLD as a panacea for all kinds of operational
problems. The utilization of TLD programs
should certainly not lead to a disinvestment in
other kinds of psychosocial or mental health sup-
port activities.
Outcome measures for TLD effectiveness thus
far have focused only on the perceived utility of
this kind of support. Here, troops who participate
largely report their satisfaction. This does not
necessarily mean mental health of soldiers
improves after 3 days on a third location. Other
outcomes besides satisfaction must be investi-
gated. These would include such mental health
symptoms of depression, stress, and trauma; rates
of domestic violence; signs of improved reinte-
gration and adaptation; cohesion and morale
indicators; cues of reduction of stigma toward
mental health; and indications of improved sleep
amount and quality. Also, reduction of risky
behaviors after deployment (e.g., alcohol and
substance abuse, aggressive driving or behavior,
mental rumination) should be included in future
research, and randomized controlled designs are
needed to determine program effectiveness.
Future studies should also be planned ahead to
allow for systematic data collection and have
clear definitions about what outcomes to mea-
sure. It is also important to establish priorities as
to whether or not the outcomes should be ori-
ented toward operational or mental health issues.
At this writing, mental health professionals
involved in TLD programs generally agree as to
the effects decompression could or should
achieve. These include improved morale,
improved relationships with family members,
reduced driving accidents, and lowered stigma
associated with seeking mental health care. Even
so, they generally agree that decompression alone
may not reduce PTSD rates, physical injury rates,
and suicide rates. Future research is needed to
better document these possible outcomes,
because decompression programs carry signifi-
cant costs and must be defended to the civilian
public and taxpayers.
Also, it may be unrealistic to provide TLD to
all personnel returning from deployment on the
basis of mission length. Ideally, the decision on
whether to include a TLD should be made after
an in-depth analysis of the context of each par-
ticular operation, based on the type of operation,
the length, conditions, and level of hardship and
risk. On the other hand, it is crucial that this deci-
sion is communicated to both the soldiers and
their families in order to avoid last minute nega-
tive reactions or counter-productive opinions and
rumors. More energy should be devoted to the
management of communications about these pro-
grams. Each nation should show its gratitude and
7 Psychological Adjustment After Military Operations: The Utility of Postdeployment…
102
recognition for the troops who have done their
duty, serving their countries and the world in
risky and arduous operations.
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7 Psychological Adjustment After Military Operations: The Utility of Postdeployment…
... Özellikle bireylerin aktüel hayatlarındaki uyum odaklı ritüeller, yas sürecinin optimal bir düzeyde yaşantılanmasında önemli bir konuma sahiptir. Bu travmatik yas sürecinde bireyin evden çıkmayıp gündelik ritüellerini askıya alarak kendisine acı veren olayları ve kişileri dissosiye ya da inkâr etmesi kısa vadede iyi bir strateji olarak değerlendirilebilmekteyken, uzun vadede ise gerçekleştirilen bu travmatik dissosiyasyon reaksiyonları bireylerin hem kendisini hem de çevresini bir bütün içerisinde algılamasına ket vurarak dissosiyatif bozukluklar ve travma sonrası stres bozukluğu gibi psikopatolojilerin ortaya çıkmasına neden olabilmektedir (De Soir, 2006, 2017Öztürk & Derin, 2020). Travmatik yaşantıların akut etkilerini minimize hale getirmeyi hedefleyen kriz psikolojisi, psikososyal destek sürecinin üç temel unsuru olduğunu vurgulamaktadır. ...
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