- Email: [email protected]
Peacekeeping
C H A P T E R
50 Peacekeeping B. Litz1, S. Maguen2, A. Tankersley3, C. Hundert3 1 2
VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA UCSF Medical School, San Francisco, CA, USA; San Francisco VA Medical Center, San Francisco, CA, USA 3 VA Boston Healthcare System, Boston, MA, USA
O U T L I N E Types of Peacekeeping Missions 401 Operation Restore Hope and Operation Continue Hope in Somalia 401 Operation Joint Endeavor and Operation Joint Guard in Bosnia-Herzegovina 402 Recently Established Peacekeeping Missions 402
Abstract The role of peacekeeping in a military context has shifted over time since the inception of the United Nations in 1945. Over the last few decades, peacekeepers have increasingly been deployed to areas with active hostilities. As a result of this shift, peacekeepers are at high risk for exposure to typical warzone stressors such as life threat, as well as stressors unique to peacekeeping missions, such as role conflicts. Despite these risks, most service members deployed on peace enforcement missions tend to adapt well and report positive outcomes. However, some peacekeepers develop mental health problems such as posttraumatic stress disorder. Moving forward, it is important to appreciate and attend to the mental health needs of service members deployed to peacekeeping missions.
TYPES OF PEACEKEEPING MISSIONS Peacekeeping has changed considerably following the inception of the United Nations (UNs) in 1945. There have been 69 peacekeeping missions since 1948, and currently there are 16 active operations throughout the world.1 Historically, the role of the military in peacekeeping operations has been that of maintaining a strictly neutral presence by overseeing peace accords between formerly warring parties. However, post-Cold War, peacekeepers have shifted to enforcing peace in the midst of active hostilities. These modern missions have placed peacekeepers into more dangerous and conflict-laden
Stress: Concepts, Cognition, Emotion, and Behavior http://dx.doi.org/10.1016/B978-0-12-800951-2.00051-0
Unique Stressors of Peacekeeping
402
Psychological and Behavioral Impact of Peacekeeping 403 Conclusions and Recommendations
404
References
404
environments. Modern missions require service members to be combat trained, yet able to model restraint and maintain neutrality. As a result, peace enforcement is one of the most stressful duties a service member can be exposed to in the modern military, and the possibility of exposure to potentially traumatic events and death has become even more likely in recent missions. For example, according to data released by the United Nations, there have been 857 fatalities due to “malicious acts” on peacekeeping missions since 1948, and 25% of those have occurred in the last decade.2 This chapter provides brief summaries of the stressors associated with peacekeeping, briefly reviews recent peacekeeping missions, summarizes the unique stressors of peacekeeping, and highlights the psychological impact of these missions.
Operation Restore Hope and Operation Continue Hope in Somalia As a result of the civil war that erupted in Somalia in 1991, humanitarian relief efforts aimed at curbing famine and the spread of disease were interrupted and sabotaged. The United Nations, with extensive support from the United States, decided to guarantee the provision of humanitarian aid as well as to enforce the peace in
401
Copyright © 2016 Elsevier Inc. All rights reserved.
402
50. PEACEKEEPING
KEY PO INTS • Peacekeeping refers to a military presence that increases the likelihood of peace and reduces the likelihood of fighting among two or more formerly warring parties. However, modern peacekeeping missions often take place in regions where hostilities are still ongoing, thereby increasing physical and psychological risk for peacekeepers. • Peacekeeping involves duties such as guarding and patrolling vulnerable areas, helping maintain crowd control, operating checkpoints, providing humanitarian assistance, and facilitating with the rebuilding of infrastructure, all of which can expose peacekeepers to potentially traumatic events. • Some peacekeepers may experience role conflict (i.e., exposure to competing demands of neutrality and restraint in the face of life threat or danger), which may lead to feelings of helplessness or frustration. Peacekeeping rules of engagement prohibit the use of weapons except in extreme circumstances, which differs from how service members are traditionally trained to handle life threat.
Somalia. During this mission, peacekeepers became peace enforcers, and the risk of exposure to potentially traumatic events grew exponentially. Although the first phase of the peacekeeping mission, Operation Reserve Hope (ORH), was a great success with regard to the provision of medical and food supplies, the mission is often considered to be a failure because Somalia continues to be at risk for the devastating effects of famine, political instability, and violence. Operation Continue Hope was initiated when ORH concluded, in May 1993. While in Somalia, US military personnel were assigned to a variety of tasks, ranging from policing duty to combat-like duty (e.g., patrols, disarming civilians). Peacekeepers were exposed to a fairly well-armed civilian population who were actively engaged in interclan war. Peacekeepers in Somalia were also subjected to acts of aggression by some Somalis, yet the strict rules of engagement sharply restricted options for protection or retaliation, creating a general sense of threat.
Operation Joint Endeavor and Operation Joint Guard in Bosnia-Herzegovina In 1991, following the declaration of independence of Slovenia and Croatia, a civil war erupted in the former Yugoslavia. The disillusion of the state gave rise to power struggles over governing control of the remaining states
and to old race-based hatreds. Horrible atrocities were perpetrated, including genocidal acts. In response, approximately 60,000 North Atlantic Treaty Organization (NATO) and US military personnel were deployed as peacekeepers. Peacekeepers in Bosnia-Herzegovina were subjected to shelling and sniper attacks and a minority of peacekeepers were also taken hostage. Some UN peacekeepers had to stand by helplessly while atrocities were taking place.
Recently Established Peacekeeping Missions Locations of recent UN peacekeeping missions include: (1) the Central African Republic (MINUSCA) since April 2014, (2) Mali (MINUSMA) since April 2013, (3) Abyei, Sudan (UNISFA) since June 2011, (4) South Sudan (UNMISS) since July 2011, (5) the Democratic Republic of the Congo (MONUSCO) since July 2010, and (6) Darfur (UNAMID) since July 2007.1
UNIQUE STRESSORS OF PEACEKEEPING Peacekeepers are at risk for exposure to stressors that are typical of a war zone (e.g., artillery fire, land mines, small arms fire, bearing witness to the aftermath of malicious violence). Even when peacekeepers are tasked with maintaining a firm peace, they are faced with the possibility of life threat. They may be fired upon as a result of a misunderstanding, accidentally in cross fire between two armed feuding parties, or during firing close, which occurs when the opponent wishes to intimidate the peacekeepers in order to keep them away from a certain area. Peacekeepers may also witness violence and atrocities committed against fellow peacekeepers and civilians as well as the malicious destruction of property. Other types of stressful experiences for peacekeepers are boredom, isolation, family separation, exhaustion, unfavorable climatic conditions, and demoralization about the mission’s efficacy. Role conflicts may also provoke additional stress in peacekeepers. For combat-trained service members from larger nations, peacekeeping duty may feel incongruent with their training. For example, peacekeepers, unlike traditional service members, are often restrained from taking offensive action in conditions of life threat. In addition, the types of defensive military structures that are commonplace in war are often not as available on peacekeeping missions due to the proximity that is required in order to provide humanitarian assistance and protection. The emphasis on proximity rather than protection creates considerable hypervigilance and arousal in peacekeepers and contributes to a general sense of fear. Peacekeepers
2. COGNITION, EMOTION, AND BEHAVIOR
PSYCHOLOGICAL AND BEHAVIORAL IMPACT OF PEACEKEEPING
who are unclear about how to respond to threats and/or who experience repeated threats of injury, with little or no opportunity for recourse, are likely to experience great anxiety, helplessness, and anguish. Furthermore, peacekeepers who are forced to suppress their frustration, fear, and anger are at risk for acting out their feelings during a mission and/or upon their return home. Roméo Dallaire, Force Commander of the UN peacekeeping force for Rwanda between 1993 and 1994, has poignantly described his unique experience of witnessing the Rwandan genocide as someone sent there to establish and maintain peace: Rwanda will never ever leave me. It’s in the pores of my body. My soul is in those hills, my spirit is with the spirits of all those people who were slaughtered and killed that I know of, and many that I didn’t know. … Fifty to sixty thousand people walking in the rain and the mud to escape being killed, and seeing a person there beside the road dying. We saw lots of them dying. And lots of those eyes still haunt me, angry eyes or innocent eyes, no laughing eyes. But the worst eyes that haunt me are the eyes of those people who were totally bewildered. They’re looking at me with my blue beret and they’re saying, ‘What in the hell happened? We were moving towards peace. You were there as the guarantor’ – their interpretation – ‘of the mandate. How come I’m dying here?’ Those eyes dominated and they’re absolutely right. How come I failed? How come my mission failed? How come as the commander who has the total responsibility – We learn that, it’s ingrained in us, because when we take responsibility it means the responsibility of life and death, of humans that we love.3
PSYCHOLOGICAL AND BEHAVIORAL IMPACT OF PEACEKEEPING Although there are many potentially traumatizing experiences and psychological conflicts associated with being a peacekeeper, the great majority of service members appear to adapt well. However, a sizeable number of peacekeepers are at risk for the development of psychopathology related to their deployment. The most frequent mental health problems associated with peacekeeping are posttraumatic stress disorder (PTSD), depression, anger and hostility problems, and alcohol abuse. Mehlum and Weisaeth reported that 7 years following service, 16% of prematurely repatriated service members from southern Lebanon met criteria for PTSD.4 Passey and Crocket found that more than 20% of the service members deployed as peacekeepers to Bosnia endorsed symptoms of PTSD and depression.5 In Litz and colleagues’ examination of US military personnel who deployed to
403
Somalia, 25% of Somalia veterans reported clinically significant psychological distress, particularly hostility and anger problems, and 8% reported clinically significant PTSD6; Dirkzwager and colleagues found similar rates of PTSD among peacekeepers who served in Yugoslavia.7 Among Kosovo peacekeepers, Maguen and colleagues found that 4% endorsed clinically significant PTSD symptoms8; Dirkzwager and colleagues found similar rates of PTSD among peacekeepers who served in Cambodia.7 Gray and colleagues found that although most follow a standard pattern of PTSD development, some peacekeepers exhibit delayed-onset PTSD after a period of minimal distress.9 Adler and colleagues examined factors that predicted PTSD in US military personnel deployed to the Bosnia peacekeeping mission and found that longer deployments and first-time deployments were associated with an increase in distress scores.10 Interestingly, the association between deployment length and distress was significant only for male service members. In a prospective study of Kosovo peacekeepers, Maguen and Litz found that preexisting stress symptoms and exposure to stressful war zone events (e.g., going on dangerous patrols) were the most robust predictors of PTSD symptoms.11 Similarly, in Litz and colleagues’ study of Somalia peacekeepers, the extent of exposure to stressful war zone events and frustrations with aspects of the peace enforcement mission (e.g., restrictive rules of engagement) predicted the severity of PTSD.12 The relationship between war zone exposure and PTSD was strongest for Somalia veterans who had high levels of frustration with the negative aspects of peacekeeping duty. Additional variables associated with PTSD symptoms reported by Dirkzwager and colleagues were feelings of powerlessness and threat, belief that the mission had become meaningless, and lack of perceived control during deployment.7 Litz and colleagues also found that cohesion and morale during deployment were negatively associated with symptoms of psychological distress and PTSD.12 However, Barnes and colleagues found that higher stress in a peacekeeping context was associated with worsening subsequent perceptions of military support.13 Thus, although organizational support may protect peacekeepers against the development of PTSD, stress symptoms can also affect the manner in which individuals perceive said support. On the other hand, Michel and colleagues found that postdeployment adversities most strongly contributed to poor mental health among Swedish peacekeepers that deployed to Bosnia.14 Peacekeeping duty can also promote positive outcomes. Dirkzwager and colleagues found that the majority of peacekeepers reported positive consequences of their deployment, with 82% reporting a broadening of their horizon and 52% reporting increased self-confidence.7 Britt, Adler, and Bartone documented that following deployment to Bosnia, many peacekeepers reported an
2. COGNITION, EMOTION, AND BEHAVIOR
404
50. PEACEKEEPING
increase in political understanding, stress tolerance, and professional qualifications.15 They also found that service members who identified more closely with the role of peacekeeper and who believed their assignment to be important were more likely to report a perceived benefit from their peacekeeping experience and were less likely to report burnout and adverse psychological consequences. Finally, the researchers noted that service members who reported benefits as a result of the deployment had at least some exposure to the physical damage caused to the local civilians and service members from other nations.
CONCLUSIONS AND RECOMMENDATIONS Even in the context of conflicts that arise as a result of counterterrorism, peacekeeping and peace enforcement missions will thankfully outnumber wars internationally. Although the psychological casualties resulting from peacekeeping stress do not compare to combat, it is important to appreciate the mental health needs of service members who return from peacekeeping missions, particularly ones that entail unforeseen escalations in hostilities. Peacekeepers may experience a wide range of potentially traumatic events and numerous uniquely stressful experiences. Peacekeeping, and especially peace enforcement, missions should include provisions for secondary prevention interventions for those service members most at risk for chronic mental health problems following homecoming.
References 1. United Nations. Current peacekeeping operations. http://www.un.org/ en/peacekeeping/operations/current.shtml; Accessed 10.02.15.
2. United Nations. Fatalities by year and incident type. http://www.un. org/en/peacekeeping/fatalities/documents/stats_5.pdf. Published January 31, 2015. Updated February 9, 2015. Accessed 10.02.15. 3. Interview: General Romeo Dallaire. PBS Frontline website. http:// www.pbs.org/wgbh/pages/frontline/shows/ghosts/interviews/ dallaire.html. Published April 1, 2004. Accessed 18.02.15. 4. Mehlum L, Weisæth L. Predictors of posttraumatic stress reactions in Norwegian U.N. peacekeepers 7 years after service. J Trauma Stress. 2002;15(1):17–26. 5. Passey G, Crocket D. Psychological consequences of Canadian UN peacekeeping in Croatia and Bosnia. In: Paper Presented at 7th Annual Meeting of the International Society for Traumatic Stress Studies; 1995; Boston, MA; 1995. 6. Litz B, Orsillo S, Friedman M, Ehlich P, Batres A. Posttraumatic stress disorder associated with peacekeeping duty in Somalia for U.S. military personnel. Am J Psychiatry. 1997;154(2):178–184. 7. Dirkzwager A, Bramsen I, van der Ploeg H. Factors associated with posttraumatic stress among peacekeeping soldiers. Anxiety Stress Coping. 2005;18(1):37–51. 8. Maguen S, Litz B, Wang J, Cook M. The stressors and demands of peacekeeping in Kosovo: predictors of mental health response. Mil Med. 2004;169(3):198–206. 9. Gray M, Bolton E, Litz B. A longitudinal analysis of PTSD symptom course: delayed-onset PTSD in Somalia peacekeepers. J Consult Clin Psychol. 2004;72(5):909–913. 10. Adler A, Huffman A, Bliese P, Castro C. The impact of deployment length and experience on the well-being of male and female soldiers. J Occup Health Psychol. 2005;10(2):121–137. 11. Maguen S, Litz B. Predictors of morale in U.S. peacekeepers. J Appl Soc Psychol. 2006;36(4):820–836. 12. Litz B, King L, King D, Orsillo S, Friedman M. Warriors as peacekeepers: features of the Somalia experience and PTSD. J Consult Clin Psychol. 1997;65(6):1001–1010. 13. Barnes J, Nickerson A, Adler A, Litz B. Perceived military organizational support and peacekeeper distress: a longitudinal investigation. Psychol Serv. 2013;10(2):177–185. 14. Michel P, Lundin T, Larsson G. Stress reactions among Swedish peacekeeping soldiers serving in Bosnia: a longitudinal study. J Trauma Stress. 2003;16(6):589–593. 15. Britt T, Adler A, Bartone P. Deriving benefits from stressful events: the role of engagement in meaningful work and hardiness. J Occup Health Psychol. 2001;6(1):53–63.
2. COGNITION, EMOTION, AND BEHAVIOR
50 Peacekeeping B. Litz1, S. Maguen2, A. Tankersley3, C. Hundert3 1 2
VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA UCSF Medical School, San Francisco, CA, USA; San Francisco VA Medical Center, San Francisco, CA, USA 3 VA Boston Healthcare System, Boston, MA, USA
O U T L I N E Types of Peacekeeping Missions 401 Operation Restore Hope and Operation Continue Hope in Somalia 401 Operation Joint Endeavor and Operation Joint Guard in Bosnia-Herzegovina 402 Recently Established Peacekeeping Missions 402
Abstract The role of peacekeeping in a military context has shifted over time since the inception of the United Nations in 1945. Over the last few decades, peacekeepers have increasingly been deployed to areas with active hostilities. As a result of this shift, peacekeepers are at high risk for exposure to typical warzone stressors such as life threat, as well as stressors unique to peacekeeping missions, such as role conflicts. Despite these risks, most service members deployed on peace enforcement missions tend to adapt well and report positive outcomes. However, some peacekeepers develop mental health problems such as posttraumatic stress disorder. Moving forward, it is important to appreciate and attend to the mental health needs of service members deployed to peacekeeping missions.
TYPES OF PEACEKEEPING MISSIONS Peacekeeping has changed considerably following the inception of the United Nations (UNs) in 1945. There have been 69 peacekeeping missions since 1948, and currently there are 16 active operations throughout the world.1 Historically, the role of the military in peacekeeping operations has been that of maintaining a strictly neutral presence by overseeing peace accords between formerly warring parties. However, post-Cold War, peacekeepers have shifted to enforcing peace in the midst of active hostilities. These modern missions have placed peacekeepers into more dangerous and conflict-laden
Stress: Concepts, Cognition, Emotion, and Behavior http://dx.doi.org/10.1016/B978-0-12-800951-2.00051-0
Unique Stressors of Peacekeeping
402
Psychological and Behavioral Impact of Peacekeeping 403 Conclusions and Recommendations
404
References
404
environments. Modern missions require service members to be combat trained, yet able to model restraint and maintain neutrality. As a result, peace enforcement is one of the most stressful duties a service member can be exposed to in the modern military, and the possibility of exposure to potentially traumatic events and death has become even more likely in recent missions. For example, according to data released by the United Nations, there have been 857 fatalities due to “malicious acts” on peacekeeping missions since 1948, and 25% of those have occurred in the last decade.2 This chapter provides brief summaries of the stressors associated with peacekeeping, briefly reviews recent peacekeeping missions, summarizes the unique stressors of peacekeeping, and highlights the psychological impact of these missions.
Operation Restore Hope and Operation Continue Hope in Somalia As a result of the civil war that erupted in Somalia in 1991, humanitarian relief efforts aimed at curbing famine and the spread of disease were interrupted and sabotaged. The United Nations, with extensive support from the United States, decided to guarantee the provision of humanitarian aid as well as to enforce the peace in
401
Copyright © 2016 Elsevier Inc. All rights reserved.
402
50. PEACEKEEPING
KEY PO INTS • Peacekeeping refers to a military presence that increases the likelihood of peace and reduces the likelihood of fighting among two or more formerly warring parties. However, modern peacekeeping missions often take place in regions where hostilities are still ongoing, thereby increasing physical and psychological risk for peacekeepers. • Peacekeeping involves duties such as guarding and patrolling vulnerable areas, helping maintain crowd control, operating checkpoints, providing humanitarian assistance, and facilitating with the rebuilding of infrastructure, all of which can expose peacekeepers to potentially traumatic events. • Some peacekeepers may experience role conflict (i.e., exposure to competing demands of neutrality and restraint in the face of life threat or danger), which may lead to feelings of helplessness or frustration. Peacekeeping rules of engagement prohibit the use of weapons except in extreme circumstances, which differs from how service members are traditionally trained to handle life threat.
Somalia. During this mission, peacekeepers became peace enforcers, and the risk of exposure to potentially traumatic events grew exponentially. Although the first phase of the peacekeeping mission, Operation Reserve Hope (ORH), was a great success with regard to the provision of medical and food supplies, the mission is often considered to be a failure because Somalia continues to be at risk for the devastating effects of famine, political instability, and violence. Operation Continue Hope was initiated when ORH concluded, in May 1993. While in Somalia, US military personnel were assigned to a variety of tasks, ranging from policing duty to combat-like duty (e.g., patrols, disarming civilians). Peacekeepers were exposed to a fairly well-armed civilian population who were actively engaged in interclan war. Peacekeepers in Somalia were also subjected to acts of aggression by some Somalis, yet the strict rules of engagement sharply restricted options for protection or retaliation, creating a general sense of threat.
Operation Joint Endeavor and Operation Joint Guard in Bosnia-Herzegovina In 1991, following the declaration of independence of Slovenia and Croatia, a civil war erupted in the former Yugoslavia. The disillusion of the state gave rise to power struggles over governing control of the remaining states
and to old race-based hatreds. Horrible atrocities were perpetrated, including genocidal acts. In response, approximately 60,000 North Atlantic Treaty Organization (NATO) and US military personnel were deployed as peacekeepers. Peacekeepers in Bosnia-Herzegovina were subjected to shelling and sniper attacks and a minority of peacekeepers were also taken hostage. Some UN peacekeepers had to stand by helplessly while atrocities were taking place.
Recently Established Peacekeeping Missions Locations of recent UN peacekeeping missions include: (1) the Central African Republic (MINUSCA) since April 2014, (2) Mali (MINUSMA) since April 2013, (3) Abyei, Sudan (UNISFA) since June 2011, (4) South Sudan (UNMISS) since July 2011, (5) the Democratic Republic of the Congo (MONUSCO) since July 2010, and (6) Darfur (UNAMID) since July 2007.1
UNIQUE STRESSORS OF PEACEKEEPING Peacekeepers are at risk for exposure to stressors that are typical of a war zone (e.g., artillery fire, land mines, small arms fire, bearing witness to the aftermath of malicious violence). Even when peacekeepers are tasked with maintaining a firm peace, they are faced with the possibility of life threat. They may be fired upon as a result of a misunderstanding, accidentally in cross fire between two armed feuding parties, or during firing close, which occurs when the opponent wishes to intimidate the peacekeepers in order to keep them away from a certain area. Peacekeepers may also witness violence and atrocities committed against fellow peacekeepers and civilians as well as the malicious destruction of property. Other types of stressful experiences for peacekeepers are boredom, isolation, family separation, exhaustion, unfavorable climatic conditions, and demoralization about the mission’s efficacy. Role conflicts may also provoke additional stress in peacekeepers. For combat-trained service members from larger nations, peacekeeping duty may feel incongruent with their training. For example, peacekeepers, unlike traditional service members, are often restrained from taking offensive action in conditions of life threat. In addition, the types of defensive military structures that are commonplace in war are often not as available on peacekeeping missions due to the proximity that is required in order to provide humanitarian assistance and protection. The emphasis on proximity rather than protection creates considerable hypervigilance and arousal in peacekeepers and contributes to a general sense of fear. Peacekeepers
2. COGNITION, EMOTION, AND BEHAVIOR
PSYCHOLOGICAL AND BEHAVIORAL IMPACT OF PEACEKEEPING
who are unclear about how to respond to threats and/or who experience repeated threats of injury, with little or no opportunity for recourse, are likely to experience great anxiety, helplessness, and anguish. Furthermore, peacekeepers who are forced to suppress their frustration, fear, and anger are at risk for acting out their feelings during a mission and/or upon their return home. Roméo Dallaire, Force Commander of the UN peacekeeping force for Rwanda between 1993 and 1994, has poignantly described his unique experience of witnessing the Rwandan genocide as someone sent there to establish and maintain peace: Rwanda will never ever leave me. It’s in the pores of my body. My soul is in those hills, my spirit is with the spirits of all those people who were slaughtered and killed that I know of, and many that I didn’t know. … Fifty to sixty thousand people walking in the rain and the mud to escape being killed, and seeing a person there beside the road dying. We saw lots of them dying. And lots of those eyes still haunt me, angry eyes or innocent eyes, no laughing eyes. But the worst eyes that haunt me are the eyes of those people who were totally bewildered. They’re looking at me with my blue beret and they’re saying, ‘What in the hell happened? We were moving towards peace. You were there as the guarantor’ – their interpretation – ‘of the mandate. How come I’m dying here?’ Those eyes dominated and they’re absolutely right. How come I failed? How come my mission failed? How come as the commander who has the total responsibility – We learn that, it’s ingrained in us, because when we take responsibility it means the responsibility of life and death, of humans that we love.3
PSYCHOLOGICAL AND BEHAVIORAL IMPACT OF PEACEKEEPING Although there are many potentially traumatizing experiences and psychological conflicts associated with being a peacekeeper, the great majority of service members appear to adapt well. However, a sizeable number of peacekeepers are at risk for the development of psychopathology related to their deployment. The most frequent mental health problems associated with peacekeeping are posttraumatic stress disorder (PTSD), depression, anger and hostility problems, and alcohol abuse. Mehlum and Weisaeth reported that 7 years following service, 16% of prematurely repatriated service members from southern Lebanon met criteria for PTSD.4 Passey and Crocket found that more than 20% of the service members deployed as peacekeepers to Bosnia endorsed symptoms of PTSD and depression.5 In Litz and colleagues’ examination of US military personnel who deployed to
403
Somalia, 25% of Somalia veterans reported clinically significant psychological distress, particularly hostility and anger problems, and 8% reported clinically significant PTSD6; Dirkzwager and colleagues found similar rates of PTSD among peacekeepers who served in Yugoslavia.7 Among Kosovo peacekeepers, Maguen and colleagues found that 4% endorsed clinically significant PTSD symptoms8; Dirkzwager and colleagues found similar rates of PTSD among peacekeepers who served in Cambodia.7 Gray and colleagues found that although most follow a standard pattern of PTSD development, some peacekeepers exhibit delayed-onset PTSD after a period of minimal distress.9 Adler and colleagues examined factors that predicted PTSD in US military personnel deployed to the Bosnia peacekeeping mission and found that longer deployments and first-time deployments were associated with an increase in distress scores.10 Interestingly, the association between deployment length and distress was significant only for male service members. In a prospective study of Kosovo peacekeepers, Maguen and Litz found that preexisting stress symptoms and exposure to stressful war zone events (e.g., going on dangerous patrols) were the most robust predictors of PTSD symptoms.11 Similarly, in Litz and colleagues’ study of Somalia peacekeepers, the extent of exposure to stressful war zone events and frustrations with aspects of the peace enforcement mission (e.g., restrictive rules of engagement) predicted the severity of PTSD.12 The relationship between war zone exposure and PTSD was strongest for Somalia veterans who had high levels of frustration with the negative aspects of peacekeeping duty. Additional variables associated with PTSD symptoms reported by Dirkzwager and colleagues were feelings of powerlessness and threat, belief that the mission had become meaningless, and lack of perceived control during deployment.7 Litz and colleagues also found that cohesion and morale during deployment were negatively associated with symptoms of psychological distress and PTSD.12 However, Barnes and colleagues found that higher stress in a peacekeeping context was associated with worsening subsequent perceptions of military support.13 Thus, although organizational support may protect peacekeepers against the development of PTSD, stress symptoms can also affect the manner in which individuals perceive said support. On the other hand, Michel and colleagues found that postdeployment adversities most strongly contributed to poor mental health among Swedish peacekeepers that deployed to Bosnia.14 Peacekeeping duty can also promote positive outcomes. Dirkzwager and colleagues found that the majority of peacekeepers reported positive consequences of their deployment, with 82% reporting a broadening of their horizon and 52% reporting increased self-confidence.7 Britt, Adler, and Bartone documented that following deployment to Bosnia, many peacekeepers reported an
2. COGNITION, EMOTION, AND BEHAVIOR
404
50. PEACEKEEPING
increase in political understanding, stress tolerance, and professional qualifications.15 They also found that service members who identified more closely with the role of peacekeeper and who believed their assignment to be important were more likely to report a perceived benefit from their peacekeeping experience and were less likely to report burnout and adverse psychological consequences. Finally, the researchers noted that service members who reported benefits as a result of the deployment had at least some exposure to the physical damage caused to the local civilians and service members from other nations.
CONCLUSIONS AND RECOMMENDATIONS Even in the context of conflicts that arise as a result of counterterrorism, peacekeeping and peace enforcement missions will thankfully outnumber wars internationally. Although the psychological casualties resulting from peacekeeping stress do not compare to combat, it is important to appreciate the mental health needs of service members who return from peacekeeping missions, particularly ones that entail unforeseen escalations in hostilities. Peacekeepers may experience a wide range of potentially traumatic events and numerous uniquely stressful experiences. Peacekeeping, and especially peace enforcement, missions should include provisions for secondary prevention interventions for those service members most at risk for chronic mental health problems following homecoming.
References 1. United Nations. Current peacekeeping operations. http://www.un.org/ en/peacekeeping/operations/current.shtml; Accessed 10.02.15.
2. United Nations. Fatalities by year and incident type. http://www.un. org/en/peacekeeping/fatalities/documents/stats_5.pdf. Published January 31, 2015. Updated February 9, 2015. Accessed 10.02.15. 3. Interview: General Romeo Dallaire. PBS Frontline website. http:// www.pbs.org/wgbh/pages/frontline/shows/ghosts/interviews/ dallaire.html. Published April 1, 2004. Accessed 18.02.15. 4. Mehlum L, Weisæth L. Predictors of posttraumatic stress reactions in Norwegian U.N. peacekeepers 7 years after service. J Trauma Stress. 2002;15(1):17–26. 5. Passey G, Crocket D. Psychological consequences of Canadian UN peacekeeping in Croatia and Bosnia. In: Paper Presented at 7th Annual Meeting of the International Society for Traumatic Stress Studies; 1995; Boston, MA; 1995. 6. Litz B, Orsillo S, Friedman M, Ehlich P, Batres A. Posttraumatic stress disorder associated with peacekeeping duty in Somalia for U.S. military personnel. Am J Psychiatry. 1997;154(2):178–184. 7. Dirkzwager A, Bramsen I, van der Ploeg H. Factors associated with posttraumatic stress among peacekeeping soldiers. Anxiety Stress Coping. 2005;18(1):37–51. 8. Maguen S, Litz B, Wang J, Cook M. The stressors and demands of peacekeeping in Kosovo: predictors of mental health response. Mil Med. 2004;169(3):198–206. 9. Gray M, Bolton E, Litz B. A longitudinal analysis of PTSD symptom course: delayed-onset PTSD in Somalia peacekeepers. J Consult Clin Psychol. 2004;72(5):909–913. 10. Adler A, Huffman A, Bliese P, Castro C. The impact of deployment length and experience on the well-being of male and female soldiers. J Occup Health Psychol. 2005;10(2):121–137. 11. Maguen S, Litz B. Predictors of morale in U.S. peacekeepers. J Appl Soc Psychol. 2006;36(4):820–836. 12. Litz B, King L, King D, Orsillo S, Friedman M. Warriors as peacekeepers: features of the Somalia experience and PTSD. J Consult Clin Psychol. 1997;65(6):1001–1010. 13. Barnes J, Nickerson A, Adler A, Litz B. Perceived military organizational support and peacekeeper distress: a longitudinal investigation. Psychol Serv. 2013;10(2):177–185. 14. Michel P, Lundin T, Larsson G. Stress reactions among Swedish peacekeeping soldiers serving in Bosnia: a longitudinal study. J Trauma Stress. 2003;16(6):589–593. 15. Britt T, Adler A, Bartone P. Deriving benefits from stressful events: the role of engagement in meaningful work and hardiness. J Occup Health Psychol. 2001;6(1):53–63.
2. COGNITION, EMOTION, AND BEHAVIOR