USEFULNESS OF ONE DAY PSYCHOEDUCATIONAL INTERVENTION FOR

MANAGING STRESS AMONG PAKISTANI SOLDIERS DEPLOYED AT SIACHIN

Munsif Ali*, Malik Wajid Ali**, Mowadat Hussain Rana***

Department of Mental Health Combined Military Hospital, Skardu*, Department of Mental

Health Combined Military Hospital Quetta**, Armed Forces Institute of Mental Health,

Rawalpindi***.

ABSTRACT

Background: This study is based on assessing the effectiveness of a one day psycho-

educational program delivered to troops deployed at high altitude.

Duration of the Study: 06 months from Oct 12th 2010 to Mar 15th 2011.

Study Design: Quasi-experimental

Material and Methods: A total of 120 troops selected for the study found to be stressed on a

75 stem stress questionnaire were included in the study. A one day psycho-educational package

of stress management was delivered to soldiers. Soldiers were reassessed after six months for the

benefits of a one day workshop on the basis of stress questionnaire.

Results: Out of 120 troops selected for the study all were males 120/120 (100 %). Mean age

was 21-30 years. Average service of the soldiers was 10 years. 71.7 % soldiers were having basic

education up to matric. 83 soldiers were found to have significantly reduced stress scores when

reassessed six months after the workshop.

Conclusions: It is concluded that a one day psycho-educational program of stress management

is effective in reducing stress among soldiers.

Keywords: Combat Stress, High Altitude, Psycho-education, Stress Management, Relaxation

Techniques.

INTRODUCTION:

Stress is defined as an imbalance or mismatch between environmental demands and the person’s

perceived coping resources. Empirical studies increasingly assess and address potentially adverse

psychological health outcomes from the stress of military operations and deployment, but no

standards yet exist for interventions applied to troops serving at high altitude [1]. Military life is

full of hassles, deadlines, frustrations and demands. A certain degree of stress is necessary to

make us live an active and productive life. It is only when it exceeds the individual stress

tolerance threshold level that it affects our psycho-biological system, which, if left unattended,

sooner or later manifests in the form of one or more multiple psychobiological diseases. Stress

can contribute to errors in judgment and performance, reducing operational effectiveness.

Serving at high altitude particularly raises psychiatric morbidity. Psychiatry's involvement with

soldiers experiencing psychological stress resulting from combat experience has been reported

for many years (Zajtchuk, 1995). It has been demonstrated that a myriad of diagnosis to include

depression, anxiety, somatoform, adjustment disorders and psychotic behaviors also emerge

(Wain et al., 1996, 2005a). Research studies have reported stressful effects of high altitude on

military personnel and found that altitudes greater than 3000m adversely affect physiological and

psychological well-being, mental processes, senses, sleep, and physical work capacity [2],[3].

Combat and Operational Stress Reactions are expected and predictable emotional, intellectual,

physical, and behavioral reactions from exposure to stressful event(s). COSR are not restricted to

combat operations [4]. Such reactions may occur as the result of combat like conditions that are

present throughout the entire spectrum of military operations to include: training, all phases of

the deployment cycle, peacekeeping missions, humanitarian missions, stability and

reconstruction, and government support missions [5]. Combat stress reaction is an important

vulnerability marker. Veterans with combat stress reaction were 6.6 times more likely to develop

posttraumatic stress disorder (PTSD). Thus, the development of training programs that

successfully prepares personnel for the psychological rigors of operations, in addition to the

physical and technical demand, are important for operational effectiveness and maintaining the

well-being of individual military personnel. In the U.S. Army, members of combat operational

stress control (COSC) units have unique skills to assist soldiers and their families not only

throughout all phases of a deployment, but also throughout a soldier's entire career [6]. The aim

of the study is to determine the effectiveness of a one day psycho-educational workshop on

improving the symptoms of stress.

MATERIAL AND METHODS:

This is a quasi-experimental study carried out at Combined Military Hospital Skardu

among soldiers deployed at Siachin. Duration of study was from Oct 12 th 2010 to Mar 15th 2011.

The total sample (n-120) consisted of active duty servicemen of 17-55 years. They were

randomly selected out of the total 250 healthy soldiers who scored more than 70 on the stress

questionnaire. These soldiers had been serving at an altitude of > 14000 ft for more than six

months. Subjects were divided in three groups each group consisting of 40 individuals (three

separate training sessions were conducted due to lack of space for all 120 subjects). Selection for

inclusion in a particular group was made randomly. Informed consent was taken from all

soldiers. Exclusion criteria included current or past history of medical illness or psychiatric

disorders. We used an indigenous stress questionnaire for measuring stress levels. The

questionnaire consists of 75 stems. Each stem asks about a particular body symptom of stress and

has a scoring ranging from 0 to 4 where zero indicate if a symptom has never occurred while

four is when it is regularly occurring. Stress levels are thus divided in to mild, moderate and

severe based on end scoring. The stress questionnaire was validated by translating into Urdu and

retranslating in to English and then again in Urdu. Those scoring above 70 (a cut off score of

stress considered to be above average and such individuals are advised to learn active coping

strategies to manage their stress) were provided with a one day psycho-educational workshop on

stress including the learning and practicing of relaxation techniques in the form of deep breathing

and progressive muscle relaxation. Copies of a stress manual and an Urdu translation of stress

management were also distributed among all the troops. Stress questionnaire was used to assess

the soldier’s pre and post intervention scores of stress. The workshops started from 9 in the

morning and concluded at 3 in noon. Soldiers learned relaxation techniques in an adequate

manner during the workshop and practiced it at least five times. All soldiers were advised to

practice relaxation daily. Three months after the workshop all the soldiers were again assessed

for their stress. This time the score was significantly low which clearly showed that a one day

interventional program for managing stress was effective. The data obtained was subjected to

statistical analysis using SPSS (Ver. 13). P < 0.05 was considered significant.

RESULTS:

A total of 120 soldiers were subjected to the study and all of them were males. After a one day

workshop upon reassessment 83 of the study subjects were found to have reduced stress scores

which is a significant finding. The mean of stress scores before the workshop was 79.83 %

( SD∑9.21) while it dropped to 20.57 %( SD∑3.25) in 83 subjects three months after the

workshop was conducted. 24.2 % soldiers were having 15 to 20 years of age, 53.3 % between 21

and 30 years, 13.3 % 31 to 40 years, 3.3% 41 to 50 years and 2.5% more than 50 years. The

mean age of the study subjects was 32 years. For other variables i.e education, marital status and

service see table. T-test was applied to evaluate the impact of the psycho-educational

intervention on stress scores both before and after the workshop. There was a statistically

significant decrease (P Value <0.05) in stress scores from pre- to post-workshop.

DISCUSSION:

Soldiers in a combat zone are subjected to multiple stressors [7]. Although persons with

combat stress reaction may recover, combat stress reaction often crystallizes into chronic

posttraumatic stress disorder (PTSD) [8]. A variety of prevention and treatment approaches have

been used including combat stress control; outpatient therapy; exposure therapy; and brief

behavioral health consultation [9]. The most common concepts used for treating combat stress

reactions in deployed settings are the BICEPS, PIES, and PIE principles [10]. BICEPS is an

acronym for management of combat stress reactions using six principles: brevity (in-patient

treatment usually lasts less than 72 hours); immediacy (treat as soon as symptoms are evident);

centrality (treat in a centralized Combat Stress Control [CSC] unit separate from but near a

medical unit); expectancy (expect that casualties will recover and return to duty in the deployed

location); proximity (treatment at or as near the battle front as possible); and simplicity (use of

approaches such as rest, food, hygiene, and reassurance) [11]. Brief early front line interventions

have the potential to be effective with at-risk occupational groups [12]. The PIES (proximity,

immediacy, expectancy, and simplicity) and PIE approaches are similar except that they are

limited to three or four of above principles [13]. A study using found Spiritually Based Group

Intervention for Combat Veterans with Posttraumatic Stress Disorder to be moderately effective

[14]. Psychological inoculation (PI), was found to be partly beneficial for troops [15]. Prolonged

exposure therapy was effective in significantly reducing PTSD symptoms [16]. A pilot program

showed that family stress interventions including structured reading and social skills training

exercises proved effective with soldiers and their families [17]. The 2-day program's

psychoeducational restorative program showed reduced stress levels after the program was

implemented [18]. Psychological debriefing was found to lack significant benefits [19]. Stress

Gym, an online CBT-based self-help intervention has been found effective for managing stress

and demonstrates the intended goal of reducing stress. Self-management cognitive behavior

therapy may be a way of delivering effective treatment to large numbers with unmet needs and

barriers to care [20, 21]. Interventions designed to bolster unit support, resilience, and

postdeployment support may help protect against traumatic stress and depressive symptoms, and

improve psychosocial functioning in veterans [22]. Few studies have evaluated the effectiveness

of mental health treatments for the combat stress reactions of military service members treated in

deployed locations [23]. Anger management interventions with individual and group counseling

were found to have preventive role []. Research has shown that military mental health providers

should apply both traditional and novel principles of stress control[]. Behavioral health treatment

and prevention activities are a crucial part of the medical support provided to troops in a harsh

environment, serve as force multipliers and help conserve the fighting strength of combat

troops[]. Families overcoming under stress (FOCUS), a family-centered evidence-informed

resiliency training program developed at University of California, Los Angeles and Harvard

Medical School, has been found to be effective [24]. There are no local studies specially those

conducted on troops at high altitude. Nevertheless, the significant changes between pre- and

post-treatment stress scores provide preliminary data to support the utility of the 1-day program

and its benefits for troops suffering from deployment-related stress. During the three months

period participitants of the study remained at their respective posts at high altitude, therefore

improvement in their scores was mainly attributed to psychoeducational training imparted.

LIMITATIONS OF THE STUDY:

The study has several clear limitations, including absence of controls, small sample, and

lack of follow-up data after program completion. Because of these reasons the findings cannot be

generalized. It is a study conducted for a short duration and therefore long term outcome need to

be confirmed.

CONCLUSIONS:

The one day group psychoeducational program for stress management was found to be useful.

Mental health professionals can provide selective interventions targeted to a unit or Soldier

whose risk of stress is higher than average. In addition they can carry out Unit Assessments

during predeployment. The Department of Mental Health at Combined Military Hospitals of

Gilgit and Skardu can provide such services by arranging and conducting stress management

workshop and by collecting/interpreting data which will aid prompt diagnosis and management

near to deployed soldiers thus ensuring high morale and optimal operational performance of

soldiers at high altitude. More such studies are needed to prove the effectiveness of such

programs.

RECOMMENDATIONS:

Recommendations for combat stress reactions in future are made based upon the results of our

study. The results underscore the need to tailor interventions and undertake trainings to address

combat stress effectively and to develop theoretically sophisticated, evidence-based knowledge

to identify service members at risk of problematic stress related issues. Army doctors performing

duties at the front should be an important element of such training activities. The focus should be

on screening, early prevention, and treatment implemented before, during and after deployment

of troops in high altitude terrain. Therefore more mental health professionals (Psychiatrists,

Psychologists, and Social Workers) will be needed to achieve this aim. Similarly stress

management trainings should be regularly conducted and should encourage maximum

participation of General Duty Medical Officers and unit leaders including junior leaders. The

need for establishing trauma psychiatric services in armed forces was felt long before [25] and

now it is a reality in the form of Centre for Trauma Research and Psychosocial Interventions at

the Armed Forces Institute of Mental Health (AFIMH). The centre is serving survivors of

psychotrauma throughout the country both army personnel and civil population. Further research

is needed to test the effects of psychoeducational interventions for managing stress reactions

among troops.

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Table; Three variables; Education, Marital status and Service.

Education Marital Status ServiceFrequency Percent Frequency Percent Frequency Percent

Middle

4 3.3 Married 79 65.8 1-10 Years

103 85.8

Matric 86 71.7 Unmarried 41 34.2 11-20 Years

14 11.7

FA 6 5.0 > 20 Years

3 2.5

BA 23 19.2

MA 1 .8

Total 120 100.0 Total 120 100.0 Total 120 100.0