USEFULNESS OF ONE DAY PSYCHOEDUCATIONAL INTERVENTION FOR

MANAGING STRESS AMONG PAKISTANI SOLDIERS DEPLOYED AT SIACHIN

Munsif Ali*, Malik a!i" Ali**, M#$a"a% Hussain Rana***
Department of Mental Health Combined Military Hospital, Skardu*, Department of Mental
Health Combined Military Hospital Quetta**, Armed Forces Institute of Mental Health,
a!alpindi***"
A&STRACT
#ack$round% &his study is based on assessin$ the effecti'eness of a one day psycho(
educational pro$ram deli'ered to troops deployed at hi$h altitude"
Duration of the Study% )* months from +ct ,-
th
-),) to Mar ,.
th
-),,"
Study Desi$n% Quasi(e/perimental
Material and Methods% A total of ,-) troops selected for the study found to be stressed on a
0. stem stress 1uestionnaire !ere included in the study" A one day psycho(educational packa$e
of stress mana$ement !as deli'ered to soldiers" Soldiers !ere reassessed after si/ months for the
benefits of a one day !orkshop on the basis of stress 1uestionnaire"
esults% +ut of ,-) troops selected for the study all !ere males ,-)2,-) 3,)) 45" Mean a$e
!as -,(6) years" A'era$e ser'ice of the soldiers !as ,) years" 0,"0 4 soldiers !ere ha'in$ basic
education up to matric" 76 soldiers !ere found to ha'e si$nificantly reduced stress scores !hen
reassessed si/ months after the !orkshop"
Conclusions% It is concluded that a one day psycho(educational pro$ram of stress mana$ement
is effecti'e in reducin$ stress amon$ soldiers"
8ey!ords% Combat Stress, Hi$h Altitude, 9sycho(education, Stress Mana$ement, ela/ation
&echni1ues"
INTRODUCTION'
Stress is defined as an imbalance or mismatch bet!een en'ironmental demands and the person:s
percei'ed copin$ resources" ;mpirical studies increasin$ly assess and address potentially ad'erse
psycholo$ical health outcomes from the stress of military operations and deployment, but no
standards yet e/ist for inter'entions applied to troops ser'in$ at hi$h altitude <,=" Military life is
full of hassles, deadlines, frustrations and demands" A certain de$ree of stress is necessary to
make us li'e an acti'e and producti'e life" It is only !hen it e/ceeds the indi'idual stress
tolerance threshold le'el that it affects our psycho(biolo$ical system, !hich, if left unattended,
sooner or later manifests in the form of one or more multiple psychobiolo$ical diseases" Stress
can contribute to errors in >ud$ment and performance, reducin$ operational effecti'eness"
Ser'in$ at hi$h altitude particularly raises psychiatric morbidity" 9sychiatry?s in'ol'ement !ith
soldiers e/periencin$ psycholo$ical stress resultin$ from combat e/perience has been reported
for many years 3@a>tchuk, ,AA.5" It has been demonstrated that a myriad of dia$nosis to include
depression, an/iety, somatoform, ad>ustment disorders and psychotic beha'iors also emer$e
3Bain et al", ,AA*, -)).a5" esearch studies ha'e reported stressful effects of hi$h altitude on
military personnel and found that altitudes $reater than 6)))m ad'ersely affect physiolo$ical and
psycholo$ical !ell(bein$, mental processes, senses, sleep, and physical !ork capacity <-=,<6="
Combat and +perational Stress eactions are e/pected and predictable emotional, intellectual,
physical, and beha'ioral reactions from e/posure to stressful e'ent3s5" C+S are not restricted to
combat operations <C=" Such reactions may occur as the result of combat like conditions that are
present throu$hout the entire spectrum of military operations to include% trainin$, all phases of
the deployment cycle, peacekeepin$ missions, humanitarian missions, stability and
reconstruction, and $o'ernment support missions <.=" Combat stress reaction is an important
'ulnerability marker" Deterans !ith combat stress reaction !ere *"* times more likely to de'elop
posttraumatic stress disorder 39&SD5" &hus, the de'elopment of trainin$ pro$rams that
successfully prepares personnel for the psycholo$ical ri$ors of operations, in addition to the
physical and technical demand, are important for operational effecti'eness and maintainin$ the
!ell(bein$ of indi'idual military personnel" In the E"S" Army, members of combat operational
stress control 3C+SC5 units ha'e uni1ue skills to assist soldiers and their families not only
throu$hout all phases of a deployment, but also throu$hout a soldier?s entire career <*=" &he aim
of the study is to determine the effecti'eness of a one day psycho(educational !orkshop on
impro'in$ the symptoms of stress"
MATERIAL AND METHODS'
&his is a 1uasi(e/perimental study carried out at Combined Military Hospital Skardu
amon$ soldiers deployed at Siachin" Duration of study !as from +ct ,-
th
-),) to Mar ,.
th
-),,"
&he total sample 3n(,-)5 consisted of acti'e duty ser'icemen of ,0(.. years" &hey !ere
randomly selected out of the total -.) healthy soldiers !ho scored more than 0) on the stress
1uestionnaire" &hese soldiers had been ser'in$ at an altitude of F ,C))) ft for more than si/
months" Sub>ects !ere di'ided in three $roups each $roup consistin$ of C) indi'iduals 3three
separate trainin$ sessions !ere conducted due to lack of space for all ,-) sub>ects5" Selection for
inclusion in a particular $roup !as made randomly" Informed consent !as taken from all
soldiers" ;/clusion criteria included current or past history of medical illness or psychiatric
disorders" Be used an indi$enous stress 1uestionnaire for measurin$ stress le'els" &he
1uestionnaire consists of 0. stems" ;ach stem asks about a particular body symptom of stress and
has a scorin$ ran$in$ from ) to C !here Gero indicate if a symptom has ne'er occurred !hile
four is !hen it is re$ularly occurrin$" Stress le'els are thus di'ided in to mild, moderate and
se'ere based on end scorin$" &he stress 1uestionnaire !as 'alidated by translatin$ into Erdu and
retranslatin$ in to ;n$lish and then a$ain in Erdu" &hose scorin$ abo'e 0) 3a cut off score of
stress considered to be abo'e a'era$e and such indi'iduals are ad'ised to learn acti'e copin$
strate$ies to mana$e their stress5 !ere pro'ided !ith a one day psycho(educational !orkshop on
stress includin$ the learnin$ and practicin$ of rela/ation techni1ues in the form of deep breathin$
and pro$ressi'e muscle rela/ation" Copies of a stress manual and an Erdu translation of stress
mana$ement !ere also distributed amon$ all the troops" Stress 1uestionnaire !as used to assess
the soldier:s pre and post inter'ention scores of stress" &he !orkshops started from A in the
mornin$ and concluded at 6 in noon" Soldiers learned rela/ation techni1ues in an ade1uate
manner durin$ the !orkshop and practiced it at least fi'e times" All soldiers !ere ad'ised to
practice rela/ation daily" &hree months after the !orkshop all the soldiers !ere a$ain assessed
for their stress" &his time the score !as si$nificantly lo! !hich clearly sho!ed that a one day
inter'entional pro$ram for mana$in$ stress !as effecti'e" &he data obtained !as sub>ected to
statistical analysis usin$ S9SS 3Der" ,65" 9 H )"). !as considered si$nificant"
RESULTS'
A total of ,-) soldiers !ere sub>ected to the study and all of them !ere males" After a one day
!orkshop upon reassessment 76 of the study sub>ects !ere found to ha'e reduced stress scores
!hich is a si$nificant findin$" &he mean of stress scores before the !orkshop !as 0A"76 4
3 SDIA"-,5 !hile it dropped to -)".0 43 SDI6"-.5 in 76 sub>ects three months after the
!orkshop !as conducted" -C"- 4 soldiers !ere ha'in$ ,. to -) years of a$e, .6"6 4 bet!een -,
and 6) years, ,6"6 4 6, to C) years, 6"64 C, to .) years and -".4 more than .) years" &he
mean a$e of the study sub>ects !as 6- years" For other 'ariables i"e education, marital status and
ser'ice see table" &(test !as applied to e'aluate the impact of the psycho(educational
inter'ention on stress scores both before and after the !orkshop" &here !as a statistically
si$nificant decrease 39 Dalue H)").5 in stress scores from pre( to post(!orkshop"
DISCUSSION'
Soldiers in a combat Gone are sub>ected to multiple stressors <0=" Althou$h persons

!ith
combat stress reaction may reco'er, combat stress reaction

often crystalliGes into chronic
posttraumatic stress disorder

39&SD5 <7=" A 'ariety of pre'ention and treatment approaches ha'e
been used includin$ combat stress controlJ outpatient therapyJ e/posure therapyJ and brief
beha'ioral health consultation <A=" &he most common concepts used for treatin$ combat stress
reactions in deployed settin$s are the #IC;9S, 9I;S, and 9I; principles <,)=" #IC;9S is an
acronym for mana$ement of combat stress reactions usin$ si/ principles% bre'ity 3in(patient
treatment usually lasts less than 0- hours5J immediacy 3treat as soon as symptoms are e'ident5J
centrality 3treat in a centraliGed Combat Stress Control <CSC= unit separate from but near a
medical unit5J e/pectancy 3e/pect that casualties !ill reco'er and return to duty in the deployed
location5J pro/imity 3treatment at or as near the battle front as possible5J and simplicity 3use of
approaches such as rest, food, hy$iene, and reassurance5 <,,=" #rief early front line inter'entions
ha'e the potential to be effecti'e !ith at(risk occupational $roups <,-=" &he 9I;S 3pro/imity,
immediacy, e/pectancy, and simplicity5 and 9I; approaches are similar e/cept that they are
limited to three or four of abo'e principles <,6=" A study usin$ found Spiritually #ased Kroup
Inter'ention for Combat Deterans !ith 9osttraumatic Stress Disorder to be moderately effecti'e
<,C=" 9sycholo$ical inoculation 39I5, !as found to be partly beneficial for troops <,.=" 9rolon$ed
e/posure therapy !as effecti'e in si$nificantly reducin$ 9&SD symptoms <,*=" A pilot pro$ram
sho!ed that family stress inter'entions includin$ structured readin$ and social skills trainin$
e/ercises pro'ed effecti'e !ith soldiers and their families <,0=" &he -(day pro$ram?s
psychoeducational restorati'e pro$ram sho!ed reduced stress le'els after the pro$ram !as
implemented <,7=" 9sycholo$ical debriefin$ !as found to lack si$nificant benefits <,A=" Stress
Kym, an online C#&(based self(help inter'ention has been found effecti'e for mana$in$ stress
and demonstrates the intended $oal of reducin$ stress" Self(mana$ement co$niti'e beha'ior
therapy may be a !ay of deli'erin$ effecti'e treatment to lar$e numbers !ith unmet needs and
barriers to care <-), -,=" Inter'entions desi$ned to bolster unit support, resilience, and
postdeployment support may help protect a$ainst traumatic stress and depressi'e symptoms, and
impro'e psychosocial functionin$ in 'eterans <--=" Fe! studies ha'e e'aluated the effecti'eness
of mental health treatments for the combat stress reactions of military ser'ice members treated in
deployed locations <-6=" An$er mana$ement inter'entions !ith indi'idual and $roup counselin$
!ere found to ha'e pre'enti'e role <=" esearch has sho!n that military mental health pro'iders
should apply both traditional and no'el principles of stress control<=" #eha'ioral health treatment
and pre'ention acti'ities are a crucial part of the medical support pro'ided to troops in a harsh
en'ironment, ser'e as force multipliers and help conser'e the fi$htin$ stren$th of combat
troops<=" Families o'ercomin$ under stress 3F+CES5, a family(centered e'idence(informed
resiliency trainin$ pro$ram de'eloped at Eni'ersity of California, Los An$eles and Har'ard
Medical School, has been found to be effecti'e <-C=" &here are no local studies specially those
conducted on troops at hi$h altitude" Me'ertheless, the si$nificant chan$es bet!een pre( and
post(treatment stress scores pro'ide preliminary data to support the utility of the ,(day pro$ram
and its benefits for troops sufferin$ from deployment(related stress" Durin$ the three months
period participitants of the study remained at their respecti'e posts at hi$h altitude, therefore
impro'ement in their scores !as mainly attributed to psychoeducational trainin$ imparted"
LIMITATIONS OF THE STUDY'
&he study has se'eral clear limitations, includin$ absence of controls, small sample, and
lack of follo!(up data after pro$ram completion" #ecause of these reasons the findin$s cannot be
$eneraliGed" It is a study conducted for a short duration and therefore lon$ term outcome need to
be confirmed"
CONCLUSIONS'
&he one day $roup psychoeducational pro$ram for stress mana$ement !as found to be useful"
Mental health professionals can pro'ide selecti'e inter'entions tar$eted to a unit or Soldier
!hose risk of stress is hi$her than a'era$e" In addition they can carry out Enit Assessments
durin$ predeployment" &he Department of Mental Health at Combined Military Hospitals of
Kil$it and Skardu can pro'ide such ser'ices by arran$in$ and conductin$ stress mana$ement
!orkshop and by collectin$2interpretin$ data !hich !ill aid prompt dia$nosis and mana$ement
near to deployed soldiers thus ensurin$ hi$h morale and optimal operational performance of
soldiers at hi$h altitude" More such studies are needed to pro'e the effecti'eness of such
pro$rams"
RECOMMENDATIONS'
ecommendations for combat stress reactions in future are made based upon the results of our
study" &he results underscore the need to tailor inter'entions and undertake trainin$s to address
combat stress effecti'ely and to de'elop theoretically sophisticated, e'idence(based kno!led$e
to identify ser'ice members at risk of problematic stress related issues" Army doctors performin$
duties at the front should be an important element of such trainin$ acti'ities" &he focus should be
on screenin$, early pre'ention, and treatment implemented before, durin$ and after deployment
of troops in hi$h altitude terrain" &herefore more mental health professionals 39sychiatrists,
9sycholo$ists, and Social Borkers5 !ill be needed to achie'e this aim" Similarly stress
mana$ement trainin$s should be re$ularly conducted and should encoura$e ma/imum
participation of Keneral Duty Medical +fficers and unit leaders includin$ >unior leaders" &he
need for establishin$ trauma psychiatric ser'ices in armed forces !as felt lon$ before <-.= and
no! it is a reality in the form of Centre for &rauma esearch and 9sychosocial Inter'entions at
the Armed Forces Institute of Mental Health 3AFIMH5" &he centre is ser'in$ sur'i'ors of
psychotrauma throu$hout the country both army personnel and ci'il population" Further research
is needed to test the effects of psychoeducational inter'entions for mana$in$ stress reactions
amon$ troops"
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Table; Three variables; Education, Marital status and Service.
Education Marital Status Service
Frequency 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. 11-0
Years
14 11.7
F! 6 5.0 " 0
Years
3 .5
#! 3 19.
M! 1 .8
Total 10 100.0 Total 10 100.0 Total 10 100.0