Impacts of Post Traumatic Stress Disorder on the Performance of Pakistan Army Veterans Deployed for War on Terror

Syed Sajjad Nasir Kazmi, Arshad Ali^*

Department of Civil Engineering, MCE National University of Sciences and Technology, Islamabad, Pakistan

Abstract

Many a people across the world are affected by Post Traumatic Stress Disorder (PTSD) which may pose as a debilitating illness not only inhibiting an individual’s life but also seriously disrupting the performance at the work place as a whole. Functioning level of PTSD varies from individual to individual depending upon the level of its impairment to that of an inversely proportionate level of job performance. There is very limited knowledge of PTSD as most of the people are barely informative about this serious issue, the world faces even today. PTSD develops only after an occurrence of traumatic event with one of its potential risks it embodies i.e. the PTSD affected individual may not display symptoms quite readily. For instance, a war veteran may be a vector of PTSD owing to a set of traumatic events or just an event, yet there may be a few hidden disasters, trauma(s) or some other veiled psychosocial injuries that may not be disclosed or recognized imminently, therefore PTSD may not be considered at all. The PTSD is further classified into four main areas of focus which are its major symptoms too i.e. Event Re-experiencing, Avoidance Behavior, General Numbness and Hypersensitivity. On one pretext or the other, these exist primarily because each one is feeding the other to sustain the overall existence of PTSD. It may also be noted that every trauma survivor may not experience or posses either one or all of the four above mentioned symptoms but s(he) will still be a carrier. Combat PTSD is usually linked consistently to the poor performance outcomes of veterans. Therefore, study in question, investigates this relationship further in consonance with four components of PTSD, thereby analyzing how combat related PTSD is associated with work performance of veteran employees of Pakistan Army whereby contrary US, Vietnam and The NATO veterans had findings of the drastic PTSD impacts. This academic research also suggests that even the slight reduction or gain in PTSD symptoms may vice versa lead to an employee’ performance gains or poor work performance with respect to an overall symptom level, in combination with certain other factors.

Keywords

PTSD, Veterans, Trauma, Performance, Impacts, War on Terror

Received: April 7, 2015 / Accepted: April 18, 2015 / Published online: May 19, 2015

@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license. http://creativecommons.org/licenses/by-nc/4.0/

1. Introduction

"Post Traumatic Stress Disorder (PTSD)" is a psychological condition of a person which is usually given out due to any terrifying event by either directly experiencing it or witnessing it. Flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event are its major symptoms; Mayo Clinic (2013). In technical terms, it may be a psychological reaction occurring post an event which is highly stressful. Its symptoms may last for months or even years, usually disturbing the whole body functioning. It affects a person who had been shocked due to a difficult or bad experience of combat fighting followed by melancholy and nervousness; Learner’s et al; (1980). Since the prehistoric era of conventional warfare to the present-day global war on terrorism, we as human beings have learnt to survive bloodshed by creating an element of resilience. With the passage of time, a great know-how has been sought about psychological trauma duly faced as a consequence to the natural and other man-made disasters, and in addition, a need has also been felt too, for seeking those psychological interventions which address the issue of PTSD; [1]. It has also been observed that in the implementation of the effects of the PTSD, factors like depression, separation anxiety and generalized anxiety are directly related to the severity of exposure to trauma; [2]. Hats off to the veterans, members of the armed forces and their families who have always bore the unprecedented burdens of those wounds of war which are not only exposed but also the hidden ones. PTSD is a difficult injury to understand, to tolerate, and to overcome especially the one related to the conventional war and off course it becomes the most difficult for the soldiers exposed to the war on terror. Psycho-stress of conventional war is quiet different from that of war on terror because here the enemy is hidden and cis-frontier, war is elapsed over a long period of time and the results obscure. Success series in the conventional war against the exposed enemy is a great motivational force thus making the combat PTSD less drastic against the war on terror where the success stories lay far behind the death dance at each passing moment. Since September the 11^th 2001, alongside the roles played by the US troops as well as the NATO Forces in Iraq and Afghanistan, Pakistani Nation and her valiant forces too are faced with the war on terror countrywide since last more than one and a half decade, especially in Khyber Pakhtunkhwa (KPK) province.

Pakistani Nation has paid the heavy price for peace by laying more than eighty thousand lives; its soldiers too have faced the PTSD with the equal stamina and endurance. Here, the point of concern is that PTSD constructs have a dogmatic impact on the performance, especially on the military soldiers.

This research focuses on how this innovative and diverse environment has forced the factor of PTSD to impact against the performance of world’s best fighting machine and a disciplined organization i.e. Pakistan Army to engage the time, money and human resources that add value to her effectiveness.

1.1. Problem Statement

Pakistan Army went through the multifaceted warfare for its age of sixty seven years and suffered the agonies of variety of trauma including its veterans and also those families of recipients of highest military awards and battle honors who laid their lives for the sole cause of national interest. Consequently, PTSD has come into play on one pretext or the other impacting the job performance, the severity of which needs to be established for war against terror.

1.2. Objectives of the Study

The research in question primarily serves following three objectives:-

i. To find out the impact of PTSD on the performance of employees of Pakistan Army and its veterans engaged in war on terror.

ii. Does the impact of PTSD exist there in? If so, then how much, did it impact the performance of Pakistan Army soldiers? Either it did not impact or had a negligible impact, then what is / are the factor(s) responsible to it?

iii. To find out the cause(s) of PTSD impacts (if any) and suggest the remedial measures (if at all) to address these causes and also to find out such issue(s) or gap(s) necessitating further deep research.

1.3. Significance of the Study

In current situation of the country, where there is politico-economic instability prevailing with each passing day, the nation is pushing against the war of survival. Our adversary on the eastern borders is already pressing hard for the proxy war to harp the politico-military advantage in Afghanistan. By no means, the geo-economic interests of the big power in the region for her long presence could be ruled out. Albeit, Pakistan Army is getting seasoned too, with each drop of blood, it oozes out through the war on terror but here lies the point of major concern and an optimum significance that factor of PTSD is well attached to it, for it may not be felt now but in the long run, effects of such impact may appear when it could be too late to identify and take precautionary measures. Therefore, it is of paramount importance to do it now and take on both with the precautions and remedies to keep our guards well on toes and always fighting fit.

This research stabs to fill the gap between the existing and in the previous studies by investigating the impact of PTSD on employees’ performance ex Pakistan Army while utilizing the data of those all ranks who are, or had recently been engaged in the operational area of war on terror in Dir/Swat valleys and Federally Administered Tribal Area (FATA) of KPK province.

The study in question will also help Pakistan Army’s leadership to determine the path of seeking maximum employee performance under PTSD compressed combat environment both in peace and war. Moreover, this research is expected to achieve valuable contribution to the body of the literature thus assisting the policy makers to determine an efficient set of elements for maintaining and enhancing the employee performance and satisfaction under such circumstances when going gets tough but the tougher gets going.

2. Literature Review

2.1. PTSD Symptoms

In addition to the four significant symptoms referred above; impairment of affect regulation, chronic destructive behavior i.e. self mutilation, eating disorders, drug abuse etc, amnesia, dissociation, somatization, alterations in self relationship, distorted relationship with others and loss of sustaining beliefs; [3]. The NATO soldiers on return from Afghan war faced the problem of having excessive alcohol addiction, committing crimes at high rate and then pluming suicide in most of the cases; [4]. NATO Veterans are prone to suicide; [5]. Among the US Marines; the suicide rate among veterans has increased three hundred percent to the national average; [6]. Statistics from the year 2009 indicate that double the strength of British veterans is in jail than what they have now deployed in Afghanistan. In addition, a quarter of homelessness, street-sleeping and relationship breakdown are those observed problems among combat PTSD affected soldiers who had previously served in the armed forces of UK and NATO; [7].  The number of military veterans hailing from UK is in jail has been increased to 200 percent or above from year 2003 to 2009 [8]. Due to combat stress, there has been an increase of 53 % the veterans’ referrals from doctors on account of psychological and emotional stresses; [9].

2.2. Role of Pakistan Army and the "War on Terror"

Since the inception of Pakistan in August 1947, its army, besides having fought the conventional wars of 1948, 1965, 1971, Kargil 1999 and Border Escalation 2001/2002, has also been actively combating terrorism in Basham District (Alpuri along Karra Korram Highway-KKH), in Dir & Swat valleys, South Waziristan and now in North Waziristan. In addition to this, Pakistan Army has also faced diverse challenges e.g. Siachin Operation (1984/1986 till date) where the weather is the most cruel enemy besides, round the clock skirmishes along Line of Control (LOC) in Indian Occupied Kashmir (IOK). Extensions of Pakistan Army i.e. Civil Armed Forces (Rangers and Frontier Constabulary) are heavily committed in maintaining law and order situation while also street fighting terrorism i.e. target killing, suicidal attacks against the educational institutions, major installations, infrastructures and community centers. In the natural disasters like earthquake 2005 and floods of 2010, 2012 and 2014, Pakistan Army has executed numerous humanitarian support missions. In all such scenarios of conventional warfare, counter terrorism and disaster management, whole nation’s hope is the Armed Forces. Even, in any sort of political turmoil, the nation looks towards this prime institution. From purely, the resource-based point of view, investment in high-performance work practices ought to develop such distinct capabilities among employees that lead to superior performance; [10].

2.3. Combat/Veteran Employee Engagement

Recent literature suggests that positive beliefs and attitudes are directly associated with employee engagement for all professions in general but combat employee in particular because of highly responsible demands. Therefore, such an engagement contains three interrelated components i.e. cognitive, emotional and behavioral components. The cognitive approach defines the employee’s beliefs about his/her unit or organization i.e. his/her top management (leadership) as well as the work environment, in peace or in the battlefield. Emotional component focuses on the employee’s perceptions about his/her attitudinal composition which may be positive, negative or sometimes neutral once they perform amongst the family and friends and also the setups where they serve in the presence or absence of management.  The behavioral component in fact, is a value-added feature for organization and has the discretionary efforts like extra time, employee commitments towards organization, devotion and motivation to fulfill the task; [11]. All these help in the management of combat stress and PTSD compressed work environment thereby maintaining the affected performance of combat employees.

2.4. Agency Theory

Agency Theory delineates upon the both the interests of the employees and employer who should have close enough an association to achieve organizational goals. It has similar application to the complex combat environment where every commander strives to achieve maximum performance out of his employees but all the expectations depend upon the skills of the employees in battle worthiness and their willingness to align operational goals with those of the tactical ones. High training content would tend to help the military outfit for the selection of right person(s) for the right job as each role for war in terror is defined. Performance appraisal of the soldiers, their motivation and compensations would ultimately enhance the satisfaction which results in increased performance in the shape augmented fighting spirit. All such like practices help to moderate the effects of PTSD.

2.5. Combat/Veteran Employee Performance

Highest motivation, true empathy, belief in religion, divine reward, espirit de corps and keenness for martyrdom play a rich dividend in the organizational development and in enhancing the employee and organizational performance against combat PTSD. Walton (1985) and Lawler (1986) both emphasize upon the employee involvement in decision making process thereby enhancing the employee’s commitment and satisfaction in order to directly influence the employee performance for the overall benefit of the outfit. The performance of an individual employee is optimized by high motivation. Motivation is one of the most studied factors because it assumes that a satisfied employee exhibits better performance that leads to overall organizational performance and growth. Ostroff (1992) in his research concluded that organizations having more satisfied employees performed well than those organizations that had low employee satisfaction due to lacked motivation. Front line employees’ i.e. combat soldiers represent their unit in the battlefield. Depending upon the level of motivation and training, they decide whether to stay on with the combat stresses on the battlefield or postpone it for the rest of life for the attainment of ultimate mission to be accomplished. The quality of such interactions depends on the attitude of front line employees. If he/she is satisfied with his organization, then he /she will exhibit extra role of behavior and will try to leave a good impression of his/her organization as a role model. To stay on the competitive edge and thrilling atmosphere, army needs to produce continuous value for their countrymen. If the employees perform well, the overall performance will be expected to be good enough in the interest of the state. In short, employee performance is a base for any potential survival. Employee performance is a very important variable in the studies of PTSD but since post World War II events and the very lately the war on terror, the researchers had been trying to ameliorate this concept and develop constructs for its empirical investigation. It’s the same way as the employees’ performance reads out the organizational behavior; Borman & Motowidlo, (1993). What is performance? Is it the output of the employee at the work place emanating from his/her behavior? To answer this question, previous literature emphasized that it is better to stress on behavior of the employee than to focus on results (Murphy, 1989). On the other hand, by cheating and or using other unfair means, an employee can show good results but it will not be long lasting as the bullet in actual war never spares. Murphy (1989) recommends defining employee job performance in terms of his or her behavior at job rather than on the basis of the results. He defined performance as the behavior of the employees that must match the overall organizational goals. Adding Murphy, Later Campbell (1990), defined job performance as the series of controlled actions of the employees that may lead to goals of the organization and that can be measured on the individual level. This definition extended the previous definition by adding employee controlled behavior or actions leading towards the fulfillment of organizational goals.

2.6. Performance Relationship with Combat PTSD

Combat PTSD is usually common with military veterans as almost one million soldiers from Vietnam war had experienced combat effects, fifty percent of them recovered a bit but remaining half is still in a condition that persisted through 1990s, Kulka et al;(1990). As per National Comorbidity Survey of WW-II and Korean Conflict veterans, around 58% of the male veterans had the diagnosis of combat trauma with very disturbing and painful traumatic episodes, Kessler et al; (1995). It was found that PTSD was strongly associated with poor work performance among veterans of Vietnam. Savoca and Rosenheck (2000) used data from national survey of Vietnam generation and found that lifetime PTSD was associated with 50% lower probability of current employment. McCarren et al; (1995) found similar outcome in the study of one zygote twins. Zatzik et al (1997) also found that male veterans diagnosed with PTSD were three times more likely to be out of work than those of normal. The relationship of PTSD to work hours and wages was also not that evident. "Savoca and Rosenheck (2000) also found that PTSD was associated with lower wages but not with few hours per week. PTSD has not been found significantly associated among pair of veteran twins with different occupation groups, McCarron et al; (1995). Veterans experiencing the effects of PTSD usually face many difficulties associated with the workplace. Researchers suggest that the employers must play a vital role in expediting the PTSD affected individuals’ recovery by identifying the challenges while also making reasonable accommodations for ensuring workplace triumph. However, condition severity and the degree of limitation may vary among individual veterans owing to the intensity of that particular disorder which affects only that specific part of workplace performance e.g. there may be factors carrying aggravated effects such as supplementary pressures, vigor, tension and each other’s affiliation. An organization must need to know that not all veterans affected due to PTSD will require accommodations to display their job performance but there may be only few recommended cases who may need accommodation and recovery.

3. Study Design and Methodology

The study is basically qualitative in nature using the methodology of different types of interviews and the focus group discussions. Interview types included witting, unwitting, telephonic and one on one interviews with the respondents. A random sampling of one hundred fifty veteran / soldiers was taken at the rate of fifty each who had participated in the war on terror at Swat (Provincially Administered Tribal Area-PATA), South Waziristan and North Waziristan (FATA). Fall out hospitals i.e. District Headquarter (DHQ) Hospitals and Combined Military Hospitals located at Mardan, Risalpur, Nowshera, Peshawar and Dera Ismael Khan were also included to seek data and interview the soldier’s admissions. Each group also included their families at the rate of ten members each i.e. twenty percent. Separate questionnaires were also developed for veteran soldiers (officers, junior officers and other ranks) and their families / friends. Out of one hundred fifty, only one hundred forty two expressed their willingness to talk about and discuss regarding their traumatic experience(s) of war on terror. The response rate was 94.6 %.

4. Discussion on Findings & Summary of Results with Regards to the Impact of PTSD on Soldiers / Veteran Performance

Following endeavor is made to solicit the discussion out of the summary of results with appropriate reasons and justification whereby hypothetical effects had been derived from the literature review that PTSD had significant impact on the US and NATO soldiers:-

i      Based on the literature review, it was hypothesized that the symptom "Event Re-experiencing" carrying the items; intrusive thoughts, recollections and / or recurrent dreams will affect the performance of veteran soldiers but it was not supported for the reason that most of the Pakistani veterans had been through such experiences recurrently. It made them not much affected rather prone to such trauma in routine military life. Other factors like motivation, love for the religion Islam as well as strong desire for martyrdom were also found to be the overriding and contributory factors. Another point of interest is that the soldiers were found to be still charged and motivated to end those terrorists who are inside the national boundaries and they wouldn’t let them allow destroying their homes for the question of honor and respect of their beloved families.

ii    It was also hypothesized that the symptom "Avoidance Behavior" carrying the items like  avoiding activities, situations, people, and/or conversations associated with the trauma will affect the performance of veteran soldiers but it was also not supported for the reason that this symptom  is somehow related to the first one i.e. "Event Re-Experiencing". Once the recurring trauma did not make the soldiers much affected then the avoidance symptoms were not produced. Resultantly, the result was negative.

iii   "General Numbness" carrying the items like loss of interest in surroundings and detachments had been found congruent upon the performance at the rate of eleven percent for the reason of veteran / soldiers having prolonged involvement in the war on terror i.e. fourteen years or so where the families and the friends had the significant impact. In fact, these are the initial symptoms of PTSD suffering which has been noticed in the subject analysis too.

iv  Analysis of symptom "Hypersensitivity" has revealed to affect the veterans/ soldiers performance at the rate of fifteen percent for the reason that items of Hypersensitivity ; sleeplessness, apprehensive thoughts, startled rejoinder and anger outbursts are interrelated with "General Numbness" i.e. loss of interest in surroundings and detachments. It wouldn’t be wrong to comment that the General Numbness leads to Hypersensitivity i.e. loss of interest in surroundings, isolation and detachment creates sleeplessness, anxiety, overactive, startled behavior, hyper vigilance, irritation and anger outbursts. Infact, this becomes the second stage of PTSD suffering, further leading to acute or chronic PTSD. It was evident from age groups of the veterans in the sample that the young soldiers were found with positive initial symptoms but with growing age, the PTSD gets to the acute stage from where the recovery also becomes ardent and inevitable.

v    It was also a pint of serious concern that the doctors, psychologists and the paramedics had little or meager knowledge of the issue and the PTSD affected soldiers / veterans were being treated by the psychiatrists instead of psychologists. There is neither mentionable diagnostic of combat related PTSD among the medical staff nor is there any treatment centre.

vi  For even more prolonged period of Pakistan Army’s war on terror, PTSD issue is likely to become more sever from where the strength of sufferers is likely to increase at the fast pace with increased anxiety if the remedial / protective steps are not taken.

5. Conclusion

This study provides a brief account of PTSD and its shape in the combat zone in a way, how Pakistani veterans took effect on their job performance. The relationship between PTSD and veteran employee performance in the combat zones for war on terror at North/South Waziristan and Swat have explored the new venue for further research where we as a nation stay far behind than those actually battling it out since past more than one decade. It also marks a further question; shall our nation get rid of such trauma in future, near far and that of PTSD too which is deeply attached to it. Well, if we have to live with it, we need to work it out also, find its remedies, not only for our veterans but also those Internally Displaced Persons (IDPs) in millions who lay under the sky with their destroyed homes, community structures as well as their society. Our country’s geo-strategic location and politico-military struggles coupled with economic and vested interests of existing and emerging super powers tell the fate as a Muslim sovereign. How would the peace prevail in the wake of corruption, economic instability, political unrest, adventurous terrorism and Talbanization, hostile eastern neighbor and weak Afghanistan? In this milieu, long war on terror and Indian proxy war is predestined to test the national stamina at high pitch. Pakistan is fighting terrorism in FATA and PATA only in the declared terms but what about the one in Karachi, a shelter home for terrorists as well as political militancy. Is it all OK in Quetta, Hyderabad, Lahore, Islamabad, Gilgit Baltistan (GB) and Peshawar, let’s ask ourselves. How much PTSD has impacted the Pakistani nation as a whole, needs to be investigated and researched where as of now, we stay ignorant, what to talk of combat PTSD only. Besides these manmade disasters, we too are prone to natural disasters and live among the worst hit disaster regions of the world thus putting a tremendous impact of disaster event PTSD on our national fiber.

Recommendations

In the backdrop of this research study as a whole and the discussion above, few of the following pertinent recommendations with inbuilt suggestions are proffered:-

i      As a long term measure, PTSD and its impacts both clinical and combat, be studied at national level by a team of researchers as a study group duly comprised by members from National Institute of Disaster Management (NIDM), National University of Science and Technology (NUST), National Institute of Clinical Psychology (NICP), National Defense University (NDU), Armed Forces Institute of Rehabilitation and Medicines (AFIRM) and other member researchers from HEC. Recommendations of this study should be presented to the PM of Pakistan to form national PTSD Management Council for subsequent effective management of PTSD.

ii    To manage the combat PTSD in the short term, PTSD report centers be established in the fall back hospitals of FATA and PATA. These may include the DHQ Hospitals of Swat, Mardan, Nowshera, Peshawar, Kohat, Bannu and DI Khan alongside the Combined Military Hospitals (CMHs) located at the same above listed cities for identification, segregation and immediate treatment of PTSD affected soldiers and the civilians. Acute or chronic PTSD sufferers (including limb loss) be further evacuated for treatment at AFRIM and other major rehabilitation hospitals.

iii   There is dire need to select the team of doctors (Psychologists and Psychiatrists) and paramedics at the above referred districts in particular and major rehabilitation hospitals in general for PTSD management / training courses abroad, especially in UK and USA. Funds to this effect should be dedicated in the National, Provincial and Defense budgets.

iv  An ordinance to this effect be promulgated in the National Assembly to introduce an act thus framing the national policy / guidelines for post traumatic rehabilitation and job employment of PTSD affected civilians and the veterans in various organizations and departments.

v    To obscure the impacts of combat PTSD among the veterans, it is essential to avoid elongated or repeated exposure of military units for war on terror at the same sector. An effective release and rotation plan of body of troops is essential for rest, recreation and refitment with adequate motivational back up. Six months to one year exposure is recommended to be enough.

vi  An effective system of promotion incentives, financial rewards, battle honors / awards, children education, free medical treatment, post retirement rehabilitation / accommodation in the shape of jobs in civilian, govt / semi govt institutions, allotment of agricultural land / residential plot, house or apartment may play a rich dividend in this regard.

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