Clinical practice guidelines for well-being among security personnel

INTRODUCTION

India is situated in one of the most dangerous neighborhoods on this planet, sharing borders with an emerging superpower, two nuclear-capable states, and terror threats from multiple sources. The result has been that armed conflict, of virtually every description, has challenged the resilience of our men and women in uniform. Additionally, maintaining peace and security inside the country is also shouldered by the different forces in uniform tasked with maintaining security (this includes army, paramilitary forces [Central Armed Police Forces], and police). Maintaining law and order and security on the borders is a tough ask that requires dedication and discipline. There is a sense of devotion, common purpose, strictly followed hierarchy, and commitment to uphold the integrity of the country. The subspecialty of military psychiatry attempts to understand the mental health issues related to persons in uniform.

Military Psychiatry is the medical discipline that concerns itself closely with the resilience, combat efficiency, and preparedness of those who give their all in the service of the nation. It concerns itself with the following, either directly or indirectly:

1. Mental health and adjustment in the battlefield.

2. Early diagnosis and treatment of mental disorders in the field and peace.

3. Appropriate medical categorization of serving persons suited to their disability and employability, including discharge from service on medical grounds of persons permanently unfit for military service on account of mental illness.

4. Selection and training of security personnel.

5. Combat stress and its impact.

6. Maladjustment and misconduct (socio-occupational dysfunction) related to alcohol and substance abuse.

7. Disability limitation, as well as harm reduction, in security personnel with mental disorders.

Some of these concerns are also valid for paramilitary forces who deal with border security, insurgency, security of industrial installations, airports, and other sensitive transport systems, and rapid response standby forces called to action in circumstances of disturbances or potential threats. The police forces (with each state having its own police force) also have to encounter such stresses, though the contours and connotations may be slightly different, and they deal with interpersonal issues and pressures to maintain harmony in the community and enforce the rule of law.

Performing such duties for persons in the armed forces also often involves staying away from their families and in adverse environmental conditions, including harsh weather. Additionally, irrespective of the festivity and other celebrations, persons in uniform are expected to be on duty.

The nature of work, stresses of particular deployment, individual vulnerabilities, opportunities of dissipation, and life circumstances may lead to individuals serving in the uniformed services being at risk of stress and ill health. Thus, addressing their well-being is important so that the health (including the mental health) of the unit is maintained and the morale is high to discharge their duties.

The present guidelines outline the mental health profile of the security personnel and discuss the approaches that can be used to foster their well-being. It must be acknowledged that the suggestions here are generic, and the aim is to provide some of the available options. Their applications in specific scenarios should be cognizant of the organizational culture and aligned with the strategy espoused by the leadership. Nonetheless, the guidelines reflect the attention that needs to be given to the well-being of uniformed security personnel in the country.

The guidelines do not focus on the assessment and management of various psychiatric disorders in persons for armed forces as the general principles of management of various psychiatric disorders, irrespective of the profession, remain the same. For the management of specific psychiatric disorders among people in uniform, the readers are requested to go through the clinical practice guidelines of the Indian Psychiatric Society for various disorders.

Scope of the mental health concerns among the security personnel

Several studies have been conducted among the armed forces, paramilitary forces, and police forces in the country. While formal prevalence figures are hard to come by, stress and mental distress have been recognized in these forces. It has been observed that armed forces individuals with polytrauma admitted to hospitals have a high rate of post-traumatic stress disorder (about 25%). Individuals deployed in counter-insurgency operations have been reported to have high rates of use of alcohol, decreased efficiency, frustration, maladjustment, depression, tension, and isolation. Suicides and fratricides have been reported in army personnel, though the rates of suicides have been reported to be less than the general population.

Among the paramilitary forces as well, psychiatric morbidity has been evaluated. A study by Rao et al.[1] found that the common psychiatric disorders were depression and generalized anxiety disorder among the Central Industrial Security Force (CISF) personnel. Personnel serving in the more stressed areas had higher rates of distress. Several sources of stress were identified, including lack of regular work hours, not getting leave, lack of concern from seniors, and no appreciation of work. A large study among police personnel by Channabasavanna et al.,[2] which included more than 2000 police personnel, reported that psychiatric morbidity was present in 24.4 to 36.8% of the sample. Issues related to job and family were the most common stressors. Similarly, there are other studies that have documented the mental health of individuals in the security forces.[3]

It has been seen that despite the individuals being screened at the time of intake into the forces, some develop psychiatric disorders like psychosis, mood disorders, and substance use disorders over the course of time. Such disorders may occur in the general population as well, and personnel working in the armed forces may face additional vulnerabilities as well. Most of the security forces have their mechanisms of handling mental illnesses among their personnel. The army has specialized mental health services for evaluation, treatment, and rehabilitation of individuals with psychiatric issues.

Approaches for promoting well-being of security personnel

Approaches to promote well-being of security personnel can be multiple. Approaches to maintaining well-being of those serving in the security forces have been schematically depicted in Figure 1. The approaches have been divided into force level, unit level, and individual level. The specific measures for personnel deployed in stressful areas (e.g., border positing, or low-intensity conflict areas, or insurgency hit areas, or areas with acute disturbances) are discussed later and presented in Figure 2.

Figure 1.

Approaches to enhance well-being in the security forces

Figure 2.

Approaches for well-being during deployment

Force level

At the force level, several approaches can be implemented to improve the mental health and well-being of the personnel. One of the major issues faced by personnel serving in the armed forces is the availability and utilization of leave. Granting leaves equitably and reasonably is not an easy task. Personnel may request leaves to attend to important or urgent activities (e.g., attending to the birth of children, marriages of close family members, settling property disputes, etc.). However, the previous utilization of leaves, pending requests from other personnel, and the necessity of the situation (e.g., election periods) may necessitate deferment or rationalization of leaves. There is, hence, a necessity for a clearer leave policy and probably routing leaves electronically (to enable transparency and reduce human tilt in leave grants) for sanctioning leaves for force personnel.

At the force level, reduction of stigma by enabling non-judgmental talk about mental health problems can enable those experiencing stress and suffering from psychiatric issues to seek help. Additionally, the availability of services for psychiatric help in the force or contracting services from local government or private healthcare can enable referral of those with problems for assessment and further treatment. Sometimes, people do not disclose their illnesses inside the forces due to the risk of being ridiculed by colleagues. At the organizational level, greater discussion about potential human frailties and methods to improve well-being would help to reduce stigma. Sharing success stories of those who recover from mental health issues and resume productive work can also reduce the stigma toward mental health problems. A generic view that mental health problems can occur, as can any physical health issue, may help to normalize the occurrence of such a problem to facilitate treatment (rather than prolonging the untreated duration of psychiatric illness).

Another issue that comes up in security forces is the strict hierarchy and discipline. Maintaining hierarchy has been perceived to be important to ensure orders are executed, and chaos is avoided. However, the leadership is respected more, and hierarchy is appreciated when the superiors are considered to be fair and compassionate. A credible leadership goes a long way in avoiding heartburn among the force personnel. Having informal interaction between the superiors and juniors can help each other understand their points of view. Common games, celebration of festivals, and meals can be icebreakers. Aligned with this is the need to have a grievance redressal mechanism. When genuine grievances are overlooked, then it may generate resentment. At the same time, frivolous grievances would need to be side-stepped, or else the major work may become grievance redressal. Nonetheless, the force should have some mechanism of grievance redressal to check perceived or actual high-handedness or unfairness.

One issue raised by some personnel is the stagnation in the job and lack of avenues of growth. Having a set career path pattern for each personnel might be difficult. However, some form of upskilling or deputation may be considered to enhance the skills and repertoire of experience. However, one has to caution against too much “transfer” that impairs the unity of the unit. Financial considerations are an important issue for many personnel whose salaries sustain families far away. Money management and financial planning may also be coached to the personnel so that they can avoid entrapment in debt and excessive expenditures on family affairs. Every serving person is subject to extant disability compensation rules and guidelines of their respective organization and is entitled to compensation from the government for disabilities arising out of specific service conditions. The same may be denied if they fail to report the disability to the authorities within the stipulated time limit and the same is not documented in his/her medical records.

Unit level

Several measures can be taken at the unit level to improve the well-being of the security personnel. The first and foremost is the sensitization of commanding officers about mental health issues. Each commanding officer has the responsibility of welfare of the unit under him/her, and each one has his/her own leadership style for management. Managing several hundred individuals on a continuous basis without a break is a tough ask. Yet, sensitization of the commanding officers about mental health (ways to enhance mental health and functioning and key insights into failing mental health) would be beneficial. It would sensitize them to know how to improve the well-being of the unit, that mental health problems can happen to anyone, and they can be identified and treated. Often, the commanding officers would have to portray a persona of know-all and would have had some experiences, and hence sensitization may be more of a group exercise, building up from their previous situations and their experience of management, at the same time emphasizing the positive aspects of well-being to smoother functioning of their unit. Enhancing leadership skills by imbibing feedback may also enable the commanding officers and superiors to be more empathetic to the needs of the personnel. A balance needs to be stuck between disdain and excessive empathy for the junior personnel.

At the unit level, a buddy system or variants thereof can be helpful. In the buddy system, two service personnel at the same rank are paired and are responsible for each other's welfare. The buddy system enables a specific person to fall back on during times of need. Buddies may provide company to ward off loneliness and may provide pragmatic suggestions for problems. They may also act as bridges to the chain of command if signs of vulnerability are visible. Other formats of such buddy systems have been implemented (e.g., a group of three service personnel being assigned to each other). Apart from such a designated person for an individual, units sometimes can have priests/other religious figures to provide guidance in times of stress and need. Morale boosting and team building exercises can be implemented in the unit to enhance a sense of cohesion. Such cohesion and camaraderie can make the personnel more committed to a common purpose. This can also enhance the resilience of the members posted in the unit. The team-building exercise can be in the form of common events, exercises, games, and other measures.

Individual level

Several measures can be taken at the individual level to enhance their own well-being. It is assumed that individuals in the armed forces would have a daily physical fitness regimen. An annual appraisal also checks on the physical endurance of the service personnel. Regular engagement in physical exercise can also help individuals have good mental health. The positive mental health effects of regular physical exercise have been well acknowledged, and individuals from the forces often have dedicated time, opportunity, and directive to engage in different physical exercises (sometimes mandatorily).

Another proposition is screening individuals for mental health and substance use concerns. Personnel in the forces have to undergo annual health checkups, in which often screening of mental health concerns is ingrained. Screening, detailed assessment, and referral when necessary can help in early identification of those with mental health issues, so that help can be afforded quickly. The screening process should not have a punitive intent, but efforts should be made for prompt help and reinduction to active services. An alternate mechanism of providing tele-counseling or online help to individuals in need can be considered. This may proffer support for uniformed services personnel with pragmatic solutions before encountered difficulties become entrenched and cause dysfunction. Resilience training of personnel is another approach that can enable them with difficulties. This can enable us to reduce the effects of life's challenges, which cause depression and anxiety. This may involve developing a positive outlook, developing and maintaining strong relationships, and changing how one responds to situations. Table 1 presents some of the resilience improvement approaches that have been used worldwide and which may be considered for different forces.

Table 1.

Snapshot of resilience training across different regions in security personnel

Authors	Country	Resilience enhancement approaches
Cacioppo et al.[4]	USA	Social resilience training – address feelings of isolation and maladaptive social cognition, Written reflection
Crane et al.[5]	Australia	Coping skills training, self-reflection
Jones et al.[6]	United Kingdom	Participating in social networks, managing emotions, capitalizing on personal strengths and weaknesses, increasing awareness of psychological symptoms, and knowing methods to promote resilience
Neiderhauser et al.[7]	Switzerland	Considering individual emotions, thoughts, and behaviors, reflecting on their contributions to interpreting stress, improving optimism; identification of values and core beliefs, identifying individual coping strategies and modifying dysfunctional ones; detecting favorable communication styles, and detecting individual character strengths

On an individual level, housing the service personnel with family during peace postings may help to allay the anxieties of families placed distantly. This may also provide emotional and social support to the personnel, enhancing their morale and reducing the concern about the well-being of the family. Contact with the family through leaves can help to maintain family ties and rejuvenate the personnel. Additionally, in cases of family interpersonal issues, counseling with family members can potentially be used to enhance harmony in the family and alleviate anxieties on the home front.

Well-being during deployment

During the deployment to active/conflict/stressful areas, the well-being of the uniformed services personnel needs greater attention. It must be mentioned that deployment is related to constraints in terms of provided services and the added stress of the difficult deployment situation. The deployment may be planned or unplanned, and the field of deployment may present physical and mental challenges (like high altitude, difficult terrain, uncertainty of adversary, etc.). Sometimes, deployment may make communication with family and friends difficult, reducing the opportunities for stress buffers to work. Some approaches that can help maintain and promote well-being are presented in Figure 2.

Combat fatigue is treated on the following lines of the PIES[8] Principle:

1. Proximity: Treat as close to their units and battle as possible.

2. Immediacy: Treat immediately/as soon as possible.

3. Expectancy: A soldier is expected to recover from combat fatigue. This should be conveyed in no uncertain terms.

4. Simplicity: Use simple straightforward and brief methods (4 R's. Reassure of normality, Rest, Replenish physiological status, Restore confidence with activities) using non-medical terminology and techniques.

This has also been described as “three hots and a Cot,” i.e., three hot meals and uninterrupted sleep. The overall approach is to avoid medicalizing the often severe symptoms and evacuation from the battle-front.

Pre-deployment briefing of the personnel can help to ally anxieties and uncertainties. Individuals being deployed in difficult terrains and circumstances would benefit from the explanations and experiences of previously posted individuals. A briefing from the superiors about the expected circumstances, team members, chain of command, availability of rations, rest schedules, medical supplies and help, anticipated threats, and procedures for dealing with them can help to enhance the team cohesion and prepare the personnel for the field. The manner in which leadership approaches the deployment to difficult situations can enhance the well-being and overall performance of the men and women in uniform. Preventive measures like having rotated units and periodically rotating the troops from the front lines and having provisions for annual periods of long leave can be of benefit.

Family aspects for well-being of in-service personnel

One of the major concerns expressed by in-service personnel is about their families. Distance from their loved ones makes it challenging for men and women in uniform. Alternating peace and frontier posting provides a respite from distance from the families, and leaves provide an opportunity to be with the family members. Still, maintaining internal and external security requires spending time away from the family on many family occasions and sacrificing time that could have been spent caring for children, supporting elders, and attending to spouses. Hence, efforts at enhancing the interaction with family and taking care of them in times of distress can reassure the service personnel and enable them to retain their focus on the security mandate. Some of the potential measures for the family that may foster the well-being of the men and women in uniform are presented in Figure 3.

Figure 3.

Approaches related to family members to ensure the well-being of security personnel

Providing timely and rational leave as per the defined rules to the personnel can be helpful for them to spend time with their family. Such leaves enable them to retain the family ties to the extent possible, resolve issues, attend important family events, and provide care during times of illness. Not only leaves, but arrangements of travel and tickets can go a long way to enable personnel to make the requisite travel (as last-minute bookings may not yield suitable travel arrangements).

Social support for family members through informal networks (e.g., army wives' welfare association) can be another means whereby the family receives help in times of need. This can reassure the posted individual when away from home that the family will receive help when required. During peace posting, stationing with the family can help the service personnel feel content and enhance their overall well-being.

Financial support may sometimes be necessary to tide over acute familial expenditures. Financial distress has sometimes been a cause of significant distress, leading to suicides. Thus, enabling advances and financial training on personal financial management may help the deployed personnel to ward off financial crises.

In the armed forces, medical treatment of the serving persons and their dependents is free of cost, and the government bears the cost. However, this benefit can only be availed if the patient takes treatment through authorized service channels. Taking treatment from private civil practitioners may lead to significant out-of-pocket expenditure by the patient, causing financial loss to those individuals.

Legal and ethical aspects

Security forces are employed in a weaponized environment. They may also be a part of the command structures of long-range missiles with conventional or nuclear warheads. Any security forces personnel with a mental illness or substance use disorder (SFPMI) may pose a risk to themselves or others. Therefore, a referral system originating from the chain of command through the Medical Officer in charge of the unit should ensure prompt removal of the SFPMI from this environment. After treatment, a medical board should deliberate on the employability of the SFPMI and the need for environmental modification, and suitable directions should be passed on to the chain of command. This may include exclusion from duties with access to lethal weaponry and driving military transport including special vehicles like tanks and self-propelled artillery/missiles. In addition, other service accommodations for disability limitation and harm reduction may be recommended such as restrictions on airborne or maritime duties.

If the referral channel is bypassed and the SFPMI goes directly to mental health practitioners and is treated surreptitiously (without keeping the authorities informed), the risk of harm to self or others continues to be present, even if the treatment is effective. This is because the SFPMI is unable to ensure continuity of treatment due to posting at remote places, receives no service accommodations, and so continues to operate in hazardous conditions, with access to lethal weapons and be part of the command structure dealing with sensitive weaponry.

It is common knowledge that psychiatric treatment is incomplete without environmental modification and that a conducive milieu is essential for recovery. The same cannot be ensured without keeping the SFPMI's employers in the picture. Therefore, it appears to be an ethical imperative to inform the SFPMI's unit authorities about his illness or treatment.

In addition, as per the Army/Navy/Air Force Acts, concealing one's illness is a clear-cut violation of good order and discipline of the armed forces and is punishable. In the case of Security personnel not subject to these acts, withholding information from a public servant (including security forces authorities) that may interfere with their functioning is a punishable offense as per the Indian Penal Code. A mental health establishment/practitioner who is treating an SFPMI surreptitiously may well attract these provisions.

Approaches to promote well-being of those who have suffered from mental illness

It is quite possible that during the course of their service, some service personnel become affected by mental health issues. Most mental health problems are amenable to treatment in current-day psychiatric practice. Hence, after treatment, these service personnel need to be reintegrated into the armed forces or suitably rehabilitated. The following efforts can be made to promote the well-being of armed service personnel who have suffered from mental illnesses:

1. Non-discriminatory approach to the provision of opportunities.

2. Ensuring regular treatment and follow-up with the treating professionals.

3. Ensuring compliance with medications when necessary.

4. Graded reintegration into the workforce, including deployments.

What should a non-force psychiatrist do while dealing with an individual from armed forces

Many times, individuals serving in the armed forces, paramilitary forces, or police seek treatment in the non-force related setting (and in some instances without disclosing their job profile). They may either be referred, or they may come on their own accord. The following flowchart [Figure 4] may help to guide the clinician/mental health professional in such circumstances.

Figure 4.

Dealing with the force personnel in a non-force setting

It is prudent for psychiatrists to note down the identification details, accompanying persons, current posting and deployment, and whether there is a referral letter when a person from services seeks treatment in the non-force setting. If the personnel comes on their own accord without being referred, it would be advisable to clarify why they have not initially shown up to the medical officer/psychiatrist appointed by the force they are serving in. Documentation of records should be paid attention to and kept safely. Risk assessment should be paid attention to, especially with the risk of harm to others (as many of them have access to weapons). The risk of harm to self should also be assessed. If the individual is suffering from a common mental illness, and the risk of harm is less, then the treatment may continue, with suggestion to the personnel that he/she could inform to his superiors or commanding officer/medical officer. If the risk is high, then efforts should be made to inform the commanding officer/medical officer of the force. Emergency treatment can be instituted in such circumstances, and the reader can refer to the relevant IPS Clinical Practice Guidelines on the topic.

One situation that requires consideration is when the service personnel requests for leave. The treating psychiatrist may consider recommending leave prospectively as per assessment, documenting in the records the reasons for such a recommendation. However, the leave should also be recommended only if the personnel has come with a proper referral from the medical services of the force. In case a fitness to join is asked for, it might be prudent to recommend for evaluation by a medical board, especially if the individual is suffering from severe mental illness or has a history of risk of harm to others. Being on medications itself may not be a contraindication for the fitness of the individual.

CONCLUSION

Mental health and support of security forces personnel are central to their combat efficiency and ability to provide internal and external security. Therefore, policies and protocols must be put in place to achieve the following objectives:

1. Promote the inclusion and integration of well-being into all aspects of service life

2. Stigma reduction approaches for mental health concerns

3. Encourage personnel at all levels to seek medical help including psychiatric help when they need it

4. Reassure security personnel that they and their families will not be abandoned by society

5. Empowering and protecting the rights of security personnel with mental health disability

There are a range of well-being measures that can be implemented. The characteristics of the forces, current prevailing circumstances, resources available, vision of the leadership, and felt need by the security personnel would determine the measures taken for implementation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.