Exposure to combat and deployment; reviewing the military context in The Netherlands

Abstract

This paper reviews the military context of exposure to combat and deployment in Dutch soldiers. It does so by reviewing war victims and military psychiatry after WWII in the Netherlands, and describes Dutch deployments from the late 1970s to the present. ‘Who is the Dutch soldier’ is asked to articulate the mental load on the individual soldier before, during, and after deployment. The narrative review of this paper allows one to review how the armed forces personnel is challenged in relation to their specific assignment and in what respect the psychological dimensions are addressed and met in the face of risk and adversity. Finally, some critical considerations for future veterans care programmes are raised.

Keywords:

• Combat
• deployment
• Netherlands
• military
• PTSD

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Introduction

In this paper we will review the military context of exposure to combat and deployment in Dutch soldiers. We will do so by reviewing war victims and military psychiatry after WWII in the Netherlands and describe Dutch deployments from the late 1970s to the present. We are asking ‘who is the Dutch soldier?’ to articulate the mental load on the individual soldier before, during, and after deployment. A narrative description allows us to review how the armed forces personnel is challenged in relation to their specific world and in which respect the psychological dimensions are addressed in the face of risk and adversity. Finally, we have some considerations for future veterans care.

Exhaustion and fatigue in the second world war

When World War II broke out in September 1939 most people in the Netherlands thought the country would remain neutral. During the Great Depression in the interwar years, the budget for Defense had been cut sharply, and the organization had weakened considerably, leading to a reduction in compulsory service from 24 months to 6 months. The Netherlands regrouped the armed forces abroad whenever possible and tried to fight conflicts in this way.

During the interbellum period, the interest in psychiatric patients and war psychiatry had dropped. This meant that knowledge and experiences from the previous World War had to be rediscovered. Because of the high cost of war pensions, the British military medical authorities were keen to give the diagnosis shell shock this time little chance. It was not allowed to make the diagnosis. More neutral labels came up: not yet diagnosed (nervous), NYD (N). In addition, other concepts were used, such as battle neuroses and anxiety syndromes, as well as the older effort syndrome. In 1942, the Allied Forces carried out an exhausting struggle in the desert of North Africa. Military psychiatrists spoke about exhaustion and fatigue (battle-exhaustion, combat-exhaustion) (Grinker & Spiegel, 1945). The cause of the collapse had to do with fatigue due to a lack of sleep and excess physical exertion. The acceptance of combat exhaustion also offered armed forces personnel the opportunity to ask for help, without taking on the stigma of a psychiatric case.

War victims and military psychiatry after WWII in The Netherlands

War victims of WWII

The Second World War resulted in many categories of victims (the word victim is usually carefully avoided in this literature) (see also Kleber, 1986, 1994). The Netherlands had remained outside international conflicts from 1815 onwards. Materially the Netherlands was one of the most affected countries in Western Europe. An important part of the 300,000 deployed military personnel were not or were hardly involved in actual fighting, yet heavy fighting took place in many places in the Netherlands, such as at the Grebbeberg, around and in Rotterdam, and at the northern part of the country at Kornwerderzand. A total of 2192 Dutch soldiers were killed, and about 8000 (severely) injured. Of the total 13,000 soldiers who were taken to Germany and Poland in captivity, another 400 would not survive the war (Amersfoort & Kamphuis, 2005). Also during the war, 210,000 Dutch citizens (of a population of 9 million) lost their lives as a result of military operations or internment in camps. Approximately 140,000 of them died in camps, in prison, by internment, or by executions (among them 107,000 Jews). In addition, there were tens of thousands of deaths as a result of infections caused by malnutrition.

In the first years after the war almost 300,000 Dutch people from the former Dutch East Indies came to the Netherlands. They had experienced the Japanese occupation—often interned in camps—as well as the turbulence (the Bersiap period) and the struggle for independence after 1945. Many suffered from long-term consequences of the war (Mooren & Kleber, 2013).

In the 1950s and 1960s, the focus was mainly on participants in resistance [‘het verzet’]. It was often stressed that the difficulties of them only emerged late after the liberation. In the 1990s, Op den Velde and colleagues (Hovens et al., 1992, 1998; Op den Velde et al., 1993) studied former members of the Dutch resistance, and found that many of them had symptom-free intervals of many years. It was often only in the period of retirement that complaints and problem areas came up (Adler, Britt, Castro, McGurk, & Bliese, 2011). With the arrival of specific laws and provisions for war victims, attention was gradually drawn to categories other than resistance members and concentration camp survivors, such as the civil citizens of the cities (see Bramsen, Klaarenbeek, & Van der Ploeg, 1995; Bramsen & Van Der Ploeg, 1999; Schreuder, van Egmond, Kleijn, & Visser, 1998).

Military psychiatry after WWII

Military psychiatry is a fairly young discipline. Experiences with soldiers who had psychological problems in the First World War and the Second World War resulted in many countries taking special measures to help psychologically wounded soldiers with specific problems.

The Dutch army had no experience with military psychiatry until after World War II. The attention of military psychiatry came largely to the recruitment and selection of personnel. In the wake of the Americans, soldiers now also received a mental examination in addition to a physical examination. To ensure that persons with psychological problems of a serious nature were barred, they were psychologically tested. In addition to selection, military psychiatry had two other tasks related to the general mental health of its troops: the prevention of psychological problems, also called ‘mental hygiene’, and the curing of not too serious psychological problems. All soldiers who had serious mental health problems were dismissed after a re-examination. Since the US (WWII and later the Korean War) and the UK (WWI and WWII) had a lot of experience with military psychiatry, they looked at their methods and vision. Especially the UK has had a lot of influence on Dutch military psychiatry. Outpatient mental healthcare was not the first priority within the military psychiatry in the Dutch Armed Forces. This was partly due to the prevailing deterministic vision on the causes of war neuroses. Characteristics of the soldier would be the most important cause of psychological complaints on the battlefield. A soldier who succumbed to a war neurosis was usually considered to have a predisposition that made him vulnerable to a conflict stressor. Soldiers with a defective intellectual development and mental maturation, with hysterical and psychopathic traits and with neurotic reactions, were less able to cope—according to the psychiatric insights of that time—and to adapt to military reality. The lack of adaptability led in turn again to rapid mental collapse or war neurosis. According to the doctors, environmental factors, such as the military organization and the reality of the battlefield, also played a role in the occurrence of mental complaints, just like external circumstances, such as separation of family and life in a closed group. A lengthy combat action could result in varying degrees of emotional exhaustion. As van’t Hooft (1949) summed up: ‘We can understand most of the mental disorders of soldiers in Indonesia as psychopathological reactions of not fully-fledged personalities to very difficult ones circumstances’ (pp. 193–195).

The Military Neurosis Hospital at Austerlitz (Zeist), founded in 1946, was based on the English Northfield Hospital (Hutschemaekers & Oosterhuis, 2004). One of the first rules for standard procedures concerned the treatment of soldiers with mental health problems. This Military Neurosis Hospital was the first psychiatric specialist hospital of the Dutch army. The hospital was specifically established to help soldiers with psychological problems caused by traumatic experiences during warfare. In Austerlitz people worked from the idea that neuroses, in addition to a disease, were also the result of disturbed social relations. This sociological approach led to experimenting with group therapy. The hospital was renamed the Rehabilitation and Training Centre in 1958, and Austerlitz was closed in 1964. In the same years the military hospital in Utrecht was named the ‘Military Hospital dr A. Mathijsen’ (also called MHAM). A characteristic of the MHAM was that, in addition to a military hospital, it was partly a civilian hospital. The patient files of Dutch military psychiatry at this time consisted mainly of young conscripts who could not cope with military life because of isolation or a weak character. Military psychiatry had a very different character than psychiatry in general. It had an occupational health character, and was more focused on refusing psychiatric patients than treating psychiatric patients. Those who were treated did not have serious problems and were, therefore, suitable for psychotherapy. It was precisely that distinct character that was probably responsible for the development of military psychiatry.

First deployments

Approximately 200,000 soldiers—ultimately in vain—were deployed to keep the Dutch East Indies a colony. After the so-called police actions in the Dutch East Indies/Indonesia (1947–1953), the war in Korea (1950–1954), and the war in New Guinea (1960–1962), where Dutch soldiers developed psychological problems, the attention nevertheless turned to other matters than war victims. Psychiatry in the Netherlands left out the war traumas of many soldiers and veterans (Oostindie, 2011). The Indies veteran came home and went to work in the prosperity of the developing society. Little time or recognition was available for their bewildered stories, which were only shared behind closed doors (Beaulieu-Boon, 2009; Oostindie, Hoogenboom, & Verwey, 2018). Van Meurs (1955) provided a detailed medical and psychological study of battle fatigue based on his experience as a medical officer with the Dutch UN contingent in the Korean War. Not until the 1970s and 1980s did society become more aware of the psychological consequences of deployment in the Dutch East Indies/Indonesia. The Indies veterans still form the largest group of Dutch veterans. Many of them, of whom 25,000 are still alive, subsequently experienced a painful lack of recognition and support.

It was only in the years after the US in Vietnam (1965–1973) suffered an unprecedented military defeat, that war trauma came on the map. The conquered US military (more than 500,000 at its peak in 1968), unlike World War II veterans, was not recognized. They were often portrayed by television as war criminals who shot at women and children. As we learned from history, many Vietnam veterans developed psychological problems and were no longer able to be part of social life. In the Vietnam period the symptoms were called ‘combat stress’ or ‘acute combat stress’. As we know now, many years later, under political and social pressure, signs of recognition came (Foy, Sipprelle, Rueger, & Carroll, 1984). Psychiatry recognized Vietnam trauma by including post-traumatic stress disorder in DSM-III (Horowitz, Wilner, Kaltreider, & Alvarez, 1980).

Dutch deployments in the late 1970s to the present

After the participation of the Netherlands in the peace-keeping mission UNIFIL (1979–1985), a confrontation with traumatized veterans of the Lebanon-conflict followed. They ran into problems with justice, problems with alcohol and drugs, relationship problems, and suffered from disbelief. The nature of the mission and the risks of trauma were under-estimated. After all, it had not been a war mission, but a peace-keeping deployment. Some of the UNIFIL soldiers had been, however, confronted with shelling, hostage taking, threats, intimidation, and exposure to wounded and killed peace keepers. Furthermore, the Lebanon veteran (still draft army at that time) had felt a feeling of impotence in their mandate: they had to monitor, observe, and watch, and were not allowed to do anything. After Lebanon, the social awareness in the Netherlands grew slowly that military commitment also involved psychological risks. The resistance against this idea also dropped within the armed forces. At the time of operational deployment in Lebanon there was a serious break with the deterministic philosophy that prevailed during the campaigns in the Dutch East Indies/Indonesia and Korea. Doctors and therapists believed that environmental factors were the underlying causes for mental illnesses. This led to a different approach in the field of mental health. There were ideas that psychologists and psychiatrists could contribute to the prevention and treatment of psychological problems in deployed military personnel (see Vermetten, Meulman, Francato, & Unck, 2007). These developments led to the gradual emergence of a system of psychological support of Dutch participation in missions. It was believed that a soldier with psychological problems should not be discharged through medical channels, but preferably aided through a soft sector approach that was adopted from the civil society at more peaceful times.

This psychological support for the Dutch troops (labelled as ‘forward psychiatry’) took on a more concrete form only in the early 1990s. This initiative originated from the military psychological and sociological service of the Army. For example, clinical psychologists from the Army’s Individual Assistance Department [Sectie Individuele Hulpverlening, SIH] organized lessons and training classes on stress and trauma in the preparatory school for peace missions. The same psychologists were also sent along with the troops. They stayed with the units for an entire deployment period and provided preventive and curative psychological care during deployment on an outreaching basis. At the end of the deployment, each soldier received a personal interview with this psychologist. The result of this approach was that, within the ranks of the military the psychological assistance/support around deployment became a well-known phenomenon. From this time on the motto emerged that stress is a normal reaction to an abnormal situation. This approach meant that the soldier with complaints was no longer viewed from a predominantly psychiatric/medical disease model.

With the abolition of compulsory military service in 1994, the need for a professional army and the recognition of deployment-related complaints from military and veteran personnel, the care for the soldiers to be sent on deployment was receiving increasing attention. Until the 1990s, however, there was still hardly any publicity with post-traumatic complaints among the military who had been sent to Lebanon, Cambodia, and other conflict areas. The Dutch involvement in the second Gulf War (1990–1991) and the wars in the Balkans (former Yugoslavia, 1992–present), Africa (Angola, Darfur, Ethiopia) and Iraq (2004–2006), and Afghanistan (2003–2010) resulted in a continually expanding and refining psychological support for military personnel, and their home front was continually expanded and refined. Since 1994, the Department of Psychiatry of the Central Military Hospital has been actively involved in the treatment of PTSD.

Srebrenica was a pivotal event in the history of peace-keeping by the Dutch armed Forces. The fall of Srebrenica (also known as the ‘Srebrenica massacre’) on 11 July 1995 was the capture of the Bosnian city of Srebrenica and the subsequent deportation and genocide of more than 7000 Muslim boys and men. On this day in July, when more than 400 Dutch UNPROFOR soldiers (successively the battalions Dutchbat I, II, III and IV) did their protective work in Tuzla and Srebrenica, Bosnian Serb troops under the command of General Ratko Mladić entered the city and deported and murdered a large part of the Muslim men and boys. It is the worst act of genocide in Europe since the Second World War. The fall of the Srebrenica and the subsequent events in 1995 have become the subject of a national commemoration in the Netherlands. This is held annually on 11 July at Het Plein in The Hague under the bilingual motto: ‘Never forget—Nikad ne zaboraviti’.

Especially after Srebrenica in 1995, but also because of the chronicity of complaints reported by veterans from previous deployments, it once more became clear to society what long-term impact on a peace-keeping deployment could have. However, it took until 2001 before the Veterans Institute was established. The Ministry of Health, Welfare, and Sport, and the Ministry of Defense formally authorized the military psychiatry service in the year 2000 to provide post-active military (veterans) extended psychiatric care. This ultimately resulted in the National Care Centre for Veterans [Landelijke Zorglijn Veteranen], which up to this day coordinates the care for post-active soldiers in civil–military cooperation in the Netherlands. A Centre for Research within the Military Mental Health Care started in 2001, carrying out basic and clinical research studies. It resulted in a fresh new look at the biological basis of PTSD in soldiers and veterans, validated their disorder, provided cross-disciplinary research, as well as novel approaches to therapy, e.g. Motion Assisted Multi Modal Memory Desensitization and Reconsolidation for veterans with PTSD (Van Gelderen, Nijdam, & Vermetten, 2018). It has also given the start of a longitudinal cohort study in soldiers before deployment to Afghanistan with pre-deployment assessment of biological markers (blood and saliva) as well as psychological factors, a design that by now has been copied by many others with fruitful results. The results have been published in many research papers (for an overview see Van der Wal, Gorter, Reijnen, Geuze, & Vermetten, 2019).

Soldiers and deployment in the year 2019

(Recent) history tells us that soldiers can become traumatized by their efforts during missions. What are the factors during such a deployment that contribute to the risk of developing psychological complaints? We explore the hypothesis that, under exceptional circumstances, the physical and mental resilience can decrease, with the final resultant dysfunction, traumatization, and pathology. We do this in the form of an anthology about the soldier himself, his mates, his commanders, his unit, his training, and his operational commitment.

Who is the Dutch soldier?

We do not know much about the contemporary Dutch soldier. He may not be that different from armed forces personnel in other Armed Forces. We can undoubtedly provide statistics on previous education, recruitment, selection, and training of military personnel. But that still does not answer the question of who this Dutch soldier actually is. What motivates someone to become a professional soldier and to be motivated for a mission? What is the personal history of people who are under arms? How do they deal with their military formation? What expectations do they have of a mission? What images do they have in their heads? What does a mission do with these expectations and images? How do they find the way back after a mission? And how does it go? Do they go on mission again, and again, and again? And what do they do when they leave the military profession and go back to civil society as a veteran? Answers to these kinds of questions can provide insight into the question behind each request for help: who is this person who has these symptoms? There are many questions, but only a few answers.

In the military society the ordinary daily actions of life, such as: dressing, walking, greeting, eating the meal, the daily routine, going to sleep, are not left to individual coincidence or personal custom, but on the contrary deeper individualized. and tightly uniformed, it is all required differently, in a different version, under different circumstances and conditions, at fixed times, and on noisily or tacitly, that at least does not contradict. (…) Everyone must be dressed in a uniformly prescribed manner, behave in the same, prescribed manner. In the implementation of the set rules, an absolute punctuality is required (Somers, 1966, p. 145).

This quotation has been chosen to give an idea of ​​how completely different military life is in comparison with regular civil life. Despite the fact that the quotation dates back to 1966, the core has been preserved. When you start your job, you give up a lot of personal freedom, and you have to surrender yourself to a totally different way of life. The Dutch soldier is a professional soldier. Conscription was suspended in 1994. That changed the character of the armed forces. Moreover, the connection with society, of which his sons were obliged to make themselves available for the defense of the fatherland, was cut through. The professional soldier wants to and is not forced to serve in the army. Currently (2019) the military population consists of almost 44,000 soldiers (91% male and 9% female), with a mean age of 35 years. On average they have 11 years of service. A total of 49% of this population went on deployment, with an average of twice deployed.

With various preparatory training, young people can receive a contract of employment with Defense for a long or short period. Depending on the pre-education level, young people can be trained to become soldiers, non-commissioned officers, or officers. They form the executive, direct management, and middle and higher leadership level in the organization, respectively. Young people can also indicate which functional areas they find attractive: if they want to fight, they become an infantryman; if they want to build, they are engineers; if they want to transport, they become truck drivers; if they want to nurse, then they will take care of the wounded. The youngster often opts for the adventure. The recruitment campaigns are in line with this need. The ‘fit–unfit’ campaign delicately explains that you are not a nerd and that you know what you want when you come to the armed forces. The Air Force acts as a gleaming team for peace and security. And the Navy, finally, shows you more of the world. Of course, the prospective army soldier tells in a well-reasoned motivation why he wants to be employed. He wants to contribute to world peace, to act against forces that violate the international legal order (human rights), to fight terrorism and other extreme forces, etcetera. Other motives, such as a well-paid job and allowances for exercises and deployments, are equally appealing. Especially in economically worse times the influx of candidates for a job as a soldier can grow.

Deployment and potentially traumatizing events

It is well known that the deployed soldier is at risk of being exposed to potentially traumatic events. This chance is variable because missions differ in nature and risk. Moreover, there are differences in the nature, intensity, and frequency of such events. The sight of human suffering in the refugee camps of Rwanda is of a different kind than a gunfight with the Taliban. Furthermore, not every soldier acts the same way. The infantryman who runs dangerous and tiring patrols has a higher risk of a traumatic experience than the maintenance engineer at the camp. Soldiers are aware of the impact that such experiences may have. They are prepared for this in their training. They are also trained in providing adequate psychosocial care to each other after a traumatic event. There are also professionals (psychologists, social workers, doctors, and chaplains) on site who offer stepped psychosocial care. In most recent deployments of Dutch soldiers to Afghanistan, servicemen were often exposed to high potential traumatic events (see Table 1 for examples of exposure to combat-related stressors). In the first phase of the deployment, the opposing military forces (OMF), that is the Taliban, went into battle with the Dutch troops. In these so-called troops in contact (TICs), the Dutch were usually superior to their opponents. As a result, in the later phases of the deployment, the opponent only relied on committing attacks on troop movements, police stations, and markets. These were attacks with improvised roadside bombs (improvised explosive devices, IED) (Hoencamp, 2015). Suicide bombers were also used a few times: young men who blew themselves up with a bomb vest in the vicinity of Dutch troops. A well-known statement by the military was that they had ‘consumed a guardian angel’ again. Sometimes, however, things went very wrong. In 6 years, 26 Dutch soldiers died and over 150 were wounded by war violence. Most victims fell through IED attacks (Hoencamp et al., 2014).

Table 1. Exposure to combat-related stressors (n = 780), a population of Dutch ISAF soldiers in Uruzgan, period 2006–2008. Data obtained as part of the PRISMO study (see Van der Wal et al., 2019).

	Item experienced
Item	n	%
Enemy fire	483	61.9
Witnessed people suffering	460	59.0
Witnessed wounded	367	47.1
Colleague injured or killed	350	44.9
Incoming fire	302	38.7
Witnessed dead	287	36.8
Rejected by locals	261	33.5
Personal danger	230	29.5
Witnessed others injured/ killed	156	20.0
Heard people screaming	153	19.6
Insufficient means to intervene	133	17.1
Mission experienced as useless	105	13.5
Insufficient control over situation	104	13.3
Memories of earlier deployments	94	12.1
Held at gunpoint	37	4.7
Physical injuries	19	2.4
Colleague held hostage	3	0.4
Held hostage	0	0

The impact of combat exposure

Over the years, a fairly good picture has emerged of how soldiers respond to confrontations with combat events. During an attack or fight and immediately afterwards, most of them automatically apply their skills and drills; the soldier acts on it. He does what he has learned, and the leadership on the spot gives instructions in a direct way. During a fight, the tension rises so that it is sometimes expressed in the shouting of power terms and curses. Sometimes more rounds are also shot than would be necessary from a tactical point of view. In case of an attack (IED), the action is aimed at restoring your own safety and taking care of and disposing of injured persons. Dissociative, apathetic, or passive reactions are rare. The soldiers call this a ‘black out’: they stay where they are and do not move anymore. The gaze is infinite and they are not receiving input. Soldiers who do experience this are often ashamed of their reaction afterwards. The fear of having to experience something so humiliating again can lead to avoidance of the patrolling again. Discharge or ‘blow off steam’ (defusing) after an incident takes place in the subsequent hours. The discharge can take various forms: from extremely emotional, sad, angry, to recapitulating to a controlled manner what has happened. There are also reactions of guilt and shame if it did not work as it should. All (stress) reactions are normalized, and care is taken to ensure that they support each other. Structure is offered and information provided. Professional psychosocial help is immediately offered if there is an indication for this. The armed force personnel are monitored in the days and weeks after an incident by their colleagues and professional aid workers in a watchful waiting system. On the first days after an attack, acute stress reactions can be recognized on average in one in five military personnel. They are restless, tense, impatient, short-tempered, emotional, and sleep badly. Many soldiers start to exercise intensively as a form of distraction. Others isolate themselves by playing computer games. There is also a lot of talk and jokes are made. Most recover within a week of the incident and pick up work again. Some, on average ∼5%, continue to suffer from stress reactions (see Bramsen, Dirkzwager, & Van der Ploeg, 2000; De Kloet, Vermetten, & Unck, 2002; Engelhard et al., 2007; Reijnen, Rademaker, Vermetten, & Geuze, 2015). Some of them are looking for help for this (Taal, Vermetten, van Schaik, & Leenstra, 2014). With relaxation techniques, EMDR, and imaginary confrontation they are usually treated in the deployment area. Those who do not seek help immediately recover in the following weeks on their own. They function less well for a while, but continue with the work. It is also expected that they will bounce back after an incident and, after a short recuperation, will be deployable again. Some, however, remain much more alert than before (hyperarousal), and some are no longer motivated to go on patrol (avoidance). A few soldiers leave an incident uneasy, especially if one has lost a comrade. In addition, there is the constant insecurity during the work. Experiencing (almost) traumatic experiences several times in succession makes a major appeal to the militaries adaptive ability. His reserves (vitality) decrease, his affect dulls (indifference, cynicism), and he is less sharp (reduced concentration). Some groups can offer a supportive context, others cannot. The loss or injury of a comrade can strengthen the mutual bond. However, there are also examples of groups that disintegrated after losing a group member, and could no longer support each other.

Symptoms of acute stress disorder, sometimes predating a PTSD diagnosis, can sometimes be seen during the deployment. This can occur either after a single incident, or as a result of cumulative incidents. A high number of military personnel can be sent out and have already confronted deployment experiences, but they can potentially just tip over a threshold, and manifest in response to a minor stressor. The aim of mental health workers is to treat the military with short-term, targeted interventions during the deployment. As a result, he retains control and can resume his work. (Traumatic) deployment experiences can often bring underlying dysfunctional schemas or personality problems to the surface due to decreased adaptive capacity. PTSD in military personnel can, therefore, be a complex disorder that is acquired in a specific deployment context. Complex problems are usually not treated in the deployment situation, but must take place in the Netherlands after a deployment. The specific deployment context is quite different from normal Dutch life. Because of this, the soldier can sometimes hardly share his traumatic experiences with family or friends. The soldier may think he is not understood by others than his own buddies. This can put the soldier in isolation with respect to his loved ones. There may also be an obstacle in the provision of relief to the armed forces personnel, because a therapist cannot find a sufficient connection with the military's deployment experience. This constitutes a risk to treatment.

Stigma and taboo

Although armed forces personnel are increasingly aware of the fact that a traumatic experience or other deployment experiences can lead to psychological problems (see Vermetten et al., 2014), there is still a taboo (public stigma, treatment attitudes, anticipated stigma or self-stigma). The military identity is difficult to identify with ‘no longer being able to cope’. Continuous information, training, and normalization of symptoms lead to more openness among each other. The trick is to re-label so-called weakness (the recognition of problems) as a force. Fortunately, this process is going on in the Dutch armed forces, partly due to the fact that by now half of all soldiers have been deployed at least once, which leads to a better understanding for those who have been traumatized.

Yet, there are soldiers who never cross the threshold to talk about their complaints and problems. They withdraw and suffer in silence. Sometimes this is also accompanied by an idealization of the deployment experience and, even years after leaving the service, the military identity is carefully nurtured. Sometimes these soldiers visit reunions, but often they don’t, in order to not be confronted with colleagues who have a different experience of the deployment. They are then annoyed that others act lightly, as if the deployment was actually a holiday. There is also a sense of competition between the soldiers who have experienced something and those who have not experienced anything. Sometimes the stories of those who have not experienced anything are more impressive than the real stories. This stings and frustrates. Identification with the deployment is accompanied by stories that go with it. A narrative that symbolizes an experience that others have not had. The story can becomes something exclusive, which only insiders can take note of and understand. Others are excluded. The bitter thing is, however, that the (ex) military generally excludes himself from further development in other important life tasks and relationships. It is not uncommon that relationships stall or break apart, or that one cannot find their pace with another employer.

Care as close as necessary and far away as possible

Psychosocial care for the deployed armed forces personnel is present and available. The starting point is to use care as close as necessary and as far away as possible from the military. Care may not deprive the military of the opportunity to recover from a traumatic experience on its own strength (autonomy and self-regulation, control). On the other hand, care must also be present, accessible, recognizable, credible, and outreaching. Both before, during, and after the deployment, care activities have been set up for the benefit of the military and his home front. Prevention, information, early signalling, psychosocial, and psychiatric assistance are linked together in healthcare. This includes training in stress management, home front information, mental care conferences, team building sessions, regional contact days for the home front, call circles, adaptation programmes, recovery exercises, return interviews, and post-deployment screening questionnaires.

Signals and symptoms of sustained stress

Six months after deployment, the Defense Ministry zooms in once again on the psychological well-being of the armed forces personnel and their home front. All soldiers who have been on duty for more than 30 days receive an invitation for themselves and their home front to participate in the so-called aftercare investigation [nazorg vragenlijst] (Gersons, Gorissen, Vries, IJzerman, & Wiersma, 2006). By means of a questionnaire, which is used as a screening instrument, it is determined whether there is any reason to offer aftercare. If, for example, there are health complaints or psychosocial complaints, the serviceman will be called by a doctor or the home front by a company social worker. Only when the serviceman or the home front calls for it, is care actually provided.

What are the signs and symptoms that are reported?

In an overview of the years 2013–2014, it was indicated that ∼80% of the deployed military personnel feel as healthy after their return as they felt before. About 10% even feel healthier and ∼10% feel less healthy. Personal positive growth is also reported. Around 50% feel more strongly connected with other people, and 58% say that life has gained more value. The following findings for approaching military personnel are found in the screening, conducted with the aid of an aftercare questionnaire, on the complaints that military personnel may experience: 7–9% externalized problem behaviour (such as serious conflicts with the environment, the tendency to something to do or the need to push boundaries), 8–10% possible excessive alcohol consumption or want to decrease, 6–7% have not found his/her turn at work, and 2–3% have not found his/her turn at home; 9–10% have depressive feelings, 9–10% have fatigue symptoms, 9–10% have sleep problems, 7–9% suffer from increased stress, and 1–2% have a risk of PTSD. Ultimately, there is no reason for 65% of the military to call for help while 35% have a so-called call indication. Only a part do make use of care. The reason for not making use of care is that soldiers think they can handle the complaints themselves, or that the complaints are not serious enough. The screening is, therefore, set up to call a few more soldiers rather than to miss soldiers who do have a complaint (Duel, Elands, & van den Berg, 2017).

Train as you fight

In international comparisons, Dutch soldiers appear to have fewer complaints than soldiers from, for example, the US (Hoge, Auchterlonie, & Milliken, 2006) or the UK (Fear et al., 2010). The reasons for this are difficult to state unambiguously. The way in which the Netherlands has organized the care for military personnel aims, in addition to prevention, to identify and support problems of the military at an early stage. In addition, the deployment duration plays a role. The longer a deployment, the greater the chance of trauma symptoms or complaints. The type of mission and method of action also play a role in potential complaint development. It is important to stay alert and to keep an eye on the individual soldier, as he remains a vital part of society (Vermetten, Baker, & Yehuda, 2015).

The most important network for armed forces personnel during a period of deployment is the team in which they serve: hence group cohesion during deployment emerged as the main predictor of resilience after deployment (Adler, Bliese, McGurk, Hoge, & Castro, 2009). The basis of group cohesion can be established during daily operations: ‘work as you fight’. At team level, cohesion can be established through regular training in accordance with the principle ‘train as you fight’ (Dutch Defence doctrine). Given the importance of the team, it is also advisable to be aware that studies indicate that things such as team spirit, supportive behaviour, mutual trust, and the ability to adapt can be expected to decline during deployment and when enduring stress. Systematically monitoring the processes within the team and taking prompt action to resolve identified problems in a constructive way can help to maintain resilience within the team. Empirical studies of military personnel also indicate that the group leader has a large influence on the mood and morale within the team. The inspiration provided by the leader’s competence, their reliability as a source of information, and the care and attention they devote to the members of the team are important aspects that can boost both morale and psychological resilience. Leadership factors at team and organizational levels are key. Both levels require the provision of so-called transformational leadership. Transformational leaders are able to motivate personnel by altering their attitudes, concepts, and values so their performance meets and also often exceeds expectations. At team level this requires leaders to communicate their vision, motivate, inspire, and support their team members, and actively build team spirit. At an organizational level, autonomy, meaningfulness, and recognition become more important aspects of leadership. It is, therefore, essential to devote attention to these aspects of leadership in leadership training programmes.

Prospective research PRISMO

The Prospective Research In Stress-related Military Operations (PRISMO) study was initiated in 2005 by the Research Centre of the Military Mental Healthcare at the Dutch Ministry of Defence, to prospectively and longitudinally study the biological underpinnings of the mental health of Dutch troops deployed to Afghanistan. At the time of the study’s start, the long-term impact of deployment and exposure to traumatic events in wartime on mental health had already gained widespread recognition, as epidemiological evidence from a range of studies indicated that the incidence of mental health problems after deployment was quite substantial. However, both aetiological evidence as well as biological determinants were sparse, even though they were highly warranted. We, therefore, facilitated prospective research on the correlation between stress-related systems and the occurrence of mental health problems that were presented in deployed troops. Considering its size and estimated duration, the Dutch participation in the International Security Assistance Force (ISAF) in Afghanistan offered a unique opportunity to gain excellent understanding of the long-term impact of military deployment on mental health, and to map the different biological and psychological factors that contributed to the development of stress-related mental health symptoms. Whereas other cohort studies have attempted to address the impact of military service and deployment on mental health, the PRISMO study is different from other cohorts in including a pre-deployment measurement (cf. The King’s Cohort, The Millennium Cohort), collecting biological data in addition to psychological data (cf. The Cooperative Studies Program (CSP) No. 566), and including a long-term follow-up period up to 10 years after deployment (cf. The Army Study to Assess Risk & Resilience in Servicemembers–Pre/Post Deployment Study (Army STARRS–PPDS), Marine Resilience Study (MRS)). Not unlike other longitudinal cohort studies the findings generated by the PRISMO cohort can contribute to an outlook on vulnerability and resilience, while they are also aimed at aiding the identification of factors in order to protect the mental health of service personnel and veterans (paragraph quoted from Van der Wal et al., 2019). To date, a total of over 30 publications with a mix of epidemiological, biological, as well as psychodiagnostics papers have resulted from the cohort. A complete list of publications can be found online (www.prismo.nl).

Considerations for future veterans care

On 1 August 2010, the mission with the Netherlands as the leading nation in the Afghan province of Uruzgan came to an end. This is almost 10 years ago. There are ongoing deployments, which undoubtly will remain an important task of the Forces. It is important that the history of these deployments will remain part of our vocabulary. Society must be informed about them, to warrant recognition of the mission and the status of the veteran in society.

A six-part documentary of National Geographics, Diary of Our Heroes: the Dutch Mission in Afghanistan, followed 12 Dutch soldiers in everything they experienced on this mission. Here we tried to answer the question of who are the people who are willing to risk their own safety and to exchange a comfortable life in the Netherlands for life threatening conditions. The series aims to give a realistic picture of the work and life of Dutch soldiers and civilians on missions.

This paper has attempted to describe how the armed forces personnel is challenged in relation to deployment, and in which respect the psychological dimension is addressed. It is very important that there is ongoing attention and awareness for veterans needs, partly through government and partly through media. For both the young and old veterans groups, media attention is an important factor that reflects the perceived compassion and recognition. When there is attention, and when this is positive, veterans can feel acknowledged and appreciated. Society at large is appreciative for veterans, but this is not always felt by some veterans groups. Only when society is well acquainted with veterans and their stories, will the post-active service members continue to feel understood.

It could be good for the coming years to work together between different veteran organizations and different research institutions to arrive at an (inter)national veterans research programme and veteran policy. That way it could be ensured that scientific and practice-oriented research into veterans and veterans policy will be institutionalized. That offers the possibility of specific areas that currently receive less attention in current scientific and practice-oriented research, and allow us to consider which forms of interdisciplinary research would be relevant. The institutionalized structure of veteran organizations could make it possible to meet the wishes with regard to the necessary knowledge, after which, in consultation with relevant research institutions, it can be seen how this should take shape. This could create a permanent knowledge infrastructure for research to veterans and veterans policy, with an explicit connection to the veterans themselves.

Acknowledgements

The authors acknowledge Leo van Bergen, PhD, for his assistance in the writing of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.