INTRODUCTION
Stress affects everyone and has been labeled the “Health Epidemic of the 21st Century” by the World Health Organization. Constrained by the demands imposed at the professional and personal realms; overwhelmed by personal aspirations and expectations of peers, subordinates, and superiors; restricted by either the limitations of one's capabilities or resources; every man and woman in every walk of life undergoes the phenomenon of stress in varying degrees. While stress affects the emotional and physical health of any individual for a finite time period in any job or profession, the impact of stress on the continued well-being of an individual is nowhere as pronounced as it is when the individual is in the Armed Forces.[1] Indian Navy is a rapidly expanding blue-water Navy and its objectives are to defend the nation's maritime borders, and in colligation with other Armed Forces, to prevent or defeat any coercion or aggression against the territory, people or maritime interests of India, both during war and peace. It also promotes bilateral relations among nations by means of joint exercises, goodwill visits, and humanitarian missions, including disaster relief. With the ever-increasing capabilities and roles played by the Indian Navy, the quantum of stress experienced by Naval personnel has increased over time.
UNDERSTANDING STRESS
Stress has different meanings for different people under varied conditions. Hans Selye's general adaptation syndrome model defined stress as a nonspecific, conventional response of the body to any demand made on it. He described the reaction of body under three stages, namely alarm, resistance, and exhaustion.[2] Stress, Selye emphasized, is not something to be avoided. Certainly, it cannot be avoided since just remaining alive creates some demand for life-sustaining energy.[3] In general, stress improves performance until an individually set tolerance limit is reached when exhaustion sets in and impairs performance.
Eustress or positive stress is a normal part of our everyday life. It positively affects us and keeps us going. It has a motivational effect, increases our activity and productivity, and is essential for our performance. Distress or negative stress is the type we usually refer to when we are talking about stress in general. This type of stress has negative effects on our health as it affects both our mind and body and prevents us from thinking clearly and calmly.
STRESSORS IN ARMED FORCES
Armed Forces personnel are exposed to combat as well as noncombat stress due to their professional obligations and the nature of deployment. When service personnel deploy into any theater of operation, they encounter a sustained series of stressors unlike those they would encounter at home station. These stressors can lead to a variety of negative health consequences, both physical and mental, for exposed individuals. Due to operational and security concerns, those deployed have more restrictions than choices. Restrictions on dress, behavior, communication, movement, and interaction with the resident population can add to a feeling of powerlessness. In addition, differing standards on length of deployments, isolation from family and friends, ambiguity of individual roles or unit missions, and boredom associated with operational routines can all add to the stress of deployment for individuals and units.[4] The US Army data also show that the suicide rate is higher on forward operating bases where soldiers have easy access to phones and computers with which to call home and lower in more primitive outposts. Because of this easy access to stressors of home, those deployed must not only deal with the separate stressors of deployment but also deal with the family, financial, children, and/or personal relationship problems back home with which they have no ability to influence.[5]
According to Schouten, Callahan, and Bryant, “violence, regardless of fatalities,” can produce fear and expectant reactions predictive of “psychological and somatic symptoms” as well as other negative effects such as “decreased productivity, job neglect, decreased performance, and job dissatisfaction.” There is a compelling evidence that people who have witnessed violent deaths, as well as colleagues of the victims, experienced intense and persistent symptomatology (anxiety, depression, and posttraumatic stress disorder [PTSD]).[6]
The increased frequency, length, and high operations tempo of deployments that individuals and military units experience, too, can have a negative effect on health. According to Bartone, “increased deployments necessitate other stressful changes in military units as well, such as an increased number and intensity of planning sessions, training exercises, and equipment checks, all of which increase the workload and pace of operations.”[4]
Along with these psychological stressors, deployed soldiers also must deal with the physiological effects of sustained stress on both their physical and mental health. Among the US troops returning from Iraq and Afghanistan, rates of PTSD ranged from 4% to 31% and rates of depression ranged from 3% to 25%.[7]
Work stress has been implicated as an important health hazard for military personnel. In a study of 472 personnel who had not been exposed to any war, 26% reported to be suffering from significant work stress. Nearly 20% blamed work stress for causing significant emotional distress and 10% reported that work stress was severe enough to adversely affect their emotional health. This was independent of the sex, age, educational levels, marital status, and years of military service. The job stressors described by these personnel were not specific to military service but common to civilians, such as change in work hours, work responsibilities, or type of work.[8]
While individuals deal almost exclusively with stressors, groups and organizations collectively deal with environmental changes that cause stress on the organization. In a military operational context, this resembles a units' reaction to changes in the operational and tactical environments. In this context, however, the stressors of individual members must not be marginalized or ignored since the pejorative effects of stress on individual performance will ultimately affect the collective performance, competence, and capability of the group.
STRESSORS UNIQUE TO NAVY
Naval personnel are exposed to a unique set of stressors because of the peculiarity of the operating platforms and varied roles played by the Navy. Commonly encountered stressors while serving onboard ships and submarines are depicted in [Table 1].
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Table 1: Stressors unique to the Navy
The perennial concern of military planners is that technological surprise will give an opponent a definite advantage in the event of war. Modern ships, submarines, and aircrafts have technologically advanced machinery, weaponry, maritime surveillance, communication, and other systems that require a constant update of knowledge, skills, working abilities, and decision-making capacities of naval personnel at all levels which immensely add to the stress experienced by naval personnel.
In a study of occupational stress and social support involving 5077 Indian Naval personnel, high occupational stress was seen in personnel serving afloat (66.47%) as compared to those serving ashore (51.55%) and on submarines (53.72%). Among those serving afloat, occupational stress was highest among junior sailors in comparison to senior sailors and officers. Occupational stress was also related to poor psychological health as measured by the General Health Questionnaire (GHQ). Perceived social support was effective in decreasing occupational stress in officers and senior sailors but not in junior sailors where unexpectedly it seemed to lead to greater occupational stress.[9]
Another study involving 413 Indian Naval personnel serving onboard ships, submarines, and shore establishments showed that junior sailors had significantly higher occupational stress than officers and senior sailors which is unusual as generally junior sailors have little responsibility and generally carry out orders assigned to them. Personnel serving ashore reported greater occupational stress than those serving onboard ships and submarines. This is at variance with the usual perception of ship life being tough due to long working hours, difficulty in getting leave, and frequent disruptions in personal life due to sailing. Occupational stress was least onboard submarine where conditions are said to be the toughest. This may be due to greater unit cohesion among submariners than others.[10]
In a 3-year study by the Royal Navy, the two main causes of stress were balancing work versus home life and discord in working relationships and that good supervisor support was very effective in managing stress.[11] High levels of occupational stress have also been reported in the lower ranks in the Armed forces of the United Kingdom.[12]
EFFECTS OF STRESS
Combat stress manifests as acute stress reaction, adjustment disorder, and PTSD. The consequences of chronic stress can be in the form of physical and psychological symptoms such as headaches, body aches, tiredness, reduced sleep or appetite, and lethargy. Chronic stress may also manifest as psychosomatic disorders or psychiatric illnesses.[13]
Evaluation of 601 polytrauma patients at one of the service hospitals revealed the incidence of PTSD as 24.3%.[14] A series of 140 limb fracture patients at a service hospital reported significantly higher scores on the GHQ, Michigan Alcoholism Screening Test, Carroll rating scale for depression, impact of events scale, and fatigue scale. The limb fracture patients also had a high prevalence of alcohol dependence/abuse and depressive disorders.[15]
In another study, troops deployed in counter-insurgency operations showed higher and significant signs of stress indicators such as use of alcohol, unfavorable response to tasks, diminished efficiency, frustration, maladjustment, tension, isolation, and depression.[16]
STRESS CONTINUUM MODEL: A MODEL FOR EARLY DETECTION OF STRESS
Leaders at all levels are responsible for maintaining the psychological health of their officers, sailors, as well as their family members, just as they are responsible for maintaining their physical health. To promote psychological health, leaders must actively foster resilience, prevent and recognize stress problems, eliminate the stigma associated with getting needed help, and take decisions about whether to deploy personnel experiencing stress problems.
The major differences between physical injuries and stress injuries of great importance to leaders in Navy are that stress injuries are not physically visible, harder to recognize, and burden their bearer with greater social stigma. They are, therefore, less likely to be voluntarily reported by injured individuals.
A prerequisite for implementing an organization-wide effort in the military to promote resilience and recovery and to prevent adverse stress outcomes is a language and classification system for stress that can be employed equally by military leaders, service members, family members, and medical and mental health professionals. Every member of the organization must hold a similar concept of the stress states to be promoted or prevented, and each must share a similar understanding of the words used to describe these states. To meet this challenge, the US Marine Corps' three air–ground–logistics Marine Expeditionary Forces convened a working group in 2007 consisting of marine leaders, chaplains, and medical and mental health professionals. The result of the working group's deliberations was the combat and operational Stress Continuum Model, a heuristic that divided the spectrum of possible stress states into four color-coded zones designated green (ready), yellow (reacting), orange (injured), and red (ill).[17]
The two overarching objectives of the Stress Continuum Model are to create and preserve a ready force and to promote the long-term health and well-being of the naval personnel and their family members. These two objectives are interrelated and are recognized as of paramount strategic importance since the mission of the Navy is to win wars and to return good citizens to civilian life after those wars are fought. Taking care of naval personnel and their families and leaving no one behind are also mandated by the services' core organizational values.
Ready: The green zone
The green zone is the zone of adaptive coping, optimal functioning, and personal well-being. The green zone is not the absence of stress, for the lives of marines, sailors, and their family members are seldom without stress, but rather its effective mastery without the experience of significant distress or impairment in physical, social, or occupational functioning. The ability to remain in the green zone under stress, and to return quickly to it once impacted by stress, are two crucial aspects of resilience.
Reacting: The yellow zone
The yellow zone is the zone of mild and temporary distress or changes in functioning owing to stress. By definition, yellow zone stress reactions are always temporary and reversible since yellow zone stress does not significantly exceed individuals' coping capacities. Each individual's yellow zone, therefore, is defined by their current level of resilience in body, mind, and spirit – their current ability to bounce back from hardship and adversity of various levels of intensity. It is vital for service personnel to attain and maintain yellow zone stress capacities as the yellow zone is where maximum operational challenges are encountered. Hence, military training constantly and purposefully drives service personnel into their yellow zones.
Injured: The orange zone
Orange zone stress is defined as more persistent and severe distress or dysfunction, resulting from stressors that exceed, in intensity or duration, the functional limits of individuals' biological, psychological, social, and spiritual coping machinery. In comparison to yellow zone stress which represents a breakdown under force, orange zone stress is considered to represent a literal wound in the body, mind, or spirit of the individual. It is a subclinical and preclinical state from which most individuals are expected to recover. However, the orange zone is also a marker of risk, both for possible failure of role performance (loss of operational resilience) and future mental disorders or behavioral problems (loss of psychological resilience).
Ill: The red zone
The red zone is the zone of diagnosable mental disorders arising in individuals exposed to combat or other operational stressors. Because red zone illnesses are mental disorders, they can only be diagnosed by health professionals. Nevertheless, commanders, unit leaders, peers, and family members can and should be aware of the characteristic symptoms of stress illnesses so that they can identify them and make appropriate referrals as soon as possible. The most widely recognized stress illness is PTSD, but well-recognized mental disorders arising from stressor exposures in vulnerable individuals include depressive and anxiety disorders, together with substance abuse and dependence.
The Stress Continuum Model is broad in its scope, encompassing likely responses and outcomes of stress, both for service members and their families, and provides a framework for recognizing and understanding the spectrum of stress experiences. By promoting and maintaining psychological health, it can effectively help to preserve both fighting strength and the long-term health and well-being of service members and families. It can further reduce stigma and demystify aspects of psychological health promotion, thereby addressing the challenges posed by warfare to the psychological health of service members and their families.
However, the Stress Continuum Model has not yet been empirically tested, and an empirical evaluation will validate some aspects of the model while suggesting improvements to other aspects. Further, induction of this model in an effective manner can only be done over a period of time as it will require large-scale training of the naval personnel and their families about the stress and its reactions. A pilot study along these lines will further support the evidence for its implementation.
The US Navy and Marine Corps have implemented a variety of psychological intervention programs such as Special Psychiatric Rapid Intervention Team (SPRINT), Operational Stress Control and Readiness (OSCAR) and Carrier Psychology Program.[18] However, in this article, we have focused on the detection of stress. The relative utility of such intervention programs is outside the scope of this article and may be addressed subsequently.
STRESS CONTINUUM MODEL: INDIAN NAVAL CONTEXT
Since no Naval personnel is immune to stress regardless of strength or preparedness, the prevention of stress injuries and illnesses requires continuous monitoring and alleviation of the stressors to which individuals and units are exposed. Induction of the Stress Continuum Model in the Indian Navy will serve this purpose by timely recognition of the spectrum of stress experiences and symptoms before they become stress disorders. It would further help leaders to identify not only the stress reactions, injuries, and illnesses experienced by their officers and sailors but also the day-to-day stressors that they encounter. The core function of identification will make secondary prevention possible by timely necessary interventions. It would also serve as a tool to maximize performance and minimize risk for damage to the mind, brain, or spirit from excessive stress. However, implementation of the same would require large-scale efforts of educating and imparting knowledge about the stress and stress reactions to all naval personnel and their families over a period of time. Further, the effectiveness of the same would have to be judged periodically by standardized ways and methods.
There already exists the divisional system in the Indian Navy where even the junior-most sailor is mentored up the chain by divisional leadings/chiefs/MCPOs/officers. This is a time-tested system for man management which has even been implemented outside the naval milieu in tri-service organizations such as the National Defence Academy. It is expected that the Stress Continuum Model will add to the efficiency and effectivity of the existing structure in detecting stress.
CONCLUSION
Naval personnel are exposed to combat as well as noncombat stress due to their professional obligations and nature of deployment. The Stress Continuum Model has been utilized as a tool for detection of stress reactions. Utilization of this model and early detection of stress reactions will prevent them from evolving to stress-related disorders. Thus, a larger number of individuals will be available for operational duties, thus enhancing operational effectiveness. A pilot study along these lines will further strengthen the evidence for its implementation in the Indian Naval context.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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