Tuesday, April 19, 2016

War Trauma in the military, their families and Communities


Ruwan M Jayatunge  M.D.  

Combatants Affected by the Prolonged War

The 30 year armed conflict in Sri Lanka has produced a new generation of veterans at risk for the chronic mental health problems that resulted following prolonged exposure to the war. Over 200,000 members of the Sri Lanka armed forces and police had been directly or indirectly exposed to combat situations during these years. There had been nearly 20 major military operations conducted by the Armed Forces from 1987 to 2009. A large number of combatants from the Sri Lanka armed forces were exposed to hostile battle conditions and many soldiers underwent traumatic battle events outside the range of usual human experience. These experiences include seeing fellow soldiers being killed or wounded and sight of unburied decomposing bodies, of hearing screams for help from the wounded, and of helplessly watching the wounded die without the possibility of being rescued. Following the combat trauma in Sri Lanka, a significant number of combatants were diagnosed with Post Traumatic Stress Disorder (PTSD). The combat operations in the North and East had involved military personnel in major ground combat and hazardous security duty. A significant number of combatants had posttraumatic reactions soon after the traumatic combat events. Majority of these reactions were undetected and untreated. The deaths include 27,639 LTTE carders, 23,327 Sri Lankan soldiers and police officers, 1,155 Indian soldiers, and tens of thousands of civilians. The last phase of the war resulted 280,000 internally displaced persons.

Combat Trauma Experienced by the Soldiers

War is particularly traumatic for soldiers because it often involves close violence, including witnessing death through direct combat, viewing the enemy before or after killing them, and watching friends and comrades die (Hendin & Haas, 1984). After exposing to combat trauma soldiers are more likely to have psychological ailments predominantly stress related symptoms, problems with social relationships and various other problems. The wounds that they received from war are not confined to the battlefield it frequently transformed to their domestic environment as well. Although studies are needed to systematically assess the mental health of members of the armed services, a very few studies were conducted during the last 30 years. The most common mental health issue for soldiers is post-traumatic stress disorder and related symptoms of depression, anxiety, inattention, sleeping difficulties, nightmares, and survival guilt.
The dedication and the courage of the armed forces cannot be underestimated and the Sri Lankan combatants fought one of the longest and deadliest armed conflicts in the world and they were able to gain a clear victory. Sri Lanka paid an immense price for the victory. As a result of the three-decade war, many soldiers became physical and psychological casualties. Unfortunately the society is gradually forgetting the scarifies made by these people. Although many see war as a heroic effort, there are thousands of untold traumatic stories in the Eelam War.  Some soldiers shared their traumatic stories with us and these stories reveal the magnitude of their suffering. These stories represent the true nature of combat trauma in Sri Lanka.

The psychological casualty of the operation liberation
The Operation Liberation or Wadamarachi Operation was conducted in 1987. It was the first major military operation in Sri Lanka. Nearly 8,000 soldiers participated in this campaign.  The most popular and the famous officer of the Sri Lanka Army the late Gen Denzyl Kobekaduwa commanded this military offensive against the LTTE. Corporal Ax36 is one of the psychological casualties of Operation Liberation. During this battle, he faced many battle stresses. He was physically and mentally exhausted. After serving, a number of years in the Army Cpl Ax36 witnessed many traumatic events.  He suffered nightmares, intrusions, hyperarousal, and flashbacks. He was avoiding people and places related to his traumatic experiences and became emotionally numbed. In 2003, Cpl Ax36 was diagnosed with PTSD. 

Corporal Ax36 describes his present emotional and physical ailments as follows.

I was one of the soldiers who took part in the Wadamarachi Operation in 1987. Our main aim was to liberate Jaffna Peninsula and destroy the LTTE positions. When we came near the Thondamanaru Bridge, the LTTE destroyed the bridge using explosives. We had to advance slowly. One of our soldiers died in front of my eyes as a result of a booby trap. I can still recall his face filled with blood. It was a horrific incident. Needless to say that I was terrified by this event. Because I am a human although I wore a military uniform. I was shaken by the death and demolition. Even after many years, I still see these events in my dreams. To evade the nightmares I used to take alcohol and go to sleep. I cannot stand any loud noises, I become frightened and my heart started pounding. Often I try not to think about past events. When I see the TV if I see any combat related story or a pictures I disconnect myself with it. I hate to talk about past events especially those related to the war.

I have no strength in my body now. My joints are aching. I cannot even walk a mile.  Prematurely I have grown old. My mind is full of melancholic feelings. I am unable to feel happiness. For many years, I never experienced cheerfulness.
I am unable to concentrate and I am very forgetful. I have forgotten the names of my fellow soldiers who served with me in the same unit. Sometimes I feel that I have no reason to live. My family members avoid me because of my hot temper. Unlike early days, I cannot control my anger. I have been turned in to an irritable cold person. Several times, I thought of disappearing from this world. But according to my religion it is a sin. Therefore, I have resisted the idea of committing suicide.

Private K and Survival Guilt
There is a higher incidence of depression in veterans who had been in combat and lost a friend. Survival guilt is an especially guilt invoking symptom.
“Survivor guilt” is the term used to describe the feelings of those who, fortunately, emerge from a disaster, which mortally engulfs others. On an irrational level, these individuals wince at their privileged escape from death’s clutches(Harvery, 2007).

Private K is a soldier who was severely troubled by the survival guilt. He joined the Army in 1992 and served in the North. While serving in the combat his buddy was shot in front of his eyes near the Punani station. He fell down and lost his consciousness. Although Private K wanted to help his friend, he could not reach the friend due to heavy fire. Along with the other soldiers, he attacked the enemy and eventually went near his friend. But he was dead. This incident made him so upset. He felt guilty that he could not help the buddy.

By 1997, he often experienced headaches, intrusions about his dead friend and showed a marked depression. He became irritable and gave a startling reaction to any slightest sound. Private K felt uneasy with the military duties and wanted to avoid military situations. In 2003, he was referred to the Military Hospital Colombo and diagnosed as having PTSD.   Private K’s condition improved following drug therapy (SSRI) and psychotherapy (CBT and EMDR). By 2005, he was free of most of the PTSD symptoms. After cognitive restructuring, he got the insight and now Private K knows that he was not responsible for the death of his friend.

Did I bury him alive?
Private Lx26 became pitiful when he witnessed the death of his fellow soldier who got killed by a sniper shot. The troops had no means to bring the body back. After confirmation of death, Private Lx26 was ordered to bury the body. When he touched his friend’s body, he could feel the body warmth may be due to the hot Northern climate. Private Lx26 dug a pit and buried his friend’s body in the mist of sorrow. Then they advanced towards Omanthai. After a several days, Private Lx26 had an irrational and guilty feeling that he had buried his friend alive. He suppressed this painful feeling for a long time. Gradually it became a distressing thought, which he could not bear anymore. In 2003, he experienced a severe depressive reaction following survival guilt. He had full-blown symptoms of clinical depression. He was treated with Rational Emotive Therapy in which his irrational and illogical ideas were confronted via a friendly and therapeutic mediation. After the therapeutic intervention, Private Lx26 was free from devastating psychological burden that he had carried for long years.

My Sergeant died in my arms: says Private RS
I was born in a small village in Pollonarwa and often our village became the LTTE target. Several times the LTTE attacked our village slaughtering men women and little children. We had mass funerals after these attacks and most of the villagers felt utterly sad and insecure.  As a child, I saw these horrendous things around me. At night, we did not sleep in houses, for security we slept in the jungle. I did not see a way out for these tremendous problems except joining the military. So I was determined to join the Army.

Our family had to face many financial hardships and that affected my education. I could not study further and I joined the Army. After my basic training, I served in Welioya and Vavunia.

In 1997, I participated in Jayasikuru (Victory Assured) operation and we were given a task to capture the Mankulam highway. We fought the enemy face to face. The gunfire lasted for nearly 3 hours. A commando unit came for our support and we were able to advance further. Sergeant L who was my senor NCO and my mentor was behind me. He taught me many combat skills. We always fought the enemy together. He used to cover me and I used to cover him. Both were lucky for many years. However in Mankulam he was hit by a bullet. Sergeant L was bleeding profusely. I helped to evacuate him. I carried him while praying for his life. His breathing became shallow. I could not reach the medics, half way he died in my arms.

After his death, my conscience blamed me for not saving him. I felt guilty. I wish I could have taken him to the Medical Point on time. If I had done that, it could have saved his life. But I was late and Sergeant L died. I was troubled by this guilty feeling and combat related nightmares and various intrusions. My life became to a standstill. I was filled with sorrow and repulsion of combat events. I was disgusted with all these issues and once I wanted to shoot myself and end the suffering. Somebody or some power saved me from self-harm and showed the way towards life. Again, I saw light.
(Private RS was found with PTSD comorbid with depression.  Following intensive treatment, he was able to recover. He became free of survival guilt that had troubled him for a long time. Now he is serving in his unit without firearms and doing light duty. )

Rifleman Sn34 and Baptism of Fire
I became a psychological casualty at the Yal Devi operation says Rifleman Sn34 revealing his story thus.
Operation Yal Devi was my first combat experience. We faced the enemy with courage. I witnessed a lot of traumatic incidents there. Our fellow soldiers died in front of my eyes leaving us in sorrow. On one occasion, the enemy gave us a surprised attack and we were scattered. I jumped in to a pit and waited all night long. It was a dark night. I saw the enemy collecting weapons from our bunkers. I was alone and feared for my life because I knew, the enemy had no mercy. I had seen dead bodies mutilated by the enemy. I thought they would do the same thing to me if they could capture me. It was an awful idea. I had vivid mental pictures of my funeral and I saw my parents were crying. I did not want to be captured by the enemy and let them mutilate my body.

The entire night I was praying for my life and by dawn the reinforcements came and they rescued me. I was taken to the hospital. Although I had no physical injuries, my mind was deeply wounded. Nevertheless, doctors said I was ok. I felt something was wrong with me. I was sent to the battlefield again. I had fear feelings and every night I saw the same horrible dream. I saw myself trapped in a pit and the enemies were all over. Despite the fear and resentment, I did the duty that was requested from a soldier. My mental health was deteriorating and I had no salvage. Finally, I decided to become AWOL.

I went home as a completely changed person. The innocence of youth and affection towards the family members had gone away. They saw me as a frightened cold soul. My parents thought that some evil spirit had got in to my body and they did Thovilaya, the ancient ritual to chase dark spirits to heal me. But it did not help. My memory was fading and I couldn’t sleep. Nightmares ruined me to the end.

My family arranged a marriage for me thinking that it would help me to get away from alienation. After my marriage, again I went back for duty. But I was a lost soldier. I was anxious performing military duties. I had intense fear of enemy attacks. The noise of the gunfire made me startle.

I went home after several months serving in the North. I had no happy feelings that I got a vacation after so many months fighting in the jungle. My emotions became numbed and I was no longer interested in marital life. I became more and more hostile and physically abused my wife. Since I couldn’t have a sound sleep, I started indulging in alcohol.  Practically day and night, I was drinking secretly. But it made me worse. It made me a monster. My wife was afraid of me. When I came home, she was shivering in fear. When I was angry, I destroyed the house property. Nothing gave me relief.
Eventually I decided to talk to one of my senior officers whom we trusted. The officer listened to my grief and helped me to get psychological therapies. I was treated at the Psychotherapeutic unit at the Military Hospital Colombo for nearly 3 weeks as an inward patient. Then they got down me to the clinic and treated me. Counseling and medication helped me to get away from the trauma that I experienced for a long time. Today I am a new man who is not abusing alcohol and I love my family. I enjoy life and do not live in past memories.

The soldier who did not like to attend military funerals
I hate to participate in Military Funerals says Lance Corporal S who described his military life in the following account.
In 1987, I was posted to Kurumbasevadi camp near the Palali Base Camp. There I faced the baptism of fire. In that camp, I served nearly one and half years and was then sent to Welioya camp. I was at the forward defense line. At the Welioya camp, I witnessed many horrendous combat events. The enemy attacked us with heavy weapons killing my fellow soldiers. I saw how they were lying on the ground with bullet or shrapnel wounds. I collected the dead bodies and put them in to body bags. I was utterly devastated when collecting human remains.

In 1991, I served in a non-operational area but my official duty was to participate in funerals of our soldiers who died in action. When I was at these military funerals, I had various intrusions about the battlefield and my dead buddies. My heart was broken when I heard the mourning and wailing of the relatives. At one funeral, I saw a mother was crying for her dead son. He was a good soldier whom I knew. Her weeping reverberated in my ear. I recalled the dead soldiers at Welioya, how they were lying on the sand. Some with opened eyes.  Many weeks I could not sleep. I hated to participate in these depressing military funerals. However, my duty required such participations. In each funeral, I had flashbacks and deep sensation of sadness.

By 1998, I got a transfer to Mannar District. There while I was traveling by bus I met with a land mine explosion. I was wounded and treated at the hospital. Although my physical wounds healed, the fear I experienced at that event was re-occurring. My mind was full of various battle events, military funerals and the land mine explosion, which I met in Mannar. I had nightmares and fear feelings. I became more irritable and sexually inactive.

My body became a source of pain. Every joint in my body started aching. When I experienced an unbearable headache, I could not stand noises.  After the land mine explosion, I was again posted to the former camp in the non-operational area to fulfill funeral duties, which I hated. Regrettably, the senior officers gave no ear to my grievances. I was there for another one and a half years. During that time my illness progressed rapidly and once I decided to commit suicide inside the camp. My unsuccessful   suicide attempt alarmed the platoon officer and I was sent to the hospital. At the hospital, I was treated and given medication and psychological support. After months of treatment, my condition improved. Today I am doing light military duty in a non-operational area. But still I cannot see the dead and war memorials.
(Lance Corporal S was diagnosed with PTSD treated with SSRI and EMDR. After intense therapy, his anxiety based symptoms were reduced to a significant level)

In my dreams I see the enemy is attacking my bunker says Private Rx68 (A known PTSD patient)
….My memories are still filled with the events that took place on the 24th of August 1993. Now for many years I still live with these horrendous memories. Practically every day I recall these events and it gives me pain and anguish.
On that doomsday at 12 o’clock midnight I was at the bunker. Two of my buddies who were with me had a rest while I was on guard. Suddenly I heard gunshots and one of our corporals shouted that the enemy is attacking the Janakapura North Camp. I awakened two of my buddies and asked them to be on alert. Within a few moments, a group of LTTE attacked our bunker.

I heard the scream at the adjacent bunker. The enemy attacked them with a hand grenade and I presumed that they had captured that bunker. So we were on our own and fighting the enemy. Three of us fired at the enemy from three different directions and we never wanted to surrender.

The enemy came towards us like an unceasing wave.  I attacked the enemy with my LMG killing a dozen of them. One of my buddies near me sustained a gun shot and fell down. Hence, two of us had to face them.
We fired at them without giving any break. Suddenly they attacked my bunker with a RPG and the bunker collapsed. A large Palmyra log fell on to my head and I was semi-conscious.  My ears became blocked and I felt bleeding from my head. I knew if we stayed there, we would be killed. Therefore, we came out from the wreck and crawled towards the center of the camp. While we were moving several LTTE carders came to capture us alive and I threw a grenade to escape.

When two of us went further, we met a group of our soldiers. We regrouped and attacked the enemy.  The assault went for a long time, by dawn the enemy withdrew from the camp leaving many casualties. Although I was injured and tired, I fought with my guys without dropping my weapon.  In the morning, I was sent to the hospital for treatment.

I still recall how my friend at the bunker fell like a log after being hit by a bullet to the head.  We fought while he was gasping and we had no time to pay attention to him. He must have died within a few minutes. These memories hound me at nights. When I am half a sleep I see shadows, and I become vigilant. I always get a feeling that the enemy is crawling towards me. I fear that the enemy would attack with a RPG. Then I open my eyes and my heart starts to beat like an accelerated machine. Afterward for several hours, I am unable to sleep. Awake at night I am thinking about my friends who died in the battle. Then I feel that it was so unfair that I am alive and they are no more.

Sometimes I see battle events in my dreams. Often when the enemy attacks I am unable to return fire, my gun is jammed. Since I am unable to shoot the enemies, they are approaching me little by little. I can hear their voices scolding us in Tamil Punde Army, Punde Army.  I become helpless. I hear someone throw a grenade. My fear increases and I shout. Then I realize that it was another nightmare.

My family members are now used to my screenings at night. My great fear is when I am sleeping I might harm someone who is near me. Therefore, I often tell my wife and children not to be near me when I am sleeping. My life has changed dramatically and I am not the same person anymore. My emotions are numbed and I cannot cry for my dead friends.

The Story of Private UG
Private UG met with a blast injury in 1997 near the Thaladi camp. He was wounded and psychologically shattered by the blast. After several months of the injury he complained of severe headache, insomnia and fear feelings. Gradually he developed PTSD symptoms. Private UG found it difficult to sleep and experienced nightmares related to the blast injury. He had fright feelings and always wanted to avoid the places and conversations related to the blast injury. Any slightest sound made him jumpy. He became irritated and could not control his anger. Often he experienced sexual dysfunctions and as a result of family turmoil, his wife left him. Following family problems and overwhelming anxiety, he tried to commit suicide.

When Private UG was referred for psychological therapies, he was treated with CBT and EMDR which minimized his PTSD symptoms. Today he is able to sleep without nightmares and intrusions hardly bother him. He does not get excessively angry as early. He has learnt to manage his anger without destructive behavior. The final follow up revealed that his wife had returned and Private UG is leading a productive life.

I was hiding in a hole in the ground: Rifleman Mx38
The night of the 27th of September 1998 was the most terrible hours of darkness of my life.  I was at the FDL in the Paranthan area. The LTTE attacked my bunker and they managed to come very close. My friends had thought that I was dead and the enemy had captured my bunker. Then they too attacked the bunker with their weapons. I was trapped facing enemy fire as well as friendly fire. Without many options, I decided to abandon the bunker. I crawled and moved away from the FDL.  Then I found a pit and I was hiding in there. I heard the enemy’s movements and lot of gunfire. I thought this would be the end. Within a few moments, they would discover me and they would not think twice to kill me. I saw child soldiers moving towards the FDL with heavy weapons, then the LTTE female carders with AK 47 in their hands. Luckily, no one saw me or not expected me to be in a hole in the ground.  I could hear heavy fighting and I decided to stay inside the pit. I was trapped there for several days. I had no food   and my water bottle finished by the second day.  On the third day, I was thirsty and I was compelled to dink my urine. By the fourth day, I had no alternative. I decided to move towards the FDL. I noticed the defeated enemy retreating group by group. I took cover and avoided them. It was a dark night and I made no noise. I was without food and water with severe exhaustion. I moved slowly.

When I came near the FDL I had to be vigilant not to attract friendly fire. I shouted at our soldiers. I told them my name, unit and my serial number. Then they recognized me with a surprise. They had thought that I was killed or captured by the enemy. I was taken to the C/O and he admired my courage. I evaded death like a miracle. I was lucky to come alive. But this happiness lasted for few days. Often the fear and isolation that I experienced inside the ditch bothered me. I could not rest, every time I had to be on guard anticipating an invisible enemy.   Days went by, I was still feeling fear. When I went to an ambush I became restless, I was looking at the front, then my inner feeling said the enemy is behind you, I looked back, and no one was there. I could not concentrate my mind. It was a terrible mess and became an obsessive ritual to watch every direction for the enemy.

My head started aching and often I forgot things. Several times, I was warned by senior NCOs and Officers for leaving my weapon elsewhere. I could not concentrate or remember things. At nights, I was practically awake. A slightest sound made my heart ooze with fear. My heart started pounding giving me aches and pains. I had terrible nightmares. In my dreams, I saw I was trapped in a hole in the ground and surrounded by the enemy. I hated to go to sleep.
(Rifleman Mx38 was diagnosed with PTSD treated with SSRI and Psychotherapy –CBT& EMDR. According to the 12th April 2005 follow up he experienced no major PTSD symptoms. His sleep became normal and the startle reactions became minimal. No intrusions or flashbacks troubled him)

The story of Lance Corporal AS – The soldier who was living in isolation
I was happily married but things changed when I became wounded. In 1990, I was at the Thaladi Camp, Mannar. There I saw fierce battles.  The LTTE attacked us with heavy weapons killing nearly 40 soldiers. With utmost difficulty, we were able to defeat the enemy. My heart cried when I saw the dead bodies of our fellow soldiers. We were like one large family. Prior to the attack we had meals together and made jokes about odd things. They have gone forever. When I put their bloodstained bodies in to the body bags, I cursed the enemy.

After this event I became more isolated and had intrusive memories. There was no one to speak about my anguish. I became alienated.  When I came home, my wife often asked what was wrong with me. However, I did not tell anything to her. Because it was a pointless effort to tell my sorrow to her and she would never understand what happened in the battlefield. Therefore, I silently lived with my grief. But I became more and more irritable.

In 1996 we went to Kodikamam and ambushed the enemy. There was no proper camp for us. We lived in abandon houses, which were ruined by the shellfire. It was a hostile ground. The enemy was everywhere. If you do a stupid mistake, you would sleep in a body bag. I was uncertain of my life. We lived day-by-day avoiding enemy fire and booby traps.

One day we accidentally walked to an ambush and the enemy fired at us in close range. Eight of our men died in this attack and they died in front of my eyes. We too attacked the enemy and eventually managed to escape. But we had to leave the bodies due to the advancing hostile forces. I still feel guilty for leaving their bodies. Indeed it was a terrible time. During these years, I saw many dead soldiers as well as the members of the LTTE. Some bodies were decomposed or mutilated. I saw large monsters eating dead bodies. The things I have seen confirmed me that there is no glory in death for sure.  Once I saw a dead body of a staff sergeant (he was known to me), the enemy had shot his eyes. It was a horrible image to see, a dead body without eyes and instead of the eyeballs, I could see the deep bullet wounds. For many years, that image was deposited in my mind. I even had bad dreams.

When I came home these battle events started roaming around my mind. I wanted to be left alone. But my wife wanted to know what’s wrong with me. I was not interested in sex life. I was avoiding my wife. She thought I was having an illegal affair. I could not stand her accusations. I became depressed and could not tolerate noise. When my children played and shouted I became extremely angry. I punished them severely. When my wife protested, I used to beat her too. One day I smashed the TV and chased everybody out of the house.

My family was suffering with me. When I came home, I used to physically abuse my wife for a slightest argument. She felt uneasy during my presence. Even the children feared me as if I am a monster. Little by little, I was losing my family. When the physical abuse escalated, my wife went to her parent’s house with the children.  I was all alone and I started abusing alcohol.

My nights became more and more disturbed. I experienced battle events in my dreams and relived painful moments. Sometimes I could hear gunshots, artillery fire and helicopter sounds. I was trapped in reality and illusion. I had a deep loathe when I saw military vehicles and uniforms. I was afraid of going back to the battlefield. I never knew what fear was but now my body shivers even for a slightest sound like a firecracker.

My wife refused to come back then I became more depressed. I wanted to end suffering by shooting myself. Once when I was on duty at the Army camp, I took a weapon to take my life. A senior NCO jumped and grabbed the weapon. Then I was produced before my Officer in Command. I thought I had to face charges violating military discipline. Instead of punishing me, they sent me to the Military Hospital. There I was treated and the doctors were kind enough to arrange an open interview with my family. The doctors convinced my wife to come back and finally she agreed. With   treatment, I was able to control my anger. My intrusions and nightmares diminished and gradually I became a productive person. Now for over two years, I live with my family and I do not abuse them.

I lost my voice in the height of the battle – Lance Corporal W
Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, or dissociative reaction. Psychogenic aphonia is a conversion symptom, which arises following an unconscious psychological conflict.  There were many soldiers who lost their voices without any organic factors in the Eelam War. These soldiers mainly had overwhelming combat stress factors, which led to their aphonic condition. Lance Corporal W who is a known PTSD patient described how he lost his voice in the midst of the war.

I joined the military in 1995 and faced many battle events. In 2000, I went to serve in the Pallai camp where the LTTE attacked us with mortars. I was shattered by the sound of this mortar fire. I felt a profound breakdown inside my body. Every time I took cover to incoming mortars. I could feel the shockwave.  I saw how our soldiers sustained injuries. I still recall one event in which a soldier succumbed to a mortar blast. His bowels came out and blood splashed  all over. It was a cruel and painful death. I was always on guard for incoming mortars. When that ‘zooooo’…..noise comes I always took cover. I knew what was going to happen in the next moment.  Mortar come with that sound and gives a terrible blast. If you don’t go down you would be hit by shrapnels. Although I was extra careful, I was not lucky. Once I sustained minor injuries as a result of a mortar attack. Shrapnel pierced my thigh.   I was hospitalized and treated for a few days.

Pallai experience was a horrendous experience for me. I was not sure of my life and often lived in uncertain situations. However, I was lucky to be alive and returned from Pallai. Then I served in a relatively favorable environment. In 2003, I re-experienced Pallai events and I frequently had nightmares. My fellow soldiers did not like me because I used to scream at midnight with fear. Some thought that I was smoking ganga. One night when I was sleeping, I saw an incoming mortar. I cried for help but there was no sound. I became speechless. . Ever since, I could not speak and I lost my voice.
(Lance Corporal W was aphonic for several weeks and underwent psychotherapy. He was treated with hypnotherapy and was able to regain his voice. His PTSD condition lasted for a long time. Medication and CBT helped him to minimize the condition)

I had walked to the enemy lines: Private SK
“I was confused and did not know what I was doing. I had walked to the enemy lines. Luckily, a team of Special Forces saved me. When they found me, I had dropped my weapon and was wondering towards the enemy lines. I don’t remember how I left my defense point or where I dropped my T56. I was taken to the camp and produced before Col ….. I was heavily questioned.  Later they blamed me for abandoning my post and losing the weapon. I was severely punished for that offence”.

(Private SK had gone into a psychogenic fugue state following overwhelming battle stress. He could not recall what really took place on that day. He served at Nedunkurni and witnessed the death of four soldiers as a result of an artillery fire. He saw how their bodies had been blown into pieces and instantly he was shocked. After this incident, he gradually became a victim of combat related PTSD which was undiagnosed and untreated. He had dissociative features as well. Several times, he went into fugue states and in the final event, he had walked to the enemy lines.   After he was rescued Private SK was referred to the Psychological Treatment Center at the Military Hospital, Colombo. At the center, he underwent a series of psychological assessments and cyber testing method to elicit autonomic arousal. He was diagnosed as having PTSD. Private SK was treated with SSRI and SPDT (Short Term Psychodynamic Therapy). With the treatment, his mental state improved)

POW s with PTSD
There are a number of POWs of the Eelam War who still carry the psychological scars. Most of them suffer from DDD Syndrome which was delineated by Farber Harlow in 1956. The DDD Syndrome consists of Debility, Dependency and Dread.  POWs often show depression, apathy, suspicion and fear. Some have large memory gaps and still feel guilty about their POW days.

Lance Corporal U has served 17 years in the Sri Lanka Army. During the Balawegaya operation, he sustained a gun short injury to his leg and became immobile. When the enemy advanced, he could not move and hence he became a prisoner. When he was captured, he was severely beaten and threatened with death. But one of the LTTE regional leaders stopped the beatings and sent him for medical treatment.

When the medical treatment was over, he had to undergo vigorous interrogations. He was tortured to get information about his Camp and its inner structure and guard points. He was handcuffed and kept in painful positions for long time. Frequently his guards physically assaulted and humiliated him. However, Lance Corporal U admits that there were some members who were kind to him and brought food sometimes.

From July 1991 to March 1995 L/Cpl U spent his life as a POW facing torture, humiliations and uncertainty. He was kept in a very small cell with forty other prisoners. They had no space to move. The prisoners were allowed to take a bath once in two weeks or sometimes longer than that. Many suffered skin infections. Their meals were not served regularly. Following the intolerable conditions, the prisoners launched a hunger strike and eventually he was released in March 1995 after the interference by the ICRC.

Although Lance Corporal U became a free man, he often suffered from an unexplainable fear. The POW days memories hounded him severely. Some nights he used to wake up with fear thinking that he is still in the LTTE prison cell. He was depressed and surrounded by guilty feelings. In order to avoid nightmares, he was indulging in alcohol. More he used alcohol more he became depressed. He often physically abused his spouse. Lance Corporal U began to avoid everything related to his traumatic experiences.

He was suspicious about the surroundings. He lost the ability to trust and feel intimate. He was affected by emotional anesthesia. He had flashbacks and sometimes he could not distinguish reality from fantasy. His physical strength was weakening and slightest exertion gave him an immense body pain. In 2003, he was diagnosed as having PTSD.

The Cook of the Poonari Camp
Mr. N -a civilian worked as a cook in the Poonareen Camp. When the LTTE attacked the Poonari camp in 1993, many lost their lives. To evade the enemy he was hiding inside the building complex and was later found by LTTE carders. He was beaten and threatened to be killed on the spot. He was mistakenly identified as an officer in disguise. He was subjected to numerous physical and mental tortures. Eventually the Red Cross intervened and established his correct identity.

For nearly nine and half years, he lived his life as a prisoner under the LTTE. He was homesick and practically every day prayed for his freedom. For long time he lived with uncertainty without knowing what his future would be. When the Air Force attacked the LTTE camps, their guards used to ill-treat them severely. His condition significantly improved when he met another POW – Capt Boyagoda from the Sri Lanka Navy. Captain Ajith Boyagoda became a POW when his naval ship   “Sagarawardene,” was attacked by the Sea Tigers in 1994. Capt Boyagoda gave him courage and strength to face the callous conditions. Along with the other POWs, he spent the time discussing their release and writing letters home via ICRC.

He was released on the 30th of September 2002. After his release, he gradually developed stress related physical symptoms like headaches, backaches which did not subside to painkillers. He was unable to sleep. At nights, he was awake and thinking of the past. He often felt melancholic feelings, and troubled by emotional anesthesia. He could not feel the happiness of becoming a free man. His emotions were dead. Mr. N was losing the will to live. Several times, he planned to commit suicide.

He was referred for psychological therapies and in the assessment, many somatoform features were found in him. Despite the traumatic symptoms, he positively responded to psychological and drug therapies. Gradually he was able to get away from his melancholic feelings, intrusions and psychosomatic troubles. He was lucky to receive a lot of psychosocial support, even a house donated by the Ceylinco Group. Today Mr. N is very much symptoms free and living a productive life.

Combatants with Partial PTSD
According to Kulka partial PTSD is a sub diagnostic constellation of symptoms that was associated with significant impairment. They have sufficient features of re-experiencing and hyperarousal with insufficient features of avoidance and numbing and comorbid alcohol abuse or dependence.

Cpl Tx3 was a member of the Army Special Forces engaged in a number of military operations. He often worked with the long-range reconnaissance patrols (LRPP). Cpl Tx3 met with numerous hostile enemy conditions, which affected him psychologically. On one occasion, they had deeply penetrated the enemy area. He was with a five-man team and they operated silently. Suddenly he met with two LTTE female carders face to face and none of them fired. Cpl Tx3 was in a dilemma situation, if he had fired at the two LTTE female carders his team would have been in a great danger. Unbelievably, the two women disppeared into the jungle. He was confused and dazed for a while but was able to return safely.

For many years, this incident stuck in his mind. He always questioned himself “why didn’t they shoot? With these intrusive thoughts, he re-experienced combat events that occurred in the North. He would have a startle reaction to any loud noise and became vigilant all the time. Despite the posttraumatic features, he was not avoiding combat situations. Therefore, the avoidance feature was not seen in Cpl Tx3.

Lance Corporal Ax4
Lance Corporal Ax4 who was diagnosed as having partial PTSD, expresses his combat experience thus.
“In 1992 I was posted to Kaytes Island. My own brother served with me in the same unit and I was not comfortable with it. Therefore I requested for a transfer and I was asked to serve in Kajuwatta, Mannar. While I was serving in Kajuwatta camp, one day I got a message saying that my brother was killed in action at Keerimalei. Although I was given leave to attend my brother’s funeral, when I went home the funeral was over. But I attended  the religious ceremonies after his funeral.

When my leave was over, I had to report back to the camp. My mother was devastated over my brother’s death. When I went to say goodbye to her she asked me to stay with her. But I had to report to duty. So I left home. While I was traveling to the camp, again I got a message near Puttalam stating that I should report home immediately. My inner mind told me that some bad thing had occurred. When I went home, I met with another disaster. My mother had committed suicide. I was relentlessly shattered. I lost my brother and now my mother. This time after her funeral, I did not report to work and became AWOL. After several months,   I decided to report for duty and this time I was posted to a rescue mission at Poonary. In this mission I sustained a mortar blast injury and was taken to the hospital.

“After I was discharged from the hospital I participated in Rivirasa operation. We walked up to Killinochchi facing hostile enemy attacks. A lot of buddies died in front of my eyes. At Killinochchi the enemy attacked us with mortars. I sustained injuries and I was bleeding. I asked others to help me. No one came to help me and I felt fear. Then I saw a sergeant passing near me and I asked him to help me. But he left me just giving a glance. I was helpless and in pain. I gathered my entire energy and strolled   towards Elephant Pass. Half way, a group of soldiers helped me. They put me in a cab and took me to the nearest Med Aid Point. There I lost my consciousness and when I opened my eyes, I was at Anuradapura hospital.”

“I was treated several weeks at the Anuradapura hospital and then discharged. I realized that I was experiencing some distressing past events and these intrusive memories troubled me. I could not tolerate sudden noises. My mind was full of traumatic events that I had experienced in the recent past. Some nights I could not sleep and I was having a severe headache. When I am with physical and emotional pain, I become restless. I am not afraid of the battle. As a soldier, I can go to the warfront at any time. The war does not scare me anymore”

My commanding officer was hit in front of my eyes: Private SN
Private SN who was shattered by war stress expresses his past experience in the following manner……

At Mallakam (1995) the LTTE attacked us with RPG. I stood near my commanding officer. I fired at the enemy with my T56, killing two of them, then a mortar exploded near us. I saw my commanding officer wounded and bleeding heavily. His uniform was soaked with blood. I expected help form our buddies. When I looked at the right flank, I saw no one. I shouted for help. Then another mortar exploded near me. I too sustained injuries. Blood came from my left ear.  I had no strength to help my commanding officer. While he was lying on the ground I crawled towards the rear side. I had severe guilty feelings for abandoning him on a hostile ground. But I had no option. When I was crawling,    I met some of our soldiers. Then I shouted at them “the CO is wounded get him soon” .

So they went to rescue him. I went further. I could not crawl anymore. I lost my energy. The world was trembling in front of my eyes. I could hear the gunfire, artillery explosions and the incoming mortar sounds. My eyes were covered with a dark strip. I lost consciousness. When I opened my eyes, I was at the Palali Hospital.

I was treated at the hospital for nearly one and half months. When I was discharged from the hospital, I went back to my unit. I realized that my personality was changing   little by little. I was a daring soldier. But the events at Mallakam changed my life. Day and night, my mind was full of these events. Gunfire, black smoke, incoming mortars, images of the enemies and the wounded commanding officer were vivid mental pictures that were ruminating inside my mind. I became more vigilant. I could not sleep at nights.  I used to wake up for a slightest sound. These sounds gave me fear. When I was disturbed by a slightest sound, I felt a burning sensation in my chest.  I used to get up in the middle of the night with fear and sweat. Gradually I became depressed and felt that my life was wasted. I wanted to commit suicide. One day when I was at the bunker alone, I tried to release the pin of a hand grenade. Then I saw the eyes of my wife. I put the grenade aside.

My world was upside down.  I did not like to stay in the operational areas. I felt uneasy when I saw military uniforms and vehicles. I disliked participating in ground operations. But I had no option. I was compelled to fulfill military duties. I went with my platoon secretly suppressing my fear and avoidance. My symptoms were aggravating.  I was about to explode.
Finally, I told my fears to one of my unit leaders. He listened to me for a long time and said “you need medical treatment”. So I went to the military hospital seeking salvage. I was referred to the psychiatric unit and treated for nearly three months. I received drug therapy and psychotherapy. My symptoms reduced little by little. Then I felt much easier. Today I am doing light duty. But I have not been completely freed from the Malakam events. Occasionally I see the face of my commanding officer.

The Johny Batta that changed a young life
Private Hx26 became a victim of an anti-personnel mine in the North and underwent B/K[1] amputation. He became shocked when his foot had blown off from the ankle and for a long period, he relived this traumatic incident. After he met with the injury, his life fell apart. The girl who promised to marry Private Hx26 left him.  He could not adjust to the life with a prosthetic foot. He became more and more alienated and stopped associating with people. His life was limited to a wheel chair.

Although he was recommended rehab therapy, Private Hx26 did not actively participate in the rehabilitation program. Once he made an unsuccessful attempt to jump into the pool at the rehab center with his wheel chair. After his attempted suicide, Private Hx26 was referred for psychological therapies and he was diagnosed with PTSD.

Private Hx26 ’s therapeutic schedule consisted of drug therapy as well as counseling. After 6 weeks of inward treatment, his suicidal ideation changed and he was gradually came to terms with his disabled condition. Private Hx26 underwent further psychotherapy and finally he gave his consent to undergo the rehabilitation program with the Psychiatrist’s supervision. He selected a handicraft profession- shoemaking and successfully completed it. Two year follow-up revealed that Private Hx26 is free of PTSD symptoms.

The EPS debacle was my worst experience
The Elephant Pass debacle that occurred in 2000 due to poor leadership and inefficient strategic evacuation plan led to loss of many lives. It was a tactical withdrawal of the Elephant Pass camp but it was carried out in the hot sunny afternoon. Many soldiers died of dehydration and heat stroke. During the EPS debacle, 359 military personnel were killed, 349 were listed as Missing in Action and some 2500 were injured. Corporal K described the events that took place between the 21st and 22nd of April 2000.

On the 21 of April 2000, I was at the FDL of the Elephant Pass Camp. We were told that the evacuation order would be given at any moment. The following day at about 10.30 am, the enemy attacked the Elephant Pass camp with heavy artillery. While the enemy was attacking, our soldiers withdrew towards Kilalli lagoon. There we met Brigadier Percy Fernando who was a brave officer. He tried to reorganize and launch an attack’ then to go for a safe withdrawal. We assaulted the enemy and moved toward Pallai. The LTTE attacked us with mortars and their snipers targeted our officers and signalmen. I saw Brigadier Percy Fernando sustain a gunshot injury. It was a disastrous moment. Brigadier Percy did not abandon us. Some cowardly senior officers saved their skin and got away leaving us to the enemy. But Brigadier Percy Fernando stayed with us and gave us leadership until the end. When he fell down, I knew that we were doomed.
We were tired and exhausted. Many of our soldiers could not walk. Hot sun and dry wind sapped our energy. I felt thirsty but my water bottle was empty. Many of us did not have sufficient water. We were walking like zombies in the hot sand. Some drank salty water from the lagoon. Some began to sing songs as they lost their minds.  Many fell down with exhaustion and never got up.

While we were moving enemy attacked us with mortars. Many soldiers were dying without water and facing enemy attacks. We had to walk fast to avoid the enemy fire. There was no air cover for us. Some fainted in front of my eyes. I knew they would never return home. One solder became insane. He was singing and dancing asking for a cup of tea. Wounded soldiers asked us to carry them. But we all were worn out and had no energy to carry a fellow soldier. We were on our own and every man for himself. It was an egoistic moment that I cannot forget until my last day.

My energy was ending. I could not carry the ammunition pack. I had to throw my belongings.  Finally, I threw my weapon which was my savior for a long time. I walked in the hot son with other soldiers. All I needed was water. My head was dizzy and I fell down. I saw the hot sun. There were no clouds in the sky.  Many soldiers passed me by but no one helped me. I knew if I stayed there, I would be dead soon.  I gathered my energy and again started to crawl avoiding enemy attacks. Panicked solders trampled me and ran towards Pallai. On my way, I saw many dead bodies.

One soldier grasped my boots. He was wounded and bleeding. He pleaded with me and those very words still echoes in my mind. He said I am dying and I don’t want you to carry me, then he gave his name and address and asked me to convey his death to his parents. I still cannot forget this incident. I didn’t know who he was and by the time I came to Pallai I was unconscious. I too suffered a heat stroke and later recovered. I have forgotten his name and the address. I could not convey the message to his relatives up-to-date. But I still remember his face filled with utter despair. “

The acute PTSD victim of 2005 ceasefire
Signalman Px54 met with a claymore mine explosion in Jaffna in December 2005. He sustained minor injuries to the left hand as a result of this explosion. But 13 other soldiers died in this incident. Signalman Px54 witnessed the terrible deaths of two privates and a sergeant. These events changed the psychological equilibrium in Signalman Px54 and he was diagnosed with acute PTSD. This is how he describes the event that drastically changed his psyche.

“That was a horrible event indeed. We went to Jaffna town by a truck.  I was in the middle holding my weapon. Suddenly I heard a large noise. The soldiers in front of me fell down. Then I realized that, it was an enemy attack. Despite the ceasefire agreement they attacked us with claymore mines and then with small arms. When the enemy attacked, our driver sustained injuries.  But he was able to keep the vehicle stable and we kept on going further. There was a large tyre inside the truck beside which I took cover. While I was lying down two wounded soldiers asked for water from me. But there was no water. We had to travel a few more kilometers to the nearest camp. Another wounded sergeant crawled near me and said something. His mouth was full of blood.  Within a minute or two, he became motionless. His eyes were open and he was dead. When the truck entered the nearest camp, I rushed to help the wounded men. Most of them were dead, including the two soldiers who had asked for water. I felt really sorry for them. I could not help these soldiers even to give a cup of water.

The soldier who became overwhelmed after killing the enemy
Sergeant Sx78 served nearly ten years in the operational areas exposed to heavy combat. He faced fierce battle events defending the Jaffna Fort. The Jaffna Fort was under siege and the enemy attacked them with heavy weapons. The operation “Midnight Express” was launched to rescue troops that were trapped inside the Fort. During the confrontation, he killed five of the enemy carders. After some years, he became preoccupied with the thoughts that were related to these killings. Although they came to kill us, they too human beings says Sergeant Sx78.

They were poor village boys like us who had no many options in lifeThey were indoctrinated, poisoned with hatred and directed to attack us. We had no alternative except firing at them. In a war things are intense, either you or the enemy. If you don’t kill him, he will kill you. Anyhow, these Tamil youths had parents like us, they too had expectations. All ended sadly. Someone, somewhere may be still missing them. I know killing is bad. It is a violation of the first Buddhist precept. I was compelled to do that act”.

Sergeant Sx78 feels that one day he has to face the Karmic repercussions. His conscience was shattered and he became more religious. Sergeant Sx78 wishes to be a monk after his retirement from the Army.

The final days of the War
Lt Col ……… is an experienced field officer who participated in many operations.  He shared his experiences on the final days of the Eelam War.
……….When we liberated Thoppigala I knew we were invincible. Others may have felt that. So we advanced further. The last days of Eelam War were hectic. The LTTE built a large sand walls and it was difficult to penetrate it following heavy fire. They were among the civilians creating a human shield. We had to be extra cautious not to harm civilians.
However, in a war civilian casualties are inevitable. For instance, how many civilians died in Iraq and in Afghanistan when the US forces retaliated? But I remember several events, when the enemy attacked, our soldiers did not attack back due to the civilian factor. The outside world would never know about these facts.
I remember when the enemy fired from a bunker, one of our soldiers tried to attack the bunker with a Tomba gun. Another soldier stopped him saying that there were civilians near the bunker. They had to find other means to destroy the bunker without causing civilian casualties.

In another event, I saw soldiers carrying little Tamil children when the civilians broke the sand wall and came towards us. These humane stories were never told and only negative points were highlighted.

I agree, in a war atrocities are often committed and in every army you see people like William Calley who did the My Lai Massacre. I personally think that the media should comment on atrocities as well as humane stories of the war. Otherwise, there will be no reconciliation at any point. After all, man is not pure evil.

I have been living with the war for many years. I have seen perished soldiers, and dead LTTE carders. All these people were the children of this land. The final days of the war were traumatic. I saw human suffering. I have seen enough blood. Those who cry for war and glorify the war from Colombo should have been there. Then they would know what the war is really like.

I felt sorry for the Tamil civilians who followed a mirage. When I first came to the North as a schoolboy at the age of 16, I was touched by the kindness of the Tamil people. The Jaffna people were cultured and educated. They had a great civilization that cherished non-violence. When the conflict erupted in early seventies, things changed drastically. Then I had to come to the North in a combat fatigue.

Tamil people in the North paid an immense price for the war. Their property were destroyed, children were forcibly recruited. They faced deaths and destruction. They lived under poverty. What happened to the millions of dollars that was pumped by the NGOs and by the Tamil Diaspora to the North? The people of Wanni had no infrastructure, people were malnourished. If this money was used to develop the North, they could have built a little Singapore.
I am glad that the war is over. We must rebuild the North and work for the ethnic harmony. We must forget our petty racial differences and work for peace with our Tamil brothers. Otherwise, within 20 years there will be another bloody war…………

Functional Impairment Following Combat Trauma
Warfare has placed great stress on combatants. Death, grief and social disorganization have been inevitable accompaniments of war. Violent conflict is part of social experience and memory (Davis, 1992).  Combat can produce distant reactions involving

Affective (anxiety, depression, irritability), Motivational (low productivity), Cognitive (confusions, poor attention and memory), Interpersonal (conflicts and withdrawal), and Biological (associated with somatic complaints) dimensions causing maladaptive behavior.

Difficulties in parenting
Many of the skills children acquire are fundamentally dependent on their interactions with their parents. Parent-child interactions are crucial in child development especially self-esteem, academic achievement, cognitive development and behavior.  PTSD patients find difficulties in parenting. Many PTSD patients are unable to express love since there are troubled by emotional anesthesia.

Sergeant KP8 a known PTSD patient described his inability to enjoy his role as a father in following manner…..
Since I became ill, my 8-year-old daughter is detached from me. She is highly frightened when I went in to tantrums and had quarrels with my wife.   Once I got very angry and dashed plates and cups, which were on the table. She started crying and hid under the bed. In the past years, she used to sleep with us, but I wake up for a slightest sound with terror and overwhelming reaction. I have fears that I might harm her when I experience flashbacks of the battlefield. I am unable to express my love for her and my feelings may be dead. I have become a cold father.

Domestic Violence
Family violence is a widespread problem that occurs among the combatants with PTSD. They use force to inflict injury, either emotional or physical, upon their spouses. Many combatants sublimate their rage. Domestic violence is a form of sublimation and transformation of anger. Based on our study, out of 56 Sri Lankan soldiers with PTSD, 13 of them frequently physically abused their spouses. Beatings and house property damage were common among them. Their anger and rage were focused towards their wives. They were irritable and hostile in family affairs.

There are many types of abuse that take place as part of domestic violence. These are emotional abuse, physical abuse and verbal abuse. They have gradual withdrawal from day to day activities. There are marked personality changes which affect their function as an active member in society as well as in family circles. Often they break family commitments, both major and minor. They become impulsive, numbed and inhibited. These features destroy a successful family life and positive parenting.

Men with PTSD commonly have sexual dysfunctions. This may be due to the anxiety and depression that they suffer. Long term use of antidepressants for their PTSD and Depression also can cause erectile dysfunctions. Some males become suspicious and have sexual jealousies. This factor too escalates family violence.

Many combatants with PTSD admit that when they go in to tantrums they over punish their children. Children often live in fear and despair. The physical abuse takes place inside the family system and rarely mothers admit that the beatings were done by their husbands. When the children are hospitalized for physical abuse, mothers always conceal the physical beatings in order to evade child protection laws.

Once a soldier with PTSD went in to flashbacks and strangulated his little daughter. The girl was choking and luckily neighbours came and rescued her. In another incident, a PTSD father became annoyed when his eight year old son could not solve mathematical sums and he beat his son with a cricket bat. Later the child was admitted to the hospital and treated for three weeks.

Lance Corporal P has served seven years in the combat zone. He sustained a gunshot injury to the right leg. After he came home he could not get a sound sleep. He had nightmares with startle reactions. To avoid his sleep difficulties and intrusions, he consumed alcohol practically every night. He became depressed and aggressive. Lance Corporal P used to physically abuse his children and the spouse. Several times he became AWOL. For nearly 3 years he went undiagnosed and untreated. Subsequently, he was referred to the Psychological Unit Military Hospital Colombo and diagnosed with combat related PTSD.  After 6 months of successful medication and psychotherapy program, Lance Corporal P was free of his PTSD symptoms. Today he is having a productive family life.

Occupational Problems
Soldiers who suffer from PTSD have occupational problems. Their productivity is weakened. They are detached from co-workers. Soldiers with combat stress have dysfunctional interactions at work places. Traumatized soldiers develop their own peculiar defenses to cope with intrusions and increased psychological arousal. One officer who was diagnosed with PTSD felt uneasy and often manifested startle reactions when soldiers come and halted with a salute. The noise made him frightened. Therefore, he used to stay away from others. Another soldier who had trepidation of uniforms felt uneasy when he comes to the camp. The irritability and spontaneous rage make them more socially isolated. They deliberately keep away from people in order to avoid confrontations. They easily get provoked. Some have homicidal tendencies.

Private WX6, who sustained a gun short injury to the face in  Operation Ranagosa in 1999, became more and more dysfunctional. He had intense rage, suspicion and homicidal ideas. He frequently had conflicts with the soldiers and officers in his unit. In 2002, following a work related dispute, Private WX6 planned to kill six of his platoon members including the platoon sergeant. His movements became suspicious and he was not issued firearms. Later, Private WX6 was referred for psychological counseling and work related disputes were resolved avoiding a major disaster.

Compulsive Exposure
Some traumatized individuals have a compulsive urge to expose to situations reminiscent of trauma. Professor Bessel Van der Kolk (1996) gives numerous examples. This is a common feature among the Sri Lankan combatants too. Many combatants believed to be suffering from combat trauma have joined the private security firms, working with politicians and engage in violence during election periods, or working with the mob. Repetition cause further suffering for the victim and for the people around them (Kolk, et al., 1996).

Cpl FC8 was psychologically devastated when he witnessed the deaths of three of his platoon members in Silavathura and later developed PTSD symptoms. He left the military prematurely and joined with a local politician. During the 1999 infamous Wayamba PC election, Cpl FC8 engaged in many election related violence that was instigated by his political master.

Private AX4 experienced numerous traumatic combat events from 1996 to 2001. He became AWOL and joined with an underground criminal gang that committed several bank robberies. For several years he was evading the police and the CCMP. In 2005 when the criminal gang attempt to rob a bank in Mathara district, they were arrested by the Police. Today Private AX4 is serving a prison term.
Capt KF9 lost his leg in the Northern territory as a result of an anti-personal land mine which was called Johnny Batta. He underwent below knee amputation and was transferred to a non-combat unit. After serving several years in a non-combat environment, he became distressed and wanted to go to the war front. He had marked posttraumatic features with intense rage. He was affected by severe hyper arousal and traumatic reminiscences. After leaving the Army, he joined a private security firm and worked for several years. His occupational difficulties were intensifying. Once he had a severe conflict with the Police and was arrested for assaulting a Police Officer.

Suicide and Deliberate Self-Harm
Studies estimate that patients suffering from PTSD have up to a seven-fold increased incidence of suicide, and four-fold increased risk of death from all external sources (Bullman & Kang, 1994). A significant number of soldiers have committed suicide in the battlefield during the Eelam War. In addition, considerable number of attempted suicides has been recorded. Suicide is a complex event. There are biological, psychological and sociological causes of suicide and suicidal behavior. Among the 824 combatants referred to the Psychiatric Unit, Military Hospital Colombo during 2002 Aug – 2005 March, 22 of them had suicidal attempts. These combatants had used various methods such as self-poisoning, shooting, hanging and in one case a planned road traffic accident.

Private HX67 was deployed in Kokkuthuduwai in the height of the Eelam war and he felt that his life was in danger. His platoon was in the jungle, they had minimal facilities and continuous heavy rain made things worse. Private HX67 shot his leg with his weapon and forced an evacuation. He was immediately taken to the hospital and treated. After his recovery Private HX67 had to face disciplinary charges.

Sergeant LX54 witnessed a number of traumatic events in the North. He witnessed the death of his platoon members and handled human remains. By 2002, Sergeant LX54 had no life interests. He had an intense death wish. Once he went to the armory, took a T-56, and placed it under his chin. The soldiers who were on duty grabbed the weapon. Subsequently he was referred for psychological therapies. Sergeant LX54 was treated with SSRI and CBT. After the treatment, he became free of suicidal ideas.

Alcohol and Substance Abuse
Alcohol and substance abuse is an observable condition among the combatants especially those who suffer from combat stress. These negative stress coping methods are often used to displace the intrusions and negative thoughts. Alcohol and other substances give a temporary sedation but in long term, it causes an enormous damage to the soldier both in physically and psychologically.

Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. It is differentiated from alcohol dependence by the lack of symptoms such as tolerance and withdrawal. Traditionally alcohol has become a part of the military culture. Alcoholic beverages are offered in the Officers Mess and sometimes the officers are indirectly encouraged to have alcohol.

Rise in alcohol and Substance Abuse among the Sri Lankan combat veterans suffering from PTSD have been observed. The veterans consume alcohol and other substances to suppress traumatic war-related memories, escape flashbacks and to achieve a combat nightmareless sleep.

A number of reports indicate that individuals meeting diagnostic criteria for Post Traumatic Stress Disorder (PTSD) are likely to also meet DSM-3 R criteria for alcoholism and /or drug abuse. Among Vietnam Veterans seeking treatment for PTSD 60-80% exhibit concurrent diagnoses of drug or alcohol abuse or dependence (Kofoed, Friedman, & Peck, 1993).
Alcohol dependence, as described in the DSM -4, is a psychiatric diagnosis describing an entity in which an individual uses alcohol despite significant areas of dysfunction, evidence of physical dependence, and/or related hardship. Chronic Alcoholism has serious consequences on a person’s health and personal life, on family and friends, and on society.

Combatants suffering from combat stress easily go into negative stress coping methods like alcohol abuse. Alcohol and substance abuse is evident among the combatants suffering from war trauma. Those veterans who experienced prolonged exposure to heavy combat are especially vulnerable. Soldiers abuse substances such as drugs, alcohol, and tobacco for varied and complicated reasons. When we interviewed 56 Sri Lankan combatants with full blown symptoms of PTSD we found 8.9% of them were severely addicted to alcohol. They were found to have alcohol related symptoms and their liver function were seriously affected following the misuse of alcohol. They consumed a large amount of alcohol in order to avoid sleep disturbances and eliminate scary nightmares. The heavy drinking may also seem to relieve anxiety and block out intrusive memories associated with combat events. But the truth is excessive drinking can disturb the natural sleep process, interrupting REM dream patterns; the veteran may become more vulnerable to the symptoms of PTSD.

Capt NX453 served in the Army for over 16 years and exposed to heavy combat situations. In an incident near Paranthan, his team was ambushed by the enemy. He saw the death of fellow soldiers and their final outcry. Another member was shot in the abdomen and his bowels came out. After they made an unsuccessful attempt to resuscitate him, the soldier died in Capt N’s arms. For number of years he blamed himself for taking his men to the enemy’s jaws.

He was disturbed over the incident and he increased his alcohol intake in order to get a better sleep and disassociate from the horrific combat event. Hence, he could not sleep without alcohol. Gradually Capt NX453 had   long periods of being drunk, he started drinking alone. He was neglecting his official duties and the senior officers could not trust his capabilities anymore. Several times, he was reprimanded for being drunk on working hours. In 2004, he was diagnosed with Harmful Use of Alcohol.

Tobacco addiction is another unseen factor, which has serious health related consequences.  Nicotine dependence is an addiction to tobacco products caused by the drug nicotine.  Nicotine can produces physical and mood-altering effects and frequent usage can increase risk of numerous health problems. The common symptoms of nicotine dependence are inability to stop smoking, experiencing strong withdrawal symptoms such as anxiety, irritability, restlessness, difficulty concentrating and sometimes headaches.

Veld and  colleagues (2002)found that cigarette smoking was more prevalent in those with current PTSD. The researchers hypothesized that, in trauma survivors, current substance use is associated with peri-traumatic patterns of psychological tension–reduction modes.

Lance Cpl RXC143 met with traumatic combat events at Mandathivu. He was troubled by the war trauma that he experienced there. He became more and more isolated and took to smoking. He became a chain smoker and couldn’t be without a cigarette. According to his wife, Lance Cpl RXC143 smokes 30 -40 cigarettes per day.

Warrant Officer AXE86 joined the Military in 1973 and participated in all the combat operations until 1999. During these times, he witnessed numerous traumatic events especially in 1988 -89. He was diagnosed with Adjustment Disorder and Nicotine Addiction. Warrant Officer AXE86 smoked over 30 cigarettes per day which caused serious vascular obstruction in his lower extremities. In 2003, he underwent below knee amputation.

Substance abuse is another issue that has to be dealt effectively. Substance abuse refers to the overindulgence in and dependence on a stimulant, depressant, chemical substance, or herb leading to effects that are detrimental to the individual’s physical health or mental health, or the welfare of others.

Our 2005 study revealed that cannabis was the most frequent substance that was often used by the Sri Lankan combatants.

Cpl  WXC45 who was an experienced combatant diagnosed with Cannabis intoxication described how he became addicted to cannabis. The narration below is based on his testimonial.

I was first posted to Nadenkerni. Our team consisted of young fearless soldiers. We knew our days were numbered; death was several inches ahead of us. To evade the nostalgic feelings and homesickness we smoked ganga. When you take the puff inside, you feel that you are disconnected with the reality. No enemy, no bullets, no mortar attacks make you frightened. In an attack, you can advance like a wind. You don’t feel the heaviness of your backpack, you don’t  feel pain even when you sustain a gunshot injury.

The supply was a problem. We used to buy the stuff in Colombo. There were many joints where you could buy it. There were a number of places in Boralla, Maradana, Slave Island etc.  Only problem was to bring it to the Northern war front. If we travel by air through Ratmalana, the Air force guys used to search us. If you get caught you are in a real trouble. We used several methods to traffic it. The popular method was to put the stuff in to a condom and then insert it inside the anal cavity.

Although there were many restrictions, our guys used to bring it and we smoked it. When we did bunker duties ganga cigars kept us awake. Thus, we were on guard all night long.

We often used Madana Modaka (Aurvedic cannabinoid product) as well. It’s like a toffee. When some of our group mates went for the operations, they kept it in the wallet. Madana Modaka gave a sensational feeling. You can run, jump and move your body like a rubber when the effect comes. We feel no pain even we sustain injuries. Some said it prolongs your ejaculation and we used to take it home when we got duty leave.

After long usage of cannabis, Cpl WXC45 had low motivation, aimlessness, apathy and sluggishness in mental and physical responses. He presented with poor self-care and transient disorientation, as well as impaired memory. Today he knows the negative effects of cannabis.

Heroin usage was not in abundance among the Sri Lankan combatants according to our experience. From 2002 to 2005, we systematically interviewed 824 soldiers and we found only three heroin users. Heroin is a highly addictive opiate, which is processed from morphine. Although it’s illegal in Sri Lanka, the addicts know the places where it can be bought. Sri Lankan heroin addicts usually sniffed or smoke it and intravenous injection of heroin is not popular among them. Why we had very minimal number of heroin addicts among the soldiers that we interviewed? When strict rules and regulations are applied to the soldiers in the Army camps, heroin uses find it extremely difficult to obtain and use it. Often they become AWOL and continue their addiction with heroin.

The effective measures have to be taken to prevent alcohol and substance abuse among the combatants. In the post war era, there is a possible risk that is prevailing and we have to take urgent measures.There are many examples from other countries that indicate the excessive use of alcohol and other substances among the combatants. According to the 2000 and 2001 NHSDUH reports[2] on illicit drug use among the US Veterans, an estimated 6 percent of all veterans living in the United States used an illicit drug in the past year. Of the 256,000 veterans in need of treatment for illicit drug use in the past year, 20 % had received treatment during the past year. These studies show that we too are at risk.

Untreated and undiagnosed PTSD
As pointed out by Lipkin, Blank, Parson and Smith (1982) many cases of PTSD go underreported because many Psychiatrists and Psychologists fail to ask about military experience or what happened to the person while in the military. We have found a number of combatants who had manifested dissociative reactions; symptoms of acute PTSD in the height of the battle who were not treated or referred to psychological therapies. When the symptoms aggravated with malignant PTSD they were referred to the Psychiatric Unit, Military Hospital Colombo.

Hence we can give a case example. Corporal T had nightmares, intrusions and disorientation during the operation Jayasikuru or the Victory Assured in 1997. He became distressed and asked for medical attention. He was taken to the nearest MSD and treated with analgesics. With the difficulty that he experienced he was sent back to the battle front. After two weeks he lost his voice or in other words he had a dissociative reaction of psychogenic aphonia. Still he was not sent for any kind of treatment. After many months, he became depressed and threatened to commit suicide. Then he was posted to Anuradhapura where there was no active combat, but had to handle dead bodies and human remains. Only in 2002, he was referred to the Psychological therapies. By this time, Corporal T had developed chronic PTSD with severe functional impairments.

Kessler’s Phenomena
According to Kessler 16% of PTSD patients can have psychotic features. When the PTSD sufferers are affected by the psychosis, they seem to loose of contact with reality. They are affected by hallucinations, delusions and thought disorders.

Private SK67 was actively involved in combat and on one occasion, he and a small team of soldiers were trapped behind enemy lines for over 3 days. By 2003, his mental condition was failing and he experienced passivity feelings, ideas of reference, thought broadcasting, thought insertion and disorganized thinking pattern. He was diagnosed with Schizophrenia at the North Colombo Teaching Hospital, but on re-assessment he was found to have key symptoms of PTSD such as hypervigilance , avoidance,  nightmare etc in  Private SK67.

Recruit SD45 developed an abnormal reaction after being wounded by a MBI (Mortar Blast Injury) to the left shoulder. His flashbacks were wrongly interpreted as visual hallucinations and distress reaction was misinterpreted as manic features. After a detail assessment, this soldier was diagnosed as having PTSD.

Delayed Reactions of PTSD
Currently the definition of delayed-onset PTSD encompasses symptoms that surface only up to 6 months following an event. Sometimes PTSD can emerge many years after the original trauma. According to Robertson and colleagues (Ruzich, Looi, & Robertson, 2005), large numbers of older veterans are present with nightmares and intrusive memories of the war. Some are experiencing these features for the first time in their lives. For some World War II veterans, memories of the war can still be upsetting more than 50 years later.

Late onset trauma plagues war veterans in a devastating manner. Those who are in their old age are now troubled by disturbing war memories. The delayed reaction, could be triggered by a subsequent stressful event
In a study of 147 Dutch veterans who had fought in the Resistance against the Nazis in WW2, it was found that forty years after the end of the war over half of these people are still suffering from PTSD and  only 4% showed no symptoms at all (Hovens et al., 1992).

A new study (Boscarino & Adams, 2009) that assessed New Yorkers exposed to the events of September 11, 2001 provides additional evidence that posttraumatic stress disorder (PTSD) can surface up to 2 years after the event in individuals with preexisting emotional or social problems.

Some of the Sri Lankan veterans too have shown delayed-onset PTSD reactions. They have manifested posttraumatic features many years after original trauma.  Combat trauma experienced by them may result in long-term sequelae.
Sergeant TH7 was an experienced combatant who participated in numerous combat operations in the North. During 1988 / 89 insurgency period, his platoon was deployed in the Southern part of Sri Lanka to fight the left wing Sinhala rebels who launched attacks against the Government. In the height of the conflict, the rebels attacked the Army killing several soldiers. This incident escalated to fathomless atrocities.

In 1989, Sergeant TX7 and his group arrested some of the suspects and eliminated them.  Sergeant TX7 tortured one of the suspects who was believed to have masterminded the attack on soldiers. He shot the suspect, poured petrol while the victim was alive. Then set fire. When the victim was on fire, he made an unsuccessful attempt to grab Sergeant TX7.  Sergeant TX7 narrowly escaped the fire and he became shocked and utterly frightened. Then he aimed his firearm towards the blazing man and fired several shots. Then the suspect died instantly. After a few weeks, he completely forgot the incident.

In 2002, thirteen years after this incident one night Sergeant TX7 s wife tried to light the Kerosene lamp while they were having dinner. Then she accidentally dropped it and the lamp exploded. His wife s clothes caught the fire. She was on flames. Immediately Sergeant TX7 poured water onto his wife and extinguished the fire. She went unharmed. But Sergeant TX7 was utterly devastated.

When his wife was on fire, the 1989 incident came into his mind immediately. Instead of his wife, he saw the JVP suspect who tried to grab him a moment before death. From that night, he had nightmares of the original incident and continuous intrusive memories. Sergeant TX7 startled easily and he was gradually turned in to different person. He became depressed and started abusing alcohol. He lost his life interests. Once he planned to commit suicide. He went to the railway station and walked along the railway tract. When the train was a few meters away, he changed his mind and jumped off.

Sergeant TX7 was diagnosed with PTSD in late 2002 and treated with medication and psychotherapy. (EMDR and CBT). By 2003, he was free of most of the PTSD symptoms.

Lt Col XXD participated in the Operation Balawegaya in 1991 and faced heavy fire by the enemy. In front of his eyes, several soldiers died following sniper fire. He took a key effort to prevent the enemy advance and sustained a gun short injury to the leg. He thought that he would be dead as his fallen soldiers. While lying on the battlefield his thoughts, were about his home, parents, wife and the children.

He was bleeding profusely and the other combatants took a great effort to evacuate him immediately. He was transferred to Palaly hospital and then air lifted to Colombo.

The doctors took massive effort to save his leg and eventually the operation became successful. He recovered his physical injuries soon and went back to his unit. His physical and mental health was stable.
In 2003, he suffered DVT or Deep Vein thrombosis and experienced unbearable pain. While he was in physical pain he had flashbacks of the 1991 Operation Balawegaya events, how he sustained a gunshot injury, how he was lying on the ground etc. he even saw the late General Denzel Kobbekaduwa in his flashbacks. He became restless and had a PTSD attack.
After he was treated for the Deep Vein Thrombosis his pain subsided, but he was hounded by the battle events. He experienced intrusive memories, flashbacks and startling reactions. His sleeping pattern changed and in order to avoid nightmares he started to work until late nights. Lt Col XXD adopted a workaholic attitude to evade disturbing ruminations. After sometime, he was physically and mentally exhausted. His system could not cope any more. Then he had a second attack, which manifested as an aggressive fearful reaction.  Lt Col XXD was treated with SSRI and relaxation therapies for a long time and gradually his posttraumatic symptoms subsided.

Eelam War and the War Widows
One harsh reality of the war is that the every soldier killed in war leaves behind grieving family and relatives. It has been a reality since the Trojan War.

The women who were left widows as a result of the Sri Lankan conflict are facing radically altered circumstances. There are estimated thousands of war widows and war-affected family members from the Tri Forces who still experience grief reactions. Many widows are in the 22 to 35 age group; and with the death of their husbands these women have become a psychologically and socially vulnerable group. Most of the women who underwent severe emotional pain still have not completely recovered. Many have become the victims of pathological grief. They are unable to work through their grief despite the passage of time. With the widowhood, they experience identity change, role adjustment and change in social status.

Many researches concur that the mental trauma of the war widows can last for long years. Depressive reactions are common among the Sri Lanka war widows. In 2005, 86 Sri Lankan war widows were clinically interviewed based on Beck’s depression scale and depression was diagnosed in 23 (27%). Ten war widows said that they had contemplated suicide after they lost their husbands (12%). (Jayatunge, 2005)

The war widows of the other conflictive areas in the globe are facing similar consequences. The conflict in Iraq had recorded high numbers of war widows.  According to Olga Ghazaryan, Oxfam’s regional director for the Middle East, the Iraqi war has made widows of an estimated 740,000 women and left many others fatherless (Rubin, 2009).  After 1991, many Iraqi war widows became sole wage earners, often going hungry to feed their children; possibly 60% suffered from psychological problems, with physical manifestations such as weight loss and difficulty breast-feeding (Hoskins, 1997 quoted in (Salvage, 2002).

In the conservative Asian societies, widows face social, economic and legal handicaps. Widow as its name denotes is associated with some form of socio-cultural stigma and humiliation. They are considered as bad omen in many Sri Lankan rural areas. They are marginalized by their own communities. These factors affect their self-esteem. In some events, the accusations were made by the in laws stating that the husband’s death occurred because of the unluckiness of the wife and they are partially answerable for the husband’s death. They experience lack of social support and loss of their social possession in their own family circles.

The war widows face a number of mental health problems. They have suffered bereavement as a result of the violent deaths of their husbands and these traumatic memories hound them for long years. They are often subjected to extreme forms of discrimination and physical, sexual, and mental abuse. Therefore, widowhood represents a form of “social death” for these women.  Their plight and vulnerability lead to numerous psychological ailments.
Many of the widows carry the memories of their late husbands. They are emotionally troubled by the loss and grief.  In the overall view the large percentage of women are having following psychological features.

Common symptoms included intrusive memories about their dead husbands, fear and uncertainty about the future, self-pity, low self-esteem, sleep disturbances, irritability, displacement of anger, emotional numbing, feelings of guilt, and psychosomatic complaints like persistent headaches and backaches which do not have any medical basis and do not respond to painkillers.

Many Sri Lankan widows have a tendency to experience and communicate psychological distress in the form of physical symptoms. Some have multiple unexplained somatic symptoms. Most often, the complaints involve chronic pain and problems with the digestive system, nervous system, and reproductive system. These young war widows, who have suppressed their biological needs following the cultural pressure and family honor, often manifest conversion reactions.
In a study by Gabriel Silverman and colleagues (2000), traumatic grief, PTSD, and major depressive episode were found to overlap with each other to similar degrees. Of those with traumatic grief, 47 percent also received a diagnosis of major depressive episode, 33 percent met criteria for PTSD, and 40 percent had traumatic grief.

Individuals who meet the diagnostic criteria for prolonged grief disorder have been shown to be at an increased risk of developing clinically distinct posttraumatic stress disorder, generalized anxiety disorder, major depressive disorder as well as suicidal ideation (Grey, Prigerson, & Litz, 2004). The violence of war does not end with the return to peace for those living closest to former combatants. Following is the experience of a war widow whose husband died in the operation Jayasikuru in 1997.

When I heard of the death of my husband, my entire world collapsed. He was a Lance Cpl in the Army and we were living in his house with his mother and two unmarried sisters. I still have a fragmented memory of the funeral. Some events I cannot remember. My three-year daughter who had no clue about father’s death asked various questions. I did not know what would happen to my daughter and me after my husband’s death.

After several months, my mother in law and husband’s two sisters started passing negative comments. They blamed me for his death. They implied that I was unlucky and since I came to their house, the things changed negatively. Even the neighbors avoided me.

I had to go to Panagoda Army pension branch to get my dead husbands’ pension. They said he was a volunteer and it would take some time and gave me papers to fill up. I had no idea how to do the paper work. I asked my cousin brother to help me. The day I went to his house with the daughter to get the paper work done my mother in law came up with false accusations and blamed me for seeing men soon after the husband’s death. She humiliated me and demanded the full pension of my husband saying that I have no financial rights.

I had no place to go and my parents died when I was small. My relative had no financial ability to look after me and my daughter. Therefore, I had no other option but to live with the husband’s relatives, facing humiliations every day. When I received my husband’s pension, my mother in law took it. We were given only food.

Every month I had to go to the Grama Niladari to confirm that I am still a widow and not remarried. When I went to get his signature on the document he used to pass inappropriate jokes and once tried to touch my hand. I scolded him and left the office. Ever since, he delayed signing my papers.

I became depressed and when my daughter goes to sleep, I cry alone. If not for her, I would have committed suicide, ending this suffering. My mind is preoccupied with the events of my husband’s funeral. I had the mental pictures of the coffin, his dead body, ceremonial uniform, and many more things. I had mental pictures of these miserable events. Constantly I had feelings of fear and uncertainty about the future. My memory started fading and I could not concentrate. Gradually I have become a living dead………….

Mrs AT87 had been married only for seven months when her husband became MIA (missing in action). This is her story.
……..When my husband went missing in action, I was 30 years old. We had been married for seven months. As a young wife, I had to face the challenges of life. I waited for him many years but he did not return. Every day was a painful anticipatory day for me. I went to many army camps, to the ICRC and even went to the North during the ceasefire era in search of my husband. There was no news about him. My relatives urged me to marry again but I refused.  I still cannot believe that he is dead. I hope one day he would come back…..

Mrs. HK34 faced severe hardships with the death of her husband who was a full corporal in the Army. She was driven out from the husband’s family which accused her of being unlucky. She was living in a small house with her four years old son. Her neighbor – a middle-aged man tried to help her with different motives in his mind.  When his intentions were revealed, Mrs. HK34 did not speak to him and avoided him. Then he started spreading malicious rumors about her in the village. The villagers, especially the women, humiliated her publicly.  Some nights, stones were thrown to her house. As Mrs. HK34 believed, her neighbor was behind all these mock incidents. When the troubles intensified, she decided to leave the village but she had no place to go.

The conflict in Sri Lanka has generated a large number of war widows in the North and East.  Widows in the North and East province totaled some 89,000 in 2010 (Mohamed Hizbullah, 2010). Many women are living in abject poverty and despair.

Many women in war are faced with the main responsibility for care giving in the family, with the destiny of their husbands unknown and new and unfamiliar duties placed on them. If the household is facing hardships, this may overload women’s capacity to cope; as preoccupation with the needs of the family may lead to neglecting their own needs, especially if they become widows.

The late Air Chief Marshall Harry Goonetilleke conducted a valuable psychosocial assisting project for the war widows of Sri Lanka under the Ranaviru Family Counselling Association. This project helped the war widows to reconstruct their lives and gain confidence. He believed that there should be a permanent rehabilitation policy for the war widows at the national-level. Until his death in 2008, Air Chief Marshall Harry Goonetilleke actively engaged in the rehabilitation work of the Sri Lankan war widows.

Mrs. KL342 was able to face her destiny with courage and determination after her husband’s premature death that occurred in the Eelam war.

…………. When I heard the terrible news of my husband’s death in the war front, I was utterly devastated. For many months, I was in a denial stage and could not believe that he would never come back.  Somehow, I had to gather strength for the sake of my two little children. I knew that being a widow in a deeply conservative society is not easy. But I had no alternative and with courage I faced the consequences.

Ranaviru Family Counselling Association offered me strength and guidance. At the meetings, I saw women like me who were struggling to survive. I learned new skills and started to work in an income-generating project. While working and attending to my children’s needs, my emotional trauma was reduced. But the deep sorrow was always with me. I had to be the sole breadwinner of the family; I had to be responsible for my children.  I was determined to live a life with dignity.
During the cease-fire in 2002, a group of war widows from the North visited us. Their husbands were LTTE carders who died in the battle. When I saw them, I had angry feelings. I thought for a while probably one of the husbands of these women had killed my husband. My heart stated beating rapidly. I saw they were looking at us. Simultaneously I thought they would be having the same feelings about us. That moment I realized that anger and hatred offer nothing but destruction. My anger dropped to the zero level. We welcomed them, the women from the opposite side but who share the same grief as us. We all are victims of the war no matter the racial differences. After all our tears and suffering had no ethnic difference. We spoke with these women and exchanged ideas. Soon we became friends. We cried together for the memories of our dead husbands who left us so unexpectedly. At the end of the day, we parted like sisters. Some of these women still write to me and we are good friends…….

Mrs. GF54 lost her sense of purpose in life when she underwent a pathological grief reaction following her husband’s death in 2001 during the Operation ‘Agni Kheela’. She was extremely focused on the loss and reminders of her husband. She had problems accepting the death, preoccupied with sorrow, inability to enjoy and move on with life, trouble carrying out normal routines and was withdrawn from social activities. She was treated with medication and EMDR, which gave optimum results. Today Mrs. GF54 is rationally facing her life. She is self-employed and building a house for herself and her children.

Rachel Tribe and Padmal De Silva (1999) highlight the importance of integrating coping strategies, self-help principles changing perceptions, attitudes and stereotyped beliefs when improving mental health issues of the Sri Lankan women who were widowed following extreme traumatic events. As they recommend the cultural and socio-political issues should be taken in to consideration.

As a matter of fact, very few governments and non-government organizations view widows as a special category with individual problems and special status. Therefore, war widows are marginalized in many communities around the world. The higher levels of stress and mental illness among women, common in many post conflict societies, are even higher in Sri Lanka due to the prolonged war(Somasundaram, 1998). The war widows carry extra burden than the average women in the Sri Lankan society. Apart from their traumatic experience, daily stressors such as poverty, family conflict, health problems, unemployment, social isolation and harassments exert a significant effect on their stress levels. Some widows take care not only of their children but often of their extended family as well.

The mental health interventions of the war widows should be followed with the specific cultural contexts and not contradicting religious beliefs of the victims. The war widows need strength-based psychosocial interventions. Welfare and rehabilitation of widows are essential with teaching of coping strategies, facilitating education and job training for the socially shunned widows. The measures are needed to help women transform their new skills into financial independence and sustainability. At the same time as strengthening women’s existing skills, new skills should be introduced in traditional and non-traditional fields.

There must be a permanent rehabilitation policy for the war widows at the national-level that helps widows to build a new life, regain confidence and gently adjust to a new life. The children of these war widows should have a secure and dignified future as their fathers always expected.  It is the duty of the nation to repay their dues to these families who have become the invisible victims of the Eelam war.

Children Affected by the Eelam War
UNICEF recently estimated that over 90% of the victims of today’s warfare is women and children. Children who are a vulnerable group have suffered severe traumatic events during the Eelam War.

Worldwide studies indicate children of the war zones undergo severe psychological trauma. The research in Gaza, Rwanda, Mozambique and Cambodia reveal children who were exposed to war and atrocities are at a high risk of developing PTSD. Thabet (2000) did a study to estimate the rate of Posttraumatic stress reactions in Palestinian children who experienced war traumas. The sample consisted of 239 children of 6 to 11 years of age. 174 children (72.8%) reported PTSD reactions of at least mild intensity, while 98 (41%) reported moderate/severe PTSD reactions.

Organized and institutionalized violence like war can affect children in many ways. The effects of traumatic events on children are even greater when that trauma is due to modern warfare. In Sri Lanka a large number of children have been exposed to war trauma.

Little K was nine years old when she became a victim of a cross fire between the armed forces and Tamil militants in the North. She sustained a gunshot injury to her left arm. She underwent a traumatic amputation of the left hand. The doctors were compelled to perform this operation in order to save her life. After the operation she was taken to an orphanage in Mulangavil in the Killinochi district. She has feelings of fear, night terror, bed wetting, hyperarousal and alienation. Traumatized war- zone children like little K carry the psychological scars throughout their lives.

Children who have experienced or been exposed to war trauma often have anxieties and insecurities that can cause them to perceive every aspect of the world as being unsafe and frightening. They grow up with a generalized fear and hostility which affects their future lives. Trauma is often associated with intense feelings of humiliation, self-blame, shame and guilt, which result from the sense of powerlessness and may lead to a sense of alienation and avoidance. Therefore the initial trauma could become a vicious cycle.

The following case study gives the longitudinal effects of psychological trauma on children, which can affect their later lives.

Master S was 12 years old when the 1983 communal riots erupted. His family was hiding in a neighbour’s house to evade the mob attack. The attackers burnt their house while Master S and his kid sister were hiding under a bed in their Sinhalese neighbour’s house. He could hear the shouting of the mob and the screaming of the victims. Master S had feelings of fear and he thought that the mob would kill him. These fears lasted for many years as he grew older.

The following day, their kind neighbour with the help of the Police took them to the refugee camp at Bambalapitiya Kadirashan Kovil. Before going to the camp Master S had a quick glance at their house which was completely destroyed by the fire. He felt sorry for losing his books and toys.

After spending several months in the refugee camp, his father was managed to get asylum in West Germany. For many years S had nostalgic feelings for his lost books and toys and also feared that a group of people would come and attack him unexpectedly.

After coming to West Germany S underwent a prolonged cultural shock and frequently felt a misfit in Western society. He became more isolated and neglected his studies. As a teenager he became more and more hostile and frequently had conflicts with his parents. After spending 12 years in West Germany S moved to Canada and got married. But he always felt the empty space and became emotionally numbed. On some occasions, he could not control his temper and engaged in domestic violence. His violent outburst resulted in an injury to his wife and S was charged by the Canadian authorities. Today he is serving a prison term.

Children who had witnessed the war trauma and atrocities can have diminished cognitive abilities. They frequently have learning difficulties at school. Some have behavioral disorders. Most of them do not receive proper psychological therapies and rehabilitation. As Osofsky (1995) indicates the differential response to trauma depends, in part, on the child’s age and level of psychological maturity. Children vary in their reactions to traumatic events. Some suffer from fears and terrifying memories immediately after the event, which dissolve with time and emotional support. Other children are more severely affected by trauma and experience long-term problems. Children of the war zone may exhibit regressive behaviors such as bed-wetting, thumb-sucking or fear of the dark. They may have increased difficulties separating from their parents. Also they can have attention problems and learning difficulties at school. Many of these affected children can have somatic complaints, irrational fears, sleep problems, nightmares, irritability and angry outbursts. They may appear to be depressed and more withdrawn.

Adolescent (ages 12 to 18) responses are more similar to adults and they are at increased risk for problems with substance abuse, peer problems and depression. Child soldiers have been exposed to events beyond the normal boundaries of human experiences. This is a story of a child solder whose pseudonym is SE .

SE was 11 years old when he was forcefully recruited as a child soldier by the LTTE. During the training period he was beaten and threatened to be killed if he did not obey the orders. Once he saw a killing of a rival member by the LTTE. Along with other children he had to take part in a number of attacks against the Sri Lankan Army. They were called the members of the Baby Brigade. The Baby Brigade was a support team for the adult fighters. They never had the opportunity of going to school after they became child soldiers. Instead of books they carried AK 47 and grenades. Their childhood had been stolen.

Little SE witnessed a number of horrific events which changed his psychological makeup drastically. He was forced to observe torture, then forced to induce it on victims. Today SE is in a rehabilitation center but his horrendous psychological scars have not left him completely. He has intense rage, suicidal urge and alienation. Once a bright and innocent student has now become a victim of the Eelam War.

Exposure to war situations cause children to lose predictability in their lives. They become withdrawn from daily routines and daily habits which provide security for them. It affects their psychosocial development negatively.

Master P was terrified when air attacks took place in Jaffna. During this attack his neighbor’s house was destroyed and some were critically injured. They were taken to the Jaffna hospital. Master P becomes anxious when he hears aircraft sounds. He has startle reactions, intrusive memories of the air attacks and sometimes nightmares.

Children’s well-being and development depend very much on the security of family relationships and a predictable environment. Miss L was 13 when the LTTE attacked their village in the North Central Province of Sri Lanka. The attackers shot the adults and killed the children and women with knives. She was lucky to be alive. When the village was attacked she managed to escape with her uncle. But her parents and the younger brother got killed. Miss L couldn’t continue her education after the tragedy. She became more depressed and had constant feelings of being threatened, nightmares of the attack, and psycho somatic ailments.

During the Eelam war some of the Sinhalese and Tamil children witnessed the deaths of their parents or other family members. They have experienced loss of loved ones and loss of property. These children have undergone severe grief and some have developed pathological grief reactions. These children carry the psychological scars of these past traumatic events. Obviously the majority of them have not received adequate treatment and rehabilitation; they will become adults with the unhealed trauma. Their anger will be sublimated to the society and this is going to be a vicious cycle.

Master D (10 Y) was a bright student who suddenly showed learning difficulties and behavioral problems when his father died in the Rivirasa operation. He became aggressive and started bed wetting. He lost interest in social activities and showed positive features of Paternal Deprivation Syndrome. He was not a happy child after his father’s death.

Living with a father who is affected by the combat trauma is another predicament faced by some children. Little B was an eight year old boy who was beaten by his PTSD father an ex-combatant with sudden rage. The boy was hospitalized and received treatment for his physical injuries.

Miss M (15Y) and master L (12Y) are sister and brother of the same family. Many days they had to spend the nights at neighbor’s house when their father became aggressive and went into tantrums. He is a combatant suffering from PTSD. When he experienced combat related flashbacks, he became extremely violent. Their mother left the house following continuous physical aggression by the father.

In recent years, since 1990, nearly 49 wars have been waged, and 46 have been fought with small weapons. Over 40 million men, women, and children have been forced into refugee status due to war violence. A situation of war, frequently experienced by refugees, has a disorganizing and traumatizing effect on the entire family. The Eelam war caused displacements of civilians at large. Many are still living in refugee camps.

Master M (9Y) and his family had to flee from his village with the other neighbors when the LTTE ordered the Muslim people to leave the North. Their family came to Puttalam and lived in a small hut without basic facilities in Alankuda, Kalpitiya. Master M became more isolated and showed positive features of anxiety and depression. He was nostalgic for his native village in Mannar. His education was disrupted and today M works as a three wheel driver in Puttalam town. M feels himself as an alien in Kalpitiya .He is addicted to cannabis and has no long term life plans.

During the Eelam War, the LTTE launched a number of suicide bombings sometimes targeting civilians. Master N (15Y) was a psychological victim of the dreaded Central Bank Bombing by the LTTE. When the blast occurred they were in a motor car. They sustained minor injuries, but master L was psychologically shattered. He had feelings of fear, startle reactions, intrusive memories and nightmares for nearly a year.

How to heal the wounds that occurred due to the armed conflict ? These children need medication, psychotherapy, psychosocial rehabilitation and long term monitoring. In Sri Lanka there is a big scarcity of experts in this area. Very often traumatized children grow up without psychosocial support. Unhealed traumas affect their cognitive and personality development.

Time does not heal the trauma. Therefore active measures are needed. Social support should be given to the children who were exposed to war trauma. Children’s resiliency to traumatic events is influenced by the degree of social support and positive community influences (Garbarino & Kostelny, 1996).

To minimize the psychological damage the children need effective care. Parental support is highly essential to heal the emotional scars experienced by the war-zone children. As the experts point out children with adequate family cohesion manifest less stress in reaction to trauma and are better able to recover from the initial impact of the trauma.

Cultural factors and traditional healing systems play a vital role. Community ideology, beliefs and value systems contribute to resiliency by giving meaning to traumatic events, allowing children to identify with cultural values, and enabling children and adults to function under extreme conditions (Melville and Lykes, 1992). In treating war zone children family therapy, group therapy, Cognitive-behavioral therapy (CBT) , art therapy, music therapy, EMDR and school and community interventions have been used. Also they are helped with coping skills.

War trauma in Sri Lanka has created a critical situation. A large number of children have been affected by the prolonged armed conflict in Sri Lanka. This has become one of the crucial problems that would affect our future. Consider that a significant numbers of our next generation are traumatized and unhealed.

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  1. A lengthy article with a lot of information. This topic is very interesting but I feel that you miss Sinhala readership. To be reasonable, I suggest you to publish a brief version in Sinhala language.

  2. The symptoms of shell shock could be different from person to person, right? Also, could it be hidden for a while and emerge later?

    Have you read about the incident where Gen. Patton dismissed shell shock as "an invention of the Jews" ? We've come a long way from then, eh?
    But, is there a chance of misdiagnosis or misidentification of the cause sometimes? Every mental condition of a soldier being attributed to battle experience?

    1. Pl read my article shell shock to palali syndrome ; answer is there

  3. I'm afraid I got bored while reading this post doc. I suppose its because of the length. Segmentation of this article into two would have been a solution for it. Not to offend you, just stating my honest opinion :)

  4. නොකී කතාApril 20, 2016 at 2:20 AM
    A lengthy article with a lot of information. This topic is very interesting but I feel that you miss Sinhala readership. To be reasonable, I suggest you to publish a brief version in Sinhala language.



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