How do you see me? The impact of perceived societal recognition on PTSD symptoms amongst Norwegian peacekeepers

ABSTRACT

Background: The peacekeeper role is different to that of traditional combat, however, peacekeepers, like combat soldiers, may also be exposed to high levels of dangerous and/or potentially morally injurious events (PMIEs).

Objective: It was hypothesized that given the centrality of societal approval for the peacekeeping mission, in addition to the known relevance of perceived social support, perceived societal recognition would influence PTSD symptoms (PTSS) and depression. It was hypothesized that perceived societal recognition would moderate the effect of exposure to potentially traumatic events and PMIEs on psychological outcomes.

Method: 8341, predominantly male, former UNIFIL peacekeepers, almost three decades following deployment, answered a survey to determine the impact of perceived social support and perceived societal recognition, on PTSS and depression symptoms. Hierarchical regression analyses were performed for PTSS and depression separately and moderation analysis was performed for perceived societal recognition.

Results: Exposure to potentially traumatic events showed the greatest predictive value for PTSS and exposure to PMIEs and potentially traumatic events were equally predictive of depression symptoms. While perceived social support presented the strongest buffer for PTSS and depression symptoms following UNIFIL deployment, perceived societal recognition also significantly contributed to the prediction of both PTSS and depression symptoms. There was a weak moderation effect of perceived societal recognition on trauma type in the development of PTSS.

Conclusions: Even decades following peacekeeping deployment, military experiences have a significant impact on psychological functioning. This impact is both from the types of events experienced and from the perception of social and societal support upon return home.

HIGHLIGHTS

• Peacekeepers receive little attention in general military research and their missions are often directly influenced by public perception.

• The current study found that key military traumas; danger based and moral injury based events, were prevalent in the peacekeeper population and predicted PTSD symptoms and depression symptoms respectively.

• While there was a weak moderation effect, perceived societal recognition was a unique predictor of PTSD symptoms. Those who perceived negative levels of societal recognition of the UNIFIL mission had greater PTSD symptoms than those who perceived neutral or positive levels of societal recognition.

Antecedentes: El papel del personal de mantención de paz es diferente al de combate tradicional; sin embargo, el personal de mantención de paz, al igual que los soldados de combate, también pueden estar expuestos a altos niveles de eventos peligrosos y/o potencialmente perjudiciales moralmente (PMIEs, por sus siglas en inglés).

Objetivo: Se planteó la hipótesis de que, dada la centralidad de la aprobación social de la misión de mantenimiento de la paz, además de la relevancia conocida del apoyo social percibido, el reconocimiento social percibido influiría en los síntomas de TEPT (PTSS, por sus siglas en inglés) y la depresión. Se planteó la hipótesis de que el reconocimiento social percibido moderaría el efecto de la exposición a eventos potencialmente traumáticos y PMIE en los resultados psicológicos.

Método: 8.341 individuos, predominantemente hombres, ex cascos azules de la FPNUL (UNIFIL), casi tres décadas después del despliegue, respondieron una encuesta para determinar el impacto del apoyo social percibido y el reconocimiento social percibido sobre el PTSS y los síntomas de depresión. Se realizaron análisis de regresión jerárquica. Se realizó un análisis de moderación para el PTSS y la depresión por separado y para el reconocimiento social percibido.

Resultados: La exposición a eventos potencialmente traumáticos mostró el mayor valor predictivo para el PTSS, mientras que la exposición a PMIE y eventos potencialmente traumáticos fueron igualmente predictivos de los síntomas de depresión. Si bien el apoyo social percibido presentó el mayor amortiguador para el PTSS y los síntomas de depresión después del despliegue de la FPNUL, el reconocimiento social percibido también contribuyó significativamente a la predicción tanto del PTSS como de los síntomas de depresión. Hubo un débil efecto de moderación del reconocimiento social percibido sobre el tipo de trauma en el desarrollo del PTSS.

Conclusiones: Incluso décadas después del despliegue de mantención de paz, las experiencias militares tienen un impacto significativo en el funcionamiento psicológico. Este impacto proviene tanto de los tipos de eventos experimentados como de la percepción del apoyo social al regresar a casa.

KEYWORDS:

• PTSD
• moral injury
• recognition
• society
• peacekeepers

PALABRAS CLAVE:

• TEPT
• daño moral
• reconocimiento
• sociedad
• fuerzas de paz

1. Introduction

The role of a soldier puts an individual at a higher risk of posttraumatic stress disorder (PTSD) due to the increased and repeated exposure to potentially traumatic events (Hines et al., 2014). PTSD describes the collection of reexperiencing, avoidance, arousal and mood-related symptoms following exposure to actual or threatened death, serious injury or sexual assault (American Psychiatric Association, 2013). Specifically, deployment to combat zones increases the risk of PTSD regardless of whether the deployed individual is delineated as a combat or non-combat professional (Peterson et al., 2010; Smith et al., 2008).

There is now heightened awareness that soldiers face exposure to a range of potentially traumatic events, in addition to those typically associated with fear-based traumas (Shay, 2011). As in other professions with high stakes decisions, the soldier role has been associated with higher exposure to events which challenge ethical and world beliefs, specifically related to right and wrong behaviours and a sense of control or ability to influence outcomes (Britt & Adler, 2003; Litz et al., 2009). Such events, termed potentially morally injurious events (PMIEs) may be experienced together with, or separate from predominantly fear-based events outlined in traditional psychiatric conceptions of events preceding PTSD. When experienced in conjunction with traditional fear-based PTSD events, they may increase symptoms and reduce functioning (Maguen et al., 2022). While exposure to PMIEs may not prevent traditional PTSD treatments from reducing PTSD symptoms (Held et al., 2021), moral injury (MI) symptoms may be unresponsive to traditional PTSD treatments (Finlay, 2015; Griffin et al., 2019). Furthermore, these MI symptoms can be detrimental to reintegration in civilian life (Molendijk et al., 2022). It is thought that PMIEs are more likely to lead to depressive-type symptoms while danger-based events are more associated with hyperarousal and traditional PTSD conceptions (Koenig et al., 2020; Levi-Belz et al., 2020).

1.1. The peacekeeper role

Peacekeepers are placed in a unique military situation; on the one hand active soldiers, armed with the capabilities to engage an enemy in battle, on the other, constrained with specific and restricting rules of engagement, different to the warrior role traditionally ascribed to soldiers. In The Morality of Peacekeeping, Daniel H. Levine describes peacekeeping ‘as a limited form of war, distinguished from other forms of warfare by its object rather than by its nature’ (Levine, 2014, p. 193). Peacekeepers may be exposed to violence and atrocities familiar to a war zone but defensive military structures, normally available to combat soldiers, are generally less available due to the need for proximity to civilian localities. Additionally, central to their role, peacekeepers are required to exercise restraint which can come at great psychological cost (Litz et al., 2016).

The ‘holy-trinity’ of peacekeeping virtues has been described as consent (the need for the community in which they are serving to consent to their presence); impartiality (no enemy-hero dichotomy); and minimum use of force. These virtues require attentiveness, restraint and creativity, characteristics not traditionally ascribed to the warrior identity (Levine, 2014). Unlike other military missions and units which have developed consistent identities, the peacekeeping mission is often unstable and lacking in direction (Franke, 2003). Military identities formed in basic training, combined with the conceptualization of a warrior identity, may induce an identity tension born through cognitive dissonance, further compounded by peacekeeping tasks viewed as less prestigious or honourable than other military roles (Franke, 2003).

1.2. Enhanced ambiguity and the search for an identity

The complexity in the role of a peacekeeper is confounded by a potentially greater number of morally ambiguous situations given the lack of clear enemy-comrade distinction. The absence of a distinct enemy coupled with the necessity to emotionally connect with conflicting parties for non-forceful negotiation places soldiers under heightened individual responsibility and may result in conflicted allegiances (Britt & Adler, 2003; Levine, 2014). Indeed, as recently reported, the cognitive flexibility required to interpret such situations may even be a risk factor for the later perception of PMIEs and development of MI (Zerach et al., 2023). The urban setting of peacekeeping troops may also increase the potential for the development of MI given the increased difficulty assessing threats and the influence of emotional duress inherent in civilian interactions (Griffin et al., 2019).

The peacekeeper role is characterized by a degree of ambiguity in both its role and purpose. This often necessitates a foundational belief in the righteousness and duty of their service. Some argue that given their perceived lack of status within the broader military community, the perception of peacekeeping missions might be significantly shaped by societal and social communications (though this is based on largely anecdotal work; Galantino, 2003).

The sustainability of peacekeeping missions often seems to hinge on the backing of the international community. While there are parallels between their role and that of a police force, a key distinction emerges in the source of their legitimacy. While a police force may have inherent authority within its jurisdiction, peacekeeping forces are at the mercy of validation from the international community (Levine, 2014). This potentially heightened connection with societal views, paired with an arguably less defined professional identity compared to other military roles, might mean that peacekeepers are particularly attuned to public opinion. They could rely on media and political channels not just for validation, but also as a means to shape their professional identity.

Specifically, years after returning from deployment to one’s home country, the contextuality of the post trauma experience becomes relevant. Contextuality has been discussed in reference to culture, childhood trauma and in the psychodynamic literature, but not in reference to the wider relationship with society. The way a culture embraces the trauma of their members and envelopes those who have been through traumatic experiences can deeply affect trauma presentation (DeJong, 2004). Validation within families is evidenced as critical in diminishing the negative outcomes of childhood sexual abuse (Godbout et al., 2014). This concept is also familiar in the psychoanalytic literature as mediating the trauma response across the lifespan, particularly due to the ‘experiential chasm’, the isolation born from the emotional distance between those who experienced and did not experience the traumatic event (Stolorow, 2007). When the depth of traumatic experiences are not reflected by others, not acknowledged, or given validation, the suffering can become a uniquely individual experience, causing further withdrawal from society and indeed further suffering (Herman, 2023; Maercker & Horn, 2013).

1.3. The Norwegian peacekeeping force

Specifically in reference to the Norwegian peacekeeping mission, the perception among both civilian and military leadership throughout the majority of the period that Norway deployed peacekeepers to Lebanon, was that the mission was not relevant for national security (Børresen et al., 2004). The Norwegian military is historically associated with peacekeeping missions fitting with Norway’s image as a ‘peace nation’ (Sjöstedt & Noreen, 2021), though qualitative and quantitative studies have revealed high levels of exposure to violence and threat throughout peacekeeping service (Gjerstad, Bøe, Falkum, Martinsen, et al., 2020; Wallenius et al., 2004). The Norwegian peacekeeping force was deployed in Lebanon for 20 years, from 1978 and until 1998 as part of the UNIFIL (United Nations Interim Force in Lebanon) mission. More than 22,000 Norwegian men and women have served in Lebanon. The troops sent to Lebanon consisted mostly of volunteers who completed one year of conscription service and then returned to civilian life after service in Lebanon. Only 20–30 per cent of the soldiers were professionals, i.e. in a military career. Most of the contingents only received two to three weeks of training before departure to the area of operations. Generally speaking, the quality of the Norwegian forces was considered sufficient to act as peacekeepers, despite receiving limited combat training before deployment (Strømmen & Leraand, 2005). Overall, not specific to the Norwegian contribution, the UNIFIL mission was largely criticized and not considered to have met its objectives (Nachmias, 1999).

A strong, credible national deterrence was the main rhetoric for Norwegian defense politicians, and despite a large Norwegian commitment to the UN, foreign operations counted as a secondary task. Moreover, service as part of a peacekeeping mission was unpopular within the military organization, and due to perceptions of such service having low reliance for national defense it was regarded as a poor career move to deploy to Lebanon (Børresen et al., 2004). The low status of such missions had occupational consequences for those who participated in the international operations, as veterans experienced differential treatment on the part of the Armed Forces. Though in principle they were perceived as representatives of the Norwegian Armed Forces, they were in practice treated more like private individual idealists or adventurers (Mehlum & Weisæth, 2002; Strømmen & Leraand, 2005). Internal studies have shown how Lebanon veterans felt no special connection to Norway when they served, but this attachment emerged in relation to homecoming, when veterans wanted society to recognize this experience (Moldjord & Holen, 2005).

1.4. Perceived societal recognition and social support

The current study was designed to investigate the unique contribution of perceived societal recognition in predicting severity of symptoms associated with PTSD and moral injury (posttraumatic symptoms, PTSS, and symptoms of depression). Social support on a more intimate level, from friends and family (Levi-Belz et al., 2022; Pietrzak et al., 2010) and from the local community (Nichter et al., 2020) is known to protect against PTSD and associated symptom development following trauma exposure in veterans. It is repeatedly identified as a resilience factor against the development of PTSD following general trauma exposure (Bonanno, 2004; Olff, 2012), and provides an anchor from which to understand the added contribution of perceived societal recognition.

Perceived societal recognition and social discourse have been indicated to shape veterans’ reintegration to society following deployment (Molendijk et al., 2022). Qualitative interviews have identified lack of societal recognition as a distinguishing factor between those with chronic military PTSD and those who recover (Ferrajão & Aragão Oliveira, 2016). Additionally, societal recognition is deeply embedded in cultural dialogue; countries that glorify war may represent soldiers as heroes and cultures which are uncomfortable with the use of force may sanitize/cleanse or condemn military violence. Both these representations may be experienced as ‘misrecognition’, specifically in the case of moral injury or non-heroic traumas, and contribute to the experience of moral injury (Molendijk, 2018).

1.5. Hypotheses

Perceived societal recognition was hypothesized to contribute to veterans’ experiences of PTSD and depression in addition to, and, following traumatic and potentially morally injurious experiences in their service as peacekeepers. The current study was designed to explore the potentially moderating effect of perceived societal recognition on the relationship between military trauma exposures (general and moral injury specific), PTSS and depression symptoms. Perceived social support on a more intimate level, from family and friends, was included in the current study, for comparison.

2. Method

2.1. Participants

The study used data from a cross-sectional, post-deployment survey of UNIFL peacekeepers. Norwegian military personnel deployed to Lebanon between 1978 and 1998 were invited by the Norwegian Armed Forces Joint Medical Services, during 2014/15 to participate in the study. Average time since deployment was 27 years (range: 18–38 years). Of the invited personnel, 11,633 responded. However, 1,028 of these were either active refusals (913) or incomplete (115), resulting in 10,605 valid responses and a final positive response rate of 51.3 per cent. The response rate was comparable to those obtained in other studies on military populations (Forbes et al., 2016; Mcandrew et al., 2013). As with most studies on military populations, there was a significant overrepresentation of men in the study population. For the current study, only participants who reported that they only served in the peacekeeping forces (N = 8341) were included in the analyses. Participants who reported serving in units other than UNIFIL peacekeeping corps (N = 1998) were excluded from analyses in order to create a uniquely peacekeeping sample not confounded by other combat military service.

The age distribution of the participants was as follows: 30–39 (1%), 40–49 (29%), 50–59 (47%), 60–69 (17%), 70+ (7%). Most participants had a full high school education (54%), with a further 28% having an additional undergraduate degree and 10% a post graduate degree. Sixty nine percent of participants finished their military service with no advanced training, and the remainder had completed officer’s training or higher.

2.2. Procedure

The participants received a printed copy of the survey questionnaire and a letter with a link to the digital version, so they could choose to answer either version. A mail-reminder was sent twice and then again by mail and SMS. Study procedures, collection, storing, and distribution of data were done in accordance with the existing legislation regulating the Norwegian Armed Forces Health Registry. This study involving human participants were reviewed and approved by the Norwegian Armed Forces Joint Medical Services Research Council and the Regional Committee for Medical and Health Research Ethics of South-East Norway.‏ The participants provided their written informed consent to participate in the study.

2.3. Measures

Traumatic exposure in Lebanon. Deployment-related stressors were measured by the traumatic exposure scale developed by the Lebanon research group, based on a literature review of experiences typically eliciting PTSD during a war-zone deployment and those experienced during peacekeeping deployment in Lebanon. Items and prevalence are reported in supplementary data 1. Each item was rated on a 5-point Likert scale ranging from 1 (no) to 4 (yes, more than 5 times), giving a total score range of 39–156, with higher scores indicating exposure to more stressors. The scale has been used in other research with this population (Gjerstad, Bøe, Falkum, Martinsen, et al., 2020).

For final analysis, a cumulative score of total stressor exposure was used. Also, a subset of moral injury related items was used to assess the specific contribution of exposure to PMIEs (eg. ‘Did you hurt or kill someone during the service, which you later thought was unnecessary, and which you therefore regret?’ and ‘Were you involved in things that were morally questionable?’). Selection of items for the moral injury variable was based on the semantic content of the items correlating with items from the Moral Injury Events Scale (Nash et al., 2013). They included self and other perpetrated PMIEs, but not betrayal, which can be considered a separate factor and was not studied in the current research (see supplementary material).

Perceived Societal recognition: Participants were asked 5 questions to ascertain level of recognition felt from Norwegian society. They were asked to rate from 1–5 whether they agree (5 = strongly agree) or disagree (1 = strongly disagree) with the statements; ‘I feel that my efforts have been appreciated/recognized by [the government/political establishment, media/in the public debate, family and friends, society in general, the Norwegian armed forces]’. See Table 1 for descriptive data. Data was combined into a total score. Cronbach’s alpha was 0.90.

Table 1. Frequency of recognition felt by the various facets of Norwegian society.

Felt recognized by	Strongly disagree or disagree (%)	Neutral (%)	Strongly agree or agree (%)
The government	25.2	37.1	37.7
Media/public debate	24.6	42.7	32.7
Family and friends	8.9	32.7	58.4
Society in general	19.5	44.8	35.7
The Norwegian Armed Forces	19.5	33.1	47.4

Perceived Social support: Participants were asked ‘In the time after returning home, how many people were so close to you that you could have counted on them if you had had major personal problems?’. Response options were no one (1), one person (2), two people (3), three to five people (4) or six or more people (5).

Depression: The Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983) consists of 14 items and is divided into two subscales, one for anxiety (7 items; HADS-A) and depression (7 items; HADS-D). Only the HADS-D was used in the current research. Each item is rated on a scale from 0 to 3, giving a maximum score of 21 for anxiety and depression alike. For screening purposes, a sum score of 11 or higher on either subscale is generally considered to represent a ‘case’ of psychopathology, while scores of 8–10 are considered as ‘borderline’ and 0–7 is viewed as ‘normal’ levels of distress. Cronbach’s alpha for the current sample was 0.86.

Posttraumatic Stress Disorder: The Posttraumatic Stress Disorder Checklist-17 (PCL-17) (Weathers et al., 1993) is a self-rating instrument consisting of 17 items that corresponds to the diagnostic criteria for PTSD in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev (American Psychiatric Association, 2000). Each item is rated on a scale from 1 (not at all) to 5 (extremely), which gives a maximum score of 85. A score of 44 or above was regarded as a likely case of PTSD with scores of 30 and above considered borderline (Blanchard et al., 1996). The edition that was utilized was the military version and Cronbach’s alpha for the current sample was 0.95.

2.4. Data analysis

Pearson’s correlations between study variables were performed and hierarchical linear regressions were performed for the outcome variables of PTSS and depression. Time since deployment was entered into the regression at step one to control for distance from military service. Trauma exposure; total and moral were then added in the second step, perceived societal recognition and social support in the third step and interactions between perceived societal recognition and social support with types of trauma exposure were added in the fourth and final step. An ANOVA was carried out to assess group differences between perceived societal recognition categories (low recognition, neutral and high recognition). Finally, a moderation analysis was performed using PROCESS 4.2, model 1 (Hayes, 2013). Z-scores were used to create standardized data. Given the lack of significant interaction for moral exposures in the regression, only cumulative trauma exposure was entered as a predictive variable and perceived societal recognition was entered as a moderator with PTSS as the outcome variable.

3. Results

3.1. Trauma exposure and psychopathology

Over 80% of the sample participated in operational missions (82%). Amongst other combat exposures, 46% reporting being fired upon and 9% reported being captured or hijacked. Additionally, amongst the items included in the moral event subscale, 16% reported being involved in things which were morally questionable and 3% regretted hurting or killing someone unnecessarily. According to DSM-IV diagnosis (both criterions and a PCL cut-off score of 44), 6% of the sample had likely PTSD (N = 507), a further 791 participants had scores on the PCL ranging from 30 to 44 indicating subthreshold levels of symptoms (10%). Four percent of participants had likely depression.

3.2. Perceived societal recognition

The mean and median reported value for all facets of perceived societal recognition studied was 3, ‘neither agree nor disagree’ except in the item of family and friends recognition which was 4 (mean = 3.62, SD = .91), ‘agree’. The spread of data can be seen in Table 1 and total score, the cumulation of all facets of perceived societal recognition, was used for further analysis.

3.3. Relationship between symptomology and predictive factors

Hierarchical linear regressions were carried out for the outcome variables of PTSS and depression symptoms as outlined above. Final standardized and unstandardized beta values are reported in Table 2.

Table 2. Final stages of multiple regressions for PTSS and depression symptoms.

Variables	B	Beta	R^2
PTSD Symptoms			.34**
Time since deployment	.06	.03 *
Total trauma exposure	.36	.26**
Moral-based stressors	1.42	.11**
Perceived societal recognition	-.4	-.17 **
Social support	−1.67	-.19 **
Trauma exposure *recognition	-.87	-.1 **
Moral*recognition	-.08	-.01
Trauma exposure *social support	-.75	-.08**
Moral * social support	-.4	-.05**
Depression symptoms			.21**
Time since deployment	-.00	-.00
Total trauma exposure	.05	.1 **
Moral-based stressors	.38	.1 **
Perceived societal recognition	-.13	-.17 **
Social support	-.66	-.24 **
Trauma exposure *recognition	-.19	-.07 **
Moral*recognition	-.01	-.00
Trauma exposure *social support	-.13	-.05*
Moral * social support	-.13	-.05*

Note: A significant b-weight indicates the beta-weight and semi-partial correlation are also significant. b represents unstandardized regression weights. beta indicates the standardized regression weights. * indicates p < .05. ** indicates p < .001.

When mean perceived societal recognition was coded as low (1-2), neutral (3) or high (4-5), there were significant differences between all groups for PTSS (F(2,8091) = 425.9, p < .001) and depression symptoms (F(2,8111) = 300.68, p < .001). Those who perceived low societal recognition had higher PTSS (M = 28.46, SD = 14.77) than those who perceived neutral (M = 22.58, SD = 9.12) or high (M = 20.8, SD = 7.31) societal recognition. The same pattern was seen for depression symptoms (low; M = 3.8, SD = 4.22, neutral; M = 2.54, SD = 3.14, high; M = 1.77, SD = 2.6).

3.4. Moderation of perceived societal recognition

Perceived societal recognition was entered as a moderator for the effect of trauma exposure on PTSS. In accordance with the interaction demonstrated in the regression analyses, the moderation model was significant, R = .22, p < .001, F(3,7781) = 716.71. The interaction effect of perceived societal recognition and trauma exposure on PTSS was significant, R²= 0.01, F(1, 7781) = 93.13, p < .001. When veterans reported having low societal recognition, trauma exposures were most strongly associated with PTSS (β = 0.36, CI 0.33, 0.38) followed by average perceived societal recognition (β = 0.28, CI 0.25, 0.3) and high perceived social recognition (β = 0.2, CI 0.16, 0.23) (see Figure 1).

Figure 1. Interaction effect of perceived societal recognition on military trauma exposures in predicting PTSS.

Note. _____ low perceived societal recognition, -.-.-. average perceived societal recognition _ _ _ high perceived societal recognition.

4. Discussion

Peacekeepers are a unique branch of the military, trained for active war, yet practicing restraint and interacting most frequently with a civilian population. With the growing understanding of the impact of social influence on traumatic stress, the current study assessed the contribution of perceived societal recognition on PTSS. The results demonstrated the contribution of both intimate social support (from friends and family) and perceived societal recognition (from the country, government, and social institutions) on the severity of PTSS and depression symptoms in addition to trauma and moral event exposures during service. Additionally, perceived societal recognition was demonstrated to partially moderate the relationship between military trauma exposures and PTSS such that for those with lower levels of perceived social recognition, there was a greater relationship between trauma exposure during the military and subsequent PTSS.

The correlations between cumulative exposure to military trauma, morally conflictual experiences and resulting presence of psychopathology, even after a span of three decades post-deployment, were notably significant. Indeed, figures in the current cohort (Gjerstad, Bøe, Falkum, Martinsen, et al., 2020; Gjerstad, Bøe, Falkum, Nordstrand, et al., 2020) indicated a greater prevalence of PTSD amongst peacekeeper veterans than those previously reported in short term studies of this population group (Forbes et al., 2016; Maguen et al., 2004). The current sample reported similar levels of self and other perpetrated PMIEs to those reported in American combat samples (Jordan et al., 2017). While the contribution of individual non-military trauma exposures has been related to the development of PTSD in the period following homecoming and military discharge (Andrews et al., 2007; Mota et al., 2016; Polusny et al., 2011), the focus of the current study was specifically on the contribution of the perception of an external factor, how society recognized veterans’ service on individual psychopathology.

How peacekeeper veterans perceived society’s recognition of the UNIFIL mission predicted both PTSS and depression symptoms. Veterans with low perceived societal recognition experienced significantly higher PTSS and depression scores compared to those with higher, positive perceptions of societal recognition of the peacekeeping mission. While depression scores remained substantially below the cut off for clinical depression across all three groups, mean PTSS for the low recognition group approached clinical values. This finding is in coherence with the qualitative work on Dutch peacekeepers which found that many veterans felt the public did not recognize that ‘‘I'm a human being too’’ (Molendijk, 2018, p. 319) and that regardless of mission characteristics, perceived societal recognition can have a profound impact of the mental health of those who have taken part in peacekeeping missions which are so reliant on public opinion (Levine, 2014).

The current findings on the contribution of perceived societal recognition were reinforced in the context of more intimate social support. Social support is a known resilience factor following trauma exposure. It has frequently been identified as a protective factor for veterans against PTSD and depression symptoms (Olff, 2012; Pietrzak et al., 2009, 2010). Social support has also been widely and successfully applied as a method to alleviate psychological suffering after exposure to traumatic events (e.g. in World Health Organization protocol) (Brooks et al., 2018; World Health Organization, 2011). Nevertheless, sharing painful experiences as a way of managing trauma is a Western perspective of coping, primarily anchored in clinical studies aiming to treat PTSD symptoms (Mojaverian & Kim, 2013; Taylor et al., 2007) and may present a particular challenge for military veterans (Nieuwsma et al., 2020; Vermetten & Jetly, 2018). Given the current findings, increasing awareness of the beneficial effects societal recognition may represent a more achievable strategy for stimulating resilience factors for struggling peacekeepers and offer a cross-cultural alternative to individual-focused therapy interventions.

In recent years, there have been active governmental efforts in Norway to change public perceptions of the status and value of military veterans (Rones et al., 2020). Concrete examples of new measures to increase societal recognition have been the rebranding of the WWII liberation day to a conjoint ‘Liberation and Veterans Day’ celebration, with several events, intended to specifically recognize veterans and raise awareness of their sacrifices, held at various locations throughout Norway (Haaland & Gustavsen, 2021). With the advent of the moral injury dialogue, there has also been an increase in interventions for PTSD which consider society’s responsibility to shoulder the burden of war. Interventions such as the Moral Injury Group (Cenkner et al., 2021) include a ceremony where veterans share their experiences with the public who recognize their service. Other interventions, such as the first author’s Peace of Mind programme, were designed prior to the widespread recognition of moral injury but include the facet of recognition (in this case by having Israeli veterans hosted by a Jewish community) as an integral part of the transition from military personnel to civilian life (Harwood-Gross et al., 2022). The impact of this recognition component has yet been studied, rather developed from clinical sensitivities. Given the current findings, it may be a critical aspect of such programming which should be implemented more widely.

4.1. Limitations

The current study explored the experiences of a large sample of Norwegian peacekeeping veterans, though it was limited in its cross-sectional nature. In addition to the clear added value of longitudinal research, future studies could map the development of public opinion together with fluctuations in mental health of returning veterans. This would offer the opportunity to study perceived societal recognition through a variety of sources, offering multi-disciplinary collaboration and could compare subjective and objective measures of perceived societal recognition in order to delineate personality, psychopathology and societal variables.

Furthermore, the current study was based on discussions between authors on the specific impact of societal opinion on peacekeepers and those in non-traditional military positions. In order to ascertain whether there is indeed a difference in the effect of perceived societal recognition on different vocational roles, further cross-sectional research is warranted with a broader population. This would also offer the opportunity to delve deeper into the specific nuances of recognition and contribute to the burgeoning field of moral injury in what are considered ‘dirty work’, socially unacceptable jobs (Press, 2021). The questionnaire for perceived societal recognition used in the current study was apt for preliminary, broad and exploratory research but a more detailed and validated questionnaire is needed now that an initial effect has been established. This limitation is true too for the questionnaire on social support; a more in-depth questionnaire which assesses social support prior to, during and following military service would allow a greater interpretation of the centrality of this variable on the experience of PTSS and depression.

5. Conclusions

Society plays a part in both delineating the importance and recognition of peacekeeping missions and in supporting soldiers upon their return home. The current study highlighted the impact of potentially traumatic military events and moral-based events on PTSS and depression symptoms, but also that of social and perceived societal recognition in buffering against such psychopathologies amongst veterans of the peacekeeping corps. Future research is warranted to consider which elements of perceived societal recognition play a significant role and whether there are differing levels of impact for service type and over time. Clinical programmes aimed at aiding reintegration into civilian life post-military service, especially for the current population, should incorporate components that address perceived societal recognition. This can be achieved either through single community sessions or by situating the entire programme within a community, fostering appreciation and acknowledgment of service.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets presented in this article are not readily available because they are stored in accordance with the existing legislation regulating the Norwegian Armed Forces Health Registry. Requests to access the datasets should be directed to the Norwegian Armed Forces Health Registry, email: [email protected]