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A review by mburnamfink
Signature Wounds: The Untold Story of the Military's Mental Health Crisis by David Kieran
informative
medium-paced
3.0
Signature Wounds is a comprehensive, if theoretically disorganized, account of how the US Army and the Veterans Administration responded to psychological issues relating to the Global War on Terror. The book describes an array of programs to treat the psychological effects of combat, ultimately closing with the 2009 Comprehensive Soldier Fitness program and the embrace of Martin Seligman's "resilience" positive psychology as doctrine.
At its best, Signature Wounds presents deep accounts of policy entrepreneurship. While some changes were pushed from the top down, many of the efforts involved dedicated medical professionals and low-senior officers (say, Colonels and Major Generals in more staff roles, rather than three and four star generals, or unit commanders) trying to maneuver an institution that is very resistance to change to do something. These are interesting stories about the tension between the time required to develop evidence-based treatments versus the need to provide care immediately to those who are suffering, and about implementing a good idea versus span of control.
The best chapter concerns mTBI (mild Traumatic Brain Injury). One of the key medical developments of this era was the realization that being near explosions causes brain injuries, which manifest as cognitive difficulties and emotional instability. Emotional instability is also one the key diagnostic criteria of Post-Traumatic Stress Disorder, so teasing out the co-morbidities between physiological and psychological wounds was one of the major medical efforts of the era, leading to an evidentiary compromise that left few people happy.
The rest of the book suffers from redundancy: Kieran organizes his chapters thematically: general combat psychiatry, veteran's suicide, access to care in the active duty military, care for military families, mTBI, active duty suicides, and VA suicides again. This thematic organization is a defensible choice (academic writing is hard), but makes it difficult to piece together a chronology of psychological efforts and to integrate the story with one of the war more broadly.
On a weird note, the invasion of Iraq is recent enough that it's impossible to separate history and politics, and Kieran barely tries. Democratic politicians are quoted at length demanding better Army and VA psychological care, which Kieran outright describes as anti-Bush administration posturing rather than some kind of sincere effort to do good policy. Meanwhile, Rep Steve Stockman (R-TX) Veterans Second Amendment Protection Act, which requires a judge to make a determination of mental incompetence, and was a response to a VA anti-suicide campaign to supply gun locks when requested, is just lawmaking. The fact that the stated rationale for the invasion of Iraq, Saddam's weapons of mass destruction program, was a deliberate lie, and the role of the Coalition Provisional Authority in stoking the civil war in which the US military found itself embroiled in, are simply glossed over. Statements from the architects of the war, George W. Bush, Dick Cheney, Donald Rumsfeld, and Colin Powell are notable by their absence.
This inability to engage with the elephant in the room is a fatal weakness. Excerpts from veteran's memoirs sprinkled throughout the book suggest that one major source of their distress was that they knew they were fighting for a lie that the country didn't care about. Jonathan Shay's work on PTSD, Achilles in Vietnam (not cited in this book, fyi), locates a primary source of PTSD in the betrayal of moral foundations from above. In as much as the horrors of war are survivable, it's because the military fits them into a heroic context. The war in Iraq, which was transparently an imperial adventure run in a way to minimize the immediate political impacts, was a continuous moral betrayal. I'm hardly objective in this matter, but I didn't write the book. There's no such thing as unbiased history, but the poorly concealed biases in Signature Wounds are embarrassing.
There are interesting pieces in this narrative, which I'd assess as broadly one of demedicalization. While medical ideas serve as policy anchors, such as the combat stress reaction, PTSD, and mBTI, managing the distress of soldiers and veterans became a whole army project, not just one confined to psychiatric or medical specialists. Culture is what it is, and the macho culture of the military could not accept explicit carve outs for counselling. While there are substantial gaps in practice, for example, it is still shockingly difficult to maintain a timely and comprehensive record of veteran suicides, the Army did eventually adapt, if only after it was forced to by events.
At its best, Signature Wounds presents deep accounts of policy entrepreneurship. While some changes were pushed from the top down, many of the efforts involved dedicated medical professionals and low-senior officers (say, Colonels and Major Generals in more staff roles, rather than three and four star generals, or unit commanders) trying to maneuver an institution that is very resistance to change to do something. These are interesting stories about the tension between the time required to develop evidence-based treatments versus the need to provide care immediately to those who are suffering, and about implementing a good idea versus span of control.
The best chapter concerns mTBI (mild Traumatic Brain Injury). One of the key medical developments of this era was the realization that being near explosions causes brain injuries, which manifest as cognitive difficulties and emotional instability. Emotional instability is also one the key diagnostic criteria of Post-Traumatic Stress Disorder, so teasing out the co-morbidities between physiological and psychological wounds was one of the major medical efforts of the era, leading to an evidentiary compromise that left few people happy.
The rest of the book suffers from redundancy: Kieran organizes his chapters thematically: general combat psychiatry, veteran's suicide, access to care in the active duty military, care for military families, mTBI, active duty suicides, and VA suicides again. This thematic organization is a defensible choice (academic writing is hard), but makes it difficult to piece together a chronology of psychological efforts and to integrate the story with one of the war more broadly.
On a weird note, the invasion of Iraq is recent enough that it's impossible to separate history and politics, and Kieran barely tries. Democratic politicians are quoted at length demanding better Army and VA psychological care, which Kieran outright describes as anti-Bush administration posturing rather than some kind of sincere effort to do good policy. Meanwhile, Rep Steve Stockman (R-TX) Veterans Second Amendment Protection Act, which requires a judge to make a determination of mental incompetence, and was a response to a VA anti-suicide campaign to supply gun locks when requested, is just lawmaking. The fact that the stated rationale for the invasion of Iraq, Saddam's weapons of mass destruction program, was a deliberate lie, and the role of the Coalition Provisional Authority in stoking the civil war in which the US military found itself embroiled in, are simply glossed over. Statements from the architects of the war, George W. Bush, Dick Cheney, Donald Rumsfeld, and Colin Powell are notable by their absence.
This inability to engage with the elephant in the room is a fatal weakness. Excerpts from veteran's memoirs sprinkled throughout the book suggest that one major source of their distress was that they knew they were fighting for a lie that the country didn't care about. Jonathan Shay's work on PTSD, Achilles in Vietnam (not cited in this book, fyi), locates a primary source of PTSD in the betrayal of moral foundations from above. In as much as the horrors of war are survivable, it's because the military fits them into a heroic context. The war in Iraq, which was transparently an imperial adventure run in a way to minimize the immediate political impacts, was a continuous moral betrayal. I'm hardly objective in this matter, but I didn't write the book. There's no such thing as unbiased history, but the poorly concealed biases in Signature Wounds are embarrassing.
There are interesting pieces in this narrative, which I'd assess as broadly one of demedicalization. While medical ideas serve as policy anchors, such as the combat stress reaction, PTSD, and mBTI, managing the distress of soldiers and veterans became a whole army project, not just one confined to psychiatric or medical specialists. Culture is what it is, and the macho culture of the military could not accept explicit carve outs for counselling. While there are substantial gaps in practice, for example, it is still shockingly difficult to maintain a timely and comprehensive record of veteran suicides, the Army did eventually adapt, if only after it was forced to by events.