Signature Wounds: The untold story of the military’s mental health crisis
By David Kieran. New York: New York University
Press 2019. ISBN 978-1479892365. AU$32.98.
Reviewed by Darren Cronshaw
Warning: This review includes information on mental illness, trauma and suicide that may be disturbing to some readers. Support is available through your Chain of Command, Chaplaincy or Health Centre, Lifeline 131144 or Open Arms 1800 011 046.
Wars in Iraq (2003–11) and Afghanistan (2001–21) meant Coalition forces were deploying continuously over two decades as part of the Global War on Terror. This led to a considerable cost in veteran mental illness, especially post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and suicide. These came to be known as signature wounds of the conflicts. What can we learn in Australia from the experience of the US Army and veterans’ support?
David Kieran is an Assistant Professor of History and Director of American Studies at Washington & Jefferson College. He interviewed nearly 50 high-ranking Army leaders and gleaned insights from thousands of pages of Freedom of Information requests to investigate the story of US Army’s and Veterans’ Affairs (VA) response to the mental health crises that Iraq and Afghanistan deployments produced. He also analysed how politicians, activists and society gave attention to mental health problems as part of debates about militarism and foreign policy.
I learned about the challenges of these 21st Century wars to mental health. The US Army had been preparing for a short, intense war in Europe but instead dealt with unforeseen long, protracted counterinsurgencies and more frequent and prolonged deployments. There was limited time away from the front line and no areas were safe from Improvised Explosive Devices (IEDs). IEDs were causing PTSD and TBI, which medical staff were only beginning to understand and diagnose, often misdiagnosing as personality disorder to facilitate discharges. Part of the challenge is that medical care treatments were not keeping pace with military developments: ‘It is the story of how the advancement of medical knowledge moves at a different pace than the needs of an army at war.’ (p.4) Other challenges included mental illness being missed in screenings, lack of resources, the marked insufficiency of stress debriefings, dilemmas of the role conflict of Medical Officers, lack of communication between caregivers and supporting organisations, contention over whether soldiers should deploy on medications, and unawareness of veteran benefits. Descriptions of VA’s efforts are variable, but all too often under-resourced, understaffed and, unfortunately, sometimes callous and bureaucratic. Kieran concludes a tragic reflection of ‘when the nation fails to prepare for the aftermath of the wars that it chooses to wage.’ (p.280)
The ultimate tragedy is when war service and mental illness lead to suicide. US Army used to be able to say, like Australia, that their suicide rate is less than the national average, but this changed in 2007. Alarmingly, three-quarters of those who took their lives gave no indication of ideation prior, fewer than half had a clear reason, and obvious causal links are not easy to delineate. The American experience reminds me that suicide is a complex and wicked problem, and calls for medical, chaplaincy, Command, team and individual collaborative strategies, ideally from the grassroots and not just top-down.
I also appreciated learning about the responses of the US Army and VA. Kieran suggests their response was aggressive and progressive with cultural change, albeit with lots of debate and some failures. I had three takeaway lessons from the US experience. Firstly, there have been efforts to reduce stigma—essential given that 90% of soldiers would not seek behavioural healthcare out of concerns it would affect their career or at least they would be ridiculed by peers.
Secondly, it has been valuable to make mental health care more accessible to soldiers in units. Mental health professionals embedded in units are an extension of the practice of treating soldiers as close to the front as possible. Their experience is then similar to what Chaplains describe, as one mental health carer reflected: ‘Being there, wearing the same uniform as they are, sleeping in the same kind of locations as they are, sharing some of the hardships, speaking their language a little bit—quite a few of the guys came in.’ (p.128) The other aspect of accessible mental health care comes from Commanders and colleagues who have the insight and confidence to reach out in support. I was inspired by one officer who often said to troops, ‘If you feel like harming yourself, here’s my number—call me anytime’. A challenge Kieran identifies is that less qualified junior officers often lack the developed skills to ensure wellbeing. The book did not describe much about grassroots peer support programs that may be one of the most effective ways of reducing stigma and ensuring support.
Thirdly, there have been significant developments in resilience training. For example, the BATTLEMIND training program has focused on strengths and helping soldiers be aware of war’s moral challenges: ‘The Soldier’s inner strength to face fear and adversity in combat with courage [from] existing skills and inner mental strengths.’ (p.61) I assume the Australian Army’s Battlesmart program has learned lessons from BATTLEMIND. US Army’s Comprehensive Soldier Fitness (CSF) program also seeks to elevate and develop resiliency by utilising positive psychology. This was fast-tracked through by Command despite psychologists arguing for more research. Resilience training is also a response to supporting families. However, it aims to develop self-sufficiency rather than offering meaningful support and does not necessarily alleviate the sources of stress in the first instance. Prevention is helpful, but once families or members feel strained, treatment and support are also needed.
Two other areas of concern are mentioned but not explored deeply—military sexual trauma and moral injury. The book includes stories of both, but both are significant traumas in themselves, and both increase the risk of mental illness and suicide. Given the ethical dilemmas of counterinsurgency, moral injury is arguably also a signature wound of recent conflicts that will need more attention.
As new military threats emerge and the nature of conflict continues to change exponentially, it is critical to properly plan mental health programs to prepare and support defence personnel to protect against the physical, mental, ethical and spiritual traumas and dilemmas they may face. As Kieran argues, it is also important to weigh carefully and consider under what circumstances we as a country will engage in conflict at such significant costs. We cannot sidestep this complex mental illness IED staring at us in the room.
The views expressed in this article are those of the author and do not necessarily reflect the position of the Australian Army, the Department of Defence or the Australian Government.
Darren Cronshaw is a Support Chaplain at the Defence Force School of Signals. He is also an adjunct Professor of Practical and Intercultural Theology with the Australian College of Ministries (Sydney College of Divinity).
Corresponding Author: Darren Cronshaw, darren.cronshaw@defence.gov.au, dcronshaw@acom.edu.au
Authors: D Cronshaw1,2
Author Affiliations:
1 Australia Army – Chaplaincy
2 Australian College of Ministries
