Summarizes key findings and recommendations from Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (Tanielian and Jaycox [Eds.], MG-720-CCF, 2008), a comprehensive study of the post-deployment health-related needs associated with post-traumatic stress disorder, major depression, and traumatic brain injury among veterans of Operations Enduring Freedom/Iraqi Freedom.

Dillon J. Carroll’s Invisible Wounds examines the effects of military service, particularly combat, on the psyches and emotional well-being of Civil War soldiers—Black and white, North and South. Soldiers faced harsh military discipline, arduous marches, poor rations, debilitating diseases, and the terror of battle, all of which took a severe psychological toll. While mental collapses sometimes occurred during the war, the emotional damage soldiers incurred more often became apparent in the postwar years, when it manifested itself in disturbing and self-destructive behavior. Carroll explores the dynamic between the families of mentally ill veterans and the superintendents of insane asylums, as well as between those superintendents and doctors in the nascent field of neurology, who increasingly believed the central nervous system or cultural and social factors caused mental illness. Invisible Wounds is a sweeping reevaluation of the mental damage inflicted by the nation’s most tragic conflict.

There’s no real homecoming for many of our veterans returning from the wars in Iraq and Afghanistan. They may go through the motions of daily life in their hometowns, but the terrible sights and sounds of war are still fresh in their minds. This empathic, inside look into the lives of our combat veterans reveals the lingering impact that the longest wars in our nation’s history continue to have on far too many of our finest young people. Basing her account on numerous interviews with veterans and their families, the author examines the factors that have made these recent conflicts especially trying. A major focus of the book is the extreme duress that is a daily part of a soldier’s life in combat zones with no clear frontlines or perimeters. Having to cope with unrecognizable enemies in the midst of civilian populations and attacks from hidden weapons like improvised explosive devices exacts a heavy toll. Compounding the problem is the all-volunteer nature of our armed forces, which often demands multiple deployments of enlistees. This results in frequent cases of post-traumatic stress disorder and families disrupted by the long absence of one and sometimes both parents. The author also discusses the lack of connectedness between civilian society and military personnel, leading to inadequate healthcare for many veterans. This deficiency has been highlighted by the urgent need to treat traumatic brain injuries in survivors of explosions and the high veteran suicide rate. Bouvard concludes on a positive note by discussing some of the surprising and encouraging ways that the chasm between civilian and military life is being bridged to help reintegrate our returning soldiers. For veterans, their families, and especially for civilians unaware of how much our soldiers have endured, The Invisible Wounds of War is important reading.

Since October 2001, approximately 1.64 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq. Early evidence suggests that the psychological toll of these deployments -- many involving prolonged exposure to combat-related stress over multiple rotations -- may be disproportionately high compared with the physical injuries of combat. In the face of mounting public concern over post-deployment health care issues confronting OEF/OIF veterans, several task forces, independent review groups, and a Presidential Commission have been convened to examine the care of the war wounded and make recommendations. Concerns have been most recently centered on two combat-related injuries in particular: post-traumatic stress disorder and traumatic brain injury. With the increasing incidence of suicide and suicide attempts among returning veterans, concern about depression is also on the rise. The study discussed in this monograph focuses on post-traumatic stress disorder, major depression, and traumatic brain injury, not only because of current high-level policy interest but also because, unlike the physical wounds of war, these conditions are often invisible to the eye, remaining invisible to other servicemembers, family members, and society in general. All three conditions affect mood, thoughts, and behavior; yet these wounds often go unrecognized and unacknowledged. The effect of traumatic brain injury is still poorly understood, leaving a large gap in knowledge related to how extensive the problem is or how to address it. RAND conducted a comprehensive study of the post-deployment health-related needs associated with these three conditions among OEF/OIF veterans, the health care system in place to meet those needs, gaps in the care system, and the costs associated with these conditions and with providing quality health care to all those in need. This monograph presents the results of our study, which should be of interest to mental health treatment providers; health policymakers, particularly those charged with caring for our nation's veterans; and U.S. service men and women, their families, and the concerned public. All the research products from this study are available at http://veterans.rand.org. Data collection for this study began in April 2007and concluded in January 2008. Specific activities included a critical reviewof the extant literature on the prevalence of post-traumatic stress disorder, major depression, and traumatic brain injury and their short- and long-term consequences; a population-based survey of service members and veterans who served in Afghanistan or Iraq to assess health status and symptoms, as well asutilization of and barriers to care; a review of existing programs to treat service members and veterans with the three conditions; focus groups withmilitary service members and their spouses; and the development of a microsimulation model to forecast the economic costs of these conditions overtime. Among our recommendations is that effective treatments documented in the scientific literature -- evidence-based care -- are available for PTSD and major depression. Delivery of such care to all veterans with PTSD or majordepression would pay for itself within two years, or even save money, by improving productivity and reducing medical and mortality costs. Such care may also be a cost-effective way to retain a ready and healthy military force for the future. However, to ensure that this care is delivered requires system-level changes across the Department of Defense, the Department of Veterans Affairs, and the U.S. health care system.

Many veterans face "invisible wounds" of war. By examining various types of war narratives in literature we can understand how these veterans cope with their invisible wounds and what others can do to help them process their trauma. This project considers types of trauma theory in addition to several short stories by Tim O'Brien and Phil Klay. Veterans of Vietnam, Iraq, and Afghanistan often face these "invisible wounds," and these stories help us see that trauma in its complexity. War itself is a traumatic experience, but for some veterans post-traumatic-stress occurs after the war is over. It is my hope through this project we can understand the invisible wounds of war such as post-traumatic-stress disorder and traumatic brain injury while also understanding combat stress and the struggles that veterans face in their civilian life. By examining two texts of short stories from two completely different wars, we can look at trauma from different points of view. During Vietnam some veterans were faced with isolation, often times tempted with alcohol, drugs and suicide. These members of the armed forces were not welcomed home in most cases, and Tim O'Brien's short stories let us understand just how daunting it was to be at war, and how storytelling is key to comprehending the difficulties of this war. Drawing on another kind of wartime experience is Phil Klay, who brings about the bureaucracies of Iraq and the difficulty that some Marines face when they are home trying to integrate into civilian life. Sometimes the stories are difficult, raw, and hard to comprehend, but processing trauma also allows one to improve the quality of life. By listening to these stories we are making the storyteller valued, and we are also learning about historical and cultural contexts. In my time as a Graduate Teaching Assistant, I was fortunate to work with student-veterans returning to the university after deployments. These students, all from diverse backgrounds allowed me to understand what it truly means to listen to the story and be attentive to what these students wanted and needed. By introducing war narratives, short stories, and poems in the classroom we give student-veterans an opportunity to see that writing is not only an outlet for self-expression, but also a way to let the public know what military life and deployments are like.

As seen in military documents, medical journals, novels, films, television shows, and memoirs, soldiers’ invisible wounds are not innate cracks in individual psyches that break under the stress of war. Instead, the generation of weary warriors is caught up in wider social and political networks and institutions—families, activist groups, government bureaucracies, welfare state programs—mediated through a military hierarchy, psychiatry rooted in mind-body sciences, and various cultural constructs of masculinity. This book offers a history of military psychiatry from the American Civil War to the latest Afghanistan conflict. The authors trace the effects of power and knowledge in relation to the emotional and psychological trauma that shapes soldiers’ bodies, minds, and souls, developing an extensive account of the emergence, diagnosis, and treatment of soldiers’ invisible wounds.