Post-Traumatic Stress Disorder is more tied to context than most other injuries. Time and place are intrinsic to the damage done. And, along with the context of the trauma being key, its diagnosis as well is culturally mediated. Adam Montgomery’s book is a welcome addition to the field because it focuses on this context, examining how understandings of and treatments for PTSD in Canada have changed over time. Starting with the ‘shell shock’ of the First World War and moving to discussion of mental trauma among Canadian peacekeepers and veterans of the war in Afghanistan, The Invisible Injured asserts the importance of understanding the changing context of PTSD, arguing that treatment cannot be disentangled from the culture in which the trauma occurred.
Taking a view that covers nearly a century, Montgomery shows the construction of trauma as existing on individual, community and national levels. Trauma is experienced directly by an individual, but also shaped by communal factors – dialogue with physicians and psychiatrists for example, and by society more generally, including contemporary ideas about appropriately masculine behaviour and the morality of the conflict that caused it. This means that the injury is not separate from society. Carried forward, it also means that looking at PTSD and responses to and treatment of it, is an illuminating angle for examining broader society. ‘Historically, each trauma manifestation was an individual illness, but considered together they reveal how Canadians, over one hundred years, have understood war and its psychological effects on soldiers’ (p. 16).
These societal aspects have myriad implications. An important aspect of the difficulties PTSD sufferers face is the invisibility of the injury. Montgomery shows that sometimes what society thinks it knows can cause further problems. After the First World War shell shock became a symbol of modern warfare, but the symbol drowned the individual; distress was presumed to take on a limited range of symptoms regardless of what individual soldiers suffered. How a specific war is seen also contributes to the interpretation of traumatised veterans. Returned soldiers faced particular difficulties after WWI, for example, because that war was widely seen as just and noble, and fighting in a just and noble cause should not lead to mental trauma. Similarly, Montgomery shows that PTSD among peacekeepers went unrecognised for a long while because it was assumed this kind of trauma came only from war. Further, there seems to have been a certain moralistic nationalism about this – Canadian peacekeepers could not suffer from it because PTSD was associated with American veterans of the war in Vietnam, and thus with feeling guilty about participation in unrighteous wars. Understanding of trauma is difficult to disentangle from reactions to the conflict in which they occurred.
The book also traces the rise of psychiatry, neurology and psychology over this century, showcasing the important connections between war and the development of the psychiatric professions, for whom these conflicts provided experience as well as increased legitimacy and recognition. Montgomery chronicles the changing definitions in the Diagnostic and Statistical Manual of Mental Disorders (DSM) that were a key part of this. He shows, for instance, that breakdowns in WWII were generally characterised as coming from personal or family history, and deemed to be avoidable by weeding out unfit men right from the beginning. This would save the military time and money. It also placed significant blame on ‘improper’ parenting, especially by mothers who were blamed before and after WWII for raising weak boys who would break under the pressure that service to their country required. The connection between trauma and gender roles, both on the part of the injured and his mother, is a key theme in the book. Another is the frequent post-war desire to forget and return to ‘normal’, with clear negative implications for those whose suffering carried on after the armistice.
The coverage in this book is rather uneven. The first part, examining the First and Second World Wars, draws together a breadth of secondary research, and is considerably shorter than the rest of the study. The second part is based on more original work, including interviews with affected veterans. The author seems more engaged in the latter material, perhaps justifiably, but a less cursory grounding would help prove his argument about the importance of the changing social construction over time. I would also have liked connections drawn more frequently and explicitly between past and present; analyses of individual conflicts are fairly self-contained. Including discussion of the first half of the twentieth century becomes less useful if these conflicts are not drawn on for their contrasts and continuities.
Montgomery’s discussion of contemporary issues shows skill and sympathy. Along with being poorly understood by wider society and problematic to governments who must pay for pensions, he highlights the idiosyncrasies of military culture, and the complications it adds to obtaining treatment. The book is not about offering solutions, but it discusses changing contemporary responses that seem to help. Community and communication are important, as is a slower transition from the conflict zone back home, giving a veteran time to decompress. Greater awareness of the issue, both within the military and wider society, seems to be helping too. It is no small thing to say that this book, arguing for the importance of understanding context and culture along with medical treatment, should assist in this matter as well.
