Trauma, Psychiatry and the War on Terror

Janice Haaken

Combat Trauma:
Imaginaries of War and Citizenship in Post-9/11 America
By Nadia Abu El-Haj
Verso Books, 2022, 352 pages, $29.95 paperback.

IN THIS INSIGHTFUL and timely new book, anthropologist Nadia Abu El-Haj takes up a genre of war stories that gathered notable currency in the 21st century. She traces the expanding role of psychiatrists and psychologists in the cultural production of what she terms the combat-trauma imaginary.

Public concerns over the problems of returning soldiers are as old as warfare itself. But how those problems are understood, El-Haj observes, is quite dynamic. The dead haunt the living in images of returning body bags, military cemeteries with rolling hills of white crosses and granite memorial walls. But emotionally damaged survivors bring their war stories home in ways that often destabilize official accounts.

Nadia Abu El-Haj is Ann Whitney Olin Professor in the Departments of Anthropology at Barnard College and Columbia University. Her previous books, Facts on the Ground: Archaeological Practice and Territorial Self-Fashioning and The Genealogical Science: The Search for Jewish Origins and the Politics of Epistemology, explore controversial subjects in the production of ideology. (Facts on the Ground provoked a campaign by a rightwing American settler in the West Bank who unsuccessfully demanded that Barnard fire Abu El-Haj.)

In the history recounted in Combat Trauma, psychiatry is not cast as simply an agent of social control — a standard line of left critique. Rather, El-Haj follows shifts in the role of psychiatry in contemporary military interventions, homing in on the deployment of trauma diagnoses in two decades of the post-9/11 War on Terror.

The Vietnam War brought onto the public stage a new cast of suffering veterans and war-related afflictions. The disciplines of psychology and psychiatry flourished historically through U.S. warfare, from testing and treating soldiers unable or unwilling to fight to psychiatric care for disabled veterans housed in the sprawling mental asylums created for the war-wounded.

The figure of the shell-shocked soldier and the mentally haunted veteran with the 1000-yard stare loom large in the American iconography of warfare. But the antiwar movement during the Vietnam War era profoundly changed the iconic portraits of mentally afflicted veterans. Activists insisted that war produces pervasive and persistent forms of madness. Even psychotic symptoms in war fighters could be described as a “normal response to an abnormal situation.”

Further, the psychiatric casualties of warfare, previously shuttered away in asylums, had a great deal to say about the irrationalities of war. In the decades that followed official recognition of PTSD in 1980, the political story of this valorized diagnosis became far more complicated. Combat Trauma traces this complex history of military-related trauma disorders as political battles raged during the protracted “War on Terror.”

Crises and Division

The book is structured through three sections that cover periods of crisis and what El-Haj terms the civil/military divide.

Section I looks at the Vietnam War era and alliances between veterans and radical psychiatrists and psychologists. While mental health professionals have been part of military war planning since the First World War and were vital to the Second World War mobilization, the social movements of the 1960s and 70s set the stage for rebellions in the psychiatric professions. El-Haj traces this history of radical psychiatry and the emergence of the post-traumatic stress disorder diagnosis as a political intervention.

Section II centers on the era that begins with 9/11, and takes up the profusion in trauma stories that accompanied the decades of war in Iraq and Afghanistan. The post-9/11 traumatized veterans in these emergent accounts are shorn of the critical political commentary, guilt and outrage that were touchtone motifs of troubled veterans in the Vietnam-era.

In Section III. El-Haj gathers up trends in the post-9/11 period that bring pastors, chaplains and Christian concepts of redemption into the psychology of military-related trauma. This section looks closely at the emergence of the concept of moral injury in the PTSD field — a condition thought to be produced by seeing or participating in situations that violate the service member’s conscience in some way. The concept, having been embraced by many clinicians, spawned a burgeoning field of trauma sub-specialists.

The Vietnam War era sets the stage for the historical trajectory outlined in the book — an era when veterans worked with mental health professionals to campaign for the entry of PTSD into the DSM, the official diagnostic manual in the mental health field. The guilt, anger and outrage coursing through the accounts of Vietnam War veterans joined a chorus of civil rights, student protests, feminists and peace groups in shaping public discourse on war and U.S. militarism.

As the trauma model took hold in the mental health field over subsequent decades, El-Haj shows how psychiatric portrayals of returning soldiers were increasingly depoliticized. She explains how the traumatized combatant emerges as a kind of collective Rorschach card upon which diffuse public anxieties could be projected.

Even as traumatized veterans were granted increased public recognition, they had less and less to say about the wars themselves. Mental health professionals played leading roles as public interlocutors and translators of the hidden meanings of military-related trauma symptoms.

In Psychiatry, Politics and PTSD: Breaking Down (2021), I take up this same historical terrain and similarly look at how the diagnosis of PTSD and the trauma model acquired such wide currency in framing the consequences of warfare.

Like El-Haj, I argue that this diagnosis lost its progressive edge as it was increasingly incorporated into official psychiatric manuals and treatments, including in U.S. military war planning and VA treatment protocols. And I agree with El-Haj that the key question is not so much whether PTSD is a valid diagnosis or how many solders suffer from this condition, but rather how it acquired such wide currency in public discourse.

The Victim/Hero Imaginary

Combat Trauma shows how the concept of military-related mental trauma mediates public anxieties over a protracted and open-ended war. El-Haj brings an interdisciplinary lens to her study of the figure of the traumatized soldier and the role of psychiatry in what cultural critic John Berger terms ways of seeing. In the picture drawn by El-Haj, psychiatry intervenes to focus on that figure of soldier as trauma victim/hero separate from the background conduct of war.

As an anthropology scholar, El-Haj is attuned to cultural dynamics that shape war stories. Anthropology has produced a rich literature on social boundaries between groups — on how those boundaries are formed and maintained. An important contribution of Combat Trauma lies in its astute analysis of what she frames as the combatant/non-combatant imaginary.

As the demographic distance between civilians and service members widened after the Vietnam War, public identification with war fighters took increasingly imaginary forms. Fewer people know actual service members and thus rely on popular culture and the media for authoritative accounts, causing the trauma stories of veterans that emerge and circulate in popular culture to be increasingly estranged from the actual experiences of war fighters.

In this sense, El-Haj invokes the idea of the imaginary to literally describe a shift from reality to fantasy. This same widening social distance creates a gap where veterans’ stories can be taken up to advance a range of ideological interests.

As El-Haj explains, veterans occupy a complex place in the American political imaginary. Those who have served in the military carry their own documented grievances and harms suffered, many extending for decades into postwar periods.

Stories of veterans abandoned or betrayed by the same government that sent them to fight and die dominate antiwar literature. Veterans are able to make claims on the state because of their military service — claims from which other groups are politically barred. Indeed, Congress summoned bipartisan support for veterans’ healthcare and disability benefits during the rise of neoliberal policies of the late 20th century when it slashed spending on social welfare and other programs for poor and marginalized groups.

El-Haj describes the special claims and moral authority granted to veterans as “truth-sayers.” But the truths spoken by veterans echo political changes on the home front. Deployed by veterans against the Vietnam war, accounts of mentally tormented fighters told a larger tale of the irrationality and the immorality of the war itself.

In the post 9/11 era, accounts of the traumatized soldier were increasingly shed of those critical currents.

The moral authority of returning veterans had always rested on their presumed direct knowledge of battlefield brutalities. But trauma therapists increasingly guided how that knowledge was translated. A key principle of the trauma model centered on the dissociated or fragmented character of traumatic memories and how recovery depended on unconditional acceptance of the veteran as victim as well as perpetrator.

El-Haj’s shows how this collapsing of victim and perpetrator in the trauma model guided various “listening” campaigns. In calling on the public to adopt an uncritical stance toward veterans, the actual conduct of service members and the wars themselves receded from the picture.

In her tracing of psychiatric framing of military trauma, El-Haj notes how the clinical fixation on soldiers’ psyches served to politically marginalize foreign victims of U.S. military interventions. Her portrayals of U.S. war fighters are less nuanced than they might be, however, even as she effectively argues that public calls for “listening and caring for our veterans” had the effect of silencing critics of military operations.

The PTSD diagnosis and clinical protocols based on the trauma model also narrowed the scripts available to veterans in framing their own war stories. The broader theater of war and troubles with the military command that dominated the stories of Vietnam War era were displaced by a more narrowly drawn set of PTSD scripts that relied on identifying a “index trauma” — a discrete event that produced the symptoms.

Moral Injury and “Hidden Wounds”

One of the many contributions of the book is in the author’s analysis of how the concept of moral injury gained currency in the mental health field in the decades after 9/11. In my own experience of presenting critiques of the PTSD diagnoses at conferences, clinicians routinely turn to the concept of moral injury in what they see as a corrective to the limitations of the PTSD diagnosis.

Whereas PTSD is bound to a psycho-physiological model, the diagnostic lens of moral injury appears to open up a more humanistic and expansive way of understanding the suffering of veterans. Proponents claim that it invites recognition of deeper forms of the “hidden wounds of war” — an idiom popularized by the PTSD movement.

I argue that this category is another version of the impact model — a modern version of the shell shock story.

While it may direct attention to the existential crisis of war fighters, moral injury remains bound to a narrowly drawn schema of battlefield impacts. Rather than understanding disturbing emotions as indicators of an awakening critical consciousness, providers treating the condition frame symptoms as a form of traumatic injury.

El-Haj makes the important social observation that therapeutic discourse on moral injury has advanced a widening array of spiritual advisors, preachers, chaplains and healers whose professed expertise came to dominate the ways that the public is asked to listen to veterans.

El-Haj takes up the shifting demographics of military personnel as central to unpacking the civil/military divide as well. She challenges the widely held view that the poor are most vulnerable to military recruiters, arguing instead that the military draws most deeply on sectors of the middle class and particularly segments of the middle class in rural conservative communities.

The transition from the draft during the Vietnam War to the all-volunteer military of the post-Vietnam era figures into this emerging divide between civilians and military service members. Extensive commentaries are available to explain the widening gap between service members and the general U.S. population. El-Haj notes that the gap is not evenly distributed across social classes and regions, however.

She describes close alliances between those who serve in the military and the police — social alliances that create their own means of bridging the civil/military divide.

Civilian and Combatant

El-Haj offers rich insights on the question of how the position of civilian is constituted in relation to the combatant. She shows how this discursive companion to the combatant operates in American culture as a floating signifier without a stable signified.

As the position of the civilian/non-combatant came to be cast primarily as a duty to listen and validate veterans, El-Haj explains how this position served to maintain public moral innocence in relation to the long wars.

In the various psychodramas described, where veterans present dramatic readings, the civilian is inhibited from questioning veterans about the conduct of warfare. Their duty as civilians is to care and to listen.

Such framing of moral obligations draws on principles that animate the trauma therapy field: listeners are to adopt a position of non-judgmental receptivity to accounts of emotional suffering.

The context of those accounts, or our obligations to act on what is heard, are peripheral or may even risk re-traumatizing the trauma victim. Listening to veterans emerges in itself as an act of moral courage.

In her analysis of the role of psychiatry in making war stories comfortable for a worried public, Nadia Abu El-Haj seeks to unsettle those accounts. She offers through this thoughtful book a bracing awakening to the psychiatric soporifics offered by the armies of clinicians deployed to attend to the hidden wounds of war.

Combat Trauma thus shows the costs of some of these forms of expertise that sooth jagged nerves, even as we sleepwalk into another era of U.S. imperial interventions. The Epilogue in this important work takes up that very present horizon of U.S. militarism and is itself very much worth the read.

July-August 2023, ATC 225