Meghan Fitzpatrick. Invisible Scars: Mental Trauma and the Korean War. Vancouver: University of British Columbia Press, 2017. Pp. 196.
By Russell W. Glenn, G2, U.S. Army Training and Doctrine Command
This review appears in Canadian Military History Vol. 27 No. 2 (2018).
The focus of Meghan Fitzpatrick’s Invisible Scars is Commonwealth Division soldiers who served in the 1950-1953 Korean War. It was a conflict that presented its participants with a devil’s cocktail of severely harsh weather, wicked terrain, and an able enemy in sometimes overwhelming numbers; a war during which well-known war journalist Max Hastings believed soldiers “suffered privations of almost Crimean proportions” (p. 2). It was certainly a war which confronted soldiers with multiple potential sources of severe stress, and it is with psychiatric casualties among the Commonwealth Division’s Australians, British, Canadians, and New Zealanders that Fitzpatrick concerns herself.
Such casualties have previously drawn the attention of many fine researchers; Anthony Kellett, Samuel A. Stouffer, and Roy R. Grinker but three among them. Nor has interest been limited to the non-fiction arena. Novelist Pat Barker won the 1995 Man Booker Prize for Ghost Road, one of three novels in her Regeneration Trilogy drawing on the experiences of actual First World War veterans that included Dr. (Captain) William Rivers, Siegfried Sassoon, and Wilfred Owen at the Craiglockhart psychiatric treatment facility outside Edinburgh.
Fitzpatrick’s detailed research covers the treatment received by Commonwealth psychiatric casualties in the field and thereafter, and what their experiences offer in the way of lessons for treatment today. She argues that while “the Korean War was a pivotal turning point in the development of battlefield medicine…fewer advances were made in psychiatry” (p. 7). Her insight likewise holds true for conflicts some six decades later. For all the near-miraculous advances made in saving lives on twenty-first-century battlefields, nations today are still less than adroit at dealing with the wounds inflicting Fitzpatrick’s hidden scars. The dearth of those qualified to provide effective psychiatric care in Korea provides a historical echo too familiar to those who might have benefitted from the skills of qualified professionals during or after recent service in Iraq and Afghanistan. So too does her reference to treatments relying on pharmaceuticals (pp. 75-77). A U.S. Army battalion commander deployed to Afghanistan confided his concerns in this regard to this reviewer during a 2012 research trip to that country, observing that he had during—and after—multiple combat tours seen far too few psychiatric professionals available to assist with all-too-apparent problems. Soldiers and veterans were instead treated with the Band-Aid of psychiatric medications which did little other than supress symptoms rather than address underlying ailments.
The author employs commendable reach in the gathering of evidence. Korean War veteran, family member, and psychiatrist interviews, archives, and personal correspondence are among the ores mined (p. xi). Ultimately, however, less than half of the book directly covers its focal questions (p. 4), providing instead supporting but somewhat peripheral material: a brief history of military psychiatric casualty treatment from the First World War to the Korean War (Chapter 1), an overview of allied medical cooperation (specifically with respect to the Commonwealth Division, Chapter 2), and a synopsis of soldiers’ living conditions (Chapter 3). Fitzpatrick gets to the meat of her subject in Chapters 4 and 5, and the book’s conclusion. We find that her identification of Korea as a medical turning point more in terms of combat treatments other than psychiatry is indeed correct. So too, we learn that Korea marked a significant change in the relationship between three of the countries comprising the Commonwealth Division and the United Kingdom. Canada, Australia, and New Zealand were considerably less willing to march to a British drumbeat during the Korean War than had been the case during the Second World War. Commanders in this trio of armies not infrequently threatened using “red cards,” claiming precedence of national priorities over following British orders thought inappropriate (p. 41). Although all three nations’ (and British) medical officers often turned to the Americans and their medical capabilities (p. 63-64), Fitzpatrick accurately notes that “Commonwealth officers were also quick to defend their trusts from the worst excesses of American command,” particularly in the case of overly detailed direction which violated the tenants of what we today know as mission command (p. 42). These frictions with American commanders once again foretell what would become an increasingly familiar occurrence in later conflicts as noted by historians such as Dr. Robert A. Hall in Combat Battalion, a history of his Australian countrymen during the Vietnam War.
All Commonwealth Division soldiers’ wounds were not treated equally after the Korean War any more than during it. It was the Australian, Canadian, New Zealand, or United Kingdom governments that bore the burden of proof that a Korean War physical injury was unrelated to military service during pension considerations (p. 87). The opposite was the case for psychiatric casualties. Canadian compensation was not forthcoming “unless positive proof of definite exaggeration of symptoms during service” existed (p. 88). Furthermore, veterans suffering certain forms of psychiatric problems were denied pensions outright while others could receive support only if they underwent and failed treatment at a recognised institution (p. 88). Even obtaining informal support such as that offered by members of veterans’ groups such as Australia’s Returned and Services League was difficult thanks to members’ belief that Korea was nothing more than a police action (p. 91).
Notable shortfalls in Fitzpatrick’s book are few in what is an informative offering of value to those responsible for or merely having an interest in soldier psychiatric casualties and their treatment. Better editing would have eliminated the too many instances of repetition (e.g., mention of 3 Royal Australian Regiment employing initial individual rather than unit rotation appears on both pages 47 and 65). A clearer statement of the first three chapters being largely background material would have been helpful to those wishing to focus primarily on the stated issue of Korean War psychiatric casualties. Conversely, Fitzpatrick correctly recognises that the primary objective of in-theatre treatment was—and remains—to provide high return to unit (RTU, elsewhere often referred to as “return to duty” or RTD) rates (pp. 11, 75, 78). She likewise appreciates that the “establishment of long-term care and support systems is as important as the development of forward and front-line psychiatric treatment” (p. 105). The latter is particularly interesting given recent research suggesting that prioritising RTU/RTD may increase the likelihood of later developing Post-Traumatic Stress Disorder (PTSD) in those so treated.
Fitzpatrick argues that “the Korean War…represents the last major deployment of Commonwealth forces before a revolution in psychiatric medicine” (p.104). She cites a 2005 Monash University (Australia) study that interviewed eighty-one per cent of Australia’s surviving Korean War veterans. Its authors conclude that they were “‘five to six times more likely to meet the criteria for PTSD than [other] men of a similar age” (p. 100). Revolution or not, treatment of soldier psychiatric casualties remains largely an unmet challenge. The U.S. suicide rate among military war veterans remains notably higher than for those who never served. The country’s Department of Veterans Affairs (VA) reports that in 2014, “after adjusting for differences in age, risk for suicide was 18% higher among male veterans when compared to U.S. civilian adult males” while that for female veterans was 2.4 times higher. Given the resistance of some previous wars’ veterans to accepting those who served in Korea into their organisations, it is perhaps ironic that it was Australia which first recognised in 1982 that the PTSD sufferer is a legitimate casualty of war and deserved appropriate access to counselling. Only in the early 1990s did New Zealand establish similar services with Canada and the United Kingdom doing so in the latter years of that decade or early in the next (p. 94).
The ultimate value in Dr. Fitzpatrick’s study reaches well beyond its considerable historical significance. The VA estimates that twenty U.S. veterans take their lives each day; the country’s Department of Defense puts the number at one. So large a discrepancy is disturbing, but an accurate count is impossible. Three of the nation’s most populous states—California, Texas, and Florida—do not report death by suicide. Nor is it always possible to determine whether a former service member’s demise is self-inflicted, for example when he or she is killed in a single vehicle accident. Whether one, twenty, or otherwise per day, the United States has lost more veterans and serving members of its armed forces to suicide in the time between its entry into Afghanistan and the present than due to combat fatalities. PTSD continues to plague surviving veterans of Korea, Vietnam, Iraq, and Afghanistan. It will inevitably do so for others serving in contingencies yet to come. Better treatment is called for but to this point in time remains elusive. That prescription narcotics alone are insufficient is a given. So too is the unfortunate dearth of psychiatrists or other qualified medical personnel available to treat veterans of recent conflicts. Fitzpatrick’s is a book that acknowledges advances made in treating these men and women while reminding us that much has yet to be done.
 Anthony Kellett, Combat Motivation: The Behavior of Soldiers in Battle (Boston: Kluwer Boston, 1982); Samuel A. Stouffer et al., The American Soldier: Combat and Its Aftermath, Volume II (Princeton: Princeton University Press, 1949); and Roy R. Grinker and John P. Spiegel, Men Under Stress (Philadelphia: Blakiston, 1945).
 Pat Barker, The Regeneration Trilogy: Regeneration, The Eye in the Door, The Ghost Road (London: Viking, 1996).
 Robert Hall, Combat Battalion: The 8th Battalion in Vietnam, Crow’s Nest, Australia: Allen & Unwin, 2000. See also Robert A. Hall, “A Long Bridge in Time: The 1st Australian Task Force in Vietnam via Malaya and Borneo,” and Anthony Rawlins, “Mission Command in Iraq – The Australian Experience on Operation Catalyst,” both in Trust and Leadership: The Australian Army Approach to Mission Command, Russell W. Glenn, ed., forthcoming in 2018 as part of the Association of the United States Army book programme.
 Mark C. Russell and Charles R. Figley, “Is the Military’s Century-Old Frontline Psychiatry Policy Harmful to Veterans and Their Families? Part Three of a Systematic Review,” Psychological Injury and Law 10 (February 2017), 72-95. The authors concluded that official claims that forward treatment enhances the welfare of soldiers so treated was not supported by evidence. While finding that some studies imply that later PTSD rates are higher in those treated forward versus such rates for veteran populations in general, Russell and Figley could not categorically conclude such treatment was harmful in the longer run.
 “VA Suicide Prevention Program Facts about Veteran Suicide July 2016,” U.S. Department of Veterans Affairs, https://www.va.gov/opa/publications/factsheets/suicide_prevention_factsheet_new_va_stats_070616_1400.pdf (accessed 27 October 2017).
 The reviewer thanks Ken Falke, chairman and founder of Boulder Crest Retreat for Military and Veteran Wellness and the EOD (Explosive Ordnance Disposal) Warrior Foundation for his observations regarding veteran suicide estimates and the difficulty in accurately determining actual values in this regard. Ken Falke email to Dr. Russell W. Glenn, Subject: Digital Intro, 2 October 2017.
 “Statement of Ken Falke, Chairman, Boulder Crest & EOD Warrior Foundation. Written Testimony for U.S. Senate Committee on Veterans Affairs – ‘#BeThere: What More Can Be Done to Prevent Suicide?’”, 27 September 27 2017, https://www.veterans.senate.gov/imo/media/doc/Boulder%20Crest%20Retreat%20Stmt%20FTR%2009.27.2017.pdf (accessed 28 October 2017).