L. M. Otero/The Associated Press

Maj. Nidal Malik Hasan, the 39-year-old Army psychiatrist accused of Thursday’s mass shooting at Fort Hood, Tex., had recently expressed deep concerns about being sent to Afghanistan. His cousin, Nader Hasan, said that Major Hasan had counseled scores of soldiers with post-traumatic stress disorder and was “mortified” about being deployed.

So much is still unknown about the case, but among the many issues raised is the question of post-traumatic stress among caregivers. Is this an issue experts in trauma treatment consider?



Secondary Stress Disorder

Charles Figley holds an endowed professorship in disaster mental health and trauma at Tulane University. He is founding president of the International Society for Traumatic Stress Studies, founding editor of the “Journal of Traumatic Stress” and editor of “Traumatology.”

Exposure to case after case of combat-related stress injuries often has negative effects for the caregivers who handle these cases. Yet in many instances, those professionals (not to mention family members) do not get proper attention and care for their emotional needs.

Service branches are recognizing the extraordinary problems of secondary trauma on caregivers.

My research on secondary traumatic stress — defined as the consequent stress and emotions caused by helping a traumatized and suffering person — has found that the negative effects can be similar to those of primary exposure.

Military caregivers are especially vulnerable because (a) the high concentration of trauma patients they see; (b) inability to change jobs; (c) their focus is on readiness and keeping the troops sufficiently healthy to be re-deployed; (d) the expectation of being deployed (often multiple times), and; (e) the complexity of providing treatment while fighting the fear, stigma and embarrassment of active duty personnel who are forced to seek such treatment.

Read more… All branches of service recognize the extraordinary problems of secondary trauma and have implemented programs to help. The Army, for example, has the formed the Provider Resilience Training Program for this very purpose. In many cases, the caregivers can suffer from intrusive imagery, avoidance of reminders and cues, hyperarousal, distressing emotions, and functional impairment including anxiety disorders.

In the most extreme cases, secondary stress may warrant a diagnosis of post-traumatic stress disorder. There are other names for this effect, including “compassion fatigue” and “vicarious trauma.” This is more than “burnout” or even anxiety caused by poor social support at a difficult workplace. Much can be done to help promote wellness and resilience among military caregivers. First is self-awareness to identify changes as a result of working with the traumatized. The first sign is elevations in stress and/or depression that is accompanied by problems of sleep. Second, developing a trusting relationship with another — fellow counselor, chaplain, or other type of caregiver — to disclose what is being experienced. Third, the caregiver needs to get the right kind of help. Sometimes, but not always, that means therapy. While military installations need to create supportive work environments, it is critical that family members be assertive with the caregiver if they see problems and make them get the help they need.

What Caregivers Need

Laurie Anne Pearlman, a clinical psychologist, is a member of the complex trauma task force of the International Society for Traumatic Stress Studies.



Trauma treatment experts are increasingly aware of the potential negative effects of providing assistance to traumatized persons.

Even seasoned clinicians can, at times, need clinical help.

These effects can take any or all of the following forms: vicarious trauma (a personal transformation in the caregiver that results from engaging with and feeling a sense of responsibility for a traumatized patient or client), compassion fatigue (an exhaustion of the helper’s ability to respond compassionately), burnout (a gap between what the caregiver can give and what s/he is expected to give), and countertransference (an activation of the helper’s personal issues in response to a particular client or patient).

Read more… Everyone who provides care to traumatized people needs his or her own support systems, both personal and professional. Personal support includes making time for non-work and non-trauma-work experiences, community, and connection with whatever gives meaning to each caregiver’s life. Professional support should include training in working with trauma survivors and on-going clinical consultation, even for seasoned clinicians. In addition, trauma therapists and counselors require adequate time off, access to mental health care, and opportunities to talk about the work in confidential professional settings.

What I Worry About

Kristin Henderson is married to a Navy chaplain and the author of “While They’re at War: The True Story of American Families on the Homefront.”

My husband just left on his third war zone deployment. So far, this one has been the easiest — we know more and knowledge is empowering. Plus, for the first time he’s not constantly on the move and under fire. Instead, he’s on a base, the chaplain at a combat hospital. Rockets and mortars sometimes hit the base but rarely result in casualties. Physically, he’s safer than ever before. That’s not what I worry about.

Who takes care of the caregivers in the military?

What worries me is that for the next six months he will help care for children and young service members who’ve been blown apart or shot. He’ll support the medical staff who fight to save their lives. He’ll absorb their pain.

Read more… By regulation, a chaplain is the only person in the military to whom you can confess anything and trust that the conversation will remain confidential. The chaplain can’t talk about it with anyone else unless you give the chaplain permission. That’s why, if you’re on the edge and want help but fear it might hurt your career, the chaplain is often the first person you tell. Chaplains aren’t equipped to treat something like post-traumatic stress disorder, but they, like my husband, can and do help suffering service members realize they’re not alone. He helps them reach out to mental health caregivers, provides spiritual and moral guidance, and keeps all the details to himself. My husband wants to do this work. It’s the most worthwhile, satisfying part of his job. Yet it takes a toll, and who takes care of the caregivers? The price of pain is usually hidden from the public because most caregivers, like most suffering service members, don’t go on rampages. Usually, if there’s a price to be paid, only the family pays it. As a military wife, that’s my biggest worry.

Healing Oneself

Peter P. Vitaliano is a professor of psychiatry and behavioral sciences, psychology and health services at the University of Washington, Seattle.

Given the horrific events that took place on Thursday at Fort Hood, many are asking why and how this could have happened and if it could have been prevented.

Caregivers all bring their own vulnerabilities to their work.

There is no question that there is extensive research to suggest that full time caregivers, whether they are paid or not paid, are at risk for problems of their own. Of course, many caregivers do not have problems and others do seek help. It’s important to understand that individuals who perform services for others, whether they are physicians, airline pilots, or unpaid family caregivers, all bring their own vulnerabilities to their work and these interact with their environments to influence their thoughts, emotions and behaviors.

We don’t yet know all the facts about the Fort Hood gunman or his motives. News reports have indicated that he told relatives that other soldiers harassed. Many organizations that employ mental health workers have venues for them to express their feelings and to receive feedback. It is unclear if Dr. Hasan had ever articulated his beliefs to colleagues who could have helped him.

Read more… If he had been isolated, he may not have been able to express his beliefs and receive constructive feedback about their validity. What we do know is that his situation was not unique. But his reported anxiety about deploying to a war for which he had counseled returning soldiers may have been a factor that made him snap. His horrific action can’t be explained rationally. Still, the fact is, professional caregivers who have been trained to spot trouble in others are not necessarily able, when under stress and isolation, to see that they themselves need help.

Combat Stress Is on the Rise

Helen Benedict, a professor of journalism at Columbia University, is the author of “The Lonely Soldier: The Private War of Women Serving in Iraq” and a novel, “The Edge of Eden.”

Whatever drove Major Hasan to shoot 13 people to death and wound 28 more at Fort Hood yesterday is still unknown, but his violence draws attention to the bitter toll taken on U.S. troops by this country’s seemingly endless wars in Iraq and Afghanistan.

P.T.S.D. takes a toll on the troops, their loved ones and the people who take care of them.

The veterans of these wars are suffering higher rates of trauma and breakdown than this country has seen for decades, so high that neither the military nor the Department of Veterans Affairs appears to able to cope. Veterans often have to wait months for treatment, and many have to travel for miles to find a VA hospital or clinic.