Pressed by wars, military counselors feeling the strain

Bret A. Moore was an Army psychologist who quit after feeling burned out. Bret A. Moore was an Army psychologist who quit after feeling burned out. (Bret A. Moore via New York Times)
By Benedict Carey and Damien Cave
New York Times / November 8, 2009

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NEW YORK - Many of the patients who fill the day are bereft, angry, broken. Their stories are gruesome, their distress lasting, and the process of recovery exhausting. In time the repeated stories of battle and loss can leave even the most professional therapist numb or angry.

And hanging over it all, for psychiatrists and psychologists in today’s military, is the prospect of their own deployment - of working under fire with combat units in Iraq and Afghanistan.

That was the world that Major Nidal Malik Hasan, an Army psychiatrist, inhabited until Thursday, when he was accused of one of the worst mass shootings ever on a military base in the United States, an attack that killed 13 and left dozens wounded. Five of the dead were fellow therapists, the Army said.

Investigators are still trying to determine Hasan’s motives, exploring everything from job pressures to harassment as a Muslim to his strong opposition to the wars in Iraq and Afghanistan.

But those who work treating the psychological wounds of the country’s warriors say Thursday’s rampage has put a spotlight on the strains of their profession and of the patients they treat. Hasan was one of a thin line of military therapists trying to hold off a rising tide of need. This year 117 active duty Army soldiers were reported to have committed suicide, up from 103 in 2008. By the latest Army count, there are only 408 psychiatrists - military, civilian, and contractors - serving about 553,050 servicemen and women around the world.

As a result, some soldiers home from war, suffering from nightmares and panic attacks, say they have waited almost a year to see a psychiatrist. Many military professionals, meanwhile, describe crushing schedules with 10 or more patients a day, most struggling with devastating trauma.

Some of those hired to heal others end up needing help themselves. Some go home at night too depressed to talk to their children. Others, like Bret A. Moore, a former Army psychologist at Fort Hood, ultimately look for other work.

“I planned for a career in the military, but I burned out’’ after about five years, he said.

The biggest problem, Moore said, was “compassion fatigue.’’

“I thought that was a bogus phenomenon, but it’s true,’’ he said. “You become detached, you start to feel like you can’t connect with your patients, you run out of empathy. And the last thing you want to do is talk about it with someone else.’’

Whatever the facts in Hasan’s case, some therapists who work with the military agree the tragedy could have a “lasting impact on how we look at mental health providers,’’ said Dr. Martin Paulus, a psychiatrist at the University of California at San Diego and the Veterans Affairs San Diego Healthcare System.

The Army has added to their ranks in recent years, as the number of soldiers with the diagnosis of post-traumatic stress disorder climbed to 34,000. But the shooting has raised a pressing question: Who counsels the counselors? Moore and other therapists who have worked in the military or for Veterans Affairs said that mental health evaluations of therapists themselves were nonexistent.

Military therapists face an added pressure: they can be overruled by commanders who need soldiers in the field. Since 2001, the military has deployed many soldiers with post-traumatic stress disorder or other ailments. The military has made big strides in taking mental health issues seriously, but “the focus in the military is readiness,’’ said Charles Figley, a psychologist at Tulane University. “There is an inherent conflict that will always be there.’’

At Fort Hood, where traffic in and out of war zones is a constant, the work conditions were especially stressful, according to at least one report provided to the Army.

Dr. Stephen M. Stahl, a psychiatrist at the University of California at San Diego who worked on the report, said the base’s program for soldiers returning from Iraq and Afghanistan lacked the staff it needed. He said there were about 15 psychiatrists on staff, treating hundreds of inpatients and outpatients. Generally, the psychiatrists did not do therapy but prescribed medication.

In war zones, the relationships between soldiers and mental health providers can be especially fraught. Therapists in Iraq said they could often do little more than provide a few coping tips to soldiers, just enough to keep them functioning. There were simply too many people and not enough time, as Army officials have acknowledged.

Providing care has its own risks. In studies of therapists working to soothe mental distress in victims of violence, whether criminal, sexual, or combat-related, researchers have documented what is called secondary trauma: contact distress, of a kind. In one 2004 study of social workers on cases stemming from the Sept. 11, 2001, attacks, researchers found that the more deeply therapists were involved with victims, the more likely they were to experience such trauma. The same associations have been found in doctors working with survivors in war zones.

If it turns out that Hasan did in fact break partly under the stress of the job and impending deployment, many veterans would not be surprised.

“If this guy can go over the edge, imagine what it is like for the actual combat troops who have been through four or five deployments,’’ said Bryan Hannah, 22, a disabled Iraq war veteran from San Marcos, Texas, who was stationed at Fort Hood until he was discharged a year ago because of post-traumatic stress disorder and other injuries.

He added, “There are a lot of others who are worse off than him.’’

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