The ghastly Texas massacre of last week might have derailed the Pentagon's plans to induct a large number of psychiatrists on frontlines.
Besides many seem to believe that the much harried army psychiatrists could be suffering from compassion fatigue themselves.
One in three US soldiers say they can't reach a counselor when they need to, according to an Army survey last year. But bridging the gap doesnt seem to be all that easy.
Indeed there is a concerted effort these days. They are now flying in therapists to far-flung places in numbers not seen before.
Col. Carl Castro, a psychologist and director of Army Military Operational Medicine, says "flying mental health care providers exclusively to servicemembers who need help is unprecedented. It's almost like the EMTs (emergency medical technicians) that you see on the interstate when they block the road and land the helicopter. It's just never been done."
As of now, about 45 uniformed mental health workers are spread out across eastern Afghanistan. Teams of psychologists, psychiatrists and social workers fly to four dozen isolated bases or outposts each month.
An additional 25 U.S. military behavioral health specialists are in southern Afghanistan and were to be joined in the months ahead by about 45 additional therapists, says Army Lt. Col. Jeffrey Hill, a psychiatrist who overseas behavioral health care for soldiers in Afghanistan. The plan had been to "disperse them as far forward as possible," Hill says.
In addition to the stress control teams, there are psychologists and psychiatrists assigned to individual fighting brigades who tend to those soldiers,
Gregg Zoroyasaid reporting for USA TODAY.
Their tasks range from providing security and mentoring Afghan soldiers and police to working with farmers in improving yields.
Crucially, they also†take physical risks in Afghanistan, flying over mountainous terrain by helicopter or running the gauntlet of roadside bombs by convoy. Outposts are rocketed. Counselors get stranded at a base for days or weeks when helicopters are diverted elsewhere.
"We're really close to the fight. We're really close to where the rubber meets the road," says Air Force Lt. Col. Randall Nedegaard, a psychologist who leads the Air Force combat stress control teams there.
Forthood executioner Major Nidal Malik Hasan had told his family he had no desire to go to war. Earlier this year, President Obama sent more troops to Afghanistan, increasing the demand for mental health providers. As a result, the Army is pushing a policy of sending into combat soldiers who have never been overseas.
For Hasan, with 12 years of service and no deployments, it was time to go. He wouldn't, nor would many others in the camp.
At least three of those killed were therapists slotted for Afghanistan. And six who were wounded are part of the 1493rd Combat Stress Control team to which Hasan was assigned and which was heading to Afghanistan, the Army says.
Army spokesman George Wright said Sunday that commanders are wrestling with whether to cancel deployment of the team because it was so decimated by the shootings. "This will represent a challenge," Wright says, "but we anticipate we can meet the challenge."
It is also noted that doctors generally have relatively high suicide rates, with psychiatrists having the highest rates.
Both male and female physicians are significantly more likely to commit suicide than the rest of the population, according to a 2004 article in the American Journal of Psychiatry.
Among all physicians, psychiatrists are considered to be at greatest risk for suicide, according to the 2007 version of Kaplan and Sadock's Synopsis of Psychiatry.
Major Hasan had experienced the conflict almost as if he had been in the combat zone for the past six years, psychiatrists and traumatic stress experts said.
"Many of the soldiers you evaluate and treat talk to you about horrific events," said Dr. Daniel Amen, a former Army psychiatrist who, like Hasan, once worked at Walter Reed Army Medical Center. "Psychiatrists can develop something called compassion fatigue. You just get worn out by the trauma."
At its worst, compassion fatigue becomes secondary trauma - a condition similar to post-traumatic stress, mental health experts said.
If post-traumatic stress is in essence a memory-management problem, an inability to effectively manage the frightening experiences they've had, secondary trauma too causes symptoms like sleep disruptions, nightmares, depression and jumpiness.
Sufferers may avoid situations that remind them of past stresses. A mental health practitioner also may feel guilty about not having done more to help a patient or may obsess about individual patients - particularly those with whom they identify.
One noted study found that social workers who treated survivors, victims' families and first responders at the World Trade Center after 9/11 were most susceptible to secondary trauma if they lacked social support, Dallas Morning News reported.
And when there is an acute shortage of trained mental health workers, it leaves the therapists emotionally drained and overworked, with limited time to prepare for their own war deployments.
A military mental health task force in 2007 expressed concern about the stress on non-deployed mental health personnel because of the shortage which, it said, was leading to high attrition rates. "A vicious cycle has formed that will probably continue to worsen before it improves," the report said.