As most of you are aware, on November 5th, 2009, army psychiatrist Maj. Nidal Malik Hasan, for reasons unknown at the time of this blog entry, went on a shooting spree at his station base Fort Hood.  As a result of his actions, 13 people were killed and 30 wounded.  My deepest condolences and sympathies go out to the victims (and their families) of this senseless act.

Although more details are likely to emerge in the days and weeks to come, I thought this might be an appropriate time to address the issue of post-traumatic stress disorder (PTSD) and trauma treatment.  Although this term has yet to get much coverage in the wake of this story, I am particularly focused on the concept of vicarious traumatization in this incident.  Vicarious traumatization is also known as "secondary trauma", and involves involves therapists (and other close caregivers) of trauma victims becoming traumatized themselves through the process of empathizing (stepping into the patient's shoes as if he/she was the person) with the patient as he/she re-lives the trauma during the treatment.

In this case - and I should be clear that I do not have all the pertinent information - it appears that Dr. Hasan was treating multiple cases of severe combat-related PTSD while struggling with his own personal and religious beliefs about the wars in Iraq and Afghanistan.   As I follow the coverage of this story, I find myself wondering what kind of peer supervision or consultation system he had in place to process his experience of treating these complicated trauma cases.  Mental health providers are always encouraged to seek consultation or supervision for difficult cases.  Trainees are obligated to be supervised as part of the degree and licensure process.  However, once licensed, consultation/supervision is no longer mandatory.  However, almost all mental health associations - including the American Psychological Association, of which I am a member - strongly encourage their members to continue to seek out peer consultation / supervision, and self-care.  Why is this important?  Because countertransference, or the therapist's personal reaction to the clinical material, is unavoidable.  In the case of trauma, the material is extremely graphic and disturbing, which increases the likelihood of a strong countertransference reaction in the therapist.  Even therapists with extensive experience providing trauma treatment cannot avoid having reactions to some of the stories they hear from their patients.  For this reason, it is important for mental health professionals to have outlets to process their reactions, and ultimately provide better care to the patient.

Another issue that this incident raises in my mind is the differences in training across disciplines.  Psychiatrists, while often viewed at the top of the hierarchical chain perpetuated by the medical model, often have the least experience amongst mental health professionals in providing therapy treatment.  As MDs, psychiatrists are trained first and foremost to understand the biological and pharmacological dimensions of mental illness.  This is an extremely important piece of a comprehensive mental health treatment approach, and I do not want to minimize it.  But the provision of specific training in providing therapy is often minimal for psychiatry students.  Thus, I often come across psychiatrists who only provide "medication management" - that is treating mental illness from a diagnostic and pharmacological perspective.  They have little experience or desire to provide therapy to their patients for the illnesses they are treating pharmacologically.  Let me be clear - I have many colleagues who are psychiatrists andprovide outstanding therapy treatment.  But if you ask many of them, Isuspect they will tell you that they sought out additionalpost-doctoral training in therapy to augment their work.  I believe this raises a troubling ethical question.  What happens, when because of strained provider resources, psychiatrists who do not have the proper experience are thrust into a therapeutic treatment role? 

In the case of Dr. Hasan, he appears to have had expertise in working with PTSD.  But was this expertise in the pharmacological management of the disorder - or in treating it therapeutically?  In addition, what kind of consultation/supervision was he seeking or receiving in support of his work?  What resources (or lack thereof) did the military provide in support to the mental health professionals treating service members with PTSD?  These seem like important questions that need to be addressed as the investigation of this incident unfolds.

If you, the blog reader, are someone who has experienced a trauma or are suffering from symptoms of PTSD, I would like to offer some advice for you as you consider seeking treatment of your trauma (or if you currently are in treatment).  Do not be afraid to ask your treatment provider about what whether he/she receives consultation/supervision in support of his/her work.  Depending on your provider's theoretical orientation, he or she may not feel comfortable sharing this information with you (some providers belief that self-disclosure is a distraction from the patient's clinical material).  Regardless, this could lead to an interesting, productive, and ultimately empowering conversation about what it is like for the therapist to bear witness to your trauma and share in this experience with you. 

A great book I recommend on the subject of trauma (and vicarious traumatization) is "Trauma and Recovery" by Dr. Judith Herman (who is, ironically, a psychiatrist).  This book is geared towards mental health professionals, but I believe can also be helpful for trauma victims.