As we prepare to send a "surge" of 30,000 more troops to Afghanistan, we must look urgently and squarely at the mental health as well as the military and political consequences of our deployment. This means preparing American men and women to deal as effectively as they can with the fear and confusion that battle will bring and with the sometimes ambiguous life-and-death decisions they will make, and help them grow through rather than succumb to the long-term consequences of living, fighting, and dying, as troops so mordantly and accurately put it, "down-range." As we help our troops to maintain or recover their wholeness, we also need to develop strategies to sustain the caregivers who support them before, during, and after they deploy. And as we implement these strategies, we need to take into account the painful lessons taught by the caregiver who apparently went mad and committed the massacre at Fort Hood.
Indeed, it is far less important for us as a nation to focus on the troubled psyche and deeply troubling political beliefs of Maj. Nidal Hasan, the Army psychiatrist who is charged with 13 counts of premeditated murder and 32 counts of attempted premeditated murder from his Nov. 5 shooting at Fort Hood, than it is to prevent future, similar occurrences. We do certainly need to do better at identifying and disarming the so-called 'ticking bombs,' the men and women who give warning signs of impending lethal behavior, but this is only a part of the job. The larger task is to defuse the rage and relieve the pain that is far more widespread, to make available comprehensive psychological and social support, as well as more appropriate training, for all those who care for troubled troops as well as for the troops themselves.
The US military has estimated that some 600,000 veterans of the wars in Iraq and Afghanistan will suffer from post-traumatic stress disorder (PTSD), major depression, and/or traumatic brain injury. These conditions distress and may disable them, and may well deform the ways they relate to other troops as well as to their military mission and their families. PTSD in particular has been associated with violent behavior, especially towards family members and oneself.
The health and mental health professionals who work with these troops are overwhelmed by the magnitude of the task at hand. There are, in spite of efforts at recruitment, far too few of them. They are, moreover, as recent front page articles in The New York Times and The Washington Post have reaffirmed, handicapped by the stigma and the very real risks that still attach to seeking psychological help. For many seeking help is still tantamount to a confession of "weakness" that feels inappropriate to military men and women. And, in a system that imperfectly safeguards therapist-patient confidentiality, there is the very real possibility that what is revealed in a time of psychological distress may later present a permanent roadblock to military advancement.
Caregivers face another more subtle challenge that complicates their lives and may compromise their work. Each day they are responsible for listening to, and for helping, men and women who have seen, and often endured, the most extreme suffering. At Walter Reed Army Medical Center and at bases like Ft. Hood, where Maj. Hasan served, there are military men and women who bring extraordinary emotional resources to dealing with terrible physical damage--losses of limbs and eyes, and disfigurement. There are many more who are disabled by injuries that are less apparent--those who suffer the relentless headaches, disorientation, cognitive disturbance, and mood swings that may come with traumatic brain injury and the agitated, memory-haunted fearfulness and withdrawal of PTSD and major depression.
Their caregivers hear over and over the stories of comrades lost in combat, of guilt for death caused or actions taken or omitted--guilt that seems so hard to lay to rest even when it is unearned. They sit with troops who struggle with the impossibility of communicating what it was, and is, like to have been in and be reliving combat; with men and women who are agitated and conflicted because they don't fit in back home and want--and fear--to be back with their buddies "in country;" and with troops with the painfully mixed feelings that come to some about wars in which they have lost so much.
These clinicians are inevitably troubled by the pain and suffering they hear and see, and often frustrated by the difficulties of remedying their patients' frustrations. A very significant number of them--those who have not yet served in Iraq and Afghanistan as well as those who have been downrange--are experiencing what the mental health literature describes as "secondary trauma," and suffering from "compassion fatigue" and "professional burnout."
These descriptions of caregiver stress and trauma have taken on real and poignant meaning for me as I've sat in small groups with mental health and health professionals who are serving the US military, as I listen to them share--most often for the first time--the sorrow, anger, and pain they see and feel each day as they deal with "wounded warriors" and their families; as they grapple with their own temptations to deny or medicate away the psychic pain in others; as they sometimes question the wars that produce all this pain; and as they deal with feelings of helplessness and hopelessness that violate their own professional standards and shadow their most private moments.
For the last thirteen years, my colleagues and I at The Center for Mind-Body Medicine (CMBM) have worked with and trained professional caregivers in war- and post-war situations--in Bosnia, Kosovo, Macedonia, Israel, and Gaza, as well as in the US. The patterns I see with professionals serving the US military are strikingly similar to the ones I have observed overseas. These dedicated professionals pay great attention to the suffering of others and too often deny the pain they themselves are feeling. They devote longer and longer hours to selfless work and less and less attention to themselves, the human beings, who are doing the work. They sometimes carry as much as or even more weight than the troops they treat. Believing they should be able to handle their emotional burdens, they may well be even less likely to seek help than their patients.
At CMBM, we've developed a program designed to care for as well as train the caregivers, to teach them to deal with their own trauma and stress so they can, in turn, help the troops whom they serve. In the first part of our training, we help these caregivers to recognize and give voice to their own pain. We teach them to use relaxation techniques and meditation to quiet their anxiety and give them a calmer, more compassionate perspective on their lives and the work they do with others. They learn to use guided imagery, written exercises, and drawings to uncover the sources of their suffering and frustration and find intuitive answers to stubborn dilemmas. In our trainings they participate in a small, utterly confidential group in which they can experience and safely share their vulnerability as well as access their strengths and enhance their resilience.
Sometimes in these groups here and abroad, deeply traumatized and frustrated caregivers have confessed to murderous feelings and fantasies, or wishes to die and join in the afterlife those who have already been killed in combat. Some feel helpless to change the way they feel or to give adequate help to their patients. Only after we help them to express these dark wishes and fears are they able to begin to free themselves from them. Only as they learn to care for themselves are they truly, authentically, able to help others to do the same.
Later, in our Advanced Training, we teach clinicians to lead the same kind of educational and supportive small groups in which they have participated. In between the trainings and afterwards, we organize consulting and supervisory groups so they can continue to share the challenges of their lives as well as their work. Using the model they have learned from us--one which emphasizes education, skill-building, and sharing rather than diagnosis and individual treatment--they are able to continue to help themselves and one another. Sharing their own experiences openly, and offering this model to others, they attract and offer hope and help to troubled and angry military men and women who do not want to see "the shrink," be stigmatized, or medicated.
This kind of care and support is, in fact, essential to all those who are caring for our warriors. It makes it possible for these professionals to share their burdens and understand and have compassion for themselves as they learn from the difficulties and frustrations they inevitably face in their work with others. Our research tells us that our program decreases the caregivers' level of stress; enhances their professional effectiveness, their commitment to their work, and their connection to others. Perhaps, most important, it brings them greater hope for the future--in the midst of war as well as after it.
Certainly this kind of "care for the caregivers" helps our military clinicians to work more effectively and compassionately with troubled troops and their families. Perhaps even as we evaluate our military effort in Afghanistan, it can also help forestall future unnecessary tragedies among both patients and professionals.
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