Death By Denial

“While investigators probe for a motive behind the mass shooting at the Fort Hood military base in Texas Thursday, in which an army psychiatrist is suspected of killing 13 people, military personnel at the base are in shock as the incident ‘brings the war home’… Tragically, Fort Hood has also born much of the brunt from its heavy involvement in both occupations. Fort Hood soldiers have accounted for more suicides than any other Army post since the U.S. invasion of Iraq in 2003. In this year alone, the base is averaging over 10 suicides each month – at least 75 have been recorded through July of this year alone.”

Dahr Jamail, Inter Press Service, 11/6/09

“The parents of US Army Reserve Specialist Chancellor Keesling, an Iraq war veteran, received a letter yesterday from the VA asking that their son complete his ‘Post Deployment Adjustment.’ The only problem is, Chance Keesling had killed himself in Iraq nearly five months ago….” The father of Chancellor Keesling stated “I don’t think as a country we understand mental health…as we go through the longest war in our history since Viet Nam, and multiple deployments, using civilian soldiers like reservists and the Guard in ways we have never used them in this country before…we have to be very conscious that mental health issues are going to impact these soldiers.” 11/11/09

Maj. Nidal Malik Hasan, an Army psychiatrist accused of shooting to death 13 people and wounding 30 others on November 5, 2009, was responsible for treating a heavy caseload of PTSD patients whose severely disabling trauma symptoms result from horrendous combat experiences in the ongoing bloody and violent occupations of Afghanistan and Iraq. The Major is opposed to US military invasions of those two countries. He is also a practicing Muslim, who also feels it is wrong for Muslims to kill Muslims.

This much we all now know.

At a time when the military as a whole is concerned about the climbing rate of suicides among soldiers—NPR reports that rate is at a thirty year high (2/17/09)—managing the mental health needs of the 70,000 troops, relatives and support staff living at Fort Hood (the world’s largest military base) must require unimaginable skill and knowledge. I was thinking this, when I heard a radio broadcast of a “mental health professional” from Fort Hood saying that any trauma Maj. Hasan suffered could not have been anywhere near that experienced by the soldiers returning from Iraq and Afghanistan (and they didn’t come back and commit mass murder). Other such comments from Texas psychiatrists were widely published within a few hours or days of the tragic shootings (Fort Worth Star-Telegram, Texas, 11/08/09)

Research has shown that those who experience “secondary trauma” as witnesses to another’s horrible suffering, often have worse symptoms and poorer treatment outcomes than the trauma victims who receive treatment. Why? Because the person involved in the traumatic incident has the “advantage” of a real situation to examine, an actual experience to come to terms with. They can express and feel guilt or anger regarding their actual behavior; make amends, or place the blame where it belongs…and thereby connect, recover and manage feelings.

A relatively powerless witness to the torment of another, has none of those “tangible” circumstances to work through and resolve. The very helplessness of witnesses who can do nothing to impact the horror of the situation heard about or witnessed, leaves them outside the process—unable to participate personally in the problem-solving, reframing, grieving, and forgiving of personal behaviors and actual experiences. Yet their feelings may be intense and more consciously experienced while listening to the details of the murders of innocent children, rapes, violations of human dignity, destruction of homes, villages, dehumanization, and torture of the young and old citizens of the occupied country (often committed in dissociated or altered states of mind.) Those of us who have listened to Iraq veterans struggle through recounting their military experiences, or to the testimony of the “Winter Soldiers” of both Iraq and Viet Nam, know how difficult it is to listen to these confessions just once on video. Imagine listening “live”, repeatedly, everyday.

Denial of the need for therapeutic help is often stronger in the person who witnessed, but was not the actual victim of a traumatic event. Hence, what appear to be sudden, unanticipated eruptions of repressed and dissociated emotions. Acting out dissociated feelings is a possible complication of post-traumatic syndrome disorder, but not always a necessary consequence of PTSD. (For more in depth discussion and research on this, see works by Judith Lewis Herman, M. D. of the “VOV Treatment Outcome Research Project,” and Joyanna L. Silberg, Ph.D. “Dissociative Features Profile”) Research studies by Dr. Judith Herman (2003) concluded that it takes more than trauma to cause the kind of radical dissociative behaviors we used to describe as “Multiple Personality Disorder,” and later “Dissociative Identity Disorder.” Successful “attachment” relationships provide one with the ability to regulate triggered emotions and maintain an awareness of “self”–acting in accordance with a strongly established identity. If one is suffering from PTSD and also from an Attachment Disorder, situations that recall the traumatic events and trigger emotions associated with those events, can also provoke dissociative experiences. There is also a wide range of dissociative symptoms from being unaware or unconscious of your behavior, to experiencing yourself as other than “self” while acting in unfamiliar ways.
Most attachment studies focus on early childhood. However, it might be useful to understand how later experiences in life—and throughout one’s life—that are deeply challenging, undermining, and demeaning of one’s identity and sense of self can lead to feelings of disconnection, loss of relationships, social isolation; and personality destabilization, confusion and vulnerability; as well as erosion of affect management skills. Added to this for consideration should be the life-long impact of repressed nightmarish memories inherited from victimized relatives and their surviving communities. However, it is not my intent to present here a professional examination of the field of PTSD and Dissociation. Simply to raise the issue that “secondary PTSD” is a reality that must be addressed and adequately treated as much as other trauma symptoms.

Like many of the tens of thousands of soldiers at Fort Hood, Maj. Hasan joined the military in order to get an education he could not otherwise afford. Also similar to some of those who enlisted, Maj. Hasan is against the occupations of Iraq and Afghanistan. Unlike most other soldiers who have spoken out against the war, Major Hasan’s opposition may be influenced by the fact that his Palestinian parents come from a country that has endured brutal occupation, racism, and all the worst forms of humiliation, exploitation, and torture for over 60 years.

In 1997, Malik Nadel Hasan enrolled in a tuition-free medical school program at the Uniformed Services University of Health Sciences in Bethesda, Md. He graduated in 2003. More than five years ago, Major Hasan confided to his family his disappointment with the Army and complained of Anti-Muslim harassment. The report that he began to look for a means of terminating his military commitment, sought legal advice, and offered to pay back the cost of his graduate education. Maj. Hasan’s military obligation would not be over until 2010. In the meantime, with his much needed mental health and language skills in scarce supply, military discharge seemed unlikely.

Relatives say that humiliating harassment the Major experienced consisted of insults like “someone had put a diaper in his car, saying, ‘That’s your headdress.’ In another case… someone had drawn a camel on his car and written under it, ‘Camel jockey, get out!’” Another such incident involved “ a soldier who had served in Iraq…angered by a bumper sticker on Maj. Hasan’s car proclaiming ‘Allah is Love’…ran his key the length of Major Hasan’s car. The loss of his parents in 1998 and 2001 seemed to have been very difficult for the Major. Acquaintances say he turned for solace to Islam (although his Muslim parents were described as “not observant”), and withdrew socially, and isolated himself, “delving into books on Islam.” (NYT 11/8/09)

None of this excuses the murders Maj. Hasan is reported to have committed. Nor will the search for an al-Qaida connection provide anything close to an adequate explanation of his possibly suicidal and certainly homicidal behavior, nor the behavior of other military officers and soldiers who committed similar crimes before him. Among the latter, remember the killing of two mental health workers and three soldiers (patients) by an Army Sergeant at Camp Liberty’s combat stress center in Baghdad on May 11, 2009. The 44-year-old Sergeant was on his 3rd Iraq deployment.

Reporting on that incident, The Psychiatric Times (July 2009) stated that, since the invasion of Iraq (“Operation Iraq Freedom”), there had been six previous incidents where service members killed their fellow soldiers. Also cited was “A large-scale, nongovernmental assessment of the psychological and cognitive needs of military service members conducted by RAND Corporation [that] found that nearly 20% of military service members who have returned from Iraq and Afghanistan—300,000 in all—reported symptoms of PTSD or major depression. Nevertheless, only slightly more than half have sought treatment.” A year earlier, a Mental Health Advisory Teams reported on the “issue of adequacy of behavioral health staffing for the troops.” At that time there was one mental health worker for every 1426 soldier or Marine. Maj. Hasan’s caseload had been constantly increasing.

An Uncle living in Palestine recounted that along with “ethnic taunts” his nephew said he endured, his work was also extremely stressful: “(H)e was haunted by the wartime disabilities of soldiers he treated as an Army psychiatrist…and was overwhelmed by a growing caseload he felt unable to manage…He didn’t have time even to breathe…Too much pressure, too many patients, not enough staff ..He would say, ‘I don’t know how to treat them or what to tell them,’ because he didn’t have enough time. They just kept coming one after the other. Sometimes he cried because of what happened to them. How young they are, what’s going to happen to the rest of their lives. They’re going to be handicapped; they’re going to be crazy. He was very, very sensitive.” (LA Times 11/8/09). Others have related how he chose the field of mental health, instead of surgery, after fainting while observing surgery on a child; and fainting again, at the sight of blood, while delivering a baby.

In another interview the uncle stated: “I saw him with tears in his eyes when he was talking about some of patients, when they came overseas from the battlefield…One has no face, one he have no legs. Hasan struggled to appear calm and unaffected to his patients…He didn’t have enough time to spend with all the patients. … I think he couldn’t handle it as he wanted to.” (Boston Herald/AP 11/7/09)

As a psychotherapist who worked with adult and child trauma patients for many years, I can appreciate a little what it means to be part of an understaffed, overworked trauma unit, under the best of circumstances. Yet, I cannot begin to imagine what it would be like to endure the same pressures in the world’s largest military base.

We do not need excuses, or scapegoats, in order to intelligently confront the reality of what transpired at Ft Hood, and to prevent repeats of this awful incident. We do need to understand the circumstances that can drive a military mental health worker to a homicidal breaking point, just as we need to recognize the circumstances that cause more and more soldiers at Fort Hood and else where to commit suicide everyday.

There are no doubt other important aspects of this particular tragedy and the larger problematic picture it illuminates that need to be considered and investigated. No one knows as well as Maj. Hasan himself what lead him to shoot and kill his fellow soldiers. As Jayne Lyn Stahl points out in her article for Counterpunch (11/6/09) we do not know the circumstances of Maj. Hasan’s deployment. Was his background as a Muslim and a Mental Health Worker going to be exploited in work with US interrogators as has happened with other mental health workers? All we really know, as she points out, is that he was being deployed and he definitely did not want to go. Stahl cites the case of Alyysa Peterson, an Arabic speaking psychology major and Army career intelligence officer, forced to participate in “a clandestine operation” using so-called ‘alternative enhanced interrogation techniques.” Actually, she refused to cooperate, and became “deeply despondent about what she witnessed at the detention camp in Iraq. On September 15, 2003, she was found with a bullet wound to her head, a victim of what the Army euphemistically called ‘non-hostile weapon discharge.’”

The point is, there is so much more than what is being reported daily in the mass media that we do not know about.

I admit to feeling a moment of hope that possible “Secondary PTSD” and “Dissociation” might be considered seriously when I saw a report (AP 11/10/09) that “A lawyer for the Army psychiatrist accused in a deadly shooting spree at Fort Hood said Monday he asked investigators not to question his client and expressed doubt that the suspect would be able to get a fair trial, given the widespread attention to the case.” Will the lawyer see his client before the FBI has questioned him? Will the real facts come out, truth and justice prevail, intelligence and compassion be applied to the process of examination and analysis of what happened and how to prevent its repetition? Or will another evil Imam with al-Qaida connections grab media attention, and justify an even greater investment in the War on Terror at home and abroad? Stay tuned, but don’t hold your breath waiting for the blindfolded Lady with sword and scales.

MARY LYNN CRAMER, MA, MSW, LICSW worked for many years as a clinical social worker treating children and adults with PTSD and Dissociative symptoms. She can be reached at


Mary Lynn Cramer, MA, MSW, LICSW has degrees in the history of economic thought and clinical social work , as well as over two decades of experience as a bilingual child and family psychotherapist. For the past five years, she has been deeply involved in “economic field research” among elderly women and men dependent upon social security, Medicare, and food stamps, living in subsidized housing projects. She can be reached at: