Could an assessment have been the "Ounce of Prevention "that might have averted the tragedy at Fort Hood? Although I strongly dislike any sort of hindsight analysis, I feel that I must speak out after the horrendous tragedy that occurred at Ft. Hood this past week. Sadly, the horror might have been preventable, but we will never know. First of all, the alleged shooter clearly manifested most of the "red flag" risk factors for potential violence and suicide. A number of people interviewed who had known Major Hasan said that they observed the danger signs. Unfortunately, these individuals did not convey their concerns to a "gate-keeper," head counselor, medical director, someone who felt responsible for assuring that "no one on his watch would commit suicide or an act of violence."
This misfortune points toward major flaws in our mental health system for military personnel, including the mental health of psychiatrists, psychologists and counselors treating our troops. The most important is the lack of training and information provided to military personnel about the risk factors for violence and suicide, a lack which can be easily remedied.
The risk factors for violence are known and well-researched: they are no longer a mystery. However, not everyone is familiar with them. Therefore, it is imperative that the people in charge of our mental health system in the military learn what the danger signs are. There are reliable assessment instruments containing these risk factors currently available to professionals in the field of mental health.
For example, the personal revelations provided by Major Hasan to others and posted on the Internet prior to the tragedy closely fit the five Levels or Factors on the Firestone Assessment of Violent Thoughts [FAVT], (Firestone & Firestone, PAR, 2007).
The reliability and validity of this assessment scale have been established through empirical research and can be used as a quick screening tool to assess for violence potential.
Level 1: "Paranoid/Suspicious" can be found in Major Hasan's statements during a 2007 presentation for an environmental health class. Hasan argued that Muslims were being targeted by the U.S. anti-terror campaign and reportedly told classmates that he was 'a Muslim first and an American second." Major Hasan appears to have been extremely sympathetic to Islamic suicide bombers, evidently perceiving them as freedom-fighting martyrs protecting their countrymen and fellow Muslims. His threatening postings on the Internet attracted the attention of Federal law enforcement officials about six months ago. On a personal level, he apparently felt he had been unfairly targeted and harassed by his military colleagues regarding his religion and ethnicity.
Level 2: "Persecuted Misfit," He portrayed himself as a misfit often wearing Muslim garb to work and the army fatigues to mosque. He also seemed troubled in the relationship sphere having asked an Eman at the mosque to help him find a wife but his attempts failed there as well. He was aggressively attempting to arrange a discharge from the Army, hiring an attorney and offering to repay the considerable cost of his 8-year medical education. However, his request to terminate his obligation with the U.S. government had gone nowhere, thereby placing Major Hasan in the classic "double-bind" situation. When ordered to deploy overseas where he believed that he might have to kill his fellow Muslims, he perceived his deployment as a persecution and felt victimized by it.
Level 3: Self-Depreciating/Pseudoindependent: He was an isolated loner his inability to find a wife and a tendency to "take care of himself," to feel as though he needed no help from the outside. He lived an isolated existence and was probably impacted, in ways we can only guess, by the death of his mother nine years ago. It also seems to have coincided with 9/11. It seems he became more religious, perhaps more fanatic, following the death of a person to whom he was closely attached.
Level 4: Overtly Aggressive: Major Hasan probably experienced overtly aggressive thoughts. Indications of his overtly violent musings were discovered on Internet postings where he referred to suicide bombings and other threats. His statements equated suicide bombers to soldiers who throw themselves on hand grenades to save the lives of comrades. He saw nothing morally wrong in killing others, indeed, he saw violence as a means to a moral end. His strategy for that fatal day was well-thought out and meticulously planned as evidenced by his buying guns to carry through his planned attack and putting all his affairs in order.
Level 5: Self-Aggrandizing Thoughts: Major Hasan probably saw himself as a hero carrying out his interpretation of Allah's commands "God is Great!" He appears to feel himself superior for being a Muslim in spite of feeling persecuted for it.
It is also important to note the overlap between violence and suicide which is common and strongly evident in Major Hasan's case. He exhibited all the well-known signs of someone who would endorse levels of serious suicide intent on the Firestone Assessment of Suicide Intent (FASI).
In addition, he gave away his furniture and other possessions to a neighbor and copies of the Koran to friends, also signals of an impending suicide. He informed his landlord that he would be leaving his apartment on the day of the shooting, despite the fact that he was not likely to actually be physically deployed for another few months. It appears that he did not plan to survive his attack on his fellow soldiers.
Therefore, it is important to assess for suicide potential as well as for violence. The U.S. Army recently reported that everyday five U.S. soldiers attempt suicide and the army has experienced a six-fold increase since the start of the war in Iraq and Afghanistan with suicides occurring prior to, during, and after military deployment. This alarming increase has left the Army looking for means to assess and treat those at risk for suicide. The problem can be compounded by the general attitude of the Army, in which soldiers are encouraged to be strong and keep their emotions in check. This can make having suicidal thoughts feel all the more shameful and isolating. Often soldiers who attempt to get help are thwarted in their efforts by superiors who do not understand.
The Air Force began addressing this problem and found that as you change the culture surrounding soldiers, you change the rate of suicide risk. The program they deployed and developed involved de-stigmatizing mental health treatment (actively encouraging soldiers to seek help). They also made preventing suicide everyone's responsibility from the top general down. In addition, they implemented David Jobes CAMS (Collaborative Assessment and Management of Suicide Risk) in which the suicidal individual is regarded as the expert on their own affliction. Therapist and patient work collaboratively instead of the typical hierarchical structure of the military. The program yielded extremely impressive results with a quicker resolution of the suicidal crisis. The Air Force suicide prevention program when fully implemented reduced their suicide rate dramatically.
The individuals responsible for the mental health care of our military -- including care-givers themselves -- must become familiar with these warning signs, and they must require that soldiers in their command be assessed, not only for PTSD and depression, but also for their potential for suicide or violence. The number of soldiers needing assessment and treatment are staggering. In April 2008, the RAND Corporation reported that "Nearly 20 percent of military service members who have returned from Iraq and Afghanistan -- 300,000 in all -- report symptoms of post-traumatic stress disorder or major depression, yet only slightly more than half have sought treatment."
Summary: Suggestions for prevention in the future:
- 1. Everyone who is entering, exiting or even in the throes of military duty should be assessed in terms of both suicide and violence risk. Training for understanding and treating suicide should also be included. http://www.glendon.org/index.php?pageid=46
- 2. Why not immediately include in Ft. Hood's Army Resiliency Training Program a base-wide assessment of violence and suicide potential? The total time spent in this screening per soldier and counselor would be approximately 45 minutes. If everyone is required to answer these two questionnaires, then no one is singled out for stigmatization. Moreover, intervention [secondary prevention] designed to decrease the intensity and press of these destructive thoughts could be immediately put into place.
- 3. Once we screen these individuals, intervention could be provided to those at risk. We can do more than resiliency programs which tell participants to change the way they think under stress, we can treat the underlying pain driving their suicidal and violent behavior.
Lisa Firestone PhD is and International Expert on Suicide and Violence
Director of Research and Education for the Glendon Association.
She is a founder and contributor at PsychAlive.org and a blogger for Psychology Today.