“The medical-care piece was easy,” said Col. Kimberly Kesling, M.C. “Helping people with their initial coping mechanisms and then getting them ongoing, long-term care is a bigger challenge.”

Kesling's challenge was the aftermath of the shooting at Fort Hood, Texas, on November 5 that left 13 dead and 31 wounded. Kesling is chief of the medical staff at the Carl Darnall Medical Center at Fort Hood.

Maj. Nidal Hasan, M.C., an Army psychiatrist, has been charged with 13 counts of premeditated murder. The case was shocking in its origins and tragic in its outcome, occurring in a community that believed it was safe and that death and danger lay far away in the Middle East.

“The sheer volume of casualties was daunting at first, even to a medical staff with experience in Iraq or Afghanistan,” said Kesling. The injured were triaged at the scene and transported to medical facilities on the post or in civilian communities within a 30-mile radius.

Once the shooting stopped and the wounded attended to, the work began for the behavioral health personnel attached to the medical center. They usually include 20 or so psychiatrists, 25 psychologists, 75 social workers, 20 to 25 counselors, and 15 to 20 military or civilian behavioral health technicians, plus the post's chaplain corps, said Lt. Col. Ben Phillips, M.C., one of three child psychiatrists and chief of behavioral health at Darnall. The medical center offers a variety of inpatient and outpatient services for soldiers and their families.

Kesling, Phillips, and Col. James Polo, M.C., spoke in a group telephone interview with Psychiatric News in mid-November. Polo is a child psychiatrist who ordinarily serves as the assistant deputy for health policy for the assistant secretary of the Army for manpower and reserve affairs at the Pentagon and who was detailed to help out at Fort Hood.

The post was not unprepared to respond to the events like those of November 5. Military communities have developed resources and programs for resiliency in recent years, which may have helped the post cope.

In addition, Fort Hood holds at least two mass-casualty drills every year, some in conjunction with nearby civilian communities and others with the troops garrisoned on the post.

“Behavioral health personnel usually take part in table-top exercises but are not usually deployed in drills because they are so involved with patient care,” said Kesling.

The behavioral health response to the event took place all over the post, beginning at the emergency room. Social workers are always on duty there, and they and others began helping not only the wounded and their families but also many of the first responders on the scene, said Kesling.

“Some of the staff had difficulty with the event itself,” she said. The majority of the active-duty staff have served in war zones and so had experience dealing with casualties, although not in the numbers that presented themselves that day.

“Over the next few days, some people [on the staff] experienced difficulties, and some are still fighting with this,” she said. “Some of this represents de novo trauma or triggering of memories of things they saw in theater.”

Mobilizing the mental health resources on the post was part of the effort to restore a sense of safety and trust, maintain Fort Hood's military mission, and avoid pathologizing the experience.

“We went out talking to people to help them work through this event and move on,” said Kesling.

Additional help was immediately available from other Army and military sources, although some local civilian medical facilities were engaged too. Army medical and behavioral health personnel are accustomed to the service's culture and share a frame of reference with soldiers and their families.

They included specialists in children's mental health including several from the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md.

Stephen Cozza, M.D., a professor of psychiatry at USUHS and associate director of its Center for the Study of Traumatic Stress, spoke initially with the local school superintendent to discuss how to integrate counseling services in the schools, then held a teleconference with 50 area principals.

“This event happened in a community where children were already under the ongoing stress of deployments and separation over the last eight years,” said Cozza, a former Army child psychiatrist who specializes in mental health issues of the children of military personnel.

“We wanted to help parents and teachers help kids understand what was happening and make sure that when they were talking with children that they could identify and rectify any distorted thinking by the children,” he said in an interview.

That the accused gunman was an Army psychiatrist inevitably affected feelings of trust among some children.

“We have to recognize, not minimize, that this [situation involves] someone who was supposed to help people, but we also have to remind children that this was an extremely rare event and that far more people who were there to help them and whom they can trust,” he said.

Teachers have to be clear and open, taking the children's questions seriously and clarifying the situation but not dwelling on the event, he said. If some children are having continuing problems, the teachers can refer them for evaluation and care by specialists.

While help was being provided to survivors, families of the dead and injured, and other affected members of the community, the Army also began planning for the inevitable longer-term response, said Polo.

“Our overarching goal is to meet the physical, emotional, and spiritual needs of this community by reducing the impact of the event and enhance recovery for everyone,” he said.

Doing that will involve educating everyone in the community to be more aware of the emotional state of those around them, to identify when someone “doesn't seem quite right,” and get them the support or help they need, said Polo.

Polo brought in a team of outside experts to work with personnel at Fort Hood and review a three-phase campaign. The first phase dealt with the immediate crisis—helping those directly affected and their families. The second phase acknowledges that the meaning of the event often takes some time to surface.

“We will treat people up front and also continue surveillance so as not to miss the less obvious cases,” he said. A care-management approach will provide continuing contact with those affected, so that if problems develop, a relationship will exist in which to provide help.

Finally, the Army will extend its epidemiological surveillance and continue follow-up for those with difficulties, with a focus on children and families.

“The data we gather will guide our need for future providers while we try to serve our community without gaps of access or gaps of care,” said Polo.

Fort Hood's comprehensive behavioral health care plan is posted at <www.hood.army.mil/incident/BehavioralHealthCampaignPlan.pdf>.