August 27, 2010 — It is an unusual legal case when a psychiatrist is charged with murder. But it may be unique in American jurisprudence when a psychiatrist is charged with multiple murders and then uses an insanity defense, arguing that his own patients' narratives drove him to it.
Nidal Malik Hasan has been charged with 13 counts of premeditated murder and 32 counts of attempted murder in the shooting of soldiers preparing for overseas deployment at Fort Hood, Texas, last November. Hasan is the sole suspect in the shootings, which occurred just before he was to ship out to Afghanistan. His case starts its legal journey through the military justice system October 12.
Hasan's defense team has indicated that secondary posttraumatic stress disorder (PTSD) may be a key defense argument. "The relevance is that it goes to what mental state he was in," says his lead defense lawyer, Col. John Galligan. "The evidence is that he was professionally concerned [about his patients' narratives of 'war crimes']; concerned enough to go to legal authorities both inside and outside of Fort Hood," Col. Galligan told Medscape Medical News.
Hasan's Background
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| Maj. Nidal Malik Hasan |
Nidal Hasan was born in Arlington, Virginia, in 1970 to parents who immigrated to the United States from the West Bank.
He earned a bachelor of science degree in biochemistry from Virginia Tech in 1995. Reportedly against the wishes of his parents, Hasan enlisted in the army and was commissioned an officer in 1997. He was then selected to attend medical school at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, earning his medical degree in 2003. His internship and residency in psychiatry at Walter Reed Army Hospital was completed in 2007. That was followed by a 2-year master's degree fellowship in disaster psychiatry.
According to his relatives, after the death of his parents Maj. Hasan became more religious and spent more time in mosques in the Washington area, seeking solace. In 2001, Hasan attended a Virginia mosque when Anwar Al-Awlaki was imam there. Al-Awlaki, known for giving anti-American sermons, is now believed to be hiding in Yemen and is the only American on the CIA "targeted kill list."
Hasan never married and always lived alone. At the Silver Spring, Maryland, mosque he attended, he listed himself on a form seeking a spouse as born in the United States but Palestinian in nationality.
He sought legal advice about being discharged, but according to a family member, Hasan was told he would not receive one because the army needed both psychiatrists and Arab Americans.
During his residency at Walter Reed, he sought legal advice about being discharged, but according to a family member Hasan was told he would not receive one because the army needed both psychiatrists and Arab Americans. Hasan decided to stay in the army through the end of his commitment in 2010.
A classmate reported that Hasan gave a presentation in a seminar in June 2007 titled "Why the War on Terror is a War on Islam." He was supposed to address a medical topic but instead lectured senior army doctors on threats the military could face from Muslims in the US military. Hasan quoted the Koran throughout this medical lecture; his presentation slides warned against killing Muslims but argued that killing unbelievers was permissible for a just cause.
One of Hasan's military supervisors at Walter Reed, Thomas Grieger, MD, reported that Hasan received special additional counseling during his residency but that such counseling was not uncommon and that Hasan responded to the extra supervision.
In May 2009, after completing his master's fellowship, Hasan was promoted to major and reassigned to Fort Hood in Texas. He moved into an off-base apartment in a rundown complex that cost $350 a month. Two days later, at an off-base gun store, he bought an automatic pistol with laser sights. Hasan's mosque is a quarter mile down the road from the gun store.
Maj. Hasan was assigned to the psychiatric unit of the US Army Medical Center on base, and his job function was "assessment of soldiers before deployment." Hasan's own deployment date was set as November 28, 2009.
The Incident
He said goodbye to people and asked forgiveness from one man for any past offenses...'I'm going traveling,' he told one worshiper.
At 6 am on November 5, 2009, after giving away his furniture and copies of the Koran to his neighbors, Hasan left his apartment and traveled to his neighborhood mosque for morning prayers. He said goodbye to people there and asked forgiveness from one man for any past offenses he might have caused. "I'm going traveling," he told one morning worshiper.
At 1:20 pm, Hasan walked into the Soldier Readiness Center at Fort Hood, where soldiers receive routine medical treatment. According to eyewitnesses, he prayed at an empty table, then stood up, drew his pistol, said "Allahu akbar!" and began shooting fellow soldiers. Within minutes he had shot more than 100 rounds, choosing some victims to shoot repeatedly.
Two minutes after the initial 911 call, civilian police officers from the Fort Hood police department arrived to find Major Hasan chasing a wounded soldier outside the building. Female officer Sgt. Kimberley Munley exchanged fire with Hasan and was herself shot 3 times. Police Sgt. Mark Todd arrived moments later and fired shots that took Hasan down.
A medic who treated Hasan found he had 4 bullet wounds and reported that his pockets were still full of pistol magazines. In 10 minutes, Hasan had killed 12 soldiers, one of whom was pregnant, and 1 civilian, a physician assistant. Hasan wounded 32 others.
Although Hasan was thought to have been killed, a medic detected a pulse, and Hasan was transported to the same hospital as 10 of his victims.
Hasan was later moved to Brooke Army Medical Center at Fort Sam Houston in San Antonio, Texas. He regained consciousness on November 9, paralyzed by a bullet through his spinal cord.
Trial Preparation, Theories of Motivation
After 5 months of convalescence, Hasan was sent to the Bell County Jail in Belton, Texas, near Fort Hood. An Article 32 hearing, similar to a civilian grand jury hearing, is scheduled for October 12, at which time a decision to seek the death penalty under the military justice system will be made.
Some of his relatives believe that Hasan's motivation for the shootings was in response to harassment for his Middle Eastern heritage. According to his Fort Hood civilian neighbors, his car had been vandalized and hate-filled graffiti written on it.
Hasan's aunt agrees that he wanted to be discharged because of harassment but adds another motivation. Noel Hasan told the New York Times he was disturbed by war-related injuries he saw at Walter Reed, "...and he must have snapped."
His deployment date was approaching, which added a ticking clock to his despair over the war. His cousin Nader Hasan also told the New York Times, "...the last 5 years, that was probably his worst nightmare."
The Federal Bureau of Investigation had become aware of Hasan's Internet postings in which he equated a suicide bomber who kills himself to protect other Muslims as the same as a soldier who throws himself on a grenade to protect his comrades.
A military activist, US Army Sgt. Selena Coppa, pointed out a different contradiction to news organizations, that Hasan "was a psychiatrist and was working with other psychiatrists every day and they failed to notice how deeply disturbed someone right in their midst was."
A former classmate, US Air Force physician Val Finell, MD, told the London Telegraph that he complained to superiors about Hasan's "anti-American rants" against "infidels" and said, "He at least should have been confronted about these beliefs, told to cease and desist, shape up or ship out."
ABC News has reported that investigators suspect that Hasan's shootings may have been triggered by his superiors' refusal to act on his request that some of his patients be prosecuted for war crimes based on statements they made to him during psychiatric counseling.
Cpt. Shannon Meehan, who was undergoing treatment at Fort Hood for injuries suffered in Iraq, told the Dallas Morning News he learned of Hasan's requests for war crimes prosecutions from other base psychiatrists. Meehan expressed skepticism with Hasan's requests, saying that the patients opening up to Hasan during counseling sessions "...are going in there confessing their pain and guilt. He's trying to turn it into a war crime."
Is PTSD Contagious?
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| Col. John Galligan |
Was his superiors' refusal to act or, as Hasan's defense attorney Col. John Galligan has suggested, the information itself shared with Hasan by his patients the cause of Hasan's breaking point?
Hasan never served in combat and never visited one of the war zones, so it appears that he could not have suffered primary PTSD.
According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) definition, PTSD may be diagnosed in patients who have experienced traumatic events and who responded with intense fear, horror, or helplessness.
Secondary trauma is an indirect exposure to trauma through a firsthand account or narrative of a traumatic event. But the DSM-IV has blurred the distinction between primary and secondary trauma, further defining the stressor event as when one learns of a traumatic event to a loved one.
A 2003 report...points out that secondary PTSD, brought on by a vivid recounting of trauma by the survivor, may result in a set of symptoms in the clinician that parallels primary PTSD.
Secondary trauma has been called "compassion fatigue" and "vicarious traumatization." A 2003 report ("Secondary Traumatization in Mental Health Care Providers" in Psychiatric Times. 2003;20[ 4]) points out that secondary PTSD, brought on by a vivid recounting of trauma by the survivor, may result in a set of symptoms in the clinician that parallels primary PTSD.
Some detractors of the theory of secondary PTSD say it is not a disorder, but rather the reaction of the clinician. Yet some studies suggest that a small percentage of individuals, up to 4%, will develop the full psychiatric disorder.
Some factors that may be positively associated with secondary traumatization include personal trauma history and heavy personal caseload. According to the 2003 Psychiatric Times review of the empirical literature, factors that may be predictive of secondary traumatization include the following:
Insufficient training;
Identification with victims;
Insufficient support in the workplace; and
Insufficient social and familial support.
All 4 factors may have been in play in Maj. Hasan's case.
Experts Weigh In
Anthony Ng, MD, the immediate past president of the American Association of Emergency Psychiatry, told Medscape Medical News, "We do see secondary PTSD among health care workers such as those treating EMTs [emergency medical technicians] after mass casualty events. It happens through seeing the patients, hearing their stories, from the stresses of the work, and from stigmatization."
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| Dr. Anthony Ng |
Another psychiatrist, former US Army infantryman and US Navy flight surgeon Eric Anderson, MD, says he cannot comment on Hasan's mental state without personally examining him, but he says he has questions about whether Hasan truly has secondary PTSD and whether secondary PSTD could be a causal factor in someone hurting others.
"My patients talk to me about what they've seen, their own traumatic experiences. [With Hasan] it's almost as if there's less of a personification with his patients than with the civilians who died in an action. For him to identify not with the combatants, but with the civilians, it takes a few mental steps to get there. I have to ask myself out of thousands of psychiatrists and emergency room doctors, many of them fresh out of residencies, why don't more of them do that?"
Dr. Anderson points out further that professionals who identify too much with a patient run a risk to themselves. "If they begin to take on patient's problems themselves, if they forget the dividing line between a professional and a patient, then they are apt to suffer psychological consequences. If you take it personally, you lose your objectivity; you lose your ability to be a healer. To take that another step and to do harm adds another layer of complexity."
One legal difficulty for Hasan's defense may be in introducing as evidence his army patients' personal stories that came out of their treatment consultations. Is there an ethical barrier, a presumption of confidentiality in military physician-patient relationships that would preclude Hasan from discussing his patient's deepest secrets? Dr. Anderson says no because officers voluntarily take a military oath of loyalty.
The bottom line is that people were killed, and whether it was because he identified more with dead civilians, or he hated the army, or he was mentally unstable, or he was simply bored, that's for lawyers to argue and for the jury to decide. Just remember, those guys put their lives on the line overseas. Then they came home for help. To be betrayed is abhorrently unacceptable.
"There is no such thing as privacy in the military, no such thing as physician-patient confidentiality. I was a flight surgeon, and I had a duty to inform the commanding officer if I knew something about a service member that could affect the entire unit. That's because the commander has a right to know the physical and mental condition of his troops. You have to wear 2 hats. Certainly, you're a physician. But you're also a military officer charged with maintaining military readiness of your unit to its optimum ability. So therefore you're obligated to tell your commanding officer anything that threatens the cohesion of the unit."
Dr. Anderson says that arguments over secondary PTSD being a possible motivation for Hasan do not change the results of his outburst. "Was it mental illness or a cold, calculated decision? The bottom line is that people were killed, and whether it was because he identified more with dead civilians, or he hated the army, or he was mentally unstable, or he was simply bored, that's for lawyers to argue and for the jury to decide. Just remember, those guys put their lives on the line overseas. Then they came home for help. To be betrayed is abhorrently unacceptable."
According to Maj. Hasan's attorney Col. John Galligan, Hasan's Article 32 hearing on October 12 is expected to last 30 days and will be followed by a sanity board hearing. The outcome of those hearings will determine whether Hasan faces a full military jury trial with the death penalty as possible punishment.
The last time the US military carried out the punishment of death against one of its soldiers was nearly 50 years ago, in 1961.
Ron Zimmerman is a freelance writer based in San Antonio, Texas, who also reports for ABC News.
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Cite this: Army Psychiatrist Faces Death Penalty in Fort Hood Shootings - Medscape - Aug 27, 2010.
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