Amputations. Combat stress. Divorce. Suicide. For troubled service members, military therapists are at their sides.
But with the U.S. fighting two wars, an acute shortage of trained personnel has left these therapists emotionally drained and overworked, with limited time to prepare for their own war deployments.
An Army psychiatrist is suspected in the shootings at Fort Hood, Texas, and the rampage is raising questions about whether there's enough help for the helpers, even though it's unclear whether that stress or fear of his pending service in Afghanistan might be to blame.
An uncle of Army Maj. Nidal Malik Hasan said Saturday that Hasan was deeply affected by his work treating soldiers returning from war zones. "I think I saw him with tears in his eyes when he was talking about some of the patients, when they came overseas from the battlefield," Rafik Hamad told The Associated Press from his home near the West Bank town of Ramallah.
Rep. Tim Murphy, R-Pa., a psychologist in the Navy Reserves, said the toll is sometimes described as "compassion fatigue" or "vicarious trauma."
"They may not see combat themselves ... but they see the outcome of it and they hear the stories of it day in and day out," Murphy said. "It can be very real when you are dealing with people's difficulties everyday."
A military mental health task force in 2007 expressed concern about the stress on nondeployed mental health personnel because of the shortage, which it said was leading to high attrition rates. "A vicious cycle has formed that will probably continue to worsen before it improves," the report said.
Dr. Layton McCurdy, a psychiatrist and dean emeritus at the Medical University of South Carolina who served on the task force, said the shortage continues with the thousands of troops needing help because of combat-related stress.
"The psychiatrists are working with more people than they have time to work with," McCurdy said. "They are pressured in terms of the numbers."
Doctors seeing a constant stream of troops with symptoms of post-traumatic stress disorder can start to have problems of their own -- an issue that has not gotten enough attention, said Dr. Allen Taylor, a cardiologist at Walter Reed Army Medical Center for 20 years before recently moving to Washington Hospital Center.
"It's time for some introspection: Who cares for the caregivers?" he said.
The military has used bonuses, scholarships, and allowed the hiring of legal nonresidents as part of its effort to bolster the number of therapists. It's even trying a pilot program that allows older health care providers to enter the Army for two years.
With the efforts, Defense Secretary Robert Gates said recently at a mental health conference that in the past two years, the Army has added nearly 900 behavior health providers -- a 50 percent increase.
But he said that still leaves the service with a shortfall of more than 330 specialists, which is a gap that will grow to more than 500 if the Army follows through on recommendations to put uniformed providers in every brigade.
Barbara Cohoon, deputy director of government relations at the National Military Family Association, said while some therapists are embedding with units in the war zones, others are in more isolated areas at war where they might not be in the company of other therapists. She said the association has grown increasingly concerned about whether therapists are getting enough support in the war zones and on the home front.
"Who do they go to if they are feeling stressed?" Cohoon said.
Part of medical training -- for psychiatrists, too -- is learning when to seek help, Dr. Robert Ursano, psychiatry chief at the Uniformed Services University of the Health Sciences, told a meeting between military and civilian medical researchers Friday.
While it may be difficult, those providing support to troops must be willing to seek it themselves, said Capt. James Joppy Jr., a social worker in the Pennsylvania Army National Guard who is preparing to deploy to Iraq.
"We experience the same things everyone else does. It just happens we're helping everyone," Joppy said.
Brig. Gen. Terry "Max" Haston, the assistant adjutant general of the Tennessee Army National Guard, reminded about 100 mental health and substance abuse counselors meeting at a Guard center in Smyrna, Tenn., on Friday that combat affects more than just soldiers who went to war.
"This soldier had never deployed, but he listened to soldiers who had come back from theater and it had that large effect on him," Haston said. "What I am doing is cautioning you to take care of yourself. We are at war right here and you are on the front lines each and every day and you're dealing with a real hidden enemy."