MED/MHS Checkup: Foreign Service Members Weigh In
As part of our look into mental health services for the Foreign Service, we asked members in the field for their thoughts. Here is a compilation of candid views.
As part of our look inside the world of mental health care for the Foreign Service, we wanted to hear from members in the field. Due to the sensitive nature of the topic, and known concerns about privacy, we took the unprecedented step of offering to print comments without attribution. Almost everyone took us up on that offer. Each note below is from a different individual, known to the FSJ.
We sent out a set of seven questions, listed here. We received 45 responses from FS members in Washington, D.C., and overseas, some entry-level and a few retired, from the foreign affairs agencies, primarily State and USAID. The gender split was about even.
For space reasons, we are unable to publish all the responses in full, so the individual commentaries have been trimmed. Specific recommendations (primarily responses to Question 7) have been extracted and are presented in one place (see below).
Based on the feedback, it became clear that issues relating to family members, and in particular children, require a separate discussion. We are therefore reserving the responses specific to mental health and special needs care for FS children for an article in a future issue of the FSJ. It is too important a topic to relegate to a sidebar.
- Please share your experience with mental health issues and mental health care in the Foreign Service.
- How do you rate the mental health support offered to members of the Foreign Service and eligible family members? If improvements are needed, please share your suggestions.
- To what extent do privacy concerns have an effect on whether or not you seek mental health care?
- To what extent do concerns about medical and security clearances have an effect on whether or not you seek mental health care?
- Have you personally ever experienced a negative outcome from seeking psychological help or reporting a history of mental health treatment on your SF-86 (“Questionnaire for National Security Positions”)?
- Are you satisfied with the mental health support provided for Foreign Service personnel heading to and returning from high-threat assignments (such as the out briefing at FSI and the Deployment Stress Management Program)? If you or someone you know has sought help for symptoms of PTSD, what was your experience?
- What would you like to hear from management regarding mental health care in the Foreign Service?
—Shawn Dorman, Editor
Unusual Stresses and Dangers
Our work in the FS is unique and not well understood outside of our community. We face stresses and dangers most friends and family will never understand back home. That said, it is hard for FSOs to express themselves to colleagues they are living and working with without feeling they are revealing a vulnerability.
Only after serving in Afghanistan did several colleagues share how much mental hardship they endured during their tour. I am not sure the [foreign affairs] agencies truly appreciate the mental health burden some of our colleagues deal with; nor do they extrapolate that back to its impact in the workplace.
A safe environment needs to be formed for people to seek help without fear of recrimination. We are in the relationship business... healthy colleagues = healthy workplace.
PTSD: Pretending to be All Right
The mental health support offered is generally good, though there is room for improvement in helping members respond and recover after trauma and crisis. As a supervisor, I have been impressed with the skill, compassion and discretion of RMO/Ps in dealing with substance abuse and mental health problems.
I am concerned that the effectiveness is undermined by the predisposition of MED or RMO/Ps to recommend curtailment when treatment at post might be a good first step; this predisposition acts as a disincentive to report problems.
I myself was evacuated from post for PTSD and enrolled in the State Department’s treatment program. The treatment was in the form of counseling sessions with a contracted provider. I have since reviewed the literature on PTSD treatment and recognize what the counselor was trying to do; but the counselor was not effective and the treatment, for me, was useless. Nonetheless, it became clear to me that my ability to secure a new medical clearance to go on to my next assignment was dependent on satisfying my counselor that I was “cured,” thus validating his treatment.
I swore up and down that I was all better (when in fact I was not at all improved) and thanked everyone concerned for having helped me so much, and in this way I earned back my medical clearance and was able to head to my next post. Some years later, I consider myself recovered from PTSD, but I attribute that to time and the opportunity to rebuild my life and relationships, not to the counseling that I had to pretend was effective.
PTSD: Treatment Traumas
I was injured in a terrorist attack overseas. This was in 2004, before the State Department began to take seriously PTSD and mental health issues that develop as a result of high-stress, high-threat assignments.
Compared to 2004, a lot has changed for better and for worse. I was injured, medevac’d from Iraq, treated for my physical injuries and received counseling from someone the department recommended. Then, at my request, I returned overseas just a few months later to a hardship (though not “dangerous”) post. I was glad they allowed me to return to work abroad so quickly—I think it was helpful to my recovery.
I struggled with PTSD in my onward assignment, but did not seek treatment. I should have. I resisted because I was concerned that seeking treatment would result in bureaucratic hassles and threats to my medical clearance. Also, my illness caused me to resist doing anything that brought additional attention to me, which seeking help would have done. Privacy concerns have had a huge effect on whether or not I seek mental health treatment (or any other kind of medical help) at post.
Gossipy family members should not be given positions in medical units where confidential medical information on embassy staff is handled. I don’t have this concern with our direct-hire medical staff, but they need to be careful who they hire and what kind of access they give to uncleared family members with no experience in the medical field or in handling medical information.
My continued use of medication (left over from my PTSD diagnosis) has had no impact on any clearances. Although my experience was not bad, I hated having to answer questions about my PTSD more than five years after I had recovered. Don’t let it be a red flag every time clearances are renewed if it doesn’t need to be. Dealing with the bureaucracy after having sought mental health treatment is itself enough to cause PTSD.
I was serving in an isolated post and having trouble at home. My wife and I were arguing constantly, and things seemed to be falling apart. So when our health unit advertised the visit of a regional psychiatrist, I signed up.
Then came the medical clearance renewal form: Have you consulted with a mental health professional? I checked yes, and said I had felt depressed over the state of my personal life. Six months later, as I prepared to depart for my new post, I received word that my medical clearance was on hold. I was angry, but there was nothing to do but acquiesce to a series of meetings with MED’s Mental Health Services.
This was a breakthrough experience. First, I realized MED/MHS was trying to make sure I really was OK. Second, I learned a few things about myself. Anger had been part of the problem with my marriage and my life in general. There were some root causes going back to my youth that I fully understood. But an experienced counselor was able to walk me through ways other people have dealt with that.
To say it improved my life is an understatement. In the end, I went to post on time. For a few more months, MED/MHS kept tabs on me, and then they signed off. Since then, I have been a big supporter of MED/MHS.
More and more officers understand the need to deal with mental health as just another medical issue. However, we still have too many officers who treat mental health counseling as taboo.
Senior officers, in particular, need to set the example by ensuring that their employees understand that a mental health issue, like any ailment, is best addressed early. Until they do, we will all still sign notes like this as… Anonymous.
I started taking a light dose of an anti-depressant after a difficult break-up that happened shortly before I left to go back overseas. When I arrived at post and met with the regional medical officer, he advised that I stop taking anti-depressants, because they “weren’t a good thing.” I told him that it was helping me to feel better and sleep regularly. I really dislike the attitude of the State Department toward mental health care and treatment.
Here’s another example: During a rough patch in a relationship, my partner and I sought couples counseling. When my security clearance was up for renewal, I was grilled by the investigator regarding this counseling. I had to defend myself for wanting counseling, and the harsh and critical tone she took for me wanting to do what I needed for my relationship was upsetting. I got the clearance, but it was a stressful process.
Denying PTSD to Preserve Security Clearance
Services for family members have improved considerably, but much remains to be done. Concerns about possible adverse impacts of mental health issues on employees or families are justified.
After service in Iraq, there is no doubt in my mind that I suffered from PTSD. Now (several years later), I see my symptoms as both classic and obvious. At the time I was suffering, however, I hid my symptoms out of fear that knowledge that I suffered from PTSD would harm my career. That concern was heightened by the intense questioning I endured by a Diplomatic Security agent conducting a security clearance update when I was serving in Iraq.
When it became known that I had sought mental health care, I was hassled and forced to repeat the content of a private discussion with a mental health professional to a DS agent with zero mental health training. I found the entire episode both distasteful and inappropriate.
According to the agent, because I was having a “special” security clearance update done (I was up for a chief-of-mission slot), I was required to tell him what I discussed with a State Department mental health practitioner. When I objected, he said my clearance would be held up “for at least six months and probably longer” since someone at DS would have to review my objection, refer it to lawyers for an opinion, etc.
He made it clear that failure to answer all of his questions about my conversation with a mental health professional would negatively impact my career. This experience led me to deny having PTSD symptoms during a post-service interview.
Concern over mental health issues was one of the factors that led me to take early retirement. (Shortly after retirement, I began seeing a mental health professional.) I do not “blame” the Foreign Service; these were my issues to deal with, and there were many factors well outside the control of the Foreign Service.
In retrospect, however, I denied myself help because I feared being seen as “weak” or having mental health issues would have derailed my assignment. I do know a number of people who were treated for PTSD while and after serving in a war zone. Most reported good things, but some complained of their treatment derailing an assignment or delaying paneling.
Class 2 Medical Clearance
I do not rate the mental health support for members of the Foreign Service very high. I called ECS from post and spoke to a back-up social worker for my region. He was fairly rude, as if contemplating divorce was not a big issue.
My spouse and I sought mental health support from the RMO/P, and ultimately we were both sent on medevac—not my choice; my FS tandem spouse did not play nicely, and adequate mental health resources were not available at post. My marriage was deemed volatile, and given that we did not have positive support from State MED or my post, we both ended up curtailing.
In the process of renewing my MED clearance in 2012, I was open about my weekly, then monthly, private therapist meetings due to my recent divorce. I told MED that I’d set up the possibility for continued support via Skype when I went to post along with my prescription for a low dosage of an anti-depressant/anti-anxiety medication.
My mistake—I was told by MED that I’d be given a Class 2 because of seeking continued therapy. I thought that showing that I’d made arrangements for my mental health would ensure a Class 1, but instead that’s what gave me the Class 2.
Geez, why be honest with MED—it could have cost me my assignment. Fortunately, my onward post could support a Class 2 because there was an RMO/P at post. I would appreciate it if management understood that employees doing the necessary to care for their own mental health should be recognized. I was no danger to myself or others. What about the cost to the department if my assignment had been broken?
I will seek mental health care as needed, but I will not be forthcoming with MED about it. I have no worries about my DS security clearance because the investigators have been quite clear that seeking therapy for PTSD or marital types of issues does not need to be reported.
Mental Health Care Stigma
As a second-tour officer coming from the private sector late in my career, what I have found most surprising about the Foreign Service is the traditional culture within the department surrounding mental health care. Although the department has the infrastructure and mechanisms to support such care, the cultural attitude among officers is entirely different.
During training, I heard A-100 colleagues’ advice from friends who had been in the diplomatic corps longer to never reveal mental health services for fear of security clearance risks. And over the past few years I have witnessed several colleagues try to bury or cover up issues rather than seek help for that same reason. The career can be demanding for dependents, challenging for officers, stressful and even overwhelming at some posts; and, unfortunately, the cycle of rotations encourages employees to just grin and bear it until the move.
Through my own family’s experience, I have found the professionals within Mental Health Services at State to be responsive and informed. However, I do not believe this trickles down to all posts, and there remains a lack of clear understanding about the effects on clearance.
I saw this misunderstanding most evident at AFSA, where it was assumed that DS had autonomous power to pull clearances. Clearly DS is not very transparent. But rather than provide more services, State needs to educate officers in writing about the real effects of receiving mental health care on the clearance. Without this, we may continue to see stressed-out managers venting their stress on subordinates who fear seeking help or taking action without tenure.
Concerns about Privacy and Security Clearances
Considering what a stressful job this is, it’s too bad it’s so difficult to get help.
I have been ordered twice to meet with a visiting regional psychiatrist—once when my colleague was murdered, and once when my house was broken into and my family lost $8,000 in personal possessions. I didn’t find these counseling services all that useful.
The only time I met with an FS mental health professional of my own accord, it was very helpful. The therapist helped me put things into perspective and greatly assisted in my recovery from a short stint of depression.
Privacy concerns: Even filling out this survey without having true anonymity (you can see my email address) makes me nervous. The worst part about seeking mental health care is knowing that DS will ask if we’ve sought mental health care when we renew our security clearance every five years. I met with a therapist who told me he never wrote anything down because all of his FS clients were terrified of getting caught seeking assistance for their stress-related problems. It’s sad.
Concerns about security clearances have a big effect on whether or not I seek mental health care.
Recovering from Trauma
I experienced a personal trauma, and my supervisors and post leadership were terrific. But I found our mental health professionals overseas inadequate to the job. I do not believe they are prepared to deal with grief, certainly not traumatic grief. If you appear to be functioning, they will basically ignore you in favor of more squeaky wheels.
I feel that if I had declared myself an alcoholic I would have gotten more attention from MED than when I was traumatized and sat in my office working, feeling like an isolated zombie.
A professional should come to post to see individuals who have experienced serious trauma. We had compounded trauma, yet all we got were phone calls in a place without adequate local English-speaking psychological support.
I am not concerned about my privacy for something like grief. If I had depression or other mental health problems, I would never see a State Department medical practitioner. I would curtail if overseas and see someone private in the United States.
I would never tell Diplomatic Security or MED about outside mental health services, but would seek the help I need. I am an honest person, but in this case I feel that State should do with mental health what they do with physical health—a spot assessment every few years for suitability for service abroad—and leave it at that. There’s no need to find out if I have ever sought counseling, any more than if I have ever broken a bone. The question should be whether I am on medication now, whether I need help and, if I do, whether I get a Class 1, 2 or other type of medical clearance.
Once I accidentally ticked the box stating that I had received mental health counseling, then explained that it had been many years ago and strictly family counseling. Still, I was forced to get a statement from my medical provider that I was not under care for a mental health issue. I argued that perhaps I should get my doctor to tell them all the diseases and illnesses of the body I also did not have.
I certainly suffered from PTSD as a result of my trauma and feel that no one from MED could be bothered as long as I showed up to work. I am not functioning at my best now, but I am functioning, so I suppose that’s good enough.
Tackling Mental Health Care Issues
RECOMMENDATIONS TO MANAGEMENT FROM MEMBERS OF THE FOREIGN SERVICE
- I would like to be reassured that mental health care will not negatively affect security clearances, and that management understands and appreciates the benefits of mental health care and genuinely encourages people to receive the help they need.
- I would like MED to give a credible guarantee that self-reported mental health symptoms will not negatively affect clearances and assignments; in the absence of this guarantee, the disincentive to report will remain irresistible.
- I would not only like to hear, but I would like to see evidence that management will not allow the seeking of mental health care to burden the medical clearance and assignments process for years to come.
- I would like management to be more vocal on the subject. Only when we can talk more freely can the mental health of FS personnel and their families be improved.
- Mental health care in the Foreign Service is exceptional, thanks to MED’s company of regional psychiatrists and the Employee Consultation Service. I have benefited from their help, and I have four recommendations for improvement: (1) More licensed clinical social workers to work in large posts and cover regions throughout the world; (2) More psychiatrists assigned to smaller regions so they do not need to worry about their own mental health; (3) A commitment to deal with unrealistic goals and consequent unrealistic workloads on employees that lead to excessive stress, anxiety and depression; and (4) Vigilance on the part of State Department executive management to combat the excessive bullying and hazing caused by inexperienced DCMs and other managers who don’t uphold the values of human dignity and respect.
- I would like to hear that it’s okay to seek mental health care, and that we have nothing to fear in terms of losing our security clearances and, thus, our jobs.
- During security clearance reviews, interviewing agents for DS should be forbidden from asking about mental health issues. If such questions need to be asked, they should be handled directly between mental health professionals and patients.
- Research has shown that some of the most intelligent, creative people are also those most vulnerable to mental health issues. It would be helpful reframe mental health issues as not necessarily a series of illnesses to be stigmatized but indicative of a type of “cognitive diversity” to be recognized and managed within our oft-trumpeted “diverse” Foreign Service. Also, we must support people in a holistic way in this career path, because it isn’t a normal 9 to 5 job. We essentially live at our work sites by being assigned overseas.
- I would appreciate it if management understood that employees doing the necessary to care for their own mental health should be recognized, evaluated fairly and not simply slapped with a Class 2.
- I would like to see examples cited over and over again of people who have sought mental health support who have not been hassled by DS. I have only heard the opposite.
- Employees and their families need to hear there is high-level commitment to meeting their mental health needs without impeding their ability to maintain a clearance. The constant transition of leadership in MED/MHS and MED has resulted in abrupt changes in interpretation of roles and focus. Families are frustrated by the lack of communication and explanation of policies. The evasive attitude toward youth mental health is not helping to de-stigmatize the topic, nor does it demonstrate the department’s commitment to the well-being of its personnel and their families.
- I would like to hear that State will implement additional support for FS families focused on ease of access to appropriate mental health care from English-speaking providers and more general emotional/therapeutic support for couples, singles and families overwhelmed by the transitions—perhaps incorporating online counseling (such as Skype).
- The Foreign Service should adhere to the same standards of privacy and professionalism as other U.S. mental health care providers and, given the number of officers exposed to trauma, should train managers to respond more appropriately.
- I would really like to see the department take substantial measures to assist with mental health care. At FSI, we had a presentation about “resilience,” which now seems to be a buzzword; but it takes more than holding meditation sessions to provide a healthy working environment. Mental health is one reason why I might be seeking to separate from the Foreign Service, and it seems like making substantial steps in this area would help retention.
- The Foreign Service Benefit Plan should support Skype or phone therapy. The regional psychiatrists should visit embassies more often and be empathetic about people’s mental health needs rather than threatening to revoke medical clearances. They should also follow up with people who do require medication and be more available as a resource for them.
- Regarding PTSD, I have four recommendations: (1) Use a more extensive screening checklist for PTSD as part of the regular physical exam, and do not allow it to be waived; (2) If the screen shows potential PTSD, MED should reach out to the individual at six and 12 months post-assignment; (3) Update regulations for mental health evacuations, allowing for reimbursement. (People are hospitalized only if they threaten to harm themselves or others, which is not normally the case. Treatment needs to be reimbursed and followed up for a year as with a regular medevac); (4) Inform FS members clearly on the current policy, in particular the difference between medevac and medical curtailment: Medical curtailments do not allow for reimbursement of medical care.
- I’d like to hear that MED is hiring more psychologists and giving them adequate support, training and resources. And I’d like to hear that we’re dealing with how our management styles can contribute to our stress and hold us back.
- Out briefings and support for issues like PTSD, anxiety and depression should be addressed not just at FSI, but also at post. It would help to reduce the number of people who reach a point of crisis like I did.
- Before seeking assistance from the State Department for a mental health issue, I would want to see State’s policy on the following in writing: (1) Are discussions with the regional psychiatrist confidential, and what are the psychiatrist’s obligations to the patient and to the department? (2) What, if any, parts of the session must a regional psychiatrist share with post’s Front Office? (3) What mental health issues will result in a curtailment from post? What types of mental illness are relevant to a security background check? (5) Does ECS not serve family members?
- Top-level managers need to do a better job of managing the managers. And they need to do a better job of assuring real RMO/P coverage—not just fly-ins every few months. They should also ensure patient privacy is respected. Having the RMO/P out brief with the ambassador and DCM present does not inspire trust. The department should find ways to provide therapy services to patients overseas—studies have shown apps and online therapy can be just as useful as face-to-face therapy.
- Finally, mental health needs to stop being a joke (“That guy needs some happy pills” or “He’s going to be wack-evac’d”). In an organization where our job is not just a lifestyle, but almost our entire life (e.g., your employer owns your phone, your house), our employers have an extra responsibility to ensure that we actually do have a balance between our work and our life.
—Compiled by Shawn Dorman
Note: Each recommendation is from a different
individual among those who shared
their views with the FSJ.
Although I have not personally experienced a denial of clearance, I was concerned during the clearance process about questions regarding anxiety medication I had taken during some personally stressful times in our family from a loss of one income and a cancer diagnosis.
Once I joined the Foreign Service, I could easily understand why there is an impression that the Service has an alcohol abuse problem—it’s self-medication that is easy to hide from a clearance process. I find that distressing and disturbing and extremely unsupportive.
Because I have known other employees who had difficulty with their security clearance updates as a result of seeking mental health care or counseling, I have always avoided seeking mental health care. Doing so would require that when my security clearance renewal was due, DS would require me to obtain information from the health care provider and would want to know what happened. It is an additional administrative burden that I do not need, would not be something that I would want to talk about with an investigator, and it would undoubtedly slow down the process.
Despite former Secretary of State Hillary Clinton’s message a few years ago telling employees that their clearance will not be affected by seeking mental health treatment, that is not what happens in practice. DS investigators zero in on this, considering it a red flag, as if mental health were any different than physical health. The investigator does not need to know if I have had counseling or treatment for most mental health matters.
In my opinion, mental health treatment is a medical issue and should be dealt with through MED channels and in the medical clearance process. It should not be part of a background check. For serious behavioral issues, MED could make a determination to refer matters to DS. If this change were made, I would be much more willing to seek mental health care.
USAID’s Staff Care
The lack of mental health support is a big downside to the Foreign Service. A few years after joining, we realized that my husband suffered from an anxiety disorder. We were wrapping up one overseas tour and about to move to an even more isolated and poor country for my next tour. It felt lonely and difficult to have to figure out his mental health needs in countries without adequate English-speaking care available.
When I spoke with the visiting regional psychiatrist about my husband’s mental health needs and the possibility of getting him anti-anxiety medication, his response was that my husband shouldn’t have been medically cleared to come to post. This response was unhelpful: it did not provide me with the information I needed to help my husband, and it did not make me feel safe to get my husband the help he needed. Also, the regional psychiatrist only came to post once during my two-year tour, not an adequate number of annual visits.
My husband was eventually able to get medication, thanks to the embassy medical officer. …In addition, we explored the option of talk therapy. …I was disappointed to learn that the Foreign Service Benefit Plan would not support Skype or phone therapy.
Our saving grace has been the Staff Care services at USAID. Through Staff Care, my husband was able to receive Skype therapy, and we were able to receive Skype couple’s therapy—mental health challenges take a toll on spouses and families too! It has been an invaluable resource and the main type of mental health support we have received.
After being in Washington for a while, I am bidding on overseas posts again, but I am nervous for my husband and his ongoing mental health challenges and worried about the impact on my family’s clearances that seeking mental health care for my husband could have.
No matter what management says about the importance of mental health, if there are no real changes, then the Foreign Service will continue to be an ineffective and unsupportive mental health environment.
Thank you for dedicating an issue to this topic.
Curtailment: One Size Fits All
The Foreign Service should offer more access to social workers and counselors for officers and their families overseas. At smaller and isolated posts there is little privacy and few people to talk to about your problems. Often it’s not the stresses of the job, but issues associated with living overseas, problems with a supervisor or disappointments during promotion and bidding season that wear on you.
There is no one outside the embassy to talk to, and these are not the kind of issues for the community liaison officer. A visit by the regional psychiatrist every couple months for a day or two is completely insufficient. You also do not know who the regional psychiatrist’s client really is: you or the State Department? Does a psychiatrist see you as a patient who needs help or just a problem for the Foreign Service best remedied by removing you from post? Those of us overseas would benefit from counselors without having to resort to the regional psychiatrist.
I would not seek assistance from post’s nurse or a regional psychiatrist for a mental health issue out of fear that any discussion of such a problem would immediately be relayed to the management officer and then to the front office. And then you can lose control over your job and career.
A colleague who went through a difficult personal time at post raised this with a regional psychiatrist, was curtailed and sent back to D.C. against her wishes. No attempt was made to deal with the mental health issues at post or to comply with the officer’s desires to address the problem. Curtailment is the one-size-fits-all solution.
Unprepared for PTSD
My experience with mental health care at State was that they were completely unprepared to deal with someone with PTSD symptoms abroad. My regional psychiatrist in coordination with the embassy doctor took quick action to get me back to D.C., but from there the entire process was riddled with problems and was extraordinarily disappointing. I’ve never felt so abandoned.
At the time, MED was contracting with a facility that had no established contacts to assist State employees dealing with PTSD or any understanding of the Foreign Service working environments. (Even the regional psychiatrist was stunned that there was nothing in place.) I was placed in an outpatient facility that specialized in dealing with patients transitioning from a 24-hour in-hospital mental health care facility. It was a locked-in day program. On the first day I knew this wasn’t what I needed. I was told to give it a try for a week as an evaluation. Multiple medications were prescribed and a sleep study was ordered to rule out any physical problems for the sleep disruption.
At the end of the week, I again asked for a different treatment option. Again I was told to stay. Mental Health Services left me there for another week—a total of three weeks—at considerable cost. The facility knew that there was nothing they could do for me. I eventually found a psychiatrist to help me, and MED agreed.
Throughout the ordeal, I had been encouraged to curtail, so that I could return to D.C. for long-term treatment. I translated this to mean: “Curtail and then you won’t be our responsibility.”
I did return to post. I was still having most of the symptoms, though some had decreased after working with the PTSD psychiatrist. My sleep problems continued to the point that I was having trouble getting up in the morning to go to work. Needless to say, this was causing problems with my boss. I felt I wasn’t going to get better while still working for State, so I opted to retire.
Apparently I was the first person to be sent to D.C. from post for a PTSD evaluation. State didn’t seem to think there was a problem with PTSD. (It’s not that no problems exist; but after being separated from family for more than a year, most people do not want to self-identify a problem that could potentially result in a curtailment and disrupt their families’ lives again.)
MED had assured me that everything would be reimbursed, but I later learned that because I was not hospitalized, many of my expenses would not be reimbursed. More troubling was that after more than a decade in war zones, MED’s regulations for reimbursement had never been updated to deal with the realities of our work environment.
The mandatory out brief improved between the time I returned from Afghanistan in 2007 and 2012, when I returned from Iraq. However, both times I was told that the symptoms in the PTSD questionnaire are normal for six months and not to worry unless they persist. (And I was offended when taken aside after the briefing and asked how pervasive I thought infidelity was in Baghdad.)
I understand that State had determined that performance levels of employees returning from war zones decline. Knowing this, I do not understand why more wasn’t being done to understand the link with PTSD.
Coping with PTSD
During my first tour, I was diagnosed with PTSD and medevac’d for treatment. My symptoms were so severe that I spent a month hospitalized and from then on worked with a therapist on a weekly basis. During the onward assignments process, MED refused to consider my needs as identified by my therapist, instead assigning me to a post where there was no one in-country who could serve as an appropriate psychiatrist.
There, I raised an issue of concern with the health unit nurse, who in turn shared it with the management officer, who then told my supervisor that I was “nuts.” This was not only a violation of my privacy; it reflected total ignorance on the management officer’s part of what PTSD and its symptoms are.
I continue to go to therapy. I have been tenured and promoted. I recently became engaged. In other words, I have learned how to cope. However, I did all this with no support from the Foreign Service, which instead stigmatized my condition and assigned me to posts that were inappropriate for me at the time.
I would like to hear an apology from management and a promise to treat other officers with mental health needs with care and concern.
We Need Privacy
State medical care has been fantastic, except for one regional psychiatrist, whom I won’t name for fear of retaliation. Due to the incompetence of that doctor, we were forced to seek psychiatric care locally. Luckily things have worked out; but it is a shame that a bully is in such a position to deal with mentally ill people.
My biggest complaint is the lack of confidentiality due to the physical setup of overseas health units for mental health patients. The health unit willingly sets up appointments for visiting regional psychiatrists, but there is absolutely no way to keep these visits confidential given that everyone knows when the psychiatrist is visiting and the person is required to either wait in the hall outside of the health unit or in the reception area in full view of everyone else with appointments with the doctor.
This does not encourage people to seek help. There must be a better way.
Medevac for PTSD
I had to be medevac’d out of my first assignment due to mental health problems related to work and entered a treatment program in coordination with MED. I have since exited the program and moved on with my career.
I would rate the mental health support at 3 out of 10, with 10 being the best. Working in a high-stress post that was not a “high-threat” post, my colleagues and I were given limited support in a time of crisis. Further, MED was unwilling to cover full treatment for my condition due to the situation, and my psychiatrist believes I should have had further therapy before coming back to my job.
MED was unprofessional when it came to extending the length of the treatment program I was in and did not refer me well to an available psychiatrist. I saw it as a betrayal by the institution I have worked so hard for. Improvements to the medevac system, as well as more training for MED, might mitigate these issues.
Many of my colleagues cautioned me not to see a psychiatrist or therapist because of clearance concerns. However, I strongly recommend that if colleagues have problems, they go for treatment. Your mental health is just as important as your physical health and is necessary to do this job.
I hesitated for two days after a panic attack to seek medical attention because I was concerned about my privacy and security clearance. After feeling like I was having another one, I sought medical help. Security clearances had a profound effect on my decision, primarily because I was a first-tour officer. I did not want to ruin my career.
I have only just been diagnosed with PTSD, but now that I’ve had it, I’m noticing it in other people who have been to non-“high-threat” posts.
Security Clearance—Checking That Box
We have had incredible medical staff at all our posts (five). We have had to use them for all sorts of odd medical stuff, and have been 100-percent satisfied. Top-level, smart, caring, hard-working, conscientious...or we have been extremely lucky.
However, I had three bouts of depression during these years with State that were related to stress at work and not having time to properly take care of myself after caring for family and work. I learned my lesson and now put my health and well-being first (i.e., ensuring I have daily exercise, eat well, meditate, etc.), but that doesn’t always jive with certain elements of the department. The culture does not lend itself to putting ones’ health first, unfortunately, and all depends on who is in charge.
After the second bout, I coincidently had to renew my security clearance and made a conscious decision to admit to the illness and subsequent medication. It was horrible. I spent an inordinate amount of time dealing with MED in Washington, and then DS, explaining, justifying, verifying, goodness knows what else, all while on home leave between countries. In the end, I answered all their questions, filled out all the paperwork, did all the “visits” and evaluations that were required, and did get my clearance renewed. Needless to say, I’m not doing that again. Did I say it was a nightmare?
I also have dealt with some odd-ball psychiatrists in the State Department; one had anger issues and displayed inappropriate behavior in public forums. So I have not had a great experience with the State mental health professionals, who do not seem to be of the same caliber as our GP doctors and nurses.
There needs to be more focus on mental health issues in the Foreign Service, less stigma and more work on the conditions that make life stressful. I don’t just mean in war zones—I mean bosses who yell and scream, as well the pressures put on people to excel, work extra hard, all so that they can, maybe, get promoted.
Let me laud the Special Needs Education Allowance program. State has provided a level of cognitive behavioral therapy to my mildly autistic son that staggers the imagination. His progress has been the topic of psychiatry seminars, and the funding for therapy cited as a large contributor to the equation for his success. Without this support, I would have had to drop out of the Foreign Service. Thank you.
In order to join State, on account of having seen a psychiatrist in the past, I had to visit a State psychiatrist. Having worked with people I would call “out of touch” with their psychiatric issues, I explained how ironic I found the fact that a raging psychopath with no psychiatric treatment would have no problem getting a job at State, while a mildly depressed guy in treatment has to be screened by a psychiatrist.
If mental health is a criterion for employment, all new hires should be screened accordingly. Otherwise, only those responsible enough to identify an issue and seek treatment will be screened out, to the detriment of the Foreign Service. I am now a Foreign Service old-timer and can say that, in spite of the often Kafka-esque bureaucratic mire we wade through, this is a fantastic workplace for a mildly depressed guy in treatment.
Regarding treatment overseas, and its maddeningly inconsistent effect on clearances, I could say a great deal. I could tell disheartening stories about my spouse, who received life-threatening, actionable malpractice from bad RMO/Ps. I could tell uplifting stories about RMO/Ps going above and beyond the call of duty to provide exceptional care. But I’m sure similar stories will make their way to AFSA through this effort.
QUESTION 21: THE BASICS
When it comes to filling out the required Standard Form 86, “Questionnaire for National Security Positions,” nothing causes more angst than the so-called “Question 21” (actually Section 21 on the 127-page form).
SF 86 is the federal security clearance application form, which you may also know as e-QIP, the online Electronic Questionnaires for Investigations Processing. Section 21 is the place where you are asked about whether you have had or are in mental health counseling.
Section 21 has been revised some 10 times since the 1950s, and it is still evolving and under regular review. The latest update included a third exempt category: mental health care related to being a victim of sexual assault.
The Section 21 language currently in effect, as of December 2015, reads as follows:
Section 21 – Psychological and Emotional Health
Mental health counseling in and of itself is not a reason to revoke or deny a clearance. In the last seven (7) years, have you consulted with a health care professional regarding an emotional or mental health condition or were you hospitalized for such a condition?
Answer “No” if the counseling was for any of the following reasons and was not court-ordered: (1) strictly marital, family, grief not related to violence by you; or (2) strictly related to adjustments from service in a military combat environment.
Please respond to this question with the following additional instruction: Victims of sexual assault who have consulted with the health care professional regarding an emotional or mental health condition during this period strictly in relation to the sexual assault are instructed to answer “No.”
If you answer “Yes,” then you fill out the rest of Section 21, including dates of counseling, provider names and contact information. That does not, however, give Diplomatic Security permission to contact those providers. DS reviews the file and determines whether a MED review is needed; if so, the case is referred to the MED psychologists who work exclusively on clearance issues.
MED then decides whether they need more information; if they do, MED notifies the employee and asks her or him to sign a release allowing MED to contact the mental health provider for a summary report. According to MED, no provider is contacted without the release.
It’s No Joke
The first MED-directed mental health intervention that was provided in Tripoli after the Benghazi attacks on Sept. 11, 2012, was a video conference in April 2013, conveniently less than a week before the Director General arrived for a visit to Libya. Prior to that, the only service provided was a discussion with the nurse about “fostering resiliency” several months after the attack…hardly a useful assist.
The half-day course for those returning from hardship posts is a joke. I took it after my first (!) unaccompanied tour (UT), and both the instructor and some of the other students made fun of me for enrolling, since at the time my tour was seen as one of the “cupcake UTs,” without an active war going on outside the embassy walls. I refused to take the course after my second UT. No one from HR or my bureau asked if I’d taken it or even how I was doing after the second UT.
An RMO/P made fun of some of my coworkers in a high-stress, high-threat post that happened to be a popular destination for American tourists. He told them that they had no idea what serving in an actually difficult post was like, comparing it to the regional city where he was based. Never mind the fact that almost every person at that highly desirable but still challenging post got there via a tour in Iraq or Afghanistan.
I have neither respect for nor faith in MED’s mental health efforts. As long as MED is staffed with people who see mental health as an inconvenience, supported by State leadership (from the very top down) who barely pay lip service to mental health and a work-life balance, there’s no hope for anyone who suffers in the aftermath of an emotionally catastrophic tour abroad. At least there is solidarity among those who survived terrible times abroad.
On Managing Grief
I obtained grief counseling after my husband of 25 years passed away quite suddenly. The counseling was tremendously helpful. I worked with an excellent psychiatrist who covered more than 30 countries. There were times when I needed very much to see her but she was unavailable due to her work travels.
I am grateful for the mental health assistance available to me. If it weren’t for grief counseling, I would have qualms about seeing the RMO/P, because I’d need to disclose this in the five-yearly security update. And while that disclosure might not affect my security clearance, I still think there’s a stigma attached to the fact that I needed mental health assistance.
Access to Services
As a veteran of two priority staffing post (PSP) tours—one in Iraq (2007–2008) and the other in Afghanistan (2013–2014)—my experience with transition support has been abysmal. Just getting authorization to attend out briefings and to access mental health services was impossible. At the end of my tour in Iraq, the department had just gone out with a cable requiring all officers returning from PSP tours to return to Washington to participate in the then-new out-briefing program.
When I approached the HR office in Baghdad for orders to return to post via Washington (to attend the mandatory program), I was informed that since I had performed my year of service in a temporary duty (TDY) status (due to my decision to leave my family at post rather than relocate them to the United States, as permitted), the policy did not apply to me. I was to return to post directly and have the RMO/P in the region conduct the out brief. It took almost four months after I returned to post for the RMO/P to find time to do so.
Five years later, on returning from Afghanistan the same thing happened: Since I had performed my service TDY, I was not allowed to return to Washington to access services, but told to go forward to my next assignment. Once there, months passed before I was screened for PTSD or other issues.
In both cases, I really wanted the chance to access the counseling services offered only in the D.C. area. In both tours, I did not serve in the embassy but at remote outposts with the military and had a much different experience than the majority of Foreign Service members assigned to these theaters.
These experiences have left me very frustrated with the system, which I believe has done an admirable job of recognizing the issues and providing resources, but has not solved the HR and other roadblocks to actual access to these resources.
While serving overseas, I became extremely unwell. I suffered from a massive clinical depression that was almost the end of me. I also had powerful, unmanageable surges of energy and was drinking heavily to self-medicate. Knowing I needed help, I went to the health unit, and they suggested it was a thyroid problem.
I was scheduled to go on R&R, and the post doctor thought it a good idea to check in with State MED on my way. There, after a 10-minute discussion, they informed me that I had bipolar II disorder (BPII). Apparently there had been a lot of back and forth between post and State MED about my condition, of which I was unaware. Receiving such a diagnosis so quickly was a shock. I remember thinking, “Do you have a handout here about BPII? A flyer, perhaps?
State MED sent me to a psychiatrist who told me I needed to be admitted to a psychiatric unit in a Washington, D.C., hospital. That was scary, but after calling friends and family, I decided that I had better do what State was recommending.
During a week in the psychiatric ward getting medication and having my blood levels checked, I read everything I could about bipolar II disorder and realized that MED’s diagnosis was correct. After my discharge from the hospital, MED informed me that since I had been hospitalized, I was not allowed to go back to post and would have to work at Main State. Unable to return and pack out, my dear friends at post took care of that. They also sold my car for me.
I went to California on leave to see my family. Once back in Washington, I took another week of leave because I had no place to live and no winter clothes. From the Oakwood in Rosslyn, I went to Nordstrom to buy a winter coat and boots and then trudged out in the snow to find an Apartments for Rent guide. Man, that was a depressing time. I missed my friends at post and the life that was ripped away from me.
I didn’t know if I was going to get better, and if I would ever serve overseas again. After a year in Washington, I convinced MED that I was able to continue my overseas career and subsequently received a Class 2 medical clearance. Since then, I’ve had to go through extra hoops to get cleared for onward assignments and to renew my security clearance. I check in with the RMO/P when he is in town and my Washington psychiatrist when in D.C.
This episode was quite an upheaval and tremendously frightening, but ultimately worth it, because I feel so much better! My message to you is to get the help you need, even though it may wreck your regularly scheduled life. Once through it, you’ll have another life that is healthier and happier. If I hadn’t sought help, I don’t know if I would be alive right now.
Suck It Up? Really?
We are still in the dark ages of what mental health care means. It does not mean you should seek mental health care only at the point at which you are a danger to yourself or others.
So people limp along, dragging their issues to their next post and either try to resolve them while also being in demanding jobs (aren’t they all?), or they don’t deal with things and wind up passing on the dysfunction by treating others as they were treated, creating yet another painful situation.
I was a second-tour ELO and was receiving little in the way of guidance, support or even acceptance from my management. My medical officer recommended a chat with the psychiatrist for support and advice, and to get on record that I reached out for help. The psychiatrist was stationed in another country, so we talked by phone. The man sounded swamped. He explained that they’d cut psychiatrists all over and were expecting the existing ones to take on extra work.
His advice for my situation? Talk to my problematic managers. I told him that I had tried that. He said to just try it again because unless I was a danger to myself or others (which I wasn’t), there was nothing he could do.
He said that in the State Department we have to figure out how to “suck it up.” Seriously. He was nice about it, and I could tell it bothered him, too, but that was his advice. We’re a tough bunch, and when we go so far as to ask a mental health professional for help, chances are we need solid advice. I dealt with my issue on my own and never called back.
Please stop overworking the psychiatrists. Add more. Train them to our circumstances. Give them resources.
I am not concerned about medical and security clearances as they relate to mental health care. Most people have seen a therapist at one time or another, and I don’t think it would affect a security clearance. But corridor reputation is a concern. Even when people need to talk to a mental health professional, they’re more worried about their corridor reputation and often won’t seek help due to the stigma of being “weak.”
From what I’ve observed, it’s not the high-threat posts that are creating all the issues, but rather the not-very-effective, poorly monitored management we have to work under at times. There are many devoted, capable and highly competent managers in the Foreign Service who are great mentors, but there are also an inordinate amount who are not.
I have colleagues who talk about PTSD triggered by working with abusive or incompetent managers who are not held accountable, because their superiors can’t or won’t deal with them, or are not examining how these managers are performing their duties (or not). It hurts the subordinate; but it’s also harming the manager, who is not being mentored to become effective. I believe that’s where we really hurt ourselves as well as compromise the work. I could be wrong here. I wish we were talking about it more.
Support Each Other
Anxiety; it’s an illness unseen but omnipresent. It’s especially palpable within the Foreign Service. Many officers self-medicate with alcohol and other “acceptable” vices instead of seeking assistance. Why is this so? Is it because of the stigma associated with mental illness? Is it because of the difficulty in finding a trustworthy and competent psychologist, specifically in certain high-differential postings? Is it because of the constant pressure associated with representing the United States 24/7? I don’t have an answer.
However, if you notice someone struggling, don’t judge, don’t assume, simply try to be understanding. If they confide in you, don’t respond with disparaging and dismissive remarks. When something is difficult to acknowledge, it is all the more worth discussing. Let’s move toward positive change by beginning with dialogue!
Bullying Leads to Resignation
I believe bullying by deputy chiefs of mission (DCMs) and other managers is the leading cause of mental health problems in the Foreign Service, followed by unrealistic workloads caused by unrealistic expectations from ambassadors and office chiefs. State currently has very few social workers outside of Washington, D.C., and we need many, many more.
In my final post, when I had finally had enough bullying from my fourth bully boss (three of whom were DCMs and one a GS-15), I worked with the regional psychiatrist who prescribed two anti-anxiety/anti-depressants and a sleeping pill to help me cope. I sought assistance from the ombudsman, but received no help, so I resigned.
I miss my career in the Foreign Service, and I made significant contributions to the State Department. Ultimately, I had to look out for my health. I am off all anti-depressants and sleeping pills. Why couldn’t I have been given reasonable work conditions in the State Department?
Bad Bosses and Mental Health
Anyone who’s been around the Foreign Service can tell you that there are some fairly awful FSOs who use their positions to abuse others. Why wait to deal with the mental issues and damage these people cause to others instead of dealing with the problem at the source?
I recently worked for a manager who bullied and abused me and the local staff on a regular basis. It takes a real toll when you are screamed at, publicly humiliated, never thanked and blamed (to senior staff) for the boss’s own bad decisions. Staff who had always gone the extra mile stopped doing so, sick days rose and some left—all as a result of one manager’s behavior. The front office did nothing, calling it “communication misunderstandings.”
Several people would have been tempted to get mental health counseling had they known about it. But privacy was a big concern. The guy would look for anything at all to use against us. Even with complaints and documentation, the lack of action from anyone was appalling.
Human resources experts say that an organization has to change its culture if it is having problems in an area. When State does not actively intervene in cases of abusive behavior, managers are given the impression that they have carte blanche to do whatever they want. Even if victims get mental health care afterwards, the damage has been done.
From what I hear, the problem is getting worse and more widespread. It doesn’t have to be this way. Instead of sending out feel-good cables on workplace atmosphere and bullying, put policies in place that have real teeth. A zero-tolerance policy for workplace bullies, administered neutrally and enforced by D.C., would lead to an instant decrease in unacceptable behaviors and the resulting damage they cause.
Make it like soccer. If you get a yellow card, you get mandatory management and anger counseling. Get a red card and you’re automatically not considered for promotion for a year or two. Two red cards, and you’re out for the rest of the match/tour.
We can’t help violence or chaos outside the embassy doors. What goes on inside, that we can fix.
Thanks, this is an issue which really needs to be addressed.
ISO Work-Life Balance
I’m very concerned about the mental health support offered to members of the Foreign Service and eligible family members. A few years ago I was diagnosed with generalized anxiety disorder (GAD). I was fortunate—I was at a post with an eligible family member (EFM) working as a nurse practitioner. I had discussed my mental health with the regional psychiatrist during his visits, but he just gave me Xanax and told me panic attacks were normal. He asked me about work-related stress, but reported the results of our meetings with post leadership, contributing to my stress.
The nurse practitioner helped me with a low dose of Lexapro that was life-changing. I knew the benefit of cognitive behavioral therapy (CBT) for GAD, but while overseas was unable to access it; local health care was poor, and there was no private space in the embassy for a video connection with a therapist in the United States. When I finally came back to the United States I began CBT with a therapist and a psychiatrist who continued my prescription. My GAD improved dramatically, and I learned useful skills for managing stress.
Unfortunately, when I moved back overseas, the GAD returned. The techniques I learned to manage it are not very useful in an organization that pays lip-service to work-life balance, but in reality demands extreme working hours even when unnecessary (in places that are not war zones). Work demands make it difficult to find time to exercise, and bosses hesitate to allow annual leave because there might not be enough people around if there’s an emergency.
Having GAD does not make me bad at my job. I can put in long hours and work in stressful situations. But working long hours every single day just to push out another perfect memo or not scheduling annual leave because you have to be prepared for every possible contingency at all times is not healthy.
Mental Health and Toxic Workplaces
It’s great that the State Department is attempting pro-active measures and screening programs focused on officers in priority staffing posts (PSPs), but I do not think there is enough emphasis on good mental health care for all officers and their family members regardless of where they serve.
I went through the required screenings and classes for finishing service at a PSP and experienced neither difficulty with mental health during the tour nor delayed effects afterward. So it took me by surprise when, just a few months into a new assignment in a fairly nice city, I developed depression and anxiety while working with a difficult supervisor at a post that I would characterize as having toxic leadership issues (which made it difficult to find higher-ups to assist with my supervisor issue).
It took me a while to realize that it was not just temporary stress and difficulty learning a new job; an unhealthy work environment pushed me into a full-blown depression. I finally sought treatment when physical symptoms that had no underlying physical cause doctors could identify began making my life difficult.
I appreciated the fact that my post had a regional psychiatrist, because that made it easier to discreetly and quickly seek help. I was referred to a locally-based American citizen psychologist and pursued several months of therapy. Between that and the fact that a few key people at post who were sources of toxicity finally left, I improved my life and work level. Once I felt safe enough to talk with colleagues about what I’d gone through, several told me they had experienced the same difficulties with the same people.
This begs the question: What prevents us from speaking up? Part of the answer is that we are in a work culture where there is little incentive to rock the boat. Also, there is an element of “stiff upper lip” expected. I felt like there was something wrong with me for not “managing up” correctly. I realize now that it wasn’t a problem with me, and I have learned certain things I would do differently if I were to again find myself in such a situation.
Though my therapy was successful, I was disappointed that the RMO/P had initially suggested prescription medication. I think in U.S. culture and in the liability-driven work culture of government, we over-emphasize quick solutions and pop-a-pill-and-make-it-go-away attitudes too often. We need to bring a level of holistic analysis to any problem, whether it is mental health treatment or developing foreign policy.
In the absence of a supportive and empathetic response to people dealing with mental health issues, privacy is of the utmost importance for creating a sense of safety, which supports the treatment process.
I remember how important it was to me to see lots of messaging from the State Department and the Secretary (e.g., department notices, management announcements) making it clear: getting treated for a mental health issue is a sign of strength and responsibility, not weakness.
The intent for the mental health screening programs for people returning from high-threat assignments is correct, but the execution still feels very pro forma. In the check-out process from my PSP post, a big group of us were seated in an auditorium and asked to go through a checklist of “Do I have this symptom [insert an extreme symptom example]?” Is that environment and process conducive to sharing or reflecting on an issue they may be having?
Instead, we need to emphasize colleagues and family members watching out for each other; they are truly the first people who are going to notice if someone is acting differently and experiencing difficulty.