The Foreign Service Journal, January-February 2016

22 JANUARY-FEBRUARY 2016 | THE FOREIGN SERVICE JOURNAL director for Mental Health Services. Haynes worked at developing a coherent program that relied more on direct-hire mental health staff than on contractors. Haynes also hired a psy- chologist, Dr. Samuel Kar- son, whose particular skills and extensive experience in personality testing were well-suited to the depart- ment’s growing need for experts in clearances in the 1980s. (From the 1950s to the mid-1970s, the clinical backbone of the department’s mental health clearance section had been a group of six private-practice psychiatrists fromWashington who came into the department for an hour once a week to do evaluations for the Office of Medical Services.) The Field Mental Health Officer During the 1970s, another innovation in the use of overseas mental health personnel occurred that ultimately resulted in the regional medical officer/psychiatrist (RMO/P) program. Specifically, in 1974 Embassy Kabul decided to deal with a rash of mental health crises (including three suicide attempts) by using post funds to hire a psychologist, Dr. Richard West- maas, as a personal services contractor to establish a practice at the embassy. His work was so helpful that the department employed him as a direct-hire Foreign Service employee and made him the regional mental health officer for Afghanistan, India and Pakistan. By the time Westmaas left his position in 1977, the idea of a regional mental health officer had proven itself, and he was suc- ceeded by former Peace Corps psychiatrist, Dr. Elmore Rigamer. Like Westmaas, Rigamer proved his worth. During his second year in Kabul, the Dubs assassination occurred, devastating the entire embassy community. Rigamer met with members of the community to discuss the psychological impact of the event, providing vital assistance to the community’s recovery from the trauma. By the time he left Kabul to continue regional psychiatry in New Delhi in 1979, the Foreign Service psychiatry program was off and running. Between 1979 and 1982, mental health positions were estab- lished in Vienna, Bangkok, Monrovia and Cairo. Although the Bangkok position was first occupied by a psychologist, Sam Karson’s two-year tour as a regional mental health officer in Thailand (1981-1983) was a one-off. MED preferred psychiatrists, not just because they could write prescriptions, but because they are physicians and have broader training. Thus, psychiatrists are in a posi- tion to identify (and rule out) any physical/medical issues that might be the cause of mental problems. Foreign Service mental health positions subsequently went to psychiatrists. In the RMO/P skill code, for example, the P stands for psychiatrist; there is no skill code for a Foreign Ser- vice psychologist position. Funding mental health care had always been an issue, because mental health care, even more than general medical care, is fraught with confidentiality concerns. And, when the psychiatrist works for the patient’s employer, the problem of “dual agency” arises. As a result, efforts in the 1970s and early 1980s often involved support for programs located outside the immediate influence of an embassy or the State Department. The idea of using contractors, such as Westmaas had been in Kabul, was an obvious one; because Westmaas’ position had been created with local embassy funds, it reduced the dual agency conflict. But he was soon hired directly by the depart- ment as a Foreign Service regional mental health officer, and since the 1970s mental health contractors have only rarely been used by the department. Other Models of Care Embassies used other models of mental health care, too. Several made use of mental health clinics for expatriates that had been set up during the 1970s in cities such as Cairo, Tehran and Kuala Lumpur. And embassy health units developed lists of local practitioners they could work with. One community mental health initiative during the 1970s and 1980s that seemed to work for many embassies was the “mental health grants” program. Established in 1974, the program grew to more than $250,000 per year. Given out in amounts ranging from $700 to $18,000, the grants paid for edu- cational presentations, support groups, library resources related to mental health, as well as programs related to crisis interven- tion and referral for therapy. The grants also paid for “preven- tive mental health” presentations and helped support expats Between 1979 and 1982, mental health positions were established in Vienna, Bangkok, Monrovia and Cairo.