The Foreign Service Journal, December 2006

54 F O R E I G N S E R V I C E J O U R N A L / D E C E M B E R 2 0 0 6 W ith the increased emphasis on diplomatic service in war zones and high hardship- differential assignments, the possibility of exposure to violence and chronic stress is greater than ever. From the Office of Medical Services’ perspective, State Department employees, both Foreign and Civil Service, should take advantage of the mental health support options that the department offers. MED has 14 psychiatrists in various assignments around the world today. The department employed its first psy- chiatrist, Frank E. Johnson, in 1971, and then expanded the program signif- icantly in the 1980s and 1990s in response to the Iran hostage crisis, the Beirut embassy bombing in 1983 and the East Africa embassy bombings in 1998. Currently, Mental Health Ser- vices has 17 domestic and overseas psychiatrists, four psychologists, seven social workers, a nurse practitioner and a nurse case manager. Although post-traumatic stress dis- order is not inevitable following expo- sure to a life-threatening event, some transient psychological symptoms emerge in almost everyone so expos- ed. A widely quoted study of soldiers serving in Iraq, conducted by Dr. Charles Hoge of the Walter Reed Army Institute of Research and his col- leagues in 2004, found that 15 to 17 percent of soldiers returning from Iraq met screening criteria for major de- pression, generalized anxiety disorder or PTSD (www.pbs.org/wgbh/pages/fro ntline//shows/heart/readings/nejm.pdf). Unlike the military, we do not have the ability to compel returning Foreign Service officers to complete a mental health screening survey, but our impression is that the prevalence of these conditions is significant. Hoge’s study also found that 23 to 40 percent of those who screened positive for a mental disorder sought mental health care, so it is important to publicize what is available through MED for employees covered by the department’s medical program. The Outbriefing The high-stress assignment out- briefing is the most important service. Mandated for those returning from Iraq since 2004, but encouraged for those returning from Afghanistan and others who wish to take advantage of it, the outbriefing is a joint effort of FSI and MED. Details about the program were recently reissued in State 40966 (dated March 14, 2006), titled “Outbriefing Sessions and Psychosocial Support for Iraq Returnees.” The briefing is design- ed to offer information on adjustment to more normal circumstances following Iraq service, warning signs of a psycho- logical problem, and how to get help if a problem develops. From the MED perspective, if an employee develops PTSD at an over- seas posting, he or she can be treated by the regional psychiatric officer, or MED will facilitate referral to whatever local resources are available. In the U.S., an employee can contact the director of Mental Health Services for guidance and referral for treatment. Since the time of the East Africa embassy bombings, MED has devel- oped relationships with some of the world’s experts on PTSD. We can usu- ally arrange an effective referral to a qualified clinician, depending on indi- vidual circumstances. Domestic em- ployees with problems requiring only short-term counseling can also be seen free of charge through the Employee Consultation Service. Effect on Security Clearances As has been the case for years, the biggest barrier to mental health care is concern about the effect on the securi- ty clearance (and to a smaller degree, the medical clearance). Mental Health Services, which reviews mental health security clearance issues for the Bur- eau of Diplomatic Security, takes a very tolerant view of treatment for stress- related problems. DS, with the cooper- ation of MED, issued a department notice in 2004 that stated its position on this issue. I will quote from it, because it is very much to the point. The notice says, in part: “Executive Orders 10450 and 12968 require the department to make a determination of an employee’s ability to safeguard clas- sified information. In certain situations, DS asks the Office of Medical Services to review the DS investigation, seek per- tinent information, and make a ‘whole person’ assessment as to whether there Help After High-Stress Assignments By Samuel B. Thielman, M.D., Ph.D. Samuel B. Thielman is director of Mental Health Services in the State Department’s Office of Medical Ser- vices. Since the time of the East Africa embassy bombings, MED has developed relationships with some of the world’s experts on PTSD.