MH Care Won't Harm Careers in Foreign Service, Clinton Says

Secretary of State Hillary Rodham Clinton issued a statement strongly encouraging foreign-service personnel serving in or returning from high-stress areas of the world to seek mental health treatment if they need it.

The secretary's statement, a forceful endorsement of mental health treatment for foreign-service officers—many of whom have served in Baghdad, Kabul, Islamabad, and other areas of military conflict or regions experiencing stress and trauma—follows a report on the subject in August by the State Department's Office of Inspector General (OIG). That report found that many officers may not seek out services provided by the department for fear of adverse effects on their career.

“At the State Department and USAID [United States Agency for International Development], we work long hours on complex problems with few clear-cut solutions,” Clinton said in her September 7 statement. “Many of you serve in dangerous and remote posts, often far away from friends and loved ones.

“I know that your service here comes with sacrifice, both for you and your families, and with unique stresses,” she continued. “We are committed to ensuring that every member of the State Department and USAID family has all the support they need. That's why we've made it a priority to provide access to social workers and mental health counselors, a mandatory high-stress outbrief program, and training for anyone who seeks it and particularly for those who are returning from or working with returnees from high-stress posts.”

Clinton was emphatic that seeking and receiving mental health treatment will not harm an officer's career.

“No one at State has lost a clearance because he or she sought mental health counseling or treatment,” she said. “In fact, Diplomatic Security [the office charged with periodic reviews of security clearance] has advised that receiving recommended treatment for mental health concerns is a favorable factor during security clearance determinations. For all of us, managing our mental health is an essential part of maintaining our well-being, and recognizing the need for help is a sign of maturity and professionalism. Talking to someone can make all the difference in the world.”

Few Attend Post-Service MH Briefings

The secretary's remarks were a direct result of the August report titled “Review of Support for Employees Who Are Serving or Have Served in High-Stress, High-Threat, Unaccompanied Posts.” Among its findings, the report stated that “[e]mployees believe there is still a significant stigma attached to seeking mental health assistance” and that the department “needs to issue a clear and persuasive high-level statement informing employees that seeking mental health assistance is a positive step and a normal part of a person's health care.”

The report also found that fewer than 60 percent of returnees from Iraq and Afghanistan have attended mandatory follow-up briefings designed to assess mental health problems, and “very few from other high-stress posts for whom it is voluntary” have availed themselves of the briefings.

The OIG issued six recommendations, including one that the department's Office of Medical Services expand the counseling services it offers employees and establish a schedule for a 2011 survey of employees and health providers to determine the effectiveness of its programs (see See also: Recommendations Encourage Personnel to Get Mental Health Help for other recommendations).

Psychiatrist Chris Flynn, M.D., director of mental health services in the Department of Medical Services at the State Department, said the foreign service typically attracts highly educated, high-achieving professionals who are not likely to fear mental health treatment, per se, but who may be zealously protective of careers they have spent years pursuing.

“It's a difficult selection process, and it's not easy to get into the foreign service,” Flynn told Psychiatric News. “These individuals want to be successful despite placement in difficult and challenging locations, and they are liable to think, ‘If I seek mental health treatment, what will happen to my career I've worked so hard to build?’”

But Flynn underscored the secretary's remarks, saying that of more than 1,000 security clearances that have been reviewed in the last several years involving officers who had sought mental health treatment, not one had his or her security clearance denied because of seeking care. All clearances are decided by Diplomatic Security, but those involving a mental health history receive consultation from the Department of Mental Health Services.

Flynn said foreign-service officers also need to obtain a medical clearance, which can involve three levels of clearance: unlimited, meaning that an officer can serve in any post anywhere in the world; limited, in which they are permitted to serve in any area that has medical (including psychiatric) care appropriate to their condition; and restricted, in which they can serve only in the United States.

The restricted clearance is typically reserved for personnel who have been hospitalized in the prior year or have intensive treatment needs and are deemed likely to require ongoing treatment of similar intensity.

Flynn said of more than 350 medical clearance reviews conducted in the last six months, 86 percent of officers received unlimited clearance, just 12 percent received limited clearance, and only 2 percent were restricted to the United States.

“We want our officers to know [that] you aren't going to lose your medical or security clearances simply because you seek mental health treatment,” he said.

Though the OIG report was principally concerned with how employees accessed services provided by the department internally, comments from some psychiatrists within the Washington Psychiatric Society who have treated State Department personnel appear to confirm the generally supportive stance of the State Department regarding mental health treatment.

One psychiatrist, responding anonymously to a list-serve inquiry, stated: “I have never had a patient denied a posting or security clearance, although many have had some anxiety about whether or not they would be denied. In my dealings with State psychiatrists, I have found them to be pretty empathetic and wanting to understand what supports the person would need, particularly in high-risk postings. They seem to be aware that individuals who are able to acknowledge their anxiety and depression are better able to deal with it under pressure. Certainly SSRIs and sleep aids and benzodiazepines are common and do not raise alarm in my experience. I have not had any patients on large doses of mood stabilizers or antipsychotics.”

Catching Up With the Military

Flynn, who is also an Air Force reservist and served in the first Gulf War, said the State Department is seeking to “catch up” to the military, which has had almost two decades since that first Gulf War to build an array of pre- and post-military deployment medical and mental health screening services. “We have never had so many foreign-service officers in harm's way for as long as we have had now [since 2003] and we are trying to implement something like what the military has been doing to be sure we don't miss helping those in need,” he said.

Flynn said that based on an internal survey in 2007 to which 877 foreign service officers responded, it is estimated that about 15 percent of personnel returning from high-stress areas display symptoms of posttraumatic stress disorder.

But while the military and the foreign service both share an international mission focus, they differ dramatically in institutional culture—hence the reluctance of State Department employees returning from Iraq or Afghanistan to access the High Stress Assignment Outbrief, despite the fact that such briefings are “mandatory.” “If we are going to help our officers, we either need to develop a bigger stick or better carrots to encourage officers to get the briefings—and I prefer better carrots,” Flynn said.

He said that in 2008 the department created the Deployment Stress Management Program in which a psychiatrist and two social workers offer predeployment training to officers going into high stress areas, as well as treatment for returning officers who are diagnosed with PTSD. Additionally, the department has deployed mental health professionals to be stationed and provide care in Baghdad, Kabul, and Islamabad, as well as regionally deployed psychiatrists who make frequent visits to war-zone posts as well.

Flynn said he believes the department needs to better publicize its efforts to care for its war-zone veterans—an undertaking that Clinton's statement is bound to enhance. He reported that the Deployment Stress Management Program staff have said their “e-mail is lighting up” with messages from interested officers in the wake of the secretary's statement.

“I think our message is going to resonate with people,” he said.

“Review of Support for Employees Who Are Serving or Have Served in High-Stress, High-Threat, Unaccompanied Posts” is posted at <http://oig.state.gov/documents/organization/145424.pdf>.