On the Infamous Q21, PTSD and the Wholeness of People in the Foreign Service

Last week, Defense Secretary Robert Gates announced that applicants for government security clearances will no longer have to declare whether they sought mental health counseling after serving in combat zones. He emphasized while talking to reporters at a new PTSD center at Fort Bliss, Texas, that the troops’ psychiatric counseling for wartime mental health problems is "not going to count against them" if they apply for national security clearances for sensitive jobs. The announcement received wide media coverage. You can read the coverage by AP, WaPo, and Air Force Link by clicking on each hyperlink here.

The new policy revises the infamous Question 21 on the SF-86 Questionnaire for National Security Positions. The revised question excludes counseling related to marital, family, or grief issues, unless related to violence by the applicant. It also excludes counseling for adjustments from service in a military combat environment. You can read the official guidance from the Office of the Secretary of Defense dated April 18, 2008 here (the link will open as PDF file). The WaPo report also indicates that this change will apply not only to military and civilian employees of the Department of Defense but also to all applicants for security clearances.

Hmmn …. I’ve looked at that guidance from OSD and it was only addressed to all military components . I’ve scoured the net for a similar guidance from OPM addressed to other Federal agencies but so far have come up empty. I’ve searched state.gov – nada (could not also find any easy reference to post traumatic stress disorder there).

In January this year, AFSA’s Foreign Service Journal did devote an entire issue on PTSD or post traumatic stress disorder in the Foreign Service. It also included a sidebar containing a joint State Department M/DG/DS Press Guidance dated May 4, 2007 about mental health and security clearance (see below):

Q: Does seeking mental health treatment following service in Iraq or Afghanistan jeopardize one’s security clearance?

Seeking mental health treatment following service in Iraq or Afghanistan does not jeopardize one’s security clearance. To suggest so is not only incorrect, but does a disservice to our employees who have served so admirably in these dangerous assignments. In fact, in October 2004, the department issued a notice to employees titled “Mental Health Counseling and Your Security Clearance,” specifically stating that concerns about their security clearance should not deter any employee from seeking professional assistance.

Q: What is our reaction to the warning issued by the “Concerned Foreign Service Officers” to Foreign Service officers regarding seeking mental health care?

The warning issued by Concerned Foreign Service Officers to Foreign Service officers regarding seeking mental health care is completely unfounded. Furthermore, the department considers this “warning,” which has no basis in fact, detrimental to the health of our employees.

The group referred to in the second question runs an open blog called, Dead Men Working and they have written about the security clearance and PTSD recently here and here. This issue was a gut-wrenching read because anyone in the FS could easily imagine oneself in such a position, have friends who've been through this and could not rule this out as a potential affliction in everyone's card. Below are selected excerpts from the FSJ issue.

Kristin K. Loken was a Foreign Service officer with theU.S. Agency for International Development from 1980 to 2001. She served in El Salvador during the civil war, Lebanon, West Bank/Gaza, Eritrea and India. You can read her entire story here (document will open in PDF file):

"In late 1981, after two-and-a-half years in this war zone, I returned to Washington. It took several weeks before I realized I wasn’t getting back to normal. I still jumped at loud noises and saw dead bodies on desks at work at the State Department. Strong emotions would come and go without any relevance to what was happening around me. I had regular nightmares about running away from uniformed men with guns trying to kill me. Sometimes I would also have what I called “daymares.” I would encounter a person at work in a meeting and see them suddenly fall victim to some horrible trauma — a car wreck, a shooting, a bomb explosion. These daymares struck quickly, then disappeared, leaving me sitting in a meeting not knowing what I had missed."

"I went to my boss and told her I thought I was going through some postwar emotional problems and asked if the State Department or USAID had some counseling services available. She said she was sympathetic but thought senior people would probably frown on my having emotional problems, and advised that disclosing my condition might negatively affect my eventual tenuring with USAID. So it would be best to keep a “stiff upper lip.” Her advice was to see a private therapist, for which she would give me as much administrative leave as I needed."

"As I tried to regain normal functioning, I noticed that my mouth wouldn’t work right; I couldn’t talk properly and could hardly communicate with people around me. There was a great deal going on inside my head, but it had no relevance to what was going on in the world around me. I could answer a direct question in a few words, but then could not say anything more for long periods of time. I didn’t feel sad; I didn’t feel happy. Often I didn’t seem to feel anything at all. "

Rachel Schneller joined the Foreign Service in 2001, serving in Skopje, Conakry and Basrah, where she was a Provincial Action Officer from 2005 to 2006. You can read her entire story here (document will open in PDF file):

"It has taken enormous amounts of energy and effort to endure and withstand PTSD treatment. To hazard a comparison to something I know nothing about, I would compare the process to learning how to walk again after a major car accident while kicking a cocaine habit. It was something I did because the only alternative I had was to go through life in a zombie-like state of misery and despair, and I didn’t like that alternative."

"In June 2006, after having worked in Basrah for several months, I took leave to return to Washington for a few weeks. A Foreign Service National employee in my office had been murdered, and I’d dreamed of hanging myself from my office light fixture. During leave, I asked the Medical Services Bureau for help and they referred me to an in-house social worker. While telling him about the whole horrible situation, including the dream about killing myself, I broke down in sobs. The social worker was nice but offered me no actual treatment. He did not refer me to a psychiatrist for an evaluation; he did not offer me medication for my depression; and he did not address my thoughts of suicide. Disappointed, but fearful of being labeled a “quitter” or worse, I chose to return to Iraq."

"After all I’d been through, I was grateful to be home alive and in one piece, reunited with family and friends. But soon I just stopped functioning normally. I was unable to sleep. I started getting lost on my way home from work, waking up in a sort of fugue state blocks away from my apartment in Georgetown. I don’t remember precisely how, but I burned myself several times so badly that I scarred — yet I didn’t feel it. I only noticed the burns the next day. Rage overwhelmed me. I nearly attacked another person in one of my FSI training classes, but walked out of the class in time and had a meltdown in the bathroom. (That poor woman had no idea how close she came to being strangled by me for making a completely innocent comment.)"

And then there was the story of a senior FSO whose name was withheld by the Journal. The anonymous writer was not suffering from PTSD but something more common than we’d think – depression. Below are selected excerpts of his account on seeking help, and getting entangled with the security and medical clearance process within the State Department. You can read the entire account here (document will open in PDF file):

"His first question was whether anything had changed since I had submitted the online form, and I mentioned my weekly counseling sessions and the antidepressants. He just nodded in a kindly fashion. Imagine my surprise when, last April, I received an e-mail from a security officer in Washington. It demanded that I ask the regional psychiatrist to answer a set of questions fully within the next 10 days, and warned me that my medical condition could “affect [my] security clearance eligibility or suitability for employment.”

The FSO eventually had his clearance renewed for five years but further writes:

“The department’s handling of mental health treatment surprised me once again during my recent medical clearance exam. I learned that I would receive a Class II medical clearance because I am on antidepressants. I had assumed that treating my depression with medication would be on par with treating my osteoporosis with medication, as other people treat their diabetes, high cholesterol or high blood pressure with prescription drugs. Instead of applauding me for tackling my problem head-on, however, State seems to prefer that I go off my meds and become the unhappy, less productive, less collegial employee I was a year ago. No wonder so many FSOs are in bad moods!"

Considering that State has its own clearance process and is a separate agency from DOD, I’m waiting for revised guidance for State Department personnel from Secretary Rice herself. Uhm, no offense intended; the guidance from “M” or “DGHR” or “DS” is fine but I don’t think that really cuts the cake here.

I’d like to see the Department of State, at the highest level of the 7th Floor, affirm and strongly endorse the practice of seeking professional help to address all health related concerns, including mental health. The press guidance above only refers to service in Iraq and Afghanistan, but what about service in the rest of the FS hardship assignments? The emotional toll of constant moving and relocation coupled with dangerous and challenging assignments is not something that we can or should ignore. Depression is a real cloud in our midst and unless we want a bunch of dysfunctional individuals running around trying to do their jobs, we must ensure that people get appropriate help without fear that their jobs could be jeopardized.

At a chance of being accused as having a “me, too” mentality here, I would like to see the Department of State, like DOD, publicly articulate that it considers seeking appropriate healthcare, including mental health care, whenever needed, as a mark of strength and maturity (and not a sign of weakness and deficiency). Clear guidance from Secretary Rice similar to the one released by Secretary Gates would help ensure that all the moving parts of the State Department are on the same page. We cannot leave to chance the possibility that Q21 would be parsed and interpreted in many different ways by the employees or the clearance issuance arm.

The organization of the 21^st century will be judged by the wholeness of its people. Here’s the first step to getting us there.

- - - Available Online Resources:

Returning from the War Zone – Guide for Families of Military Members (PDF file with some information useful to returning Foreign Service Members)

A Guide to Managing Stress in Crisis Response Professions

National Center for Post Traumatic Stress Disorder

PTSD - National Institute of Mental Health

PTSD Sanctuary - Resources