On the Infamous Q21, PTSD (Again) and High Threat Unaccompanied Assignments

The OIG has released its inspection report dated July 2010 on  the State Department's support for high stress, high threat, unaccompanied posts.  Some interesting details excerpted below. I have also republished the full report in ScribD for easy access (read below).

The Stigma of Seeking Mental Health Care:

The Department of Defense, led by the Secretary of Defense, has undertaken a campaign to reduce or eliminate this stigma. The Department also has made an effort in the past but can do more. The Department, as have the Department of Defense and other federal government agencies, now exempts mental health consultations relating to service in a military combat environment (i.e., Iraq and Afghanistan) from being reported on employees’ security clearance forms (it still has to be reported on medical clearance forms). That is just one, though important, step.

There is still a lack of clarity as to what employees must report on the security clearance form. For example, does a discussion between an employee and a health professional on how to manage stress have to be reported even if it does not involve diagnosis and treatment of a mental disorder? Opinions differ on that point. However, if such “preclinical” discussions have to be reported, that will ensure that fewer will take place, even if the Department is more successful than in the past in reducing the stigma. This would undercut the Department’s efforts to build resiliency among its employees.

The Department needs to address the overall issue of the stigma. The next step should be a message from the Department’s leadership to all employees making some of the following points (which have been made to the OIG team by MED and DS):

• The Department encourages its employees to seek mental health care. It is a positive act and a normal part of maintaining one’s health and preparedness.

• Employees could be more likely to put at risk their clearances and job performance when they do not seek such care.

• Only two employees have lost their security clearances over the past fi ve years because of mental health issues (which did not involve PTSD).

• Of the 517 cases concerning mental health issues that DS referred to MED during 2009, not one resulted in denial of a security clearance for mental health reasons.

Two years ago, we called for such a high level message from Secretary Rice in On the Infamous Q21, PTSD and the Wholeness of People in the Foreign Service(May 2008): 

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.

We're a small fly in a thick soup, of course; that did not go anywhere.  Secretary Clinton as far as we are aware has not issued a message similar to Secretary Gates' message. 

This report by the way, notes that "In the past five years, 18 employees have been formally diagnosed with PTSD. Of these, 10 had served in posts other than Iraq or Afghanistan." So there are more posts at play here than just the war zones. 

Leadership and Stress:

In practically any conversation about the causes of stress and inefficiency in the Department or at overseas posts, the issue of inadequate leadership/management comes up. For some employees, this is a greater problem than danger and hardship. Good leadership can do a great deal to create high morale and effectiveness at difficult posts. Poor leadership, of course, can be a problem at any post or bureau, but it can be especially harmful at a high stress, high threat post. In the OIG survey, leadership problems were cited by 45 percent of the respondents as a source of stress for them or their colleagues. As noted above, this was less than the percentage citing danger, workload, and separation from families, but leadership problems generated more passionate comments than any other issue. That is probably because, unlike danger and separation, employees feel that something can and should be done about leadership.

This is not to say that poor management is widespread at high stress or more “normal” posts. In fact, OIG inspections have found that at a substantial majority of posts, the top leadership is doing fairly to very well. Also, inspections have found that inexperienced personnel have put an additional burden on top leadership as well as middle managers. (See section below on whether the right people are being assigned.) However, recent inspections have found too many cases of managers at the top and middle levels who cause unnecessary stress and inefficiency and thus impair the morale and smooth functioning of their post, bureau, office, or section.

Are the right people on the right bus?

The OIG survey asked whether the Department generally was assigning employees with the necessary skills, experience, and temperament to high stress, high threat posts. Over 60 percent of respondents said no. In their comments, those who served in Iraq and Afghanistan and answered in the negative made observations such as: there are too many people who are there just for the money, their next assignment, or to save a failing career. There are people who do not have the necessary experience or the mental and physical resiliency to be effective; such people make work more difficult for the others. There was a feeling that taking virtually anyone who volunteers has a negative impact on the post.

Lessons not learned, again:

Care should be taken in setting numerical staffing targets. A smaller, higher quality staff can usually do a better job. The OIG inspection of Embassy Baghdad found that many employees thought that staffing levels were too high as a result of the “civilian surge,” even taking into account the need to compensate for the absence of staff because of rest and recuperation leave (R&R) and other factors. The OIG inspection of Embassy Kabul found that the Baghdad experience was being repeated, with staff added before functions were identified and job descriptions developed.

An ALMOST “fitness for duty” policy:

OIG would support the Department’s developing a stronger “fitness for duty” policy that would be fair not just to the individual, but also to his or her colleagues, and that would maintain the effectiveness of a high stress, high threat post. Administrative and legal barriers, however, limit the Department’s options. In a recent review of the issue of physical fitness for high threat posts, the Department concluded that providing employees with the information to make an intelligent self-assessment of their capabilities was the best available means of handling this problem.

Finally, in Recycling News:

Care should also be taken in reviewing the skills and experience of employees hired under the 3161 authority for Iraq and Afghanistan, both for fi rst-time hires and re-hires. A number of people in the OIG survey expressed concern that 3161 employees who did not do very well in Iraq were being hired to go to Afghanistan, and many more thought that 3161 personnel in general needed greater knowledge of the objectives and operations of the Department and other government agencies to be effective in their jobs.

The original OIG report is posted here (OIG Report No. ISP-I-10-44 - Review of Support for High Stress, High Threat, Unaccompanied Posts - July 2010).

State Department/OIG Report of Inspection | Review of Support for Employees (Unaccompanied Posts)

Related articles by Zemanta

• Robert Morgenthau: Ending the Stigma of War Related Stress (online.wsj.com)
• "About 1 in 10 Iraq veterans develops a serious case of PTSD, researchers say" and related posts (latimesblogs.latimes.com)
• Vets can lead fight on mental health stigma (airforcetimes.com)

DS Agent Arrested After Wife Reports Assault

Image via Wikipedia

HeraldNet reported June 25 that a federal agent was arrested for assault in the Snohomish County of Washington State. Excerpt:

The man was arrested June 17 for investigation of second-degree assault. Deputies seized 15 guns from the home, including his duty weapon, according to a police affidavit filed in Everett District Court.

He told investigators that he is an agent with the U.S. Department of State in Seattle. His wife told authorities that he is a diplomatic security officer.

Sheriff’s deputies were summoned to the couple’s house after the woman reported that she’d been assaulted during an argument.

Two children were home at the time of the incident, according to the report.

The woman told police that she and her husband were arguing when she slapped him across the face. She said he picked her up and threw her on the ground and then slammed her head against the floor several times before letting her go.

She said he discouraged her from calling 911, saying that if she summoned police, he would be fired from his job.

The woman complained of blurred vision and head pain. She was taken to Valley General Hospital and later transported to Providence Regional Medical Center in Everett where she was treated for a head injury and bruising to her face.
[...]
A court commissioner on Monday ordered him to stay away from his wife and children. The woman told the commissioner that since her husband returned from deployment to Afghanistan, he has been quick to anger.

She told police she believes he may be suffering from post traumatic stress disorder.

Read the whole thing here.


The report did say that "No charges have been filed against the 42-year-old man. The case is under review by the Snohomish County Prosecutor’s Office." Email: prosecuting.attorney@co.snohomish.wa.us.

It looks like under Washington State laws, assault in the second degree is considered a class B felony, which means a maximum penalty of 10 years in prison and $20,000 fine.

Also, folks in the State of Washington can get in trouble for interference with the reporting of domestic violence (RCW 9A.36.150). The wife was reportedly "discouraged" from calling 911. Not the same as "preventing" or "attempting to prevent" as enumerated below, but might still play out badly in court if this case gets there:

(b) Prevents or attempts to prevent the victim of or a witness to that domestic violence crime from calling a 911 emergency communication system, obtaining medical assistance, or making a report to any law enforcement official.

Beyond the possible immediate problems with the local court, the unnamed agent in this report could also be in trouble with his employer under the following regulations.

FAM 4370 which catalogs the List of Offenses Subject to Disciplinary Action in the Foreign Service is careful to point out the guidelines set in 3 FAM 4130:

3 FAM 4130 sets forth guidelines for deciding an applicant's suitability for the Foreign Service and for taking disciplinary action against a Foreign Service employee. As explained in 3 FAM 4130, the attainment of foreign policy objectives requires the maintenance of the highest standards of conduct by employees of the Foreign Service. Because of the uniqueness of the Foreign Service, employees are considered to be on duty 24 hours a day and must observe especially high standards of conduct during and after working hours and when on leave or travel status. Accordingly the commission after work hours of many of the offenses listed here under "Conduct on the Job" would still be punishable if affecting the ability of the individual or the agency to carry out its responsibilities or mission. No action against a Foreign Service employee should be considered without a careful review of 3 FAM 4130.

So we went and looked up 3 FAM 4130 - the Standards for Appointment and Continued Employment. You may read it in full here. It does not include "domestic violence" but specifically mentions "spousal abuse" as an example of "Notoriously Disgraceful Conduct."

3 FAM 4139.14 Notoriously Disgraceful Conduct
(TL:PER-303; 11-08-1995)
(Uniform State/USAID/USIA)
(Applies to Foreign Service Employees)
Notoriously disgraceful conduct is that conduct which, were it to become
widely known, would embarrass, discredit, or subject to opprobrium the
perpetrator, the Foreign Service, and the United States. Examples of such
conduct include but are not limited to the frequenting of prostitutes,
engaging in public or promiscuous sexual relations, spousal abuse, neglect
or abuse of children, manufacturing or distributing pornography, entering
into debts the employee could not pay, or making use of one’s position or
immunity to profit or to provide favor to another (see also 5 CFR, Part 2635)
or to create the impression of gaining or giving improper favor.
Disqualification of a candidate or discipline of an employee, including
separation for cause, is warranted when the potential for opprobrium or
contempt should the conduct become public knowledge could be reasonably
expected to affect adversely the person’s ability to perform his or her own
job or the agency’s ability to carry out its responsibilities. Evaluators must
be carefully to avoid letting personal disapproval of such conduct influence
their decisions.

The unnamed DS wife told the court that her husband had been to Afghanistan and also told police she believes he may be suffering from PTSD.

In a related note, the June 2010 issue of State Magazine, Ed Warner has an article entitled Unaccompanied Support | Department provides tangible, intangible benefits and I quote in part:

"The buzzword associated with some tours at unaccompanied posts is post-traumatic stress disorder, but Yun [MED Director Dr. Thomas Yun] said its incidence is low. That’s because PTSD is associated with being in life-threatening danger or witnessing someone in such danger, explained David Panakkal, acting director of MED’s Deployment Stress Management Program. Panakkal said health units at AIP posts [Afghanistan, Iraq, Pakistan] monitor for stress-related ailments on arrival, during and at the conclusion of the employee’s tour. While an employee can be medically evacuated if the emotional problem is big enough, he said problems can arise long after the employee returns home."

This is not totally off topic, but isn't it surprising to hear the MED Director quoted about PTSD's "incidence" as "low" without citing any statistics?  The State Department does not do post-deployment screenings as recommended by the GAO, so who is monitoring the employees after they return home?  I am actually curious how anyone could tell the "incident is low" is they are not tracking/evaluating employees after service in unaccompanied posts and the warzones?

[W]hile DOD requires medical screening of civilians before and following deployment, State requires screenings only before deployment. Prior GAO work found that documenting the medical condition of deployed personnel before and following deployment was critical to identifying conditions that may have resulted from deployment. GAO recommended, among other things, that State establish post-deployment screening requirements and that DOD establish procedures to ensure its post-deployment screening requirements are completed. While DOD and State agreed, DOD has developed guidance establishing procedures for post-deployment screenings; but, as of April 2010, State had not provided documentation that it established such requirements.  

Finally, it is perhaps telling that the unnamed wife called 911 despite being warned that the husband/agent "would be fired from his job."  

KiroTV also has this news item posted in its website with additional details including allegations of prior shoving and kicking as well as a restraining order now taken against the agent which requires him to be at least 100 yards away from his wife.

Updated: 7/1/2010:
An astute Diplopundit reader just sent a quick addition, which I was not even aware of.  Under what's called the Lautenberg Amendment (officially called the Domestic Violence Offender Gun Ban ("Gun Ban for Individuals Convicted of a Misdemeanor Crime of Domestic Violence", Pub.L. 104-208,[1] 18 U.S.C. § 922(g)(9)[2]), an amendment to the Omnibus Consolidated Appropriations Act of 1997 enacted by the 104th United States Congress in 1996), this agent could be in deep kimchi with his guns alone: 

"The act bans shipment, transport, ownership and use of guns or ammunition by individuals convicted of misdemeanor domestic violence, or who are under a restraining (protection) order for domestic abuse."

The agent in the news has not been charged or convicted of domestic violence, but since kirotv reports that there is a current restraining order against him, does that mean he can no longer use/carry/own even his officially issued weapon (or own any of the 15 guns seized from his home)?

Wonder if Diplomatic Security is investigating?

Insider Quote: Returning to the Real World

Image by wallyg via Flickr

"At my mandatory “PTSD” course taken right when I got back last month, they described the process that one will experience upon returning to the “real world.” Regardless of who you are, what you do, or where you come from, coming down off of a 13 month adrenaline rush – that is the constant high level stress (both work and environmental stress) – is not an easy feat. They were correct. Irritability, lack of energy, odd emotional responses, hyper alertness, lack of sleep, too much sleep, trouble reconnecting with old relationships, fatigue, restlessness, appetite shifts, stress bursts, irrational responses to loud noises, irrational responses period – are all “normal”. Okay. Good to know I am “normal.” I did ask “how long should it last?” – the response was “if it lasts longer than six months, we encourage you to seek professional help.”

by Erin The next chapter From FS Blog: Overseas View

What's State Doing with Question 21?

“Question 21” on Standard Form 86, is the item in the government security-clearance form that specifically asks applicants or employees renewing their clearance whether they have ever received treatment for mental-health issues. Here is DOD on Security Clearance Question 21. What is the State Department doing with Q21? Walter Reed Strives to Remove Stigma from Mental Health Care Military Works to Eliminate Perceived Mental Health Treatment Stigma Leaders Should Step Up, Receive Mental Health Care if Needed DoD Changes Question to Encourage Troops to Ask for Help Gates Announces Change to Security Clearance Question 21

Related Posts:

• Join the Petition: Revise Q21 for the Foreign Service
• PTSD on the Cheap?
• On the Infamous Q21, PTSD and the Wholeness of People in the Foreign Service

“Pieces of Equipment” Out of Iraq

I wanted to post this because I know this is going to keep me awake tonight.

Salon.com is currently running "Coming Home," a weeklong investigative series on preventable deaths at Fort Carson, a U.S. Army post in Colorado, among troops who have returned from combat tours in Iraq. Salon national correspondent Mark Benjamin and Colorado-based journalist Michael de Yoanna reviewed more than two dozen incidents of suicide, suicide attempts, prescription drug overdoses and murder involving Fort Carson troops and examined 10 of those cases painstakingly.

The first story "The Death Dealers took my life!" is about Army Pvt. Adam Lieberman who tried to kill himself via prescription drug overdose at Fort Carson, Colorado.

Excerpts below:

“After swallowing the pills, he painted a suicide note on the wall of his barracks that read, "I FACED THE ENEMY AND LIVED! IT WAS THE DEATH DEALERS THAT TOOK MY LIFE!" Lieberman survived the attempt. Five days later, his mother, Heidi, arrived in Colorado and was told that her son would be charged with defacing government property for scrawling his suicide note on the barracks wall. Heidi Lieberman told her son's commanding officer that she would repaint the wall herself to "make this stupidity go away."

The next day Heidi called Adam's company commander, Capt. Phelps.

"You know," Heidi fired at Phelps, "I still have a hard time wrapping my mind around the fact that my son is being charged with defacing government property and you people are more concerned about your wall than my son," she stammered. Then she threatened, half jokingly, "I will paint that wall and make this stupidity go away."

A pause, and then Phelps snapped, "We'll contact supply and have them bring you the matching paint."

And so, the Army allowed a mother to paint over her son's suicide note. Heidi's handicapped sister helped.

[...]

"Nobody is willing to help anybody," he [Adam] said about his experience at Fort Carson after returning from Iraq. "You have to understand. We are just pieces of equipment."

The Army says it is working hard to erase the stigma of seeking mental healthcare. It isn't working at Fort Carson. Adam says he was actively discouraged from looking for help.

"If you have a problem, you are going to be a problem," he explained. "You don't ask for help -- ever. That is just the Army's way. Always will be."

A document obtained from another unit at Fort Carson supports Adam's description of a culture that discourages "weakness." Someone in the 3rd Brigade Combat Team prepared a mock official form called a "Hurt Feelings Report," and left a stack of copies near a sheet where soldiers sign out to see a doctor. (View it here.)

Here is the photo of the room with Adam’s suicide note. Here is the photo of his mother painting over his suicide note on USG property.

Obviously there are folks in this story suffering from either dumb brain syndrome or heartgone paralysis. This is a terrible and painful story to read. How could a commanding officer react in such a callous way as if these people were objects in space? And to allow a mother to paint over her son’s suicide note as if the Army does not have enough staff to do this work is not only shameful but offensive.

And this buck stops where?

If you’re mad enough to call or write - below are a couple of useful info:

To contact Major General Mark Graham, Fort Carson Commanding General, use the Hotline: (719) 526-2677 (6-2677). To send an email click here, select Contact Us and use the Commander General Hotline option. To contact the Office of the Secretary of Defense, use the following:

Dr. Robert M. Gates Secretary of Defense 1000 Defense Pentagon Washington, DC 20301-1000 Pentagon Switchboard: 703-545-6700 Public Communication: 703-428-0711

Join the Petition: Revised Q21 for the Foreign Service

I don't know what it is like to have post-traumatic syndrome disorder or PTSD; the closest I've been was what I'd call "moving blues" which lasted for about six months. It was dark and depressing but nothing like what Kristin Loken, a Foreign Service officer with USAID had experienced. In the January 2008 issue of the Foreign Service Journal, she writes:

"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. 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."

It seems like every week, I get somebody online with the search phrase "PTSD and security clearance concerns." It's been months since the Secretary of Defense has successfully advocated the revision of Question 21 of the SF-86 Questionnaire for National Security Positions for DOD and I have not heard a single thing out of State. With a few remaining days left in office, I doubt if this is going to get any attention from the current occupant of the 7th Floor. I also find it troubling that none of the webpages of Mental Health Services, Bureau of Diplomatic Security or "M" carry any information nor guidance on mental health consultations/treatment and its relevance to the employee's medical and security clearance. Please don't tell me they are on the intranet. Family members and partners do not have ready access to that thing. In any case, I figure that with an incoming Secretary of State, this would be a good time to initiate a petition. I have considered the pros and cons of an online petition and have reservations not just with publicly posting names of petitioners, but also whether the intended recipients ever actually read online petitions. Thus, this one is going to be an old fashion, paper and snail mail petition. Below is the text of the petition urging the revision of Question 21 of SF-86 for the Foreign Service. You can download the petition in Word file here or PDF file here. Please sign it, collect five other names/signatures from your immediate colleagues and mail it off to the Mother ship. I also urge you to pass on this petition to family members and friends of the Foreign Service for additional support. The Senate Foreign Relations Committee is scheduled to examine the nomination of Hillary R. Clinton to be Secretary of State on Tuesday (January 13, (9:30 am, SH-216). On January 15, the SFRC will have a business meeting to consider HRC's nomination. With a simple majority needed for confirmation, I expect that she will be confirmed very shortly after the new president takes office. I would therefore suggest that petition letters be mailed off between now and February 20, 2009 to help ensure that the letters will be at her office when she assumes her duties. ~ ~ ~

Date

The Honorable Hillary R. Clinton Secretary of State U.S. Department of State 2201 C Street NW Washington, DC 20520

PETITION: Revised Q21 for the Foreign Service

We, the undersigned call on the Secretary of State Hillary Clinton upon assumption into office, to reaffirm that the Department of State strongly endorses the practice of seeking professional help to address all health- related concerns whether mental or physical; to also reaffirm that the Department of State considers it a mark of strength and maturity to seek appropriate health care whenever required; and to make clear that seeking professional care for mental health issues in and itself is not a reason to revoke or deny an individual’s security clearance. This is important in the Foreign Service, whose members are exposed to traumatic events with psychological impact not only in conflict zones but also in diplomatic hardship assignments worldwide.

Nearly 60% of our Foreign Service personnel are at posts considered by the U.S.Government as "hardship" due to difficult living conditions (for example, violent crime, harsh climate, social isolation, unhealthy air, and/or terrorist threats). Of those hardship posts, half are rated at or above the 15-percent differential level which constitutes great hardship, and where family members are unable to accompany such assignments.

In April 2008, the Secretary of Defense has successfully advocated the revision of Question 21 of the SF-86 Questionnaire for National Security Positions, which asks about mental health treatment. The revised question excludes counseling related to marital, family or grief issues, unless related to violence by the applicant/employee. It also rules out counseling for adjustments from service in a military combat environment. The OSD guidance also points out that failure to seek care increases the likelihood that psychological distress could escalate to a more serious mental condition, which could preclude an individual from performing sensitive duties.

Your immediate predecessor has not released a similar affirmation to encourage the treatment of PTSD and other related mental health issues. The Concerned Foreign Service Officers has noted “the continued revocations of security clearances based on mental health treatment - a practice that the Bureau of Diplomatic Security routinely perpetuates even after DOD and OPM have agreed not to count certain types of treatment, e.g. for PTSD, against the employee.”

The organization of the 21^st century will be judged by the wholeness of its people. The first step to getting us there is to help ensure that Foreign Service officers, specialists, and family members and partners obtain the help they need without fear that such consultation/treatment jeopardizes their security clearance and employment.

Sincerely, Employees, Family Members/Partners and Friends of the U.S.Foreign Service

Your name/signature:

Collect five more names/signatures

Name/signature 1:

Name/signature 2:

Name/signature 3:

Name/signature 4:

Name/signature 5:

References:

Office of the Secretary of Defense - Revised Q21 http://www.army.mil/docs/OSD_Guidance_on_Revised_Q21.pdf

Concerned Foreign Service Officers Warning On Mental Health Treatment http://www.emaxhealth.com/7/11720.html

Foreign Service Journal January 2008: Focus on PTSD and the Foreign Service http://www.afsa.org/fsj/2008.cfm

Executive Order 10450 http://www.archives.gov/federal-register/codification/executive-order/10450.html

Executive Order 12968 http://www.opm.gov/extra/investigate/eo12968.asp

~ ~ ~ Download: Petition in Word (if you want to insert your own story) Petition in PDF Sorry I don't have a mail budget so the stamp is on you :-). Please mail signed petition to:

Secretary of State U.S. Department of State 2201 C Street NW Washington, DC 20520 Many thanks for your help!

PTSD on the Cheap?

Christopher Lee reports today in the Washington Post (May 16, 2008; Page A02) on a VA official who urged fewer diagnoses of PTSD:

"A psychologist who helps lead the post-traumatic stress disorder program at a medical facility for veterans in Texas told staff members to refrain from diagnosing PTSD because so many veterans were seeking government disability payments for the condition." "Given that we are having more and more compensation seeking veterans, I'd like to suggest that you refrain from giving a diagnosis of PTSD straight out," Norma Perez wrote in a March 20 e-mail to mental-health specialists and social workers at the Department of Veterans Affairs' Olin E. Teague Veterans' Center in Temple, Tex. Instead, she recommended that they "consider a diagnosis of Adjustment Disorder."

VA staff members "really don't . . . have time to do the extensive testing that should be done to determine PTSD," Perez wrote.

Uhm ... I really don't get it ... if VA staffers don't have time to do the extensive testing required to determine PTSD --- then, who the heck should make time for this? To be or to do ... that is the question - applicable even to Veterans Affairs. Reports indicate that this is an isolated case concocted by this official in Texas but I wonder if this is more widespread in reality. The reason I'm wondering is I know somebody who was attacked in Gitmo, had a botched surgery which caused permanent nerve damage, and was medically discharged. This person took and passed the FS exam, joined State, served in one of our toughest posts, survived that, and was assessed by his subsequent supervisors in the next post as difficult. It's hard to see if this person had PTSD out of Gitmo, or out of the first FS assignment as he/she was never diagnosed with PTSD until after he/she was kicked back stateside by his/her superiors (I think the nicer word for this is "involuntary curtailment"). Symptoms of PTSD can include:

• Hypervigilance and scanning
• Elevated startle response
• Blunted affect, psychic numbing
• Aggressive, controlling behavior (a high degree of insistence on getting your way)
• Interruption of memory and concentration
• Depression
• Generalized anxiety
• Violent eruptions of rage
• Substance abuse
• Intrusive recall -- different from normal memory in that it brings with it stress and anxiety
• Dissociative experiences, including dissociative flashbacks
• Insomnia
• Suicidal ideation
• Survivor guilt

I worry that if supervisors are not schooled on how PTSD manifest among employees, we may have a lot of employees who would be deemed "difficult" eventually. And by highlighting PTSD for those who serve in the war zones only, we may be ignoring those who serve in other hardship assignments outside of Iraq and Afghanistan (70% of FS assignments are considered hardships). I fear that they would fall into the cracks or get lost in the shuffle.

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