Statement
of
Dr.
Laurence G. Brown, MD
Medical
director
Department
of state
BEFORE
SUbCOMMITTEE
ON middle east and south asia
house
Committee on foreign affairs
HEARING
ON
Working in a War Zone: Post Traumatic Stress Disorder in
Civilians Returning from Iraq
june
19, 2007
Introduction
Good afternoon Mr. Chairman and members of the
Committee.
I am Larry Brown, Medical Director for the Department
of State and the Foreign Service. Dr.
Raymond De Castro, Chief for Mental Health Services for the Department of
State, joins me.
I appreciate the opportunity to
appear today to present some information on Post Traumatic Stress Disorder
(PTSD) in Foreign Service employees. I
will briefly describe PTSD, let the subcommittee know how the Department planned
for and continues to give mental health support pre-departure, during service,
and after return from Iraq
and other high stress assignments, and describe how we are currently gathering
information about the effect of high stress assignments on our employees.
What is Post Traumatic Stress Disorder?
In the world of emotional and
behavioral disease, Post Traumatic Stress Disorder (PTSD) is not encountered so
frequently as depression or alcohol abuse, nor is it as uncommon as
schizophrenia. In the general population, as many as 10% will have the
condition at some point during the course of a lifetime.
Patients with this disorder in the United States
are often victims of motor vehicle accidents, rape or other violent crimes, or
physical and sexual abuse in childhood. Certain occupations carry increased
risk of developing PTSD, such as law enforcement, firefighters, emergency
medical technicians and of course the military.
Unlike some illnesses in which
genetics may play a greater role than environmental factors, PTSD is by
definition dependant upon a sentinel experience. Our understanding indicates
that, while some individuals are at greater at risk than others, there is no
person who will not respond with many of the cardinal symptoms under the impact
of a trauma of a certain quality and of sufficient intensity. This was
increasingly recognized over the latter part of the 20th century as
the consequences of its wars were studied in an increasingly science based
medical profession.
The essential feature of PTSD is
the development of certain characteristic symptoms after direct personal
exposure to an extreme stressor involving actual or threatened death or serious
injury, or learning about the same in regard to a family member or close
associate. The immediate emotional reaction includes intense fear, helplessness
or horror. The characteristic symptoms that subsequently emerge cluster in
three domains: persistent re-experiencing of the event (dreams, nightmares or
intrusive recollections); persistent avoidance of stimuli associated with the
event and generalized numbing of emotional responsiveness; and persistent
symptoms of increased arousal (insomnia, irritability, exaggerated startle
response, poor concentration or hyper-vigilance).
The presentation of symptoms after
such an event can vary markedly from one individual to another. In one person
they may appear immediately, be of relatively short duration, and resolve
spontaneously; in another they may emerge more than 6 months after the event
and become chronic; and there are wide variations between these two, including
many sub-clinical presentations in which only one or a few symptoms emerge from
only one or two of the domains, and of insufficient intensity or duration to
become diagnostically significant.
Similarly, the person experiencing
these responses symptoms is less likely to seek treatment if the distress is of
short duration, lesser intensity and presents only intermittently. As in most
of modern psychiatry, diagnosis and treatment is dependent upon the severity
and duration of subjective distress, and the presence of impairment from
previous levels of functioning.
The Department’s Office of Medical
Services
has been aware for many years that employees may develop a variety of anxiety
and stress related problems, including post-traumatic stress disorder (PTSD),
as a reaction to stressors while living overseas. Foreign Service employees
have never been immune to causative agents for the condition, and in fact have
always served in environments that pose increased challenges of social
instability with greater attendant dangers, including much higher rates of
traffic fatalities, criminal or political violence, and civil unrest. The East Africa bombings in Nairobi and Dar
es Salaam in 1998, the terrorist attack in New York and Washington DC of
September 11, 2001 and the subsequent release of anthrax into the US and
diplomatic pouch mail system, the terrorist attack on the consulate in Jeddah
Saudi Arabia in 2004, the Karachi consulate bombing of March 2006, are only
recent examples of a traumatic sentinel event that can affect employees exposed
to this violence.
The war in Afghanistan and in Iraq
represent another level of stressor due to the high levels and widespread
incidence of violence that involve greater numbers of serving Foreign Service
employees than past incidents. This has
undoubtedly resulted in larger numbers of acute anxiety reactions — I will give
more detail about this further on — and we might well expect an increase in
numbers of those with PTSD as well.
Mental Health Support for Employees in Iraq
In December 2003 the Deputy for
Mental Health Services and the Mental Health Chief for Crisis Response, two
psychiatrists from the Department of State’s Office of Medical Services (MED)
visited Baghdad
in response to a request from post for additional mental health services. Although they found morale to be good at the
time, there were a number of issues contributing to an extremely stressful work
situation, including:
- Constant work
- Lack of diversion
- Physical danger
Beginning in November 2003 Department employees assigned to Baghdad were mandated to attend a two week Diplomatic
Security Anti-Terrorism Course (DSAC) to better prepare for their service in Iraq. Training includes the Bureau of Near East
Affairs’ overview of policy objectives and life at post; country and language
familiarization (FSI Area Studies and Language); and Iraq specific personal security
training (emergency medical, weapons familiarization, improvised explosives
recognition, hostage survival, chemical/biological threat awareness,
surveillance detection, and coping with stress). This course has been renamed and is now
called Foreign Affairs Counter-Threat course (FACT).
When the Office of Medical Services
opened a Foreign Service Health Unit in Baghdad in July 2004, a psychiatrist
was part of the medical team (including a general medical officer, two nurse
practitioners, and a registered nurse) deployed for support. The psychiatrist was moved nearby to Amman, Jordan
in December 2005 to better cover the region, including Baghdad.
A Master of Social Work (MSW) clinical counselor familiar with stress
and PTSD issues was then added to the Baghdad Health Unit staff specifically
for mental health support.
In anticipation of additional
mental health needs for FSOs returning from Iraq, MED held a 2-day
informational and planning conference in July 2004. All 15 medical officer/psychiatrists were in
attendance. They heard from officials in
the Department from the Office of the Director General for Human Resources
(DGHR), various geographic regional bureaus, and a panel of Iraq
returnees. Additionally they heard from
three national experts whose expertise is in dealing with people following
traumatic events: Dr. Carol North, Professor of Psychiatry, Washington
University; Dr. James McCarroll, Professor of Psychiatry, Uniformed University
of the Health Sciences; and Dr. Robert Ursano, Professor of Psychiatry,
Uniformed Sciences University and Chair, American Psychiatric Association Work
Group on Practice Guidelines for the Treatment of Patients with PTSD.
MED decided, based on information
and recommendations from this conference, to offer an out briefing session to
all Iraq
returnees. These sessions are given in
conjunction with the DGHR and the Foreign Service Institute (FSI). The out briefings, made mandatory in August
2004, give employees information on:
- What to expect as a stress reaction
- Healthy coping mechanisms for these situations
- Where to get further help with the Department if
needed
- Other administrative details for Iraq
returnees
Specifically these sessions were
not set-up to offer psychotherapy or counseling, and did not constitute a
clinical contact for security reporting purposes. They are not critical incident stress
debriefings as these have been shown to be more harmful than beneficial. MED wanted employees to feel free to come to
these sessions. In Washington these sessions are held regularly
at FSI; overseas the session are offered by the RMO/Ps or other FS medical
staff at the employee’s post of assignment.
Recently out briefings have been formally scheduled as part of an onward
assignment for Department employees, and supported with per diem during
attendance.
The Iraq out brief medical facilitator
gives special emphasis to insomnia and problems relating to a spouse or
partner. Chronic insomnia is itself a risk factor for further decline and
offers a non-psychiatric entrée to a medical professional to begin talking
about any changes that are worrying them. When an anticipated happy reunion
with family is instead sabotaged by unwanted and unpleasant feelings of
resentment, the disappointment can be enormous and may lead to an emotional
distancing that bodes poorly for the long-term health of the relationship. The
point is made in the out brief that short-term counseling offers very good
results in these circumstances.
For those who require counseling,
or just a few sessions of sharing their experiences in Iraq, the
Department’s Employee Consultation Service provides a confidential service for
this. Six trained MSW level counselors
familiar with the Foreign Service and familiar with service in Iraq staff this
employee assistance program. For those
employees with more serious or long-term mental health issues we maintain
several referral sources in the Washington
area. For employees stationed overseas,
all of our practitioners are trained in primary care counseling, and the
Department’s psychiatrists are readily available for individual consultations
as well.
What should the Department of State expect with employees
assigned to war zones?
Among veterans of the Vietnam War
and the Gulf War, 15% were diagnosed with PTSD.
Of about 245,000 soldiers
discharged from service in Iraq
and Afghanistan,
more than 12,000 sought counseling for symptoms of PTSD; and in a survey of
3,671 soldiers and Marines involved in combat in those theatres, 17% reported
symptoms consistent with major depression or anxiety, including PTSD. Those
with PTSD did not significantly vary from those without in regard to sex, race
or age, but there were significant differences based on the characteristics of
the military service, i.e. the level of combat exposure predicts the risk of
the mental disorder; combat stress, then, poses greater risk of a mental
disorder than deployment stress. Those
statistics and conclusions are consistent with studies on the consequences of
the Oklahoma City bombing and the attacks on the
World Trade Center
and the Pentagon.
While the traumatic event itself
and its nature is the most predictive variable of a pathological response,
evidence also indicates that persons with a previous history of a psychiatric
problem are at greater risk of PTSD. It is the policy of the DOS Office of
Medical Services that only officers with a class 1 medical clearance will be
approved for assignment to the embassy missions in war zones.
What is the Department of State actually finding in our
returnees from Iraq?
The Office of Medical Services has
been gathering anecdotal information from those who have attended the Iraq out
briefs; those few who have sought treatment; those evaluated for medical
clearance to an onward assignment; and from a very few individual officers who
simply reach out to share their experiences either in service to the Department
or in complaint. MED finds that almost
all are affected in some way by their service there, more so than the average
overseas assignment.
Commonly these employees have one
or several of these reactions:
- Insomnia for up to several months, the most common
symptom
- “Easy to startle” response for several months
- Irritability and anger outbursts
- Some numbness and emotional distance; “The color is
out of life”
- Trouble concentrating, particularly noted in those
studying a new language for an onward assignment
- Problems relating to a spouse or partner; sometimes a
re-negotiating of relationships is needed, particularly with loved ones
A large percentage
of employees have some of these stress-related symptoms, but there have been
very few whom actually present with a full-blown picture that meets the
criteria for a diagnosis of PTSD. Most employees experiencing one or more of
these symptoms improve over several months with brief counseling or without any
counseling at all.
There have not been any employees who lost their
medical clearance because of PTSD or PTSD-like symptoms. Some employees (I estimate fewer than 20) may
have had their medical clearance changed from unlimited worldwide availability
to a post specific availability. This
change would allow MED to assure that a post of assignment had counseling or
treatment services, if needed, for the employee. Those employees with diagnosed PTSD that
require ongoing therapy would fall into this category of post-specific
clearance for assignment.
In the previous and following sections I refer to Foreign
Service or Department employees.
Although many employees working in Iraq are direct-hire Foreign
Service employees, others are Civil Service employees working on a Limited
Non-Career Appointment (LNA) or 3161's: Civil Service employees
appointed on a temporary basis under 5 USC
3161. All of these employees come under
the Department’s medical program in Iraq and must have a worldwide
medical clearance to be posted there.
They are eligible for pre-assignment training, medical and mental health
services while in Iraq,
and post-assignment out briefings.
Although medical services for the “3161s” end with termination of their
employment, they are covered by worker’s compensation for
injuries or occupational health conditions that developed in performance of
duty or as a direct result of employment. As with all work related injuries or
occupational health concerns a causal link to employment must be established and
claims submitted in a timely manner with supporting evidence to the Department
of Labor, the adjudicating agency.
Some contractor personnel in Iraq are personal services
contractors (PSC) that have the same medical support as do direct hire
employees. Other contract personnel are
either non-personal services or professional services contracts. While all the large
contract companies have full responsibility for medical and mental
health care and follow-up for their employees, there are several
smaller contract companies who are authorized to use Government furnished
medical support in Baghdad.
What more is the Department planning to do?
In an effort to find out more about
our employee’s reaction to service in Iraq (and other unaccompanied
danger posts), MED worked with the Family Liaison Office to develop a survey
for all returnees from unaccompanied posts.
This anonymous survey opened on the Department’s intranet on June
1. The survey period will run for a
month, and we hope to capture information from most of the approximately 2000
Foreign Service employees who have served under difficult circumstances,
including those who have served in Iraq. The survey asks specifics about what stresses
and dangerous situations an employee was exposed to, what they did about it,
and what counseling or other treatments they may have sought since. A group of the questions was taken from
standard PTSD questionnaires so that we can compare the information that we get
with other similar surveys done by the military and other organizations. We will use the information from the survey
to better hone the information given to employees prior to and post-deployment
in Iraq,
and to develop additional support programs or services if needed.
In July MED in conjunction with the
Department’s Family Liaison Office MED will offer support groups in the
Department for returnees from unaccompanied high-stress assignments.
Summary
In summary the Department’s Office
of Medical Services is doing the following for those assigned to Iraq and other
unaccompanied posts:
- As part of the FACT Course prior to deployment,
Mental Health Services discusses stressors and other mental health issues
- A full DOS Health Unit supports those employees in Baghdad: a medical
officer physician, two nurse practitioners, one registered nurse, and one
MSW. All are trained in mental
health counseling in addition to their standard medical training
- A
short, elective and well-attended briefing session is given in Baghdad by the
clinical social worker prior to an employee leaving post permanently. Employees are educated on the various
support services in Washington
DC and at their next
assignments/post. Some employees use this opportunity to discuss their
experience, and they are encouraged to share them during the formal out
briefing sessions.
- Out briefing sessions, now mandated, are given to
employees in Washington
or overseas for informational purposes.
- ECS is available for confidential counseling for
those in Washington. Referrals are made to outside resources
if needed or if asked for by the employee.
Overseas the medical program has primary care providers and
psychiatrists for care and consultation.
- The Department through MED and DGHR assist with any
issues that involve the Worker’s compensation system
In the future:
- Study results of the June 2007 survey of all
returnees to ascertain what other services would be useful and then
implement them.
- Begin support groups for returnees in July 2007,
modifying the group focus and size when more clinical experience is
gathered.
Mr. Chairman, this concludes my prepared
remarks. We are available to answer any
questions you may have.
Cited references:
Friedman, M. (2004). Acknowledging the Psychiatric cost of
War. The New
England Journal of Medicine.
Vol 351 (1) pgs 75-77.
Friedman, M. (2006). Posttraumatic Stress Disorder Among Military
Returnees from Afghanistan
and Iraq. American Journal of Psychiatry. Vol 163(4(, pgs 586-593).
Friedman, M. (2005). Veterans’ Mental Health in the Wake of
War. The New
England Journal of Medicine.
Vol. 352 (13), pgs. 1287-1290