Managing a Life of Frequent Travel: Best Practices - Seminar, April 27, 2000

Esther Roberts, MD, Regional Psychiatrist / Europe, Medical Services, U.S. Department of State, London, UK

DR. STRIKER: Dr. Esther Roberts will talk now on one model of mental health program for travelers.

DR. ROBERTS: Thank you very much, Jim.

I am doing this because Jim Striker did ask me. Ours has been a long association. While I have been at the State Department as the Director twice of the Mental Health Program for the Diplomatic Service, I wanted to [?] I am sorry Dr. Bagshaw is not here [?] I thanked him during the intermission that as a psychiatrist who travels a great deal in Europe on British Air, that I have found as the psychiatrists they answer to a number of the stresses in a good gin and tonic on BA. That was one thing he forgot to mention as one of the coping mechanisms.

Nevertheless, I wanted to at least present this afternoon, the State Department's mental health program. A number of people are unaware of the fact that psychiatrists are involved as part of the Diplomatic Service, and a number of people who have a number of interesting observations that they make about the necessity of having psychiatrists involved in the diplomatic business.

I want to assure people that we are not making policy, and we are not necessarily holding the hands of the people who are.

But I think it is important to take a look at the model that was developed for the State Department because it indicates not necessarily the way in which things are decided at an organizational level and then put into place. The State Department's psychiatric program came about almost inadvertently in 1978 with the advent of a psychologist who was out in Islamabad at the request of one of our medical offices, who recognized that a number of the stresses that people were experiencing overseas had less to go with their geographic locations, but a number of issues that had to do with their psychological well-being.

Certainly, this physician decided that he would invite a colleague from the University of Michigan to come out and work with this particular community, which he did for a year, a year-and-a-half, and took a look at a number of strategies, working with families who were there, families who were having to deal with some of the frequent relocations as well as some of the educational needs of the children in the community.

At the end of that particular point, a colleague of his was invited, who was a psychiatrist, to come out to take his place, and at that particular point a very unfortunate circumstance, but certainly one that was the bellwether of things to come in the foreign service took place. And that has to do with the assassination of the Ambassador, Ambassador Dubs [ph] in Islamabad, at that particular point—in Afghanistan, I am sorry.

And, at that particular point, the State Department wanted very much to have that psychiatrist involved again with the community from the point of view of dealing with post-traumatic stress for the individuals who were there in that community.

Based on the success of that psychiatrist's intervention and certainly with the number of issues that were brought about and to the attention of management, they decided to expand the mental health service. To expand, they meant to add one more psychiatrist located somewhere else geographically. That psychiatrist decided to be based in Vienna. This was the State Department's interpretation of really where psychiatrists ought to be.

[LAUGHTER]

So, at that particular point, we had two psychiatrists in the field, one in New Delhi and one in Vienna. At that particular point, again, adversity worked to the advantage of the program because the Tehran hostage situation occurred in 1980. At that particular point, when I joined, they were basically looking at methods of working with the families who were very vocal and very visible in American media about their concerns about the hostages and, certainly as the time went on for 444 days, increasingly critical of the State Department's handling of the situation in their particular support and needs.

At that particular point, I came onboard and was in charged with taking a look at that one particular piece of debriefing of the Tehran hostages, when they were released as well as taking a look at what the families' needs were.

At that point, we were joined by a number of psychiatrists who were in other organizations, primarily military, to work with that particular release group. Fortunately, because of the support that was offered by that team, the State Department then offered the medical program at the State Department, a number of opportunities for developing of various additional positions out overseas for psychiatrists.

As head of the program at that particular point, I was given the leeway to design by geographic areas where these additional positions ought to be for psychiatrists. And we started off with not only the position, as it was, in New Delhi, the position then in Vienna, but then we expanded the program to the point that today we have ten psychiatrists who are overseas, located in the embassies in various geographic areas—Tokyo, Bangkok, Lima, Peru, Mexico City, Pretoria, Abidjan, Ivory Coast, London, Vienna, New Delhi and Cairo.

This program expanded to this particular capacity in a ten, fifteen-year period where the role of the psychiatrist as a member of the medical program and as medical foreign service offices themselves were allowed to be a part of the overseas community. I listened to a number of my colleagues this morning who talked about a theoretical opportunity to put in place various kinds of mental health strategies. It is quite another to all of a sudden find yourself as a participant in a very overseas community with all of the adjunct culture shock issues, relocation of your own particular family, all of the stresses of alienation and isolation and finding yourself in a number of situations as psychiatrists exposed to people who see you not only as the psychiatrist but also their next door neighbor and also vice versa for a number of psychiatrists to find themselves closely observed with their own particular stresses and the stresses of their families.

I almost wish that every one of my colleagues who has a theoretical premise about how to intervene in people's lives almost would have to have this first-hand kind of experience; it certainly makes you quite humble.

I think then with the number of positions overseas, the mandate for various kinds of interventions kind of grew. They grew out of the interests of the psychiatrists who were there, the kinds of ways in which they certainly saw the community needs and then in terms of how the organization, mainly the embassies in these various locations and their geographic embassies for which the psychiatrists were charged with providing mental health services, that the mandate has now exceeded the original purpose, which was to provide clinical intervention along with psychiatric interpretation of things that were happening to individuals and to their families, to the broader base of assessing some of the local mental health care services that are available and, in some situations where there are none, actually in terms of looking at ways of pulling together some of the individuals who find themselves in an overseas position as counselors independently to develop various kind of community-based mental health preventive programs that are there. There was money certainly for that as well.

The psychiatrists provide consultation to the mental health providers in the region, that means the other medical offices of which there are 50 in the Foreign Service, also sometimes co-located and other times not, but always based within an embassy as part of the medical program, the Foreign Service nurse practitioners of which there are probably about 50 and the other contract nurses who are within the area.

So, all told, the entire medical program of more than 100 people, including medical technologists, are part of the resources along with the psychiatrists for taking a look at both the medical and psychological aspects of the welfare of the Foreign Service employees and their families.

From that, the opportunity to give feedback to post management, mainly the Ambassador, the DCM, people who are making decisions locally about personnel issues, lengths of tour, this grew out of the confidence as well as of the experience that a number of people had with the psychiatrists acting initially on the basis of clinical intervention to the point that now a number of psychiatrists provide feedback about post-morale issues, having to do with some of the issues of housing, some of the issues of the local environment, certainly some of the safety issues, and, most importantly, in terms of some of the work-related issues that cause a great deal of stress.

This allows a number of opportunities for the psychiatrists who are working with an individual around a particular issue that they describe as being stressful to be able to tease out the very determinants of what exactly they are addressing when they talk about stress.

It is interesting as I listened earlier this morning when we try to find a consensus about exactly what the stresses are of the international travelers. Well, it is not always the same for each individual. It certainly is not the same in each geographic area. And so, it is very important in terms of the role of the psychiatrist that there is not a cookie-cutter approach to any of this. Based on some of the geographic territories that the psychiatrists have to be involved in, some of it has to do with multitude of travel issues, as a regional area for the employees is covered, so we have a number of employees who may be frequently gone from their families at that particular post, some of the educational needs of their children that cannot be met and in other ways in which certainly they are almost geographically defined based on the age of the employees.

For instance, in Europe I find there are older employees in the Foreign Service who are looking at different implications of their careers and certainly some of the stress is not so much offset by having an opportunity to be in Europe as an assignment, but it represents sometimes the end of their career, sometimes earlier than they had expected, with a number of health issues.

So, the areas of concern and the areas of stress are quite different from perhaps what I saw when I was in an African assignment, when the issues had to do with the environment and with the younger children and some of the resources that were not available for supporting the families.

I think that looking at all of these various aspects of being able to provide stress management also gives the psychiatrists an opportunity to participate on a preventive level, so that a number of the issues that they are observing across the region, looking at the Foreign Service across longitudinal period of time, they provide in terms of feedback not only to the organization but to individuals, so that individuals can make a decision about whether or not this is the best environment, best career, best for their own particular psychological makeup to continue.

They also provide a number of presentations on stress reduction, issues that have to do with some of the sad seasonal variations, issues that have to do with aging process, dementia, a number of issues that are germane to their particular area.

The question always gets asked: Just how effective is this and what difference does it make in terms of having psychiatrists involved in the diplomatic business? I must say that sometimes it is awfully hard to be able to talk to some of my psychiatry colleagues who are in the maelstrom of all of managed care in the United States to tell them about the degree of autonomy and a lot of the interventions that we are able to provide while out overseas, traveling as well as living with our colleagues, especially at a time when they find themselves with so much remorse about what is happening with their particular professional lives back here in the states.

But I would say that this does represent a model of effectiveness in terms of the potential for not only intervention but taking a look at the various clinical issues that people psychologically bring with them when they move overseas, certainly in terms of taking a look at the potential for reduction of the various psychiatrist implications that may very well shorten an individual's potential for being able to be out overseas and hence effective.

I certainly think that the program as it is currently seen by the State Department represents an effective utilization and perhaps even an effective model for taking a look at what an organization may very well and perhaps inadvertently find to be very beneficial.

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