Opinion: US staff in high-threat environments need mental health support

As the 117th U.S. Senate session comes to a close it is time to set up and fund an appropriate and comprehensive mental health treatment system for the U.S. Department of State and U.S. Agency for International Department personnel serving in high-threat environments. To not do so is to fail staff and their families, and ultimately, those communities they are serving the world over.

My name is Beth Cole, a retired U.S. government civilian with service in our foreign affairs agencies, diagnosed with complex post-traumatic stress disorder, or PTSD, late in my career. I have worked in positions focused on some of the most dangerous hot spots on the earth.

My name is Gregg Martin, a retired U.S. Army general diagnosed with bipolar disorder late in my career. My bipolar disorder went undetected and undiagnosed even though I led thousands of troops during the Iraq War.

We both share a common goal: To ensure our colleagues in the defense and foreign affairs institutions receive the mental health care they deserve without fear or stigmatization.

We have witnessed an awakening in the U.S. Department of Defense, or DoD, over the past few decades as it grapples with endemic suicide, PTSD, and the fallout from wars on service members and family alike.

While the recognition of bipolar and other disorders is not adequate to date, at least the DoD admits there is a problem and has taken steps to address it. Just late last month, Deputy Secretary of Defense Kath Hicks announced that the DoD is creating a “first-of-its-kind” suicide prevention task force, with a strength of up to 2,000 clinicians and mental health specialists. This bold move is on top of the considerable progress the DoD has made already in the recognition of the support needed for mental health conditions.

In contrast, the Department of State, or DoS, and USAID lag behind, leaving a battered workforce in the wake of inaction. The DoS Bureau of Medical Services handles both institutions, which underlines how vital it is that leadership and initiative on this matter be taken at both USAID and DoS levels.

After the 2013 suicide of Michael Cameron Dempsey, a young USAID contractor with service in Iraq and Afghanistan, USAID leadership created a Senior Advisory Group to help shape and respond to an unprecedented assessment of USAID personnel working in high-threat environments, HTEs.

Notably, the undersecretary for management at the State Department and the DoD surgeon general contributed to this effort. A sentence in the opening paragraph of the assessment published in 2015, sums it up:

“The USAID workforce is currently exposed to severe and unsustainable levels of stress that (a) are adversely affecting the health of the workforce, (b) very likely are reducing the mission effectiveness of the Agency, and (c) require a coordinated, holistic institutional response.”

Sadly, seven years later, little to nothing has been done to address the alarming situation among personnel. Inaction at the DoS is equally appalling. 

This inaction is particularly disturbing given that their congressional appropriators have asked both the DoS and USAID three years in a row for the status of current mental health programs for those working in HTEs, plans for a more robust system, and some projections for how much an adequate system would cost. The paltry responses have matched the inadequacy of the current mental health systems at both departments.

High stress and dangerous occupations leave personnel more vulnerable and at greater risk for developing or exacerbating mental health conditions, which include suicidality, depression, bipolar disorder, PTSD, traumatic brain injury, survivors’ guilt, moral injury, and others. The military, first responders, and yes — deployable government civilians who serve in the DoS, USAID, and other agencies that deploy to high-stress and high-danger areas such as war zones and disasters — are at even higher risk.

So how can the detection, diagnosis, and treatment of mental health conditions become a priority for these government agencies?

First comes the critical ingredient of leadership. The mental health of the workforce must be elevated in importance to the same level as physical health and job skills and be seen and promoted by leaders at the DoS and USAID as a priority. All they need to do is look across the river to the example set by the secretary and deputy secretary of Defense.

Leaders must care, be informed, allocate resources, encourage people to share their personal stories, and lead by example. There is no substitute for strong leadership. With it, anything is possible. Without it, little will get done.

Second is setting up a system to promote understanding, awareness, and identification of personnel at risk. This must include baseline screening, education, and training. Every agency must have an education and training program that ensures employees can recognize the basic symptoms of various mental health conditions and know what actions to take or help to seek. The brain is by far the most important organ in the human body and acts with our nervous system to help ensure survival under the direst circumstances but it is also the least understood.

Psychological education for personnel — from leaders to middle management to young staffers, and for junior to senior members of the foreign service — would help people understand how their brain and nervous system react to constant perception of threat and high levels of stress.

Third, agencies must work to reduce and eliminate the stigma surrounding mental health conditions. And people with suspected mental health conditions must be able to seek help without threat to their careers. We must dispel the harmful myth that these conditions are due to moral failings, lack of willpower, or weakness of character. They are just as physiologically real as cancer, diabetes, and heart disease — conditions with little to no stigma attached.

Stigma poisons the environment and prevents people from seeking help. It is ignorant and cruel and must stop. People battling mental health conditions should be seen in the same light as women battling breast cancer.

Fourth, mental health providers and resources must be available to serve at-risk people, from the bottom to the top of the organization. Many who are experiencing mental health conditions need help rapidly; they cannot afford to endure long waits and delays for medical services whether they serve at headquarters in Washington, D.C., or in the field. Their lives could very well be at risk. Solutions and resource requirements must be understood and allocated.

Among best practices is the development of a peer support system to increase the professional mental health cadre. Personnel within agencies offering peer support can have that “uncomfortable conversation” without fear or retribution. There will be a cost for this care, but it must be paid. This is precisely why congressional appropriators have asked for costs associated with a comprehensive mental health care system for those working on or in HTEs — because they know it must be resourced.

Finally, opportunity awaits. In the waning days of the 117th session of the U.S. Congress, appropriators may once again put language in a bill.

This time, Congress may compel action by the recalcitrant institutions instead of asking for yet another plan and budget that is routinely ignored. In doing so, they may just save some lives.

These very lives are serving under fire in Ukraine, among the deadly drought and insecurity in the Horn of Africa, with the threat of fatal diseases in disparate corners of the globe, and the persistent scourge of extremism that places bullseyes on their backs. They deserve everything we have to keep them healthy for what they are giving back to the country they work for and the populations across the globe they are serving.