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22

JANUARY-FEBRUARY 2016

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THE FOREIGN SERVICE JOURNAL

director for Mental Health

Services. Haynes worked

at developing a coherent

program that relied more

on direct-hire mental health

staff than on contractors.

Haynes also hired a psy-

chologist, Dr. Samuel Kar-

son, whose particular skills

and extensive experience

in personality testing were

well-suited to the depart-

ment’s growing need for experts in clearances in the 1980s.

(From the 1950s to the mid-1970s, the clinical backbone of the

department’s mental health clearance section had been a group

of six private-practice psychiatrists fromWashington who came

into the department for an hour once a week to do evaluations

for the Office of Medical Services.)

The Field Mental Health Officer

During the 1970s, another innovation in the use of overseas

mental health personnel occurred that ultimately resulted in

the regional medical officer/psychiatrist (RMO/P) program.

Specifically, in 1974 Embassy Kabul decided to deal with a

rash of mental health crises (including three suicide attempts)

by using post funds to hire a psychologist, Dr. Richard West-

maas, as a personal services contractor to establish a practice

at the embassy. His work was so helpful that the department

employed him as a direct-hire Foreign Service employee and

made him the regional mental health officer for Afghanistan,

India and Pakistan.

By the time Westmaas left his position in 1977, the idea of a

regional mental health officer had proven itself, and he was suc-

ceeded by former Peace Corps psychiatrist, Dr. Elmore Rigamer.

Like Westmaas, Rigamer proved his worth. During his second

year in Kabul, the Dubs assassination occurred, devastating

the entire embassy community. Rigamer met with members

of the community to discuss the psychological impact of the

event, providing vital assistance to the community’s recovery

from the trauma. By the time he left Kabul to continue regional

psychiatry in New Delhi in 1979, the Foreign Service psychiatry

program was off and running.

Between 1979 and 1982, mental health positions were estab-

lished in Vienna, Bangkok, Monrovia and Cairo. Although the

Bangkok position was first occupied by a psychologist, Sam

Karson’s two-year tour as a regional mental health officer in

Thailand (1981-1983) was

a one-off. MED preferred

psychiatrists, not just

because they could write

prescriptions, but because

they are physicians and

have broader training. Thus,

psychiatrists are in a posi-

tion to identify (and rule

out) any physical/medical

issues that might be the

cause of mental problems.

Foreign Service mental health positions subsequently went

to psychiatrists. In the RMO/P skill code, for example, the P

stands for psychiatrist; there is no skill code for a Foreign Ser-

vice psychologist position.

Funding mental health care had always been an issue,

because mental health care, even more than general medical

care, is fraught with confidentiality concerns. And, when the

psychiatrist works for the patient’s employer, the problem of

“dual agency” arises. As a result, efforts in the 1970s and early

1980s often involved support for programs located outside the

immediate influence of an embassy or the State Department.

The idea of using contractors, such as Westmaas had been

in Kabul, was an obvious one; because Westmaas’ position had

been created with local embassy funds, it reduced the dual

agency conflict. But he was soon hired directly by the depart-

ment as a Foreign Service regional mental health officer, and

since the 1970s mental health contractors have only rarely been

used by the department.

Other Models of Care

Embassies used other models of mental health care, too.

Several made use of mental health clinics for expatriates that

had been set up during the 1970s in cities such as Cairo, Tehran

and Kuala Lumpur. And embassy health units developed lists of

local practitioners they could work with.

One community mental health initiative during the 1970s

and 1980s that seemed to work for many embassies was the

“mental health grants” program. Established in 1974, the

program grew to more than $250,000 per year. Given out in

amounts ranging from $700 to $18,000, the grants paid for edu-

cational presentations, support groups, library resources related

to mental health, as well as programs related to crisis interven-

tion and referral for therapy. The grants also paid for “preven-

tive mental health” presentations and helped support expats

Between 1979 and 1982,

mental health positions

were established in Vienna,

Bangkok, Monrovia

and Cairo.