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WORKING IN A WAR ZONE:

POST TRAUMATIC STRESS DISORDER IN CIVILIANS

RETURNING FROM IRAQ

HEARING

BEFORE THE

SUBCOMMITTEE ON 

THE MIDDLE EAST AND SOUTH ASIA

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

JUNE 19, 2007

Serial No. 110–71

Printed for the use of the Committee on Foreign Affairs

(

Available via the World Wide Web: http://www.foreignaffairs.house.gov/
(II)

COMMITTEE ON FOREIGN AFFAIRS 

TOM LANTOS, California, Chairman 

HOWARD L. BERMAN, California 

GARY L. ACKERMAN, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

DONALD M. PAYNE, New Jersey 

BRAD SHERMAN, California 

ROBERT WEXLER, Florida 

ELIOT L. ENGEL, New York 

BILL DELAHUNT, Massachusetts 

GREGORY W. MEEKS, New York 

DIANE E. WATSON, California 

ADAM SMITH, Washington 

RUSS CARNAHAN, Missouri 

JOHN S. TANNER, Tennessee 

GENE GREEN, Texas 

LYNN C. WOOLSEY, California 

SHEILA JACKSON LEE, Texas 

RUBE ́ N HINOJOSA, Texas 

JOSEPH CROWLEY, New York 

DAVID WU, Oregon 

BRAD MILLER, North Carolina 

LINDA T. SA ́ NCHEZ, California 

DAVID SCOTT, Georgia 

JIM COSTA, California 

ALBIO SIRES, New Jersey 

GABRIELLE GIFFORDS, Arizona 

RON KLEIN, Florida 

ILEANA ROS-LEHTINEN, Florida 

CHRISTOPHER H. SMITH, New Jersey 

DAN BURTON, Indiana 

ELTON GALLEGLY, California 

DANA ROHRABACHER, California 

DONALD A. MANZULLO, Illinois 

EDWARD R. ROYCE, California 

STEVE CHABOT, Ohio 

THOMAS G. TANCREDO, Colorado 

RON PAUL, Texas 

JEFF FLAKE, Arizona 

JO ANN DAVIS, Virginia 

MIKE PENCE, Indiana 

JOE WILSON, South Carolina 

JOHN BOOZMAN, Arkansas 

J. GRESHAM BARRETT, South Carolina 

CONNIE MACK, Florida 

JEFF FORTENBERRY, Nebraska 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

BOB INGLIS, South Carolina 

LUIS G. FORTUN ̃ O, Puerto Rico 

GUS BILIRAKIS, Florida 

ROBERT R. KING, Staff Director 

YLEEM POBLETE, Republican Staff Director 

SUBCOMMITTEE ON THE MIDDLE EAST AND SOUTH ASIA

GARY L. ACKERMAN, New York, Chairman 

HOWARD L. BERMAN, California 

DAVID SCOTT, Georgia 

JIM COSTA, California 

RON KLEIN, Florida 

BRAD SHERMAN, California 

ROBERT WEXLER, Florida 

ELIOT L. ENGEL, New York 

RUSS CARNAHAN, Missouri 

SHEILA JACKSON LEE, Texas 

MIKE PENCE, Indiana 

STEVE CHABOT, Ohio 

JO ANN DAVIS, Virginia 

JOE WILSON, South Carolina 

J. GRESHAM BARRETT, South Carolina 

JEFF FORTENBERRY, Nebraska 

BOB INGLIS, South Carolina 

CONNIE MACK, Florida 

GUS BILIRAKIS, Florida 

DAVID ADAMS, Subcommittee Staff Director 

HOWARD DIAMOND, Subcommittee Professional Staff Member 

GREGORY MCCARTHY, Republican Professional Staff Member 

DALIS BLUMENFELD, Staff Associate 
(III)

C O N T E N T S 

Page

WITNESSES 

The Honorable George M. Staples, Director General, Foreign Service and 

Director of Human Resources, Department of State ......................................... 7

Laurence G. Brown, M.D., Director, Office of Medical Services, U.S. Department of State ........................................................................................................ 10

Mr. Steve Kashkett, Vice President, American Foreign Service Association ..... 34

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

The Honorable Gary L. Ackerman, a Representative in Congress from the 

State of New York, and Chairman, Subcommittee on the Middle East 

and South Asia: 

Prepared statement .............................................................................................. 3

Article from the Washington Post dated June 19, 2007, entitled ‘‘Embassy 

Staff in Baghdad Inadequate, Rice is Told; Ambassador’s Memo Asks 

for ‘Best People’ ’’ by Glenn Kessler ................................................................ 5

The Honorable George M. Staples: Prepared statement ...................................... 9

Laurence G. Brown, M.D.: Prepared statement .................................................... 12

Mr. Steve Kashkett: Prepared statement .............................................................. 35

APPENDIX 

The Honorable Sheila Jackson Lee, a Representative in Congress from the 

State of Texas: Prepared statement ................................................................... 47

(1)

WORKING IN A WAR ZONE: POST TRAUMATIC 

STRESS DISORDER IN CIVILIANS RETURNING FROM IRAQ 

TUESDAY, JUNE 19, 2007

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON THE MIDDLE EAST

AND SOUTH ASIA,

COMMITTEE ON FOREIGN AFFAIRS, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 2:08 p.m. in room 

2172, Rayburn House Office Building, Hon. Gary L. Ackerman 

(chairman of the subcommittee) presiding. 

Mr. ACKERMAN. The subcommittee will come to order. Welcome. 

Usually when we talk about post traumatic stress disorder the conversation is about members of the military, about those whom we 

unfortunately expect to have experienced the horrors of war but increasingly the United States is sending civilian employees, diplomats, intelligence analysts, reconstruction specialists, contract 

administrators, not just to hardship posts but into actual combat 

zones, and then expecting them to do their usual jobs but under extraordinary and perilous conditions. 

So it should not be any surprise that those who are now returning from Iraq and Afghanistan are returning not only with exotic 

souvenirs but with PTSD as well. Unfortunately what is not a surprise is that many civilian employees returning from Iraq believe 

their service is unappreciative and those who have symptoms of 

PTSD feel they are not getting the support and treatment they 

need. Let me say here on behalf of the subcommittee—and I would 

hope on behalf of the entire Congress—to all those United States 

Government employees who have deployed not just to hot spots but 

actual combat areas and because of it now bear the scars on their 

souls, I say thank you. We say thank you. Your nation thanks you. 

We are grateful for your courage and your sacrifice, and now that 

you are back—those of you who are—we will not forget what you 

gave and what it has cost you. Like our soldiers, there seems to 

be widespread fear among affected employees that seeking treatment will have a seriously detrimental impact on their careers. 

Employees are afraid that they may lose their security clearances, 

medical clearances or simply be perceived by superiors and colleagues as damaged goods. We need to find ways in order to dispel 

those fears. 

I was heartened to learn that the State Department has begun 

surveying overseas employees regarding mental health issues and 
2

the preliminary results show precisely why we all should take this 

problem much more seriously. Many who completed the survey said 

that their mental health, emotional state, social well being or capacity to function had been affected by work in Iraq or Afghanistan 

or other difficult posts. Almost half of those who responded to the 

survey had served in Iraq. 

Even before the department has the final results of the survey 

I think that we can all agree that there is a problem. I urge the 

department to take additional steps to address the concerns raised 

by affected employees. I think as a first step Secretary Rice should 

announce publicly, loudly and clearly that the department appreciates the service of those who have worked in Iraq, Afghanistan 

and other hardship posts and the burdens arising from this service. 

She should also make crystal clear that no stigma attaches to 

those employees who seek support and treatment for PTSD, and 

that their medical and security clearances will not be jeopardized 

for simply seeking such treatment. Indeed, the Secretary should go 

further and commit the department to investigate and punish any 

instances where employees seeking help for PTSD are subject to 

unfair treatment by their colleagues or supervisors. Beyond the 

Secretary’s statement, the department should work with insurance 

providers not only to ensure that PTSD is covered—as I understand it is by many health plans—but that there is a sufficient 

number of qualified therapists available under the health care 

plans provided. 

Lastly, while the department provides both training for employees who are being assigned to Iraq and requires an out briefing for 

those who are returning, affected employees still believe they were 

not adequately prepared for what they would eventually face. As I 

understand it, only 10 percent of returning employees attend the 

mandatory out briefing because attendance is not enforced, and 

those who have taken advantage of the out briefing have expressed 

concerns that the briefing is superficial, and does not really address the needs of employees returning from a war zone. 

At the very least I think it is time for the department to evaluate 

the effectiveness of both of these efforts and make changes so that 

employees are confident that they have the information and the 

support necessary to help them live and work in a war zone and 

to adjust to normal life when they do return. Even though the 

Bush administration has chosen to focus on the military as their 

preferred tool to fight Islamic radicalism, this conflict is ultimately 

going to be decided by civilians, by diplomats, translators, intelligence personnel and specialists in relief and reconstruction. These 

patriotic Americans are on the front line also, and they are being 

exposed to many of the same kinds of trauma as are the soldiers. 

They no less than every single one of our people in uniform deserve not only our respect and gratitude but our very best efforts 

to make sure that they are safe and healthy both in mind as well 

as in body. 

[The prepared statement of Mr. Ackerman follows:]
3

PREPARED STATEMENT OF THE HONORABLE GARY L. ACKERMAN, A REPRESENTATIVE

IN CONGRESS FROM THE STATE OF NEW YORK, AND CHAIRMAN, SUBCOMMITTEE ON

THE MIDDLE EAST AND SOUTH ASIA

The Subcommittee will come to order. Usually, when we talk about Post Traumatic Stress Disorder, the conversation is about members of the military, about 

those whom we would unfortunately expect to have experienced the horrors of war. 

But increasingly, the United States is sending civilian employees—diplomats, intelligence analysts, reconstruction specialists, and contract administrators—not just to 

hardship posts, but into actual combat zones and then expecting them to do their 

usual jobs under extraordinary and perilous conditions. So it shouldn’t be any surprise that those who are now returning from Iraq and Afghanistan are returning 

not only with exotic souvenirs, but with PTSD as well. 

Unfortunately, what isn’t a surprise is that many civilian employees returning 

from Iraq believe their service is unappreciated and those who have symptoms of 

PTSD feel they aren’t getting the support and treatment they need. Let me say here 

on behalf of the subcommittee, and I would hope, on behalf of the entire Congress 

to all those United States government employees who have deployed not just to 

‘‘hot-spots’’ but actual combat areas and because of it, now bear scars on their souls: 

Thank you. I thank you. Your nation thanks you. We are grateful for your courage 

and your sacrifice. And now that you are back, we will not forget what you gave 

and what it has cost you. 

Like our soldiers, there seems to be widespread fear among affected employees, 

that seeking treatment will have a seriously detrimental impact on their careers. 

Employees are afraid they may lose their security clearances, medical clearances or 

simply be perceived by superiors and colleagues as ‘‘damaged goods.’’ We need to 

find ways to dispel these fears. 

I was heartened to learn that the State Department has begun surveying overseas 

employees regarding mental health issues and the preliminary results show precisely why we all should take this problem much more seriously. Many who completed the survey said that their mental health, emotional state, social well-being 

or capacity to function had been affected by work in Iraq, Afghanistan or other difficult posts. Almost half of those who responded to the survey had served in Iraq. 

Even before the Department has the final results of this survey, I think that we 

can all agree that there is a problem. I urge the Department to take additional steps 

to address the concerns raised by affected employees. I think as a first step, Secretary Rice should announce publicly, loudly and clearly that the Department appreciates the service of those who have worked in Iraq, Afghanistan and in other hardship posts and the burdens arising from this service. She should also make it crystal 

clear that no stigma attaches to those employees who seek support and treatment 

for PTSD and that their medical and security clearances will not be jeopardized for 

simply seeking such treatment. Indeed, the Secretary should go further, and commit 

the Department to investigate and punish any instances where employees seeking 

help for PTSD are subject to unfair treatment by their colleagues or supervisors. 

Beyond the Secretary’s statement, the Department should work with insurance 

providers to not only ensure that PTSD is covered, as I understand it is by many 

health plans, but that there are a sufficient number of qualified therapists available 

under the health care plans provided. 

Lastly, while the Department provides both training for employees who are being 

assigned to Iraq and requires an ‘‘out briefing’’ for those who are returning, affected 

employees still believe they were not adequately prepared for what they would face. 

As I understand it, only 10% of returning employees attend the mandatory ‘‘out 

briefing’’ because attendance is not enforced. Those who have taken advantage of 

the ‘‘out briefing’’ have expressed concerns that the briefing is superficial and 

doesn’t really address the needs of employees returning from a war zone. At the 

very least, I think its time for the Department to evaluate the effectiveness of both 

of these efforts and make changes so that employees are confident that they have 

the information and support necessary to help them live and work in a war zone 

and to adjust to normal life when they return. 

Even though the Bush Administration has chosen to focus on the military as their 

preferred tool to fight Islamic radicalism, this conflict is ultimately going to be decided by civilians—by diplomats, translators, intelligence personnel, and specialists 

in relief and reconstruction. These patriotic Americans are on the front line and 

they’re being exposed to many of the same kinds of trauma as our soldiers. They, 

no less than every single one of our people in uniform, deserve not only our respect 

and gratitude, but our very best efforts to make sure they are safe and healthy, both 

in mind and body.
4

Mr. ACKERMAN. Now I would like to turn to our ranking member 

and my good friend, Mr. Pence, for any comments that he might 

care to make. 

Mr. PENCE. Thank you, Chairman, and I welcome our distinguished witnesses. I must confess that when I first heard the topic 

of this hearing I was at something at a loss. We have had more 

than 1.6 million United States service members who served in Afghanistan and Iraq. According to a recent series in one newspaper, 

perhaps as many as one-fourth of those returning veterans are suffering from some type of service-connected psychological disorder. 

Extrapolating that out there may be hundreds of thousands of 

veterans suffering from PTSD, none of which is in our jurisdiction 

but thankfully the number of State Department employees similarly affected is apparently minuscule, and I look forward to the 

testimony about that here. The good news that we can celebrate, 

as Dr. Brown will testify, is that approximately the 2,000 State volunteers to Iraq, zero State employees have lost their medical clearance because of PTSD, and yet let me be the first to say that State 

employees share the family separation, isolation and many of the 

other challenges associated with a hardship post as they are 

known. 

Mr. Chairman, I join you in lauding the effort and sacrifice of our 

State Department employees. In my five trips to Iraq and one to 

Afghanistan, I have witnessed civilian as well as contractors doing 

important work in a difficult and dangerous environment, and I 

thank them for their service. 

It seems to me there are two different issues associated with today’s hearing. One is the question of the treatment for PTSD. The 

other is the general recognition or appreciation for service in Iraq. 

On the latter, there should be no controversy whatsoever. I hope 

this hearing will dispense with the myth that our civilians working 

in the green zone 12 to 16 hours a day for instance, 7 days a week 

for sometimes as long as a year now dealing with intermittent 

rocket fire are somehow bureaucrats or political hacks building 

their resume with some kind of glamorous overseas deployment. 

On the contrary, this is some of the most challenging service of the 

United States of America. 

I also hope this hearing does not have the unintended consequence of discouraging state employees from volunteering to 

serve in Baghdad or Kabul. Today’s Washington Post reports of a 

cable dated 31 May from Ambassador Ryan Crocker to Secretary 

Rice saying that he lacks enough well qualified staff members, and 

that security rules are too restrictive for Foreign Service officers to 

do their jobs. 

Our witness, Mr. Staples, will testify that 99 percent of positions 

are now filled at the United States Embassy in Iraq but the subject 

was enough of a concern to Ambassador Crocker to raise it in this 

message to the Secretary, and we will look forward to discussing 

that. I further hope this hearing does not open the Plaintiffs bar 

to various tort claims. Pending further study, our conclusion about 

the affects of PTSD should be tentative. Before you think this is 

farfetched, the Los Angeles Times in a lead story Sunday was on 

the battle over insurance claims by civilian contractors who returned from Iraq and claimed to be afflicted with PTSD. 
5

Now these challenges will be with us for some time, although I 

am not sure that the larger question of the State’s policies are in 

our subcommittee’s regional jurisdiction. With that said, I look forward to the testimony of our witnesses, and again would simply reiterate my profound gratitude as an American and as an elected official serving in this body for the extraordinary service and sacrifice 

by State employees, civilian contractors and those about whom we 

will focus the attention of this subcommittee today, and I yield 

back. Thank you, Chairman. 

Mr. ACKERMAN. I thank the distinguished ranking member. Mr. 

Inglis. 

Mr. INGLIS. Thank you, Mr. Chairman. I would simply echo those 

comments about appreciation for those serving in places like Iraq 

and I look forward to hearing from the witnesses. 

Mr. ACKERMAN. Thank you very much. If there would be no objection, I would place in the record the Washington Post article referred to by Mr. Pence, ‘‘Embassy Staff in Baghdad Inadequate 

Rice is Told.’’ So ordered. 

[The information referred to follows:]

EMBASSY STAFF IN BAGHDAD INADEQUATE, RICE IS TOLD;

AMBASSADOR’S MEMO ASKS FOR ‘BEST PEOPLE’

Washington Post 

June 19, 2007 Tuesday 

By Glenn Kessler; Washington Post Staff Writer

Ryan C. Crocker, the new U.S. ambassador to Iraq, bluntly told Secretary of State 

Condoleezza Rice in a cable dated May 31 that the embassy in Baghdad—the largest and most expensive U.S. embassy—lacks enough well-qualified staff members 

and that its security rules are too restrictive for Foreign Service officers to do their 

jobs. 

‘‘Simply put, we cannot do the nation’s most important work if we do not have 

the Department’s best people,’’ Crocker said in the memo. 

The unclassified cable underscores the State Department’s struggle to find its role 

in the turmoil in Iraq. With a 2007 budget of more than $1 billion and a staff that 

has expanded to more than 1,000 Americans and 4,000 third-country nationals, the 

embassy has become the center of a bureaucratic battle between Crocker, who wants 

to strengthen the staff, and some members of Congress, who are increasingly skeptical about the diplomatic mission’s rising costs. 

‘‘In essence, the issue is whether we are a Department and a Service at war,’’ 

Crocker wrote. ‘‘If we are, we need to organize and prioritize in a way that reflects 

this, something we have not done thus far.’’ In the memo, Crocker drew upon the 

recommendations of a management review he requested for the embassy shortly 

after arriving in Baghdad two months ago. 

‘‘He’s panicking,’’ said one government official who recently returned from Baghdad, adding that Crocker is carrying a heavy workload as the United States presses 

the Iraqi government to meet political benchmarks. 

‘‘You could use a well-managed political section of 50 people’’ who know what they 

are doing, the official said, but Crocker does not have it because many staffers assigned to the embassy are ‘‘too young for the job,’’ or are not qualified and are ‘‘trying to save their careers’’ by taking an urgent assignment in Iraq. 

‘‘They need a cohesive, coherent effort on all fronts,’’ the official said, speaking on 

the condition of anonymity because he was not authorized to speak to the media. 

‘‘It’s just overwhelming.’’

But some lawmakers have balked at what they consider the unbridled expansion 

of the embassy. ‘‘Having said over and over again that we don’t want to be seen 

as an occupying force in Iraq, we’re building the largest embassy that we have. . . . 

And it just seems to grow and grow and grow,’’ Sen. Patrick J. Leahy (D-Vt.) said 

to Rice during a hearing last month. ‘‘Can we just review who we really need and 

send the rest of the people home?’’

The State Department said that as of last week, 99 percent of the positions in 

the embassy and in regional reconstruction teams had been filled. But State officials 
6

privately concede that in the rush to fill slots—each person serves only one year—

not enough attention has been paid to the management of the flux of people. 

‘‘In terms of Iraq and Afghanistan, the secretary has put the department on a war 

footing,’’ said State Department spokesman Sean McCormack. ‘‘If one of her ambassadors says he needs something, she will get it for him.’’

Crocker, in an interview, confirmed the authenticity of the cable. He insisted it 

was not intended as criticism of Rice or of the staff. He said the cable reflected the 

urgent nature of the tasks he has faced since becoming ambassador. 

‘‘The big issue for me, in my estimation, was simply not having enough people,’’ 

Crocker said. ‘‘The people here are heroic. I need more people, and that’s the thing, 

not that the people who are here shouldn’t be here or couldn’t do it.’’ Crocker said 

he does not know why the changes he is pressing for had not taken place sooner. 

The embassy was established three years ago, when the Coalition Provisional Authority was dissolved. 

Shortly after arriving in Baghdad, Crocker asked Rice to dispatch Pat Kennedy, 

the State Department’s director of management policy, to Baghdad to conduct an 

extensive assessment of staffing and security issues. Kennedy was directed to come 

up with a plan to bring greater order to embassy staffing, beef up the political and 

economic sections, and make sure the embassy has greater control over staffing decisions. 

Kennedy’s 80-page report includes 88 recommendations, including doubling the 

personnel devoted to political and economic reporting and analysis, State Department officials said. The embassy previously had 15 political officers, and Crocker 

has won an additional 11. The nine-person economic staff will be increased to 21 

and will add four contractors. Many of the slots will be transferred from functions 

that are ending, such as reconstruction projects. 

In the cable, Crocker said the State Department’s human resources office ‘‘has 

made heroic efforts to staff the embassy, but to a large extent HR has been working 

alone.’’ Referring to the floor where Rice and her top aides work, Crocker said there 

should be ‘‘a clear message from the Seventh floor . . . that staffing Iraq is an imperative.’’

Crocker also called for ensuring that responsibility for recruiting and assigning 

personnel for the embassy rests with the Bureau of Near Eastern Affairs, which covers the Middle East and North Africa. All other bureau assignments ‘‘should be held 

until there are sufficient bidders with requisite qualifications for Iraq positions,’’ 

Crocker wrote. 

Crocker, in the interview, said the human resources department does not have the 

capacity to make sure the best people are placed in Baghdad. ‘‘They can’t do this,’’ 

he said, whereas the Near East bureau, which oversees Baghdad, has the skills to 

‘‘identify the right people with the right skill sets.’’ State Department officials acknowledge that hiring has been haphazard, but a team has been set up in the Near 

East bureau to work with the personnel department. 

Crocker’s cable also complained about the ‘‘overly restrictive’’ security rules that 

the diplomats must operate under because of a law passed after the 1983 bombing 

of the Beirut embassy. ‘‘If the Department’s normal standards for operation were 

fully applied, we would not have a diplomatic presence in Iraq,’’ he wrote. ‘‘We do, 

and we must.’’ He asked for authority to operate under less restrictive military 

standards, as necessary. 

Crocker, in the interview, said diplomats are ‘‘not able to do the job needed,’’ such 

as meet with officials in cities such as Najaf, under the security rules. 

State Department officials acknowledge that the law did not envision a situation 

such as Iraq and that department lawyers are examining whether it can be interpreted to give Crocker additional flexibility. 

If military standards ‘‘are good enough for them, they should be good enough for 

us,’’ Crocker said. ‘‘We are all in the same fight.’’

Staff writer Karen DeYoung contributed to this report.

Mr. ACKERMAN. I would just comment that after the war in Vietnam we did not know about a lot of the stuff that people would experience in coming back. Many of our troops whose mental health 

needs and concerns were not fully and properly addressed, appreciated or understood, and of course returning soldiers, as I understand it, do not have the right to sue, and certainly we are pretty 

late on the uptake with many people on addressing some of those 

health care needs that were only recognized to be real and so full 
7

in their scope later on down the road as some of their problems 

progress. 

I would hope that there be no such scope or dimension, and that 

indeed that this would be minuscule compared to anything. But 

there is, nonetheless, a problem of some dimension, the full dimension of which we do not know, and I would hope that what we 

would be doing would be to address the health needs that developed out of the demands of the job that these patriotic people have 

undertaken at the behest of their government would be fully addressed, and that their health concerns and demands would be met 

so that we would not even have to be concerned about tort or tort 

reforms or abuses thereof, and I think we are probably all on the 

same wavelength there. 

That being said, let us turn to our first panel. Ambassador 

George M. Staples is Director General, Foreign Service and Director, Human Resources at the Department of State. He has been a 

career member of the Foreign Service for 25 years, and was most 

recently the political advisor to the Supreme Allied Commander 

Europe at NATO. Ambassador Staples has been Ambassador to 

Rwanda, Cameroon and Equatorial Guinea. Ambassador Staples 

also served as Deputy Chief of Mission in both Bahrain and 

Zimbabwe. He is scheduled to retire next month. I think that puts 

a smile on all those who expect to see more of you but before that 

he has just one more unpleasant task ahead of him, and that is 

this afternoon. 

Dr. Laurence G. Brown is Director of Medical Services at the Department of State, was appointed to that position in April 2003. Dr. 

Brown has served as regional medical officer in Pakistan, Indonesia, the UK and Austria. He has also held several senior medical 

positions at the department here in Washington, and has been a 

member of the Foreign Service since 1982. So that is about 50 

years between the two of you. Thank you both for your great service. Welcome to both of you to our committee, and without objection 

your written statements will be made in their fullness part of the 

record, and Ambassador Staples, we will begin with you to begin 

in any way you would like. 

STATEMENT OF THE HONORABLE GEORGE M. STAPLES, DIRECTOR GENERAL, FOREIGN SERVICE AND DIRECTOR OF 

HUMAN RESOURCES, DEPARTMENT OF STATE 

Ambassador STAPLES. Thank you very much, Mr. Chairman. It 

is a pleasure to be here today. As you say, the written record will 

be so entered. I would like to make some comments regarding this 

if you do not mind, and of course I join with my colleague, Dr. 

Brown, in appreciating the opportunity to appear before you today. 

In regards to Iraq and the staffing issues, since I became Director General, my highest priority has been to position our people in 

line with our nation’s most critical foreign policy needs, and these 

needs have changed considerably from the time when I joined the 

department, those 25, 26 years ago. The median hardship differential now worldwide for our overseas positions is now 15 percent, 

and we now have currently over 700 positions that do not allow our 

employees to bring their entire family with them to their assigned 

posts. 
8

In order to fill our most critical overseas positions first, including 

those in Iraq, I introduced last year substantial changes to the assignments process from the order in which assignments to post are 

made to changes to fair share rules requiring service at hardship 

posts and even the elimination of fourth year extensions at posts 

with less than 15 percent differential, and the process worked well. 

By the end of May, we had successfully filled 99 percent of our 

2007 positions in Iraq including those in Baghdad and the provincial reconstruction teams and nearly all of our unaccompanied positions worldwide, and we did it all with volunteers. 

In order to continue to effectively meet the challenge we face in 

staffing Embassy Baghdad and the Iraq PRTs with qualified officers, I have introduced a first ever country specific special assignment cycle for Iraq that will take effect this year for the assignments for 2008. This new system will ensure that we again fully 

staff our missions in Iraq for next year with full access to the best 

and the brightest before any other Foreign Service staffing decisions are made and our new assignments procedures have been 

successful because of our dedicated men and women who in the finest tradition of the Foreign Service and the department in general 

have taken on board the need for change and are committee to 

serving the needs of America. 

The Secretary and I are grateful and proud for their service, and 

we recognize that many are serving in dangerous and difficult 

posts that regardless of location are advancing our nation’s interest, and I can assure you the department is committed to not only 

maintaining but also improving support for our employees and 

their families. 

If I can take just a second to say something about support for 

their families. Our family liaison office has established a dedicated 

position for a specialist to work with the family members of the 

employees who are serving in unaccompanied tours, and we have 

over 200 such families in the United States today, and over 80 of 

them have loved ones in Iraq. For the Foreign Service this is unprecedented. 

We are mindful of the stresses and strains of service of unaccompanied posts. Last summer we contracted with managed health 

network to provide those employees with an educational self-help 

Web site, monthly newsletter, 24/7 hotline services and referral 

services, and we have developed age appropriate handbooks for the 

children, and we have also had special recognition awards for the 

children of those serving in unaccompanied posts, and those are 

given out all through America at different schools and locations 

and have done a great deal to encourage and to recognize the families of those serving, many of whom have told me that this makes 

it all worthwhile when their children throughout America are recognized. 

We also have a full incentive package for service in Iraq including the possibility in certain circumstances for procedures to allow 

families to remain at their current overseas post while the member 

serves in an unaccompanied position in Iraq, and we have of course 

been trying to increase maintenance allowances for those serving 

on unaccompanied tours. Though funds are scarce, we are dedicated to instituting a modernized performance pay system that 
9

fairly compensates our men and women who are serving abroad. 

We were disappointed that the legislation for that in particular for 

our FS–1 and below employees did not pass in the last session but 

we will continue to work to address the pay disparity. 

The rest of my statement—and I will not go into it—I will leave 

this for Dr. Brown. I mentioned in my statement Arabic speakers. 

I know that is a continuing concern of members here in Congress. 

Let me just summarize very quickly by saying that we have had 

a fourfold increase since 2001 in the number of personnel taking 

Arabic. We have just launched a new initiative where anyone who 

wishes to start training this September we will break them from 

their current assignment and allow them to begin training, and for 

those who need to brush up in recognition of the need to serve 

where our needs are greatest, we will allow them to do this as well. 

I just want to mention that the department also gives bonus 

points in the hiring process to Foreign Service candidates who have 

demonstrated Arabic language skills, and we recognize that we 

must improve our ability to understand, engage and influence a 

part of the world that is of great importance to our foreign policy. 

Mr. Chairman, these are exciting and challenging times. The department has adapted to changing conditions throughout its 200-

year history, and I am confident with your support and the support 

of the members we will successfully do so again. Thank you. 

[The prepared statement of Ambassador Staples follows:]

PREPARED STATEMENT OF THE HONORABLE GEORGE M. STAPLES, DIRECTOR GENERAL, FOREIGN SERVICE AND DIRECTOR OF HUMAN RESOURCES, DEPARTMENT OF

STATE

INTRODUCTION

Good afternoon, Mr. Chairman and members of the Committee. 

I am Ambassador George M. Staples, Director General of the Foreign Service and 

Director of Human Resources at the Department of State. 

I appreciate the opportunity to appear before you today. 

IRAQ STAFFING

Since I became Director General, my highest priority has been to position our people in line with our nation’s most critical foreign policy needs. Those needs have 

changed considerably from when I joined the Department 26 years ago. The median 

hardship differential for overseas positions is now 15%, and there are currently over 

700 positions that do not allow our employees to bring their entire family with them 

to their assigned posts. 

In order to fill our most critical overseas positions first, including those in Iraq, 

I introduced last year substantial changes to the assignments process, from the 

order in which assignments to posts are made to changes to the Fair Share rules 

requiring service at hardship posts and the elimination of fourth year extensions at 

posts with less than 15% differential. I am pleased to report that the process has 

worked well. By the end of May, we had successfully filled 99% of our 2007 positions 

in Iraq, including those in Baghdad and in the Provincial Reconstruction Teams, 

and nearly all of our unaccompanied positions worldwide—all with volunteers. 

In order to continue to effectively meet the challenge we face in staffing Embassy 

Baghdad and the Iraq PRTs with qualified officers, I have introduced a first-ever 

country-specific special assignments cycle for Iraq. This new cycle will ensure that 

we once again fully staff our mission in Iraq for next year—with full access to our 

best and brightest—before any other Foreign Service staffing decisions are made. 

Our new assignments procedures have been successful because of our dedicated 

men and women who—in the finest tradition of the Foreign Service and the Department in general—have taken on board the need for change and are committed to 

serving the needs of America. The Secretary and I are grateful and proud of their 

service. We recognize that many are serving in dangerous and difficult posts and 

that all, regardless of location, are advancing our nation’s interests. I can assure 
10

you, the Department is committed to not only maintaining, but also improving support for our employees and their families. 

SUPPORT FOR EMPLOYEES AND THEIR FAMILIES

We have taken a number of steps to better support our families. Our Family Liaison Office has established a dedicated position for a specialist to work with our families in the U.S. while the employee is serving in an unaccompanied tour. We have 

over 200 such families in the U.S. today, and over 80 of them have loved ones in 

Iraq. 

We are mindful of the stresses and strains of service at unaccompanied posts and 

contracted last summer with the Managed Health Network to provide separated employees and family members with an educational self-help website, monthly e-newsletter and a 24/7 hotline for information and referral services. To provide additional 

support to their children, we are developing age-appropriate handbooks to help them 

understand and cope with the stress and uncertainty of having a parent serving on 

an unaccompanied tour. We have also developed recognition awards for the children 

of those serving at unaccompanied posts. 

We have a full incentive package for those serving in Iraq, including the possibility, in certain circumstances, of allowing families to remain at an overseas post 

while the employee serves. We are also able to grant home leave for those who serve 

in designated unaccompanied posts after a 12-month tour. 

We are now trying to increase the maintenance allowances for those on unaccompanied tours, though funds are scarce, and we are dedicated to instituting a modernized performance-based pay system that fairly compensates our men and women 

who are serving abroad. We were disappointed that the legislation did not pass in 

the last Congressional session, but we will continue to work to address the pay disparity. 

ARABIC SPEAKERS

Since September 11, 2001, the number of Arabic speakers who have tested at the 

level of 3/3 (general professional proficiency) and above has increased from 198 to 

over 270, and an additional 422 State Department employees have a tested speaking proficiency of 2 or 2+ (the required level for most Arabic language-designated 

positions). State enrollments in Arabic language training at our Foreign Service Institute have quadrupled since 2001. Recognizing our needs in today’s world, we continue to increase the number of Arabic language-designated positions at our posts 

in Near East Asia and build the number and proficiency of Arabic speakers at the 

Department. Recently, we announced a new initiative that will allow tenured employees to immediately curtail assignments to begin Arabic language training this 

fall in connection with an onward assignment in the Middle East. This initiative 

supplements all of our other efforts to increase the number of personnel with Arabic 

language skills. Since 2004, for example, the Department has given bonus points in 

the hiring process to Foreign Service candidates with demonstrated Arabic language 

skills. We recognize that we must improve our ability to understand, engage, and 

influence a part of the world of continuing importance to our foreign policy. 

These are exciting and challenging times. The Department has adapted to changing conditions throughout its two hundred-year history. I am confident that, with 

your support, we will successfully do so again.

Mr. ACKERMAN. Thank you, Ambassador. Dr. Brown. 

STATEMENT OF LAURENCE G. BROWN, M.D., DIRECTOR, 

OFFICE OF MEDICAL SERVICES, U.S. DEPARTMENT OF STATE 

Dr. BROWN. Good afternoon, Mr. Chairman, and members of the 

committee. I am Larry Brown, the Medical Director for Department 

of State as you know and joining me today is Dr. Ray De Castro 

who is the chief for mental health services for the Department of 

State. I appreciate the opportunity to appear today, and I would 

like to present some information to you on post traumatic stress 

disorder in Foreign Service employees. 

PTSD is an illness that can occur following exposure to an actual 

or a threatened death or a serious injury or learning about the 

same in a family member or close associate. It is not uncommon. 

People with this disorder in the United States are often victims of 
11

motor accidents or violent crimes. Foreign Service employees may 

develop PTSD as a reaction to criminal or political or terrorist violence like the East Africa bombings in Nairobi and Daur e Salaam 

in 1998. 

Some characteristic symptoms of PTSD that emerge are re-experiencing of the events through dreams or nightmares or flashbacks, 

irritability or anger, insomnia, an exaggerated startle response, 

hyper vigilence, and a general numbing of emotional responsiveness. In one person these symptoms may appear immediately after 

the event but go away fairly quickly but in another person they 

may emerge as much as 3 to 6 months after the event and become 

chronic, and there are wide variations between those two examples. 

Mental health support for employees going to Iraq began in November 2003 with the addition of a mental health training to a preIraq orientation course. When the department opened the Foreign 

Service health unit in Baghdad in July 2004, we made certain that 

a psychiatrist was part of the deployment medical team. A clinical 

counselor familiar with PTSD was later added to the Baghdad 

health unit staff. These mental health professionals also travel to 

the provincial reconstruction teams to support our employees there. 

The department began offering mandatory out briefing sessions 

to all Iraq returnees in August 2004. These sessions give employees 

information about PTSD, where to get further help within the department’s medical program. For those who require brief counseling, the department’s employee consultation service and mental 

health services can provide confidential help. Those employees with 

more serious or long-term mental health issues are referred to one 

of several resources in the Washington, DC, area. 

For employees who are stationed overseas, many Embassy health 

units offer primary care counseling, and the department’s 14 psychiatrists who are stationed overseas are readily available for individual consultations. We have had anecdotal information from a 

small number of employees about their experience in Iraq but I 

was not satisfied with that so in an effort to find out more we developed a survey for all returnees from unaccompanied posts. 

This anonymous survey opened on the department’s internet on 

June 1 and will run for a month. A preliminary look at the survey—and we are always a little bit leery about doing this—but we 

found out some very interesting things as you had mentioned earlier. Many employees who are returning from Iraq are having insomnia, easy to startle responses, irritability and anger outbursts, 

numbness and emotional distancing, difficulty concentrating and 

problems relating to a spouse or a partner. 

Almost all employees experiencing one or more of these symptoms will improve over several months with brief counseling or 

without any counseling at all. No employee has lost his medical 

clearance because of PTSD. Some employees have their medical 

clearance changed to ensure that their post of onward assignment 

had counseling or treatment services for their needs. 

We will use the data from the completed survey to develop additional support programs and services, and we have already decided 

that starting this July the department will begin to offer support 

groups for returnees from unaccompanied high stress assignments. 
12

Although many employees working in Iraq are direct hire Foreign Service employees others are permanent civil service employees, while still others are civil service working under limited, non 

career appointments, the so-called 3161s. I want you to know that 

all of these employees come under the department’s medical program in Iraq. They are all eligible for preassignment training, for 

medical and mental health services while in Iraq and for post assignment out briefings. 

Although the medical services for the 3161s end when their employment is terminated, they are covered by workers’ compensation 

for injuries or occupational health conditions that developed in 

Iraq. Other contractor personnel in Iraq are covered by their individual companies who have full responsibility for medical and mental health care and follow up. This concludes my prepared remarks, 

Mr. Chairman. I appreciate your attention, and I am available to 

answer any questions that you may have. 

[The prepared statement of Dr. Brown follows:]

PREPARED STATEMENT OF LAURENCE G. BROWN, M.D., DIRECTOR, OFFICE OF

MEDICAL SERVICES, U.S. DEPARTMENT OF STATE

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 
13

1The Department of State Office of Medical Services has a headquarters staff here in Washington that provides management of the program. In the overseas setting physician medical officers, nurse practitioners, physician assistants and medical technologists provide medical support 

and services at United States embassies and consulates. Medical officer psychiatrists also provide overseas mental health support. All of these providers cover a region as well as their home 

posts. 

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 Services1 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 
14

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 entre ́e 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 
15

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 highstress assignments. 
16

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

Mr. ACKERMAN. Thank you, Doctor. Could one of you address 

how many civilian personnel you have during any given year in 

these areas and how long their tour might be? 

Ambassador STAPLES. Mr. Chairman, I do not think we did in 

our statements. I can just tell you about the permanent State Department staffing. As you know, there are various numbers of contractors and others. I deal with the State Department staffing but 

we have about 200 permanently assigned Foreign Service personnel in Iraq, and that is the Embassy and the PRTs, and that 

is permanently assigned for a year. At any given time we could 

have any number of personnel going in and out for special reasons, 

TDY, et cetera. 

Mr. ACKERMAN. Would you know approximately other Departments? Agriculture? Defense? 

Ambassador STAPLES. No, sir, I do not. 

Mr. ACKERMAN. Intelligence? 

Ambassador STAPLES. No, sir, I do not. 

Mr. ACKERMAN. Would that be equal to each agency the number 

that State has or the total of them be? I am trying to get a grip 

on the total dimension that we are talking about. 
17

Dr. BROWN. I think I can tell you that when we sent the survey 

out we had a list. I should not say a list. But we had a number 

of approximately 2,000 government employees in total. That includes contractors, civil service, Foreign Service and all agencies 

that we hope to reach with the survey. 

Mr. ACKERMAN. That was currently assigned? 

Dr. BROWN. No, not currently assigned but who have been assigned in Iraq since 2003. 

Mr. ACKERMAN. Could you briefly describe what the benefits 

package is to these employees? And before that—I am sorry—the 

second half of my first question was what the tour of duty usually 

is for these permanent? 

Ambassador STAPLES. The tour of duty is 1 year. The normal 

tour of duty for State Department personnel. 

Mr. ACKERMAN. So that would be 200 in a given year? 

Ambassador STAPLES. That is correct. That is what we staff 

every year. 

Mr. ACKERMAN. So that would be reason to expect a different 200 

the next year? 

Ambassador STAPLES. That is correct. 

Mr. ACKERMAN. So that would be over 1,000 just State Department employees over the current term of the war? 

Ambassador STAPLES. We can say that over 12 percent of Foreign 

Service generalists and specialists have served in Iraq so far. 

Mr. ACKERMAN. 12 percent of the generalists and specialists of 

the State Department? 

Ambassador STAPLES. That is correct. Just the State Department. 

Mr. ACKERMAN. How many are in the State Department all together? 

Ambassador STAPLES. In the State Department all together in 

terms of Americans—and I am talking Foreign Service now not 

civil service, 11,460. 

Mr. ACKERMAN. So that would be 12 percent of 11,460? 

Ambassador STAPLES. That is right. But then there are those 

who have served multiple times, TDY and so forth. So it could be 

even larger. 

Mr. ACKERMAN. That would be close to 1,500 people. 

Ambassador STAPLES. That is right. That is right. If you think 

about everybody who has ever come in and out. That is right. 

Mr. ACKERMAN. And that is U.S. citizens. But do we employ 

other than U.S. citizens, and do we provide benefits to them as 

well? 

Ambassador STAPLES. We do use and have had volunteers from 

the FSM community worldwide who have come to Iraq and served 

to help train up a local staff. I do not have the exact numbers since 

2003 but anybody from our Embassies who comes is covered as Dr. 

Brown has said by all of the programs that are provided to the regular personnel assigned to the Embassy. I think the second——

Mr. ACKERMAN. Could you give us what you understand is the 

number or percent of people who have reported that they have experienced problems that would fall into this category or nature of 

emotional or mental health or——
18

Dr. BROWN. I think it is fair to say based on anecdotal reports 

and from our survey that again is not totally complete but it appears that most people—let us say 70 or 80 percent of those who 

leave Iraq—have some sort of an emotional problem at least temporarily when they return to the United States. As I said, most of 

them——

Mr. ACKERMAN. 70 or 80 percent? 

Dr. BROWN. I would say 70 or 80 percent. 

Mr. ACKERMAN. On the military end, on the military side of the 

equation, what percent of the military would you say reports experiencing these difficulties? 

Dr. BROWN. I do not have those figures. I would have to think 

that they are quite similar. 

Mr. ACKERMAN. So if those numbers are quite similar, I think 

what you have described, Ambassador, first in those numbers that 

the civilian population at least represented by the State Department is approximately 1 percent or less of those serving in the 

military. I am just looking in my mind to extrapolate numbers from 

the percentages. So the State Department employees who represent 

a little less than 1 percent of the number of military employees, 

and you are saying 70 to 80 percent and the numbers of the percentages are probably the same of military and civilian personnel 

would be experiencing PTSD or some similar complaint. Did we expect that? 

Dr. BROWN. I think we certainly expected people when they are 

exposed to these sort of traumatic events to develop certain groups 

of symptoms as I have mentioned before, and based on other experience that we have had in the Foreign Service over the years, we 

expect a certain number of those to develop PTSD but a very small 

number. 

Mr. ACKERMAN. And this is much larger than we anticipated in 

this? 

Dr. BROWN. The percentages are not larger but the numbers of 

people that are involved in Iraq and their exposure to trauma are 

larger than we have had in any other events in the past. 

Mr. ACKERMAN. The percentage is not larger so 70 to 80 percent 

of people experiencing mental health or PTSD concerns is 70 or 80 

percent the people returning from all foreign posts? 

Dr. BROWN. No, not returning from all foreign posts. I think who 

are exposed to traumatic events that might cause them to fear for 

their life or fear for injury for themselves or their colleagues. Most 

people when they are exposed to those kinds of situations will develop some symptoms. Anger, outbursts, fear for their lives, difficulty integrating those kinds of things into their personal lives. 

But most of those people sometimes without therapy and sometimes with very simple counseling will be able to incorporate those 

and become apparently normal in a brief period of time, meaning 

weeks or months. 

A small subset of that group will develop what we would consider 

medically full blown PTSD so that it interferes with their lives and 

they cannot get on with carrying out their lives or their duties or 

their jobs. 

Mr. ACKERMAN. It was stated that they are entitled to medical 

benefits while in Iraq I believe was what you said. What about 
19

when they are out of Iraq? They are not entitled to medical benefits? 

Dr. BROWN. Yes, they are. The only ones who end their medical 

benefits are the contract employees that when they are done with 

their contract they are done as a U.S. Government employee. But 

the Foreign Service and civil service employees continue to have 

benefits as everyone else does in the Foreign Service. 

Mr. ACKERMAN. And you mentioned after that they were entitled 

to workers’ compensation? 

Dr. BROWN. That is correct. 

Mr. ACKERMAN. If they are unable to return to work? 

Dr. BROWN. It may not hinge on whether they are able to return 

to work or not but if they can meet the requirements for PTSD or 

other mental health diagnoses that will qualify them for workers’ 

compensation then they can receive that. That is done through Department of Labor. 

Mr. ACKERMAN. Okay. But the Department of Labor does not 

provide health benefits. They are no longer entitled to their health 

benefits? Just compensation for no longer being able to work or return to work? 

Dr. BROWN. That is my understanding but I do not know fully 

what Department of Labor offers. 

Mr. ACKERMAN. As I recall—and I am not going to hold myself 

to this—there is a schedule based on a percent of disability and 

whether or not they can return to work part time or full time but 

that does not provide any health benefits or medical benefits. 

Dr. BROWN. My understanding is that if they take on the case 

and agree that the person for example has PTSD, they will make 

payments for their medical care as required as long as they continue to have PTSD and require that care, whether they have private health insurance or not. 

Mr. ACKERMAN. I will be back. Mr. Pence. 

Mr. PENCE. Thank you, Chairman. I think that is the first time 

you have quoted a Republican governor before this committee. Director Staples, your testimony says that 99 percent of State’s 2007 

positions were filled in Iraq. I mentioned in my opening statement 

a report in the Washington Post—I think the chairman has introduced it into the record—that says that a cable sent by Ambassador Crocker to Secretary Rice talked about critical shortfalls and 

needs. 

I wondered if you might respond to that. Is that report inconsistent with your perception? I would love to have you reflect on 

that news account and what we might make of it on this side of 

the panel. 

Ambassador STAPLES. Sir, I will be glad to say a few words about 

that. The report in the Post regarding the cable and its contents 

were basically accurate as sent in by Ambassador Crocker, who as 

you know is facing tremendous challenges in trying to run one of 

the largest missions in the world and a mission facing huge difficulties at this time. His concerns are that we have the right people and that they have the skills needed, and the message was not 

intended, of course, to in any way say that the personnel on hand 

now are not doing the job, doing it well as they do so in difficult 

conditions. 
20

But it was meant to say and interpreted by all of us in the 

human resources bureau and the Secretary as well as laying out 

where we need to go from here, what kinds of requirements we 

have to have to ensure that as we can prepare to staff for the next 

assignment season that we have the right people with the skills 

that we need, and we certainly are fully on board with that. And 

again, I am extremely proud of the people who have volunteered 

to serve. They are doing very, very well. 

And I would just like to note as well in regards to that story 

there was a statement or two by the usual anonymous source if you 

will that we do not have people of enough of a senior level and so 

forth. That is absolutely untrue. We have former ambassadors, 

chiefs of missions. The new deputy chief of mission coming in is our 

Ambassador in Bangladesh who is giving it up to come and serve. 

We have our Ambassador in Athens who is leaving his tour of 

duty 1 year early to come and serve in Iraq. We have numerous 

DCMs, deputy chiefs of mission on the ground, and the various representatives of the senior Foreign Service and so forth, and the junior officers that we do have entry level officers who volunteer and 

we do send them to Iraq are screened and well trained, many of 

them with prior military service, and again we have wonderful people who are serving and volunteering to do so, and we do everything we can to make sure they are trained appropriately and are 

able to do the job. 

Mr. PENCE. So as the Director General of the Foreign Service 

and Director of Human Resources, Department of State, you would 

find that communication from Ambassador Crocker to be standard 

operating procedure? Gave good information to you. Nothing you 

did not know? No reason for alarm? No reason for above the fold? 

Ambassador STAPLES. No, absolutely not. No reason for alarm. 

Mr. PENCE. Okay. 

Ambassador STAPLES. He said in the cable what he said to me 

in my office when he first came through and paid a courtesy call, 

and we have discussions about staffing and what we need to do in 

Iraq continually on a continuing basis. 

Mr. PENCE. Good. Well that is an encouragement. We have 

grown quite accustomed to alarmist reports in the media about virtually every aspect of our enterprise in Iraq, and I am pleased to 

know in your good offices that there was no cause for alarm based 

on that missive or the report in the newspaper. Let me ask you 

about one proposal, if I can, and in my opening statement I know 

I said it a couple of times but I hope my tone also reflected the 

deep admiration that I have for the employees of State who are deployed in these far flung places of the world on America’s behalf, 

and I do not want to gain say that at all. 

Tell me if you can if you can tell the committee I mean we have 

been at this now for 4 or 5 years, Afghanistan and Iraq, the subject 

of this hearing. Is it ultimately maybe Dr. Brown will speak to this 

as well but is it that the issue of PTSD is not a sufficient problem 

for State to have developed a program for vetting and screening or 

is this a solution in search of a problem? 

Ambassador STAPLES. I will say something, and then I am sure 

Dr. Brown would like to talk a little more about our views as a Department on PTSD. I think everyone should recognize that the 
21

State Department faces challenges that are—in my view—unique 

at this period of time in its history. When I came to the department 

25 years ago, my first assignment was in San Salvador in the years 

as you will remember when we had conflict in Central America, 

and I served at a post in which we had Marines sandbagged on the 

roof, we had bombings and kidnappings, and people assassinated 

and it was unaccompanied for much of that time. 

Maybe the other post at that time might have been Beirut, and 

yet today we are in a position where we have 750 positions that 

are unaccompanied or limited accompanied where our personnel 

are serving 1-year tours, sometimes 2-year tours with adult family 

members, separated from families, facing dangers, and we are talking not just Iraq and Afghanistan but our posts in Pakistan, other 

places in the Middle East, as well as Khartoum, Algiers, you name 

it, and the world has basically changed and become much more 

dangerous. 

In this environment, I am very proud to say we have what the 

Secretary has called the finest diplomatic service in the world, and 

I believe that it is. We have men and women who recognize these 

challenges and desire to serve. We tell people the truth. Every year 

we have 25,000–30,000 people who have taken the Foreign Service 

exam. We bring in about 400, and most of them when I talk to 

them I tell them that they are going to serve a good part of their 

career in hardship posts. 

As I said in my statement, the mean differential is 15 percent. 

Almost 20 percent of our posts are over 25 percent hardship. I can 

tell you right now we are talking about Iraq but almost 20, 25 percent of the Foreign Service already has served in Iraq or Afghanistan, and this is going to continue, and these are the challenges 

that we face, and we have men and women who are ready to do 

it. And then there are the other places. I was Ambassador to Rwanda 4 years after the genocide, and we had a war next door, and we 

had death threats trying to heal that country. We have people who 

are facing problems with malaria, problems with carjackings, problems with you name it around this world. 

PTSD and the issues involving difficult service abroad on behalf 

of our country are not limited to just Iraq, and yet we have wonderful people who do it. We have always felt very well supported with 

our medical doctors, our regional medical officers, the trained doctors they hire locally to help us and assist us, the regional security 

officers in our diplomatic security service who keep us protected 

and to make our residences safe, and we do this because of a need 

to serve our country, and I can just say that I am very proud of 

the commitment made by every single person in the State Department in the Foreign Service, and that includes our civil service colleagues who have also chosen in many places to serve overseas including Iraq. 

Mr. PENCE. Thank you, Director. Dr. Brown, did you want to 

speak to that? It sounds to me like the Director is saying that the 

service has changed. I find it rather startling to learn that 20 to 

25 percent of the employees of State have been deployed specifically in Iraq but other hot spots around the world. To put it bluntly, is this the solution searching for a problem or has the nature 

of the enterprise of civilian employment at the State Department 
22

changed sufficient that we need to be aware of new stresses and 

new pressures? 

Dr. BROWN. Well as a physician who has been in the Foreign 

Service 25 years, I can tell you that PTSD and the associated 

symptoms and problems with it are not new to us. I think that 

what is new now is the numbers of people who are being asked to 

serve in places like Kabul and like Baghdad. That we have never 

been asked to do that before. So the sheer numbers that we are 

dealing with at any particular point in time are higher than we 

have seen in the past. 

But the condition has not changed very much. I think that as 

Ambassador Staples said, members of the Foreign Service are exposed to different traumatic events that have caused PTSD in lots 

of places around the world or even in the United States like the 

officer I talked to the other day who had been robbed at gunpoint 

in Rock Creek Park. So it is not unusual for people in the U.S. or 

people overseas to have PTSD. 

I think I am fortunate to head a medical program that has right 

now 14 psychiatrists and about 140 primary caregivers at consulates and Embassies around the world who can support people, 

and that is why they are there so that we can support them not 

only to treat their malaria but also to counsel them for PTSD and 

other mental health issues that they may have and keep them at 

their job and allow them to finish their tours and serve their countries. So I do not think that any of this per se is new as a diagnosis 

but I think the numbers are higher than we have seen before. 

Now can we do a better job? Sure. We can always do a better job. 

I think based on the survey we can probably do a better job at how 

we orient people before they go out, and I think we can do a better 

job of giving them material when they get back but it is something 

we can work on and one of the reasons we wanted to do the survey 

to see how good a job we are doing and where we can improve. 

Mr. PENCE. Thanks, Doctor. One last question, Director. As I 

have dug into this a bit, there has been a proposal at least talked 

about in the CRS report somewhere I read that when you are making these unaccompanied deployments one of the ways that you 

could take the brunt out of that is by doing team deployments. 

From your desk is that practical to do, to think about that you 

would send State Department employees into these missions maybe 

in teams of two or three or four for the same period of time that 

would provide something of a support network that predates the 

deployment? How would you respond to that as a proposal, and is 

that something that you do in part already? 

Ambassador STAPLES. I have to say, Congressman, I am not very 

familiar. I am not familiar at all with that proposal. We assign personnel to positions, and our mission for example in Baghdad and 

in Kabul and in other places, the newcomer you know there is an 

orientation program when they arrive. There are other people in 

the section with whom they work. You know the problem that we 

have is not so much sending in teams. The problem is our 12-

month tours and rotating people so many times. 

After serving in one of these positions, you should under our fair 

share rules be free for 7 years if you will, 6, 7 years not to have 

to serve in such a place again but the requirements of the service 
23

and those with special skills, in particular Arabic, it means that we 

may come and ask you to go again in three or four, and again we 

tell people that, and we seem to so far have been able to fill these 

assignments. But I do not know about a team concept as you have 

mentioned it, no. 

Mr. PENCE. Some of my notes reflect that some returning civilian 

personnel have suggested that in some reports. It might be something that you ponder institutionally. I know when I let my kids 

go swimming before they were very good swimmers I would say get 

your buddy. Go out there. 

Ambassador STAPLES. Well our people in the hardship places 

have lots of buddies I can tell you. 

Mr. PENCE. That is encouraging. 

Ambassador STAPLES. And having served most of my career in 

those places, you are very close to your colleagues. Much closer 

than if you were in London or Paris or whatever, and you all look 

out for each other. 

Mr. PENCE. Yes. No doubt. 

Ambassador STAPLES. Yes. 

Mr. PENCE. Let me yield back, and Chairman, this has been a 

very informative hearing. I thank the witnesses for their service to 

the country. You do not often get thanked when you come before 

Congress but thank you for your service to the country and your 

deep and abiding concern for the success of our various missions 

and the well being of the people under your employ and under your 

care. With that I yield back. 

Mr. ACKERMAN. Very good questions. Thank you, Mr. Pence. Mr. 

Scott. 

Mr. SCOTT. Thank you, Mr. Chairman. This is a very interesting 

hearing. It is sort of like the forgotten war within the war. Just 

briefly what in your best explanation or description constitutes post 

traumatic stress disorder? I mean if we are dealing with someone 

who you say have that, how would you describe that? What is it? 

What would they be going through? What would they be experiencing? 

Dr. BROWN. Post traumatic stress disorder takes a couple of 

things. It takes exposure to a traumatic event so that either you 

feel you are going to die or be killed or be severely injured or one 

of your colleagues or family members is going to die or be severely 

injured. That trauma triggers a number of symptoms like anger, 

hopelessness, horror initially, and then following that either immediately or maybe several months later further symptoms like disengagement psychologically from relationships, those kinds of 

things. 

Mr. SCOTT. Civilians are experiencing it. Soldiers experience it. 

Is there any difference there? 

Dr. BROWN. In terms of what they experience in terms of symptoms, no. There are individual differences from people-to-people. 

The main difference, if I may, is that we know from the military 

studies that the more combat that soldiers are exposed to the higher their chances are of developing PTSD. 

Mr. SCOTT. Okay. 

Dr. BROWN. So the more traumatic events you see, the higher 

chance you have of having this. 
24

Mr. SCOTT. So then one difference might be the percentage. Is 

there a difference say in the percentage of civilians who are serving 

in Iraq getting post traumatic stress disorder and the percentage 

of the military getting it? I think I remember back when we first 

started back in World War II. It was like 18 percent of the military. What is the percentage of the military now? What is the percentage of the civilians over there? 

Dr. BROWN. The military studies show anywhere from 8 percent 

to as high as 15 percent, and again part of that depends on who 

you survey in the military. So if you want to pick 10 or 12 or 15 

percent that would be a pretty good estimate. Because our survey 

is not done for the Foreign Service, we do not have any actual 

numbers yet but we think it is probably less than that. 

Now I should also say that for these kinds of studies they use 

pretty exacting criteria for PTSD in terms of how long the symptoms go on, how greatly they interfere with one’s life. Almost everybody that comes out of these traumatic situations has some sort of 

symptoms for a period of time but most everybody gets over it either with brief counseling or on their own. Only a smaller group 

of people go on to actually develop what we consider full-blown 

PTSD where their lives—my kids would say—are messed up. They 

cannot get on with their lives. They cannot hold a job. They have 

poor interrelationship skills because of their PTSD. 

Mr. SCOTT. Just dealing with the State Department, do we have 

a quantity, do we have a number of people that have developed this 

that is being treated? 

Dr. BROWN. I do not know the exact number although I suspect 

it is less than 10 to 15 in total. 

Mr. SCOTT. Has your Department or State Department learned 

from the experiences of the military? 

Mr. ACKERMAN. If the gentleman would yield. Was that 10 or 15 

people or percent? 

Dr. BROWN. People. 

Mr. ACKERMAN. Thank you. 

Mr. SCOTT. Really? 

Dr. BROWN. People, not percent. 

Mr. SCOTT. 10 or 15 people? Ten or 15 civilians in the State Department have been diagnosed with this? That is it? 

Dr. BROWN. That would be my best estimate, yes. 

Mr. SCOTT. And the military? 

Dr. BROWN. I do not have the numbers for the military other 

than the percentages that I had quoted you before. 

Mr. SCOTT. That number strikes me as pretty low. You are saying that just 10 or 15 civilians in the State Department have been 

diagnosed with this disorder? 

Dr. BROWN. That we know of, yes. 

Mr. SCOTT. Would that figure be symptomatic of the level of importance of this? Let us put it this way. Let me ask you this: How 

many employees are we talking about? How many civilians are 

over there? You have got 10 or 15 cases of this out of how many 

civilians in the State Department that are serving or have served 

or been experience or maybe have exposed to this? 

Dr. BROWN. As we were talking earlier, in the State Department 

approximately 1,200 who have been direct, 12 to 1,500. 
25

Mr. SCOTT. Okay. That is like about 1 percent. Would you say 

that is an accurate assessment or could it be another reason that 

there is some hesitancy on people coming forward and availing 

themselves of the counseling? 

Dr. BROWN. Well and that is our concern and why we wanted to 

do an anonymous survey because we do not know if we are seeing 

the entire world of people out there who are affected because there 

is admittedly some hesitancy, and I think it has been mentioned 

earlier that people are concerned about medical clearances unnecessarily but concerned about that and about security clearances if 

they see mental health counselors. 

Mr. SCOTT. Well let me ask both of you all this then, Ambassador 

Staples and Dr. Brown. Would not it make sense to require that 

upon leaving that it be mandatory? That that might——

Ambassador STAPLES. That is just what we have done. That is 

just what we have done. 

Mr. SCOTT. Okay. 

Dr. BROWN. What we have done is to make mandatory out briefing sessions to give people information. My own sense of it is a 

physician is that it would not be worthwhile to mandate counseling, for example, setting aside the legalities of trying to mandate 

medical treatments but usually mandated counseling is not viewed 

favorably by the people who are mandated to be counseled, and it 

sets up a very unfavorable relationship between the patient and 

the counselor. We would much rather give people information and 

invite them to come if they need be. 

Mr. SCOTT. I see. One final question if I may. 

Mr. ACKERMAN. If the gentleman would yield. 

Mr. SCOTT. Yes. 

Mr. ACKERMAN. I just want the record to be clear that the answer to the question that Representative Scott asked was that it 

is mandatory but it is true as well that 90 percent of the people 

do not go through that mandatory procedure because it is not enforced. Is that accurate? 

Dr. BROWN. From what I know of the figures, I cannot say that 

the 90 percent is accurate but I will say that up until 2 months 

ago most people did not come to the out briefings. 

Ambassador STAPLES. Mr. Chairman, at that point and before it 

was voluntarily which was the problem. Now our assignment technicians and personnel in HR when an individual is coming out and 

coming back it is included in their orders that they attend the 

course. So it is mandatory. 

Mr. ACKERMAN. It is mandatory but only 10 percent of the people 

so far have availed themselves or I should say complied with the 

mandatory out briefing. 

Ambassador STAPLES. No. It has just become mandatory. So over 

the previous years it was voluntary, and I——

Mr. ACKERMAN. So the 10 percent was on a voluntary basis, and 

now we do not know how many actually got it? 

Ambassador STAPLES. That is right. 

Mr. ACKERMAN. Right. 

Ambassador STAPLES. Our hope is that in coming to the counseling they will feel reassured, understand what is available, and 
26

then feel if they need to that they will be able to go on and seek 

counseling and care if need be. 

Mr. SCOTT. All right. So you basically would surmise that the 

reason for the hesitancy is some stigma being associated with this, 

is that it? 

Dr. BROWN. That is what we surmise. I think that there are 

probably a lot of individual reasons for people doing or not doing 

that but they are concerned about the stigma, yes. 

Mr. SCOTT. All right. Finally, if I may, Mr. Chairman, there are 

some who fall in the middle of this or in the cracks like that are 

not combat, that are not State Department, but are private contractors who are Americans who fall into neither of those categories 

but yet are in that terrible scene over there. What about them? 

What effort is there to reach out to them? I mean we have received 

some information that these Americans feel that they are not getting this kind of treatment. That it is not being made available to 

them. What is your assessment of that group of people that is kind 

of falling in this sort of twilight zone of not being a civilian in the 

State Department or with the agency but are private contractors 

doing the work? 

Dr. BROWN. My understanding is that the private contracting 

companies who provide those employees are fully in charge of both 

their mental and their medical health in Iraq and afterwards as 

well. Beyond that I cannot say but it is up to their contracting companies to provide that. 

Mr. SCOTT. Okay. So there is no government support given to 

Americans who work in Iraq for contractors but do State Department or let us say United States international development work? 

There is nothing available for them period? They are on their own 

when they come back, is that correct? 

Dr. BROWN. I am hesitating because there are so many different 

classes of contractors but in a broad brush stroke I think what you 

said is correct. 

Mr. SCOTT. Okay. Now my final point, what happens if this is 

untreated? These folks have been over there in it. They have gone 

through this. You gave a very good description of it. It is a lot of 

psychological mental imbalance happens. What happens if it goes 

untreated and they are coming back into society? What can you expect the downside to returning to America to try to lead a life 

mean? In other words, what do we in society suffer by not making 

sure these individuals who have gone through post traumatic 

stress disorder are attended to? 

Dr. BROWN. The history varies quite a great deal from personto-person. Most of them will be dysfunctional for awhile, maybe unable to hold a job, maybe unable to develop relationships and a 

family or a friend situation. Some of them become chronic and can 

never hold a job and can never manage their lives because they are 

so scattered because of their experiences. However, treatment for 

most people can be quite successful, and that is why we try to recommend it and try to get these folks in some sort of treatment earlier on. The sooner the better. 

Mr. SCOTT. Could non-treatment result in something like homicidal or suicidal? I guess what I am getting at is here. We have 

post traumatic stress disorders right here in the United States. 
27

You see it on the news all the time. Folks have it at the workplace. 

They go home. They get a submachine gun. They come back, and 

they clear everybody out. We have it at Post Offices, schools, so 

forth and so on. Do you think we suffer from things like that? Well 

assault weapons. I am sorry. Do you think we have anything like 

that to fear from? 

I mean you know I guess what I am getting at here is when it 

comes to 10 or 15 here I am not getting a sense of urgency or 

maybe this is overblown. I mean I would think it would have been 

a little more serious than this, and I am trying to get a level of 

seriousness of just one a scale of 10 to 1 just how serious this is 

that we are grappling with here. 

I mean you said only 10 or 12. I mean 12 or 15 I think you said. 

I was quite frankly shocked and startled by that. I thought it 

would be much more significant than that. I know it is with the 

military. I mean I get a mild case of it every time I watch the news 

and see the bombings and everything going on over there. I would 

be out of my mind trying to live in Iraq on a daily basis. But anyway thank you very much, and thank you, Mr. Chairman. 

Mr. ACKERMAN. Thank you very much. I am trying to understand 

the numbers because I am as puzzled as my colleague but those 15 

cases of post traumatic stress disorder is based on the 10 percent 

of the people that you have seen so far. Is it reasonable to assume 

that there would be 10 or 15 out of every 10 percent? 

Dr. BROWN. If things continue the way they are in terms of what 

we are seeing, I think that is reasonable to expect but again part 

of the reason we are doing the survey is to see that we capture all 

the people out there. Our concern is that there may be people who 

are going to private——

Mr. ACKERMAN. You mean capture in the medical sense? 

Dr. BROWN. Yes, in the medical sense. Yes. Not in the straightjacket sense. That we capture the population to see exactly what 

is going on with them. Our concern is that there may be people 

who are being seen by private practitioners that we do not know 

about it and are not reporting to us that they are not required to 

do. So those numbers may be higher. 

Mr. ACKERMAN. There is a tremendous difference in approach to 

one’s job in the military and in the civilian sector where in the 

military—and I am not talking about the full-time military. I am 

talking about the volunteer army. Most people rotate out, and they 

are done. That is not their career. That was an assignment on behalf of their country. 

People who are serving in civilian capacities have an entire career to be concerned about, and would feel I would think the possible effects of being stigmatized by reporting that they have such 

a ‘‘problem.’’ So I would suspect, unless I am wrong, that there are 

different demands on a person’s need to report. I will give you what 

is sometimes called a for instance. My wife works in the field of 

mental health. She was one of those people who were asked to 

come down after 9/11. Saw a bunch of people. 

She also works in a clinic. The New York City police and fire departments provide tremendous support services for their members 

with all kinds of problems of these or other natures, but she is beginning to see in her practice, in the clinic at which she works, peo-
28

ple years later who are career firemen, policemen showing up in 

this private practice because they are experiencing tremendous 

problems years later, not reporting to the agency for which they 

work which have great professionals working for them because 

they are afraid or concerned I should say about how it might affect 

their career and future promotions within that career. 

Is there such a concern here within the civilian populations 

working for our Government that they might not be reporting because of career concerns? 

Dr. BROWN. Well honestly, yes, that is one of my concerns that 

we are not reaching the people that we need to, and that they are 

not reporting as they should. 

Mr. ACKERMAN. You mentioned before that sometimes people 

after 3 or 4 months or so then go about their regular normal lives. 

How late in their life can this PTS show up? Before you answer 

that, is there a difference between syndrome and disorder? 

Dr. BROWN. No, not really. I think if you look in the psychological 

books and you look in the coding books for PTSD there are certain 

criteria that have to be met but syndrome or disorder we use it 

interchangeably. 

Mr. ACKERMAN. And the first question, how late can this show 

up? I mean I do not know how many of these lawyer detective prosecutor TV series things where suddenly the guy 17 years after 

whatever he served in whatever war he commits some kind of act 

of violence, and the defense is he developed PTSD. 

Dr. BROWN. I would say most of the time symptoms of PTSD are 

evident within 3 to 6 months after the exposure to the trauma. I 

think the kind of sort of case that you mentioned somebody who 

is 18 years later and all of a sudden develops PTSD actually probably had symptoms earlier on that were either missed or were negated by people that he saw, and it was not recognized at the time 

that these were symptoms of PTSD. 

Mr. ACKERMAN. But these can be real symptoms and not just recognized by your lawyer? 

Dr. BROWN. Absolutely. 

Mr. ACKERMAN. Should we have any program in place for longterm treatment or follow-up on the part of civilian agencies such 

as the State Department or other agencies that have people in 

these troubled areas to be concerned about our civilians somewhere 

down the road and to follow-up on it? 

Dr. BROWN. Well the easy answer to that is yes, we certainly 

should. The harder answer is exactly what that program would 

look like and what we ought to do. We currently do not have anything like that that tracks people with PTSD over the years. 

Mr. ACKERMAN. Should we? Assuming the resources would be 

provided, should we? 

Dr. BROWN. If the resources are there, yes. I think it would be 

a good idea. I think that——

Mr. ACKERMAN. I do not want it just for an exercise in exercise. 

Dr. BROWN. No. I mean this has real consequences to people 

down the line, and we want to make sure that if they have been 

treated for PTSD and we think things are fine and we know the 

nature of the disease is that another triggering event can happen 

years later that may bring their symptoms back again. So it is 
29

worth having some sort of system so these people can be tracked 

but also a system so they know where they can go for help. 

Mr. ACKERMAN. Could I ask that at one of your meetings you ask 

if anybody would care to give a little bit of thought to a modest proposal that we could consider funding for that would provide a backstop and perhaps be helpful in years to come for a lot of people who 

might be developing psychological problems? We did not even know 

about the physical ailments after defoliation and things like that 

and doubted a lot of people until we started seeing cases years 

later spontaneously springing up in different places. Would that be 

an appropriate thing to request? 

Dr. BROWN. I believe it would probably be useful. 

Mr. ACKERMAN. Is that a yes? 

Dr. BROWN. That is a yes. 

Mr. ACKERMAN. Okay. Thank you. Mr. Scott, did you have another question? 

Mr. SCOTT. Yes, if I may. Looking ahead and I really think that 

hopefully, hopefully we will put a greater emphasis on diplomacy 

as opposed to bullets I think that that is really the solution to the 

way forward. So it means that I would think that there is going 

to be a greater emphasis on the State Department, our Embassies, 

our Foreign Service officers. We need more of them, and let me just 

say while I am talking about them I commend them. They were not 

trained for combat in these areas as soldiers were. They were 

trained to handle a lot of the stress that they go through in combat 

and explosions and death all around them and those types of 

things and many of our civilians are not. 

But I think going forward our foreign policy is going to depend 

more heavily on diplomacy as opposed to shooting, at least I hopefully will be at the forefront of pushing that kind of policy going 

forward so we will not make blunders as we have made in Iraq and 

these situations which means that we are going to have more of 

our folks put in harm’s way. We are going to have more of them 

put diplomats in this arena. 

So what do you project going forward? As a matter of fact I think 

Secretary of State Condoleezza Rice has indicated even that much 

during the remainder of her term as Secretary of State. There 

would be more emphasis placed upon diplomacy and hot spots 

around the world where they will be exposed to some of these kinds 

of events. So what do we have to look for here? 

I would suspect that it would be more than 10 or 12 cases going 

forward. Tell me about the funding level. Do you believe that there 

needs to be more funding for this? Just give me your heads up on 

given the direction we are moving, more diplomacy, all of that. 

More of our folks being put in harm’s way and who are civilians. 

Greater need for this. What do you think is needed as far as us 

to look forward to in resources and where would we put them? 

Ambassador STAPLES. Congressman, in terms of where we are 

going to put our people, you are absolutely right. Secretary Rice 

with her vision as she has testified and made known to the world, 

transformational diplomacy. We are in the midst of a global repositioning exercise. We are putting more of our personnel overseas, 

putting more into developing countries, and countries of emerging 

and greater emphasis like China, India, the countries of South 
30

Asia. Developing countries by definition are countries in which 

there will be more perhaps unrest, more disturbances, tougher living conditions, and sure that is going to stress our people and their 

families. 

Mr. SCOTT. Tell me about the current budget situation with the 

office of medical services because I think that is where—if we get 

more funding for the treatment of post traumatic stress disorder—

it will be there. What is the current status of that, and how much 

more funding do you think we need? 

Dr. BROWN. The current status of the funding is the money I get 

to run the office of medical services come from two sources. One is 

from diplomatic and counselor program monies but I also am funded about in half through the ICASS system from all the other agencies that buy into us. So most of the medical work that goes on 

overseas and most of the positions that I have in my health units 

around the world are ICASS-funded positions. 

That is actually a good thing because it means all the different 

agencies that want to play in that get to pay into it to support my 

medical people who are overseas. Right now the funding for that 

I think is very good but as we continue to expand and add posts 

around the world and increase not only the number of posts but the 

number of people who are at posts from a number of different agencies around the world, we need to keep an eye on that to make sure 

that our funding will keep up with it. I have to say right now it 

is adequate. 

Mr. SCOTT. Just for my benefit, going forward how much more 

funding, if any—you may say you do not need any more, this is 

fine, I want to make sure I hear you right on this—how much more 

funding, if any, would you anticipate requiring to adequately meet 

the needs of the estimated number of employees with post traumatic stress disorder in the foreseeable future? 

Dr. BROWN. I am afraid I cannot answer you right now without 

looking at some of the figures and thinking about that a little bit 

more but I will get back to you on that. 

[The information referred to follows:]

WRITTEN RESPONSE RECEIVED FROM LAURENCE G. BROWN, M.D., TO QUESTION

ASKED DURING THE HEARING BY THE HONORABLE DAVID SCOTT

Based on the results from our initial survey, the Department estimates that there 

would be a need for four full time (FTE) positions for Deployment Stress Management program: a clinical psychologist to head the program, two additional mental 

health professionals and one administrative support person. The costs associated 

with hiring and other funding for the program are estimated to be approximately 

$700,000 annually.

Mr. SCOTT. Okay. Just finally I would just like to say this. I have 

traveled abroad many codels in my fifth year of Congress, and I 

really want to take this opportunity to take my hat off to the fine 

people serving in our Foreign Service, State Department, our Embassies, all of those. They are courageous. They move about. They 

are a special breed, and we deeply appreciate their service. Thank 

you. 

Ambassador STAPLES. Thank you. 

Dr. BROWN. Thank you. 

Mr. ACKERMAN. Thank you, Mr. Scott. Sort of following up on 

something Mr. Scott said, Ambassador Staples, you mentioned that 
31

the deployment of civilian provincial reconstruction teams in Iraq, 

which is a model that is pretty new, it first started in Afghanistan, 

these result in civilians actually living in forward operating positions that are subject, an area subject to combat. Looking at the 

changing nature of struggles that we might project ahead, the nature of warfare may be changing, and our military has to deal with 

that, plan for that, and prepare for that. 

What are we doing within the department because it seems that 

more and more people in civilian roles will be assigned or volunteer 

to go to posts of this kind of a nature. Are we prepared for that 

or are we preparing for that? 

Ambassador STAPLES. Mr. Chairman, we are thinking about that 

and preparing for it. Our personnel serving in provincial reconstruction teams do face special challenges but they also have special responsibilities to really get out and work in local communities 

as best they can given the security situation. We do have training 

programs, training courses at the Foreign Service Institute. We do 

have extra support mechanisms and incentives on the assignment 

side to encourage those assignments. 

For example, the personnel serving in provincial reconstruction 

teams get a priority on their assignment preference when they 

leave. For those who are going to for example a team in Iraq, we 

have a program in effect where they can leave their family behind 

wherever they are so the family, the kids can stay in school and 

not have to move and then move again after another year. The personnel in Iraq have any number of benefits, you know extra R and 

Rs, regional rest breaks. They are entitled to home leave after 12-

month service. 

So we do think about them and their service, their training, and 

what we can do to make sure that those assignments are meaningful. 

Mr. ACKERMAN. Are we going to be preparing them in greater detail and sufficiency rather than just asking for volunteers in so 

much as a greater number of them will be needed for these kinds 

of posts? You stated that you expected that 25 percent of the Foreign Service officers will have served in Iraq. Is that——

Ambassador STAPLES. No, 25 percent will have served in Iraq or 

Afghanistan easily by the time this year’s assignment cycle is over. 

Mr. ACKERMAN. This year’s assignment cycle? 

Ambassador STAPLES. That is right. Not just all in provincial reconstruction teams. That is in the posts in total. 

Mr. ACKERMAN. Well that is during the current situation, 25 percent, that is a pretty big percent. 

Ambassador STAPLES. That is since 2003. 

Mr. ACKERMAN. One would think it is looking like all Foreign 

Service officers should be trained and prepared, whether they volunteer or not or whether that system changes but should be prepared and understand what they would be facing so that they 

would be better prepared psychologically. 

Mr. SCOTT. Would the chair——

Mr. ACKERMAN. Absolutely. Would they be better prepared psychologically for these kinds of traumatic situations and would better anticipation of them be helpful in preventing the disorder or 
32

syndrome that they might face afterwards? Does that inoculate 

them in any way? 

Dr. BROWN. Probably not. It turns out that most of the programs 

that have looked at that it does not inoculate them. They still develop PTSD. They still develop symptoms. 

Mr. ACKERMAN. Mr. Scott. 

Mr. SCOTT. Yes, if I may. Thank you. I want to get a clarity on 

your 25 percent that you referred on the chairman’s question. 

Would you define that 25 percent? Was that 25 percent of just the 

State Department employees or aid all of the Foreign Service put 

together? 

Ambassador STAPLES. I am not talking about all of the State Department. I am not talking about the civil service, Congressman. 

This is the Foreign Service, generalists and specialists, since 2003 

by the end of this assignment cycle—which means currently assigned and previously assigned—about 25 percent of the Foreign 

Service will have served permanently a full 1-year tour or various 

stints of tours or time in Iraq or Afghanistan. 

Mr. SCOTT. Since 2003. Now the Foreign Service would be? I just 

want to get clarity on what universe you are talking about here. 

Ambassador STAPLES. The State Department Foreign Service officers. 

Mr. SCOTT. State Department. You are not talking about AID. 

Ambassador STAPLES. I am not talking AID, Commerce, Agriculture. No, sir. 

Mr. SCOTT. Okay. Embassies fall under there? 

Ambassador STAPLES. Yes. All of ours. 

Mr. SCOTT. 25 percent. What would be the aggregate number of 

that that you are yielding at 25 percent? What would that be a 

total, 25 percent of? 

Ambassador STAPLES. Of our generalists and specialists, that is 

11,464. 

Mr. SCOTT. So 11,164——

Ambassador STAPLES. Generalists and specialists. 

Mr. SCOTT [continuing]. Will have served in——

Mr. ACKERMAN. 2,900. 

Ambassador STAPLES. 25 percent of that number. 

Mr. SCOTT. 25 percent of that. 

Ambassador STAPLES. That is right. 

Mr. SCOTT. That is what I was after. Thank you, sir. 

Mr. ACKERMAN. That is about 2,900 people. 

Mr. SCOTT. 2,900 people. 

Mr. ACKERMAN. There have been concerns expressed that the 

people who are offering treatment for PTSD or other mental health 

issues are the same people who give the medical clearances. Do you 

think that the treatment should be separated in some way from the 

clearance decision-making process? 

Dr. BROWN. It is not true that over prolonged periods of time the 

people who are treated for mental health issues are the same ones 

that make the clearance decisions. The mental health services in 

the department may see a person once or twice for a consultation 

but most of the mental health treatment that is long-term is done 

by private practitioners or by university staff in the Washington, 

DC, area. So the treatment decisions are made by my clearance 
33

staff in Washington, DC, but it is not the same people who are 

treating these people for PTSD or whatever the mental health 

issues may be. 

Mr. ACKERMAN. Is treatment done at overseas locations as well 

in Iraq or Afghanistan? 

Dr. BROWN. Yes. In some overseas locations we do primary care 

treatment like a family physician would do in his office. Some of 

the regional psychiatrists do treatment at their home posts. 

Mr. ACKERMAN. Of the 14, I believe you said there were 14 psychiatrists? 

Dr. BROWN. That is correct. 

Mr. ACKERMAN. All together overseas. How many would be in Afghanistan and Iraq? 

Dr. BROWN. There are none assigned now in Afghanistan and 

Iraq living there but they travel there as part of their region. 

Mr. ACKERMAN. So how often say would one of them be in Afghanistan? 

Dr. BROWN. The regional psychiatrist who is based in Amman, 

Jordan goes to Baghdad approximately every 2 months but we also 

have a mental health counselor stationed there permanently. In 

Kabul, the regional psychiatrist comes out of New Delhi in India, 

and he goes there approximately every 2 to 3 months. 

Mr. ACKERMAN. The psychiatrist who goes to Baghdad once every 

2 months, does he or she stay overnight? 

Dr. BROWN. Yes. It is for several days at a time. They have also 

made trips around to see the PRTs and visit our people there. 

Mr. ACKERMAN. Is that sufficient or do we need more hands? 

Dr. BROWN. I think it is sufficient for what we need at this point 

in time. 

Mr. ACKERMAN. Back to the first question on who makes the decisions on the clearances, what about on the security clearances? 

Dr. BROWN. The security clearances are made by Diplomatic Security. It is completely separate from their medical clearances. 

Mr. ACKERMAN. And one last question concerns what kinds of 

privacy protections are in place? 

Dr. BROWN. The department’s medical program has to fall under 

the HIPAA regulations, and so we guard medical information and 

diagnoses privately as you would expect in the private sector for 

example here. We do not share medical records nor medical diagnoses with anyone outside the medical program. If there are medical concerns that are brought to us by other areas, for example 

diplomatic security, we may look into them and we may talk to the 

person. We may talk to the person’s physician and render a decision back to Diplomatic Security but we never share medical information or diagnoses with them. 

Mr. ACKERMAN. Let me say that the testimony of the panel has 

been very helpful. The committee would be very appreciative of 

your getting back to us after the mandatory out session is in effect 

for a short period of time and a greater percentage of people who 

are leaving actually do the out briefings to let us know how that 

number or percentage with regard to PTSD might or might not be 

changing. Thank you very much. You have been very helpful to the 

panel. 

Dr. BROWN. Thank you. 
34

[Pause.] 

Mr. ACKERMAN. We will now turn to our second panel which consists of Mr. Steven Kashkett who is the State Department’s Vice 

President of the American Foreign Service Association. He was 

elected to that position in 2005. Prior to that he was acting Director of the Middle East Partnership Initiative Office. 

In addition to serving various positions in Washington, Mr. 

Kashkett has also served in Canada, Lebanon, France, Haiti and 

Jerusalem. Mr. Kashkett has been a member of the Foreign Service 

since 1983. We welcome you before our subcommittee, Mr. 

Kashkett, and without objection your full statement will be made 

a part of the permanent record and you may proceed to summarize 

as you would. 

STATEMENT OF MR. STEVE KASHKETT, VICE PRESIDENT, 

AMERICAN FOREIGN SERVICE ASSOCIATION 

Mr. KASHKETT. Thank you, Mr. Chairman. We are very grateful 

to have the opportunity to speak here. As you requested, I will just 

summarize my prepared statement. We are grateful to you for convening this hearing, and for helping to raise the profile of this urgent issue with your colleagues in Congress and at the Department 

of State. 

We are the official labor union and professional association for 

the employees of the Foreign Service. The 11,000 some members of 

the Foreign Service that Ambassador Staples referred to are all 

part of our constituency. We estimate that the actual number who 

have served in Iraq since the beginning of our deployments there 

is probably close to 2,000, and the reason for the confusion over 

numbers is that you have to factor in that during the early years, 

the first couple of years, many people served there on shorter, temporary duty assignments for 3 months or 6 months or 9 months. 

So the numbers are greater than just the 200 to 300 per year who 

are assigned to the Embassy in Baghdad and the provincial reconstruction teams around the country. 

These are unique cases where we are sending unarmed civilians 

into active combat zones. Our members are accustomed to extremely difficult conditions. They serve in hardship assignments all 

throughout their careers but yet they are not soldiers and they are 

not trained for combat. In Iraq, many of them are exposed to conditions of war for which they may not always be well prepared to 

cope. 

I could go through, if you would like, some of the kinds of things 

that we have heard from our members who have returned from 

Iraq. Some of the experiences that they have had which are very, 

very different from any kind of normal experience that diplomats 

have in hardship posts. I would draw your attention to one very 

important fact which is in addition to the existing provincial reconstruction teams and the Embassy itself in Baghdad, the State Department has now created what will be called EPRTs, embedded 

PRTs in which our members will be literally embedded with mobile 

combat units of the United States military in hostile areas. So their 

experience will be even more stressful than the experience of people serving at what you might call normal PRTs. 
35

Not surprisingly some of our members who have returned from 

these postings have complained of symptoms that we understand 

are associated with post traumatic stress disorder. There is confusion over the numbers. I think it is because we do not know how 

many people are suffering from this disorder. All I can tell you is 

that I have myself spoken with several dozen of our members when 

they have returned from Iraq who have expressed to me that they 

are experiencing symptoms which I understand to be associated 

with PTSD. 

Whether they have been diagnosed as having the disorder or not 

I cannot say but they have certainly expressed those symptoms. I 

applaud Dr. Brown and the office of medical services for launching 

this survey which I understand is not yet complete but the preliminary results which have been circulating I understand show that 

more than 40 percent of those who responded have said that they 

are experiencing symptoms which we believe to be associated with 

PTSD including difficulty in sleeping, nightmares, lack of concentration, feelings of depression, thoughts of suicide and bodily 

harm and inability to cope with work. 

We believe it is imperative for the Department of State to take 

immediate steps to better prepare employees for deployment to war 

zones and to help them to cope with what they will undergo while 

posted there. Many of our members upon returning from Iraq have 

commented that they had little opportunity in their view for proper 

counseling before, during or after their assignments. 

Counseling should perhaps be thorough and mandatory for everyone so that no one can be stigmatized for having participated in it. 

Our feeling is that people should not have to self-diagnose for post 

traumatic stress disorder in order to get help. 

One of the reasons why we are not sure we have no way of knowing how many people are suffering from this disorder is because 

the people of the Foreign Service are very tough by nature. They 

are very adaptable. They are accustomed to difficult hardship postings, and some may not be willing to come forward out of fear of 

being labeled as complainers or may be concerned about retaliation 

if they speak out. 

All we are asking is that the Medical Director and the Director 

General ensure that special attention is focused on the needs of civilian employees who are sent unarmed into these war zones. The 

department must accept the long-term responsibility for the mental 

health of employees whom it places in harm’s way. Thank you, Mr. 

Chairman, again for holding this very timely hearing. I would be 

happy to answer any questions you or your colleagues may have. 

[The prepared statement of Mr. Kashkett follows:]

PREPARED STATEMENT OF MR. STEVE KASHKETT, VICE PRESIDENT, AMERICAN

FOREIGN SERVICE ASSOCIATION

Mr. Chairman, the American Foreign Service Association welcomes the opportunity to speak before this subcommittee on the subject of the challenges and problems facing U.S. diplomatic personnel assigned to war zones, specifically with regards to post-traumatic stress disorder. We are grateful to you for convening this 

hearing and for helping raise the profile of this urgent issue with your colleagues 

in Congress and at State. I will make a brief opening statement and then look forward to answering your questions. 

As you know, AFSA represents the members of the U.S. Foreign Service both as 

their official labor union and as their professional association. As AFSA’s elected 
36

Vice President for the State Department, my constituency includes more than 

11,000 State Foreign Service employees assigned both domestically and overseas at 

more than 250 embassies, consulates, and other diplomatic outposts all over the 

world, including some 200–300 members currently serving in Iraq. All are volunteers. We estimate the number of our members who have volunteered to serve in 

Iraq since 2003 at close to 2,000. 

Iraq—and Afghanistan—are unique cases where we are sending unarmed civilian 

employees of the U.S. government into active combat zones. Foreign Service members, while accustomed to serving their country overseas under extremely difficult 

conditions, are not soldiers and are not trained for combat. Yet in Iraq, they are 

often directly exposed to conditions of war which they may not always be welladapted to cope. 

Foreign Service members assigned to our embassy in Baghdad experience frequent incoming fire in the Green Zone and sleep in vulnerable aluminum trailers. 

Foreign Service members assigned to regional embassy offices and Provincial Reconstruction Teams in other parts of Iraq often live on U.S. military Forward Operating 

Bases in combat areas and work entirely in a ‘‘red zone’’ environment. Those who 

will be assigned to several newly created ‘‘EPRT’s’’ will be literally ‘‘embedded’’ with 

mobile combat units of the U.S. military in hostile areas. All of our members assigned to Iraq are exposed to attack, including from the dreaded improvised explosive devices that have killed so many U.S. soldiers, when they make any move outside of their compounds. Many have lost Iraqi and American colleagues. Most have 

witnessed violence beyond the normal experience of civilians. 

Not surprisingly, some of our members who have returned from these postings 

have complained of symptoms that are clearly associated with post-traumatic stress 

disorder. We cannot know the precise number, although preliminary results from 

the State Department survey suggest that it may affect some 40% or more, similar 

to what has been reported for the U.S. military. We at AFSA have been in contact 

with—and are today speaking on behalf of—many of our members who are struggling to readjust to civilian life. The symptoms they have described to us have included difficulty in sleeping, nightmares, lack of concentration, feelings of depression, thoughts of suicide and bodily harm, and inability to cope with work in their 

onward assignment after Iraq. 

It is imperative for the Department of State to take steps immediately to better 

prepare employees for deployment to war zones, to help them cope with what they 

will undergo while posted in a war zone, and to deal with any problems they may 

experience afterwards. Many of our members, upon returning from Iraq, have commented that they had little opportunity for proper counseling before, during, or after 

their assignments. Some felt they were penalized for raising their concerns about 

PTSD by having their medical or security clearances suspended. 

This should not happen. Counseling should be thorough and mandatory for everyone so that no one can be stigmatized for participating in it. People should not have 

to ‘‘self-diagnose’’ for post-traumatic stress disorder in order to get help. 

Foreign Service members by nature are tough, adaptable individuals, accustomed 

to difficult hardship postings and used to putting up with adverse situations without 

objection. We are therefore concerned that many who are suffering from post-traumatic stress may not be coming forward out of fear of being labeled as ‘‘complainers.’’ They also fear retaliation for speaking out. 

We call upon the Department to act right away to address this urgent problem. 

We are pleased that State has launched a survey to determine the extent of these 

problems that date back to 2003, but we cannot wait for a full analysis. People are 

on the edge now. AFSA urges the Medical Director and Director General to ensure 

that special attention is focused on the needs of civilian employees who are sent unarmed into these war zones. The Department must accept the long-term responsibility for the mental health of employees whom it places in harm’s way. 

Finally, I would note that we see this problem of post-traumatic stress disorder 

in the broader context of concerns about the size of our diplomatic mission in Iraq, 

about the security of our members in Baghdad and at the ever-expanding PRT’s, 

and about the ability of unarmed diplomats to perform the tasks assigned to them 

in the middle of a highly unstable internal conflict. These are all questions that 

merit open discussion. 

Thank you again, Mr. Chairman, for holding this very timely hearing. I would be 

happy to answer any questions you and your colleagues will have.

Mr. ACKERMAN. How is it that you as one individual, one person, 

knows of twice as many cases of people who have expressed these 

types of symptoms than the whole Department? 
37

Mr. KASHKETT. I am not sure that what I said contradicts in any 

way what Dr. Brown said. I am the Vice President for the State 

Department constituency in the Foreign Service. All of the State 

Department Foreign Service members who serve in Iraq are part 

of my constituency. Many of them do come back and talk to us 

about various concerns that they have after their service there. I 

have probably talked to several hundred of them over the past 2 

years since I have been in office. 

I am saying that a couple of dozen of them have come back to 

me and expressed to me symptoms which I understand to be associated with post traumatic stress disorder. I am not sure if Dr. 

Brown was perhaps referring to the number of people whom the 

medical office has diagnosed as having the full-blown disorder. I 

am not a doctor. I am simply explaining anecdotally what I have 

heard from our members when they come back. 

Mr. ACKERMAN. The people with whom you have spoken, did they 

present themselves to these volunteer out briefings or did they file 

medical reports? 

Mr. KASHKETT. I cannot tell you how many of them participated 

in the voluntary out brief sessions. I can tell you—again speaking 

anecdotally from what I have heard from people coming back from 

Iraq—that many of those who did, did not find it to be a particularly credible, worthwhile experience. If I understand correctly——

Mr. ACKERMAN. You are talking about going to the——

Mr. KASHKETT. The out briefing. 

Mr. ACKERMAN. The out briefings. Not going to——

Mr. KASHKETT. Yes. They described it as not a comprehensive 

session, not a counseling session, more of a 2- or 3-hour session to 

talk about a whole range of issues for returning back to duty in the 

United States but they did not feel that it addressed their psychological needs in any meaningful way, and I would add that if I understand correctly those out briefings were not just for people coming out of the two war zones at Iraq and Afghanistan but were for 

anyone returning from an unaccompanied posting, and we do have, 

as Ambassador Staples said, we do have unaccompanied posts all 

over the world which are very difficult and dangerous in their own 

ways but they are not active war zones. So the experience of people 

coming out of them is really quite different. 

You said in your verbal and written testimony that you would 

urge the department to take immediate steps to better prepare. Are 

there any specific steps you would like to see them take? What 

should they be doing? 

Mr. KASHKETT. Again I am reflecting to you what I have heard 

from our members who have come back from Iraq, and what they 

have said, mostly what I have heard from them is that they wish 

they had had much more extensive counseling before they left on 

what kinds of things they should expect, what kinds of psychological stresses they will be under, and that upon return they felt 

that the counseling should be much more extensive, and most of 

them I would say have expressed the view that it should be for everyone so that no one who participates in it can feel as if they have 

been stigmatized for doing so. 

Mr. ACKERMAN. Have any members of your association reported 

to you or filed official complaints about being harassed or discrimi-
38

nated against because of concerns they have raised about mental 

health kinds of issues? 

Mr. KASHKETT. The problem I think for our members is that if 

you come forward to say that you are suffering from some symptoms that are those that we associated with post traumatic stress 

disorder, people are afraid that their medical clearance could be 

jeopardized, could be either withdrawn or changed so that they will 

no longer be worldwide available for assignments. 

Mr. ACKERMAN. Concerns are real to people but are there any 

cases where that has happened that you know of? 

Mr. KASHKETT. I have been told of cases where people’s medical 

clearance was changed. Was changed to a different category which 

is no longer worldwide available. As Dr. Brown said, this may be 

a temporary measure but in our business, in our profession the 

only way to advance a career in the Foreign Service is to serve 

overseas. The only way to serve overseas is if you have a medical 

clearance to do so. 

So people care very, very deeply about their medical clearances 

because it is directly related to their ability to pursue their careers. 

So if people feel as if their medical clearance will be jeopardized 

or might be jeopardized if they come forward to complain of PTSD 

like symptoms, then many of them may not be willing to come forward. That is what we are worried about. 

Mr. ACKERMAN. The fears may not be well founded but nonetheless they are fears, and as such I think it is imperative for the department to deal with dispelling those kinds of notions. What could 

the department do in order to alleviate the concerns or fears that 

people have that the agency might be retributive? 

Mr. KASHKETT. I think the department could go a long way toward alleviating those fears with very clear statements and policies 

to the effect that people will not be penalized, should not have any 

concerns on that score, and that these counseling types of sessions 

would be mandatory for all so that no one could be singled out. 

This way everyone gets a certain amount of treatment without anyone having to identify themselves as having a problem that needs 

treatment. 

[Pause.] 

Mr. ACKERMAN. Should there be an outside agency to which people are referred if they express they have a concern rather than 

within the department? 

Mr. KASHKETT. By an outside agency you mean an outside medical agency to treat them? 

Mr. ACKERMAN. Yes, for mental health issues. 

Mr. KASHKETT. I am not sure I would know how to answer that. 

I have confidence in Dr. Brown and his staff to decide what kinds 

of treatment people need. 

Mr. ACKERMAN. No. I have no confidence in myself to do that. So 

I am not going to ask you to do that but the question is: Would 

employees feel more comfortable in dealing with those issues outside of the decision-makers within the agencies and feel that there 

is no way of being stigmatized by what they are telling somebody 

outside of the State Department’s employ whether that person is 

the same person they complained to the first time or second time 

because I think the implication to which were drawn from the Am-
39

bassador was that they may not see the same person the next time. 

The person to whom they complained may not be the person but 

evidently it was the same procedure and process, and it could be 

the same person. 

Mr. KASHKETT. Yes. In that case, I think some of our members 

probably would feel more comfortable speaking to an outside mental health professional if they felt that they could do so freely without it having any direct affect on their medical clearance. 

Mr. ACKERMAN. One would assume that people suffering from 

PTSD would need more than just going to one session, an out briefing, regardless of how many hours that might need. That is something as serious as this type of problem would require a degree of 

counseling over a series of sessions, the number of which I have no 

clue. It may be very extensive. Does the department provide for 

that? 

Mr. KASHKETT. I am not the right person to ask but I can tell 

you that those of our members who have come forward behind 

closed doors to tell us that they have felt these symptoms do say 

that they felt they needed much more than just the out brief that 

the department provides. 

Mr. ACKERMAN. In your written statement you urge the department to address the question of PTSD even before the survey analyzing this has been completed. What steps would you advocate 

they take immediately? 

Mr. KASHKETT. I made that remark in my prepared statement 

because it has come to my attention that there are a number of our 

members who have returned from Iraq who are suffering very 

badly at this moment in time, and that this is not something that 

can wait for a survey to be completed and for results to be analyzed. There are people who are in great, great need today, and 

those needs should be addressed. 

Mr. ACKERMAN. Before I turn to Mr. Scott, in your statement you 

referred to broader concerns about our mission in Iraq. Can you 

elaborate on what some of the other concerns are that could be affecting our Foreign Service members? 

Mr. KASHKETT. Yes. These questions surrounding post traumatic 

stress disorder are just one category of concerns that our members 

have expressed upon returning from service in Iraq. Others include 

concerns about whether they had been able to perform their jobs 

effectively in the environment in which they found themselves 

there. The broader questions of whether diplomats, unarmed civilians can actually carry out the job that diplomats have to carry out 

in an environment where there is a fairly extreme internal conflict 

going on, whether they are able to do their jobs in the security environment and the security restrictions that they have to operate 

under. Another area of concern——

Mr. ACKERMAN. I am sorry to interrupt. Does this go to the issue 

of whether or not they can be effective in those circumstances or 

is this a broader issue of the purpose of the mission in Iraq all together? 

Mr. KASHKETT. AFSA is concerned with the welfare or the well 

being of our members and the conditions of work for our members. 

We are not——
40

Mr. ACKERMAN. I am not asking you for a personal political assessment of whether we should be there or not. 

Mr. KASHKETT. Yes. 

Mr. ACKERMAN. But I am asking if this is a concern that bears 

upon people. You know the military has a different or a special approach to how to deal with purpose and sense of mission that is 

completely different than a civilian approach. My question really is 

not making a value judgment of should we be there or should we 

not. That is not your job, and it is not the purpose of this hearing. 

But is that a concern that bears on the effectiveness or ability of 

people to perform their jobs from an effective point of view and a 

psychological point of view? 

Mr. KASHKETT. Yes, I think it does. Please understand that our 

members come back with a wide variety of reactions across the 

spectrum but a significant percentage of our members who have returned from Iraq with whom we have as their representative organization have been in touch have expressed questions about their 

effectiveness, about whether what they did there was worthwhile, 

about whether it was a meaningful experience, and this does play 

into their overall experience of serving in Iraq for a year. 

One other area of very great concern for many of our members 

serving in Iraq and I think it does have some affect on post traumatic stress disorder is that they work very, very closely with 

Iraqis, with locally employed staff. Ambassador Staples referred to 

them. There are several hundred Iraqis at least who work for the 

United States diplomatic mission in Iraq, and quite a large number 

of our members returning from Iraq have expressed concerns that 

those Iraqis have not been properly looked after. That they have 

lost Iraqi colleagues. 

Iraqi colleagues have been specifically targeted because they 

have been working for the U.S. mission, and these colleagues are 

very important to our members. So seeing their colleagues, whether 

they are Iraqi or American, be targeted, injured or killed does have 

a profound affect on our members. 

Mr. ACKERMAN. Just for the record this subcommittee did hold 

a hearing on refugees and those people who are Iraqi nationals who 

have been supportive of our mission and what our obligations 

might be to them. Mr. Scott. 

Mr. SCOTT. Thank you, Mr. Chairman. Let me start with you addressing this huge inconsistency between what Dr. Brown assessment of the scope of the problem and what you say your scope of 

the problem is. Dr. Brown says there may have been 12 or 15 

cases, and I did not get that sense of urgency from his presentation. 

You seem to be coming at it from a different way with a greater 

sense of urgency, and I am wondering why this discrepancy, and 

it is especially clear in your statement where you say we cannot 

know the precise number although preliminary results from the 

State Department survey suggests that it may affect some 40 percent or more, similar to what has been reported for the U.S. military. That is a far cry from what Dr. Brown stated in where you 

are sitting in that exact chair just a few minutes ago. Can you explain that? 
41

Mr. KASHKETT. I am trying to understand the confusion over 

numbers myself. Our feeling that this is an urgent problem comes 

from two sources. One is the members who have come to us themselves to assert that they are suffering from symptoms that we understand to be associated with PTSD. I am not a doctor. I am not 

diagnosing them with PTSD. I am simply saying that they have 

come forward to say they are suffering, sometimes suffering badly 

from those symptoms. 

I have these people sitting right across from me. I feel for them. 

They are clearly human beings suffering from these kinds of symptoms. The other source of our sense of urgency is—and I am prepared to accept that maybe this is preliminary—is that the State 

Department survey which the office of medical services has 

launched has already circulating within the department are what 

I understand to be the results thus far of that survey, and unless 

I am misreading them it appeared that the results thus far indicate 

that something on the order of 40 percent or more of our people returning from these kinds of postings have expressed the feeling 

that they have these symptoms. Have complained of these symptoms. 

Whether these people have what a medical professional would 

call full-blown PTSD or not, I am not in a position to say. So maybe 

that helps to explain a bit of the numbers confusion. 

Mr. SCOTT. Okay. Well we certainly want a good number. I mean 

this committee is having this hearing for a reason. This is a serious 

problem. We want to help these people. We want to get them the 

resources they need. We want to help them. We want to get rid of 

their fears of being detected with this. We want them to be solid, 

and we do not want this to be a stigma on their careers going forward but in order to do this we have got to depend upon you all 

who represent these Foreign Service officers as you do and the 

State Department to be on the same page to give us the information we need upon which to make the most intelligent decisions 

about resources, giving you the help you need. 

So I just say that because I tell you I am personally very concerned about this. I care about our Foreign Service workers. I have 

been into Afghanistan, into Iraq. They have been there. They probably have saved my life and the lives of many Congresspersons 

when we go into those war zones. We have to depend upon them, 

and we are here to help them but we need accurate information, 

and I concur with your urgency. I mean it is not that I am not on 

the side of the good doctor here. I am sure he speaks from which 

he is there but I have a sense of urgency here in knowing this. 

Now, I want to go to one point you mentioned because I am not 

sure the American people or any of us—I know I was not aware 

of this—that we have individuals with the State Department and 

in our Foreign Service embedded in the mobile combat units that 

are actually taking place in the surge as we speak, unarmed, in 

harm’s way. What you say here exactly is Foreign Service members 

assigned to regional Embassy offices and provincial reconstruction 

teams in other parts of Iraq often live on United States military 

forward operating basis in combat areas and work entirely in a red 

zone environment, and those who will be assigned to the severally 

new corrected EPRTs will be literally embedded with mobile com-
42

bat units of the United States military in hostile areas. That is a 

true statement? 

Mr. KASHKETT. That is our understanding that this year, in the 

last 3 or 4 months, in addition to the existing provincial reconstruction teams which have been in place for well over a year now in 

various provinces of Iraq that now there will be I think four new 

PRTs that will be called EPRTs where the E—unless I am misunderstanding—refers to embedded, and that this has been described to us and to our membership as being positions that will 

be embedded within a combat unit. 

I believe all four of them—I am sure Ambassador Staples could 

clarify this—I believe all four of them are to be located in the 

greater Baghdad area but they will be actually embedded with 

those units. 

Mr. SCOTT. What do you say about this, as the union, as the representative organization of this? Is this okay with you and the association of the Foreign Service? 

Mr. KASHKETT. Our concern is that if our members are going to 

be put in those kinds of positions which are very different from almost anything that diplomatic personnel do or have done elsewhere, that they need all of the necessary training, security protection, psychological preparation, et cetera to undertake those kinds 

of tasks. 

Mr. SCOTT. I agree with you, Mr. Kashkett, and I am surprised, 

one, that they are being embedded and not with that training. So 

you are saying not only are they embedded here but they are embedded not with the training that is basically essential for them to 

protect themselves in such a situation. Is this what you are saying? 

Mr. KASHKETT. Well all of our people who are assigned to Iraq 

do receive special training, training that is different from that 

which our people receive going to other posts but as I understand 

it our people are not armed and will not be armed when they serve 

in these embedded positions with these military units. So as far as 

I know they will not be getting any kind of military or paramilitary 

training to do so. 

Mr. SCOTT. So they are not getting the training. They are embedded in the hostile combat units, and they are not allowed to carry 

a gun? 

Mr. KASHKETT. That is my understanding that they are not to be 

armed and will not be receiving that kind of training. 

Mr. SCOTT. That is absolutely remarkable, and I would like for 

you to help us and this committee and certainly myself and I cannot speak for anyone else but I would like to get any information 

on that because I think that that is clearly not right, and some 

questions need to be asked of the proper people about this. We 

need to know who to ask those questions to and how we can correct 

this situation. Let me ask you do you have any hazardous or do you 

have any casualty numbers that lives we have lost of our Foreign 

Service folks in these kinds of situations? 

Mr. KASHKETT. In Iraq in general or are you saying for——

Mr. SCOTT. In Iraq in general and any in this very perilous situation that we are working our way through right now embedded in 

combat zones, particularly in the surge and the EPRTs. 
43

Mr. KASHKETT. Well first let me say my understanding is that 

these EPRTs have not yet been stood up. The people have been recruited just over the past few months. I do not know if any of them 

have actually been deployed into these positions yet but in terms 

of Foreign Service employees serving in Iraq over the past 4 years 

I would say we have been very lucky. There have been I think 

three fatalities in total among our membership. In other words 

among the membership of the career Foreign Service. 

A certain number of injuries, it is very difficult for me to know 

how many but this has been very fortuitous because many of our 

members returning from service in Iraq have told us that they 

have had near misses. That they have been in situations where 

they could have been killed or injured but luck has been with us 

for the past 4 years and we have not suffered major, major casualties. 

Mr. SCOTT. Okay. So the EPRTs have not started yet. They are 

about to so we can get that but your reference to them being in 

combat areas I would expect that would be where they have to live 

on U.S. military forward operating bases in combat areas or in red 

zone environments where they are not allowed to carry weapons to 

protect themselves nor have gone through the training. That is certainly an area that we certainly need to address that in addition 

to the combat. I mean to the post stress syndrome disorder. 

Let me ask a series of questions, if I may, on that. I am trying 

to get at if it is at that level now and we are going to be adding 

more people to it. If I put myself in the position of a Foreign Service officer, why is it that I would not want anybody to know that 

I have been treated for this disorder? In addition to the stigmatization, would it hinder his career? Would it say that if you have suffered from this or if you have been treated for this, this is going 

to limit you in your career options going forward? Is it that kind 

of stigma that they fear will stop their career cold if it is known 

that they were treated for this? 

Mr. KASHKETT. I think it is partly that. Partly fear that it will 

impede their career enhancement. Partly fear—whether founded or 

not—that it will impact on their medical clearance, and partly fear 

that perhaps colleagues will view them as not having been able to 

handle it. I think people have all kinds of legitimate reasons for 

perhaps being very reluctant to come forward, and for this reason 

I think we really are operating in the dark in terms of trying to 

pin a number on how many people are suffering from these symptoms. 

Mr. SCOTT. Do you think it would work out? I mean we are plowing new territory here. I mean this is a new area of concern. But 

let us say he gets to treatment. Is there a system worked out? Is 

there a plan or a procedure or process worked out where you know 

particularly if you are making this mandatory now, as I see we are 

doing? There ought to be some kind of system in place which gives 

the individual some comfort level to know this is the process I am 

going through. That there will be some help upon my return of 

going back to service. 

Is there any type of reentry allowance so that the returning employees are not immediately thrust back into work without being 

ready? Is there assistance? Is there compensation forms there that 
44

he fills out? How many workers’ compensation forms have you 

filled out to date? I mean does that apply? Is there assistance in 

helping to find a therapist with expertise in PTSD? 

Does the State Department insurance cover this? How much of 

a financial burden is it going to be on him? I mean like any workplace injury or any other workplace here in the United States, 

there is a procedure. There is a process that is there so a person 

feels comfortable coming in. Do we have any of those things worked 

out for this? 

Mr. KASHKETT. I am afraid most of these questions are questions 

that should properly be answered by Ambassador Staples or Dr. 

Brown. One thing I can say to you is that our members who return 

from a year in Iraq do have the opportunity—in fact the obligation—to take home leave which is a block of time separate from 

their normal annual leave that they have to take at their home, 

their home leave location. So that period of time would be before 

they would have to start their next assignment. 

Mr. SCOTT. Yes. What I am saying though, Mr. Kashkett, and I 

know to have asked that to them, but the reason I am asking this 

of you is because you represent, if I am the guy you represent me. 

You represent the victims here. You represent the people, and I 

want to know from your perspective is there adequate procedures 

in place that give these folks a comfort level? Maybe that is not 

what it is. Maybe there is something that needs to be on the front 

end so when we get people in to do this they can have some level 

of comfort level and assurance that you are coming in and getting 

treated and doing this and getting well from this is not going to 

hamper your career. 

Mr. KASHKETT. I absolutely agree with you that the department 

needs to find ways to increase people’s comfort level to facilitate 

their ability to come forward when they are experiencing these 

symptoms to make it easy for them to get treated not harder to get 

treated. 

Mr. SCOTT. Good. The final question I want to ask, Mr. Chairman if I may, is I was very intrigued with what you said about another facet of this that is not covered in this event of an explosion, 

an IED, the combat, all of that but you mentioned that there is an 

impact of this, there is a section of this impact that is impacted on 

their association, their bonding that they had developed with Iraqis 

with whom they have come to rely on where they have had relationships. 

How severe is that? I mean how serious is that in what they are 

saying that has a very serious impact on their psychological and 

mental being? How serious is this an issue because this is where 

in my estimation where we will win in the Middle East, not 

through bullets but through winning hearts and souls and minds 

of people? And I have captured a little bit of that in you as being 

one of the great disappointments and psychological losses to people 

when they see people who have come over and have been killed or 

wiped away, and I am wondering just how serious that is. 

Mr. KASHKETT. I realize that this is a peripherally related issue 

to the subject of this hearing but I would say that this is a very, 

very serious concern for a significant number of our members who 

have returned from serving in Iraq because they do depend on 
45

their Iraqi colleagues, on the locally employed staff at the Embassy. They work with them side-by-side everyday, and when one 

of their Iraqi colleagues with whom they have become not just colleagues but friends is targeted or killed or injured or can no longer 

come to work because they are in hiding or has to flee the country, 

all of these things are experiences that our members have had with 

their Iraqi colleagues. 

This does have a serious impact on people. There is a group of 

Foreign Service returnees from Iraq who have been very openly 

and aggressively advocating for measures that the U.S. Government might take to better take care of those Iraqi employees of the 

U.S. Government who have been targeted. 

Mr. SCOTT. So you are saying in the conclusion of your statement 

is that this has a profound impact on post traumatic stress disorder? 

Mr. KASHKETT. Again I am not a doctor. I can say that it has an 

impact, very serious impact on the thinking of our members. This 

is a subject that they come back feeling very guilty about if they 

feel that they have left Iraqi colleagues behind, and if they subsequently hear that that person has been killed or injured. 

Mr. ACKERMAN. Thank you very much, Mr. Scott. Quick mathematical point. Mr. Scott said we need a good number. I know he 

did not mean that we want you to come up with a bigger number 

for the sake of coming up with a bigger number but a real number 

which is very difficult to make a determination based on the two 

panels but a mathematical extrapolation yields the following: If out 

of the 1,200 or so people that served 10 percent actually voluntarily 

had the out briefing and that yielded 15 people—let us take the 

higher number—if that yielded 15 people out of that 120, that is 

121⁄2 percent of the people that were seen, not just expressing the 

70 or 80 percent of the people that expressed the problem but are 

determined to have PTSD, 121⁄2 percent. 

If that number is an accurate sampling and of course we do not 

know that to be the case, and if 25 percent of the Foreign Service 

officers which is approximately 12,000, approximately 25 percent of 

12,000 are going to see service in Iraq, that is 3,000. If you take 

121⁄2 percent of 3,000, you have 375 cases projected of PTSD. So 

whether that is a good number, a bad number, it is mathematically 

the extrapolated number based on the data that we have heard, at 

least if that sample is exemplary of the whole Foreign Service. 

That is a real number, and that is cause for concern. 

You mentioned, Mr. Kashkett, at the beginning of your testimony 

that there are a lot of cases, and that you are very moved when 

these people sit in front of you because they are your colleagues, 

and you feel for them. Could you share one or two of those with 

us without names? 

Mr. KASHKETT. Share in what sense? 

Mr. ACKERMAN. Share how it moved you with your repeated caveat that you are not prepared or qualified to make a medical determination. 

Mr. KASHKETT. Right. 

Mr. ACKERMAN. Which we the most concerning of the cases? 

Mr. KASHKETT. I can without mentioning names I can describe 

several people who have come to me, and this is just in the past 
46

couple of months, to say that they have been back from Iraq for a 

significant amount of time, have had consistent problems readjusting, cannot concentrate on their work, are having great difficulty sleeping, feel very emotionally fragile, feel very guilty about 

the Iraqi colleagues whom they have left behind, are still reliving 

traumas where they saw people injured or killed. 

Mr. ACKERMAN. You say they are reliving it. Are these people 

that wake up in the middle of the night? 

Mr. KASHKETT. Still seeing the video in their head playing and 

are struggling. And again I am not a doctor. I am not trying to diagnose them whether they have what a medical professional would 

call PTSD but they exhibit to me all of the symptoms that I understand are associated with PTSD, and many of them have told me 

how can you expect us to take the initiative ourselves to come forward? Part of the problem is that people are very reluctant. Are 

very indecisive. Are very reluctant to put themselves in the spotlight and to come forward. So these are the kinds of things that 

I have heard from a number of our members upon returning. 

Mr. ACKERMAN. We appreciate that because there were no takers 

from the group to appear in public and to bare their souls. I presume it is a very painful kind of thing besides having career concerns, and we can appreciate that. Let me thank you on behalf of 

our subcommittee for being—as well as the first panel—so concerned about our Foreign Service officers, our State Department 

people, and our civilians that are serving our country so well, so 

diligently, so patriotically at tremendous sacrifice to themselves, at 

times at great risk to their lives and certainly their health. The 

committee stands adjourned. 

[Whereupon, at 4:25 p.m., the subcommittee was adjourned.] 
(47)

A P P E N D I X 

MATERIAL SUBMITTED FOR THE HEARING RECORD

PREPARED STATEMENT OF THE HONORABLE SHEILA JACKSON LEE, A REPRESENTATIVE

IN CONGRESS FROM THE STATE OF TEXAS

Thank you, Mr. Chairman, for convening this important and timely hearing. Post 

Traumatic Stress Disorder, or PTSD, is a major problem among those returning 

from war zones, and I believe we have the responsibility to assist them in any way 

possible. May I also take this opportunity to thank the Committee’s Ranking Member, and to welcome our distinguished witnesses, the Honorable George M. Staples, 

Director General, Foreign Service and Director of Human Resources, Department of 

State; Laurence G. Brown, M.D., Director, Office of Medical Services, U.S. Department of State; and Mr. Steve Kashkett, Vice President, American Foreign Service 

Association. I look forward to your insightful comments. 

Post Traumatic Stress Disorder (PTSD) has long been seen in soldiers returning 

from combat. Congress has recognized the need to address this serious problem, and 

in 1989 mandated the Department of Veterans Affairs to create the National Center 

for Post Traumatic Stress Disorder to treat returning veterans. Because I feel 

strongly that more remains to be done for our returning veterans, last week I was 

proud to introduce an amendment to the Veterans Affairs and Military Construction 

Appropriations Act of 2008 that would have required increase the number of medical facilities specializing in PTSD in underserved urban areas. 

PTSD was first brought to public attention in relation to war veterans, but it can 

result from a variety of traumatic incidents, such as mugging, rape, torture, being 

kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, 

bombings, or natural disasters such as floods or earthquakes. 

People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used 

to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or 

even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms 

seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping. Most people with PTSD repeatedly 

relive the trauma in their thoughts during the day and in nightmares when they 

sleep. These are called flashbacks. Flashbacks may consist of images, sounds, 

smells, or feelings, and are often triggered by ordinary occurrences, such as a door 

slamming or a car backfiring on the street. A person having a flashback may lose 

touch with reality and believe that the traumatic incident is happening all over 

again. 

Mr. Chairman, the fact of the matter is that most individuals with PTSD also 

have other psychiatric disorders, which are a direct consequence of PTSD. These 

people have co-occurring disorders, which include depression, alcohol and/or drug 

abuse problems, panic, and/or other anxiety disorders. 

The current conflicts in Afghanistan and Iraq are the most continuous combat operations since Vietnam. Only one comprehensive study has examined the mental 

health impact of the wars in Afghanistan and Iraq, and that was performed by 

Charles W. Hoge, M.D. This study looked at the experience of soldiers in the war 

zone and symptoms of psychological distress. Soldiers in Iraq are at risk for being 

killed or wounded themselves, are likely to have witnessed the suffering of others, 

and may have participated in killing or wounding others as part of combat operations. All of these activities have a demonstrated association with the development 

of PTSD. Dr. Hoge’s study indicated that 94% of soldiers in Iraq reported receiving 

small-arms fire. In addition, 86% of soldiers in Iraq reported knowing someone who 

was seriously injured or killed, 68% reported seeing dead or seriously injured Ameri-
48

cans, and 51% reported handling or uncovering human remains. The majority, 77%, 

of soldiers deployed to Iraq reported shooting or directing fire at the enemy, 48% 

reported being responsible for the death of an enemy combatant, and 28% reported 

being responsible for the death of a noncombatant. 

Previously, the Department of State has not typically had many of its personnel 

serving in war zones, nor seen significant numbers of diplomats return from overseas posts with PTSD. However, with about 1,000 Americans now staffing the U.S. 

Embassy in Baghdad and in the regional posts in Iraq, the State Department is seeing a growing number of individuals return to the United States with PTSD. Necessary infrastructure does not yet exist to address this disorder among civilian employees. 

Civilian employees in Iraq often report feelings of abandonment and distrust. 

They feel they did not receive adequate training before deployment or sufficient 

counseling upon their return, and they have stated they do not feel the State Department knows how to deal with the large number of people experiencing these 

problems. These people have served their country bravely overseas in dangerous circumstances; they, like our returning veterans, deserve the best treatment and care 

upon their return. 

Returning State Department employees have expressed a number of concerns 

with existing State Department services for returning personnel from Iraq and Afghanistan. One returning diplomat commented that the exit briefing conducted following service in Iraq actually did more harm than good, because it included nonwar-zone diplomats and highlighted the disparity in sacrifices and hardships endured by personnel at different overseas posts. These briefings failed to address the 

specific needs of diplomats serving in war zones. Another diplomat reported that the 

Secretary of State visited the embassy and took photos with the Marine Corps Detachment, but not with the diplomats serving in Iraq, despite their requests. 

Such small but crucial gestures could go a long way towards combating distrust, 

which remains a major factor in coping with PTSD at the Department of State. 

Many officers are reluctant to report any symptoms for fear of losing their security 

and/or medical clearance, both of which are necessary to be assigned overseas. The 

Department of State must create a safe environment for these individuals to seek 

the treatment they need without fear of professional repercussions. 

Mr. Chairman, I thank you for convening today’s hearing, and for drawing attention to the fact that our brave veterans are not the only ones suffering from the 

psychological wounds of war. As our involvement in Iraq drags on, more and more 

American personnel are serving in dangerous conflict zones. I strongly urge this 

Congress, as well as the Administration, to work to ensure that all who serve their 

country, whether it be as soldiers or as diplomats, receive the best possible treatment for their physical and emotional needs. 

Thank you, and I yield back the balance of my time.

Æ