 Good afternoon. Welcome to the Kabul experience. As Chairman of the Mental Health Committee, may I say on behalf of the entire committee how very glad we are that you have come to this presentation. I should like to thank the many people who have been instrumental in arranging this afternoon's program. In addition to the Mental Health Committee, the Office of Medical Services, the Director General's Office, the Family Liaison Office, the Foreign Service Institute, and the International Communications Agency have all made enormous contributions, some in the form of financing, all in the form of moral support, logistics, and just plain work. Our thanks to all of you. I should like to read to you a letter we received from Mrs. Carter. Dear Betty, thank you for telling me about the Kabul experience. As you may know, the President's Commission on Mental Health, on which I served as honorary chairperson, gave high priority to the prevention of mental illness. It is clear that one of the greatest obstacles to more effective prevention efforts is our unwillingness to admit that not only do mental problems exist, but that we must begin to speak openly about them, removing the stigma so often associated with them, seeking ways to deal with them before they become serious. I commend the Mental Health Committee for its public presentation of the Kabul experience. I hope this will be about one of many steps to encourage greater awareness of mental health problems. We must acknowledge their existence and dedicate ourselves to finding new ways to prevent them. Sincerely, Rosalind Carter. May I now present our panel members here on the stage. As the Kabul experience unfolds, they in turn will introduce the other participants at Kabul who are seated in the audience. Ambassador Ted Elliott, who many of you know, was most recently our ambassador in Kabul and was instrumental in getting the program going. Dr. Pettinga, regional medical officer for the area at the time. Dr. Westmas, the first mental health expert at POST. It gives me great pleasure to present a person we all admire not only for his tireless efforts in the field of diplomacy, but also for his interest in and concern for the people who work with him throughout the State Department, Secretary of State Cyrus Vance. Betty, Ted and Mrs. Elliott, guests and State Department colleagues. I'm very pleased to be able to personally express my full support for the important work that is being done by the Mental Health Committee and by our own Family Liaison Office. I particularly want to commend all of you who have organized this program today. At the opening of the Family Liaison Office almost a year ago, I spoke of the importance I attach to meeting the needs of the entire Foreign Service family as well as the Foreign Service officer. A healthy and stable Foreign Service family is essential to the successful conduct of our responsibilities here in Washington and particularly in overseas posts which can place a strain on family life. Without strong Foreign Service families, we won't have a strong Foreign Service. I'm greatly encouraged to know that a growing number of posts have developed programs designed to raise the morale and improve the quality of life for Foreign Service families. They've been initiated in places as diverse as Tokyo, Bonn, Singapore, Rome, Kuala Lumpur, Vienna and Kabul. The Kabul experience about which you will learn today was a successful, innovative and effective experiment in improving morale at one of our most challenging posts. Kabul is a different, difficult and isolated post and many of the problems that face Foreign Service employees and their families are particularly acute there. There was an enormously high number of medical evacuations, suicides and a serious teenage drug problem. The people who creatively tackle these problems with such notable success are with us here and they will tell you what they did and how they did it. At a time of limited resources, it is essential that the many agencies representing the United States abroad work together to build the strong sense of community and the strong sense of purpose that can contribute to our overseas efforts. We must find ways to support such programs. As you learn about the Kabul experience and discuss what we can learn from it, I want to underscore that your efforts have the full and enthusiastic support of Mrs. Vance and myself and I shall do everything that I can to work with you to help in furthering this and similar programs. Thank you very much. Thank you, Mr. Secretary. I should like to say just a few words about the family liaison office. Under Janet Lloyd's leadership, it is constantly seeking ways to improve the quality of life for all of us, as the Secretary said. There are now over 30 overseas family liaison offices, many of them providing counseling or having referral services for counseling, along with the many activities for the benefit of everyone. They work closely with the regional medical officers and nurses at post. Here in Washington, flow acts as liaison between the medical and personnel divisions and the members of the family's Medevac. When the panel is finished, Dr. Haynes, Director of Mental Health Services in the Office of Medical Services State Department, will give us an update on the Kabul Regional Program and we hope to have time at the end of the presentation for a question and answer period. I should like now to turn the meeting over to our three panelists. Mr. Secretary, Mrs. Vance, Betty, I think I have to say at the outset that those of us who worked on the problems that we saw and faced in Kabul are immensely gratified at the support we received in those days from the department and we're, of course, immensely gratified by the support, Mr. Secretary, you have given this effort, by the support that this effort has gotten throughout all the foreign affairs agencies. The three of us, I think, sitting here and the many others who worked with us, both in Kabul and here in Washington in all the agencies, have to feel being here on this platform today that we got something started and I think it's something extremely helpful, extremely useful, extremely important for the Foreign Service as a whole and I'm not just talking about the State Department, I'm also talking about AID, ICA, the Peace Corps, the various defense agencies and so forth. I also want to reiterate that we panelists alone are not responsible for what happened in Kabul for the program that existed in Kabul, many other people helped us, many other people played major roles in this effort and, of course, with the exception of Frank Pettinger, many other people are going to be carrying this on in the future. Let me give you a very brief history of how the Kabul Mental Health Program got started. It begins with a conversation that Dr. Pettinger and I had in the early fall of 1973 before either of us were assigned to Kabul. We met here in the office of the desk officer for Afghanistan and we talked about some of the problems that we thought might be facing the American community, then about 600 strong, including men, women and children in Afghanistan. We thought that this was going to be a difficult experience in many ways for us as leaders in a community, in a country which is very isolated geographically and also a country where, for cultural and political reasons, the American community is, to a very great extent, isolated from the local community. The problems of isolation and claustrophobia impose special pressures on the American and the rest of the foreign community in Kabul. In addition, we were aware that there was a serious teenage drug problem. When we both arrived in the later part of the fall of 1973, we stayed in very close touch with each other. Frank Pettinger took the lead in getting a teen center started. We worked together to revise a drug abuse program for the community, which, when we arrived, was a punitive program. That is to say, anybody involved in drug abuse was, after a due number of warnings, to be expelled from the country. We found that this was not working. The children of senior officials of the mission, for some reason or other, weren't being sent home. That the program needed to be altered, and we did alter it to emphasize that a drug abuse question, a drug abuse problem, should be addressed first and foremost in the family, in the community, and with the medical services that are available, and only as a last resort, should one think about disciplinary action for the members of the family or for the employee involved. And I think it's fair to say that in the succeeding months and years, at least I cannot recall any time when I had to take disciplinary action against an employee or a family member once we got this program going. The next thing that happened was that Dr. Pettinger came to me one day and he said, you know, our problems are sufficient here that we should see if we could get a professional mental health person on our staff. And we then launched on a project to convince the medical division back here that Kabul would be an interesting post to start an experiment with a full-time mental health practitioner. And the net result was in the summer of 1974, Dr. Richard Westmas, who is a clinical psychologist, arrived on the scene. I'm going to let Dr. Pettinger and Dr. Westmas give the details of what they did. Suffice it to say that Dr. Westmas' program was such a success that by the summer of 1975 the department had decided that he should expand his activities to include foreign service posts in India, Pakistan, and elsewhere in that area of the world. He was followed himself when he left Kabul in the summer of 77 by a psychiatrist, Dr. Elmore Riggimer, who is still in Kabul, although there was some thought being given to transferring his home base from Kabul to New Delhi for transportation and political reasons. That's the brief history. Let me say just a word about the role of the ambassador in an exercise of this kind. And I think what I'm saying about the role of the ambassador applies also to the role of a DCM, to the role of an administrative counselor. Of course, it's first and foremost important for the leadership of a mission to support a program like this. And we, I think, in Kabul, the DCM, who during most of this period was Ted Kern and the administrative counselors who I see in the audience today, Paul Kelly and Don Woodward, and the chiefs of the various other elements of the mission did what we could to see that Frank Pettinger and Rich Westmas got the logistic and other support and also the support from Washington that they needed. But I think what I want to stress most particularly is how essential it is for the administrators of a mission to stay out, completely out, of the doctor-patient relationship. We, from the very beginning, Frank and Rich and I were very concerned that this program would not work if potential patients thought that their consultations with Rich Westmas were going to come to my attention or to the attention of anybody else in a position of authority in the mission. We succeeded in maintaining this confidentiality. There were occasions where Rich would feel that a certain patient, his job effectiveness or her job effectiveness was being affected by mental health problems. There were some cases where medical evacuation seemed to be a possibility. In cases like that, I was informed or the DCM was informed or the administrative counselor was informed merely of those facts. We were never brought into, we never were asked to be brought into any of the details of any of the therapy or consultations that were going, that were in progress. I might also add that my wife, who's sitting here in the front row, was also throughout this program extremely supportive, but of course she also had absolutely nothing to do with the inner workings of Rich's or Frank's work in this field other than to make it clear to the members of the community that she was wholeheartedly supportive of the effort that was being undertaken. I think this program was successful. Frank and Rich will give you some details which will support that statement. I think that this program is something which commends itself to all the agencies working abroad for the United States government. For all these agencies, the principal resource is people. And the effectiveness of our people overseas should be a paramount concern to the management of all these agencies. And of course that effectiveness is in turn affected by the health of the families of the employees. I would urge that all of us go away from this meeting today thinking about how we can use this experience in other places in the Foreign Service, how we can make resources available to carry on this work, not only in South Asia, but in the other parts of the world. After all, Americans have mental health facilities available to them at home. I think it's high time that similar facilities were available for the Foreign Service. Thank you very much. When people talk about the experience in Kabul, two questions come up so frequently. One is, do Foreign Service families really have more problems than most American families? And to that I would like to say an emphatic no. I was in practice in Michigan for many years before coming to the Foreign Service and dealt with families. And after going to Kabul, found that Americans are the same no matter where they are in the world. They did have some different stress situations that they were exposed to in Kabul that Ambassador Elliott was just speaking about. Certainly we did have parents who in their diplomatic responsibilities felt they had to go to cocktail parties and working dinner meetings and affairs at the Pakistani embassy, et cetera, four or five or six nights a week leaving their children home. Yes, that's true. But we find that also in the American businessman. Yes, we did have drug problems and they were significant, but no more so than in Muskegon, Michigan where I came from. At characteristic that was slightly different of course was the high school senior who was going to be out of the nest the following year going to a college in the States and for once being on his own and being very apprehensive about that. But we have that experience also in families back home. The other question is what happened in Kabul that was so different that you needed a psychologist there? And again, Kabul was no different from many of the other foreign posts around the world. In my last experience, I covered 41 posts in Europe and the same stresses, the same problems, the same difficulties were present in all those posts as they were in Kabul. Some slightly different of course depending on the number of parasites that were involved in a particular area but certainly families were under the same stresses and so Kabul was no different than any other post that I've had an opportunity to be acquainted with. When I first came into the department during my indoctrination here I was briefed on my responsibilities and that these would come under two main categories certainly treatment of disease as it existed but even more important was the prevention of disease or the prevention of problems before they arose. As far as treatment is concerned these were usually fairly straightforward they were not much different from a practice back home except for a few things like again parasites but prevention, this was a bit different because we had circumstances that were a little different than the usual American community at home and we looked at the different possibilities of how we could prevent some of the mental stresses from occurring and becoming significant and being transferred into physical problems. Ambassador Elliott briefed you just a moment ago about his change in the policy of drug enforcement what to do about the person who is utilizing drugs and over a period of warning would still use him should we send him home or not? No, we decided not to because all you're doing is transferring a problem to another community and you're not doing that person any serious good usually you're not doing him any benefit. We saw that there was a need for a youth center and we got many of the leaders of the community together including the Elliott's and the Curran's the head of the different missions the AID director, Vince Brown the Colonel Eliason from the DOD Jerry Werner of ICA and we got these people together on a couple of occasions presented the problem to them and they all agreed yes they thought that a youth center would be advantageous and it's surprising once you present the problem to a community where your resources come from AID provided a house and one of the people on the mission provided a car for an old car for a mechanics shop and there were some photographic equipment and another man donated his talents in that regard and so it went on and on but I must say right at the outset that unless you have good leadership for this kind of a project it's going to fall pretty much flat on its face and we had that experience the first year we had a leader in this group in the youth center that was not well qualified the following year we went to overseas schools asked them for a grant so that we could hire a person from the Mott Foundation and the University of Michigan who was trained in community projects and community leadership and it was much more successful still left many things to be desired but certainly the principle that you need a well qualified person to handle a particular project came forward very clearly and it was much more successful the second year my wife who isn't here today because she's a new grandmother and the doctor guest who was a superintendent of schools and I put on a seminar again in the preventive area this was a family involvement training seminar that I had learned a lot about from Rich Westmas in my days in Michigan this was a seminar for parents on how to improve communication in families what do you do if your youngster seems to be going off the deep end and you don't seem to have any communication with them to make any influence surprisingly we had a great response we limited it to 12 couples but we could have doubled the size of the seminar the first time and I never forget the third session when one of the mothers came back to that session saying just for face all aglow I had an hours conversation with my teenage son last night and that's the first time that's happened in two years you can imagine how good that makes you feel we also got meaningful jobs for students in the summertime and the clue there is the meaningful job if you make a job that that child does not feel as worthwhile and he's just putting in his time it's not going to be a good experience but through again the Ambassador Elliott and the A Director primarily we did find meaningful jobs for the students well we were going through these projects and once you find that you do present a listening ear and that you are available to listen to problems suddenly problems come out of the woodwork and because of these things that we had going and because of the fact that people knew that they could come to the medical unit for any kind of problem we suddenly were deluged with all kinds of problems from many different kinds of people and to the point where we felt that we needed expert advice I had taken a seminar with Rich Westmas a number of years before on this family involvement training or similar to the parent effectiveness training that many of you know about and we talked to the Ambassador and he agreed we talked to the heads of the different agencies who were going to have to support our projects financially and they all agreed that this would be a good idea and we went to the Department of State to the medical section they also thought it was an excellent idea but as usual there was an austerity program going on there were no slots and we couldn't get a man from the states to help us out fortunately Ambassador Elliott and through the admin officer who was at that time Paul Kelly and later on Don Woodward who followed Paul as admin officer and these men really are experts in finding ways around legal ways around regulations and around government agencies and they did make it possible so that we could hire a clinical psychologist in a contract basis at post it was done through the medical department they interviewed Rich they passed on his credentials and it was with their blessing that he came out and we feel that the total experience that he will elaborate on was a very much of a success one question again old timers or people who have been in the department for a long time say we did it on our own we didn't need all this extra help we were able to support ourselves and it is true we give those people credit but these days we find that when we do help people out and we do make them more efficient the Department of State is the gain in addition to the individual person and I think we could prove many times over that we were effective in maintaining the efficiency of the department a brief example before Rich Westmas came I was involved in 11 people who for one reason or another we post early an early transfer or not allowed to come back to post or medically evacuated for some kind of psychological problem after Rich was there we didn't have a single one or very few I should say including the three suicides that Betty was talking about who we kept at post who remain very effective and we think suicidal attempts are back to life in summary what are some of the factors that I see for a successful program number one as I alluded to before the mental health worker that you hire or find or arrange for has to be competent if he is a poorly qualified person the program will be a complete failure and the whole idea of a mental health program will go down the drain if you have a good man it will support itself and so from this standpoint I think any future program should have the approval of the medical department should have the approval of the person who is going to go into the field second thing you should certainly have the approval backing support by the whole community from the ambassador on down the DCM the heads of all the departments if you have two program programs who are in competition with each other I think you'll have problems in Kabul it's fortunate we had a very willing group who were willing to work together number three was also alluded to assurance that the mental health records will never become a part of the official record the doctor patient confidentiality must never be violated and this is very important to be successful and the third thing is to have an admin officer who knows the way around the ropes to allow it to be done thank you I just wanted to ask one question right now was the term man generic or could we assume that a well qualified woman might also be okay excuse me his wife isn't here today to begin by saying that it's just delightful to be back in Washington amongst old friends from Kabul and meeting new friends my wife who's in the audience today and I have been in Michigan since we left the Foreign Service last year and I should mention too we're in a small community called Cadillac my overseas experience working with a small American community has been excellent training to work in a small rural type community back home because the small community dynamics the fishbowl atmosphere knowing everyone else in their business has a lot of commonality between these two settings I'd like to answer a question that the others have already alluded to that nearly everyone who's talked with me about my experience in Afghanistan has asked and that is why Kabul the assumption is usually made in having more than its share of problems there must have been some tremendous crises going on terribly unmanageable and so on well, Kabul has its share of problems to be sure but so do other posts and as I later had a chance to visit other posts in Pakistan, India and Nepal and Bangladesh and Tehran Kabul certainly had no more than its share of problems and I don't think was any more difficult than these others what Kabul did have as you can now see very clearly was a group of people such as Patinga and Ambassador Elliott and many others who recognized mental health problems when they saw them and were not so paranoid about admitting them that they saw the need to get some help it's really impressed me especially as I've gotten together and heard more story I came in sort of halfway as you can see as to how many people it took to work together to put this program on and to make it function and I came in at a stage where success was almost guaranteed I felt because there were so many good things that had already gone on to prepare the way for what I was to do and along with the support and spade work and intelligence support at Post of course there was support from ImMed and I had very little orientation by the way going overseas perhaps some of you were in that boat too we stopped very briefly in Washington about three or four hours as I recall that was our orientation but one very important thing happened I asked Dr. Carl Neidell who at that time was the medical director about this question of confidentiality I said who in their right mind would see a psychologist if they're working for the government and he assured me that Med had no interest whatever in knowing the names or the details of the clinical work that I was doing that the only time this information would be important was if there was a medical evacuation and they would of course need the background which was fair enough so I made a plan then to keep my notes in longhand pencil they went through a shredder when I left except for a few that I referred on to my successor Dr. Rigomer but there was great cooperation in ensuring confidentiality there was also support at Post which was continuing and vigorous and the last ingredient was a number of people with problems and you need that a psychologist needs people with problems like a teacher needs students they go together well there was no lack of this there and I found no lack anywhere that I've gone and this leads to the second question that people always ask of me and that is what kind of problems did you encounter with the people overseas and I was asking myself that question too with a little bit of anxiety I wondered if my previous experience in clinical practice in Grand Rapids, Michigan would be sufficient to handle the kinds of people and their problems that I saw overseas to my relief it was I found that people are much the same Americans anyway wherever you find them the most common problems I saw in my office in Kabul, Afghanistan were not that different from the problems I saw in my office in Grand Rapids, Michigan the most common problems were depression and anxiety and marital problems in roughly that order or not much difference anyway those three types of problems I would say would account for more than half of the clinical work that I did family relation problems would occupy another good chunk and this is very typical of my practice right now the first year contract was as was already said a pilot program and my job description involved direct clinical services of psychological assessment, psychological testing and psychotherapy individual group, family, marital therapy however I found I did not do any group therapy overseas the setting in a small community like that just did not lend itself to group therapy kind of activity I did do a lot of individual and marital therapy and working with families in a therapeutic setting I also saw a number of people whose who had concerns about a spouse, a child or an employee sometimes and served in an advisory role not seeing the person who was identified as having problems but seeing people look I know this person won't go see I've talked with them about it and I'm concerned about them you know you have any suggestions how can I handle or you know how could I talk them into coming to see you I know they need to and they don't seem to be willing to so a big part of my job and I felt really the key part perhaps of my job was the clinical services area because that is where the crucial events would occur of a person either working out the problem on the spot or having to be transferred out and it occurred to me as we were putting together this program that we really were practicing something in the Kabul experience that has been learned good many years ago in World War II that it was much easier much more efficient and much more effective to treat the problems of the combat troops up near the combat zone and return them to action and effectiveness than to transfer them out deal with them in a different setting all the complications of failure dealing with strangers not understanding your original setting and all of those kinds of things and this experience in World War II led to programs in the other conflicts since that have been implemented for that many years so we're not doing something that new and it's not a great surprise that people were receptive and the program was effective by the measures that we used and part of my job I should mention is consultation with the American International School Dr. John Gist who was at that time superintendent of the school was very supportive and very eager to have us involved I worked in consultation with him and in regular weekly sessions with the school counselor I did some training programs and communication skills and helping skills with the staff and of course worked with students and then in the summers along with assisting in the coordination of the summer job program that Frank has mentioned I developed a peer counseling program for teenagers to help them communicate with each other with more effectiveness and to assist in the process of assimilation of new teenagers into the program and to attack whatever other issues related to choices in regard to drugs and behavior that came up in the course of the program this went on for all three years and with good feedback about it then another part of my job was involving community education prevention and perhaps even a better term is mental health development I like to think even a prevention term is a little bit negative you know taking care of things that might go wrong I like to think that all of us can develop to a higher level our mental health, our attitudes about ourselves, our effectiveness and communication our effectiveness in caring about other people and some of the efforts in this direction included the program that Frank mentioned the family involvement training basically a communication training program for parents the peer counseling which I've already mentioned and a marriage enrichment program for couples whose marriages are basically good but who, like all of us can have better marriages with a little attention a little practice like Charlie Brown's Christmas Tree all it needs is a little love and it'll grow more so that was another part and finally the fourth role was consultation with community organizations and community action programs such as the youth center and the teen job program I was not directly involved as an administrator in these programs more as a resource person and a backup and a support person to the program that pretty well describes the first year of our stay the second year as was mentioned I became a foreign service officer and this opportunity presented great decisions for my wife and myself and our entire family we left with the idea of spending one year and wound up spending three I'm sure that's happened to other people so you may know the kind of agonizing that we went through as we try to determine what our course should be as an individual and as family members the second two years in produced an added dimension of regional mental health consultation to Pakistan and India especially but also to Kathmandu and Dhaka and Tehran the format for this service included referrals from the regional medical officer for evaluation and sometimes for psychotherapy to the extent I could follow through on successive visits and also involve consultation to the school which would mean seeing students who are referred for psychological services workshop of some kind with the staff sometimes a meeting with parents to discuss problems and mutual concerns and consultation with the school counselor or the person serving that function not always a formal position as that program developed I saw also another need and that was instead of just visiting these posts individually to bring together representatives from these posts for regional consultation and so the last two years I was there we also had regional workshops bringing in people from the various posts that I visited sharing ideas and most of all sharing solutions I was glad to hear from Clark Slade that this program is still going on that he attended one recently in New Delhi that Dr. Rigmar is now leading and a very beneficial thing a chance to share and to compare notes I'd like to say just a word or two about evaluation of the program I'm a psychologist and trained to some extent in research and I have to say from a scientific standpoint we don't have all that great a data because it's very difficult to evaluate a program and especially to evaluate when you're doing yourself we did try to build in from the very start certain mechanisms for monitoring and evaluating the program I'll review them briefly first we had a six month report accounting for what I did how many people I saw types of problems men or women, employees or dependents etc secondly at the end of the first year we developed a consumer questionnaire asking all the people who used the services in any way to respond and evaluate the effectiveness and the helpfulness of this service and whether or not they felt it was something that should continue we also made a special point to try to get at the factor of how many medical evacuations were prevented you know it's hard to do but we got people to estimate that then the second and third year we did a questionnaire of the regional posts, a regional post questionnaire asking again the effectiveness of the program and how well it was received all of these data indicated that the program was being used and the consumers felt they were very helpful and the estimates were that yes we were indeed preventing medical evacuations my personal impressions and personal conclusions is that it is a worthwhile program that early intervention does pay off that the crisis theory indicating that when a crisis is dealt with on the spot successful resolution can be made and sometimes even a higher level of effectiveness can result rather than a diminished level that there is a great deal of security for people at post knowing that help is available I know that I was talked about a great deal in many homes, shall we see Rich Westmas about this and even though people might choose not to the knowledge that I was there I think diminished some anxiety that the final conclusion is that people working together can solve problems mental health problems do have answers that many of them if not most of them I would like to say all have satisfactory solutions that we don't have to live with them hide them and deny them and that people working together can do a great deal to improve the quality of life in overseas posts I've asked Dr. Haynes to speak as our last speaker and then we'll have our question and answer period Dr. Haynes what you've been treated to of course is really a case book study a special kind of case book study and community action the special aspects of course are that the activity began at a fairly high level if not the highest level and involved a degree of cooperation between the ambassador and the regional medical officer I am here in a obvious it seems to me way to confirm something that you all know and that is that the cobble experience is quite alive and quite well approaching about age 5 and then the second generation hands of Dr. Elmore Riggimer is also continuing to be an evolving and very lively activity you've already heard what to me in a programmatic sense is most interesting that is that what took place in cobble could not stay confined to cobble that the demands were such that it had to move out into India Pakistan and so on and so forth in the last few months I've seen cable requests for Dr. Riggimer's services in Madrid I believe Rome Tel Aviv and so on and so forth and there's a very important message it seems to me in that at this point we do have one overseas mental health expert who replaced Dr. Westmas after he came back to the states and with this one man we attempt to cover a rather broad area again from our perspective from Med's perspective from the mental health perspective we're very grateful to the cobble experience because it turns out to be a demonstration project there are obviously many many areas throughout the world where something of this type is or could be quite applicable so we are going to have and will continue to take advantage of what became started in cobble and which became regional in a very very functional sense I think it's already been mentioned that Dr. Riggimer we plan and this is ironic that we should try to take Dr. Riggimer or that position away from cobble but it's sensible from a programmatic point of view to put it in a more central place where there are more employees and dependents and youngsters and in a place where transportation is available not only for people to come to the regional mental health expert but for him to move out on the basis of the experience in cobble and also on the basis of the experience we're acquiring from our support of the social development center in Tehran which is another long story which I won't start but we did propose and we are ready to propose at any time that teams be made available overseas roughly and I must emphasize this roughly along geographic bureau lines depending on how many teams we have or might get and these teams would be composed of basically a psychiatrist a clinical psychologist and maybe at least one and maybe more psychiatric social workers this team could support one another they would not necessarily be based at the same post but they would be in communication and could provide different functions but we are currently in a highly competitive situation when it comes to obtaining positions you're all very well aware of the cuts that are presently necessary but I'm not entirely discouraged about this because I think there's multiple evidence already and we can see it all around us about departmental awareness and sensitivity to what I consider to be the human needs I like very much I like to comment on Dr. Westmas' preference for the use of mental health development rather than preventive program I like the positive aspect of that and I'd like to reaffirm it I'd like to make a brief comment on what I think are some of the major things that are a crew from a program in which there are mental health people in the field that is the intervention can take place early intervention which is always crucial with the possibility of treatment on the site and now we can talk about such things as cost-effectiveness but I don't think that's the real issue first off my impression that and I see most of them I see them all if I'm here but medical evacuation to come back which have averaged up until this year approximately 40 and this year may actually run over 50 for the calendar year but it's my impression that perhaps half at least half of these evacuations are really unnecessary there are necessary in that they could have been handled in the field or they are necessary because we're the only we have to do the evaluation you have to move the person here now there's something that happens when you medically evacuate a person I can't really tell you what it is but it's not necessarily in the person's best interest unless it's necessary by that I mean it's comparable to hospitalizing somebody unnecessarily if there is psychiatric hospitalization it's something to be avoided if possible so again I think that the what can take place in a program of this kind again I would stress the cost-effectiveness is there when you think of what it costs to pull out a family and replace a family it can run at least 50 to 100 thousand dollars in some instances but I think the issue is really a humanistic one and in that we are offering the best possible care for our own people and doing our best to see that that's accomplished thank you Dr. Hayes thank you we do have a few minutes for questions may I ask if anyone has a question if you would just stand up so the camera can catch you yes you mentioned that the problems in Cadillac, Michigan would normally not be so very different than the problems that you would find in an overseas community such as Kabul but wouldn't you serve find the differences of language the differences of religion the differences of culture and so forth creating a far greater potential for mental health breakdown than your normal community of the United States yes those are realities and they hit women I would say dependent spouses women who do not have a career job situation going whose life situation and role in the home is very different and in a culture where women are not very easily accepted in the streets that certainly does intensify the adjustment problems I would say though that at Cadillac there's a lot of people moving up from downstate and the adjustment problems that some of these people from the large cities have coming to a small community where everyone knows each other and so on they feel kind of isolated I see the same psychological reactions even though the situation is very different and it's the people and their reactions to the situations that I as a psychologist deal with you can't always change the situation many times you can't you can do something about how you handle it how you react to it we have time for one more question yes you spoke of not being able to do group work in Kabul is that because of hierarchy in the department or because of the fishbowl or some other reason it would be the the fishbowl thing of those two more people know each other see each other socially as well as in group therapy I found even in my seminars people were probably more reluctant to disclose very much personal material as compared with in the states that is one difference that I did find but on an individual basis that didn't bother I have a question of Ambassador Elliott you mentioned the involvement of parents in the planning stages my question is did you involve teenagers and if you did at what point in the planning process I think I really should ask you Frank because you were the organizer of the teen center and I think it was really Dr. Pettinger who referred to that and you might want to say a little bit more about how you got the teen center started because you of course did involve teenagers very definitely we did have the heads of the departments as we spoke about the ambassador and the head of aid and the and et cetera but at each planning session we also had four students who did have their input and who did straighten us out on many different aspects we had a lot to learn there's no doubt about it I think this was one of the reasons why the program was a success because we dealt with their needs as they saw it and this is important in fact it wouldn't have been a success any other way Rich was the services provided to Peace Corps volunteers and used by Peace Corps volunteers yes they were fairly extensively in fact Rich you know you'll be able to judge this better than I but I think Peace Corps volunteers had some special problems in a country like Afghanistan which AID and state and ICA and so forth employees did not have I don't know whether the proportion of Peace Corps volunteers but they certainly I think found this a very supportive and useful facility to that point regulations say that the medical department should not be taking care of Peace Corps but it was Ambassador Elliott's edict that he wanted the people under his jurisdiction to have the advantage and that's why we took care of them by another question yes to what extent have other nations diplomatic services expressed an interest in this or done something similar to this and is there any liaison with other governments that might want to go into this mental health program such as you've done I can't speak for any other governments I can't speak for what is a rather uniquely American enterprise in Tehran in which the department has led the way it seems to me for U.S. corporations and their people in Tehran by the establishment of an outpatient mental health clinic staff with a well-qualified psychiatrist, psychologist, psychiatric social workers international I cannot sorry I don't have any answer to that could I ask if there's anyone in the room who would like to address or answer that or give some information on that I'd like to speak to that in my experience the Americans are the only one who take care of their own the Germans in Kabul had one doctor who would cover about 15 countries the British I think now have three doctors overseas they used to have a fairly large medical program the Italians have four or five overseas as far as I understand we are actually the only country that does have programs when a C-141 comes in after one of our badly injured patients all the rest of the diplomatic community stands in awe and says my country wouldn't do that for me at this point that the Foreign Service Education and Counseling Center has received requests from foreign embassies here in Washington for help in that endeavor and that the Association of American Foreign Service Women get frequent requests from foreign embassies to liaise with various permanent matters between the women's affairs thank you very much that's for sure yes I wonder if Ambassador Elliott might give some of us who are at a lower level who have the desire to try to mobilize the demand for these services some clues on what the best way to approach our senior officials might be going knock on their doors if you don't feel you can do it alone for whatever reason get a group together go and lay it out and discuss it with them I would hope that all our ambassadors would be open enough to receive visitations of this kind if they aren't then you'll have to come back to Washington come to the Medical Division express a need for this kind of service to the Medical Division here in Washington but I certainly if you feel the need I think you should express the need and if under Secretary Reid and the other people in charge the department's resources here don't hear about these needs he's going to feel that they may not exist to the extent you think they do thank you I think that's a terribly good note to add on thank you all very very much for coming we really appreciated it your participation and your listening and let's all go out and fight the good fight thank you