U.S.

Department of State

High Stress Assignment Outbrief Implementation Guide

Foreign Service Institute Transition Center MQ-951
Ray S. Leki

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High Stress Assignment Outbrief

Implementation Guide

Foreword & Acknowledgment

This guide is designed to assist RMO/Ps to act as FSI Adjunct Faculty in providing the High Stress Assignment Outbrief program to returnees from service in Iraq, Afghanistan, and other high threat/high stress assignments. Readers who have some familiarity with the program may use it as a benchmarking document to evaluate their own Outbrief protocols, while newcomers should be able to feel fully comfortable in delivering the program after reading through the document. Those who are interested in the background and history of the program and its organizational context are encouraged to read the Background section. If you have someone waiting in your outer office for an Outbrief, skip to the Getting Started section. General instructions appear in normal typeface; suggested phrasing, for your convenience, appears in italic typeface. The Outbrief Program has evolved through the participation and contributions of many colleagues. Sam Thieleman and I created the Outbrief model we use at the Department, and presented the model at an APA conference years ago. Bob Ursano (USUHS) participated in a review of the program and endorsed our use of the model for our population. Ray DeCastro, Alene Grabow, David Panakkal, Emily Rosenberg, Mark Johnson, Ken Garot, Tom Burke, Chris Flynn, Chris Kowalski, Virginia Foley, and others have contributed ideas and helped to improve it. Four consecutive Directors General of the Foreign Service have mandated use of the model for returnees from Iraq and Afghanistan. And, of course, hundreds of Outbrief participants have gone through the program, shared their feedback with us, and shared ideas they learned with their colleagues and family members. I thank you in advance and solicit your ideas and the techniques, phrases, and tips that have worked for you as you conduct Outbriefs at your posts. This document will be hosted on several servers and updated as needed, so please feel free to share your feedback with us. Ray S. Leki Director, Transition Center Foreign Service Institute U.S. Department of State January 2012

High Stress Assignment Outbrief

Implementation Guide

Index Foreword & Acknowledgment 2

Background The Outbrief What it is, and what it isnt

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Getting Started - The Outbrief Model

Reporting & Logistics Feedback

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High Stress Assignment Outbrief

Implementation Guide

High Stress Assignment Outbrief Implementation Guide

Background The High Stress Assignment Outbrief program was developed after the first groups of employees began coming back from assignments to Iraq and Afghanistan in 2002 and 2003 posts that would have been in evacuation status in more normal times. Returnees asserted that coming back from those posts wasnt at all like coming back from a regular foreign affairs community assignment that the Department needed to help with this particular transition in some way. Meds Office of Mental Health Services asked the Foreign Service Institutes Transition Center to assist in the development of a prototype training event, which was piloted in 2003. MED/Mental Health convened an Iraq Out-briefing Conference on July 29 & 30, 2004 at the Foreign Service Institute. The Outbrief program was reviewed and discussed by the full cadre of RMO/Ps, Dr. Robert Ursano and Dr. James McCarroll, from the Uniformed Services University for Health Sciences, Dr. Carol North, Washington University (St. Louis), with guest presentations by (then) Director General of the Foreign Service Amb. Robert Pearson and others. The program was endorsed by MED leadership and has run as a partnership between the FSIs Transition Center and MED/Mental Health Services since then. All subsequent Directors General of the Foreign Service have mandated that all returnees from Iraq (and later Afghanistan) who have served for 90 days or longer be required to attend either a group or individual Outbrief upon return to CONUS. The realities of the Foreign Service assignment system brought complications many officers had TDYed to Iraq or Afghanistan and were returning directly to their former posts. Others PCS-ed directly to follow-on assignments around the world. Clearly, a purely Washington-based program would not be effective in providing the service to all of our employees. Furthermore, many participants did not fit traditional Foreign Service employee profiles special hiring authority hires (3161s), civil service employees, and third country nationals all stepped up to serve in those war zones. RMO/Ps were instructed to deliver Outbriefs at posts or during post visits, and to communicate the name of the Outbrief participant, date, and place back to the Transition Center for entry into the Departments official training registration database to certify compliance. A DVD showing a sample one-on-one interview was created and distributed through MED channels. Compliance remains a difficult issue. While the program has received support and validation from a number of internal and external stakeholders, the unique requirement of a post-deployment de-brief coupled with a cultural reluctance in the workforce to deal with mental health or stress related issues mitigate against full participation. Since the essence of the program is to provide help to returning employees and their family members more rigorous measures to ensure compliance were seen as undesirable (e.g., holding up onward assignments or limiting or temporarily suspending clearances) and counterproductive.

High Stress Assignment Outbrief The Outbrief What it is, and what it isnt

Implementation Guide

The Outbrief is a two-way educational program. It is not a clinical session or intervention. In order for the program to work, every attempt should be made to lower the power-distance differential between interviewer and client. The implementer should strive to create an environment and context that facilitates an open dialogue between peers. To this end, finding a neutral, but private space for the interview is important a clinicians office, with its location in a medical unit and array of symbols (degrees and licenses on the walls; medical books and equipment) is not a good location. Conducting the Outbrief in a small training or meeting room is more desirable. If the client has his or her own individual office at your post, conducting the meeting in that venue might be preferable. In any case, distractions should be eliminated and privacy assured. The program is designed to be an educational dialogue between two or more individuals who should each derive significant, if different, value from the experience. The program sets the tone for this dialogue-among-equals by devoting roughly half of the session to providing information and half to soliciting the opinions, ideas, experiences, and reflections of participants. While the session can be started either way, as a pragmatic suggestion, delivering the information upfront generally helps set the boundaries for the ensuing dialogue and helps with time and energy management. Spouses/partners, and in some instances other family members can attend an Outbrief with an officer, but I recommend against having non-deployed family members attend when there is more than one officer in the session. In other words, limit individual Outbriefs to one officer and his or her family member(s). This allows the primary participant the validation of having normative decompression symptoms described by a neutral third party, but it also allows for the validation of the deep sacrifice and equally serious stress-related issues the stay-behind partner or family member might have experienced. It provides a context to understand that re-integrating into intimate relationships is some of the hardest work in the entire deployment cycle.

Getting Started - The Outbrief Model I. Welcome Home II. Thank you for your service III. Solicit basic service and personal information Where did you serve? What did you do? How long were you there? How long have you been back? How long have you been an employee? What other posts have you had? Can you tell me a bit about your personal and family background? IV. Explain the purpose of the Outbrief. Assure participants that it is neither a clinical intervention nor a screening mechanism hiding as training. It is a two way educational program that is required for all high

High Stress Assignment Outbrief

Implementation Guide

stress, high threat returnees. We want you to be aware of normal decompression symptoms, be able to identify when outside help might be needed, what types of problems might be encountered, what resources are available, how to access them, and what the implications of utilizing those services might be, AND to provide an institutionalized venue for the Department to learn from your reflections, your advice, and your hard-won experiences. V. Describe general repatriation phenomena. Everyone is different, and some of the symptoms may resonate with you, or nothing at all may resonate, but please understand that while the primary target of this information is you, and your family members, we also want you to understand these phenomena so that you will better understand and be able to support colleagues, subordinates, and supervisors who come out of high threat theaters and who may not be as resilient as you are. We as a community need to get smarter about being successful and more resilient in this new, expeditionary foreign affairs community. Describe what makes readjustment from a high stress, high threat post different decompression is caused by: 1. Ambient environment of threat and danger 2. Long work hours, constant sense of urgency, lack of privacy and normal social support structures VI. Decompression Symptoms Decompression is the normal, healthy process of normal healthy individuals readjusting from prolonged exposure to an abnormal environment and set of circumstances. 1. Sleep dysfunction 2. Irritability 3. Short-term depression 4. Hyperstartle response 5. Hypervigilance 6. Emotional lability 7. Short and medium term memory inhibition 8. Lack of mental acuity and focus 9. Difficulty reintegrating into intimate interpersonal relationships a. Unrealistic expectations Everything will be perfect I just want every thing to go back to the way it was

High Stress Assignment Outbrief

Implementation Guide

b. Chronic exposure to stress changes the officer AND those back here, i.e., family members, significant others Chronic worry; heightened incidence of first time reporting of clinical depression Weight gain / loss Impaired immune functions c. Stay-behind fatigue from: single parenting; life systems management; negative information inundation; source of support for other family members; lack of a support system d. Communication issues difficulty in discussing, explaining respective challenges faced You werent there (or here!) youll never understand what it was like e. Residual resentment - Why did you have to take that assignment? f. Renegotiating relationships 1. parenting 2. workload sharing 3. dealing with parents 4. request FLO medals for kids? g. Reinvesting in important relationships VII. Serious Outcomes and Resources 1. Most people are naturally resilient, but people vary in both levels of resilience and exposure to trauma, violence, stress, and available social support 2. Symptoms should abate if they get worse over the weeks and months post return from deployment, thats an indication that outside help might be needed 3. Most common serious outcomes

High Stress Assignment Outbrief a. short term depression b. anxiety or panic attacks c. PTSD six diagnostic criteria 1. critical incident

Implementation Guide

2. symptoms last longer than 30 days 3. avoidance/numbness 4. intrusive recurrence 5. hyperarousal symptoms 6. subjective realization of dysfunction in life, work, relationships d. Prevalence of PTSD e. Treatment programs and evidenced-based efficacy f. Resources 1. Post Med Unit & in-country resources 2. Deployment Stress Management Program 3. Employee Consultation Service 4. Mental Health Network 5. Private mental health provider through insurance plan g. Impact on clearances 1. Medical 2. Security h. Strategies for dealing with peers & colleagues 4. Questions? VIII. Interview Protocol 1. Ground rules answers are voluntary; will not be attributed; will be taking notes, but notes are available for inspection at any time during the session. Can I ask you some questions now? You dont have to answer if you dont want to but we would like your help in understanding the ever changing realities of these posts. I will be taking notes, but nothing you say will be

High Stress Assignment Outbrief

Implementation Guide

attributed to you. You can look at my notes any time you want. The purpose of the notes is to look for trends as posts and circumstances evolve to report to senior Department management. 2. Q1. Security Training Did you participate in some sort of pre-departure security training? E.g., FACT; DSAC; Camp Attibury? etc? When you look back at your experience at post, and think through the content of your security training, can you identify content that was invaluable to you, content that had no relevance, and security-related content that you really wished you had been exposed to but werent? 3. Q2. Can you comment on the general adequacy of the management infrastructure that was available to you to stay reasonably healthy and get your work done? 4, Q3, Did the R&R package work for you? Were you able to take all your leave? Does the R&R package provide the right balance between giving officers needed time off, but not so much that the work cant get done because people are on leave too frequently? 5. Q4. Can you comment on the leadership you either enjoyed or tolerated during your tenure which leadership behaviors and competencies were instrumental in helping you survive or which behaviors made your work and life much more difficult than they needed to be? Please focus on the behaviors and not the individuals. 6. Q5. Threat: was there a time that you thought you might lose your life not just as an abstract concept, but as the real fear that your life was about to end? 7. Q6. Meaning. When you reflect on your experience, do you think it had meaning? Did it make sense for you to be there? 8. Q7. Gain. Can you look back and identify areas of personal or professional growth or other gain that you experienced as a part of your deployment? 9. Q8. Follow on. Did you get the follow on assignment that you wanted? Do you feel like your organization took care of you? Where are you going, and to what job? IX. Thank you for your service. If you think of other ideas or advice you think would be useful, or if I can be of further help, my contact information / business card is in your packet. Good luck.

High Stress Assignment Outbrief Reporting & Logistics

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Implementation Guide

The Outbrief is a mandatory training course for returnees from Iraq and Afghanistan and the Department is responsible for keeping track of compliance. You are delivering the Outbrief as an Adjunct Faculty member of the Foreign Service Institutes Transition Center, and the Outbrief constitutes an official training event. As such, we need to make sure that accurate records are kept of who attended, when, and where. Sending a simple e-mail to

FSITCOutbrief@state.gov with this data will greatly

facilitate accuracy in certifying attendance and compliance. Outbriefs done with personnel from other federal agencies require an official training request form (SF182) with a funding citation. Once this training request has been approved through the proper channels, the Foreign Service Institutes Registrars Office will update the employees records to indicate attendance.