bout de papier, Vol. 17, No. 3 (2000) — Fall 2000 // Automne 2000, pp. 12–16
Editor’s Note: This article on mental health and working conditions in the Canadian public service was the first of a series being prepared by the author. A second paper was presented in Paris in June 2000 that dealt more specifically with the long-term impact of downsizing on the employees of the Federal public service. To respect the privacy of families who have provided information on this sensitive subject, the situations described have been reassembled so that individual cases are not identifiable, although all the details are actual experiences in the Canadian and international foreign community.
According to a WHO report, “as many as 1500 million people worldwide are estimated to be suffering at any given time from some kind of neuropsychiatric disorder, including mental, behavioural and substance abuse disorders. A third of them may be affected by more than one neuropsychiatric ailment. Three-quarters of those affected live in developing countries.” In the United States, mental disorders affect nearly one in five. Nearly half of those with a severe mental illness do not seek treatment. The same percentage applies to Great Britain, and to Canada, where recent tragic events made us aware that mental illness strikes anytime and anywhere. A few years ago, an assistant professor at Concordia University (Montreal) shot to death six of his colleagues. More recently, an employee of the urban transit system in Ottawa killed four colleagues. Both attackers were suffering from paranoia, the symptoms of which had been ignored by management and, in the latter case, by the family doctor. One can only hope that the intensive coverage of the two cases has opened some minds. On the other hand it has doubtless reinforced the reactionary association of mental illness with acts of extreme violence.
For in spite of the thousands of articles written about its forms and symptoms, such as depression (a favorite), the two words “mental illness” spark a wide range of emotions, perceptions, fear and shame rooted in the very distant past. “We have come a long way in understanding and accepting physical illness, but there is still a great deal of misunderstanding about mental illnesses and prejudice against those who have an illness of the mind.”
So much for the general scene. The special circumstances of official foreign service add a layer of complexity and social stigma which can only compound the problem when it occurs. Governments do not gather data on this internal affair. An educated guess, however, is that the rate of the disorder is higher in foreign service communities than in the population at large.
The triggering effect
The stress of moving on the employees of foreign services has been well documented. More scant are studies which link it to the onset of psychotic events such as hallucinatory delirium, manic attacks, deep depressions, suicides or episodes of paranoid delusion and insane rage. That is doubly unfortunate since bipolar disorder, which alternates depression with elation, is especially sensitive to the life-style of the foreign service. As experts point out, “the bipolar brain is a bridge without give. It has not been built to withstand the stress of continual life dramas … and the bipolar personality is best advised to stay free of life’s gales.” The stresses associated with a family move can be varied and intense, and therefore an effective trigger.
So powerful is the “triggering effect” that most dangerous crises have been reported within days or weeks upon arrival. These involve clear cases of bipolar disease as well as other mental disorders of diverse origin. One employee hallucinated within two weeks of arrival at the posting. Another one, with a long psychiatric past, could not cope with the birth of a child and a stressful move. Another fell into a demented anger after an especially difficult move.
“Repeats” are not only probable given the stresses of moving, but also involve a risk of increased intensity. “Mental disorders have a life of their own, a biological truth known as kindling.” For example, the first depression or manic episode may take place after an especially stressful move (e.g., a move in conjunction with pregnancy of the spouse or the death of a parent); the second one can be triggered by a much lower stress level, such as making a suitable rental arrangement for the family home; the third one can happen with no apparent relation to the move itself. “Each time it was worse,” one spouse confided, “and I found myself in a kind of repetitive nightmare. How could fate be so cruel to me?” Through personal research and extensive consultations she understood that there was no cruel destiny but rather a deep ignorance about mental issues and a naive reliance on drugs. Pills cannot override the stress of a move. “My husband should have never been re-posted; that is all there is to it. This one has destroyed our family permanently.”
It is important to add that many years may pass between repeats, especially if there is a long stretch of time between postings. The long period of tranquility may lead to the erroneous conclusion that the problem has cured itself by time or is permanently controlled by drugs — until another tragic move proves otherwise. Although the repeat episode is a clear falsification of belief that the patient was cured, it will not necessarily be accepted by the authorities as proof that they made a mistake.
A culture of denial
Although more likely than other organizations to face mental crises abroad, government foreign service agencies have been more reluctant than others to step into the minefield of mental assessment. All organizations, however, whether large or small, public or private, are almost studiously blind to mental illness. One has to say in their defense that it is not a subject for the faint of heart.
As noted above, popular understanding of mental illness is mainly built on prejudice and fear, with the disorder being associated with irrational reasoning, incoherent hallucinations, blood-curdling screams, frightening glares and criminal behaviours. Although these elements may be present in some cases, they are only the tip of the iceberg in a deceptive and extremely complex disease.
Contrary to popular belief, for example, the faculty of reasoning is not altered in most cases. Some psychopaths are able to communicate through words, sometimes with impeccable reasoning, sometimes with utter charm, sometimes manifesting what seems like extreme sensitivity. In fact, however, the mentally ill often have great difficulty in perceiving others as alter egos and are quite impermeable to their emotional needs and their points of view. Taking the paranoid as an extreme, the sturdiness of their delusions and their unwillingness to compromise make them attractive to the hesitant and the neurotic (that is, to most of us).
In other instances, acute crises are intertwined with long periods of “normality,” which may include brilliance and creativity. Not only is diagnosis difficult; a lot of cases fall into grey zones. It can be hard to differentiate between a personality disorder and a full-fledged psychosis which may or may not be the end of the road as the disorder evolves. No one knows when hypomania stops and full-fledged mania starts, or when a paranoid tendency becomes hallucinatory and dangerous.
The difficulty is accentuated by “fugitive” patients. Unlike the sufferers from other illnesses, those who suffer psychotic episodes are most of the time unaware of their state and reach a point where they are unable to seek help. They are not denying the problem like drug abusers and alcoholics do. These, although they deny, are sufficiently aware to cover their problems: they hide the bottles, they huddle in back alleys where they can find drugs, but they know they have a problem. Although they try to deny the severity of their ailment, they do sometimes look for help. By contrast, psychotics have lost the capacity to reach out. That should be rephrased: there is sometimes a demand but it is likely to be a demented one. (The paranoid may ask for his house to be debugged for example.)
This is the core of the issue. The ailment is not visible and has to be interpreted by people who may:
1. misinterpret symptoms by trying to understand them from a “normal” perspective;
2. know very little about mental disorders;
3. have a vested interest in denying the problem as long as they can.
In the foreign service, the invisibility of the problem is reinforced by some of the characteristics of the job.
The normalization of the alien
We all tend to normalize behaviours, that is, to interpret them based on our own familiar patterns. We may blame a depression on difficult circumstances whereas the most severe cases are insensitive to social environment. Our first instinct is to give credence to the discourse of the paranoid. This manifests our desire to communicate and take words at face value. On the other hand, familiarity of words and expressions is part of our acceptance. We are more prone to finding the foreigner (the real “alien”) insane, as the one who does not speak the same words with the same emotional accent.
This normal sensitivity is muted in the case of foreign service, where there is an increased opening of the mind to differences and oddities of behaviour. “We meet quite a lot of strange characters,” one officer observed, “and we become pretty tolerant when it comes to what is said and done. It goes for the international crowd encountered on duty, but also for our community itself. We see a lot and we shut up a lot.”
“We also tend to tone down the worst crisis into a minor hurdle,” said another. “It is part of the culture to describe crazy negotiations between countries as ’progressing slowly but well’.” This general dampering instinct is reflected in the words used to describe a severe mental crisis. “I could not believe it,” a spouse remembers. “Here he was, just out of the psychiatric ward, so drugged and zombie-like that the poor man could hardly walk. But he went to the office where he stared at the wall for days. And I was told repeatedly ’these things take time. He has been stressed’. Everyone acted as if it were a merely a little fatigue. I wanted to scream ’Stop it! Stop it! He is not just a little bit tired! Can’t you see? The neuroleptics make him drool, his legs are made of leather. He cannot wake up in the morning. He does not utter a single word for days. I cannot take it! Eventually I asked headquarters to bring us back to the relief of everyone. But I remember the sleepless nights I endured before picking up the phone to follow my instinct, which meant going against local medical authorities. I felt utterly alone.”
The problem of recognition is compounded when the employee arrives at the post unaccompanied. In these situations there may be no one who can make an immediate judgment that the new arrival is behaving abnormally.
Vested interests
Vested interests also play a major part in keeping matters as quiet as possible.
The first one is shared by all managers of organizations. Over the decades there has been a growing reluctance by managers to address the employee’s private life, which is increasingly protected by Charters of Rights and judicial decisions. In many countries, personnel departments are not supposed to disclose past disturbances. As a result, explains a manager, “one has to rely on gossip and hearsay” and find a legitimate dodge for refusing an employee when there is some fear of a “repeat.”
On the other hand, employees are increasingly viewed within the narrow channel of their performance, notwithstanding their ethical and social personae. It is especially clear in the world of new technology where autistic engineers perform well as long as they are glued to their computer screens. The managers’ mantra that “as long as he or she does his or her task, I do not care and I do not want to know about anything else” is spreading. This attitude is expanding to embrace some borderline psychotic behaviours. Paranoia, narcissism or hypomania are now welcomed in competitive groups. Denied as “problems,” these are rebaptised as valuable qualities.
The second incentive for denying the existence of any problem is more specific to the foreign service and has to do with image. As an officer put it, “Officials of most countries can tolerate a lot of misbehaviour, such as extreme alcoholism or abuse of women. But as soon as the word “madness’ is uttered, everybody retreats. We avoid the issue of mental illness as much as we can. The higher the rank of the employee, the more careful we are.
The third is also specific to the foreign service. There are several lines of authority involved in posting an employee abroad. Politicians, in the case of ambassadors, the personnel office, the head of post and health authorities are all involved in declaring someone “fit” for the service. This means, in practical terms, that points of view are likely to differ and accountability is bound to fall between the cracks. In other words, the crisis, however intense, will tend to be played down and denied as much and for as long as possible.
Companions and families at the crossroads
In practical terms this means that it falls to the companions, where they exist, to make a diagnosis, as well as to alert the authorities and deal with them, provided of course that they 1) are themselves aware of what is happening, 2) are not misinterpreting it, 3) are not themselves in total panic, 4) know whom to consult and call, and 5) understand the politics well enough to counter the vested interests. This is indeed a lot of responsibility on the shoulders of those who are not employees of the organization and whose role is not well defined.
It would be a mistake to believe that the companions are more likely than any one to notice dangerous changes in the behaviour of their spouses. They do not miss repeats, but when the crisis occurs for the first time, the companions are probably as much in a denying mode as anybody else.
At the opposite end of the spectrum, some spouses may be all too willing to attribute to insanity any strange behaviours of their spouses, especially if another partner is involved. A surge of random libido may indeed signal the onset of a severe mental crisis. To tell the difference between the “divine madness,” as Jung called it, and an exploded mind involves a careful monitoring of other symptoms which may not be apparent to the non-specialist.
The judgment of the companion may also be impaired by guilt, panic and anger. Mental crises trigger a spectrum of feelings within the family which are confusing at the very least, especially when one has to face them alone, upon arrival in a foreign country. Furthermore, seasoned spouses have learned that in the tight-lipped world of the foreign community, displays of emotion are not only unwelcome but can boomerang in a devastating way. If the disorder implies any kind of abuse, the spouse risks being subjected to the same tribal law of silence which is so pervasive in the ranks of the military, as revealed by a recent Canadian report prepared by the Family Violence and the Military Community research teams of the Muriel McQueen Fergusson Centre for Family Violence at the University of New Brunswick and the RESOLVE Violence and Abuse Research Centre at the University of Manitoba.
The issue of medical care, training and accountability
The obvious recourse for a distraught and confused companion is the embassy doctor, when there is one. In foreign services, this officer is usually the link to medical authorities who gave a green light to posting the employee. In the best of worlds, and it does occur, the doctor on staff would have a clear duty to help families abroad, would be openminded, well read in psychiatry, familiar with the patterns of “repeats” and be in red alert contact with the authorities at headquarters, especially in the first weeks after the arrival of the new officer. On the other hand, other combinations emerge and tragic stories are heard, ranging from refusal of help to disastrous interventions.
One companion remembers: “We had just arrived on posting and were still camping in the house. Life seemed so wonderful. My husband seemed more alive than usual, so charming. He kept talking, which was a nice change from the rather silent and remote character he usually was. But I began to be worried when sleep eluded him night after night. In the back of my mind, I felt that something was really going wrong, especially since I had heard vague hints from my in-laws that he had a ’nervous breakdown’ when he was a teenager. When it reached six nights in a row without sleep, I phoned the doctor of the embassy and confided to him my worries, begging him to prescribe some sleeping pills. I was told in so many words to mind my own business. Two days later I met that doctor for the first time, in the psychiatric ward where my husband, hallucinating, had been taken in a straightjacket. The doctor never acknowledged to the authorities that I had given advance warning, and had the gall to describe me as ’a problem spouse’ in his written assessment.”
“She was lucky in a way,” another spouse commented, “for in my case, and although there has been a trail of documented psychiatric episodes, I had to face a more borderline issue upon arrival. There was no repeat of the delirium experienced in a previous posting, but there was an uncharacteristic anger at me who had just left the hospital after serious surgery. I phoned the doctor of the embassy to ask him to try to talk to my husband and refer him to a psychiatrist. The doctor reacted angrily and refused to talk to me. He insisted on describing the issue as a personal matter. Psychiatrists I consulted when I came back had a different view. One told me that I was lucky to be still alive.”
In another instance a doctor denied there was any case of depression and potential suicide, relying on a diagnostic learned decades earlier: “Does he eat? Does he sleep? Does he function?” Since the companion answered “yes” for her spouse in absentia, she was told that there was obviously no problem (although sleeping required pills and “functioning” was anything but normal).
When the local doctor is unable or unwilling to help, one can call medical authorities in headquarters directly. In the best of cases there are psychiatric specialists on call, along with dedicated units in headquarters whose assignment is families in difficulty abroad. But distance makes it especially difficult to assess the situation. Bringing back the family may seem an obvious solution, although in some cases the stress of another move may do more harm than good. In other cases, medical headquarters may turn a blind eye to the issue in order to dodge legal responsibility. In one instance it had reduced drastically the dosage of drugs that an officer had taken for two decades just prior to a move, which turned into a major crisis. There was no debriefing of the spouse on her return, and no offer of medical assistance, even though she came back suffering herself from a severe post traumatic disorder.
In brief, all too often, the distraught family is on its own. As one spouse remembered: “I just opened the phone book and started calling every psychiatrist in driving distance.”
Local Care
Luck cooperated in this case, for she spoke the language of the posting fluently and was able to seek the help she needed, which happened to be excellent. In most cases, however, finding the appropriate care is difficult and emotionally overwhelming. As all employees of the foreign service know, health issues ratchet up a few notches when abroad. Language is especially critical when there are no broken bones to be seen or blood pressure to be measured. The psychiatric disorder must be described with words which carry different meanings between cultures and countries.
And the quality of available care differs vastly between countries. In some, psychiatric hospitals have been used as political jails. Some countries are too poor to keep updated on the exploding field of psychiatry. In those cases, repatriation is the only viable choice, provided, of course, that the disorder is recognized for what it is.
Even between countries where quality is generally at par, the situation may not be much easier. To start with, there are wide variances in diagnosis and therefore in treatment. Schizophrenia, to give one example, does not have the same meaning in Europe as in North America. These general difficulties of communication are compounded by more subtle problems when it comes to declaring a diplomat insane. A spouse recalls her first visit to the opulent office of a local psychiatrist. There were no problems of language or the sophistication of care, and she felt confident explaining the long psychiatric past of her spouse. She was flabbergasted when the doctor bent over his desk toward her and said, “I think that your government would only post an elite person with superior skills.” He then gave her a recital if all the important people he knew and ›ffered his expensive services to focus on ler problems. She nearly accepted, feeling hat she maybe was becoming insane, when i psychiatrist telephoned from her home ountry at the request of her family. “Face it,” le said, “Your husband is psychotic. Get the hell out of there as quickly as possible.”
The care of the community
In some instances, departure is difficult for complex reasons involving children who, hemselves isolated, are suffering an uncomnon ordeal of quite a different kind. (The pecial problem of children requires a septrate chapter.) In these situations support rom the community at large is vital for the pouse. We are only beginning to understand he ordeal of families who have to face men-al disorder in one of their members. Because nental illness attacks the core of communiation, one expert explains, there is no way hat the supporting family can pull through inless it can replenish itself within a larger : ommunity. Psychiatrists themselves (per-laps especially) need to go back every vening to a loving, caring, normal family ife. The need is widely recognized, and there ure now many support groups which help families to face crises as they come. Abroad, these groups, where they exist, may be difficult to join, owing to language in the first instance, but also because of the sensitivity of the issue. Diplomatic companions, although not employees, must abide by the rules of diplomacy and keep the dirty laundry within the community. This makes them totally dependent for desperately needed psychological support on the open-mindedness, good will and kindness of this small group.
What one gets is a matter of luck. Communities range from the most compassionate and caring, to cold ones which leave the companions alone to face an impossible situation that legally may qualify as a failure to lend assistance to a person in danger.
Policies
The word “luck” applies to far too many aspects of these situations, for it is the absence of clear policies and accountability that leaves the unfortunate spouse and family to dependence on luck or its lack.
Needless to say, every combination of the above has been encountered, from those who experienced total disaster to those who found help along the way. It ought not be necessary to add that the issue will sooner or later explode, forcing panicky managers and doctors to draft and enforce policies, or a court to do it for them, as in the recent case of the Ottawa transit system murders. Prevention is always better than cure. What might be done by management?
1. Recognize that a problem exists. Acknowledge that mental illness occurs, and is probably present, in the organization. This will become increasingly acute as new laws in Canada seem likely to make it impossible to deny employees the right to go abroad on the basis of past experiences. Thus, even a person diagnosed with a mental illness cannot be denied a posting on that ground. The organization will have to be prepared to cope with the consequences of a “repeat.”
2. Acknowledge it as a genuine malady. Mental illness should be recognized as a physiological ailment. “There is so much suffering in mental illness!” sighed a retired psychiatrist. Former patients agree, as biographies begin to describe the ordeal as it is lived from the inside. It should also be noted that, contrary to popular belief, serious mental illness is not necessarily a career-limiting disorder. A study conducted by the Boston University Center for Psychiatric Rehabilitation on 500 professionals and managers who have, or have had, a serious mental illness, showed that 73% were able to achieve full-time employment in occupations that ranged from those for semi-professionals, such as nurses, case managers and administrators, to lawyers, professors and CEOs. Sixty-two percent of the survey respondents had held their current position for more than two years.
3. Ensure care for the entire family when abroad. The nature and special requirements of foreign service life demand a fully conscious recognition that 1) a mental disorder in the posted employee affects families, who are at the forefront of the problem and dealing with its consequences, 2) that there is no solution other than the provision of extended and professional support to the families, and 3) that the employer has a responsibility to the family unit. This means not only a radical change in attitudes, but also extensive change in the training and preparation of all persons involved, including especially the embassy doctors. Heads of post who are titularly responsible for the well-being of families abroad should be sensitized to an issue that will no longer remain under cover. Furthermore, because they are not themselves immune to dysfunction, the second in line and staff should be given training to recognize early symptoms. Special attention should be given to the case of repeats, especially in the first weeks of a new posting. It must also to be understood that afflicted officers may need to be protected from themselves, not only in the obvious cases of depression and suicide but also in borderline situations which can have disastrous long-term consequences for their lives. Caring for distraught families upon their return should involve:
• a debriefing by health authorities,
• a careful monitoring of post-trauma impacts,
• a continuum of counseling and care.
4. Learn from the past so as not to repeat it. These are only some suggestions. A serious inquiry into past problems, leaving no stones unturned, should be the basis for developing much needed policies.
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Originally published in bout de papier, Vol. 17, No. 3 (2000) — Fall 2000 // Automne 2000, pp. 12–16. Read the rest of this issue →
