Deployment guidelines for diplomats: current policy and practice

Transcription

1 Occupational Medicine 2015;65: Advance Access publication 27 July 2015 doi: /occmed/kqv095 Deployment guidelines for diplomats: current policy and practice R. Dunn 1, V. Kemp 2, D. Patel 3, R. Williams 4 and N. Greenberg 5 1 King s Centre for Military Mental Health, King s College London, London SE5 9RJ, UK, 2 Healthplanning Ltd, Reading, Berkshire RG6 1QB, UK, 3 Foreign and Commonwealth Office, London SW1A 2AH, UK, 4 Humanitarian and Conflict Response Institute, Faculty of Humanities, University of Manchester, Manchester M13 9PL, UK, 5 King s Centre for Military Health Research, King s College London, London SE5 9RJ, UK. Correspondence to: R. Dunn, King s Centre for Military Mental Health, King s College London, Weston Education Centre, 10 Cutcombe Road, London SE5 9RJ, UK. Tel: +44 (0) ; fax: +44 (0) ; rebecca.r.dunn@kcl.ac.uk Background Diplomatic organizations routinely send staff to high-threat postings (HTPs) and consequentially have moral and legal obligations to protect their health as far as is reasonably practicable. Aims Methods To carry out an international survey of diplomatic organizations that send personnel to HTPs to establish how they deal practically with their obligations to protect the mental health of their staff. An online anonymous survey about their organizations policies relating to HTPs completed by international diplomatic organizations. Results Fourteen of 30 organizations approached completed the questionnaire, with a response rate of 47%. Deployment length varied: no minimum (15%), a minimum of 2 years (39%) and a maximum of 2 (31%), 3 (15%) or 4 years (31%); one organization did not state any maximum. HTP and lowthreat postings had the same policies in 46% of organizations. Additional care and support (66%), additional preparation (50%), enhanced leave (33%) and additional physical and mental health assessments were informally adopted to address psychosocial risks of deployment to HTPs. Conclusions There was little consensus on policies and practice for HTP deployment. We suggest that formal, consistently written guidelines, based on available quality evidence, and associated training and quality assurance should be formulated to make international practice more consistent and equitable. Key words Guidelines; mental health; military; occupational health practice; policy; psychological health. Introduction Many organizations, including commercial companies, diplomatic organizations and military forces, routinely deploy staff to highly challenging environments. When compared to staff who are posted to less-threatening environments, these staff experience greater risks of exposure to adversity and trauma, either directly (e.g. seeing dead bodies; attending scenes of destruction) or vicariously (e.g. dealing with the social aftermath of a person s death or working in operational crisis response teams). It is important for these organizations to be aware of the possible effects that lengthy deployments to highthreat postings (HTPs) may have and how to mitigate the risks through the use of evidence-based support [1] and to consider the wider welfare implications of sending staff to HTPs as part of their moral architecture [2]. Although research into the relationships between military deployment and psychosocial outcomes is more plentiful, research into the effects of HTP deployments for other organizational groups is scarce. Understanding the intricacies of the effects of deployment is vital if organizations are to successfully develop and execute deployment guidelines and support for their staff. A recent review [3] suggested increasing deployment length increased the risk of adverse psychosocial and health effects on families left behind (as is usual for HTPs) as well as the people deployed [4 6]. This effect may, at least partially, result from increased deployment length increasing exposure to potentially traumatic events [7]. The review also found that longer tour lengths were associated with increased rates of alcohol problems and posttraumatic stress disorder [8], increased rates of diagnosis of mental disorders for the wives of deployed personnel Crown copyright 2015

2 536 OCCUPATIONAL MEDICINE [5] and increased spousal aggression on return from tour [6]. While these conclusions were mostly derived from military studies, there has also been research carried out in other organizations including those that employ international relief workers [4,9,10]. This previous review [3] revealed a number of practical conclusions, including a potential for detrimental consequences when deployment length is extended [8,11], when personnel deal with circumstances outside their control or if a diplomat s future plans are perceived as unpredictable. Similarly, first time deployment to an HTP appears to be the most challenging in terms of the psychosocial vulnerability of staff [9,12]. The latter probably relates to an absence of previous experience on which staff can base their expectations and behaviours and the absence of existing social support structures during time spent in a newly challenging environment [12]. Table 1, taken from a recent literature review [3], summarizes vulnerability and protective factors that determine the outcome in respect of mental, physical and general wellbeing, particularly with regard to deploying to HTPs. An organization s policy guidelines can hold significant weight in determining the path that staff members may follow with regard to their physical and mental health. This conclusion comes from knowledge of the importance of resilience and risk factors and research showing that deployment length adversely affects the general and mental wellbeing of personnel and their families [3]. The evidence identifies many aspects of deployment and organizations practice that could be incorporated into a robust policy to better support staff s psychosocial resilience. However, there is an absence of publicly available policies which diplomatic organizations use to mitigate the effects of deployment of staff to HTPs and thus it is difficult to benchmark the effectiveness of their application. Given the lack of clarity about the contents of an effective policy for managing staff, the Foreign and Commonwealth Office (FCO) commissioned a survey of international governmental organizations that send personnel to work in similar locations to establish how they Table 1. Vulnerability and protective factors relating to deployment (taken from Dunn et al. [3]) Protective/resilience factors Vulnerability factors Being taught effective coping Stressor novelty (first mechanisms [12] deployment) [9,12] Previous deployment [12] Deployment length [12] Social support [4,10] Exposure to trauma [4,10,12] Training and psycho-education Prior mental health-related [4,10] problems [13] Decompression leave and short breaks [10] Psychological support [4] deal with this challenge. We hope that this summary of the information will help to inform policy development in accordance with best practice. Methods We created an anonymous online questionnaire on Survey Monkey, an online data collection tool. Our survey was built on information obtained from the published literature about deployment of staff to high-threat locations. It used some of the items from the King s College Military Health Research questionnaire [14], which has been validated and previously administered to military personnel. The questionnaire was developed iteratively with FCO staff with the final version piloted on them to ensure validity. We restricted it to cover topics relating to organizations policies on deploying personnel to HTPs and did not enquire about personal experiences of deployment. The survey contained 15 questions, taking approximately 30 min to complete, and is available as Supplementary Data at Occupational Medicine Online. FCO staff contacted personnel who work in international governmental organizations that deploy diplomatic staff to HTPs. They introduced them to the research team and explained the aims of the study. We then invited organizations to put forward the names of staff identified as being experts in their knowledge of policies and procedures concerning tour duration and/or support provided. This process generated 30 professional contacts whom we ed directly with an information sheet and link to the online questionnaire. We assumed that respondents who completed the online survey consented to participate (this was explained in the information sheet). We only included surveys in the final dataset if they completed all mandatory questions. We sent follow-up communications to all contacts on two occasions to maximize the responses. Our survey comprised two components: closed questions with a predetermined list of answers from which responders could choose and open text boxes seeking elaboration. We amalgamated closed questions results into tables and used thematic analysis to analyse the open text answers. The analysis was organized based on the main themes that became apparent in the survey. Where possible, we quantified and included coded data in the tables. Illustrative quotes appear in italics in text, but representative quotes where there may have been more than one example are prefixed with e.g. in brackets. Results Fourteen (47%) of the 30 contacts completed the questionnaire. Table 2 illustrates the demographics of the respondent organizations. Tables 3 5 show that the response rate fell in several areas due to invalid (vague or incomprehensible) or missing data (blank free-text

3 R. DUNN ET AL.: RISKS ASSOCIATED WITH HIGH-THREAT POSTINGS 537 Table 2. Respondent demographics Demographic factors (N) Total n (%) Main role (14) Human resources 5 (36) Health care professional 4 (29) Occupational health practitioner/adviser 4 (29) Policy maker 1 (7) Employment length of respondent thus far (14) <1 year 1 (7) 1 5 years 2 (14) 6 10 years 3 (21) >10 years 8 (57) Table 3. Factors included in the development of a high-threat deployment policy Policy factors (N) Total n (%) Last updated (12) Within last 18 months 11 (92) More than 18 months ago 1 (8) Update due (10) Yearly 2 (20) Ongoing 1 (10) (40) (10) Unknown 2 (20) Development of policy (14) Expert review 8 (57) Literature review 6 (43) Scientific review 5 (36) Advice from experienced diplomats 14 (100) Advice from other organizations 12 (86) Advice from health care practitioners 12 (86) Advice from policy makers 8 (57) Previous policy experience 2 (14) Matters driving the requirement for the policy (14) Unknown 2 (14) Known 12 (86) Of the 12 who responded known Duty of care for staff 6 (43) Legal/laws/government 4 (33) Security and threats aspects 3 (25) Cooperation with EU and USA 1 (8) Personnel experience 1 (8) boxes). Due to the anonymous nature of the survey, we collected no data from non-responders, as we could not identify which organizations had not completed the survey. One respondent reported that their organization did not have a policy on deploying diplomats to HTPs, but that one was in development. Of the remaining 12 responding organizations which made valid responses to this question, 11 (92%) had updated their policies in the previous 18 months. One organization reported that its policy was specific to Afghanistan, the Afghanistan model provides the measuring stick (it is considered the extreme) for how to handle other HTPs. However, six organizations (46%) reported that their policies for HTPs were no different to those for low-threat postings (LTPs). Of the remaining four, the most common HTP/ LTP policy difference was financial, in that HTP deployees received better financial incentives (n = 4, 57%). Although only half of organizations had a policy for HTPs which differed from that for LTPs, 92% (n = 12) of all respondents reported that specific supporting interventions are provided for staff who deploy to HTPs over and above those provided for all other members of the organization. This latter figure is considerably higher and suggests possible unwritten support provisions for those on HTPs. This additional specific support was described in the following forms: 1. Additional care and support including individualized psychosocial support and priority attention (e.g. personal visits at home, contact, video meetings, or visits at times of crisis to the work units in HTPs ), mental health intervention programmes, onsite posting visits (n = 8, 66%); 2. Additional preparation including tailored briefings and specific security training for HTPs (n = 6, 50%); 3. Enhanced leave including additional home leave, decompression leave, short breaks (e.g. Certain locations, short breath-taking leave to safe nearby territories ) and leave for medical examinations (n = 4, 33%); 4. Additional physical and mental health assessments such as mid-tour screenings, individual psychological interviews and post-tour wellbeing checks (n = 3, 25%). Organizations were able to select more than one option with regard to developing and testing their policies. We found that various sources of advice, including from experienced diplomats, health care practitioners, other organizations and policy makers, were used more frequently than scientific sources (expert, scientific or literature reviews). The detailed policy factors are shown in Table 3. Twelve of the 14 organizations provided free-text information on their policies, which we were able to code and quantify for comparisons. Physical and mental health assessments were reported by six of the organizations (50%), relating to medical clearance as part of the selection process (e.g. comprise of psychometric testing and interviews with one of the staff counsellors. It will address an applicant s ability to work in emotionally and physically challenging conditions ). Care and support issues were raised by 25% of the organizations (n = 3), for prior to posting (e.g. to discuss coping measures and security issues ), during (e.g. every three months, compulsory

4 538 OCCUPATIONAL MEDICINE consultations with a social worker under supervision of psychologist/medical advisor ) and after posting (e.g. compulsory consultation with a social worker, three times with intervals of three months ). Tables 4 and 5 detail factors considered within the deployment policies. Duration of deployment was mentioned in 13 (93%) of 14 organizations policies. Four organizations (31%) followed the same guidelines for deployment durations, a minimum of 2 years and a maximum of 4 years. One organization specifically stated that there was no minimum (although a maximum of 2 years). Another stated a maximum of 3 years but made no reference to a minimum duration. Conversely, a further organization made no reference to a maximum duration, commenting only on its 1-year minimum. Overall almost a third of organizations reported 1-year minimum postings (n = 4, 31%), with one referring to 6 months to 2-year extensions. The majority of respondents (86%, n = 12) allowed requests for adjustments to duration to be made by either deployed personnel or the organization (n = 12, 86% equally). According to 5 of 10 valid responses, if a request has been made by deployed personnel to lengthen or shorten their tour, a psychological evaluation is carried out as part of the procedure before a decision is made. When a request is made by either party to change the duration of a tour, six of the eight valid responses (75%) reported that their HTP policies do not direct any changes in support. There seemed to be little consistency in the frequency of rotation or rest and recuperation breaks. One third of responders organizations (31%, n = 4) did not comment on rotation at all. See Table 4 for the remaining options on rest and recuperation, which can be seen to vary considerably. Table 5 details the information and support factors within the deployment policies. With regard to preparation and support, all valid responses stated that diplomats deployed on HTPs were required to attend a pre-deployment briefing that included mental health specific information. Briefing information in written format is also given (n = 9, 69%) as well as a requirement for course or training attendance (n = 6, 39%). The types of training mentioned by one organization included stress management, trauma and first aid, threat avoidance, defensive driving and resiliency. Another organization reported that its diplomats have training with military personnel to give them an idea of what they may experience. Discussion We gathered information from 14 governmental organizations about customs, practices and the nature of policies on tour length for HTPs. Our results suggest a lack of Table 4. Factors within a high-threat deployment policy Policy details (N) Total n (%) Differs from LTP policy (13) No 6 (46) Yes 7 (54) Of the 7 that responded yes Additional training and awareness 2 (29) Financial incentives/compensation 4 (57) Compulsory medical clearance 1 (14) Additional leave 2 (29) Psychological status monitoring 2 (29) Tour length (14) Not included in policy 1 (7) Included in policy 13 (93) Of the 13 with it included in the policy Minimums and maximums separated Minimum 1 year 4 (31) Minimum 2 years 5 (39) No minimum stated in the policy 2 (15) Maximum 2 years 4 (31) Maximum 3 years 2 (15) Maximum 4 years 4 (31) Factors determining tour length (14) Threat level of posting (LTP/HTP) 14 (100) Employment grade/ranking/position 5 (36) Previously deployed to any overseas posting 5 (36) Previously deployed to HTP 6 (43) Duration of intended post 5 (36) Health aspects 2 (14) Living conditions and accompanying family members 2 (14) Rotation/breaks (13) Frequency of rotation not stated 4 (31) 8 weeks on, 4 weeks off 1 (8) 8 weeks on, 2 weeks off 1 (8) 8 weeks on, 6 days off 1 (8) 6 weeks on, 6 weeks off 1 (8) 6 weeks on, 2 weeks off 3 (23) 6 days on, 2 days off 1 (8) every 2½ months 1 (8) Can ask to alter tour duration (14) Yes 12 (86) No 2 (14) Can be asked to alter tour duration (14) Yes 12 (86) No 2 (14) Of the 12 that responded yes, their reasons included Medical 5 (42) Personal 6 (50) Performance review 2 (17) Not known 1 (8) Changes to support provided if tour duration changes (8) Support not changed 6 (75) Psychological support offered case by case 2 (25) Psychological evaluation as part of tour length alteration (10) Additional psychological evaluation 5 (50) No additional psychological evaluation 2 (20) Additional psychological evaluation case 3 (30) dependent

5 R. DUNN ET AL.: RISKS ASSOCIATED WITH HIGH-THREAT POSTINGS 539 Table 5. Information and support factors within a high-threat deployment policy Information and support (N) Total n (%) Mental health and welfare information for personnel (13) Oral briefing 13 (100) Written information/leaflet 9 (69) Courses and training 5 (39) E-Learning 1 (8) Mental health and welfare information for families (13) Oral briefing 6 (46) Written information/leaflet 4 (31) None 5 (39) E-Learning 2 (15) Information and support before, during and after posting (13) Information and support differs 5 (39) Same information and support throughout 5 (39) Do not know 3 (23) Support specific to HTPs (13) Yes 12 (92) No 1 (8) clear consistency in operational guidelines. HTP deployment policies were mainly based on the experience of people in the organizations of how personnel had been previously deployed to HTPs, with little indication of evidence-based policymaking. Of the organ izations that responded, almost half reported that their policies for HTPs were no different to those for their LTPs, but the majority acknowledged that in practice personnel deploying to HTPs were treated differently. This mismatch between policy and practice suggests that diplomatic staff in similar situations might be treated differently depending on who is dealing with them. Research into the effects of HTP deployments for nonmilitary organizational groups is scarce, and to our knowledge, this is the only study attempting to establish how they deal practically with their moral and legal obligations to protect the health of their staff. The low response rate and small initial sample size mean our findings may not be representative or widely applicable. We think that some non-responses were associated with the survey being sent out during the summer months when many staff members take annual leave, with other priority tasks to complete on their return. As we were unable to collect data on nonresponders, we cannot be sure of the strength of potential response bias. The brevity of the survey appears to have led to some confusion among recipients (e.g. the wording of the question about support for family members, among others). It seems respondents interpreted this question as preparation of support for family members who also deploy, rather than for family members coping with being left behind. Despite the low response rate and brief nature of the survey, we achieved a wealth of useful information, particularly in the free-text boxes. While it was apparent from the survey data that HTPs are mainly unaccompanied tours, respondent organizations were aware of the value of established social support. Effective social support has been shown to be protective of mental health [15] and our results are reassuring in that diplomatic organizations appeared to be generally aware of this although how they intended to facilitate it remains unclear. Our work shows that employers provide varying schedules of leave for rest and recuperation. One organization mentioned using post-tour decompression, which is often used by military forces returning from deployment and is an opportunity for informal social support between peers after deployment before returning home [16]. Studies from military settings have found that troops going through decompression are less likely to experience mental health problems after deployment than troops who did not [17]. It is important to note that while many organizations have a policy on leave rotation, only one organization stipulated a specified duration between full deployments. It is also notable that military studies, which have examined the effect of mid-tour leave for military personnel, have found equivocal results [18,19]. The survey also revealed inconsistent practice with regard to altering tour lengths. While changes of tour length (requested individually or by the organization) were frequently allowed, there appeared to be little evidence that organizations had recognized that uncertainty around maximum time away and ambiguity about decision-making processes might cause distress. Uncertainty about tour length has been shown to provoke feelings of lack of control over one s circumstances and ultimately to act as a factor in declining mental health [11,14]. Therefore, increased support may be needed for those whose tour length is altered irrespective of who requests it or whether the tour length increases or decreases. In the broader context of deployment, we suggest that it may be helpful for diplomatic organizations to take account of the scientific evidence about the range of stressors experienced by diplomats working in HTPs. Lock et al. have expanded on earlier work that appears in the North Atlantic Treaty Organization s (NATO) guidance to offer a typology of stressors [20] and to the NATO guidance [21]. Firstly, there are primary stressors, inherent to deployment (e.g. threat of being attacked, feeling powerless) and, while they may be difficult to manage, staff can be informed about them, assisted in their preparations and supported in dealing with them by their employers. Secondly, non-inherent to deployment are stressors such as lack of specific role training and arbitrary leadership/management, which may also be detrimental to wellbeing [20,22,23]. There is good

6 540 OCCUPATIONAL MEDICINE evidence that leadership behaviours and attitudes are strong determinants of mental health status for troops deployed to HTPs [15]. Thirdly, there is good evidence that deployment increases the propensity for unhealthy risk-taking by deployed staff, known as manufactured stressors [22,24,25]. We suggest that the evidence about improving organizational psychosocial resilience available from the literature and from our survey should be considered when making decisions about optimal tour length and support for diplomatic staff deployment. Our research has highlighted a number of topics on which further research would be beneficial. In particular, there is a lack of scientific studies focused on diplomatic staff who are deployed to HTPs. Some themes for future research could include a prospective or quasi-experimental study investigating the wellbeing of diplomats and their families through the course of a deployment (before, during and after) to determine ideal tour length, including mitigating and moderating factors, and an investigation into the impact of pre- and post-deployment briefings. Key points There is little consensus about the best approach to determining tour lengths for high-threat diplomatic postings, and most of the organizations surveyed adopted a range of measures, frequently not as part of a formal policy, to address the psychosocial risks of such deployments. Mismatches in policy and practice may result in inconsistencies in management and perceived in equalities of care for diplomats. Organizations should consider the available evidence on improving organizational psychosocial resilience when making decisions about optimal tour length and support for high-threat diplomatic staff deployments. Funding Foreign and Commonwealth Office (FCO). Acknowledgements The FCO staff who helped with the development and administrative distribution of the survey and the Health Protection Research Unit of King s College London for allowing the authors the time to complete the paper. Conflicts of interest D.P. works at the FCO as the occupational health lead clinician and N.G. carries out occasional paid work for the FCO which is unrelated to this study. References 1. Society UKPT. Trauma Stress Management Guidance. London: United Kingdom Psychological Trauma Society, Warner M, Williams R. The nature of strategy and its application in statutory and non-statutory services. In: Williams R, Kerfoot M, eds. Child and Adolescent Mental Health Services: Strategic Approaches to Commissioning and Delivering Child and Adolescent Mental Health Services. Oxford: Oxford University Press, 2005; Dunn R, Williams R, Kemp V, Patel D, Greenberg N. 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