The wrong way to help veterans

Sgt. Mark Fayloga/US Marine Corps

U.S. Marines depart a checkpoint and patrol back to Forward Operating Base Geronimo, Afghanistan, May 30, 2010.

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  • Speeding up entitlements for #veterans could ultimately hurt them

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  • Current disability determination tells someone they'll never walk again before they've even had treatment #disheartening

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  • Allow our war heroes treatment first, so they won't immediately succumb to psychological wounds #Veteransaffairs

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If all goes according to plan, by the end of the year, 10,000 American soldiers in Afghanistan will be home with their families--and their memories. As many as 20 percent of them will suffer from post-traumatic stress disorder, anxiety or depression, while suicide rates have reached tragic new highs among veterans. In response, the Department of Veterans Affairs has greatly expanded its mental health services and made veterans well aware that disability benefits are available.

It seems only logical that a veteran who thinks he has a long-lasting impairment as a result of military service would file a disability claim. The problem is that the system allows him to receive these benefits for a condition without ever having been properly treated for it. As a result, a system intended to speed up entitlements for veterans could end up hurting them.

Currently, for a disability determination, Veterans Affairs requires the claimant to go through a psychiatric exam, also known as a "comp and pension." But the session typically lasts just 90 minutes and does not provide enough information for an examiner to make a firm decision about a veteran's future function--that is, whether he or she will continue to be sick in a way that impairs the ability to work, and thus require compensation.

"But it borders on malpractice to allow young veterans to surrender to psychological wounds without first urging them to pursue recovery." -- Sally Satel, M.D.

After all, gauging the prognosis of mental injury in the wake of war is not as straightforward as assessing a lost limb. What's more, it is very difficult to predict the pace and extent of a patient's progress when the odds of success also depend heavily on nonmedical factors: the veteran's own expectations for recovery, availability of family and social support, and the intimate meaning the patient makes of his or her distress, wartime hardships and sacrifice. And there is an even more delicate risk: awarding disability status prematurely can actually complicate a veteran's path to recovery.

Consider a real-life case, a young soldier returning from Afghanistan, whom I'll call Joe. He is 23 years old and suffers from classic P.T.S.D. He is plagued by bloody nightmares. When awake, he can barely concentrate, twitches with anxiety and feels emotionally detached from everything and everybody. He fears he'll never be able to hold a job, have a family or fully function in society. He applies for "total" disability compensation for P.T.S.D., about $2,600 a month. The only humane thing to do, it would seem, is to grant the poor man those benefits.

But it's more complicated than that. In fact, total disability is probably the last thing Joe needs, because it will confirm his fears that he will remain deeply impaired for years, if not for life.

While a sad verdict for anyone, it is especially awful for someone so young. Imagine telling someone with a spinal injury that he'll never walk again--before he has had surgery and physical therapy.

This isn't a problem unique to veterans. Anyone who is unwittingly encouraged to see himself as seriously and chronically disabled risks fulfilling that prophecy. "Why should I bother with treatment?" he might think. Once someone is caught in such a downward spiral of invalidism, it can be hard to reverse course.

It's not just a matter of self-doubt. Such premature decisions create dependency, leading a capable veteran to fear losing the financial safety net if he leaves the disability rolls to take a job that ends up demanding too much.

Of course, some veterans will remain so irretrievably wounded by their war experiences that they are not likely to ever participate in the competitive workplace, and generous support is due them. But it borders on malpractice to allow young veterans to surrender to psychological wounds without first urging them to pursue recovery.

Instead, Veterans Affairs should adopt a treatment-first approach. The sequence would begin with treatment, move to rehabilitation and then, if necessary, assess a patient for disability status, should meaningful functional deficits persist.

At the same time, veterans too fragile for employment while in intensive therapy and rehabilitation--which, for some, could last up to a year--should receive financial support. Not disability payments, mind you, with their specter of permanent debilitation; call it a "recovery benefit"--as generous as total disability, but temporary.

With some exceptions, it is both realistic and important to instill the expectation in veterans that they will get better and find a comfortable and productive niche within the community and family. The road home from war is already an arduous one--the mental health system shouldn't make it any longer than it already is.

Sally Satel, M.D., is a resident scholar at AEI.

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