Chairman Miller, Ranking Member Filner, and Members of the Committee, thank you for the invitation to appear before the Committee. My name is Sally Satel. I am a psychiatrist who formerly worked with disabled Vietnam veterans at the West Haven VA Medical Center in Connecticut from 1988-1993. Currently, I am a resident scholar at the American Enterprise Institute (and work, part-time, at a local methadone clinic). I have been interested in applying the lessons we learned in treating Vietnam veterans to the new generation of service personnel returning from Iraq and Afghanistan.
At issue is the relationship between mental health treatment and compensation benefits. I have been asked to discuss the implications of granting disability status and benefits to veterans with psychiatric diagnoses before they have been treated for their mental health problems.
The Problem: Disabled yet Untreated
Much has been said about the different goals of two agencies within the Department of Veterans' Affairs: The Veterans' Health Administration, which provides treatment for veterans, and the Veterans' Benefits Administration, which adjudicates disability claims. In theory (and reality) veterans can apply for and receive disability entitlements for a psychiatric condition for which they never receive treatment. Yet treatment and rehabilitation could reasonably resolve or improve the suffering that prompted the veteran to seek compensation in the first place.
How many veterans fall through the gap between care and compensation is a question that the Committee is investigating. The scope is important, but there is little question that the problem exists.
At best, the missions of the two agencies can be integrated to enhance the welfare of veterans. Yet as policymakers consider the optimal administrative arrangement, it will be important to bear in mind the potential for inadvertent consequences -- namely, that prematurely granting disability compensation may, in some cases, derail rather than speed veterans on their path to recovery.
Goals of Disability Benefits
Before considering the interaction between treatment and compensation-how they work in concert for the benefit of the veteran or at cross purposes to his or her detriment -- a brief overview of disability compensation is in order.
According to the 2007 VA Benefits Commission the goal of disability benefits "should be rehabilitation and reintegration into civilian life to the maximum extent possible" and "should be provided [to] compensate for the consequences of service-connected disability on earnings capacity, the ability to engage in usual life activities, and quality of life."
At this time, the DVA is formulating a rating schedule for mental disorders. According to the Office of Mental Health Services, Department of Veterans, the new version will "shift the emphasis from disabling symptoms to a functional impairment model that focuses on work and income."
According to the current rating system, an individual with a service-connected rating of 100% is unemployable and highly symptomatic; a 50% rating corresponds to "occupational and social impairment with reduced reliability and productivity due to such symptoms [of PTSD, depression, anxiety]; difficulty in establishing and maintaining effective work and social relationships." A 30% rating reflects "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks."
Thus, both the current and future metrics emphasize diminished function as a core feature of what it means to be disabled. This, in turn, underscores the value of compensation as a mechanism for enabling and enhancing patient social function-and a key facet of function is work, as I will discuss.
Benefits and Treatment Integration
The standard rating assessment by VBA benefit examiners relies upon clinical "comp and pension" (C and P) exams conducted by VHA psychiatrists and psychologists. These clinician-examiners, acting strictly in an evaluative rather than a therapeutic role, base their conclusions about diagnosis, functional impairment, and relationship of impairment to military service, upon existing military, medical, psychiatric records. They also meet with applicants for face to face interviews. Typically, treatment is not discussed; it is simply not part of the C and P encounter.
To remedy this situation, veterans who have received a C and P evaluation for mental health disability, whether or not they go on to receive a compensation award, should receive care for that problem. Failure to direct the veteran to care is akin to diagnosing someone with a broken leg and then not setting it. Given that C and P examinations are a common point of contact with the VA for veterans, they afford optimal opportunities (or more strongly, the imperative) for the clinician-evaluators to encourage veterans to obtain care.
Benefits and Treatment at Cross Purposes?
The importance of linking treatment with benefits is a point of general consensus among those who have reviewed the topic of mental health and compensation (e.g., VA Benefits Commission, Institute of Medicine.) There is less agreement, however, surrounding the thorny questions raised by the process of disability assessment itself.
First, how competently can comp and pension examiners assess a veteran's functional impairment and potential for recovery if he or she has not yet undergone a course of treatment and rehabilitation? This is a complicated matter. After all, gauging mental injury in the wake of war is not as straightforward as assessing, say, a lost limb or other physical wound. At what point, for example, do normal, if painful, readjustment difficulties become so troubling as to qualify as a mental illness? How can clinicians predict which patients will recover when the odds of success depend so greatly on nonmedical factors, including the veteran's own expectations for recovery; availability of social support; and the intimate meaning the patient makes of his or her distress, wartime hardships and sacrifice?
This, of course, raises the question: at what point after a soldier is discharged from the military should the VA try to determine his or her potential for recovery and employability? What is the optimal timing of treatment relative to claims-filing?
Second, can disability payments prior to treatment have unintended consequences? I believe so. Sisability benefits, prematurely granted at the level of unemployability (e.g., 100%, Individual Unemployability), can put a veterans' recovery at risk. Consider the example below, based on an actual case.
A young soldier, let's call him Joe, was wounded in Afghanistan. His physical injuries heal, but his mind remains tormented. Sudden noises make him jump out of his skin. He is flooded with memories of a bloody firefight, tormented by nightmares, can barely concentrate, and feels emotionally detached from everything and everybody. At 23 years old, the soldier is about to be discharged from the military. Fearing he'll never be able to hold a job or fully function in society he applies for "total" disability (the maximum designation, which provides roughly $2,300 per month) compensation for PTSD from the DVA. This soldier has resigned himself to a life of chronic mental illness. On its face, this seems only logical, and granting the benefits seems humane. But in reality it is probably the last thing the young soldier-turning-veteran needs—because compensation will confirm his fears that he is indeed beyond recovery.
While a sad verdict for anyone, it is especially tragic for someone only in his twenties. Injured soldiers can apply for and receive VA disability benefits even before they have been discharged from the military--and, remarkably, before they have even been given the psychiatric treatment that could help them considerably. Imagine telling someone with a spinal injury that he'll never walk again--before he has had surgery and physical therapy. A rush to judgment about the prognosis of psychic injuries carries serious long-term consequences insofar as a veteran who is unwittingly encouraged to see himself as beyond repair risks fulfilling that prophecy. "Why should I bother with treatment?" he might think. A terrible mistake, of course, as the period after separation from the service is when mental wounds are fresh and thus most responsive to therapeutic intervention, including medication.
Told he is disabled, the veteran and his family may assume--often incorrectly--that he is no longer able to work. At home on disability, he risks adopting a "sick role" that ends up depriving him of the estimable therapeutic value of work. Lost are the sense of purpose work gives (or at least the distraction from depressive rumination it provides), the daily structure it affords, and the opportunity for socializing and cultivating friendships. The longer he is unemployed, the more his confidence in his ability and motivation to work erodes and his skills atrophy.
Once a patient is caught in such a downward spiral of invalidism, it can be hard to throttle back out. What's more, compensation contingent upon being sick often creates a perverse incentive to remain sick. For example, even if a veteran wants very much to work, he understandably fears losing the financial safety net if he leaves the disability rolls to take a job that ends up proving too much for him. This is how full disability status can undermine the possibility of recovery.
Without question, some veterans will remain so irretrievably damaged by their war experience that they cannot participate in the competitive workplace. But the system, well-intentioned though it surely is, must, at the same time, adequately protect young veterans from a premature verdict of invalidism.
Implications for timing: To the extent that granting disability may inadvertently undermine reintegration, a treatment first approach is logical. This sequence would begin with treatment, moves to rehabilitation, and then--if necessary--goes on to assessment for disability status.
The transition between military and civilian life is a critical juncture marked by acute feelings of flux and dislocation. Young men and women who are suffering from military-related mental illness will benefit most when they pursue treatment with the goal of recovery before labeling themselves beyond hope of improvement--and thus a candidate for high level or full service-connected disability status. Judging an individual disabled by a mental illness-worse, doomed to a life of invalidism in instances of unemployablity determinations -- before he or she has even had a course of therapy and rehabilitation is drastically premature.
Trauma-related distress and disorders should be treated early when symptoms are most responsive to treatment. There are excellent treatments for the component parts of PTSD (e.g., the phobias, anxiety, depression, existential dislocation). Treatments include desensitization protocols (such as Virtual Iraq), cognitive-behavioral therapy, psychotherapy, and medication. There is often a period in which treatment and rehabilitation overlap.
In general, clinical optimism is warranted and must be communicated to patients. While demoralization is not a formal diagnosis, in my experience, it can be the difference between someone who throws in the towel and someone who prevails.
In addition to the importance of a forward-looking stance is the extent to which problems of reintegration are managed. This is why quality rehabilitation addresses marital discord, readjustment to civilian life as well as to being a parent, vocational training, and financial concerns. Some veterans will need help with skills in relating to family, friends, neighbors, colleagues, and bosses. When day to day hassles are made more manageable, the patient feels more in control. Not only can he or she tolerate some symptoms better (e.g., sleep problems, distressing memories), those symptoms will likely fade faster. The veteran will be less likely to ascribe morbid interpretations to symptoms and to less apt to feel discouraged.
Does Compensation Discourage Treatment Participation? A 2007 report on PTSD compensation by the Institute of Medicine concluded that disability benefits for combat-related PTSD do not pose a disincentive to Vietnam veterans' participation in treatment or their treatment outcomes. Notably, an analysis by the DVA Inspector General found a large drop off in treatment use once 100% disability status was attained. But the other studies surveyed by the IOM found little or no difference in treatment engagement and symptom change between compensation-seeking/compensation-granted Vietnam veterans and non-compensation seeking veterans.
The striking aspect of these studies, in my view, is how little they revealed about the subjects' real-world functioning. (Moreover, the study subjects were Vietnam veterans with chronic PTSD, a group that might not be readily comparable to younger cohorts). Granted, attendance at treatment sessions and measurable reductions in symptoms is encouraging, but this is only a part of the picture. Without some kind of productive work, the goals of compensation as set forth by the Commission and the VA (fostering reintegration, rehabilitation, and quality of life) are not likely to be achieved.
Treatment entry facilitated at point of compensation evaluation-This represents a straight-forward mechanism for leveraging a major goal of disability compensation: rehabilitation. A critical feature of this arrangement would be periodic re-evaluations at 2-5 year intervals to assess progress and continued applicability of disability status.
Treatment First-As discussed, making a determination about a veteran's future functional capacity-that is, the degree of ongoing disability -- before he or she has had the opportunity for care is difficult, if not impossible.
For patients needing intensive treatment who are too fragile for employment, the VA should consider a living stipend for the veteran and his or her family during the course of care. In addition to providing income support, the stipend would allay the stress of financial insecurity that would surely undermine the veteran's clinical progress. If meaningful functional deficits persist following a substantial course of treatment and rehabilitation, the veteran would then file a disability claim.
Returning from war is a major existential project. Imparting meaning to one's wartime experience, reconfiguring personal identity, and reimagining one's future take time. Sometimes the emotional intensity can be overwhelming--especially when coupled with nightmares and high anxiety or depression--and even warrants professional help. When this happens, veterans, like Joe, should receive a message of promise and hope. This means a prescription for quality treatment and rehabilitation--ideally before the patient applies for disability status. Everyone who fights in a war is changed by it, but few are irreparably damaged. For those who never regain their civilian footing despite the best treatment, full and generous disability compensation is their due. Otherwise, it is reckless to allow a young veteran to surrender to his psychological wounds without first urging him to pursue recovery. Conferring disability status upon a veteran before his prospects for recovery are known can make the long journey home harder than it already is.
Sally Satel, M.D., is a resident scholar at AEI