Compensation examinations for PTSD--an opportunity for treatment?

Marc I. Rosen, MD Veterans who undergo compensation examinations to determine eligibility for service-connected compensation have strong feelings about the process. A recent story aired by 60 Minutes on the compensation and pension evaluation process was titled, “Delay, Deny and Hope That I Die,” capturing the anguish compensation evaluations can evince [1]. A veteran at a recent hearing sponsored by the Veterans Benefits Administration (VBA) vividly described the anger he felt about the compensation evaluator: “The guy is getting a check to deny our services” [2]. When the response to a posttraumatic stress disorder (PTSD) claim is an evaluation without a concurrent offer of treatment, a potentially adversarial situation is made worse. The compensation examiner has a responsibility to the VBA to obtain information to adjudicate a claim, and as such, the examination serves a societal need rather than a treatment need. In fulfilling this societal need, compensation examiners are put into an evaluative role that can alienate the veteran being evaluated [3]. For example, the compensation examiner may have to collect information about traumatic issues that the veteran is unprepared to address therapeutically. A compensation examination focuses on data collection rather than addressing veteran distress. In addition, a compensation interview often has more time constraints than multisession clinical treatment, and the veteran may feel rushed. Limited time is available to focus on helping the veteran process his or her subjective experience. An examiner must consider not only the veteran’s perspective but also alternative sources of data and may ask questions that challenge the veteran’s version of events. Even the expression of empathy during an evaluation can be complicated [4]. The empathic listening that mental health clinicians are trained in may trigger unrealistic wishes for help from veterans asked to describe private thoughts and traumatic events. Such wishes may be evoked by the evaluation setting. Evaluations are usually performed in Department of Veterans Affairs (VA) clinicians’ professional offices, by VA clinicians in their professional garb, with clinicians identified by their titles (social worker, doctor, etc.)—all of these features are associated with being offered succor. At the end of the encounter, the compensation examiner concludes the evaluation and writes a report that may lead to a denial of benefits. The empathy may be seen as artificial and worsen veterans’ frustration with the compensation process. The Veterans Health Administration (VHA) suffers collateral damage by administering examinations that may result in the denial of benefits by the VBA. In my opinion, OIF/OEF (Operation Iraqi Freedom/Operation Enduring Freedom) veterans applying for service-connected compensation for PTSD should routinely be offered an on-site treatment referral immediately following