Late Breaking News
Follow Us
Outlook 2013
2012 Compendium
Congress Asks: In Wake of Court Ruling, Should VA Do More to Push Troubled Veterans Into Treatment? Cont.
- Categorized in: Addiction, Department of Defense (DoD), Department of Veterans Affairs (VA), Depression, July 2011, News, PTSD, Psychiatry, Rehabilitation, TBI
Linking Disability and Treatment
Hanson’s story, while extreme, is not uncommon for veterans suffering from PTSD who either never find their way to VA treatment or for whom VA treatment is ineffective. Similar stories have been told during VA committee hearings over the last several years, prompting legislators to demand that VA incorporate community programs such as MNTC into VA treatment.
It was when legislators asked Hanson about the relationship between his disability benefits and his treatment that the issue became politically complex. Hanson freely admitted that his disability check from VA was supporting his addiction at a time when he was depressed and making very poor decisions.
He also was taking advantage of educational benefits through the GI Bill. Asked what would have happened if those benefits had been held back until he got treatment, Hanson responded, “If you said, ‘You can’t go to school until you get help,’ that would have worked for me.’”
The idea of withholding benefits, either educational or monetary, from veterans until they received mental health care, is ethically questionable and likely politically impossible. But there is a push to better integrate the disability ratings process with the treatment process.
In preparation for last month’s hearing, the VA’s Advisory Committee on Disability Compensation (VDBC) analyzed the current methods of diagnosing, evaluating, and adjudicating the claims of veterans suffering from mental illness, paying particular attention to veterans with PTSD. The VDBC’s recommendations included that VA consider any baseline level of benefits to include health care, especially for PTSD patients.
The VDBC also recommended that VA establish a “holistic approach that couples PTSD treatment, compensation and vocational assessment, and that reevaluation should occur every two to three years to gauge treatment effectiveness and encourage wellness.”
“The benefits of linking these factors is that it may reduce homelessness and suicide as well as evaluate the effectiveness of treatment programs,” explained VDBC Chairman James Terry Scott, LTG USA (Ret.) “Most importantly, it greatly improves the opportunity for a veteran suffering from mental disability to maximize his or her future contributions to society.”
Scott admitted this was a controversial recommendation and that opponents will argue it could be used as a mechanism to covertly reduce disability payments and that it differs from how VA addresses physical disabilities. The VDBC believes, Scott said, that such problems can be addressed with carefully written and explained regulations and policy directives.
Some legislators noted that, however the regulations are written, such a change in VA policy was a slippery slope.
Labeling as Barrier to Treatment
There could be a clinical argument for restructuring VA’s disability ratings process, argued Sally Satel, MD, a noted psychiatrist, advisor to the Substance Abuse and Mental Health Administration, and author of several papers on substance abuse treatment and coercion.
According to Satel, being labeled as disabled before receiving any kind of treatment can be psychologically damaging to a veteran. “Despite the best interests of this system, awarding disability levels prematurely, especially at levels that suggest unemployability, may complicate a veteran’s recovery.”
Veterans suffering from PTSD or depression are already at a very vulnerable point in their lives, and may be reluctant to enter treatment, especially since one of the symptoms of PTSD is avoidance. For VA to label those veterans as 100% disabled before they engage in therapy of any kind could encourage them to see themselves as disabled, further preventing them from seeking treatment.
Satel urged legislators to consider a disability ratings system that held off on a final rating until after attempting to treat the veteran. Without the rating, the veteran would not receive disability benefits.
While Satel admitted that such a system would never work without a stipend for the veteran and their family to live on during treatment, she said her concern is not saving money but the labeling of the veteran as disabled.
“Call it a wellness stipend, call it a treatment scholarship, call it something,” Satel said. She said she would not object to the stipend being greater than the amount of a 100% disabled benefits check, as long as it was not called a “disability check.”
Responding to Satel's suggestion, Scott said that such an idea is not out of line with the VDBC recommendations and that such a stipend would almost certainly be required. “This is a complicated solution,” Scott said. “There is no one-size-fits-all [with PTSD treatment], but I do believe in a relationship between treatment and compensation.”
Related Psychiatry Articles
- TBI, PTSD Research Will Go On Despite DoD Budget Crunch
- Who Are Most Likely Military Suicide Victims? Guard Study Offers Some Valuable Clues
- Army Seeks to Improve Troop Resilience as Suicides Increase
- Alpha Blockers Tested as Potential Treatment for PTSD Symptoms
- Free Mobile App Offers Tools to Enhance PTSD Treatment
- Enlistment Waivers for Mental Health Tougher to Get with Reduction in Forces
- Medications for Depression, Psychosis Overused in VA Long-Term Care Facilities
- PTSD May Be Influenced More by Childhood Trauma than Experiences During Wartime
- Front-Line Clinicians Get Practical Advice To Help Combat Military Suicides
- Potential Overuse of Antipsychotic Drugs for PTSD Patients is Under Review
take the money drinks and uses drugs to combat the PTSD symptoms, and choose not to get actual treatment for PTSD, they deserve compensation, but moreso actual treatment to improve their quality of life.
.
So I have some questions to ask before the VA goes down this slippery slope. As you are all very aware those with the "Invisible Wounds of War" are treated by many in the military and the public as weak, not having a real injury or just crazy. You now want to compound the feelings of anxiety and mistrust by forcing the veteran into treatment that may or may not help and they may or may not be ready for because we as tax payers have the right to demand that?
Also is it right to make mental illnesses the only disability that a veteran will not be rated for at the time they apply and not have any pay given until someone decides they are well or as well as they can get from the treatment provided? So taking that logic; when I had patients who do not comply with the diabetes or HTN treatments I recommended for the good of their health the checks should be withheld and they should not get a full rating ? Only when they have met A1c goals and controled Blood presure the money can be given. To bad if they and their families have nothing else to live on.
Sorry but when a person joins the military they are promised that the government/taxpayer will care for any medical disabilities incurred for being willing to do a job that could end in disability or death. They are to be paid for these disabilities, provided the very best care possible, have easy access to it if they wish to use it and not to be discriminated against because it is a mental injury/illness and not a physical on. They can be an alcoholic without a mental health problem and still get paid for their SC disabilities because he does not have PTSD. How is this fair?
As a current mental health patient with my local VA I can attest to the problem of immediate access when there is a urgent need. It can take months to get routine appointments and have continuity of care with the high turnover in providers.
I also can tell you there are not any programs that my VA advertises, refers to or strongly encourages me to participate in. I had to ask what else we could try to help me get better because I was fed up with being unable to keep jobs, go out in public, being very depressed and feeling hopeless. I was offered a one on one program with a counselor to try some of the new treatment modalities but they were not in any available times that would work for me. I finally gave up trying to do it with the VA and I am now working with the much more flexible Vet Center. I do support providers and the VA both pushing patients who need help at every encounter to get treatment just as we encourage smokers to stop.
I recommend that there is an advocate position created at each VA who calls and writes those who need treatment encouraging them to get the help they need with a list of the programs available that are open at multiple hours, inpatient or out patient. That same person should then invite the vet to come in a discuss the options and how they can make it work best for them. It should be some one who acts a coordinator for the patient to get help. This person is the one who can be seen as the personal advocate for those who are resistant to treatment because of fear of everything and a lack of trust with military/VA. It still all comes down to the patient being ready for treatment because you cannot make someone well. They alone must choose to work on getting better; while we as Americans continue to support the troops as promised.
The Program of Assertive Community Treatment is an evidence-based strategy that has been employed in community mental health centers for decades. ACT utilizes a team-based approach which has been effective in engaging patients in mental health treatment; the core intervention in ACT is case management, in combination with wrap-around mental health services. It's a costly program, but has the potential to reduce more expensive interventions, such as inpatient hospitalization.
The VA's Mental Health Intensive Case Management (MHICM) program has a similar model to ACT, however, this service is only available to very psychiatrically ill patients, who have been hospitalized many times.
Veterans who are having trouble engaging in "traditional" psychiatric treatment (based in a medical model) but who are not sick enough to require MHICM, may benefit an intermidiate level of service that a well-implemented ACT program can provide.
However, without addressing the widespread access issue to mental health and substance use services, ACT programs will likely fail at the VA. Being "assertive" means that when the Veteran responds to your efforts to engage him or her in treatment, there needs to be treatment available...immediately. When the Veteran is finally ready to seek substance use or mental health treatment, it is unreasonable to expect them to wait for another several months for an appointment.
Assertive Community Treatment can be a successful alternative to coercive treatment. It is voluntary, ethical and evidence-based. However, the VA will need to promote a recovery-based, integrated culture of mental health treatment for this to be feasible.
Agree with concerns regarding access and treatment.
I generally have a Libertarian philosophy and respect the right to free choice, but, is it reasonable for the taxpayers to require some form of treatment if they are paying for someone's disability?? Not an easy question to ask, but given the realities of social resources the question is likely to be forced upon us.