WASHINGTON — Does VA need to employ more aggressive tactics when it comes to getting veterans struggling with PTSD, depression and s
ubstance abuse into treatment? Should some of those tactics involve using disability benefits as an incentive to receive treatment instead of as a simple entitlement?
These are a few of the many questions that have arisen in the wake of the California court decision that ruled VA’s delay in getting mental health care and benefits to veterans is a violation of due process under their 5th Amendment rights.
The idea of coercing veterans into care is controversial and runs up against both political and ethical objections. However, veterans’ advocates, VA advisors, and many veterans agree that, when it comes to getting veterans mental health care, VA’s position should not be as passive as it has been.
More Aggressive Care
“Though the VA were there and they were supportive, they never said, ‘this is what’s going to happen if you don’t get any help,’” veteran Daniel Hanson told legislators last month at a House VA Committee hearing. “VA needs to be more assertive in their treatment of veterans. They need to say, ‘It’s time to get help, or find somewhere else to get help.’”
Hanson has told his story to Congress before — the first time at a Senate hearing in March 2010. In February 2004, Hanson was deployed with the 2nd Battalion, 4th Marines to Ar-Ramadi, Iraq. His first experience with death on that tour was a fellow marine shooting himself in the head. By October 2004, 34 more marines in his battalion suffered combat-related deaths.
“I started drinking pretty heavily [after that tour],” Hanson said. “I was dealing with things I wasn’t prepared to deal with.”
By the time Hanson returned from his second tour — this one to Okinawa, Japan — he was drinking regularly, getting into fights and battling depression. In January 2007, he left the Marine Corps. By that time, the deaths of fellow marines — either in combat for those still in Iraq or by suicide at home — was a regular part of his life. In March 2007, his brother Travis, also a marine, hanged himself in the basement of his home.
Hanson began working with the St. Cloud VAMC in Minnesota on an outpatient basis. During that time, his marriage disintegrated and he was racking up a string of DUIs, spending some time in jail. At St. Cloud, he went through the Dual Diagnosis Program for PTSD and alcohol abuse. However, Hanson said, while the program taught patients about the dangers of drugs and alcohol, it had little real-life application. Eventually, he tried to kill himself by swallowing pills, resulting in a 72-hour suicide watch at St. Cloud.
Following that suicide attempt, there was little contact from VA, Hanson said, and he went back to his life, still abusing alcohol. While in jail for another DUI, he found a flyer for Minnesota Teen Challenge (MNTC) — a 13- to 15-month faith-based treatment and recovery program.
Hanson entered the yearlong program. He visited VA once a week for military-specific mental health issues, then returned to MNTC where, he said, he received the kind of discipline that was lacking at VA. That treatment came at a cost, though — about $10,000 a year, which VA would not help fund, because MNTC was not an approved VA partner.
Remarried with children, Hanson now acts as a liaison for MNTC, telling his story to other veterans and how the program helped him. “A big part of it was that the program wasn’t filled with people who had been through the same things I had. I didn’t have to put on this macho [act],” Hanson said. “And the structure was almost like the military. They tell you when to get up and go to bed. And if you want to get in a fight, you’re gone.”
Hanson asserted that he “could have gotten better, quicker” if the relationship that VA had fostered with him over the years had been less that of a concerned friend and more like that of an assertive parent or commanding officer.
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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.”
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