Veterans benefits for post-traumatic stress disorder in the United States
The United States provides a wide range of benefits for veterans with posttraumatic stress disorder (PTSD), which was incurred in, or aggravated by, their military service. The United States Department of Veterans Affairs (VA) will provide benefits to veterans that the VA has determined suffer from PTSD, which developed during, or as a result of, their military service, and which interferes at least to some extent in their ability to work. These benefits not only include tax-free cash payments but can also include free or low-cost mental health treatment and other healthcare; vocational rehabilitation services; employment assistance; independent living support; and more.
VA disability benefits for PTSD have evolved over time, in response to legislation, scientific advances, political pressure, revised diagnostic classification schemes, regulatory changes, case law, and administrative decisions. Veterans advocacy organizations, researchers, clinicians, politicians, administrators, and citizens will no doubt continue to influence how the United States evaluates, adjudicates, and administers the program. For example, current efforts at change or reform include urging the VA to place more emphasis on vocational rehabilitation and treatment versus cash payments; revising the Rating Formula for Mental Disorders to better reflect problems experienced by veterans with PTSD; establishing a balance between efforts to decrease claims processing time (productivity) with the need for consistency and accuracy of examination results and rating decisions (quality); and considering a veteran's quality of life as a factor in determining the disability rating.
- 1 U.S. Veterans Benefits
- 2 The VA Disability Claims Process
- 2.1 Overview of claims process
- 2.2 Benefits application procedures
- 2.3 Obtaining Assistance with Filing a Disability Compensation Claim
- 2.4 Post-Adjudication Representation
- 3 The Disability Rating
- 4 The PTSD C&P Exam
- 5 Important Definitions
- 6 Notes
- 7 References
- 8 External links
U.S. Veterans Benefits
Brief History of U.S. Veterans Disability Benefits
Since the founding of the country, the United States has sought to compensate the men and women who have served in its armed forces. Initially this compensation was given to all veterans as a gratuity payment, i.e., as a 'thank you' for their service. But in 1917, the U.S. Congress initiated a shift in the rationale for compensation away from a gratuity system and toward an indemnity scheme, which was further clarified in 1919 amendments to the law. Since that year, compensation has been provided to veterans suffering from physical or mental disabilities that were incurred during, or aggravated by, military service, and which have adversely impacted the veteran's ability to work. The amount of compensation provided—both cash payments and VA-sponsored services—are based on the veteran's average impairment in earnings capacity.
Effectiveness of the U.S. Veterans Disability Benefits Program
Do VA disability benefits adequately compensate veterans with PTSD for a loss in average earnings capacity? Older veterans age 65 and up rated at 50% disabled or higher for PTSD (including individual unemployability (IU) benefits) receive more in compensation (plus any earned income and retirement benefits such as Social Security or pensions) than nondisabled veterans earn in the workforce and/or receive in Social Security and other retirement benefits. However, younger veterans (age 55 and below) generally receive less in compensation benefits (plus any earned income) than their non-disabled counterparts earn via employment. For example, the parity ratio[a] for a 25-year-old veteran rated 100% disabled by PTSD is 0.75, and for a 35-year-old veteran rated 100% disabled by PTSD the ratio is 0.69. The parity ratio for a 75-year-old veteran receiving IU benefits is 6.81.
In addition, veterans receiving disability benefits for PTSD experience a reduction in PTSD symptom severity, and have lower rates of poverty and homelessness.
At the same time, some scholars argue that the VA disability benefits program is "countertherapeutic" because it provides no incentives to overcome symptoms and problems caused by the disorder, and, in fact rewards veterans for staying sick, while other researchers take issue with this assertion. In a similar vein, some military scholars suggest that current VA disability benefits policy inculcates in veterans a lack of self-efficacy and fosters dependency.
The VA Disability Claims Process
This section provides a brief overview of the 8-step claims process; describes how a veteran files an initial claim for PTSD disability benefits; why the VA recommends that Veterans seek assistance with filing a claim; and how to locate and select sources for such assistance.
Overview of claims process
The VA provides a description of the 8-step benefits claims process on its website. This is a brief overview:
1. Claim Received - The veteran has submitted a disability compensation claim in person (e.g., while still on active duty with a VBA (Veterans Benefits Administration) representative visiting his or her base), online (via the Veterans On-Line Application [VONAPP]), or by postal mail to the VBA Regional Office (VARO) assigned to his or her geographical location (legal residence). The VARO sends a letter to the veteran via postal mail confirming receipt of the claim.
2. Under Review - A VSR (Veterans Service Representative) reviews the information submitted by the veteran to determine if VBA needs any additional evidence (e.g., service medical records) to adjudicate the claim.
3. Gathering of Evidence - VA has a legal obligation to help veterans obtain any evidence that will support their claim. For example, the VSR might request a veteran's military personnel records (e.g., to confirm unit assignments), Social Security disability records (if the veteran applied for Social Security disability benefits), or private medical records. The veteran can also obtain such records and submit them to the VBA Regional Office handling his or her claim. If necessary, the VSR will request a Compensation and Pension examination (C&P exam) at this time.
4. Review of Evidence - An RVSR (Ratings Veterans Service Representative) makes sure that all relevant evidence has been obtained, and, if so, renders a decision regarding the veteran's claim. The RVSR refers in part to the General Rating Formula for Mental Disorders when making this determination.
5. Preparation for Decision - It is not clear how this step differs from the previous step. The exact quote from the VA website is: "The Veterans Service Representative [presumably they mean the Ratings Veterans Service Representative] has recommended a decision, and is preparing required documents detailing that decision. If more evidence is required, the claim will be sent back in the process for more information or evidence."
6. Pending Decision Approval - Approval by a supervisor.
7. Preparation for Notification - Preparing the "claim decision packet" (Decision Letter and explanatory materials).
8. Complete - VBA mails the "claim decision packet" to the veteran.
Benefits application procedures
To begin the disability claim process, a veteran must submit a claim to the Veterans Benefits Administration (VBA), an organizational element of the VA. The VBA, based on their review of medical and psychological evidence, must conclude that the veteran indeed suffers from service-connected PTSD. Reaching such a determination usually requires that the veteran receive a Compensation and Pension examination (C&P exam), which is a forensic[b] mental health evaluation conducted by a psychologist or psychiatrist at a local VA medical facility or by a psychologist or psychiatrist in independent practice who conducts evaluations for a VA-contracted private vendor.
A veteran can apply for compensation benefits him or herself by writing a letter, or by filling out VA Form 21-526, Veterans Application for Compensation and/or Pension, and mailing it to their local Veterans Benefits Administration Regional Office, often referred to as the "VARO" (VA Regional Office). Note that VA Form 21-526 and the accompanying instructions are quite detailed, which is probably why the VA recommends that veterans take advantage of expert assistance from specially trained Veterans Service Officers (see next section).
A veteran may also file a disability benefits claim online using the Veterans On-Line Application (VONAPP) System.
Obtaining Assistance with Filing a Disability Compensation Claim
Veterans may receive assistance with filing a VA disability compensation claim from Veterans Service Officers, also known as "VSO Representatives" or "Veterans Service Representatives",[c] especially when they are affiliated with a nonprofit Veterans Service Organization.
Note in this regard that the VA specifically recommends that veterans ask a Veterans Service Officer to help them file a disability compensation claim. Here is a quote from the VA website, which explains why the VA makes this recommendation:
VA encourages individuals who are applying for disability compensation to work with an accredited representative ... to assist them.... Being accredited means organizations and individuals must have VA permission to represent Veterans before the Department in their claims for VA benefits. The purpose of this requirement is to ensure that Veterans have qualified and competent representation. These individuals receive specialized training in VA benefits law and procedure.
Although some veterans advocates recommend that veterans learn how to file their own claims so that they retain control over the process, e.g., "...veterans [should] file their own claims without the assistance of any sort of representative...except for an appeal" (see Post-Adjudication Representation, below, for information regarding legal representation for appeals).
The next two sections briefly describe the two types of Veterans Service Officers.
County Veterans Service Officers
County Veterans Service Officers are public employees of their State's (or Territory's) veterans affairs agency. They are often called County Veterans Service Officers, because a majority of the states have set up local veterans affairs offices in each of the state's counties.
Veterans Service Officers Associated with Nonprofit Veterans Service Organizations
Many not-for-profit Veterans Service Organizations recruit, train, and support their own Veterans Service Officers to help veterans file claims and navigate the claims process. In order to represent a veteran before the VA, the Veterans Service Organization must either have been Chartered by the U.S. Congress or have received official approval from the U.S. Department of Veterans Affairs to represent veterans in the disability compensation claims process.
As noted above, these Veterans Service Officers are sometimes called VSO Representatives.
Although to make matters somewhat confusing, the VA sometimes refers to both County Veterans Service Officers and VSO Representatives as "Veterans Service Organizations (VSO) Representatives" or "VSO Representatives." For example, if you conduct an "Accreditation Search" on the VA website and search for a "VSO Representative," the search results will list both County Veterans Service Officers and VSO Representatives.
Selecting a Veterans Service Officer
Veterans may select either type of Veterans Service Officer to help them file their disability compensation claim(s). After the veteran selects his or her Veterans Service Officer, he or she completes VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative and submits it to the Veterans Benefits Administration. This appointment authorization gives the Veterans Service Officer legal authority to represent the veteran's interest before the VBA and any other related agencies or organizations involved in the disability benefits claims process.
After VA Form 21-22 has been received and accepted by the VBA, the Veterans Service Officer helps the veteran file the initial disability compensation claim. Subsequent to filing the claim, the Service Officer may also engage in a variety of other, related, activities on behalf of the veteran, for example, calling the VBA to inquire about the status of a veteran's claim, or appearing with a veteran when meeting with VBA officials, or helping the veteran understand the Compensation and Pension (C&P) examination process.
The veteran does not pay a Veterans Service Officer for their services.
How Veterans Request a Copy of their Claims File
Veterans who wish to obtain a copy of their Veterans Benefits Administration (VBA) claims file, can write directly to the VBA Regional Office handling their claim(s). Veterans can find the name and address of their Regional Office on the first page of any correspondence they have received from VBA, or they can look up their VBA Regional Office mailing address on the VA website. Send the request via Certified Mail, Return Receipt Requested (if using the U.S. Postal Service), or other methods which provide proof of delivery, e.g., FedEx or United Parcel Service (UPS). The letter, which can be typed or hand-written, should include the veteran's full name, Social Security Number, mailling address, and signature.
If a veteran is not satisfied with the VBA's decision regarding their compensation claim, they may appeal the decision, and they may ask to be represented by an accredited Veterans Service Officer, attorney, or claims agent in the appeals process. Veterans usually appeal a decision because their claim was either denied outright or because they believe that the disability rating assigned by the VBA is incorrect.
Note that the VA does not require a veteran to be represented by an Veterans Service Officer, attorney, or claims agent.
VA prohibits attorneys or claims agents from charging a veteran for professional services prior to the adjudication of the veteran's claim. A veteran may contract with an attorney or claims agent to represent them in an appeal only after the following three conditions have been met:
- the veteran has filed his or her disability compensation claim;
- the claim has been adjudicated (a decision on the claim has been made by the Veterans Benefits Administration); and
- the veteran has filed a Notice of Disagreement (NOD) with the VBA Regional Office handling his or her claim.
Unless they agree to work on a pro bono basis, attorneys and claims agents who represent veterans before the Veterans Benefits Administration, Board of Veterans Appeals, and Court of Appeals for Veterans Claims require payment for their services. In most instances, the veteran and attorney (or claims agent) submit a signed payment agreement with the VA Office of General Counsel, which stipulates that the attorney will receive payment directly from the VA after the veteran's claim has been adjudicated, if the adjudicator awards service-connected disability compensation to the veteran. The amount of the attorney's fee is based on a percentage of the lump sum "back pay" compensation issued to the veteran by the VA.
The Disability Rating
General Rating Formula for Mental Disorders
If an RSVR determines that a veteran indeed suffers from service-connected PTSD, then he or she assigns a disability rating, expressed as a percentage. This disability rating determines the amount of compensation and other disability benefits the VA will give to the veteran. The disability rating indicates the extent to which PTSD has deprived the veteran of his or her average earnings capacity. A rating of 0% indicates that a veteran has PTSD but the disorder has not affected his or her ability to work, whereas a 100% rating theoretically means that the veteran is not capable of working at all because of PTSD.[d]
The VA assigns disability ratings for PTSD according to the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130), which specifies criteria for disability ratings of 0%, 10%, 30%, 50%, 70%, or 100%.
Some argue that by relying on the current Rating Formula, "VA uses decades-old regulations developed for mental disorders that do not resemble PTSD", and, consequently, "[i]rrelevant criteria ... may outweigh ... more relevant factors, leading VA to undercompensate veterans with valid diagnoses of PTSD." Similarly, veterans service organizations have argued, for example, that a "...veteran service connected for schizophrenia and another veteran service connected for another psychiatric disorder should not be evaluated using the same general formula" and have supported efforts to revise the Rating Formula.
Since 2001, the VA has been revising its disability rating schedule to incorporate medical advances that have occurred since the last review, update medical terminology, add medical conditions not currently in the Rating Schedule, and refine criteria for further clarity, consistency and ease of rater application.
Requests for an Increased Disability Rating
A veteran currently receiving compensation for service-connected PTSD may request in increase in his or her disability rating (the VA also refers to this as an increased disability evaluation, although increased disability rating is more common) for one of three reasons: 1) Perceived error; 2) Worsening symptoms and functioning; or 3) Individual unemployability.
A veteran must present new evidence in order to request an increase in his or her disability rating. This new evidence almost always takes the form of greater symptom severity and functional impairment and/or individual unemployability. Since the veteran's lay testimony (self-report) is generally accepted for such purposes, it is usually not difficult for a veteran to request an increase in his or her disability rating.[e]
Due to Perceived Error
A veteran may request an increased rating if he or she believes that their initial rating was in error, i.e., it was not high enough. If a veteran requests an increased rating for this reason within the first year after the rating decision, it is considered to be an appeal of the VBA's rating decision. If a Veteran does not appeal the initial rating decision within one year, then he or she technically must request an increased rating due to worsening symptoms and a deterioration in functioning, even if their "real" reason is because they believe the initial rating decision was a mistake.
Due to Worsening Symptoms and Functioning
As noted above, if a veteran believes that his or her condition has worsened, he or she may request an increased disability rating.
Due to Individual Unemployability
If a veteran believes that PTSD, either or alone or in combination with other service-connected disabilities (e.g., diabetes, a back injury, chronic pain, etc.), renders him or her incapable of pursuing and retaining gainful employment, and he or she meets the eligibility requirements, then he or she may file a compensation claim based on unemployability using VA Form 21-8940.
The PTSD C&P Exam
As noted above, the VBA almost always requires a compensation and pension examination (C&P exam) of veterans claiming service-connected PTSD. There are two types of PTSD C&P exams: Initial and Review. The Initial Examination for Post-Traumatic Stress Disorder must be conducted by a VA psychologist or psychiatrist certified by the VHA Office of Disability and Medical Assessment (DMA) to evaluate veterans for this purpose. However, note that the definition of "VA psychologist or psychiatrist" includes psychologists and psychiatrists in private practice who conduct C&P exams for a company that has contracted with the Veterans Benefits Administration (VBA) or the Veterans Health Administration (VHA) to provide C&P exam services on behalf of the VA. Companies with current VBA or VHA C&P exam contracts include Veterans Evaluation Services (VES), QTC, Logistics Health Incorporated (LHI), and Medical Support Los Angeles (MSLA).
The Review Evaluation for Post-Traumatic Stress Disorder can be completed by VA or non-VA psychologists and psychiatrists. Clinical or counseling psychology interns, psychiatric residents, licensed clinical social workers, nurse practitioners, physician assistants, and clinical nurse specialists may also conduct review PTSD exams, although they must be "closely supervised" by a psychologist or psychiatrist.
Some scholars have expressed concerns about the reliability (consistency) and validity (accuracy) of C&P exams for PTSD because:
- Some VA medical centers do not allocate enough time for C&P psychologists and psychiatrists to conduct a thorough, evidence-based assessment, with less time presumably reducing the validity of the results.
- The time allocated to conduct the exam varies from one to four hours, which in itself indicates a lack of consistency and likely lower rates of inter-rater reliability.
- One survey of C&P psychologists showed that only 15% followed VA's own guidance regarding best practices for PTSD compensation and pension exams. For example, one of the best practice recommendations is to assess veterans for PTSD using the 'gold standard' Clinician-Administered PTSD Scale (CAPS), but the vast majority of C&P psychologists do not use this validated instrument according to the survey.
- Some VA facilities prohibit examiners from using symptom validity tests to screen or assess for malingering and other forms of dissimulation, perhaps because some VA researchers argue that the rate of significant exaggeration or malingering among veterans filing PTSD compensation claims is unknown. Other researchers and news reports assert that a sizeable percentage of veterans filing PTSD disability claims exaggerate or feign PTSD symptoms.
Disability Benefits Questionnaire (DBQ)
Mental health professionals document the results of Initial and Review PTSD C&P exams on a Disability Benefits Questionnaire (DBQ). The VA developed Disability Benefit Questionnaires (DBQs) to streamline the VBA ratings process and thereby complete the claims process faster. In addition, veterans may ask their treating clinicians to complete a DBQ and possibly bypass the need for a C&P exam. However, it is important to note that the VA discourages their mental health clinicians from completing DBQs for their patients (nonpsychiatric medical providers are not discouraged from completing DBQs for their patients), and similar recommendations have been offered to private psychologists and psychiatrists whose patients ask them to complete DBQs, because it creates a dual role relationship (serving simultaneously as a treating clinician and a forensic evaluator).
In order to be eligible for VA benefits, a veteran must have been discharged under other than dishonorable conditions. Stated differently, if a veteran received a Bad Conduct discharge or a Dishonorable discharge they will, under most circumstances, not be eligible for VA benefits.
In Line of Duty and Exceptions
There are exceptions to the general rule that injuries or diseases incurred in, or aggravated by, military service are eligible for VA disability compensation benefits. For example, such injuries or diseases must meet the in line of duty criteria. "In line of duty means an injury or disease incurred or aggravated during a period of active military, naval, or air service unless such injury or disease was the result of the veteran’s own willful misconduct or ... was a result of his or her abuse of alcohol or drugs."
Veterans who have questions about eligibility for VA benefits because of willful misconduct, alcohol or other drug abuse, or discharge status (see the next section), or other factors (see the regulation referenced above), can consult with a Veterans Service Officer in their area and/or contact the VBA Regional Office closest to their home for assistance.
Matthew J. Friedman of the National Center for PTSD notes that:
PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an historical event that is considered traumatic.
A traumatic stressor is an event that meets Criterion A of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria for PTSD. The definition of PTSD Criterion A in DSM-5 is:
The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)
1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
The relevant regulation (38 C.F.R. § 4.125(a)), was updated on 4 August 2014 to reflect the publication of DSM-5. However, the required notice in the Federal Register indicated that there are exceptions to this 4 August 2014 effective date:[f]
Applicability Date: The provisions of this interim final rule shall apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after the effective date of this interim final rule. The Secretary does not intend for the provisions of this interim final rule to apply to claims that have been certified for appeal to the Board of Veterans’ Appeals or are pending before the Board of Veterans’ Appeals, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit.
The term, service-connected, means that a veteran has a disease or injury that is "connected" to his or her military service, i.e., the disease or injury was incurred in, or aggravated by, his or her military service.
The official definition in the Code of Federal Regulations begins:
Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein.
The relationship between service connection and access to VA healthcare is emphasized in this definition:
"'Service connected' veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system."
Types of Service-Connection
There are four types of service connection: direct, secondary, aggravated, and presumptive. The present article is primarily concerned with direct service connection, since that is by far the most common type for soldiers, sailors, marines, airmen, or coast guardsmen suffering from PTSD.
Examples of Direct Service-Connection for PTSD
As noted, the vast majority of veterans with PTSD have a direct service-connection, i.e., they developed PTSD as a direct result of a traumatic stressor (or stressors) they endured during their military service. Traumatic stressors can be:
- Combat-related (the most common kind), e.g., seeing a comrade's vehicle getting blown up by an IED blast, pulling him from the burning wreckage and carrying him to a helicopter, praying he will make it, only to learn a few hours later that he died en route to the field hospital.
- A personal assault.
- Such as a physical assault, e.g., as a result of domestic violence or being mugged.
- Military sexual trauma (MST), which need not be perpetrated by another service member, e.g., if a service member is sexually assaulted by a neighbor, who is a civilian, the incident still constitutes MST.
- An accident while performing military duties, e.g., during training exercises or maneuvers.
- An accident that occurs while performing military duties, e.g., a motor vehicle accident that occurs while a service member is travelling to visit family.
These are the most common situations involving traumatic stressors that can lead to direct service connection for PTSD, but it is not an exhaustive list.
Also, note that a service member is still considered to be enrolled in military service even if he or she is not performing specific military duties at the time they are injured (e.g., if they are injured at their home on their day off, that injury, if it results in a permanent disability, would in most instances be considered service-connected).
Types of Military Service
The regulations describe three categories of military service, active duty, active duty for training, and inactive duty training. These categories and their very specific definitions would be particularly relevant to a veteran who, for example, experienced a traumatic stressor that led to PTSD during a period of training for the Reserves or National Guard .
And there are some types of military service which are defined as falling under one of these three categories that might not occur to many people, such as the fact that the definition of active duty military service includes "service at any time as a cadet at the United States Military, Air Force, or Coast Guard Academy, or as a midshipman at the United States Naval Academy." Thus, a midshipman who was sexually assaulted and developed PTSD would, when he or she left the Navy, qualify for VA benefits.
And there are other specifications in this set of regulations (38 CFR § 3.6) that one would never anticipate, such as the fact that the definition of active duty for training includes National Guard soldiers who participated in the reenactment of the Battle of First Manassas in July 1961.
- The CNA report cited herein describes the parity ratio as: "A ratio of exactly 1 would be perfect parity, indicating that the earnings of disabled veterans, plus their VA compensation, gives them the same lifetime earnings as their peers. A ratio of less than one would mean that the service-disabled veterans receive less than their peers on average, while a ratio of greater than one would mean that they receive more than their peers."
- Note that the term forensic in this context simply means legally-related and has nothing to do with criminal law or law enforcement. The veterans disability benefits claims process for PTSD is ultimately a legal proceeding, which is why PTSD C&P examinations are categorized as psycholegal, medicolegal, or, most commonly, forensic mental health evaluations.
- Not to be confused with Veterans Benefits Administration staff whose job title is Veterans Service Representative (VSR).
- The adverb 'theoretically' is used here because the Rating Formula is based on symptoms, not occupational impairment. While the symptoms associated with the 100% rating for mental disorders often cause significant occupational impairment, e.g., "persistent delusions or hallucinations" or "persistent danger of hurting self or others", they do not necessarily render a veteran unable to work.
- For example, the veteran simply needs to state something like "I am having more nightmares which keep me awake at night and they are causing me to fall asleep at work" in order the meet the new evidence requirement for an increased evaluation.
- The terms effective date and applicability date are used interchangeably in the Federal Register.
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The best single source for learning about the wide range of veterans benefits. Note that the web page has versions of the book in HTML & PDF and for tablets and smartphones.
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The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations...
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Regardless of claim outcome, veterans who apply for PTSD disability benefits are highly impaired. However, receiving PTSD benefits was associated with clinically meaningful reductions in PTSD symptoms and less poverty and homelessness.
- Mossman, D. (1994). "At the VA, it pays to be sick.". The Public Interest 114: 35–47. Retrieved 13 August 2014.
Sadly, a program with good intentions has yielded a series of perverse incentives that reward illness, encourage patients to view themselves as incapacitated, and poison the relationships between patients and their caregivers.
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Department of Veterans Affairs (VA) psychiatric disability compensation and rehabilitation policies for combat-related posttraumatic stress disorder (PTSD), although well intentioned, are more than 60 years old and are seriously flawed.
- Satel, S. "PTSD’s diagnostic trap". American Enterprise Institute. Retrieved 13 August 2014.
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 his 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.
- Marx, Brian P.; Miller, Mark W.; Sloan, Denise M.; Litz, Brett T.; Kaloupek, Danny G.; Keane, Terence M. (May 2008). "Military-related PTSD, current disability policies, and malingering". American Journal of Public Health 98 (5): 773–774. doi:10.2105/AJPH.2007.133223. PMC 2374833. PMID 18381982. Retrieved 13 August 2014.
Frueh et al. present an incomplete picture of the literature and neglect substantial evidence that contradicts their thesis
- Gade, Daniel. "A Better Way to Help Veterans" (PDF). National Affairs 16 (Summer, 2013): 53–69. Retrieved 13 August 2014.
...VA benefit policies ... distort incentives and encourage veterans to live off of government support instead of working to their full capability. Adding to the problem is a culture of low expectations, fostered by the misguided understanding of 'disability' upon which both federal policy and private philanthropy are often based. The result is that, for many veterans, a state of dependency that should be temporary instead becomes permanent.
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There are numerous ways to apply for VA disability benefits depending on the type of benefit you are seeking...
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- "How To Win Your Claim". VAWatchdog dot org. VA Watchdog (Jim Strickland). Retrieved 28 April 2014.
- "About NACVSO". National Association of County Veterans Service Officers. Retrieved 30 April 2013.
The National Association of County Veterans Service Officers is an organization made up of local government employees. Our members are tasked with assisting veterans in developing and processing their claims. Between 75 and 90% of the claims presented to the Veterans Administration each year originate in a county veterans office.
- "Find Your County Veterans Service Officer". National Association of County Veterans Service Officers. Retrieved 30 April 2013.
- "Directory of Veterans Service Organizations". Explore VA - Benefits for Veterans. Department of Veterans Affairs. Retrieved 15 November 2013.
- "Chartered Veterans Service Organizations". Veterans Service Organizations. National Resource Directory. Retrieved 15 November 2013.
- "VETERANS AND MILITARY SERVICE ORGANIZATIONS, 2012/2013 Directory" (PDF). Department of Veterans Affairs. p. 1-1 to 1-38. Retrieved 30 April 2013.
Listing of Congressionally chartered and other Veterans Service Organizations recognized by the Secretary for the purpose of preparation, presentation, and prosecution of claims under laws administered by the Department of Veterans Affairs, as provided in Section 5902 (formerly Section 3402) of Title 38, United States Code (U.S.C.) and Sub Section 14.628 (a) and (c) f 38 C.F.R.
- "Accreditation Search". U.S. Department of Veterans Affairs. Retrieved 2 July 2013.
- "Publication 370 - Extra Services - Evidence They Got It - Return Receipt". http://www.usps.com. United States Postal Service. Retrieved 6 January 2015.
- "38 C.F.R. 14.636 - Payment of fees for representation by agents and attorneys in proceedings before Agencies of Original Jurisdiction and before the Board of Veterans' Appeals.". Code of Federal Regulations. United States Government Printing Office (GPO). Retrieved 30 April 2013.
- "Veterans Compensation Benefits Rate Tables". Veterans Benefits Administration. Department of Veterans Affairs. Retrieved 28 December 2013.
- "Schedule of ratings—mental disorders.". Code of Federal Regulations, Title 38: Pensions, Bonuses, and Veterans' Relief, PART 4—SCHEDULE FOR RATING DISABILITIES, Subpart B—Disability Ratings, MENTAL DISORDERS. Government Printing Office, Electronic Code of Federal Regulations (e-CFR). Note: You will need to scroll down about one page to find the General Rating Formula for Mental Disorders - it appears immediately under 9440 Chronic adjustment disorder. This placement is misleading because it appears as if the Rating Formula applies to Chronic Adjustment Disorder only, which is not the case. The Rating Formula applies to all mental disorders. Retrieved 28 December 2013.
- Simonson, Scott (2008). "Back from war—A battle for benefits: Reforming VA’s disability ratings system for veterans with post-traumatic stress disorder" (PDF). Arizona Law Review 50: 1177–1204. Retrieved 10 June 2014.
- Wilson, John. "Statement of John L. Wilson, Assistant National Legislative Director, Disabled American Veterans at the Hearing of the Subcommittee on Disability Assistance and Memorial Affairs, House Veterans Affairs Committee, on the Implementation and Status Update on the Veterans’ Benefits Improvement Act, P.L. 110-389, on 3 February 2010". http://archives.democrats.veterans.house.gov. U.S. House of Representatives. Retrieved 10 June 2014.
- "VA Disability Compensation: Actions Needed to Address Hurdles Facing Program Modernization (GAO-12-846)". United States Government Accountability Office. 10 September 2012. Retrieved 5 August 2014.
- "Types of Claims - Compensation". Veterans Benefits Administration. Department of Veterans Affairs. Note: Scroll down the web page for the New Claims section. Retrieved 28 December 2013.
- "How To Increase An Existing Rating". TheVeteransVoice.com. Jim Strickland. Retrieved 28 December 2013.
- "Section F. Compensation Based on Individual Unemployability (IU)". Veterans Benefits Administration, M21-1MR Compensation and Pension Manual Rewrite (DOC). Department of Veterans Affairs. Note: gainful employment is defined at the bottom of page 2-F-2. Retrieved 28 December 2013.
- "Individual Unemployability". Veterans Benefits Administration - Compensation. Department of Veterans Affairs. Note: This web page explains the IU eligibility requirements. Retrieved 28 December 2013.
- "VETERAN'S APPLICATION FOR INCREASED COMPENSATION BASED ON UNEMPLOYABILITY" (PDF). Veterans Benefits Administration - Compensation (DOC). Department of Veterans Affairs. Retrieved 28 December 2013.
- "CERTIFICATION OF CLINICIANS PERFORMING VA DISABILITY EVALUTIONS [sic] (VHA DIRECTIVE 1603)" (PDF). VHA Publications. Department of Veterans Affairs, Veterans Health Administration. April 22, 2013. Retrieved 23 August 2014.
- Murphy, Thomas (25 June 2014). "Witness Testimony of Mr. Thomas Murphy, Director, Compensation Service, Veterans Benefits Administration, U.S. Department of Veterans Affairs". VBA and VHA Interactions: Ordering and Conducting Medical Examinations: U.S. House of Representatives, Committee on Veterans Affairs. Retrieved 23 August 2014.
VHA supplements these C&P clinics’ capabilities, as necessary, using contracted disability examination services. These contractors support the performance of required disability examinations during surges in claims processing, for periods of staffing vacancies, or for times when specialists are required. VHA may also use these services for Veterans who do not live near a VHA medical facility. The use of these “on demand” services allows VHA to maintain examination timeliness and quality to support VA’s goals for processing disability claims. VHA medical facilities can use locally contracted services through an individual facility or utilize the centralized, national VHA Disability Examination Management (DEM) contract. ... In addition to examinations completed by VHA, VBA contracts with three vendors to conduct C&P examinations.
- "Veterans Evaluation Services". Retrieved 23 August 2014.
- "QTC Clients". QTCM.com. QTC, A Lockheed-Martin Company. Retrieved 23 August 2014.
- "LHI is Awarded Contract to Serve U.S. Veterans". LogisticsHealth.com. Logistics Health Incorporated. Retrieved 23 August 2014.
- "Veterans". MSLACA.com. MSLA, A Medical Corporation. Retrieved 23 August 2014.
- "REVIEW POST TRAUMATIC STRESS DISORDER (PTSD) DISABILITY BENEFITS QUESTIONNAIRE (VA FORM 21-0960P-3)" (PDF). Veterans Health Administration. October 2012. Retrieved 24 August 2014.
The following health care providers can perform REVIEW examinations for PTSD: a board-certified or board-eligible psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or board- eligible psychiatrist or licensed doctorate-level psychologist; or a licensed clinical social worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a physician assistant, under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.
- Institute of Medicine and National Research Council (8 May 2007). PTSD Compensation and Military service. National Academies Press. pp. 204–205. Retrieved 16 November 2014.
- Russo, Arthur (5 Mar 2014). "Assessing veteran symptom validity" (PDF). Psychological Injury and Law 7 (2): 178–190. doi:10.1007/s12207-014-9190-2. Retrieved 16 November 2014.
- Worthen, M. D.; Moering, R. G. (December 2011). "A practical guide to conducting VA compensation and pension exams for PTSD and other mental disorders" (PDF). Psychological Injury and Law 4 (3-4): 187–216. doi:10.1007/s12207-011-9115-2. Retrieved 16 November 2014.
- Jackson, J. C. et al. (October 2011). "Variation in practices and attitudes of clinicians assessing PTSD-related disability among veterans". Journal of Traumatic Stress 24 (5): 609–613. doi:10.1002/jts.20688. PMID 21913226. Retrieved 16 November 2014.
- "Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)". PTSD: For Professionals. National Center for PTSD. Retrieved 16 November 2014.
- Speroff, T. et al. (December 2012). "Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: A cluster-randomized trial". Journal of Traumatic Stress 25 (6): 607–615. doi:10.1002/jts.21759. PMID 23225029. Retrieved 16 November 2014.
- Poyner, G. (27 May 2010). "Psychological evaluations of veterans claiming PTSD disability with the Department of Veterans Affairs: A clinician’s viewpoint" (PDF). Psychological Injury and Law 3: 130–132. doi:10.1007/s12207-010-9076-x. Retrieved 16 November 2014.
- Marx, B. P. et al. (August 2012). "The reality of malingered PTSD among veterans: Reply to McNally and Frueh (2012)". Journal of Traumatic Stress (Wiley) 25 (4): 457–460. doi:10.1002/jts.21714. Retrieved 16 November 2014.
- Arbisi, P. A.; Murdoch, M.; Fortier, L.; McNulty, J. (2004). "MMPI-2 validity and award of service connection for PTSD during the VA compensation and pension evaluation". Psychological Services 1 (1): 56–67. doi:10.1037/1541-1518.104.22.168. Retrieved 19 November 2014.
- Freeman, T.; Powell, M.; Kimbrell, T. (15 April 2008). "Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder". Psychiatry Research 158 (3): 374–380. doi:10.1016/j.psychres.2007.04.002. PMID 18294699. Retrieved 19 November 2014.
- Frueh, B. C.; Hamner, M. B.; Cahill, S. P.; Gold, P. B.; Hamlin, K. L. (October 2000). "Apparent symptom overreporting in combat veterans". Clinical Psychology Review 20 (7): 853–885. doi:10.1016/S0272-7358(99)00015-X. PMID 11057375. Retrieved 19 November 2014.
- Hall, R. C. W.; Hall, R. C. W. (December 2006). "Malingering of PTSD: forensic and diagnostic considerations, characteristics of malingerers and clinical presentations". General Hospital Psychiatry 28 (6): 525–535. doi:10.1016/j.genhosppsych.2006.08.011. PMID 17088169. Retrieved 19 November 2014.
- Gold, P. B.; Frueh, B. C. (November 1999). "Compensation-seeking and extreme exaggeration of psychopathology among combat veterans evaluated for posttraumatic stress disorder". The Journal of Nervous and Mental Disease 187 (11): 680–4. doi:10.1097/00005053-199911000-00005. PMID 10579596.
- Wisdom, N. M. et al. (2014). "PTSD and cognitive functioning: Importance of including performance validity testing". The Clinical Neuropsychologist 28 (1): 1–18. doi:10.1080/13854046.2013.863977. PMID 24354897. Retrieved 19 November 2014.
- Zarembo, Alan (3 August 2014). "As disability awards grow, so do concerns with veracity of PTSD claims". Los Angeles Times. Retrieved 19 November 2014.
- Huang, Daniel (27 October 2014). "VA Disability Claims Soar: Some See Higher Fraud Risk as More Vets Seek Compensation, Overloading Doctors". The Wall Street Journal (Dow Jones & Company). Retrieved 19 November 2014.
Requests for disability pay by veterans have ballooned during the past five years, overloading many doctors who evaluate the claims and increasing the possibility of fraud, according to current and former VA staff and government watchdogs.
- "Disability Benefits Questionnaire". Veterans Health Administration. Retrieved 24 August 2014.
- "VA CLAIMS PROCESS: REVIEW OF VA’S TRANSFORMATION EFFORTS" (PDF). U.S. Senate Committee on Veterans Affairs. 13 March 2013. p. 12. Retrieved 24 August 2014.
DBQs replace traditional VA examination reports and are designed to capture all the needed medical information relevant to a specific condition at once and up front so that claims can be developed and processed in a more timely and accurate manner, with the end result being faster service for Veterans. DBQs change the way medical evidence is collected, giving Veterans the option of having their private physician complete a DBQ that provides the medical information needed to rate their claims—minimizing the need for a VA exam which adds additional time to the claim development process. Information in the DBQs maps to the VA Schedule for Rating Disabilities, and provides all of the necessary information to decide a disability claim.
- "DOCUMENTATION OF MEDICAL EVIDENCE FOR DISABILITY EVALUATION PURPOSES (VHA DIRECTIVE 2013-002)" (PDF). 4(e)(1)(c): Veterans Health Administration. January 14, 2013. p. 4. Retrieved 24 August 2014.
For mental health disability examination requests, it is recommended that the Veteran’s treating provider not complete the disability examination to maintain the integrity of the patient- provider relationship.
- Worthen, M. D.; Moering, R. G. (December 2011). "A Practical Guide to Conducting VA Compensation and Pension Exams for PTSD and Other Mental Disorders" (PDF). Psychological Injury and Law 4 (3-4): 193. doi:10.1007/s12207-011-9115-2.
...we strongly recommend not completing a DBQ for a veteran the private practitioner is seeing for psychotherapy or psychiatric treatment as it will create the awkward position of a dual role relationship with the patient, viz., psychologist or doctor and independent evaluator...
- Strasburger, L. G.; Gutheil, T. G.; Brodsky, A. (1 April 1997). "On wearing two hats: Role conflict in serving as both psychotherapist and expert witness" (PDF). The American Journal Of Psychiatry 154 (4): 448–456. doi:10.1176/ajp.154.4.448. PMID 9090330. Retrieved 24 August 2014.
The process of psychotherapy is a search for meaning more than for facts. In other words, it may be conceived of more as a search for narrative truth (a term now in common use) than for historical truth. Whereas the forensic examiner is skeptical, questioning even plausible assertions for purposes of evaluation, the therapist may be deliberately credulous, provisionally 'believing' even implausible assertions for therapeutic purposes. The therapist accepts the patient’s narrative as representing an inner, personal reality, albeit colored by biases and misperceptions. This narrative is not expected to be a veridical history; rather, the therapist strives to see the world 'through the patient’s eyes.' [citation footnote numbers omitted]
- Greenberg, S. A.; Shuman, D. W. (1997). "Irreconcilable conflict between therapeutic and forensic roles" (PDF). Professional Psychology: Research and Practice 28 (1): 50–57. doi:10.1037/0735-7028.28.1.50.
The therapist is a care provider and usually supportive, accepting, and empathic; the forensic evaluator is an assessor and usually neutral, objective, and detached as to the forensic issues. A forensic evaluator's task is to gain an empathic understanding of the person but to remain dispassionate as to the psycholegal issues being evaluated. For therapists, empathy and sympathy–generating a desire to help–usually go hand-in-hand. For forensic evaluators, the task is a dispassionate assessment of the psycholegal issues.
- "Disability Compensation: Eligibility". Department of Veterans Affairs. Retrieved 30 November 2012.
- Moering, Robert. "Military service records: Searching for the truth." (PDF). Psychological Injury and Law 4 (3-4): 217–234. doi:10.1007/s12207-011-9114-3.
- "Code of Federal Regulations, Title 38, Chapter I, Part 3, Subpart A, Subjgrp-General(Part 3), Section 3.1 - Definitions - (m) In line of duty" (PDF). U.S. Government Printing Office, Code of Federal Regulations (CFR). Retrieved 30 November 2012.
- "State/Territory Veterans Affairs Offices". Department of Veterans Affairs. Retrieved 30 April 2013.
Select a state or territory below to visit the Web site for that location's Department of Veterans Affairs office.
- "Find the closest VBA Regional Office". Department of Veterans Affairs. Retrieved 19 May 2013.
- Friedman, MD, PhD, Matthew J. "PTSD History and Overview". National Center for PTSD. Retrieved 30 November 2012.
- "DEPARTMENT OF VETERANS AFFAIRS / 38 CFR Parts 3 and 4 / RIN 2900–AO96 / Schedule for Rating Disabilities—Mental Disorders and Definition of Psychosis for Certain VA Purposes" (PDF). U.S. Government Printing Office. 4 August 2014. p. 45094. Retrieved 21 January 2015.
- "Chapter 2 Service-Connected Disabilities: Disability Compensation". Federal Benefits for Veterans, Dependents and Survivors. U.S. Department of Veterans Affairs. Retrieved 6 July 2013.
- 38 CFR §3.303(a)
- Full text of 38 CFR §3.303(a)
- Murdoch, Maureen; Hodges J; Cowper D; Fortier L; van Ryn M (April 2003). "Racial disparities in VA service connection for posttraumatic stress disorder disability.". Medical Care 41 (4): 536–49. doi:10.1097/01.MLR.0000053232.67079.A5. PMID 12665717.
- "Service Connection Explained". Nor-Cal Mobility, Inc. Retrieved 30 November 2012.
- "Code of Federal Regulations (CFR), Title 38, Chapter I, Part 3, Subpart A, Subjgrp-General(Part 3), Section 3.6 - Duty periods." (PDF). U.S. Government Printing Office, Code of Federal Regulations (CFR). Retrieved 30 November 2012.
U.S. Department of Veterans Affairs benefits information
- Federal Benefits for Veterans, Dependents, & Survivors - The best and most comprehensive description of all veterans benefits. Available as a printable document (PDF) or download it to your tablet or smartphone.
- Apply for Benefits Online - Not the most user-friendly online application process in the world, but it won't be a problem for younger vets and others with a fair amount of Internet savvy.
- VA Benefits in Brief - Quick overview of all veterans benefits (PDF document).
- Compensation and Pension Service - links to all the various C&P programs.
- VA Healthcare Benefits Overview - A well-written and well-organized PDF booklet. You receive the most comprehensive information if you also download the Veterans Health Benefits Guide (the link immediately below).
- Veterans Health Benefits Guide - Also an easy-to-read PDF booklet - download it with the VA Healthcare Benefits Overview (the link immediately above) for the most comprehensive info.
- Online VA Healthcare Eligibility Check - Easy way to begin the process of finding out what healthcare benefits you are eligible to receive, although you will probably need to wait a day or two to receive a definitive answer from the VA.
Other veterans benefits resources
- The American Veterans and Service Members Survival Guide - Published by the National Veterans Legal Services Program. Provides a wealth of information. A little challenging to navigate but a valuable reference because of its depth of coverage.
- Overview of Benefit Claims Legal Process - A free download of the first chapter of the Basic Training Course on Veterans Benefits published by the National Veterans Legal Services Program. Although the Basic Training Course is intended for Veterans Service Officers and other advocates, this first chapter is concise, well-written, and easy to understand.
- National Resource Directory - List of Veterans Service Organizations - Provides a list of Chartered and Nonchartered Veterans Service Organizations. Note that while Nonchartered organizations cannot represent a veteran before the VA in a disability claims case, they provide many other valuable services.
U.S. government resources for military personnel and veterans
- MakeTheConnection.net - A Department of Veterans Affairs website designed to encourage military personnel, veterans, and family members to 'connect' with each other, relevant VA services, support & advocacy organizations, online support resources, telephone 'crisis line' assistance, mental health treatment, and more. Features videos of service members, veterans, and families sharing their personal stories and testimonials. Contains a "customize this site" application that will feature and prioritize information on the site depending on the visitor's status, e.g., their gender; whether they are active duty, Guard or Reserve, veteran, or family member; branch of service; era of service (e.g., WWII, Korea, Vietnam, Gulf War, OEF/OIF/OND); etc.
- Make the Connection Resources Search Engine - Search for several types of information (e.g., educational programs, employment opportunities, healthcare, free transportation to a VA medical center) available on VA websites or the National Resource Directory.
- National Resource Directory - A joint project by the Department of Defense, Department of Labor, and the Department of Veterans Affairs designed to help service members, veterans, families, and caregivers find several different kinds of programs and services, e.g., job banks, benefits information, mental health treatment, family and caregiver support, homeless assistance, housing programs, and much more.
PTSD treatment resources for veterans
- Information & Resources About PTSD
- Where to get help for PTSD
- Understanding PTSD
- PTSD Treatment Programs in the US Department of Veterans Affairs
- My HealtheVet: The Gateway to Veteran Health and Wellness - veterans can download their VA medical records, read healthcare tips, and much more
- Operation Warrior Wellness: Overcoming PTSD
- Military Sexual Trauma Resources Provided by the VA
- Military Sexual Trauma Resources for Women Provided by Stateside Legal