Distinguished members of the Subcommittee on PTSD of the Gulf War & Stress:
Health Project, Vietnam Veterans of America (VVA) thanks you for the
opportunity to present for the record our views on the current state of
clinical diagnoses and the disability compensation claims process as
accorded our nation’s veterans suffering from PTSD.
- First, Vietnam Veterans of America applauds this
Committee for its obvious concern about the mental health care of our
troops and veterans.
VVA cautions, however, that providing the appropriate PTSD
clinical diagnoses and services to assist these women and men requires both
an understanding of the stresses and stressors to which they have been
exposed – and the willingness to commit the financial and personnel
resources necessary to help these veterans cope and perhaps eventually
recover. Evidence overwhelmingly supports the need for early intervention
and treatment of PTSD and related mental health disorders not only for
active duty troops and veterans but for their families as well. We must
accept that only through early intervention and treatment can we hope for
the recovery of our troops and veterans from the mental health diseases
caused by the trauma of war.
But as Dr. William Winkenwerder, Assistant Secretary of Defense for Health
Affairs observed in his testimony before the House Subcommittee on Military
Personnel in October 2005, “no one who goes to war remains unchanged.” There
is no longer any doubt that the combat experiences of veterans can and often
do cause mental health injuries that can be just as debilitating as physical
wounds. If left untreated, post-traumatic stress disorder and other
psychological traumas can affect combat veterans to the point that, over
time, even their daily functions become seriously impaired. This places them
at higher risk for self-medication and abuse with alcohol and drugs,
domestic violence, unemployment & underemployment, homelessness,
incarceration, suicide, and even medical morbidities such as cardiovascular
diseases and cancer (1).
No one really knows how many of our troops in Iraq and Afghanistan have been
or will be affected by their wartime experiences; despite the early
intervention by psychological personnel, no one really knows how serious
their emotional and mental problems will become. However, recent reports
have suggested that troops returning from service in Afghanistan and Iraq
are suffering mental health problems at a rate higher than the levels seen
in Vietnam War veterans (2, 3, and 4). In fact, VVA has no reason to believe
that the rate of veterans of this war having their lives significantly
disrupted at some point in their lifetime by PTSD will be any less than the
37 percent estimated for Vietnam veterans by the National Vietnam Veterans
Readjustment Study (NVVRS) conducted some 20 years ago.
Since 1980, when the American Psychiatric Association (APA) added PTSD to
the third edition of its “Diagnostic and Statistical Manual of Mental
Disorders (DSM-III)” classification scheme, a great deal of attention has
been devoted to the development of instruments for assessing PTSD [see Keane
et al., (5)], as well as to psychotherapy and pharmacotherapy PTSD treatment
modalities [see Foa et al., (6) and the National Center for PTSD’s Fact
Sheets (7)]. Under intense pressure from Vietnam veterans and their
Congressional supporters, the Department of Veterans Affairs subsequently
developed a unique range of mental health diagnoses and care services to
assist veterans with managing or even overcoming the most troubling of the
symptoms associated with PTSD, and the VA disability, compensation, pension,
and benefits system was amended to provide appropriate financial redress for
the debilitating effects of PTSD or other mental health disability
compensation claims related to military service. But the adjudication of
PTSD claims continues to be a complex, constantly evolving exercise affected
by regulations, legislation, and the latest medical research.
Often the VA orders a compensation examination by a VA clinician or
contractor to establish proof of a service-connected PTSD disability.
However, by the outset of the “Global War on Terrorism”, Congressional
investigations and G.A.O. reports noted that the VA was experiencing a
chronic and growing claims back log which it has had little success in
Because of reductions in staff at both the Veterans Benefits Administration
(VBA) and the Veterans Health Administration (VHA) -- mental health staff in
particular -- and other key organizational capacities in general since 1996,
too many clinicians and adjudicators (mis)-placed an emphasis on
productivity rather than quality or accuracy and believed that they must see
clients quickly, even if their examinations did not yield accurate clinical
data or the correct information upon which to adjudicate the claim.
Veterans’ complaints of 15-minute or 30-minute examinations that were by the
very nature of the process grossly inadequate to the point of being
malfeasant (with strong pressure to continue these unconscionable practices)
became commonplace. Many incorrect diagnoses have undoubtedly occurred as a
Subsequent VA attempts to address the problem led to significant variations
in disability ratings by region and adjudicators for PTSD-related claims and
other mental health disorders. Although post-traumatic stress disorder is a
commonly compensated condition (i.e., awarded PTSD claims constitute about
half of all awarded claims and about a quarter million veterans are
currently compensated), it is important to note that PTSD is NOT the most
variably rated disability; there are other disabilities for which ratings
differ far more drastically, infectious diseases, for example. But this
misconception has led to extravagant claims by some that the majority of
PTSD-related claims are fraudulent and that a “secret underground network
advises veterans where to go for the best chance of being declared
In any case, by 2002 the Department of Veterans Affairs had prepared a “Best
Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and
Pension Examinations” (8) containing scientifically validated assessment
instruments for the diagnostic evaluation of PTSD and guidelines for the
determination of a service-connected disability for PTSD. In fact, several
of the distinguished scientists who co-authored this Best Practice Manual
sit before us today.
Members of this Subcommittee, however, might be astonished to discover that
by February 2006, the VA not only has issued no directives to clinicians and
to adjudicators to use the Manual, nor provided any training on this guide,
but that even copies of it are not available to staff throughout the VA, nor
to anyone else for that matter. VVA has good reason to believe that there
are thousands of hard copies of the Best Practices Manual sitting in a
warehouse somewhere, printed with tax dollars from you and me, that they
refuse to make available.
With that said, VVA offers the following comments specific to the mental
health clinical diagnostic practices currently being offered our nation’s
veterans seeking rightful disability compensation claims for their PTSD
- VA Central Office must formally direct the distribution
and use of its “Best Practice Manual for Posttraumatic Stress Disorder…”
throughout the VA healthcare system.
The Best Practice Manual includes the following statement
on page 6: “The VHA encourages use of this protocol when examining veterans
for compensation purposes to ensure that a detailed history is obtained from
the veteran and a comprehensive evaluation is performed and documented”.
An unhurried, scientifically validated diagnostic assessment mechanism
utilizing current DSM-IV checklists must be uniformly applied to obtain the
correct type of clinical data necessary to provide accurate PTSD diagnoses.
The Best Practice Manual contains not only a standardized assessment
protocol, but also includes appropriately validated diagnostic and
psychometric assessment tools and a recommended initial examination time of
at least three hours to perform the series of psychological evaluations
needed to best decide and rate the claim, along with a 90-minute follow-up
examination. And according to the Manual, assessment for PTSD must also
include the client’s military history.
- The VA must also provide the resources for appropriate,
in-depth training for the VA mental health clinicians, staff and
adjudicators to properly and effectively implement the Manual’s protocol
Training in the use of the “Best Practice Manual” is, in
the parlance of today’s world, a “no brainer.” But adequate training is also
necessary for looking for, identifying, and assessing PTSD clients within
the framework of their particular war-related trauma and to ensure
sensitivity using non-invasive methods of inquiry, such as motivational
interviewing. In addition, a staff that is thoroughly knowledgeable with the
Manual will become familiar with both asking appropriate questions and
recognizing physiological symptoms that may better assist in accurate
diagnoses and effective evaluations.
- The VA mental health leadership in cooperation with the
Veterans Benefits Administration must change the way PTSD and other
disability claims are adjudicated.
In addition to increasing the number of adjudicators (as
well as providing much better training, competency based testing, and much
better supervision), VVA proposes a pilot project in which the most
experienced adjudicators at a VARO “triage” incoming claims, rather than
simply handling them by docket number. Relatively simple claims can then be
fast-tracked; there is no reason why a veteran who files a claim along with
the appropriate paperwork for, say, tinnitus, cannot be adjudicated within
60 days. Claims that need additional documentation can be returned to the
veteran or the veteran’s service officer. Difficult or complicated cases can
be routed to the most experienced adjudicators. Because the adjudication of
PTSD claims historically seems to have resulted in significant disparities
in adjudication decisions, these might be sent to a special group of
adjudicators well-trained and well-versed in the VA’s Best Practices Manual.
VVA believes this proposed change can improve productivity as well as morale
in both the VA and VBA systems and be welcomed by the veterans community.
- The VA should develop and launch an internal mental
health anti-stigma campaign that focuses on PTSD.
The stigma associated with seeking help for PTSD will not
decrease without a system wide campaign to change perceptions and attitudes
among staff and leadership. Educational programs for VA mental health staff,
veterans and their families should be strongly encouraged, and the programs
should present symptoms and descriptions of combat-related PTSD and other
mental health problems, publicize available resources, encourage veterans to
come forward, and guarantee that seeking assistance for PTSD within the VA
system will not be held against the individual.
1. Boscarino, J. A. In press. 2006. Post-traumatic stress disorder and
mortality among U.S. Army veterans 30 years after military service. Ann.
Epidemiol. (Epub, Aug 11, 2005, ahead of print. On-line access).
2. Kaplan, A. 2006. Hidden Combat Wounds: Extensive, Deadly, Costly. Psych.
Times XXV(1). On-line access.
3. Robinson, S. L. 2004. Hidden Toll of the War in Iraq: Mental Health and
the Military. Center for American Progress, Sept. 2004, 11 pp. Available at:
www.americanprogress.org (In: Kaplan, A. 2006. Hidden Combat Wounds:
Extensive, Deadly, Costly. Psych. Times XXV(1). On-line access)
4. Figley, C. R. In: Maze, R. 2005. Health Experts Predict a “Tsunami” of
Woe, PTSD Cases from Iraq – Say Government Is Not Ready to Handle the
Problems. Army Times, December 20, 2005.
5. Keane, T.M., Wolfe, J., & Taylor, K.I. (1987). Post-traumatic Stress
Disorder: Evidence for diagnostic validity and methods of psychological
assessment. Journal of Clinical Psychology, 43, 32-43.
6. Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for
PTSD: Practice guidelines from the International Society for Traumatic
Stress Studies. New York: Guilford Publications.
7. National Center for PTSD Fact Sheets. U.S. Department of Veterans
Affairs. National Center for PTSD (Matthew J. Friedman, M.D., Ph.D.,
Executive Director). On-line access at www.ncptsd.va.gov).
8. Watson, P., McFall, M., McBrine, C., Schnurr, P.P., Friedman, M.J.,
Keane, and T., Hamblem, J.L. (2000). Best Practice Manual for Posttraumatic
Stress Disorder (PTSD) Compensation and Pension Examinations. Department of
Veterans Affairs. 121pp.
VIETNAM VETERANS OF AMERICA
February 13, 2006
The national organization Vietnam Veterans of America (VVA) is a non-profit
veterans membership organization registered as a 501(c)(19) with the
Internal Revenue Service. VVA is also appropriately registered with the
Secretary of the Senate and the Clerk of the House of Representatives in
compliance with the Lobbying Disclosure Act of 1995.
VVA is not currently in receipt of any federal grant or contract, other than
the routine allocation of office space and associated resources in VA
Regional Offices for outreach and direct services through its Veterans
Benefits Program (Service Representatives). This is also true of the
previous two fiscal years.
For Further Information, Contact:
Director of Government Relations
Vietnam Veterans of America.
(301) 585-4000, extension 127
Thomas J. Berger, Ph.D.
Dr. Tom Berger is a Life Member of Vietnam Veterans of America (VVA) and
currently serves as national chair of VVA’s PTSD and Substance Abuse
Committee. As such, he is a member of the Veterans’ Healthcare
Administration’s (VHA) Consumer Liaison Council for the Committee on Care of
Veterans with Serious Mental Illness and the Executive Committee of the
Mental Health Quality Enhancement Research Initiative. In addition, Dr.
Berger holds the distinction of being the first representative of a national
veterans’ service organization to hold membership on the Executive Committee
of the Substance Use Disorder Quality Enhancement Research Initiative. He is
also a member of VVA’s Health Care, Government Affairs, and Project 112/SHAD
committees. At the local level he serves as both Board member and Secretary
of the Missouri Vietnam Veterans Foundation and as both Secretary and
Membership Chair for VVA’s Missouri State Council.
Dr. Berger served
as a Navy Corpsman with the 3rd Marine Corps Division in Vietnam, 1967-68.
Upon completion of his military service and then subsequently after earning
his doctoral degree, he has held faculty and administrative appointments at
the University of Kansas in Lawrence, the State University System of Florida
in Tallahassee and the University of Missouri-Columbia, as well as program
administrator positions with the Illinois Easter Seal Society and United
Cerebral Palsy of Northwest Missouri. His professional publications include
books and research articles in the biological sciences, wildlife regulatory
law, adolescent risk behaviors, and post-traumatic stress disorder.
Dr. Berger now
devotes his efforts full-time to veterans’ advocacy at the local, state and
national levels on behalf of Vietnam Veterans of America. He presently
resides in Columbia, Missouri.