Witness Testimony of Dean Kilpatrick, Ph.D., Research and Treatment Center, Medical University of South Carolina, Distinguished University Professor and Director of the National Crime Victims, Member, Committee on Veterans' Compensation for Posttraumatic Stress Disorder, Institute of Medicine and National Research Council, The National Academies
Good morning, Mr. Chairman and members of the Committee. My name is Dean Kilpatrick and I am Distinguished University Professor in the Department of Psychiatry and Behavioral Sciences and Director of the National Crime Victims Research and Treatment Center at the Medical University of South Carolina. Thank you for the opportunity to testify on behalf the members of the Committee on Veterans’ Compensation for Posttraumatic Stress Disorder. The committee was convened under the auspices of the National Research Council and the Institute of Medicine. These institutions are operating arms of the National Academy of Sciences, which was chartered by Congress in 1863 to advise the government on matters of science and technology. The work of the committee was requested by the Department of Veterans Affairs, which provided funding for the effort.
Our committee recently completed a report entitled PTSD Compensation and Military Service that addresses some of the topics under discussion in this hearing. I am pleased to be here today to share with you the content of that report, the knowledge I’ve gained as a clinical psychologist and researcher on traumatic stress, and my experience as someone who previously served as a clinician at the VA.
I will begin with some background information on posttraumatic stress disorder. Briefly described, PTSD is a psychiatric disorder that can develop in a person after a traumatic experience. Someone is diagnosed with PTSD if, in response to that traumatic experience, he or she develops a cluster of symptoms that include:
- reexperiencing the traumatic event as reflected by distressing recollections, memories, nightmares, or flashbacks;
- avoidance of anything that reminds them of the traumatic event;
- emotional numbing or feeling detached from other people;
- hyperarousal as reflected by trouble sleeping, trouble concentrating, outbursts of anger, and having to always be vigilant for potential threats in the environment; and
- impairment in social or occupational functioning, or clinically significant distress.
PTSD is one of an interrelated and overlapping set of possible mental health responses to combat exposures and other traumas encountered in military service. Although PTSD has only been an official diagnosis since the 1980’s, the symptoms associated with it have been reported for centuries. In the U.S., expressions including shell shock, combat fatigue, and gross stress reaction have been used to label what is now called PTSD.
Our committee’s review of the scientific literature and VA’s current compensation practices identified several areas where changes might result in more consistent and accurate ratings for disability associated with PTSD.
There are two primary steps in the disability compensation process for veterans. The first of these is a compensation and pension, or C&P, examination. These examinations are conducted by VA clinicians or outside professionals who meet certain education and licensing requirements. Testimony presented to the committee indicated that clinicians often feel pressured to severely constrain the time that they devote to conducting a PTSD C&P examination—sometimes to as little as 20 minutes—even though the protocol suggested in a best practice manual developed by the VA National Center for PTSD can take three hours or more to properly complete. The committee believes that the key to proper administration of VA’s PTSD compensation program is a thorough C&P clinical examination conducted by an experienced mental health professional. Many of the problems and issues with the current process can be addressed by consistently allocating and applying the time and resources needed for a thorough examination. The committee also recommended that a system-wide training program be implemented for the clinicians who conduct these exams in order to promote uniform and consistent evaluations.
The second primary step in the compensation process for veterans is a rating of the level of disability associated with service-connected disorders identified in the clinical examination. This rating is performed by a VA employee using the information gathered in the C&P exam. The committee found that the criteria used to evaluate the level of disability resulting from service-connected PTSD were, at best, crude and overly general. Our committee recommended that new criteria be developed and applied that specifically address PTSD symptoms and that are firmly grounded in the standards set out in the Diagnostic and Statistical Manual of Mental Disorders used by mental health professionals. As part of this effort, the committee suggested that VA take a broader and more comprehensive view of what constitutes PTSD disability. In the current scheme, occupational impairment drives the determination of the rating level. Under the committee’s recommended framework, the psychosocial and occupational aspects of functional impairment would be separately evaluated, and the claimant would be rated on the dimension on which he or she is more affected. The committee believes that the special emphasis on occupational impairment in the current criteria unduly penalizes veterans who may be capable of working, but significantly symptomatic or impaired in other dimensions, and thus it may serve as a disincentive to both work and recovery.
Determining ratings for mental disabilities in general and for PTSD specifically is more difficult than for many other disorders because of the inherently subjective nature of symptom reporting. In order to promote more accurate, consistent, and uniform PTSD disability ratings, the committee recommends that VA establish a specific certification program for raters who deal with PTSD claims, with the training to support it, as well as periodic recertification. Rater certification should foster greater confidence in ratings decisions and in the decision-making process.
To summarize, the committee identified three major changes that are needed to improve the compensation evaluation process for veterans with PTSD:
- First, the C&P exam should be done by mental health professionals who are adequately trained in PTSD and who are allotted adequate time to conduct the exams.
- Second, the current VA disability rating system should be substantially changed to focus on a more comprehensive measure of the degree of impairment, disability, and clinically significant distress caused by PTSD. The current focus on occupational impairment serves as a disincentive for both work and recovery.
- Third, the VA should establish a certification program for raters who deal with PTSD clams.
Our committee also reached a series of other recommendations regarding the conduct of VA’s compensation and pension system for PTSD that are detailed in the body of our report. I have provided copies of this report as part of my submitted testimony.
Thank you for your attention. I will be happy to answer your questions.